HospitalInspections.org

Based on review of Emergency Medical Services (EMS) trip reports, Patient #1's Emergency Department (ED) medical record, facility's video recording dated 1/4/2021, Medical Staff Bylaws, Medical Staff Rules and Regulations, policies and procedures, and interviews, it was determined that the facility failed to follow policies and procedures to ensure compliance with Emergency Medical Treatment and Labor Act (EMTALA), for one (1) individual (Patient #1) out of twenty (20) sampled patients, when Patient #1 presented to the ED via EMS on 1/4/2021.

Findings were:

Cross refer to A-2406, as it relates to failure to provide Patient #1 with an appropriate Medical Screening Examination when Patient #1 presented to the facility's ED on 1/4/2021 via EMS.

Cross refer to A-2407, as it relates to failure to provide stabilizing treatment for Patient #1 when Patient #1 presented to the facility's ED on 1/4/2021 via EMS.

Based on a review of Emergency Medical Services (EMS) trip reports, Patient #1's Emergency Department (ED) medical record, facility's video recording dated 1/4/2021, Medical Staff Rules and Regulations, and interviews, it was determined that the facility failed to ensure that a medical record was created for one (1) individual (Patient #1) out of twenty (20) sampled patients when Patient #1 presented to the ED via EMS on 1/4/2021.

Findings were:

Review of the EMS trip report dated 1/3/2021 revealed that an 83-year-old female (Patient #1) was transported to the facility with chief complaints of shortness of breath, dizziness, and weakness.
A review of Patient #1's ED medical record revealed that Patient #1 arrived in the ED on 1/3/2021 at 7:07 p.m. and was seen and treated by the facility.
Patient #1 was discharged from the facility on 1/4/2021 at 4:42 a.m. via EMS.
EMS returned Patient #1 to the ED on 1/4/2021 at about 4:53 a.m. and was turned away.
Review of the facility's records failed to reveal that a medical record was created for Patient #1 when Patient #1 presented to the ED on 1/4/2021 seeking emergency services.

The EMS trip report dated 1/4/2021 revealed the ambulance crew was notified that Patient #1 was to be transported home after being discharged from the facility's ED. Documentation indicated the crew arrived at Patient #1's bedside at 4:30 a.m. and departed with the patient at 4:42 a.m. Paramedic LL noted that Patient #1 was anxious, confused, alert, and oriented to person. Paramedic LL noted that as the ambulance pulled out, she obtained Patient #1's vital signs and the patient's heart rate was in the 130s to 140s. Documentation revealed Patient #1's heart rate at 4:42 a.m. was 132. At 4:49 a.m., documentation revealed the patient's heart rate was in the 150s to 160s and that the patient was in atrial fibrillation. Paramedic LL noted that she called the facility's ED and spoke with the Emergency Response Center (ERC) nurse (Registered Nurse -RN FF), and after speaking with someone RN FF informed Paramedic LL to bring Patient #1 back to the ED. Documentation revealed that upon pulling into an ambulance bay of the facility, ED Charge Nurse/RN EE came out and informed the EMS that per Physician AA the patient is to follow-up with her primary care physician and repeated "several times" that unless the patient is symptomatic the ED will not take her back. Paramedic LL noted that she and her partner did not feel comfortable taking the patient home and leaving her with her current heart rate. Paramedic LL noted that she called the EMS online medical control and spoke with a physician at a nearby hospital who told her to bring Patient #1 to the nearby hospital's ED for evaluation and treatment. Documentation indicates that Patient #1 was taken to the nearby hospital and turned over to hospital staff at 4:55 a.m. Paramedic LL further noted that the nearby hospital's physician reported that he called Physician AA and that Physician AA was never made aware of the situation.

Review of the facility's video recording dated 1/4/2021 revealed the following:
--At 4:50:38 a.m. the ED Charge Nurse/RN EE is standing at the Emergency Response Center (ERC) and is talking with RN FF who is sitting at the ERC desk with the ED Nurse Manager (NM) JJ.
--At 4:41:06 a.m. RN EE turns and walks out of camera range.
--At 4:42:10 a.m. RN FF answers the phone.
--At 4:52:14 a.m. RN EE returns to the ERC desk.
--At 4:53:21 a.m. RN EE walks out of camera range.
--At 4:53:36 a.m. RN EE walks out the exit to the ambulance bay.
--At 4:54:22 a.m. RN EE returns to the ERC desk and is observed talking with the ED NM JJ.

