HospitalInspections.org

Based on hospital policy reviews, Medical Staff Bylaws - Rules and Regulations review, Medical Staff roster review, Medical Staff meeting minutes reviews, Dedicated Emergency Department (DED) schedule book review, DED provider schedule reviews, observations during tour, Central 911 Dispatch Calls For Service report review, Central 911 Dispatch audio recording review, EMS patient record review, DED central log review, hospital medical record reviews, EMS staff interviews, time line of events review, and Root Cause Analysis review, and interviews with physicians, physician assistants, and staff interviews; the hospital failed to comply with 42 CFR §489.20 and §489.24, Responsibilities of Medicare Participating Hospitals in Emergency Cases.

The findings include:

1. The hospital staff failed to maintain a list of on-call physicians composed of physicians who are current members of the medical staff or who have hospital privileges; who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition and ensure it was available and/or posted for DED staff use in 1 of 1 hospital DED toured (Hospital A).

~ Cross refer to §489.20(r)(2) and §489.24(j)(1-2) On Call Physicians - Tag A2404.

2. The hospital's DED physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 1 patients (#21) who presented via EMS ground ambulance onto the hospital's property and was diverted by order of the DED physician assistant to another acute care hospital.

~ Cross refer to §489.24(r) and §489.24(c) Medical Screening Examination - Tag A2406.

3. The hospital's DED physician failed to ensure an appropriate transfer; by failing to complete a written physician's certification for transfer documenting the medical benefits and increased risks associated with the transfer for the patient's specific EMC; failing to ensure that if a physician was not physically present in the emergency department at the time of transfer, the QMP (Qualified Medical Personnel) signed the certification after a physician in consultation with the QMP, agreed with the certification and subsequently countersigned the certification within the established time frame according to hospital policies and procedures; and failing to ensure the physician's certification was timed by the transferring physician to closely match the time of transfer for 2 of 2 sampled patients (#13 and #15) that were transferred with an EMC to other acute care hospitals.

~ Cross refer to §489.24(e)(1)(2) Risks and Benefits, Tag A2409.

Based on hospital Medical Staff Bylaws - Rules and Regulations review, policy reviews, Medical Staff roster review, Medical Staff meeting minutes reviews, Dedicated Emergency Department (DED) schedule book review, DED Provider schedule reviews, observations during tour, physician and mid-level staff interviews, the hospital staff failed to maintain a list of on-call physicians composed of physicians who are current members of the medical staff or who have hospital privileges; who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition and ensure it was available and/or posted for DED staff use in 1 of 1 hospital DED toured (Hospital A).

Findings included:

Review on 01/27/2016 of Hospital A's current "Medical Staff Bylaws" last revision approved on 02/18/2003, revealed "ARTICLE IV MEDICAL STAFF CATEGORIES AND PRIVILEGES ...4.2 Categories of the Medical Staff. ...4.2.2 Active Medical Staff. The Active Medical Staff shall consist of Practitioners who regularly admit patients to the hospital or are otherwise regularly involved in the care of Hospital inpatients, swing bed patients or outpatients and who practice or are able to practice close enough to the Hospital to provide continuous care to their patients and who assume all the functions and the responsibilities of appointment to the active Medical Staff including, where appropriate, emergency service care and consultation assignments. ...and shall be required to attend Medical Staff meetings. ...4.4 Allied Health Professionals. ...individuals eligible for Clinical Privileges as an AHP are Physician Assistants ('PA'), Certified Registered Nurse Anesthetists ('CRNA')....and Advanced Registered Nurse Practitioners ('ARNP'). ...they are not eligible for Medical Staff Membership. ..."

Review on 01/27/2016 of Hospital A's current Medical-Staff " Rules and Regulations" last revision approved on 02/18/2003, revealed "...II. EMERGENCY DEPT. SERVICES A. The Medical Staff recognizes the increasing community needs and importance of the emergency room service; therefore, these minimum standards are specified in order to insure adequate coverage, physician response within 30 minutes of notification (either person notification or by telephone), treatment and disposition of all presenting patients. ...C. Physician Coverage - There shall be posted in the emergency room a physician call roster each day of the month or longer. The physician assigned on call duty for a particular day shall be held responsible for securing a replacement when he wishes to deviate from the schedule posted. D. Physician Responsibility: 1. The physician on call shall see and treat all patients reporting to the Emergency Department who do not have an attending physician. Additionally, the physician on call will respond to all life threatening emergencies. 2. Physicians who do not have admitting privileges, ER physicians, consent for admission shall be obtained from a member of the current active medical staff who has such privileges. 3. All patients reporting to the hospital for emergency care will receive at a minimum a medical screening exam. This examination will be performed by a credentialed individual, preferably a physician or physician extender. ...L. All members of the Active Medical staff shall be required to be available for coverage of the Hospital's Emergency Department. Specific duties shall be established by the Medical Staff Committee as necessary and appropriate to sustain and insure the adequacy of physician coverage for the Department. M. When the duties for on-call coverage of the Emergency Room are not fulfilled, the following action will be taken: The Medical Director will notify the Chief of Staff and a course of action will be mutually determined. A notation will be placed in the individual's credentialing folder. ..."

Review on 01/27/2016 of hospital policy "Provider On-Call Coverage Policy", Policy/Procedure #6231.901, effective 02/2014, revealed "Purpose: The purpose of this policy is to establish guidelines for (Hospital A) County Hospital....to be prospectively aware of which physician or qualified medical personnel ('QMP') is on site or available to provide medical screening examinations (MSE) and treatment necessary to stabilize individuals with emergency medical conditions ('EMC') in order to meet the heath care needs of the community and comply with the requirements of the Emergency Medical Treatment and Active Labor Act ('EMTALA'). Policy: The Hospital shall maintain a list of the physicians on its medical staff and QMPs who are on call for the emergency department ('ED') ...The Hospital shall make such physicians and QMP's aware of their legal obligations with respect to EMTALA and take all necessary steps to ensure compliance with such obligations. Procedure: Maintaining a List and Schedule. The Hospital ED shall maintain a list and schedule of physicians and QMPs who are on-call for the ED..."

