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An unannounced onsite complaint survey was conducted related to allegations regarding the Emergency Medical Treatment & Labor Act (EMTALA) contained within complaint number SC 00052639 at McLeod Health Clarendon on 08/08/2022 - 08/11/2022. The hospital was determined to be out of compliance with 42 CFR 489.20(l) and 494.24 at the time of the survey.

Based on review of the hospital's Emergency Department's(ED) Central Logs and patient charts, interviews, and review of the hospital's Emergency Department EMTALA (Emergency Medical Treatment And Labor) policies and procedures, review of the hospital's Emergency department video recording dated 08/03/022, and interviews, the hospital failed to capture the data for 1 of 1 patient who presented to the hospital via ambulance transport on the hospital ED's central log and failed to create a medical chart for the patient's 08/03/2022 visit. (Patient #1)

The findings are:

Cross Reference to A 2405: Hospital A failed to capture the required medical data for 1 of 1 patient who presented to Hospital A's ED via ambulance transport on the ED's central log. (Patient #1)

Cross Reference to A 2406: Hospital A failed to ensure that 1 of 1 patient who presented to the hospital's ED requesting services received a medical screening examination to determine if an emergency medical condition (EMC) existed. (Patient #1)

Cross Reference to A 2409: Hospital A failed to complete a discharge transfer form with the patient's pertinent medical information prior to transfer of the patient to Hospital B.

Based on review of Hospital A's Emergency Department's(ED) Central Logs, interviews, and review of Hospital A's Emergency Department EMTALA (Emergency Medical Treatment And Labor) policies and procedures, review of Hospital A's ED surveillance video dated 08/03/022, and interviews, Hospital A failed to capture the patient's data on the central log and in a medical chart for 1 of 1 patient who presented to the hospital via ambulance transport. (Patient #1)

The finding includes:

On 8/8/2022 at 3:00 PM, review of Hospital A's ED central log for August 2022 revealed there was no documentation of Patient #1's ED visit on 08/03/2022 registered on the ED's central log. There was no patient medical record created for the visit.

Review of Hospital A's surveillance video dated 8/3/2022 confirmed Patient #1 was transported to the ED on 08/03/2022 via ambulance by Emergency Medical Service(EMS) personnel who upon arrival to the hospital's ED transported the patient into the ED. Then, EMS personnel transported the patient back into the ambulance without the patient receiving medical care and/or services.

Review of the EMS run report form, titled, "Patient Care Record", dated 08/03/22, revealed, "EMS was dispatched to a fall at a nursing home. 911 was called by the nursing home staff after they found the patient fallen from his bed and he said his head hurt. When asked, the patient agreed that his head hurt. No trauma noted to his head on inspection/palpation. Transported non emergent to Hospital A, on arrival staff advised that CT (Computed Tomography) scanning was down, and they wouldn't be able to see the patient. The patient was loaded back into M1 (Medic 1) and transported non - emergent to (Hospital B ER)...".

On 08/09/22 at 9:13 AM, Registered Nurse (RN) #1 stated, ".....We called (EMS) dispatch and let them know we are on CT diversion, and they are supposed to let the medics know. We only had one issue with one patient who EMS called about and they were only one minute out. As they entered the door, I reminded them that we were on CT diversion and they said 'oh yes'. I looked at the patient and noted no issues. The ED (Emergency Department) doctor looked at the patient and the patient was stable, alert and oriented, no loss of consciousness, and good vitals. Once we alerted them (EMS) between the two (double) doors, they reloaded the patient and took him to Hospital B. We just did a quick assessment and the patient left with them. EMS called Hospital B and told them that they were bringing the patient."

Hospital EMTALA policy, titled, "Central Log" revealed, "The central log tracks the care provided to each individual who comes to the hospital seeking care for an EMC(Emergency Medical Condition). During a survey or review, logs must be available in a timely manner."

Based on viewing the hospital's Emergency Department's (ED) security video surveillance dated 08/03/2022, interview, and review of Hospital A's EMTALA (Emergency Medical And Treatment ACT) policies and procedures, Hospital A failed to ensure that 1 of 1 patient who presented to Hospital A's ED requesting services received a medical screening examination to determine if an emergency medical condition existed. (Patient #1)

The findings are:

Central Log
On 8/8/2022 at 3:00 PM, review of Hospital A's ED central log for August 2022 revealed there was no documentation that Patient #1's ED visit dated 08/03/2022 was registered on the ED's central log. Review of Hospital A's ED video dated 8/3/2022 confirmed Patient #1 was transported to Hospital A's ED on 08/03/2022 via ambulance by Emergency Medical Service(EMS) personnel who upon arrival to the ED transported the patient into the ED. Then, the video showed the EMS personnel transported the patient back into the ambulance without the patient receiving medical care and/or services.