Review of the Medical Staff Rules and Regulations, adopted by the Medical Staff Executive Committee on 5/19/2009, approved by the Governing Body 5/28/2009, revealed the following:
Article IV: Medical Records
Section 1. General Rules:
(a) A medical record shall be maintained for each patient who is evaluated or treated as an inpatient, ambulatory care patient, or emergency patient. The attending staff member shall be responsible for the preparation of a complete and legible medical record for each patient under his or her care. This responsibility cannot be delegated.

During an interview on 1/12/2021 at 9:30 a.m., RN EE confirmed that he was the Charge Nurse on 1/4/2021. He stated that he remembers the incident that occurred but was not familiar with Patient #1. RN EE said RN FF reported that he had just received a call from the EMS crew that had just walked out the door with Patient #1, reporting that the patient was in atrial fibrillation and that the EMS crew wanted instructions. RN EE said that since he did not know anything about Patient #1, he told RN FF to tell the EMS that if the patient was in atrial fibrillation, the patient needed to return to the ED. RN EE said that the plan was to rescind the discharge and put Patient #1 in the same room since it had not yet been cleaned.

Based on review of Emergency Medical Services (EMS) trip reports, Patient #1's Emergency Department (ED) medical record, facility's video recording dated 1/4/2021, and policies and procedures, it was determined that the facility failed to ensure that all patients presenting for treatment are entered into the ED Central Log, for one (1) individual (Patient #1) out of twenty (20) sampled patients, when Patient #1 presented to the ED via EMS on 1/4/2021.

Findings were:

Review of the EMS trip report dated 1/3/2021 revealed that an 83-year-old female (Patient #1) was transported to the facility with chief complaints of shortness of breath, dizziness, and weakness.

A review of Patient #1's ED medical record revealed that Patient #1 arrived in the ED on 1/3/2021 at 7:07 p.m. and was seen and treated by the facility. Patient #1 was discharged from the facility on 1/4/2021 at 4:42 a.m. via EMS.
EMS returned Patient #1 to the ED on 1/4/2021 at about 4:53 a.m. and was turned away.

A review of the facility's records failed to reveal an ED central log entry for Patient #1 when Patient #1 presented to the facility's ED on 1/4/2021 seeking emergency services.

The EMS trip report dated 1/4/2021 revealed the ambulance crew was notified that Patient #1 was to be transported home after being discharged from the facility's ED. Documentation indicated the crew arrived at Patient #1's bedside at 4:30 a.m. and departed with the patient at 4:42 a.m. Paramedic LL noted that Patient #1 was anxious, confused, alert, and oriented to person. Paramedic LL noted that as the ambulance pulled out, she obtained Patient #1's vital signs and the patient's heart rate was in the 130s to 140s. Documentation revealed Patient #1's heart rate at 4:42 a.m. was 132. At 4:49 a.m., documentation revealed the patient's heart rate was in the 150s to 160s and that the patient was in atrial fibrillation. Paramedic LL noted that she called the facility's ED and spoke with the ERC (Emergency Response Center) nurse (Registered Nurse - RN FF), and after speaking with someone RN FF informed Paramedic LL to bring Patient #1 back to the ED. Documentation revealed that upon pulling into an ambulance bay of the facility, ED Charge Nurse/RN EE came out and informed the EMS that per Physician AA the patient is to follow-up with her primary care physician and repeated "several times" that unless the patient is symptomatic the ED will not take her back. Paramedic LL noted that she and her partner did not feel comfortable taking the patient home and leaving her with her current heart rate. Paramedic LL noted that she called the EMS online medical control and spoke with a physician at a nearby hospital who told her to bring Patient #1 to the nearby hospital's ED for evaluation and treatment. Documentation indicates that Patient #1 was taken to the nearby hospital and turned over to hospital staff at 4:55 a.m. Paramedic LL further noted that the nearby hospital's physician reported that he called Physician AA and that Physician AA was never made aware of the situation.

Review of the facility's video recording dated 1/4/2021 revealed the following:
--At 4:50:38 a.m. the ED Charge Nurse/RN EE is standing at the Emergency Response Center (ERC) and is talking with RN FF who is sitting at the ERC desk with the ED Nurse Manager (NM) JJ.
--At 4:41:06 a.m. RN EE turns and walks out of camera range.
--At 4:42:10 a.m. RN FF answers the phone.
--At 4:52:14 a.m. RN EE returns to the ERC desk.
--At 4:53:21 a.m. RN EE walks out of camera range.
--At 4:53:36 a.m. RN EE walks out the exit to the ambulance bay.
--At 4:54:22 a.m. RN EE returns to the ERC desk and is observed talking with the ED NM JJ.