Review on 01/27/2016 of Hospital A's current Medical Staff Roster provided by CEO #2 revealed: 75 individual provider names listed on the roster. Review revealed sixty-five (65) physicians and ten (10) Allied Health Professionals. Review revealed four (4) physicians whose staff category was "active" and sixty-one (61) physicians whose staff category was "consultant." Review revealed ten (10) providers (4 physicians & 6 AHPs) with admitting privileges. Review revealed the following privileges granted: Pathology (2); Cardiology (2); Emergency Room/Hospitalist (4); Emergency Medicine/Hospitalist (1); Nephrology (4); Core Clinical (1); Anesthesia (3); Internal Medicine (1); Gastroenterology (1); Podiatry (1); Emergency Room (1); Internal Medicine/Emergency Room (1); General Surgery (1); and Teleradiology (52).

Review on 01/27/2016 of Hospital A's Medical Staff (meeting) Minutes from November 2015 to January 2016 revealed at the January 19, 2016 meeting (most recent) a total of 9 individuals attended the meeting (3 physicians and 2 AHPs). Review revealed the December 15th meeting was canceled. Review of the November 17, 2015 meeting minutes revealed a total of 10 individuals attended the meeting (3 physicians and 2 AHPs).

Review on 01/28/2016 of the DED "Schedule Book" revealed no on-call physicians list for the DED.

Review on 01/28/2016 of the DED Provider's schedule for December 2015 and January 2016 revealed the DED was staffed with either one (1) physician or one (1) mid-level on each day and night shift. Review revealed no overlapping coverage. Review revealed no physicians scheduled on-duty or on-call during the shifts where a mid-level was on-duty.

Observation on 01/26/2016 at 1400 during tour of Hospital A's DED revealed no available documentation the hospital maintained a list of on-call physicians composed of physicians who are current members of the medical staff or who have hospital privileges; who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition was available and/or posted for DED staff use.

Telephone interview on 01/27/2016 at 1455 with PA #1 revealed MSEs are performed by mid-levels (PA, NP), or physicians in the ED. Interview revealed Physician A was his supervising physician. Interview revealed there is "no" on-call physicians list for the hospital's ED. Interview revealed if I need a specialty consult I will call Hospital C to ask for a consult. Interview revealed Hospital A has "limited resources."

Telephone interview on 01/27/2016 at 1620 with PA #2 revealed revealed there was not an on-call physician's list available for staff use in the ED. Interview revealed Hospital C supplied the needed specialty physicians.

Interview on 01/26/2016 at 1400 with PA #3 during tour of the DED revealed he was the QMP on-duty in the DED. Interview revealed "technically there was no on-call physicians list" for the DED. Interview revealed there was not a physician's on-call list posted in the ED for staff use or a process in place to update the physician's on-call list. Interview revealed Physician A was available by telephone or text. Interview revealed Physician A was his supervising physician. Interview revealed the hospitalist were available during the daytime hours, but not at night. Interview revealed he does not know if the hospital has a policy for a specific response time for on-call physicians.

Interview on 01/27/2016 at 1645 with Physician A revealed he was the ED Medical Director, Chief of Staff, and Chief Medical Officer for Hospital A. Interview revealed he was the "only available on-call physician for the ED." Interview revealed he was available at all times. Interview revealed Physician D covered when he was unavailable. Interview revealed there was not an on-call physicians list posted in the ED for staff use. Interview revealed "there was no real schedule unless he was on vacation." Interview revealed he was the supervising physician for "all" mid-level (PA, NP) providers.

Based on hospital policy and procedures reviews, Central 911 Dispatch Calls For Service report review, Central 911 Dispatch audio recording review, Emergency Medical Services (EMS) patient record review, Dedicated Emergency Department (DED) central log review, hospital medical record review, EMS staff interviews, physician and physician assistant and staff interviews, time line of events review, and root cause analysis review; the hospital's DED physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 1 patients (#21) who presented via EMS ground ambulance onto the hospital's property and was diverted by order of the DED physician assistant to another acute care hospital.

Findings included:

Review of hospital policy "Medical Screening Exam & Stabilization Policy", Policy/Procedure: 6231.203, revised 02/01/2014 (in effect prior to 01/21/2016), revealed "...Policy: When an individual comes to the (Hospital A) County Hospital ('Hospital') Emergency Department ('ED') and a request is made on his or her behalf for an examination or treatment for a medical condition, or a prudent layperson observer would believe that the individual presented with an emergency medical condition ('EMC'). An appropriate medical screening examination (MSE), within the capabilities of the Hospital (including ancillary services) shall be performed by a physician or qualified medical personnel ('QMP') in order to determine whether an EMC exists, or with respect to a pregnant woman having contractions, whether the woman is in labor and where the treatment required is expressly for an EMC. If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment within the capacity and capability of the Hospital, or an appropriate transfer as required by EMTALA. ...Procedure: When a Medical Screening Examination is required: ...3. An individual is in a ground or air ambulance on Hospital property for purposes of examination or treatment at the Hospital's ED. ..."

Review on 01/27/2016 of a Central 911 Dispatch, "CFS (Calls For Service) Report", CFS#-2015-012705 provided by Emergency Medical Services (EMS) Director #1 revealed an emergency 911 call was received on 12/16/2015 at 02:14:41 reference a "55 YR (year old) HAVING TROUBLE BREATHING." Review revealed an EMS ambulance (EMS 11) was dispatched to a local residence address. Review revealed the following dispatch tracking times:
1. EMS BUILDING 12/16/2015 02:16:22 DISPATCHED;
2. AMBULANCE 12/16/2015 02:18:19 ENROUTE (10-17);
3. AMBULANCE 12/16/2015 02:23:17 ON SCENE;
4. AMBULANCE 12/16/2015 02:32:39 "LEFT SCENE|10-17 WCH (Hospital A)";
5. AMBULANCE 12/16/2015 02:36:32 "ON SCENE|WCH";
6. AMBULANCE 12/16/2015 02:42:17 "ENROUTE|(Hospital B) GENERAL REF (reference) WCH DIVERSION" (6 minutes and 45 seconds after arriving on Hospital A's property); and
7. AMBULANCE 12/16/2015 03:09:03 "ON SCENE|(Hospital B) GENERAL HOSPITAL" (27 minutes 46 seconds after leaving Hospital A's property).

Note: The address location where Patient #21 was transported from by EMS ambulance was located approximately 1.8 miles or 2 minutes from Hospital A. Hospital A is located approximately 22.2 miles or 29 minutes from Hospital B.

