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Based on medical record reviews, ambulance trip report, hospital policy and procedures, and interviews with staff, it was determined that the facility failed to conduct an appropriate medical screening examination (MSE), and stabilizing treatment for four (P#20, P#21, P#22, P#28) out of 30 sampled patients. Additionally, the hospital failed to arrange for an appropriate transfer for P #28 to Hospital C.

Cross Refer to A-2406, A-2407, and A-2409.

Based on a review of policy and procedures, medical record review and interview, the hospital failed to maintain a central log for each individual that presented to the Emergency Department (ED) seeking treatment, (Patient #28).

Findings:

A review of the facility's policy titled, "EMTALA [Emergency Medical Treatment and Labor Act] - Medical Screening, Treatment and Related Issues, with an effective date of 10/20/16, section for "Emergency Department Log, Signage, On-Call Roster" stated "All individuals who come to the Emergency Department for whom a request is made for examination and treatment should be entered into the Emergency Department electronic log and have a medical record generated, regardless of eventual disposition. The purpose of the electronic log is to track the care provided to each individual who comes to the Emergency Department seeking care for an Emergency Medical Condition."

A review of the ambulance trip report dated 02/20/23 revealed that emergency medical services (EMS) was dispatched at 3:54 p.m. to Facility A for P#28 (Patient), a 29-year-old female who was seen for a pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung) that was causing right heart strain. A further review of the EMS dispatch notes revealed that at 5:45 p.m., the EMS crew called EMS dispatch and stated that when the EMS crew arrived at Facility B, they were informed that they were at the wrong hospital and that patient (P) #28 was supposed to be seen at Facility C.

A telephone interview took place with the Charge Nurse (CN) CC on 3/29/23 at 2:33 p.m. CN CC stated she was conducting EMS intake when P#28 arrived at the ED through an ambulance service. CN CC acknowledged that P#28 was not entered into the central log. CN CC said she met the EMS crew at the EMS bay.

A detailed report by EP HH revealed that EP HH contacted Charge Nurse (CN) CC, who indicated that P#28 did arrive at the ED and was not registered. When they looked at P#28's paperwork, it indicated that P#28's report had been called to Registered Nurse (RN) II at Facility C. P#28 was then sent from the ambulance bay at Facility B to Facility C.

Cross Refer to A-2406 and A-2409.

Based on a review of policy and procedures, medical record reviews and interviews with staff, it was determined that the facility failed to provide four (P#20, P#21, P#22, and P#28) out of 30 sampled patients with an appropriate medical screening examination (MSE).

Findings:

A review of the facility's policy titled "EMTALA [Emergency Medical Treatment and Labor Act] - Medical Screening, Treatment, and Related Issues," effective 10/26/16, revealed that any individual who came to the (Emergency Department) ED requesting care should be offered an appropriate medical screening examination (MSE) to determine if the individual has an EMC (Emergency Medical Condition). If an EMC existed, the hospital should provide treatment to stabilize the condition or an appropriate transfer in accordance with the hospital's policy on transfers.

The facility should:
1. Provide an appropriate MSE to anyone who came to the ED seeking medical care for a suspected EMC.
2. Treat and stabilize any patient with an EMC; and
3. Not transfer an individual with an EMC that had not been stabilized for transfer unless several conditions were met.

PROCEDURE:

An appropriate MSE should be provided to any individual who came to the ED (and/or on hospital property) and:
(1) the individual or a representative acting on the individual's behalf requested an examination or treatment for a medical condition; or
(2) it was apparent that the person needed an examination or treatment of a medical condition based on the individual's appearance or behavior.

If an EMC was determined to exist, the individual should be provided with necessary stabilizing treatment within the capacity and capability of the facility or an appropriate transfer. Stabilizing treatment should be applied in a non-discriminatory manner (e.g., no different level of care because of diagnosis, financial status, race, ethnicity, insurance status, color, national origin, sexual orientation, disease, or handicap).

If an individual presented on hospital property that was located outside of the dedicated emergency department (DED) and appeared to be suffering from an EMC or requested an examination or treatment for a medical condition, the individual should be transported to the DED or another area in the hospital that could provide an MSE and deliver emergency services appropriate to the individual's condition.

Medical Screening Examination

1. "Medical Screening Examination" (MSE) meant the process required to reach, with reasonable clinical confidence, the point at which it could be determined whether the patient has an EMC or not. An MSE was not an isolated event. It was an ongoing process that began but did not end with triage. Triage entailed the clinical assessment of the individual's presenting signs and symptoms to prioritize when the individual was seen by physician or other qualified medical personnel (QMP).