A review of the facility's policies and procedure titled Emergency Room (ER) Access Registration Process, policy number 9150-2, last effective date 12/2018, revealed the purpose of the policy is to outline the proper procedures for registering ER patients. This policy indicated that all patients that present to the ER for admission, emergency care, diagnostic testing, therapy, invasive procedures, or any other medical services to be registered and/or admitted into the Epic System (the electronic computer system that enters patients into the Central Log and creates a medical record). A log of all patients who present to the ED for treatment is maintained through the Electronic Medical record (EMR) system. The electronic log will include the date of arrival, medical record number, patient name, age, sex, chief complaint, and patient disposition. Regardless of the point of entry (ambulance or ambulatory), all patients who present to the ED for treatment will be immediately entered into the EMR system. This log is available upon request.

Based on review of Emergency Medical Services (EMS) trip reports, Patient #1's Emergency Department (ED) medical record, facility's video recording dated 1/4/2021, policies and procedures, and interviews, it was determined that the facility failed to ensure that a Medical Screening Examination (MSE) was provided for one (1) individual (Patient #1) out of twenty (20) sampled patients, when Patient #1 presented to the ED via EMS on 1/4/2021.

Findings were:

Review of the EMS trip report dated 1/3/2021 revealed that an 83-year-old female (Patient #1) was transported to the facility with chief complaints of shortness of breath, dizziness, and weakness.

A review of Patient #1's ED medical record revealed that Patient #1 arrived in the ED on 1/3/2021 at 7:07 p.m. and was seen and treated by the facility. Patient #1 was discharged from the facility on 1/4/2021 at 4:42 a.m. via EMS.
EMS returned Patient #1 to the ED on 1/4/2021 at about 4:53 a.m. and the facility failed to provide a medical screening examination for the patient who was turned away at the ambulance bay.

The EMS trip report dated 1/4/2021 revealed the ambulance crew was notified that Patient #1 was to be transported home after being discharged from the facility's ED. Documentation indicated the crew arrived at Patient #1's bedside at 4:30 a.m. and departed with the patient at 4:42 a.m. Paramedic LL noted that Patient #1 was anxious, confused, alert, and oriented to person. Paramedic LL noted that as the ambulance pulled out, she obtained Patient #1's vital signs and the patient's heart rate was in the 130s to 140s. Documentation revealed Patient #1's heart rate at 4:42 a.m. was 132. At 4:49 a.m., documentation revealed the patient's heart rate was in the 150s to 160s and that the patient was in atrial fibrillation. Paramedic LL noted that she called the facility's ED and spoke with the ERC (Emergency Response Center) nurse (Registered Nurse - RN FF), and after speaking with someone RN FF informed Paramedic LL to bring Patient #1 back to the ED. Documentation revealed that upon pulling into an ambulance bay of the facility, ED Charge Nurse/RN EE came out and informed the EMS that per Physician AA the patient is to follow-up with her primary care physician and repeated "several times" that unless the patient is symptomatic the ED will not take her back. Paramedic LL noted that she and her partner did not feel comfortable taking the patient home and leaving her with her current heart rate. Paramedic LL noted that she called the EMS online medical control and spoke with a physician at a nearby hospital who told her to bring Patient #1 to the nearby hospital's ED for evaluation and treatment. Documentation indicates that Patient #1 was taken to the nearby hospital and turned over to hospital staff at 4:55 a.m. Paramedic LL further noted that the nearby hospital's physician reported that he called Physician AA and that Physician AA was never made aware of the situation.


Review of the facility's video recording dated 1/4/2021 revealed the following:
--At 4:50:38 a.m. the ED Charge Nurse/RN EE is standing at the Emergency Response Center (ERC) and is talking with RN FF who is sitting at the ERC desk with the ED Nurse Manager (NM) JJ.
--At 4:41:06 a.m. RN EE turns and walks out of camera range.
--At 4:42:10 a.m. RN FF answers the phone.
--At 4:52:14 a.m. RN EE returns to the ERC desk.
--At 4:53:21 a.m. RN EE walks out of camera range.
--At 4:53:36 a.m. RN EE walks out the exit to the ambulance bay.
--At 4:54:22 a.m. RN EE returns to the ERC desk and is observed talking with the ED NM JJ.

