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Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases as evidenced by:

A2405: The hospital failed to ensure a patient who was brought to the Emergency Department (ED) by ambulance was entered into the dedicated ED Log. (Patient #1).

A-2406 Medical Screening Examination: The hospital failed to provide a Medical Screening Examination (MSE) to a patient who was taken to the Emergency Department by ambulance (Patient #1). The ambulance was "diverted" by a staff member in the ambulance bay to a different hospital.

Staff #3 and #4 reported during an interview on 4/12/2022 that the ED staff person (Staff #9) who had the conversation with the ambulance personnel in the ambulance bay was provided with individual counseling and training specific to EMTALA. They also reported that all ED staff were required to complete current EMTALA training.

A review of Staff #9's personnel record revealed no documentation that he had completed any EMTALA training in 2020, 2021 or up to the dates of this investigation. Staff #3 also reviewed Staff #9's personnel record and acknowledged this. The hospital had no documentation that additional training was provided to ED personnel specific to the incident involving Patient #1.

Based on review of records, policies and procedures, hospital logs/documents, and staffi interviews, it was determined the hospital failed to ensure a patient who was brought to the Emergency Department (ED) by ambulance was entered into the dedicated ED Log. (Patient #1).

Findings include:

The hospital's policy and procedure titled, "Emergency Medical Treatment and Labor Act of 1986 (EMTALA)" included: "...[Carondelet Hospitals] will maintain a central log of individuals who come to the Emergency Department. The log will document the treatment status of the individual, including refusal of treatment, treatment, admission, stabilization, transfer or discharge."

Refer to Tag A-2406: A review of the ED log for 10/07/2021 revealed no documentation that Patient #1 presented there by ambulance and that the ambulance left with the patient prior to him receiving a Medical Screening Examination. Staff #3 reported during interviews that they did not identify this during their investigation and acknowledged the patient should have been entered into the ED log.

Based on review of clinical records, policies and procedures, hospital documents, and staff interviews, it was determined the hospital failed to provide a Medical Screening Examination (MSE) to a patient who was taken to the Emergency Department by ambulance (Patient #1). The ambulance was "diverted" by a staff member in the ambulance bay to a different hospital.

Findings include:

The hospital's EMTALA policy included the following: "...Definitions...Facility Property: The entire main campus of [Carondelet Hospitals], including the physical area immediately adjacent to the main buildings (e.g., parking lots, sidewalks, and driveways), and other areas and structures that are not attached to the main buildings but are located within 250 yards of the main buildings...Medical Screening Examination (MSE): Screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist...An individual is deemed to have come to the Dedicated Emergency Department if the individual...3. Is in a ground or air non-hospital -owned ambulance on Facility Property for presentation or examination for a medical condition at [Carondelet Hospital]'s Dedicated Emergency Department...[Carondelet Hospitals] will provide an appropriate MSE within the capability of Carondelet Hospital] to any individual coming to the Dedicated Emergency Department , including ancillary services routinely available to determine whether or not an Emergency Medical Condition exists...."

Patient #1 originally presented to St. Mary's Hospital on 10/06/2021 at 12:13 a.m. The patient was triaged by a Registered Nurse (RN) who documented the patient's chief complaint was alcohol relapse two months prior with current abdominal distention, colitis, nausea, vomiting, diarrhea, and black stools. A Medical Screening Examination (MSE) was performed at 12:55 a.m. The ED physician's documentation included the following: "...He reports that his vomit has had bright red blood in it and his stools have been 'sharpie' black and have been happening 3-4 times a day...He states that since his last admission to this hospital which was in August, he has not followed up with GI. He states he ran out of all of his medications when he was in Phoenix so he is not taking them any longer. He also reports that his abdomen is distended...His labs are extremely concerning with a sodium of 115, potassium of 2.3 chloride of 76, he also has a bilirubin of 27.5. He previously had a normal sodium. His hemoglobin is lower than his baseline at 12.5. With his abdominal pain I did obtain a CT which sows a pancreatic head mass, he also has some gallbladder wall thickening, which may be secondary to cirrhosis...Given his new pancreatic mass, he will likely need stenting, and probably endoscopic ultrasound guided biopsy. That is not a capability that we have at St. Mary's...I did reach out to (Hospital #2) transfer center, and they are looking for an ICU bed for this patient both in Tucson and in Phoenix. The patient is willing to go to Phoenix...." The ED physician who took over the patient's care at shift change documented the following note at 2:07 a.m. on 10/7/2021: "...This is a patient I received in signout...He is now just awaiting a bed...We were told that they would likely have discharges in the morning and that he would hopefully get a bed then. The patient has become progressively more restless and anxious. He is on the CIWA protocol for alcohol withdrawal. He is not confused. He has told the nurse multiple times that he does not want to go to (Hospital #2) and wants to just leave. I went and spoke to him, reiterating again why we want to send him to (Hospital #2). I explained that he would certainly not get better at home without intervention. We discussed the risks, which he said he understood. He says he lives here in Tucson with his mom and that she knows he is coming home. He signed out AMA...." The patient left the ED at approximately 3:12 a.m. on 10/07/2022.

Documentation in an ambulance "Patient Care Report" dated 10/07/2021 revealed they were called to and arrived at Patient #1's home on 10/07/2021 at 4:52 a.m. on 10/07/2021. The Emergency Medical Services (EMS) staff took the patient back to St. Mary's Hospital's Emergency Department. EMS staff documented, "...St. Mary's diverted us to (name of Hospital #2) in the ambulance bay...." The patient was not entered into St. Mary's Hospital's ED log and there was no documentation of St. Mary's staff "diverting" the ambulance to Hospital #2.

Patient #2 arrived at Hospital #2 at approximately 5:30 a.m., was triaged at 5:52 a.m., and provider care initiated at 5:56 a.m. Documentation in Hospital #2's clinical records revealed the patient reported falling at home after he left St. Mary's Hospital. The patient's condition worsened while in the ED and he was intubated for an emergent EGD (esophagogastroduodenoscopy) where he was found to have active bleeding in his duodenum. The patient was transferred to the ICU after the procedure where he continued to decline. The patient continued to deteriorate and family members made the decision to withdraw life support. The patient died at 6:54 p.m. on 10/8/2021.

Staff #3 and Staff #4 reported during an interview on 04/12/2022 that St. Mary's Hospital was notified that a patient had presented to their ED and may have been inappropriately diverted to another hospital. Their investigation revealed a staff member did go to the ambulance bay and told them the patient had been there earlier, had been evaluated, and was awaiting a bed at Hospital #2, however, he left AMA prior to the transfer. The staff member did not communicate the patient's arrival to medical staff prior to or after his conversation with ambulance staff.