Review on 01/27/2016 of a Central 911 Dispatch audio recording for EMS 11 on 12/16/2015 provided by EMS Director #1 revealed:
00:02: Dispatch Tone - (Dispatcher) - "Attention (City #1) EMS, attention (City #1) EMS, EMS is needed at (physical address) in reference to a 55 year old female who is having trouble breathing call out time 0216."
00:38: (EMT-Paramedic #1) - "EMS copies."
00:45: (EMT-P #1) - "Central EMS 11's enroute."
00:49: (Dispatcher) - "10-4 (acknowledged) 11."
01:11: (EMT-P #1) - "Central EMS 11's on scene."
01:14: (Dispatcher) - "10-4."
01:18: (EMT-Intermediate #1) - "EMS 11 to Central."
01:21: (Dispatcher) - "Go ahead."
01:25: (EMT-I #1) - "EMS 11 will be enroute to (Hospital A) County Hospital."
01:30: (Dispatcher) - "10-4."
01:39: (EMT-P #1) - "(Hospital A) County Hospital this is EMS 11 patient information."
01:56: (DED Staff) - "(Hospital A) County Hospital go ahead."
02:00: (EMT-P #1) - "2 minute ETA (estimated time of arrival) with 54 year female history of hypertension and insulin dependent diabetes. Patient's chief compliant tonight increased work of breathing with being out of her BP medicine times greater than a week. Vital signs BP 247/124, pulse rate 100, respirations are about 30, SPO2 98% with clear breath sounds, however has indications of some acute pulmonary edema with pitting edema in her lower extremities and some edema in her upper extremities without a history of CHF. ETA again is about 2 minutes will advise further upon arrival."
02:58: (DED Staff) - "EMS 11 call (Hospital A) County Hospital ER by phone."
03:04: (EMT-I #1) - "EMS 11 to Central we are arriving at (Hospital A) County Hospital."
03:09: (Dispatcher) - "10-4."
03:20: (EMT-P #1) - "(County #1) County Central this is EMS 5 (EMS 11)."
03:25: (Dispatcher) - "Go ahead."
03:32: (EMT-P #1) - "Central EMS 5 (EMS 11) is going to be enroute to (Hospital B) General with this patient. Apparently the hospital has gone back on diversion and failed to notify EMS. We received confirmation that they were taking payments [sic] patients at approximately 4 o'clock this afternoon. We will be enroute to (Hospital B) with this patient."
03:54: (Dispatcher) - "10-4."
03:59: (EMT-I #1) - "EMS 11 Central."
04:04: (Dispatcher) - "Go ahead EMS 11."
04:07: (EMT-I #1) - "EMS 11 is arriving at (Hospital B) General Hospital."
04:11: (Dispatcher) - "10-4."
04:14: (EMT -I #1) - "EMS 11 to Central."
04:19: (Dispatcher) - "Go ahead."
04:22: (EMT-I #1) - "EMS 11 clear (Hospital B) General enroute back to (County #1)County."
04:27: (Dispatcher) - "10-4."
04:31: (EMT-I #1) - "EMS 11 to Central we are clear and available back in (County #1)County."
04:38: (Dispatcher) - "10-4."

Note: The audio recording has been "time-condensed," run time: 4 minutes and 59 seconds. The time stamp on the audio recording does not correlate with the dispatch times on the CFS report. EMS 11 is the ambulance's "radio call-sign" and EMS 5 is the "vehicle/unit number."

Review on 01/27/2016 of Patient Record (PCR) #38483835 for Patient #21 from EMS Agency (EMSA) #1 provided by EMS Director #1, revealed EMS 5 (EMS 11) was dispatched on 12/16/2015 at 0216 to a local residence address for "Breathing Problems." Review revealed "Response Code: Lights and Sirens." Review revealed "Team: ALS (Advanced Life Support)." Review revealed Emergency Medical Technician - Intermediate (EMT-I) #1 was the "Driver" and EMT - Paramedic (EMT-P) #1 was the "Primary Caregiver." Review revealed EMS 5 was en-route at 0218, on-scene at 0223, departed scene at 0232, and arrived at Hospital B at 0309 (37 minutes after leaving the scene). Review of "Chief Complaint" revealed "Dyspnea on Exertion" and a "Secondary Complaint" of "Increased Work of Breathing." Review of History of Present Illness (HPI), revealed "EMS requested for a 54-year old female with difficulty breathing. Upon EMS arrival, found this alert and oriented female sitting in a chair. She is sitting forward in a tripod position. ...Patient states she has been having difficulty breathing for a couple of weeks that has worsened tonight prior to calling EMS. Patient describes becoming extremely short of breath with any exertion. Patient has a history of HTN (high blood pressure). Non-compliant with medications for over a month. Patient has had no access to medical care since the....Health Department stopped seeing adults earlier this year. Patient care transferred to staff at (Hospital B)....*Patient was initially transported to (Hospital A), the hospital had been on diversion earlier but last information from Administration at the hospital at 4PM was that the hospital was taking patients. Upon arrival, staff states they are on diversion. Patient transported to (Hospital B).*" Review revealed a past medical history (PMH) of diabetes and HTN. Review revealed at 0227 the patient's vital signs (VS) were assessed as: blood pressure (BP) 247/124 (high - abnormal), heart rate (HR) 100, respiratory rate (RR) 30 (fast - abnormal), pulse oxygen saturation (SPO2) 100% on room air (RA), pain 0 (pain free), and Glasgow coma score (GCS) 14 (15 best response, 8 or less comatose, 3 unresponsive). The patient was assessed as "Alert and Oriented. Airway Open. BLBS (bilateral breath sounds) clear and equal. Edema(swelling) in all extremities. Pitting in lower extremities. Lab values obtained....GLU (Glucose): 191 (high - abnormal)." At 0232, a saline lock (intravenous access device) was established. At 0235, the patient was placed on a cardiac monitor showing a sinus rhythm (normal heart rhythm), rate 96. At 0247, VS were reassessed as BP 227/114 (high - abnormal), HR 98, RR 28 (fast - abnormal), SPO2 100% on RA, pain zero (0), and GCS 14. At 0254, a cardiac 12-lead EKG (electrocardiogram) was obtained revealing a sinus rhythm with no evidence of STEMI (acute heart attack). Review revealed an "Impression/Diagnosis" of breathing problems and respiratory distress. At 0310, report was given and care transferred over to Hospital B's DED nursing staff. Review revealed "Transportation Factors Affecting Care: Diversion."

