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Based on document review and staff interview, the facility failed to ensure the Emergency Department (ED) staff provided appropriate stabilizing treatment to a patient (Patient #18) with an Emergency Medical Condition in 1 of 30 ED patients' medical records selected for review. The administrative staff identified an average of 550 patients per month that requested emergency medical care at the facility.

Failure to follow the facility's policies which required all patients to receive all appropriate stabilizing treatment could potentially result in the facility staff failing to offer the patient appropriate treatment for a potentially life threatening problem.

Findings include:

1. Review of the "Regional Medical Center Organizational Chart Nursing & Quality Services", revised 11/13/12, revealed the facility owned the ambulance service, and CCP A was the Emergency Medical Services Coordinator. CCP A ultimately reported to the Chief Nursing Officer at the facility.

2. During an interview on 12/18/12 at 4:30 PM, CCP A, also the Emergency Medical Services Coordinator, stated the facility owned the ambulance service. CCP A stated the facility employed CCP A and CCP E.

3. Review of the "Rules and Regulations of the Medical Staff", approved 5/13/02, revealed in part, "Federal law ... mandates that if the patient is medically assessed as having an emergency medical condition, then all appropriate ancillary services and resources of the Hospital [sic] must be utilized in treating the emergency condition, this includes appropriate stabilization ..."

4. Review of the policy "EMERGENCY EXAMINATION AND TRANSFER POLICY - EMTALA", effective 2/04, revealed in part, "If the individual has an Emergency Medical Condition, further medical examination and treatment within the capabilities of the staff and facilities must be provided as required to stabilize the Emergency Medical Condition ... [Regional Medical Center] personnel providing the medical screening will inform the individual ... of [Regional Medical Center's] responsibility to offer and ... to provide further examination and treatment as required to stabilize the Emergency Medical Condition."

5. Review of Patient #18's medical record revealed: The Regional Medical Center (RMC) Emergency Medical Services (EMS) staff responded to Patient #18's residence at 11:50 AM. When Critical Care Paramedic (CCP) A arrived at Patient #18's residence, he documented Patient #18 was sweating profusely, and looked gray in color. Patient #18 reported waking up from a nap short of breath and with chest pressure that felt like indigestion. CCP A placed a heart monitor on the Patient, which showed a sinus rhythm [normal] with ST segment elevation [abnormal finding] (The ST segment represents the period when the ventricles are depolarized.) Subsequently, CCP A obtained an EKG (electrocardiogram, a tracing of the electrical activity of the heart) , which also showed elevated ST segment, which is favorable for an acute inferior wall myocardial infarction. The ambulance staff called RMC to activate a STEMI alert (ST-Elevation Myocardial Infarction which is the most dangerous type of heart attack). EMS staff gave the Patient 4-baby aspirin and applied oxygen at 4-liters per minute.

The medical record documented: At 12:03 PM, the RMC EMS staff left Patient #18's residence, and transported Patient #18 to the RMC ED. CCP A documented when the ambulance arrived at the RMC ED, Nurse Practitioner B (a nurse with advanced education) was waiting outside for the ambulance. Nurse Practitioner B got into the ambulance, examined the EKG, documented Patient #18 was still having chest pain and difficulty breathing, and instructed the RMC EMS staff to transport Patient #18 to Receiving Hospital A. During the transfer from RMC to Receiving Hospital A, CCP A documented Patient #18 continued to experience chest pain, so CCP A decided to administer nitroglycerin (a medication to relieve chest pain) through Patient #18's IV access. Patient #18's blood pressure dropped very low due to the nitroglycerin, required CCP A to stop the nitroglycerin, and administer fluids through Patient #18's IV access to raise Patient #18's blood pressure. CCP A documented he contacted Receiving Hospital A, who was expecting Patient #18, and upon arrival to Receiving Hospital A transferred Patient #18 directly to the Cardiac Cath Lab (a place where a doctor can put a stent in the blood vessels in a patient's heart to open a blockage of the blood vessel that caused the heart attack).

On 12/8/12, Nurse Practitioner B documented on their note in the medical record: After EMS staff had assessed the Patient they requested a STEMI alert based on the EKG changes they had in the field. Nurse Practitioner B did go in the ambulance, examined the Patient, and reviewed the EKG. The EKG showed the Patient had ST elevation in leads II, III, and AVF. The Patient had received 4-baby aspirin, was alert, talkative, and reporting still having some shortness of breath and an indigestion type sternal (chest) pain. Nurse Practitioner B documented she deemed the Patient was stable and needed to proceed to receiving hospital A, the closest Cath Lab.