A review of the facility's policy Emergency Services Policies & Procedures policy #301-38 #301-38 last reviewed 9/19 revealed that a Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists. Such screening must be done within the facility's capability and available personnel, including on call physicians. The medical screening examinations in an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred. The policy further provided that screening and stabilization treatments, within the scope of this facility's ability, are provided to any individual with an emergency medical condition. No transfer to another facility or Physician's office will be accomplished until a medical screening exam and any necessary stabilization treatment is performed.

INTERVIEWS:
During a tour of the ED conducted on 1/12/2021 with the ED Assistant Nurse Manager (ANM) II at 9:10 a.m., she explained that even if the ED is on diversion and an ambulance pulls up the patient is to be brought into the ED, triaged, registered, entered into the electronic system, and provided an MSE.

During an interview on 1/12/2021 at 9:30 a.m., RN EE confirmed that he was the Charge Nurse on 1/4/2021. He stated that he remembers the incident that occurred but was not familiar with Patient #1. RN EE said RN FF reported that he had just received a call from the EMS crew that had just walked out the door with Patient #1, reporting that the patient was in atrial fibrillation and that the EMS crew wanted instructions. RN EE said that since he did not know anything about Patient #1, he told RN FF to tell the EMS that if the patient was in atrial fibrillation, the patient needed to return to the ED. RN EE said that the plan was to rescind the discharge and put Patient #1 in the same room since it had not yet been cleaned. RN EE explained that he went to notify Physician AA and the physician said he was aware of the atrial fibrillation and that if Patient #1 was asymptomatic she was to follow-up with her primary care physician. RN EE said he was not aware at the time that the ambulance was on the property. RN EE said that he went back to the ERC to update RN FF and saw the ambulance pull into the ambulance bay. RN EE said he went out to meet them and tell them that Physician AA was aware of the atrial fibrillation and that if the patient was asymptomatic, she was to follow-up with her primary care physician. RN EE said the EMS said they thought the atrial fibrillation was fixed and RN EE replied that the atrial fibrillation was not fixed because it was a chronic condition and if the patient had no symptoms, she was to follow-up with her primary care physician. RN EE said the EMS replied, alright, shut the door, and left. When asked if RN EE was aware that if a patient is on the facility's property and an MSE is requested that the facility is required to perform an MSE, RN EE replied that he should have been aware, but that at the time he just did not think about repeating the MSE. RN EE said he later received a call from a nearby facility informing him that the EMS took Patient #1 to their facility and that the EMS reported that the patient had been refused.

During a telephone interview on 1/12/2021 at 10:00 a.m., RN FF confirmed that he was assigned to the ERC desk on 1/4/2021. He explained that ERC duties include answering the phone, paging physicians for calls, answering the EMS radio, and documenting consultations. RN FF said that he was familiar with Patient #1 because she is the mother of one (1) of the ED's frequent patients. RN FF said that on 1/3/2021 Patient #1 came into the ED as a patient and that he had not seen her in the ED as a patient before this visit. RN FF said Patient #1 was placed in room #3, was seen, treated, and it was eventually decided that the patient was going to be discharged home. RN FF explained that arrangements were made for an ambulance to transport Patient #1 home but when they arrived the patient had gone into atrial fibrillation with a rapid ventricular response so the ambulance was canceled. RN FF went on to explain that after Physician AA treated the atrial fibrillation the physician spoke with Hospitalist BB about admitting Patient #1. RN FF said that after Physician AA spoke with Hospitalist BB it was determined that Patient #1 had chronic asymptomatic atrial fibrillation and that the patient could be discharged and follow-up with her primary care physician. RN FF said the patient's nurse arranged for the ambulance to transport Patient #1 home. RN FF said the EMS arrived, loaded the patient, and left. RN FF said that in a few minutes the EMS called by phone, not by the EMS radio, and reported that Patient #1 had gone back into atrial fibrillation and asked whether they needed to return the patient to the ED. RN FF said he spoke with the ED Charge Nurse/RN EE and informed him that Patient #1 had gone back into atrial fibrillation and he said the EMS should return the patient to the ED. RN FF said he then notified the EMS to return Patient #1 to the ED. RN FF said he told RN EE to notify Physician AA. RN FF explained that RN EE returned after speaking with Physician AA and said that the physician was aware of Patient #1 chronic atrial fibrillation and that if the patient was asymptomatic the patient was to follow-up with her primary care physician. RN FF said he then saw the EMS pull up and RN EE went out to speak with the crew and Patient #1. RN FF said he later found out that the EMS took Patient #1 to a nearby facility. When asked if RN FF was aware that if a patient is on the facility's property and an MSE is requested the facility is required to perform an MSE, RN FF replied that he thought about it, but there was so much going on that he did not think everything through. RN FF confirmed that the facility requires EMTALA training as part of their computer-based training (CBT) every year.