Review on 01/26/2016 of Hospital A's DED central log revealed no documentation of a log entry for Patient #21 on 12/16/2015 from 0200-0300 (timeframe patient presented onto hospital property via EMS 11).

Hospital B, closed record review on 01/28/2016 for Patient #21 revealed a 54 year old female presented via ambulance to the DED on 12/16/2015 at 0318. Review revealed "Method of Arrival: EMS - Ground: (EMSA #1 name)." Review revealed the patient was triaged by a Registered Nurse (RN) at 0325. Review revealed "Presenting complaint: Patient states: SOB (shortness of breath) times several weeks, denies cp (chest pain) at this time, pt (patient) is winded and becomes SOB with movement." Review revealed "...General: Appears uncomfortable ...Respiratory: Reports shortness of breath at rest on exertion since several weeks. Onset: ...the patient has moderate shortness of breath." Review revealed a PMH of Diabetes, Hypertension, and Hyperlipidemia (high cholesterol). Review revealed the patient was assigned a triage acuity of "Level 2 (1 most severe, 5 least severe)." Review of nursing assessment documentation by an RN at 0329 revealed "Cardiovascular: Rhythm is sinus rhythm. Respiratory: Airway is patient Respiratory effort is regular, labored, Breath sounds are clear bilaterally..." Review revealed at 0319, VS were BP 215/91, HR 97, RR 16, SPO2 100% on RA, and pain 0/10 (0 pain free, 10 worst pain). At 0417, "General: Appears more comfortable, able to ambulate to bathroom less winded, states 'I feel some better since the medications'..." At 0420, VS were BP 201/77, HR 94, RR 20, SPO2 99% on RA. At 0522, VS were BP 188/78, HR 92, RR 18, SPO2 98% on RA, and pain 0/10. At 0525, "General: Appears comfortable, sitting up at bedside....denies sob, cp..." At 0706, "...Reports shortness of breath improved since arrival." At 0707, VS were BP 186/73, HR 87, RR 19, SPO2 95% on RA, and pain 0/10. At 0732, VS were BP 164/75, HR 88, RR 23, SPO2 96% on RA, and pain 0/10. Review revealed at 0807 the patient was admitted to an in-patient telemetry unit.

Review of Medication Administration Record (MAR) revealed the patient received the following medications as ordered by Physician B:
0348 - Lasix ( Fluid pill/loop diuretic) 40 milligrams (mg) IVP (intravenous push); 0405 - Follow up: Response: Respiratory status improved.
0348 - Lisinopril-Hydrochlorothiazide (medication used to treat high blood pressure-ace inhibitor/thiazide diuretic) 20 mg-25mg, 1 pill orally; 0526 - Follow up: Response: Blood pressure is improved.
0348 - Nitroglycerin Ointment 2% ( medication used to increase blood flow-nitrate vasodilator), 1 inch topically; 0527 - Follow up: Response: Patient denies pain.
0348 - Morphine (pain medication- opioid analgesic) 2 mg IVP; 0526 - Follow up: Response: Patient denies pain.

Review of documentation by Physician B revealed a Medical Screening Examination (MSE) was conducted at 0338. Review of HPI revealed "This 54 yrs old....female presents to ED....complaints of Shortness of Breath. The patient has shortness of breath at rest, with light activity. Onset: The symptoms/episode began/occurred acutely, today. Duration: The symptoms are continuous, and are steadily getting worse. ...Risk Factors for coronary artery disease include: A history of diabetes. A history of high cholesterol. A history of hypertension. The patient's shortness of breath is aggravated by exertion, light activity, supine position, is alleviated by nothing. Severity of symptoms: At their worst the symptoms were moderate in the emergency department the symptoms are unchanged. The patient has not experienced similar symptoms it he past. The patient has not recently seen a physician. Ran out of BP meds and hasn't taken in some time. Denies Chest Pain. Leg swelling." Review of ROS (Review of Systems) revealed "...Cardiovascular: Positive for edema, orthopnea, paroxysmal nocturnal dyspnea, Negative for chest pain. Respiratory: Positive for ...shortness of breath. ...MS (musculoskeletal)/extremity: Positive for swelling, of the right leg and left leg. ..." Review of Physical Exam (PE) revealed "...Respiratory: Respirations: labored breathing, that is mild, accessory muscle usage, that is mild, tachypnea, that is mild, Breath sounds: rales, that are moderate, are located in both bases. Cardiovascular: Rate: normal, Rhythm: regular, Pulses: no pulse deficits are appreciated, Edema: 2+ edema to level of left midcalf, left ankle, right midcalf and right ankle. ..." Review revealed "Differential Diagnosis: CHF (congested heart failure) exacerbation, Myocardial infarction pulmonary edema, Pulmonary Embolism."

Review of physician's orders revealed a Complete Blood Count, Comprehensive Metabolic Panel, Troponin, CPK (creatine phosphokinase), CKMB (creatine kinase muscle brain), BNP (Brain Natriuretic Peptide); D-Dimer, EKG (electrocardiogram) and CXR (chest x-ray) were obtained as ordered by Physician B.

Review of lab results revealed the following abnormal values: 1. Glucose of 192 mg/dl (range 70-99 mg/dl); 2. D-Dimer of 2150 (range 100-400 ng/ml); 3. BNP of 453 (range 0.0-100 pg/dl); and 4. White Blood Cell count of 10.6 (range 4.0-10.0 k/ul).

Review of CXR results revealed "Impression: Cardiac enlargement with vascular congestion."

Review of Disposition revealed "Admit ordered....Preliminary diagnosis are CHF (Congestive Heart Failure), Essential hypertension. ...Symptoms have improved."

Review of an admissions H&P (history & physical) for Patient #21 dated 12/16/2015 by a Physician revealed an admissions and discharge date of 12/16/2016. Review revealed "Chief Complaint Shortness of Breath." Review of HPI revealed "This is a short-stay note the following note is the admission and discharge note. ...Patient presented with several days history of gradually worsening lower extremity edema, shortness of breath, decreased exercise tolerance. Initial workup in the emergency room showed hypertension with blood pressure in the range of 220 systolic. Chest x-ray was consistent with pulmonary vascular congestion. Patient so far has received IV diuretics in [sic] antihypertensives. Her shortness of breath has resolved. She is able to ambulate 30-40 feet without any shortness of breath. No orthopnea... Overnight cardiac enzymes were done which remained negative... Impression: 1. Congestive heart failure exacerbation 2. Hypertensive urgency 3. Diabetes mellitus 4. Hyperlipidemia. ..." The patient was discharged from Hospital B on 12/16/2015.

