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Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings included:

1. The hospital failed to ensure a thorough medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 23 sampled ED patients (Patient #19).

~ Cross refer to Medical Screening Exam - Tag A2406.

2. The hospital's Dedicated Emergency Department (DED) failed to provide an appropriate transfer that included the ordered transport mode, for 2 of 4 patients transferred to other acute care hospitals with an emergency medical condition. (Patients #16 and #29)

~ Cross refer to Appropriate Transfer - Tag A2409.

Based on policy reviews, medical record reviews and physician interviews, the hospital failed to ensure a thorough medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) existed for one of 23 sampled Emergency Department (ED) patients (Patient #19).

The findings included:

Review of the policy titled "EMTALA COMPLIANCE, INCLUDING PATIENT TRANSFERS...", reviewed/revised 02/2020, revealed "...Emergency services and care, including an appropriate Medical Screening Examination, will be provided to individuals who 'come to the emergency department' and request examination or treatment of a medical condition....'Medical Screening Exam'....means examinations, tests, studies, monitoring, and procedures that are appropriate given the individual's presenting signs and symptoms and reasonably calculated to determine if an EMC is present, including ancillary services routinely available to the emergency department. ..."

Medical Record review revealed Patient #19 arrived to the Emergency Department of Campus A on 05/03/2023 at 2003. Review revealed a chief complaint of " ...Medical Screening Exam ...Pt BIB LEO (brought in by Law Enforcement Officer) after (relative) and pt got into argument. Patient states he would like to be back on medications for his bipolar disorder. ...." Review revealed at 2014 Patient #19 was assigned a triage acuity of 3. Review of ED Provider Notes, dated 05/03/2023 at 2037, revealed the "First Provider Evaluation" was at 2003. Review revealed "...25 y.o (year old).... presenting for evaluation after being brought in by LEO under IVC (involuntary commitment). Patient states he was involved in a 'domestic' with his (relative) earlier in the month versus (sic) called and patient was arrested, booked, and released. He states he feels his (relative) is disrespectful and has difficult time getting along with him. He feels his (relative) 'pushes him to get angry.' Patient does admit to having mood swings but states they were fairly controlled previously on medication. He denies any suicidal or homicidal ideation. He denies any destruction of property. He does admit to intermittent use of illicit substances including methamphetamine. States his last use was late last night. Unable to reach petitioner - (name) .... Review of Systems.... Psychiatric/ Behavioral: Positive for agitation. Negative for suicidal ideas ....Medical Decision Making ....Patient is nontoxic-appearing, no acute distress. Patient did have an altercation with (pt's relative) this morning and is appropriately remorseful....He does admit to some impulsivity. He was offered a psychiatric eval in the emergency department but does not want to wait....There is no clear evidence that meets criteria for involuntary commitment at this time. Patient does represent a chronically elevated wrist (sic) himself given his substance use and ongoing bipolar disorder without clear, acute element. Patient was given information for (psychiatric resource name) for emotional health.... Patient has been non compliant with his medication for some time. I am unable to restart these medication without psychiatric involvement at this time....He is discharged in stable condition with strict return precautions ...."

Review of the "AFFIDAVIT AND PETITION FOR INVOLUNTARY COMMITMENT", dated 05/03/2023, revealed "Petitioner & (and) testifier appeared before Magistrate, seeking IVC on respondent, 25 year old family member ....Respondent has made threats of self harm previously, the last time about a month ago. Respondent also shows signs of paranoia, claiming that the police are always watching him & that they've put a tracking device in his pet dog. Law enforcement has been called to the house on numerous occasions, due to behavior of respondent. Based on this testimony, it appears that respondent is in need of examination & treatment at this time. ..." IVC document review revealed Patient #19 was brought to the ED for an examination on 05/03/2023 at 2004. Review of the section titled "FIRST EXAMINATION FOR INVOLUNTARY COMMITMENT" revealed the exam was conducted at 2025. Review of "... CRITERIA FOR COMMITMENT" revealed a note under "SECTION II - DESCRIPTION OF FINDINGS" that read "Patient has been evaluated by Emergency Medicine physician and Psychiatric care team. At this time, patient does not meet commitment criteria."

Telephone interview on 05/24/2023 at 1700 with PA #11 revealed the PA did not recall the patient beyond what was documented in the medical record. Interview revealed Patient #19 came in for a psychiatric evaluation, a first examination for involuntary commitment. Interview revealed from the documentation the patient was "calm, cool, collected, pretty insightful as to the days events." PA #11 stated Patient #19 was not evaluated by the psychiatric team. Interview revealed the involuntary commitment document was a standard form that was prepopulated for the providers to document. Interview revealed the prepopulated statement documented on the form was "not 100% accurate", that it should state "and/or" instead of just "and". Interview revealed the treating provider in the ED made an independent decision on whether to involve the psychiatric team. Interview revealed it was like a decision tree. PA #11 stated, he read the petition, gathered information, interviewed the patient, and reached out for collateral information. If the decision was yes, the patient met inpatient criteria, then the psychiatric care team was automatically involved. If a patient did not meet criteria, the patient was offered a voluntary psychiatric evaluation.