During a telephone interview on 1/12/2021 at 10:45 a.m., Physician AA confirmed that he treated Patient #1 on 1/4/2021. He explained that Patient #1 had atrial fibrillation with a rapid ventricular response and that he initially thought it was a new-onset. Physician AA said he called Hospitalist BB to admit Patient #1 and that when the Hospitalist reviewed the patient's history, she found that the atrial fibrillation was a chronic condition. Physician AA said that based on Patient #1's history of atrial fibrillation and the fact that she was on medications at home to control her heart rate, it was determined that the patient could be discharged home with instructions to continue her home medications and follow-up with her primary care physician. Physician AA said that at the time of discharge from the ED Patient #1's vital signs were normal, and she was stable for discharge. Physician AA said he was unsure of the time but that later the ED Charge Nurse/RN EE informed him that the EMS had Patient #1 at home and that the patient had a rapid heart rate. Physician AA said he informed the nurse that if the patient's blood pressure was normal that he had expected the patient's heart rate to fluctuate up and down just as it had in the ED. Physician AA said that while in the ED the patient's heart rate would increase when the patient got anxious or combative and would regulate when the patient calmed down. Physician AA said that he told RN EE to inform the EMS that if they had concerns, or the patient/family had concerns, they should return to the ED for a reevaluation. Physician AA confirmed that he was never informed that the ambulance was on hospital property and that had he known he would have repeated the MSE. Physician AA said that none of Patient #1's labs or x-ray results, when compared to previous results, had required admission, and that his main concern had been the patient's confusion but that he was informed by the patient's family and the EMS that this was the patient's normal state. Physician AA said that he later received a call from a physician at a nearby facility informing him that the EMS had taken the patient there. He said that he informed that physician that he had not been informed that the EMS had brought Patient #1 back. Physician AA confirmed that he had received EMTALA training in 2020.

During an interview on 1/12/2021 at 1:00 p.m., ED NM JJ confirmed that the video recording shows her sitting at the ERC desk when the ED Charge Nurse/RN EE returned from speaking with the EMS. She explained that when RN EE told her he had informed the EMS that the patient would not be seen again unless the patient was symptomatic, she informed him that the patient should have been brought into the ED and re-evaluated.

During a telephone interview on 1/12/2021 at 3:00 p.m., Paramedic LL confirmed that she and her partner were dispatched to the facility with instructions to transport Patient #1 back to her residence on 1/4/2021. Paramedic LL said she didn't know Patient #1 but that her partner had been on the ambulance that brought the patient to the ED on 1/3/2021. Paramedic LL stated that when she and her partner arrived, they were told that Patient #1 was confused and that this was her normal state. Paramedic LL said the nurse reported that earlier, after Patient #1 was evaluated and treated arrangements had been made for the patient to be transported home by ambulance, but when the ambulance arrived Patient #1 was in atrial fibrillation, so the discharge was canceled. Paramedic LL said the nurse also reported that Patient #1's heart rate and rhythm had returned to normal after receiving medications for arrhythmias (abnormal heart rhythms). Paramedic LL said she was also informed that ED Physician AA had wanted to admit the patient but after the Hospitalist BB reviewed the patient's history and the patient was monitored for a while it was determined that Patient #1 could be discharged home. Paramedic LL said the nurse reported that they had been unable to contact the patient's family before the discharge. Paramedic LL said Patient #1 asked where she was being taken and that EMS told her they were taking her home. Paramedic LL said Patient #1 reported that her son was an alcoholic and that he was probably asleep. Paramedic LL explained that she and her partner put Patient #1 on the stretcher and loaded her into the ambulance. Paramedic LL explained further that she was in the back with Patient #1 and her partner was driving the ambulance. Paramedic LL stated that as the ambulance pulled out of the ambulance parking lot, she finished obtaining Patient #1's vital signs and the Patient #1's heart rate was in the 130s and 140s, and the heart monitor showed atrial fibrillation with a heart rate of 150. Paramedic LL said she phoned the ERC desk and spoke with RN FF who told her that the patient should be brought back to the ED. Paramedic LL said the ED NM JJ had been sitting at the ERC desk when they loaded the patient into the ambulance. Paramedic LL said that when the ambulance pulled into the ambulance bay, the ED Charge Nurse/RN EE came outside and reported that the ED Physician AA knew about the atrial fibrillation, that it was not new, and that the patient was to follow-up with her primary care physician. Paramedic LL said the ED Charge Nurse/RN EE told the paramedics several times that the hospital would not take Patient #1 back unless she was symptomatic. Paramedic LL said their medical control was out of the nearby facility, and they were told to bring the patient there.