6. During an interview on 12/18/12 at 3:35 PM, Nurse Practitioner B stated: She was waiting outside for the ambulance when it arrived at the ED entrance. Nurse Practitioner B got into the back of the ambulance, and looked at the EKG CCP A had performed on Patient #1. Nurse Practitioner B looked at Patient #1's heart rate, blood pressure, and breathing rate. Nurse Practitioner B decided the RMC EMS staff needed to transfer Patient #1 to Receiving Hospital A for access to a Cardiac Cath Lab. Nurse Practitioner B told CCP A she would arrange the paperwork for Patient #1's transfer to Receiving Hospital A.

7. During an interview on 12/18/12 at 3:35 PM, Nurse Practitioner B stated she did not order the facility staff to administer Heparin to Patient #1, and did not order the laboratory staff to perform any tests on Patient #1's blood.

8. During an interview on 12/19/12 at 8:00 AM, Physician C, the Medical Director of the ambulance service stated Nurse Practitioner B did not provide any stabilizing treatment to Patient #1, prior to transferring them to Receiving Hospital A.

Based on document review and staff interview, the facility failed to ensure 1 of 30 Emergency Department (ED) patients (Patient #18), selected for review, received all available stabilizing treatment at the facility prior to transfer to another hospital. The facility's administrative staff identified an average of 550 patients per month who presented to the facility and requested emergency medical care.

Failure to provide appropriate stabilizing treatment could potentially result in disability, or the loss of the patient's life or limb.

Findings include:

1. Review of the "Rules and Regulations of the Medical Staff", approved 5/13/02, revealed in part, "Federal law ... mandates that if the patient is medically assessed as having an emergency medical condition, then all appropriate ancillary services and resources of the Hospital [sic] must be utilized in treating the emergency condition, this includes appropriate stabilization ..."

2. Review of the policy "EMERGENCY EXAMINATION AND TRANSFER POLICY - EMTALA", effective 2/04, revealed in part, "If the individual has an Emergency Medical Condition, further medical examination and treatment within the capabilities of the staff and facilities must be provided as required to stabilize the Emergency Medical Condition ... [Regional Medical Center] personnel providing the medical screening will inform the individual ... of [Regional Medical Center's] responsibility to offer and ... to provide further examination and treatment as required to stabilize the Emergency Medical Condition."

3. Review of Patient #18's medical record revealed: The Regional Medical Center (RMC) Emergency Medical Services (EMS) staff responded to Patient #18's residence at 11:50 AM. When Critical Care Paramedic (CCP) A arrived at Patient #18's residence, he documented Patient #18 was sweating profusely, and looked gray in color. Patient #18 reported waking up from a nap short of breath and with chest pressure that felt like indigestion. CCP A placed a heart monitor on the Patient, which showed a sinus rhythm with ST segment elevation (The ST segment represents the period when the ventricles are depolarized.) Subsequently, CCP A obtained an EKG (electrocardiogram, a tracing of the electrical activity of the heart) , which also showed elevated ST segment, which is favorable for an acute inferior wall myocardial infarction. The ambulance staff called RMC to activate a STEMI alert (ST-Elevation Myocardial Infarction which is the most dangerous type of heart attack). EMS staff gave the Patient 4-baby aspirin and applied oxygen at 4-liters per minute.

The medical record also documented: At 12:03 PM, the RMC EMS staff left Patient #18's residence, and transported Patient #18 to the RMC ED. CCP A documented when the ambulance arrived at the RMC ED, Nurse Practitioner B (a nurse with advanced education allowing them to write prescriptions) was waiting outside for the ambulance. Nurse Practitioner B got into the ambulance, examined the EKG (electrocardiogram, a tracing of the electrical activity of the heart), documented Patient #18 was still having chest pain and difficulty breathing, and instructed the RMC EMS staff to transport Patient #18 to Receiving Hospital A. During the transfer from RMC to Receiving Hospital A, CCP A documented Patient #18 continued to experience chest pain, so CCP A decided to administer nitroglycerin (a medication to relieve chest pain) through Patient #18's IV access. Patient #18's blood pressure dropped very low due to the nitroglycerin, required CCP A to stop the nitroglycerin, and administer fluids through Patient #18's IV access to raise Patient #18's blood pressure. CCP A documented he contacted Receiving Hospital A, who was expecting Patient #18, and upon arrival to Receiving Hospital A transferred Patient #18 directly to the Cardiac Cath Lab (a place where a doctor can put a stent in the blood vessels in a patient's heart to open a blockage of the blood vessel that caused the heart attack).