All individuals coming to the ED should be provided with an MSE appropriate to the individual's presenting signs and symptoms, as well as the capability and capacity of the hospital. Depending on the individual's presenting signs and symptoms, an appropriate MSE could involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involved performing ancillary studies and procedures, such as (but not limited to) lumbar punctures, clinical laboratory tests, scans, and/or other diagnostic tests and procedures. In deciding regarding any MSE and whether an individual had an EMC, the physician or other QMP should take into account the assessment of the triage nurse or other medical personnel and/or any information obtained from any other action taken as part of the MSE which may include, but was not limited to, laboratory results or diagnostic tests.

2. The medical record should reflect continued monitoring according to the individual's needs until it was determined whether the individual had an EMC and, if he/she did, until he/she was stabilized or appropriately transferred. There should be evidence of this ongoing monitoring prior to discharge or transfer.
The MSE should be the same MSE that the hospital would perform on any individual coming to the hospital's ED with those signs and symptoms, regardless of the individual's ability to pay.

Refusal of Examination or Treatment

1. There were two designations given to a patient when refusing examination and/or treatment:
a. Left Without Being Seen (LWBS) - Patient left the emergency department prior to MSE.
b. Against Medical Advice (AMA) - Patient left the emergency department after MSE was performed.

If at any time during an ED visit a patient refused an MSE and/or treatment or left the ED before the examination and/or treatment could be completed, the ED should make every attempt to inform the patient of the risks of refusing examination and/or treatment or of leaving before the examination and/or treatment could be completed. The staff's attempts to inform the patient of the risks should be documented in the MR (medical record). If possible, the patient should be asked to wait for the physician or QMP who could discuss the risks of leaving the hospital with the patient. If the patient decided to leave prior to the completion of his/her care, all efforts would be made to provide information, resources, and follow-up to assist in ongoing wellness.
2. The circumstances of the patient's refusal or departure should be documented in the MR and the ED staff should take every reasonable step to complete and have the patient sign a Refusal of Examination/Treatment Form if the patient LWBS or AMA. If the patient refused to sign a Refusal of Examination/Treatment Form or left before one could be prepared prior to the patient's departure, the Form should still be completed and annotated with: (1) the date and time of the request for signature from the patient; and (2) when the patient left. This should be made part of the patient's MR.

Medical Record findings:

A review of the ambulance trip report dated 02/20/23 revealed that emergency medical services (EMS) was dispatched at 3:54 p.m. to Facility A for P#28, a 29-year-old female who was seen for a pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung) that was causing right heart strain. A further review of the EMS dispatch notes revealed that at 5:45 p.m., the EMS crew called EMS dispatch and stated that when the EMS crew arrived at Facility B, they were informed that they were at the wrong hospital and that patient (P) #28 was supposed to be seen at Facility C.

A MR review from Facility C revealed that P#28 was a 29-year-old female who presented to the emergency department (ED) on 2/20/23 at 6:06 p.m. via a hospital-to-hospital transfer with a diagnosis of acute pulmonary embolism. A continued review revealed that P#28 was supposed to be transferred to Facility B with a plan for thrombectomy (surgery to remove a blood clot from an artery or vein), as discussed with the accepting physician.
A review of the ED provider's note revealed that P#28's EMS transport unit indicated that they attempted to take P#28 to Facility B but were instructed to go to Facility C.

On 2/20/23 at 9:54 p.m., Emergency Physician (EP) HH at Facility C documented that P#28 indicated she was a patient from transferring Facility A and was being transferred to Facility B for a thrombectomy procedure secondary to a massive right-sided pulmonary embolus (blood clot in the lungs).

Further review revealed that EMS took P#28 to Facility B. The receiving ED team indicated that P#28's report had been called to Facility C and sent the EMS transport unit to Facility C.

A detailed report by EP HH revealed that EP HH contacted Charge Nurse (CN) CC, who indicated that P#28 did arrive at the ED and was not registered. When they looked at P#28's paperwork, it indicated that P#28's report had been called to Registered Nurse (RN) II at Facility C. P#28 was then sent from the ambulance bay at Facility B to Facility C.

A continued review of the ED provider's note revealed that P#28's mother was notified regarding the transfer. P#28 was later emergently transferred back to Facility B for further management and the thrombectomy. P#28 departed Facility C on 2/20/23 at 9:30 p.m. P#28 returned to Facility B for evaluation and the thrombectomy on 2/20/23 at 9:54 p.m.

A review of the facility document titled "EMTALA Transfer Form" revealed the following:
Transfer date: 02/20/23
Transfer time: 4:21 p.m.
Receiving facility: Facility B.
Accepting physician: Medical Doctor (MD) BB.