Patient Chart
On 08/08/2022 at 3:30 PM, twenty- one random patient charts that included the chart for Patient #1 was requested. Staff reported there was no ED chart completed for Patient #1 for 08/03/2022.

Video Surveillance
On 08/08/2022, review of Hospital A's ED security surveillance dated 08/03/22 at 07:50 AM to 07:54 AM revealed two EMS crew members entered Hospital A through the EMS bay entrance at 7:50:34. Patient #1 was on a stretcher. The video showed: EMS crew members standing at the nurse station with the patient on the stretcher. Five staff members were in the nurse station at 7:50:57. EMS crew handed forms to a male nurse who looked at the forms at 7:51:17. At 7:51:43, EMS crew exited the nurse station. The forms were handed back to one of the EMS crew members at 7:51:47. At 7:52, EMS crew reloaded the patient into the ambulance. At 7:52:50, ED Physician
#1 walked from behind the nurse station and went down the hall of the ED. At 7:54:23, the ambulance left the hospital with the patient.

Interviews
On 08/09/22 at 9:13 AM, Registered Nurse (RN) #1 stated, "EMS (Emergency Medical Services) radio calls is taken by whatever nurse is by the radio, and sometimes the MD (Medical Doctor) will answer the calls. We called (EMS) dispatch and let them know we are on CT (Computerized Axial Tomography) diversion. They (EMS dispatch) is supposed to let the medics know. We only had one issue with one patient who EMS called about. They were only one minute out. As they entered the door, I reminded them (EMS) that we were on CT diversion and they said 'oh yes'. I looked at the patient (Pt #1) and noted no issues. The ED doctor looked at them. The patient was stable, alert and oriented, no loss of consciousness, and good vitals. Once we alerted them (EMS) between the two (double) doors, they reloaded the patient and took him to Hospital B. We just did a quick assessment, and the patient (Pt #1) left with them. EMS called Hospital B and told them that they were bringing the patient. It is protocol that EMS will call the facility."

On 8/9/2022 at 9:45 AM, the Director of Radiology and Assistant Vice President of Ancillary Services showed surveyors a written statement from the Radiology Technician(RT #1) who worked on 8/3/2022. RT #1 recorded the RN supervisor was notified that the CT scanner did not function correctly. He (RN Supervisor) asked if we needed to go on diversion? I (Radiology Technician #1) said "no" and told him (RN Supervisor) that we could still do CT studies, just not contrast studies." The Director of Radiology reported, "(Name) was the tech(Technician) that night. The CT scanner had problems from 8/2/2022 to 8/5/2022. We don't have capability to do contrast when the injector is down. Biomedical came that morning to fix it (CT). This morning, 8/9/2022, it is back working."

On 8/9/2022 from 10:45 AM to 10:55 AM via telephone call with RN #2, RN #2 was asked about the patient who presented to the hospital with the head injury on 8/3/2022. RN #2 revealed "We were on diversion for trauma and stroke. The supervisor relayed the information to the charge nurse in the ED. I was not the charge nurse. I heard the EMS call (over radio), but I was with my patient. I heard, after that, the patient was taken to (Hospital B). We do what's best for the patient."

On 8/9/2022 at 11:15 AM, in the conference room, ED Director and Chief Nursing Officer (CNO) revealed per the ED Director, "We have diversions for trauma, stroke, psychiatric, and obstetrics. The RN supervisor notifies the EMS dispatches and all surrounding hospitals, the ED Director and the Charge Nurse of the diversion. Patients presenting to the ER are to be evaluated and medically cleared by our physician. If transferred, our ED physician talks with their (receiving hospital) ED physicians. Staff is trained for EMTALA on hire and yearly. Smart-At-Work is the online training. Diversion is evaluated every 3 hours."