On 12/8/12, Nurse Practitioner B documented in the medical record: After EMS staff had assessed the Patient they requested a STEMI alert based on the EKG changes they had in the field. Nurse Practitioner B did go in the ambulance, examined the Patient, and reviewed the EKG. The EKG showed the Patient had ST elevation in leads II, III, and AVF. The Patient had received 4-baby aspirin, was alert, talkative, and reporting still having some shortness of breath and an indigestion type sternal (chest) pain. Nurse Practitioner B documented she deemed the Patient was stable and needed to proceed to receiving hospital A, the closest Cath Lab.

4. During an interview on 12/18/12 at 4:30 PM, Critical Care Paramedic A stated: Patient #18's spouse called 911, because Patient #18 woke up from a nap unable to breathe. When CCP A arrived, he had the ambulance staff obtain an EKG on Patient #18, and after reviewing the EKG, he quickly determined Patient #18 was having a severe heart attack, and called the RMC ED to notify them Patient #18 was having a severe heart attack. CCP A then had the RMC EMS staff transport Patient #1 to the RMC ED, which was only a few blocks from Patient #18's residence.

5. During an interview on 12/18/12 at 3:35 PM, Nurse Practitioner B stated: She was waiting outside for the ambulance when it arrived at the ED entrance. Nurse Practitioner B got into the back of the ambulance, and looked at the EKG CCP A had performed on Patient #18. Nurse Practitioner B looked at Patient #18's heart rate, blood pressure, and breathing rate. Nurse Practitioner B decided the RMC EMS staff needed to transfer Patient #18 to Receiving Hospital A for access to a Cardiac Cath Lab. Nurse Practitioner B told CCP A she would arrange the paperwork for Patient #18's transfer to Receiving Hospital A.

6. Review of the "[Receiving Hospital A's name] Cath Lab Alert - Transfer Protocol", dated 5/12, revealed Receiving Hospital A requested facilities such as Regional Medical Center, to perform tasks on patients having a severe heart attack such as "drawing routine labs", administering Heparin (a medication to thin the blood), and giving patients Plavix (a medication to thin the blood).

7. During an interview on 12/19/12 at 8:00 AM, Physician C, the Medical Director of the ambulance service, stated the transfer protocol was what the cardiologists (doctors who specialize in treating problems with the heart) at Receiving Hospital A decided they wanted the patients to receive for treatment and what they wanted to happen before Regional Medical Center transferred a patient with a severe heart attack to Receiving Hospital A.

8. During an interview on 12/19/12 at 9:50 AM, Registered Nurse (RN) D stated the facility had developed a kit stored in the ED that contained all the medications a patient experiencing a severe heart attack could require. The facility stored the kit in the ED so the ED staff could quickly access the medications the patient required. The medications included Plavix and Heparin.

9. During an interview on 12/18/12 at 3:35 PM, Nurse Practitioner B stated she did not order the facility staff to administer Heparin to Patient #18, and did not order the laboratory staff to perform any tests on Patient #18's blood.

10. During an interview on 12/19/12 at 8:00 AM, Physician C, the Medical Director of the ambulance service stated Nurse Practitioner B did not order Patient #18 to receive Heparin or Plavix, as requested in the protocol by Receiving Hospital A. Physician C stated he did not know if the ambulance carried Plavix or Heparin. Physician C stated Nurse Practitioner B did not provide any stabilizing treatment to Patient #18, prior to transferring them to Receiving Hospital A.

11. Review of the "Paramedic Drug Kit Price List for Inventory", dated 5/12, revealed the ambulance drug boxes (a supply of medications carried in the ambulance for administration to patients) did not contain Heparin or Plavix, thus preventing Patient #18 from receiving the medications, even if Nurse Practitioner B had ordered the paramedics to administer them to Patient #18.