Emergency Department timeline review revealed Patient #19 was discharged at 2037, 34 minutes after arrival to the ED at 2003. Record review failed to reveal an evaluation by a psychiatric care team member prior to discharge.

Based on policy and procedures, medical record review and interviews, the hospital's Dedicated Emergency Department (DED) failed to provide an appropriate transfer that included the ordered transport mode, for 2 of 4 patients transferred to other acute care hospitals with an emergency medical condition, (Patients #16 and #29).

The findings included:

Review of the policy titled "EMTALA COMPLIANCE, INCLUDING PATIENT TRANSFERS...", reviewed/revised 02/2020, revealed "...If the individual has an Emergency Medical Condition, the hospital will either stabilize the medical condition within its available staff, facilities, and resources, or....appropriately transfer the individual to a qualified receiving facility....The elements of an 'Appropriate Transfer' include all of the following....4. Transportation. The transfer will be effected through qualified personnel and transportation equipment, as required....The physician at the transferring hospital is responsible for determining the appropriate mode, method, and attendants for transfer. ..."

Review of "(Campus C) Policy and Clinical Practice Guidelines...GUIDELINES FOR PATIENTS TRAVELING BY PERSONAL VEHICLE FROM (Hospital 1, Campus C) TO (Hospital 1, Campus A), date approved 08/23/2022, revealed "...(Campus C) patients may need additional evaluation and care at (Campus A). Some patients may refuse to go to (Campus A) by medical transport and insist on going in their personal vehicle. It is important that these patients understand the risks of doing so and agree to take on these risks and consequences. The following criteria should be verified and documented in the medical record....RISK DISCUSSION WITH PATIENT.... The QMP (qualified medical personnel) will explain to the patient the risks and consequences of going to (Campus A) in a personal vehicle and the alternative options of doing so. This discussion and the patient's continued desire to go by personal vehicle must be documented in the medical record....The patient must sign the Refusal of Medical Transport Form. This Form is to be maintained in the patient's chart. ..." Review of an attached form "REFUSAL OF MEDICAL TRANSPORT TO (Hospital 1, Campus A) FROM (Hospital 1, Campus C) revealed "I understand that (Campus C) is a part of (Hospital 1), even thought they are not located on the same campus. The qualified medical professional taking care of me has determined that I need some additional testing, evaluation, or treatment at (Campus A). I was offered, and encouraged to take, a medical transport to (Campus A), such as an ambulance. I am refusing (Campus C)'s offer for medical transport, and wish to go by a personal vehicle to (Campus A). ..." Review of policies and practice guidelines did not reveal any policies or guidelines for patient's who were transported from a different campus or for patients who were transported by private vehicle to an outside hospital.

1. Medical Record review, on 05/17/2023, revealed Patient #16 arrived to the Campus C Emergency Department on 04/02/2023 at 0844. Review of an ED Provider Note, at 0906 revealed " ...This is a 91-year-old ....has a past medical history of monoclonal gammopathy (abnormal proteins found in blood), atrial fibrillation (abnormal irregular heart rate).... has been feeling increasing shortness of breath and palpitations as the medication changes are happening.... also reports difficulty with urination for the past few weeks....Review of Systems ....Positive for shortness of breath....Positive for leg swelling ....Positive for difficulty urinating .... Medical Decision Making .... Acute congestive heart failure .... Acute cystitis with hematuria (inflammation of bladder with some blood present)....Anemia....Gastrointestinal hemorrhage....ED Disposition: Transfer to Another Facility. ..." Review of the ED Care Timeline revealed, at 1038, "...EMTALA Transfer Form Section 1: Physician Certification ....Reason for Transfer: Qualified clinical personnel or service unavailable; Hospital resources not available ....Orders During Transport: Follow ALS and Agency Protocol; Cardiac Monitor. ..." At 1130, Timeline review revealed "...EMTALA Transfer Form Section 2: Nurse Certification Accepting Hospital: (Hospital 4)....Transport Mode: POV (private vehicle) Transported by....aka the Transportation Vehicle: POV.... Level of Care: Other ....POV....Transfer Date: 04/02/23 Transfer Time: 1140. ..."

Record review revealed Patient #16 was transferred to Hospital 4 by private vehicle. Record review did not reveal a provider order or other documentation to indicate that a private vehicle was an appropriate method of transport from the Campus C DED to the outside hospital. Record review did not reveal a form for refusal of medical transport in the electronic record.

Interview with Registered Nurse (RN) #6, on 05/18/2023 at 1040 revealed RN #6 recalled Patient #16. Interview revealed the patient was to be admitted to a hospital and be transported by EMS (Emergency Medical Services, ambulance). Interview revealed as the transfer was being finalized, the patient's relative asked RN #6 if the patient could be transported by private vehicle instead of ambulance. Interview revealed RN #6 asked the physician, who said it would be okay. RN #6 stated she went back into the patient's room, gave the paperwork to family, took the patient's vital signs and told them where they should go. Interview revealed "I fill out my boxes..." and the nurse did not notice the provider order was to transport by ALS on a cardiac monitor. Interview revealed RN #6 got "a paper form" (a Refusal of Medical Transport form) and had it filled out and signed. Interview revealed this form did not include a space for the physician to document agreement. Interview revealed the RN handled the form according to normal routine and it should have been scanned into the medical record. Interview revealed the RN did not know what happened to the form.