Interview on 01/27/2016 at 1215 with EMT-P #1 revealed she recalled Patient #21. Interview revealed she was the patient's primary care provider on the ambulance when the patient was transported to Hospital A and then diverted to Hospital B on 12/16/2015. Interview revealed she came on-shift at 0700 on 12/15/2016 and worked a 24 hour shift. Interview revealed her partner was EMT-I #1. Interview revealed the EMS building was located behind the hospital (on hospital property) and across from the ED's public/ambulance entrance. Interview revealed the off-going EMS crew had reported the hospital (Hospital A) was still on diversion. Interview revealed she was in the EMS office sweeping when CEO #1 came into the office and stated to her "Hey, I wanted to let you know, we are no longer on diversion. We are taking patients. We had some problems in the lab. A replacement part is coming and will be in around 1000." Interview revealed CEO #1 stated, "We are not going to stop taking patients", then left the office. Interview revealed around 0800 or 0900 EMS Director #1 came into the EMS office and stated "I hear the hospital is still on diversion." Interview revealed she replied "No, I don't think so CEO #1 said the hospital was off diversion." Interview revealed EMS Director #1 replied "I just came from the ER (emergency room) and the provider said we were still on diversion." Interview revealed later in the afternoon EOC (Emergency Operations Center) staff called and asked if the hospital was still on diversion, she told them per CEO #1, NO. Interview revealed they hung up the phone and around 1700 the EOC staff called back to the EMS office and reported the hospital "was taking patients." Interview revealed she does not know who EOC staff spoke with at the hospital. Interview revealed at that time there had been no 911 calls. Interview revealed the first 911 call was at 0216 (12/16/2015). It was dispatched as a difficulty breathing. Interview revealed the ambulance was enroute from the EMS building at 0218 and arrived on-scene at the patient at 0223. Interview revealed Patient #21 was found sitting in a tripod position and leaning forward. Interview revealed the patient was having increased work of breathing. Interview revealed she assessed the patient as alert, no neurological deficits, having increased work of breathing, and positive pitting edema of the hands and feet. Interview revealed the patient had a past medical history of hypertension, diabetes, and noncompliance. Interview revealed the patient's vital signs were BP 247/124, P 100, R 30, and SAO2 100% on room air. The patient was afebrile at 98.8 degrees F. Interview revealed her impression of the patient was uncontrolled hypertension and increased shortness of breath with dyspnea on exertion. Interview revealed she established a saline lock, obtained a 12 lead EKG, and coached the patient's breathing. Interview revealed she did not apply oxygen or administer any medications. Interview revealed the patient was placed in the ambulance and transported to Hospital A. Interview revealed the ambulance left the scene enroute to Hospital A at 0232. Interview revealed she called the ER to give report via radio and ER staff acknowledged her report. Interview revealed she started giving report when they were on Highway 64 (highway in-front of hospital) and by the time she had completed her report the ambulance was turning into the hospital's driveway. Interview revealed after she gave the patient report the ER staff called back over the radio and requested for them to call the ER by telephone. Interview revealed by the time they had called back to the ER, "We had checked on-scene at the hospital." Interview revealed the patient "lived 2 minutes from the hospital." Interview revealed they arrived at Hospital A around 0234-0235. Interview revealed EMT-I #1 called the ER via telephone. Interview revealed EMT-I #1 reported to her the ER staff stated "the hospital was still on diversion and had never came off diversion and they can't take the patient." Interview revealed "we were told to just go to (Hospital B)." Interview revealed the ambulance had "already pulled up in the parking lot out back of the hospital in-front of the ER's door." Interview revealed the patient was not taken off the truck. Interview revealed they did not exit the ambulance or speak face-to-face with ER staff. Interview revealed the ER staff did not inform her over the radio, the hospital was on diversion after her patient report. Interview revealed "we did not realize they were on diversion again." Interview revealed "the patient was not in such a manner that she could not be transported to (Hospital B)." Interview revealed they left Hospital A and transported the patient to Hospital B. Interview revealed they arrived at Hospital B at 0309. Interview revealed she had "never experienced this situation before." Interview revealed "there was a communications breakdown." Interview revealed she did not recall who she gave radio report to but it was a female. Interview revealed when they returned from Hospital B, the PA (Physician Assistant) [PA #1] from the ER came over to the EMS office and "gave his version of the events." Interview revealed after getting off shift she spoke with CEO #1 about the incident and "he was upset over what had happened and apologized." Interview revealed the 911 call was recorded on tape. Interview revealed "sometime back" the incident was discussed on speaker phone with her EMS Medical Director and the ER Medical Director.

Interview on 01/27/2016 at 1000 with EMT-I #1 revealed she recalled Patient #21. Interview revealed she was the driver of the ambulance when the patient was transported to Hospital A and then diverted to Hospital B on 12/16/2015. Interview revealed her partner was EMT-P #1. Interview revealed she came on-duty at 0700 on 12/15/2015 and worked a 24 hour shift. Interview revealed she was outside and remembered the hospital's CEO #1 going into the EMS office and then leaving shortly thereafter. Interview revealed EMT-P #1 came outside and stated the hospital had come off diversion. Interview revealed when EMS Director #1 came in around 0800 he was under the impression the ER was still on diversion. Interview revealed "our understanding was we could transport patients to the ER because they were off diversion." Interview revealed around 1600, Emergency Management called over to the EMS office and reported the hospital was off diversion as well. Interview revealed a 911 call came in at 0216 (12/16/2015). When they arrived on-scene at the patient, the patient was having respiratory difficulty. Interview revealed the patient was assessed and placed into the ambulance. The ambulance checked enroute to (Hospital A) at 0232. Interview revealed EMT-P #1 called radio report to the hospital while on Highway 64. Interview revealed EMT-P #1 was not given any instructions to divert over the radio. Interview revealed when the ambulance turned into the hospital's drive way, Central Dispatch was advised they had arrived at the hospital. Interview revealed the ambulance had already arrived on hospital property when "we were told to call the ER." Interview revealed "I called the ER and spoke with the PA." Interview revealed she did not recall his name. Interview revealed "He asked me why were we transporting to the ER, they were still on diversion." Interview revealed "he was adamant they were on diversion because lab equipment was down." Interview revealed she made the PA aware the ambulance was in the parking lot located behind the hospital and in front of the ER door and EMS building. Interview revealed the PA stated "I'm sorry there is nothing we can do, we are still on diversion and can't accept the patient." Interview revealed she relayed the information to EMT-P #1. Interview revealed they called Central Dispatch and checked enroute to (Hospital B). Interview revealed they arrived at Hospital B at 0309. Interview revealed later that morning the PA came over to the EMS office an "apologized about the call." Interview revealed she had never experienced a similar incident.

