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Based on record review, interview and policy review, the facility failed to ensure a patient who was in the emergency department for treatment was put on the emergency department log and failed to ensure a medical screening exam was performed. This affected one (Patient #21) of 20 records reviewed.

See A2405 and A2406

Based on record review, interview and policy review, the facility failed to ensure a patient who presented to the emergency department (ED) was listed as a patient on the emergency department log. This affected one (Patient #21) of 20 records reviewed.

Findings include:

Review of the transport documentation for Patient #21 dated 05/10/24 revealed he was transported from an area hospital to a separate, unaffiliated rehabilitation hospital on the third floor of The Christ Hospital for admission. Upon arrival to the rehab floor (no time documented), Patient #21's tracheostomy cuff was leaking. The Nurse Practitioner at the rehab hospital ordered the patient to be returned to the transferring hospital. The transport crew stated they could not return him without an order from the physician at the transferring hospital. The Nurse Practitioner ordered Patient #21 to be taken to the ED of The Christ Hospital, since it was in the same building as the rehab hospital.

The transport team approached the EMS triage desk and explained the situation. Medical Doctor (MD) Staff G came to the stretcher and told the transport team Patient #21 needed to be taken back to the transferring hospital. The team explained they could not return him there without an accepting physician. Patient #21 was then moved into an ED room due to low oxygen level in the transport oxygen tank. Patient #21 was placed to wall suction and was orally suctioned by a Christ Hospital staff member.

Review of the emergency department log dated 05/10/24 did not include Patient #21.

During an interview on 07/02/24 at 10:30 AM, MD Staff G revealed he worked on 05/10/24 in ED and was aware of Patient #21. That evening of 05/10/24 all of a sudden there was a medical transport team in the ambulance bay and they were somewhat confused. A gentleman walks into the ED and said they were not sure what to do with Patient #21. He was talking to the charge nurse. He explained Patient #21 just left an area hospital neurointensive care unit to the rehab hospital on the third floor. When medical transport arrived to the rehab hospital, they would not accept Patient #21 because they thought there was a small air leak in the trach, but patient #21 was stable the entire time and had an oxygen saturation of 100 percent. Patient #21 was never in the ED and only in the ambulance bay. MD Staff G stated he offered to have Patient #21 come into our ED and change the trach and then have Patient #21 go back upstairs to the rehab hospital. Medical transport said multiple times the patient was stable and only the staff at the transferring hospital were the ones to take care of the tracheostomy.


Review of the policy and procedure titled "EMTALA-Emergency Care and Transfer of Patients with an Emergency Medical Condition", revised August 2022, stated hospitals that operate dedicated emergency department and participate in the medicare program are required to comply with the EMTALA. The hospital will provide an appropriate Medical Screening Examination (MSE) for all individuals within the capability of the hospital's emergency department and ancillary departments for all individuals regardless of ability to pay, who present to the dedicated emergency department requesting examination or treatment of emergency medial condition. An appropriate medical screening examination will also be provided for all individuals presenting to the the dedicated emergency department on hospital property and which a reasonably prudent layperson would conclude, based upon the individual's appearance or behavior, is in need of emergency treatment. For patients determined to have and emergency medical condition, including pregnant women in labor, the hospital will provide necessary stabilizing treatment or will provide an appropriate transfer. The purpose of this policy is to provide guidelines for hospital employees and associates to screen, stabilize and, if applicable, safely transfer patients for continuation of medical care in accordance with all applicable laws and regulations relating to the provision of emergency services, including EMTALA.
The hospital must maintain a central log on each individual who comes to the ED seeking assistance and whether that person refused treatment, was refused treatment, or whether the individual was transferred, admitted and treated, stabilized and transferred, or discharged. The central log will include patient logs from non-emergency department patient areas where patients may present directly for emergency services, such as labor and delivery.

Based on record review, interview and policy review, the facility failed to complete a medical screening examination (MSE) on a patient that presented to the emergency department (ED). This affected one (Patient #21) of 20 patient records reviewed.