Based on review of Emergency Medical Services (EMS) trip reports, Patient #1's Emergency Department (ED) medical record, facility's video recording dated 1/4/2021, policies and procedures, and interviews, it was determined that the facility failed to provide stabilizing treatment for one (1) individual (Patient #1) out of twenty (20) sampled patients, when Patient #1 presented to the ED via EMS on 1/4/2021.

Findings were:

Review of the EMS trip report dated 1/3/2021 revealed that an 83-year-old female (Patient #1) was transported to the facility with chief complaints of shortness of breath, dizziness, and weakness.

A review of Patient #1's ED medical record revealed that Patient #1 arrived in the ED on 1/3/2021 at 7:07 p.m. and was seen and treated by the facility.
Patient #1 was discharged from the facility on 1/4/2021 at 4:42 a.m. via EMS.
EMS returned Patient #1 to the ED on 1/4/2021 at about 4:53 a.m. and the facility failed to provide a medical screening examination for the patient who was turned away at the ambulance bay.

The EMS trip report dated 1/4/2021 revealed the ambulance crew was notified that Patient #1 was to be transported home after being discharged from the facility's ED. Documentation indicated the crew arrived at Patient #1's bedside at 4:30 a.m. and departed with the patient at 4:42 a.m. Paramedic LL noted that Patient #1 was anxious, confused, alert, and oriented to person. Paramedic LL noted that as the ambulance pulled out, she obtained Patient #1's vital signs and the patient's heart rate was in the 130s to 140s. Documentation revealed Patient #1's heart rate at 4:42 a.m. was 132. At 4:49 a.m., documentation revealed the patient's heart rate was in the 150s to 160s and that the patient was in atrial fibrillation. Paramedic LL noted that she called the facility's ED and spoke with the ERC (Emergency Response Center) nurse (Registered Nurse - RN FF), and after speaking with someone RN FF informed Paramedic LL to bring Patient #1 back to the ED. Documentation revealed that upon pulling into an ambulance bay of the facility, ED Charge Nurse/RN EE came out and informed the EMS that per Physician AA the patient is to follow-up with her primary care physician and repeated "several times" that unless the patient is symptomatic the ED will not take her back. Paramedic LL noted that she and her partner did not feel comfortable taking the patient home and leaving her with her current heart rate. Paramedic LL noted that she called the EMS online medical control and spoke with a physician at a nearby hospital who told her to bring Patient #1 to the nearby hospital's ED for evaluation and treatment. Documentation indicates that Patient #1 was taken to the nearby hospital and turned over to hospital staff at 4:55 a.m. Paramedic LL further noted that the nearby hospital's physician reported that he called Physician AA and that Physician AA was never made aware of the situation.


Review of the facility's video recording dated 1/4/2021 revealed the following:
--At 4:50:38 a.m. the ED Charge Nurse/RN EE is standing at the Emergency Response Center (ERC) and is talking with RN FF who is sitting at the ERC desk with the ED Nurse Manager (NM) JJ.
--At 4:41:06 a.m. RN EE turns and walks out of camera range.
--At 4:42:10 a.m. RN FF answers the phone.
--At 4:52:14 a.m. RN EE returns to the ERC desk.
--At 4:53:21 a.m. RN EE walks out of camera range.
--At 4:53:36 a.m. RN EE walks out the exit to the ambulance bay.
--At 4:54:22 a.m. RN EE returns to the ERC desk and is observed talking with the ED NM JJ.

A review of the facility's policy Emergency Services Policies & Procedures policy #301-38 last reviewed 9/19 revealed that screening and stabilization treatments, within the scope of this facility's ability, are provided to any individual with an emergency medical condition. No transfer to another facility or Physician's office will be accomplished until a medical screening exam and any necessary stabilization treatment is performed. The policy further provides that a patient is stabilized if the treating physician attending to the patient in the Emergency Department has determined within reasonable clinical confidence that the emergency medical condition has resolved.

Emergency Services Triage System, policy number 301-13, last reviewed 5/2020, revealed the purpose of the policy is to provide a standardized system whereby patients presenting to the ED are treated in order of priority based upon acuity (severity) utilizing the Emergency Severity Index 5 Level Triage System.