Telephone interview on 01/27/2016 at 1455 with PA #1 revealed he was the provider (QMP - Qualified Medical Personnel) on-duty in Hospital A's DED when Patient #21 presented via EMS ambulance onto the hospital's property with complaints of respiratory difficulty. Interview revealed he came on-shift at 2000 on 12/15/2016. Interview revealed he received report from PA #2. Interview revealed the ED had been on diversion since 1600 on 12/14/2015 and he asked if the ED was still on diversion. Interview revealed PA #2 indicated "Yes." Interview revealed he spoke with the Medical Director (Physician A) who had placed the ED on diversion because the lab was down to 6 metabolic panel cartridges and a limited number of CBC and cardiac profile cartridges. Interview revealed there had been a large number of patients needing metabolic panels. Interview revealed the remainder of the lab cartridges had to be "balanced" between ED walk-ins and in-patients. Interview revealed "it was the Medical Director's (Physician A) decision to go on diversion." Interview revealed the ED nurse, RN #1 was told by the previous RN the ED was still on diversion "due to a lack of supplies for the lab and medications." Interview revealed "Far as I know it, from the 14th at 1600 the ED was on diversion and continued on diversion when I came on at 2000 on the 15th." Interview revealed the ED went off diversion on 12/16/2015 at 0700-0800. Interview revealed CEO #1 had told EMS on 12/15/2015 around 0700 that the ED was no longer on diversion. Interview revealed there was a radio in the ED for staff to listen to EMS radio traffic. Interview revealed EMS was dispatched to a call for chest pain. EMS responded and had arrived on scene. Interview revealed EMS called enroute to (Hospital A). At that point ED staff tried to call EMS three (3) times by radio, but was never acknowledged by them. Interview revealed RN #1 called the Communications Center to get them to contact EMS and have them contact the hospital prior to arriving at the hospital. Communications called EMS and requested they call into the ED. Interview revealed "EMS did not attempt to call until they were backing up at the hospital." Interview revealed EMS called into the ED and initially talked to RN #1. She advised them "the ED was on diversion and not to bring the patient there." Interview revealed "RN #1 handed the phone over to me and I told them we were on diversion and they needed to go to another facility, (Hospital B) was the closest." Interview revealed EMS replied "No you're not." Interview revealed "I said yes we are." Interview revealed he told EMS that he had been informed at 2000 the ED was still on diversion. Interview revealed EMS replied that they had been told the ED had been off diversion since 0700. Interview revealed EMS checked enroute to Hospital B. Interview revealed "I was aware the ambulance was on hospital property." Interview revealed later he received a phone call from the ED provider at Hospital B who asked "Why the patient was sent to (Hospital B)?" and "How can we be put on diversion?" Interview revealed, he told the provider "Dr. (Physician A) put the ED on diversion on 14th at 1600." Interview revealed Hospital B's ED provider stated "(Hospital B) sent 1 box of cartridges to (Hospital A) so you could come off diversion." Interview revealed Hospital B's ED provider stated he would contact their ED Medical Director. Interview revealed the ED does not normally go on diversion. Interview revealed "I am not aware of any policy or procedure for diversion." Interview revealed "later, I walked over to the EMS building and spoke with (EMT-P #1), she said that the CEO had told her the hospital was off diversion at 0700." Interview revealed "the next morning, Mr. (CEO #1) came into the ED and stated 'I don't know why you didn't know that we have been off diversion since 0700. I am the only person who has authority to put the hospital on diversion.'" Interview revealed he had not received EMTALA training through Hospital A nor the contracted DED provider company.

Interview on 01/27/2016 at 1320 with EMS Director #1 during dispatch audio recording review revealed he was the EMS Director for EMSA #1. Interview revealed he had been in the position since July 2015. Interview revealed Central 911 Dispatch's audio recording had been "time-condensed" and the time stamp on the audio recording did not correlate with the dispatch tracking times recorded on the CFS report. Interview revealed EMS 11 is the ambulance's "radio call-sign" and EMS 5 is the "vehicle/unit number." Further interview revealed he was made aware of the incident involving Patient #21 by EMT-P #1 the next morning. Interview revealed CEO #1 came and advised him of an "official" complaint from Hospital B. Interview revealed there was a "communication breakdown." Interview revealed the hospital had no policy or procedure for when the hospital's ED goes on diversion. Interview revealed there was no communication the ED was on diversion and why. The hospital had never been on diversion before to his knowledge. Interview revealed he is not aware of any corrective actions that the hospital has implemented as a result of the incident. Interview revealed there have been conversations to schedule "future" meetings with the EMS Medical Director and Physician A.

Interview on 01/27/2016 at 1645 with Physician A he was the ED Medical Director, Chief of Staff (COS), and Chief Medical Officer (CMO) for Hospital A. Interview revealed he was aware of the incident involving Patient #21. Interview revealed he was told the "next day" about the patient being diverted to Hospital B. Interview revealed "I know EMTALA has a very specific way of dealing with things." Interview revealed he made the decision to go on diversion on 12/14/2015. Interview revealed there was an issue with a shortage of lab supplies. Interview revealed "In my opinion I make the decision." Interview revealed there have been "arguments with the former CEO over the issue." Interview revealed to the best of his knowledge, the hospital did not have a written policy or procedure for diversion.