Findings include:

Review of the transport documentation for Patient #21 dated 05/10/24 revealed he was transported from an area hospital to a separate, unaffiliated rehabilitation hospital on the third floor of The Christ Hospital for admission. Upon arrival to the rehab floor (no time documented), Patient #21's tracheostomy cuff was leaking. The Nurse Practitioner at the rehab hospital ordered the patient to be returned to the transferring hospital. The transport crew stated they could not return him without an order from the physician at the transferring hospital. The Nurse Practitioner ordered Patient #21 to be taken to the ED of The Christ Hospital, since it was in the same building as the rehab hospital.

The transport team approached the EMS triage desk and explained the situation. Medical Doctor (MD) Staff G came to the stretcher and told the transport team Patient #21 needed to be taken back to the transferring hospital. The team explained they could not return him there without an accepting physician. Patient #21 was then moved into an ED room due to low oxygen level in the transport oxygen tank. Patient #21 was placed to wall suction and was orally suctioned by a Christ Hospital staff member.

Review of the ED log for 05/10/24 revealed Patient #21 was not on the log. There was no medical record started for Patient #21 and no documentation an MSE was completed.

During an interview with Medical Doctor Staff G on 07/02/24 at 10:30 AM revealed he worked on 05/10/24 in ED and was aware of Patient #21. The evening of 05/10/24 all of a sudden there was a medical transport team in the ambulance bay and they were somewhat confused. A gentleman walked into the ED and said they were not sure what to do with Patient #21. He was speaking to the charge nurse. He stated they had transported Patient #21 fro an area hospital to the rehab hospital on the third floor. When medical transport arrived to the rehab hospital, staff would not accept Patient #21 because they thought there was a small air leak in the trach, but Patient #21 was stable the entire time and had an oxygen saturation of 100 percent. When Staff G heard this, he got involved. Staff G stated Patient #21 was never in ED and only in the ambulance bay. The transport staff stated only staff at the transferring hospital were able to assess Patient #21's tracheostomy. Staff G called the transferring hospital, who agreed to accept the patient back.

During an interview on 07/02/24 at 11:12 AM, the rehab hospital nurse practitioner, Staff K, stated when Patient #21 arrived he was breathing around his tracheostomy rapidly and his oxygen saturation was declining rapidly and down into the 70's. Medical transport said Patient #21 was that way when they picked up from the transferring hospital. The ear nose and throat surgeon at the transferring hospital is the one who placed the tracheostomy and it had a flap. Staff at the rehab hospital were told "not to mess with it." They could not bag (provide oxygen via an ambu bag) Patient #21 because the air was not reaching his lungs and the air was coming out around his trach and making noises and so was his mouth. They are located inside of Christ hospital on the third floor. Staff K stated she called Staff G at Christ hospital ED and explained the situation and Staff G called us back and got more information from the case manager. Staff K did not think Patient #21 would make it from the unit back to the transferring hospital, so they sent him downstairs to the ED at Christ Hospital. Staff G called back and stated they were sending him back to the transferring hospital.

Review of the procedure for medical screening exam (MSE) was including all individuals who present on hospital property requesting examination or treatment of an emergency medical condition or who reasonably appear to need examination or treatment for an emergency medical condition, the hospital will provide an MSE by qualified medical personnel to determine whether or not the patient has an emergency condition. Depending on the patients presenting symptoms, the MSE may range from a simple process involving only a brief history and physical exam to a compel process that also involves performing ancillary studies and procedures, including but not limited to, clinical laboratory tests, CT scans, MRI's and diagnostic tests and procedures.

Review of the policy and procedure titled "EMTALA-Emergency Care and Transfer of Patients", revised August 2022, stated that operate dedicated emergency department and participate in the medicare program are required to comply with the EMTALA. The hospital will provide an appropriate Medical Screening Examination (MSE) for all individuals within the capability of the hospital's emergency department and ancillary departments for all individuals regardless of ability to pay, who present to the dedicated emergency department requesting examination or treatment of emergency medial condition. An appropriate medical screening examination will also be provided for all individuals presenting to the the dedicated emergency department on hospital property and which a reasonably prudent layperson would conclude, based upon the individual's appearance or behavior, is in need of emergency treatment. For patients determined to have and emergency medical condition, including pregnant women in labor, the hospital will provide necessary stabilizing treatment or will provide an appropriate transfer. The purpose of this policy is to provide guidelines for hospital employees and associates to screen, stabilize and, if applicable, safely transfer patients for continuation of medical care in accordance with all applicable laws and regulations relating to the provision services, including EMTALA.