INTERVIEWS:
A tour of the ED was conducted on 1/12/2021 with the ED Assistant Nurse Manager (ANM) II at 9:10 a.m., she explained that even if the ED is on diversion and an ambulance pulls up the patient is to be brought into the ED, triaged, registered, entered into the electronic system, and provided an MSE.

During an interview on 1/12/2021 at 9:30 a.m., RN EE confirmed that he was the Charge Nurse on 1/4/2021. He stated that he remembers the incident that occurred but was not familiar with Patient #1. RN EE said RN FF reported that he had just received a call from the EMS crew that had just walked out the door with Patient #1, reporting that the patient was in atrial fibrillation and that the EMS crew wanted instructions. RN EE said that since he did not know anything about Patient #1, he told RN FF to tell the EMS that if the patient was in atrial fibrillation, the patient needed to return to the ED. RN EE said that the plan was to rescind the discharge and put Patient #1 in the same room since it had not yet been cleaned. RN EE explained that he went to notify Physician AA and the physician said he was aware of the atrial fibrillation and that if Patient #1 was asymptomatic she was to follow-up with her primary care physician. RN EE said he was not aware at the time that the ambulance was on the property. RN EE said that he went back to the ERC to update RN FF and saw the ambulance pull into the ambulance bay. RN EE said he went out to meet them and tell them that Physician AA was aware of the atrial fibrillation and that if the patient was asymptomatic, she was to follow-up with her primary care physician. RN EE said the EMS said they thought the atrial fibrillation was fixed and RN EE replied that the atrial fibrillation was not fixed because it was a chronic condition and if the patient had no symptoms, she was to follow-up with her primary care physician. RN EE said the EMS replied, alright, shut the door, and left. When asked if RN EE was aware that if a patient is on the facility's property and an MSE is requested that the facility is required to perform an MSE, RN EE replied that he should have been aware, but that at the time he just did not think about repeating the MSE. RN EE said he later received a call from a nearby facility informing him that the EMS took Patient #1 to their facility and that the EMS reported that the patient had been refused.

During a telephone interview on 1/12/2021 at 10:00 a.m., RN FF confirmed that he was assigned to the ERC desk on 1/4/2021. He explained that ERC duties include answering the phone, paging physicians for calls, answering the EMS radio, and documenting consultations. RN FF said that he was familiar with Patient #1 because she is the mother of one (1) of the ED's frequent patients. RN FF said that on 1/3/2021 Patient #1 came into the ED as a patient and that he had not seen her in the ED as a patient before this visit. RN FF said Patient #1 was placed in room #3, was seen, treated, and it was eventually decided that the patient was going to be discharged home. RN FF explained that arrangements were made for an ambulance to transport Patient #1 home but when they arrived the patient had gone into atrial fibrillation with a rapid ventricular response so the ambulance was canceled. RN FF went on to explain that after Physician AA treated the atrial fibrillation the physician spoke with Hospitalist BB about admitting Patient #1. RN FF said that after Physician AA spoke with Hospitalist BB it was determined that Patient #1 had chronic asymptomatic atrial fibrillation and that the patient could be discharged and follow-up with her primary care physician. RN FF said the patient's nurse arranged for the ambulance to transport Patient #1 home. RN FF said the EMS arrived, loaded the patient, and left. RN FF said that in a few minutes the EMS called by phone, not by the EMS radio, and reported that Patient #1 had gone back into atrial fibrillation and asked whether they needed to return the patient to the ED. RN FF said he spoke with the ED Charge Nurse/RN EE and informed him that Patient #1 had gone back into atrial fibrillation and he said the EMS should return the patient to the ED. RN FF said he then notified the EMS to return Patient #1 to the ED. RN FF said he told RN EE to notify Physician AA. RN FF explained that RN EE returned after speaking with Physician AA and said that the physician was aware of Patient #1 chronic atrial fibrillation and that if the patient was asymptomatic the patient was to follow-up with her primary care physician. RN FF said he then saw the EMS pull up and RN EE went out to speak with the crew and Patient #1. RN FF said he later found out that the EMS took Patient #1 to a nearby facility. When asked if RN FF was aware that if a patient is on the facility's property and an MSE is requested the facility is required to perform an MSE, RN FF replied that he thought about it, but there was so much going on that he did not think everything through. RN FF confirmed that the facility requires EMTALA training as part of their computer-based training (CBT) every year.