Review on 01/28/2016 of an "EMTALA Events" time line provided by CNO #1 revealed the following:
01/05/2016 - [CEO #1] (former CEO) informed (CNO #1), CNO of the following:
·He received a call from (Hospital B)'s CEO informing him of a 'possible' EMTALA violation on 12.16.2015. Per (Hospital B) ED physician:
o(County #1) County EMS informed him that they arrived at (Hospital A)'s emergency department and was told to go to (Hospital B) because they had no BMPs (basic metabolic panel cartridges) available;
oNo exam was done for patient by (Hospital A) ED provider;
oNeither (Hospital A) ED provider nor EMS called (Hospital B) to inform the ED of transport to their facility.
·Per EMS (EMT-P #1) and (EMT-I #1), (Hospital A) ED staff told them that the hospital was on diversion, but they informed them that they were told by the hospital administrator earlier at 4pm that the hospital was not on diversion.
(CEO #1) instructed (CNO #1) to conduct interviews of (Hospital A) staff to verify information provided. Interviews were conducted on the following dates:
01/11/2016 - Interviews conducted with the following staff: PA #1, Director #1, and RN #2.
01/12/2016 - Interviews conducted with the following staff: Physician A and RN #1.
01/12/2016 - (CEO #1) and (CNO #1) conducted conference call with (Hospital A) Chief Operations Officer and Corporate attorney to discuss possible EMTALA event. The discussion included the following:
·EMTALA training for all staff including contracted providers by corporate attorney.
·More communication CEO, CMO, CNO, medical providers, hospital managers, EMS and corporate office before making major decisions that significantly impact patient care.
·All providers and staff will be informed that patients arriving to the ED must be seen without exception; and CEO and CNO must be notified immediately whenever a patient is not seen in the ER for any reason.
01/13/2016 - (CEO #1) and (CNO #1) attended meeting at (Hospital B) to discuss possible EMTALA violation investigation res

Based on hospital policy and procedures review, closed medical record reviews, physician and physician assistant and staff interviews, the hospital's Dedicated Emergency Department (DED) physician failed to ensure an appropriate transfer; by failing to complete a written physician's certification for transfer documenting the medical benefits and increased risks associated with the transfer for the specific Emergency Medical Condition (EMC); failing to ensure that if a physician was not physically present in the emergency department at the time of transfer, the Qualified Medical Personnel (QMP) signed the certification after a physician in consultation with the QMP, agreed with the certification and subsequently countersigned the certification within the established time frame according to hospital policies and procedures; and failing to ensure the physician's certification was timed by the transferring physician to closely match the time of transfer for 2 of 2 sampled patients (#13 and #15) that were transferred with an EMC to other acute care hospitals.

The findings include:

Review on 01/27/2016 of hospital policy "EMTALA - Transfer Policy", Policy/Procedure # 6231.904, effective: 01/2014 (in effect prior to 01/21/2016), revealed "...Policy: ...Authority to Transfer: Only the ED physician on duty or the QMP on duty, after consultation with the ED physician on call, are authorized to transfer a patient. ...Procedure: ...6. Certification of Risks and Benefits. The ED physician or QMP in consultation with the ED physician on call must sign an express written certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medial facility outweigh the increased risks to the individual or in the case of a woman in labor, to the unborn child, from being transferred. ..." Review of the policy failed to reveal a requirement that the physician in consultation with the QMP countersign the certification within an established time frame according to hospital policies and procedures. Further review failed to reveal any established time frames for a countersignature to be obtained established in the policy and procedures.

1. Hospital A (transferring facility), closed medical record review on 01/27/2016 for Patient #13 revealed a 77 year old female presented to Hospital A's dedicated emergency department (DED) on 10/22/2015 at 0155 by EMS ambulance for a chief complaint of "Shortness of Air." Review revealed the patient was triaged by a RN upon arrival. Review revealed initial vital signs were blood pressure (BP) 128/67, pulse (P) 95, respirations (R) 20, Oxygen Saturation (SPO2) 95% and Temperature (T) 99.9 degrees F. Review revealed pain was assessed as 8/10 (0 pain free, 10 worst pain). Review revealed a patient history of Hypertension (HTN), Diabetes Mellitus (DM), Congestive Heart Failure (CHF), and Arthritis. Review revealed "for about a week with it constantly short of air with c/o (complains of) feet pain." Review revealed the patient was triaged as "semi-emergent." Review of nursing documentation at 0215 revealed "...c/o shortness of air for the past week c (with) it becoming worse over the last 72 (hours)." Review revealed lab work and x-ray were completed at 0220 that included a complete blood count, comprehensive metabolic panel, cardiac panel, blood cultures x 2, and portable chest x-ray. Review revealed at 0215 the patient was placed on 2 liters of oxygen via nasal cannula. At 0230 the patient was placed on a cardiac monitor, a saline lock was established, EKG was performed and the patient was administered Toradol (non-steroidal anti-inflammatory) 30 mg (milligrams) IVP (intravenous push) for pain. At 0245, Lasix (loop diuretic) 40 mg was administered IVP. At 0300, "all lab results back provider notified of results at this time." At 0315, "Provider begins his examination at this time; with abnormal results provision are being made to transfer to (Hospital C)." At 0430, Lasix 40 mg IVP (repeated) was administered. At 0700, "Received bed assignment, VS 99-65-20-118/50 Pt denies chest pain or shortness of breath at this time." Review revealed at 0735, "Pt transported to (Hospital C) via EMS."

Review of Medical Screening Examination (MSE) documentation at 0300 by Physician Assistant (PA) #2 (QMP - Qualified Medical Personnel), revealed a Chief Complaint of "Shortness of Breath." Review revealed PHYSICAL EXAM - General Appearance: no acute distress, alert. RESPIRATORY - breath sounds: rales/bases. CVS (cardiovascular) - regular rate/rhythm, no JVD (jugular vein distention), murmur. ABDOMEN - non-tender, no distention, no ascites. SKIN - color normal, warm, dry, intact. EXTREMITIES - non-tender, normal ROM (range of motion). EKG: [check mark in box] interp (interpreted) by me "ST inversion -V6 ->likely LVH (left ventricular hypertrophy), no old EKG for comparison." Review of LABS & XRAYS revealed a WBC (white blood count) 13 (range Low 4.8, High 10.8), Hgb (hemoglobin) 9.8 (Low 13, High 16), Hct (hematocrit) 29 (Low 37, High 47), Na (sodium) 130 (Low 136, High 145), Gluc (glucose) 175 (Low 74, High 106), BUN (blood urea nitrogen) 28 (Low 7.0, High 18.0), Creat (creatine) 1.5 (Low 0.6, High 1.3), Troponin 1.03 (Low 0.00, High 0.05), BNP 9402 (Low 0.0, High 450). Review of CXR revealed: "bilateral interstitial alveolar opacities." Review of PROGRESS (not timed) revealed: "pulse ox 88% on RA on list, will call." Review revealed "Discussed with Dr. (Physician C) [accepting physician at Hospital C] Time: (left blank)." Review revealed CLINICAL IMPRESSION: Acute CHF, Unstable Angina. Review revealed Disposition: Transfer: 0450 "when bed available."