On 8/9/2022 at 11:44 AM, review of the hospital's "Activity Log" dated 8/3/2022 at 01:45 AM that the Radiology Technician notified the Registered Nurse night supervisor (RN #3) of the broken injector on the hospital's CT scanner and radiology could only perform CT scans without contrast. Administrator #1 was notified for request for diversion. Approval received for Trauma and Stroke diversion from 01:59 AM to 10:35 AM on 8/3/2022. RN #3 notified EMS Clarendon Dispatch at 02:07 AM and at 08:24 AM of the issue. At 10:30 AM, the Director of Radiology reported the CT machine "is back up and fully running and injector port has been fixed". Trauma and stroke diversion lifted at 10:35 AM. EMS Clarendon dispatch notified of diversion lift at 10:42 AM."

On 8/9/2022 from 12:01 PM to 12:33 PM via telephone call with RN #3 and with the CNO present, RN#3 revealed, "I'm the RN night supervisor. The ED physicians seek a diversion. I call the administrator on call (Administrator #1) and discuss with them. The diversion on 08/03/2022 was warranted as the CT scan went down early Wednesday morning. Trauma and stroke alert because they require contrast, and the injector for the CT had failed. I called the county dispatches and hospitals. We check in every 2 hours to re-evaluate the diversion. The diversion was continuing when I left in the morning at 7:27 AM."

On 08/09/22 at 1:03 PM, ED Physician #1 stated, "I was working that day. We were on trauma diversion. I was with another patient, and the charge nurse spoke with them (EMS). When they (EMS) arrived, the charge nurse informed them that we were on trauma diversion. I stated I would be happy to see that patient, and I was seeing other patients. When I saw them, EMS was packing up the patient, and they were leaving. I think he (the patient) did enter the building, but he did leave. I was the only provider during that time. The ER physician from Hospital B called me and asked me about the patient. I told him I never did a MSE (Medical Screening Exam). I didn't refuse to see the patient. He said 'I understand'. We have been having a lot of issues with the CT scanner which is challenging for patient care."

On 08/09/22 at 2:45 PM, the Director of Radiology reported "We have a mobile CT for backup on site that just came today. We got it through the McLeod Health system. No training or risk assessment done for it yet, but should be ready to use if needed in one week."

On 08/09/22 at 3:54 PM, Paramedic #1 stated, "The nursing home called and said the patient fell out the bed and possibly hit his head. I called the report to Hospital A to make them aware that we were coming. There was no mention of them being on diversion. When we got to the hospital, they said the CT was down and couldn't CT if he had a head injury. It happens on occasion that their CT is down. The charge nurse was there, and the ED Physician was around the corner and asked if that was the patient's normal state. She (ED Physician #1) said she would need to CT the head. ED Physician #1 was professional about not being able to see the patient. The conversation at Hospital A took less than two minutes. I called Hospital B to make them aware that we were coming. Hospital B told me they were on "out of county" diversion. I knew the charge nurse at Hospital B who asked me if I could take the patient to CT, and then back to Hospital A. I took the patient to a room (at Hospital B). We left the patient at Hospital B. I was looking through my phone and noticed that they (EMS Dispatch) had sent out a notice of them (Hospital A) being on trauma diversion. I never saw the notice that came across the App because we were asleep."

On 08/09/22 at 4:30 PM, Paramedic #2 stated, "We walked in waiting for a room once we picked up the patient. The patient was there for possible head injury and needed a CT scan. We had just walked in the double doors by the nurse station and had not been assigned a room yet. ED Physician #1 stated if the patient was there for a CT scan that she wouldn't be able to do it because the CT scanner was down. We didn't know that they (Hospital A) were on diversion. We had not seen this information prior to us being there. I didn't scroll through Active 911 before because I was asleep."

On 8/10/2022 from 9:16 AM to 9:28 AM, in the ED, RN #5 revealed, "I was here that day (8/3/2022) assigned to triage. I stepped back here (RN desk), and the telephone was ringing. I answered it. It was radiology, and they said Physician #1 had ordered a CT scan and asked if Physician #1 knew that the hospital was on diversion? I asked Physician #1 who said, ' I totally forgot". Physician #1 was at the computers. Then a patient arrived with EMS. RN #1 was in charge and asked the EMS 'Do you know we are on diversion? ' Physician #1 and RN #1 talked back and forth, and EMS put the patient back in the ambulance".