During a telephone interview on 1/12/2021 at 10:45 a.m., Physician AA confirmed that he treated Patient #1 on 1/4/2021. He explained that Patient #1 had atrial fibrillation with a rapid ventricular response and that he initially thought it was a new-onset. Physician AA said he called Hospitalist BB to admit Patient #1 and that when the Hospitalist reviewed the patient's history, she found that the atrial fibrillation was a chronic condition. Physician AA said that based on Patient #1's history of atrial fibrillation and the fact that she was on medications at home to control her heart rate, it was determined that the patient could be discharged home with instructions to continue her home medications and follow-up with her primary care physician. Physician AA said that at the time of discharge from the ED Patient #1's vital signs were normal, and she was stable for discharge. Physician AA said he was unsure of the time but that later the ED Charge Nurse/RN EE informed him that the EMS had Patient #1 at home and that the patient had a rapid heart rate. Physician AA said he informed the nurse that if the patient's blood pressure was normal that he had expected the patient's heart rate to fluctuate up and down just as it had in the ED. Physician AA said that while in the ED the patient's heart rate would increase when the patient got anxious or combative and would regulate when the patient calmed down. Physician AA said that he told RN EE to inform the EMS that if they had concerns, or the patient/family had concerns, they should return to the ED for a reevaluation. Physician AA confirmed that he was never informed that the ambulance was on hospital property and that had he known he would have repeated the MSE. Physician AA said that none of Patient #1's labs or x-ray results, when compared to previous results, had required admission, and that his main concern had been the patient's confusion but that he was informed by the patient's family and the EMS that this was the patient's normal state. Physician AA said that he later received a call from a physician at a nearby facility informing him that the EMS had taken the patient there. He said that he informed that physician that he had not been informed that the EMS had brought Patient #1 back. Physician AA confirmed that he had received EMTALA training in 2020.

During an interview on 1/12/2021 at 1:00 p.m., ED NM JJ confirmed that the video recording shows her sitting at the ERC desk when the ED Charge Nurse/RN EE returned from speaking with the EMS. She explained that when RN EE told her he had informed the EMS that the patient would not be seen again unless the patient was symptomatic, she informed him that the patient should have been brought into the ED and re-evaluated.

During a telephone interview on 1/12/2021 at 3:00 p.m., Paramedic LL confirmed that she and her partner were dispatched to the facility with instructions to transport Patient #1 back to her residence on 1/4/2021. Paramedic LL said she didn't know Patient #1 but that her partner had been on the ambulance that brought the patient to the ED on 1/3/2021. Paramedic LL stated that when she and her partner arrived, they were told that Patient #1 was confused and that this was her normal state. Paramedic LL said the nurse reported that earlier, after Patient #1 was evaluated and treated arrangements had been made for the patient to be transported home by ambulance, but when the ambulance arrived Patient #1 was in atrial fibrillation, so the discharge was canceled. Paramedic LL said the nurse also reported that Patient #1's heart rate and rhythm had returned to normal after receiving medications for arrhythmias (abnormal heart rhythms). Paramedic LL said she was also informed that ED Physician AA had wanted to admit the patient but after the Hospitalist BB reviewed the patient's history and the patient was monitored for a while it was determined that Patient #1 could be discharged home. Paramedic LL said the nurse reported that they had been unable to contact the patient's family before the discharge. Paramedic LL said Patient #1 asked where she was being taken and that EMS told her they were taking her home. Paramedic LL said Patient #1 reported that her son was an alcoholic and that he was probably asleep. Paramedic LL explained that she and her partner put Patient #1 on the stretcher and loaded her into the ambulance. Paramedic LL explained further that she was in the back with Patient #1 and her partner was driving the ambulance. Paramedic LL stated that as the ambulance pulled out of the ambulance parking lot, she finished obtaining Patient #1's vital signs and the Patient #1's heart rate was in the 130s and 140s, and the heart monitor showed atrial fibrillation with a heart rate of 150. Paramedic LL said she phoned the ERC desk and spoke with RN FF who told her that the patient should be brought back to the ED. Paramedic LL said the ED NM JJ had been sitting at the ERC desk when they loaded the patient into the ambulance. Paramedic LL said that when the ambulance pulled into the ambulance bay, the ED Charge Nurse/RN EE came outside and reported that the ED Physician AA knew about the atrial fibrillation, that it was not new, and that the patient was to follow-up with her primary care physician. Paramedic LL said the ED Charge Nurse/RN EE told the paramedics several times that the hospital would not take Patient #1 back unless she was symptomatic. Paramedic LL said their medical control was out of the nearby facility, and they were told to bring the patient there.