A telephone interview took place with the CN CC on 3/29/23 at 2:33 p.m. CN CC stated she was conducting EMS intake when P#28 arrived at the ED through an ambulance service. CN CC said it was not an expected transfer, so she asked RN GG if she had received an expected arrival report. RN GG was also not familiar with P#28 coming. CN CC said she met the EMS crew at the EMS bay and that the EMS crew did not enter the ED. CN CC said she reviewed the EMS report and realized that RN II, who worked at Facility C, was listed on the report. CN CC acknowledged that MD BB was the accepting physician, but she was unaware that MD BB worked at Facility B. CN CC said she called the hospital where P#28 was transferred from and was informed that P#28 was supposed to be at a neighboring hospital (Facility C). CN CC said she also contacted the neighboring Hospital (Facility C). CN CC said she contacted RN II from Facility C, and RN II acknowledged receiving P#28's report and expecting P#28 at their facility. CN CC said during the communication the EMS crew acknowledged being at the wrong hospital and decided to leave voluntarily. CN CC said at no point did she talk about insurance. CN CC said she contacted Facility C and informed them that the ambulance had left their hospital and was heading to Facility C. CN CC acknowledged that P#28 was not entered into the central log. CN CC said she met the EMS crew at the EMS bay.

A review of P#20's MR revealed that P#20 arrived at the facility on 12/29/22 at 8:38 p.m. P#20 complained of dizziness, sore throat, and headache. At 9:41 p.m., P#20's vital signs documented a temperature of 100 degrees Fahrenheit. At 9:41 p.m., Nurse Practitioner (NP) JJ was assigned to P#20. Further review of the record revealed that on 12/30/22 at 8:23 a.m., P#20's ED disposition was set to AMA (against medical advice). Further review failed to reveal a MSE, other vital sign assessment or patient monitoring from 12/29/22 at 9:41 p.m. through 12/30/22 at 8:23 a.m.

A review of P#21's MR revealed that P#21 arrived at the facility on 12/29/22 at 10:55 p.m. P#21 complained of fatigue (extreme tiredness), sore throat, and headache. At 11:04 p.m., P# 21 vital signs documented a blood pressure of 151/100 (high). At 11:23 p.m., NP JJ was assigned to P#21. Further review of the record revealed that on 12/30/22 at 8:35 a.m., P#21's ED disposition was set to AMA. A continued review failed to reveal a MSE, any other vital signs or patient monitoring from 12/29/22 at 11:04 p.m. through 12/30/22 at 8:35 a.m.

A review of P#22's MR revealed that P#22 arrived at the facility's ED on 12/30/22 at 3:41 a.m. for mental health evaluation. Triage started at 3:47 a.m. P#22 reported having suicidal thoughts about jumping off a building. A review of the Columbia Suicide Severity Rating scale revealed that P#22's risk of suicide was high. A further review of P#22's ED care timeline revealed that P#22's ED disposition was set as AMA. A detailed review of P#22's medical record failed to reveal a 1013 form (a document issued by a physician for a patient to be evaluated at a mental health facility), a MSE, to include but not limited to, a psychiatric consult to appropriately assess P#22's suicidal thoughts, laboratory studies, or one to one (1:1) sitter for safety observation. The hospital allowed P#22 to leave the ED without an appropriate MSE.

Cross Refer to A-2407 and A-2409.

Based on a review of policy and procedures and medical record reviews, it was determined that the facility failed to provide three (P#21, P# 22, and P#28) out of 30 sampled patients with stabilizing treatment.

Findings:

A review of the facility's policy titled "EMTALA [Emergency Medical Treatment and Labor Act] - Medical Screening, Treatment, and Related Issues," effective 10/26/16, revealed that any individual who came to the Emergency Department (ED) requesting care should be offered an appropriate Medical Screening Examination (MSE) to determine if the individual has an Emergency Medical Condition (EMC). If an EMC existed, the hospital should provide treatment to stabilize the condition or an appropriate transfer in accordance with the hospital's policy on transfers.

PROCEDURE:

An appropriate MSE should be provided to any individual who came to the ED (and/or on hospital property) and:
If an EMC was determined to exist, the individual should be provided with necessary stabilizing treatment within the capacity and capability of the facility or an appropriate transfer. Stabilizing treatment should be applied in a non-discriminatory manner (e.g., no different level of care because of diagnosis, financial status, race, ethnicity, insurance status, color, national origin, sexual orientation, disease, or handicap).