Policies and Procedures
Hospital EMTALA policy, titled, "Medical Screening Exam (MSE)", reads, "The MSE will be performed by a physician or Qualified Medical Personnel (QMP). The MSE will be the same or similar to the screening provided to all patients presenting to the ED/ED OB reporting the same condition or exhibiting the same symptoms or condition, and is sufficient within reasonable clinical confidence to determine whether or not an individual has an EMC, including being in labor. Process to complete a Medical Screening Exam (MSE) to determine if an Emergency Medical Condition (EMC) is present. Any individual presenting to the ED will be offered an MSE, without bias, regardless of diagnosis, financial status, race, color, national origin, disability, age, sex, etc. Transfer: Hospitals are required to provide stabilizing treatment to individuals determined to have an EMC within the hospital's capability prior to arranging an appropriate transfer. In situations where the facility may not have the necessary services or equipment, they should provide stabilizing interventions within their capacity until the individual can be transferred.

Hospital EMTALA policy, titled, "Diversion to Other Hospitals by EMS of Patients Enroute to (Hospital A)" ...if an ambulance disregards (Hospital A's) instructions and brings a patient on to (Hospital A's) grounds, the patients has come to(Hospital A's) and (Hospital A) cannot deny the patient access to services consistent with (Hospital A)'s obligations under the Emergency Medical Treatment and Active Labor Act".

Based on review of the EMS(Emergency Medical Services) run report dated 08/03/2022 for Patient #1, review of the hospital's Emergency Department(ED) video surveillance dated 08/03/2022, interviews, and review of the hospital's Emergency Medical Treatment And Labor Act (EMTALA) policy and procedure, Hospital A failed to provide 1 of 1 patient with a medical screening examination (MSE), and failed to ensure an appropriate transfer to Hospital B by communication with the accepting physician and providing an appropriate executed transfer form for the patient. (Patient #1)


The finding includes:

Cross Reference to A 2406: Hospital A (transfer) failed to ensure its ED physicians performed an MSE on Patient #1 and failed to contact Hospital B(recipient) with the appropriate verbal and written communication.

On 8/8/2022 at 3:00 PM, review of Hospital A's ED log for August 2022 revealed Patient #1 was not registered on the central log for 8/3/2022. Hospital A had no documentation that a medical record was created by the hospital for Patient #1's 08/03/2022 visit.

On 08/09/22 at 9:13 AM, Registered Nurse (RN) #1, stated, ".... I looked at the patient (Pt #1) and noted no issues. The ED doctor looked at them. The patient was stable, alert and oriented, no loss of consciousness, and good vitals. Once we alerted them (EMS) between the two (double) doors, they reloaded the patient and took him to Hospital B (recipient). We just did a quick assessment, and the patient (Pt #1) left with them. EMS called Hospital B and told them that they were bringing the patient. It is protocol that EMS will call the facility."

On 8/9/2022 at 11:15 AM, in the conference room, the ED Director and the Chief Nursing Officer(CNO) revealed per the ED Director ".....Patients presenting to the ER are to be evaluated and medically cleared by our physician. If transferred, our ED physician talks with their (receiving) hospital's ED physician......"

On 08/09/22 at 1:03 PM, ED Physician #1 stated, "I was working that day. We were on trauma diversion. I was with another patient, and the charge nurse spoke with them (EMS). When they (EMS) arrived, the charge nurse informed them that we were on trauma diversion. I stated I would be happy to see that patient, and I was seeing other patients. When I saw them, EMS was packing up the patient, and they were leaving. I think he (the patient) did enter the building, but he did leave. I was the only provider during that time. The ED physician from Hospital B called me and asked me about the patient. I told him I never did a MSE (Medical Screening Exam). I didn't refuse to see the patient, and he said 'I understand'. We have been having a lot of issues with the CT scanner which is challenging for patient care."

Hospital policy, entitled, "External Transfer", revealed, Primary physician: Determines need for transfer from a McLeod Health facility. Contacts the facility and secures the name of the accepting physician for patient transfer ...Completes and signs the Certification of Need for Transfer.

Hospital policy, entitled, "Diversion to Other Hospitals by EMS of Patients Enroute to McLeod", reads, " ...if an ambulance disregards McLeod's instructions and brings a patient onto McLeod grounds, the patient has come to McLeod and McLeod cannot deny the patient access to services consistent with McLeod's obligations under the Emergency Medical Treatment and Active Labor Act".