Interview, on 05/18/2023 at 1100, with DO (Doctor of Osteopathic medicine) #7, the physician who documented ALS and cardiac monitor during transport, revealed DO #7 recalled Patient #16. Interview revealed the patient's blood count had dropped, the patient was developing worsening heart failure and needed hospitalization. Interview revealed DO #7 did not recall a conversation with a RN about transporting Patient #16 by private vehicle, but stated she "would not be surprised" if she agreed to a private vehicle transport.

Interview with Manager #9 on 05/19/2023 revealed the scanned form was not located so was not available for review. Interview revealed the paper form was designed for patients being transported from Campus C, a freestanding ED. Interview revealed there was not another paper form for other transfers; there was a computerized form available. Interview revealed private vehicle transport was becoming more common.

2. Medical record review, on 05/17/2023, revealed Patient #29, a 16 year-old, arrived to the DED at Campus A on 05/16/2023 at 2254. Vital signs at 2303 were temperature 98, heart rate 74, respirations 16, blood pressure 92/45 and a pain score of 9. Triage was completed at 2304 and Patient #29 assigned an acuity of 3. Review of the ED Provider Note, date of service 05/17/2023 at 0042, revealed " ...Chief Complaint: Cough ....Reports cough and chest pain x since 1500. Seen here and dc to home at 1800, pain returned ....History of Present Illness (Patient #29) is a 16 y.o. (year old) .... presents for evaluation of, 'horrible pain all through my torso.' Patient was seen in the emergency department earlier for chest pain, saying ... was carrying two 5 gallon buckets up some stairs when (the patient) developed pain in her bilateral ribs. (Patient #29) had chest x-ray and EKG done that were normal, was discharged home.... chest pain has only become worse.... now has developed diffuse abdominal pain, nausea and vomiting. (Relative) says (Patient #29) has been writhing around at home, unable to get comfortable, experiencing excruciating pain.... no fevers... ED Course & Medical Decision Making ....Patient has acute idiopathic pancreatitis .... spoke with (hospital pediatric unit name - Hospital 3) who has GI and accepted patient. (Relative)....would like to take (patient) by POV (private vehicle), which I think should be fine. Patient accepted by pediatric hospitalist. Started 1.5 maintenance fluids after our conversation .... Disposition: Transfer to Another Facility. At 0804, an ED Progress Note indicated "EMTALA paperwork completed, remained stable prior to transfer." Review of the ED Care Timeline revealed "...08:03 ... EMTALA Transfer Form ... Section 1: Physician Certification ....Reason for Transfer: Qualified clinical personnel or service unavailable....Specific Medical Benefit: Inpatient pediatric GI team.... Orders during Transport: Follow ALS and Agency Protocol .... 08:09.... EMTALA Transfer Form ....Section 2: Nurse Certification ....Transport Mode: POV....Transported by....POV .... Level of Care: Other ....POV-(Relative) ... ."

Medical record review also revealed a scanned EMTALA Transfer form which included three sections; one for the physician, one for the nurse, and one for the patient/family. Review of the scanned form revealed the third section of the form included statements related to Consent, Request and/or Refusal to transfer. Review of the third section revealed a statement which read "PATIENT REFUSED EMERGENCY MEDICAL TRANSPORTATION (Request to go by Private Vehicle). I have been offered emergency medical transportation and refuse the offer. I understand that transportation by private vehicle may increase the medical risk of the transfer." The box to the left of that statement was not checked, it was left blank.

Telephone interview with MD #8, on 05/18/2023 at 1330, revealed the initial plan was to transport Patient #29 by ambulance to the receiving hospital. Interview revealed the patient's relative was uncomfortable with using the ambulance and assured the MD the patient would be taken straight to the hospital and the physician agreed to a private vehicle transport. MD #8 stated when an EMTALA form was completed, the provider generally defaulted to ambulance transport. Interview revealed at the time of transfer, MD #8 had already left and another physician signed the form.

Telephone interview with MD #3, an ED physician and Medical Director, on 05/18/2023 at 1010, revealed the decision of transport was made between treating doctor and family. Interview revealed the default on the Transfer form was ALS transport, but once the patient was accepted to another hospital, there could be a discussion between physician and family with a change to transport by private vehicle. Interview revealed the new transport decision may not always get changed on the form.

Telephone interview with RN #10 on 05/18/2023 at 1345 revealed that when report was given by the off-going nurse, RN #10 was told the patient was to be transported by private vehicle and the nurse portion of the form was documented as per private vehicle. RN #10 stated she probably should have looked over the physician section of the form.