Medical Record findings:

A medical record (MR) review from Facility C revealed that P#28 was a 29-year-old female who presented to the emergency department (ED) on 2/20/23 at 6:06 p.m. via a hospital-to-hospital transfer with a diagnosis of acute pulmonary embolism. A continued review revealed that P#28 was supposed to be transferred to Facility B with a plan for thrombectomy (surgery to remove a blood clot from an artery or vein), as discussed with the accepting physician.

A review of the ED provider's note revealed that P#28's EMS transport unit indicated that they attempted to take P#28 to Facility B but were instructed to go to Facility C.

On 2/20/23 at 9:54 p.m., Emergency Physician (EP) HH at Facility C documented that P#28 indicated she was a patient from transferring Facility A and was being transferred to Facility B for a thrombectomy procedure secondary to a massive right-sided pulmonary embolus (blood clot in the lungs).

Further review revealed that EMS took P#28 to Facility B. The receiving ED team indicated that P#28's report had been called to Facility C and sent to the EMS transport unit to Facility C.

A detailed report by EP HH revealed that EP HH contacted Charge Nurse (CN) CC, who indicated that P#28 did arrive at the ED and was not registered. When they looked at P#28's paperwork, it indicated that P#28's report had been called to Registered Nurse (RN) II at Facility C. P#28 was then sent from the ambulance bay at Facility B to Facility C.

A continued review of the ED provider's note revealed that P#28's mother was notified regarding the transfer. P#28 was later emergently transferred back to Facility B for further management and the thrombectomy. P#28 departed Facility C on 2/20/23 at 9:30 p.m. P#28 returned to Facility B for evaluation and the thrombectomy on 2/20/23 at 9:54 p.m.

A review of the facility document titled "EMTALA Transfer Form" revealed the following:
Transfer date: 02/20/23
Transfer time: 4:21 p.m.
Receiving facility: Facility B.
Accepting physician: Medical Doctor (MD) BB.

A review of P#21's MR revealed that P#21 arrived at the facility on 12/29/22 at 10:55 p.m. P#21 complained of fatigue (extreme tiredness), sore throat, and headache. At 11:04 p.m., P# 21 vital signs were as follows: blood pressure 151/100 (high). At 11:23 p.m., NP JJ was assigned to P#21. Further review of the record revealed that on 12/30/22 at 8:35 a.m., P#21's ED disposition was set to AMA. A continued review failed to reveal any other vital signs from 12/29/22 at 11:04 p.m. through 12/30/22 at 8:35 a.m. P#21's chest x-ray documented a finding of pneumonia. There was no documentation P#21 was informed of the identified EMC of pneumonia or a treatment prescribed.

A review of P#22's MR revealed that P#22 arrived at the facility's ED on 12/30/22 at 3:41 a.m. for mental health evaluation. Triage started at 3:47 a.m. P#22 reported having suicidal thoughts about jumping off a building. A review of the Columbia Suicide Severity Rating scale revealed that P#22's risk of suicide was high. A further review of P#22's ED care timeline revealed that P#22's ED disposition was set as AMA. A detailed review of P#22's MR failed to reveal a 1013 form (a form issued by a physician for a patient to be evaluated at a mental health facility), an MSE, or necessary stabilizing treatment for the identified EMC of suicidal ideations. P#22 was allowed to leave the ED AMA.

Cross Refer A-2405 and A-2406.

Based on review of medical record, hospital policy, and staff interviews, the hospital failed to arrange for an appropriate transfer for one (P#28) of 30 medical records reviewed.

Findings:

A review of the facility's policy titled "EMTALA [Emergency Medical Treatment and Labor Act] - Transfers To/From Other Facilities," effective 8/5/15, revealed procedures set forth to ensure that the hospital met the transfer requirements set forth in the Emergency Medical Treatment and Active Labor Act, 42 USC § 1395. A further review revealed all patients with an emergency medical condition (EMC) that had not been stabilized might be transferred to another medical facility if medically necessary or if requested by the patient or the patient's authorized representative.

PROCEDURE:

Transfer of Patients to Another Facility

1. Unstable Patients. An un-stabilized patient with an EMC should not be transferred unless:
a. The patient (or patient's representative) requested a transfer after being informed of the hospital's obligation to provide stabilizing treatment and the risks and benefits of transfer. The patient's request for transfer must be documented in writing in the emergency department (ED). The patient would be asked to sign the transfer request form.
b. A physician had certified that, based upon (i) the risks and benefits to the patient and (ii) the information available at the time of transfer, the medical benefits reasonably expected from medical treatment at another facility outweighed the risks to the patient's medical condition from the transfer. The physician's certification would be documented on the ED Transfer Form.
2. The transferring physician shall ensure that:
a. The receiving facility had available space and qualified personnel for the treatment of the patient and had agreed to accept the transfer of the patient and to provide appropriate medical treatment.
b. Any medical treatment within the capacity of the ED, which would minimize the risk to the individual, or the health of an unborn child, was provided.
3. Emergency Department personnel shall ensure that:
a. A copy of all medical records (MR) related to the patient's condition available at the time of the transfer was sent to the receiving facility. Information provided to the receiving facility must include the presenting signs and symptoms, a preliminary diagnosis, treatment provided, test results, and a copy of any forms signed by the patient or the patient's representative.

Medical Record findings:

On 2/20/23 at 9:54 p.m., Emergency Physician (EP) HH at Facility C documented that P#28 indicated she was a patient from transferring Facility A and was being transferred to Facility B for a thrombectomy procedure secondary to a massive right-sided pulmonary embolus (blood clot in the lungs).

Further review revealed that EMS took P#28 to Facility B. The receiving ED team indicated that P#28's report had been called to Facility C and sent the EMS transport unit to Facility C.

A detailed report by EP (Emergency Physician at Facility C) HH revealed that EP HH contacted Charge Nurse (CN) CC, who indicated that P#28 did arrive at the ED (Facility B) and was not registered. When they looked at P#28's paperwork, it indicated that P#28's report had been called to Registered Nurse (RN) II at Facility C. P#28 was then sent from the ambulance bay at Facility B to Facility C.

A continued review of the ED provider's note revealed that P#28's mother was notified regarding the transfer. P#28 was later emergently transferred back to Facility B for further management and the thrombectomy. P#28 departed Facility C on 2/20/23 at 9:30 p.m. P#28 returned to Facility B for evaluation and the thrombectomy on 2/20/23 at 9:54 p.m.

A review of the facility document titled "EMTALA Transfer Form" revealed the following:
Transfer date: 02/20/23
Transfer time: 4:21 p.m.
Receiving facility: Facility B.
Accepting physician: Medical Doctor (MD) BB.

Interviews:

A telephone interview took place with the CN (Charge Nurse) CC on 3/29/23 at 2:33 p.m. CN CC stated she was conducting EMS intake when P#28 arrived at the ED through an ambulance service. CN CC said it was not an expected transfer, so she asked RN GG if she had received an expected arrival report. RN GG was also not familiar with P#28 coming. CN CC said she met the EMS crew at the EMS bay and that the EMS crew did not enter the ED. CN CC said she reviewed the EMS report and realized that RN II, who worked at Facility C, was listed on the report. CN CC acknowledged that MD (Medical Doctor) BB was the accepting physician, but she was unaware that MD BB worked at Facility B. CN CC said she called the hospital where P#28 was transferred from and was informed that P#28 was supposed to be at a neighboring hospital (Facility C). CN CC said she also contacted the neighboring Hospital (Facility C). CN CC said she contacted RN II from Facility C, and RN II acknowledged receiving P#28's report and expecting P#28 at their facility. CN CC said during the communication the EMS crew acknowledged being at the wrong hospital and decided to leave voluntarily. CN CC said at no point did she talk about insurance. CN CC said she contacted Facility C and informed them that the ambulance had left their hospital and was heading to Facility C. CN CC acknowledged that P#28 was not entered into the central log. CN CC said she met the EMS crew at the EMS bay.

A telephone interview took place on 3/29/23 at 3:02 p.m. with the ED Director (Dir) FF. Dir FF explained that he knew about the incident with P#28. Dir FF said some confusion arose when P#28 was brought to the facility. He continued to explain that the nurse (CN CC) did not recognize any of the team members, the accepting physician was a locum doctor (a physician who worked temporarily in another practice, not his/her own), and the RN receiving the report was an RN with another facility (Facility C).

A telephone interview took place with RN GG on 3/29/23 at 3:13 p.m. RN GG said P#28 arrived at the EMS bay, and two crew members spoke with CN CC and stated it was a transfer. CN CC approached RN GG after noticing that the facility did not have an expected transfer on the record. RN GG said they (RN GG and CN CC) got on the phone and spoke with the transferring hospital (Facility A). Staff at the transferring hospital told them that P#28 was supposed to go to another nearby hospital (Facility C).

A telephone interview took place with the ED Medical Director (EMD) EE on 3/29/23 at 3:30 p.m. EMD EE said she did not know the specifics about P#28's incident. She explained that the general process when the transfer center was called regarding a patient coming for evaluation was that the facility would decide if they had the capacity and capability to accept the patient. If they decided to accept the patient, the name of the accepting physician would be given to the transfer center, and the service would be paged when the patient arrived at the facility.

Cross Refer A-2406 and A-2407.