Review of an untitled (Physician's Certification) form, number "6231227A (Rev 2/2015)" dated 10/22/2015 for Patient #13 revealed in the "PHYSICIAN" section, "I. PATIENT DIAGNOSIS: Unstable Angina, Acute CHF." Review revealed "[box left blank] The patient is stable so that, within reasonable medical probability, no material deterioration of the patient's condition is likely to result from the transfer. [box left blank] The patient is unstable, but the expected medical benefits of transfer outweigh potential risks associated with the transfer." Review revealed "I certify that I have explained the risks and benefits of transfer to the patient and/or patient's family. On the basis of information available to me at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the patient or, in the case of labor, to the unborn child." Review revealed "Transferring Physician/QMP Signature: (signature of PA #2 handwritten on line) Date/Time: 10/22/15 (handwritten on line) [time left blank]." Review revealed "Physician Countersignature, if applicable: (line left blank) Date/Time: (line left blank)." Review revealed in section "II. REASON FOR TRANSFER: (section left blank). Review revealed in section "III. BENEFITS OF TRANSFER: ...[box not marked] Other specific benefits of transfer: (line left blank). Benefits of transfer explained to: [box not marked] Patient [box not marked] family [box not marked] Other (line left blank)." Review revealed in section "IV. RISKS OF TRANSFER: [check mark in box] Deterioration related to transport (e.g. accident, delay). [check mark in box] Deterioration in condition. [box left blank] Other primary risk of transfer: (line left blank). Risks of transfer explained to: [box left blank] patient [box left blank] family [box left blank] Other (line left blank)." Review revealed in section "VIII. PATIENT CONSENT: [check mark in box] I hereby CONSENT TO TRANSFER after having been informed of the risks and benefits of the transfer. ..." Review revealed the handwritten signature of Patient #13 on the signature of patient/responsible person line.

Reviews of the certification form and record failed to reveal any available documentation that if a physician was not physically present in the emergency department at the time of transfer, the QMP (PA #2) signed the certification after a physician in consultation with the QMP, agreed with the certification and subsequently countersigned the certification within the established time frame according to hospital policies and procedures. Review revealed no countersignature on the certification form 97 days after PA #2 signed the form. Further review failed to reveal the certification contained a summary of the risk and benefits specific to the patient's EMC of Unstable Angina and Acute CHF. Further review revealed the time of the certification did not closely match the time of transfer (0735) for Patient #13. Review revealed the QMP's signature was not timed.

Review on 01/27/2016 of Hospital A's DED Provider schedule for the month of October 2015 revealed PA #2 was the one (1) QMP scheduled to work on 10/21/2015, the day shift (0800 to 2000) and night shift (2000 to 0800) for a 24 hour shift in the DED (Patient #13 was transferred on the night shift). Review revealed no physicians scheduled on-duty in the DED on 10/21/2015.

Telephone interview on 01/27/2016 at 1620 with PA #2 revealed he was an employee of Hospital A's contracted DED provider company. Interview revealed he had been on-staff for 3 years. Interview revealed the last EMTALA training he was provided was in 2013. Interview revealed when transferring patients, he calls Hospital C's transfer center and they agree if the transfer is appropriate. Then a transport service is found to transport the patient. Interview revealed he completes the transfer form (physician's certification). Interview revealed he discusses risks and benefits with the patient and/or guardian and makes sure all questions are answered. Interview revealed he was not required to document the specific risk and benefits of the patient's EMC on the form. Interview revealed "usually it's required to check the boxes" on the form. Interview revealed, "Yes, I will write something there sometimes." Interview revealed he signs the physician's certification form. Interview revealed a physician is not required to countersign the physician's certification form. Interview revealed he does not have to consult with a physician on-staff at Hospital A to transfer patients. Interview revealed "No, I am qualified to make that judgment to transfer in North Carolina." Interview revealed Physician A was his supervising physician and the Medical Director. Interview revealed Physician A "is available to me if I need to call him." Interview revealed he has "never" needed to call Physician A prior to transferring a patient. Interview revealed there was not an on-call physician's list available for staff use in the ED. Interview revealed Hospital C supplies the needed specialty physicians.

Telephone interview on 01/27/2016 at 1455 with PA #1 revealed MSEs are performed by mid-levels (PA, NP), or physicians in the ED. Interview revealed Physician A was his supervising physician. Interview revealed the mid-levels sign the physician's certification for transfer form. Interview revealed "as far as I know, I don't believe it needs a co-signature." Interview revealed "I don't know if the forms are signed at a later point by a physician." Interview revealed most of the transfers go to Hospital C. Interview revealed if he transfers a patient, he contacts the transfer center at Hospital C. The transfer center takes the patient's information and calls back with a physician on the line who accepts the patient for transfer. Interview revealed he speaks with an accepting physician prior to transfer. Interview revealed he does not consult with a physician on-staff at Hospital A prior to transferring a patient. Interview revealed "none" of the transfers are performed in consultation with a physician from Hospital A. They involve talking with the accepting physician. Interview revealed there is "no" on-call physicians list for the hospital's ED. Interview revealed if I need a specialty consult I will call Hospital C to ask for a consult. Interview revealed Hospital A has "limited resources." Interview revealed he had not received EMTALA training through Hospital A nor the contracted DED provider company.

Interview on 01/26/2016 at 1400 with PA #3 during tour of the DED revealed he was the QMP on-duty in the DED. Interview revealed he was an employee and owner of the hospital's contracted DED provider group. Interview revealed Physician A was his supervising physician. Interview revealed the mid-levels on-duty sign the physician's certification for transfer form. Interview revealed the mid-levels can sign the form without consultation of a physician on-duty at Hospital A. Interview revealed the certification did not have to be countersigned by a physician. Interview revealed there is not a specific EMTALA course offered to the mid-levels. Interview revealed there have been discussions related to EMTALA in the past.

Interview on 01/27/2016 at 1645 with Physician A revealed he was a General Practitioner and had been on the medical staff for 39 years. Interview revealed he was the ED Medical Director, Chief of Staff, and Chief Medical Officer for Hospital A. Interview revealed he was the supervising physician for "all" mid-level (PA, NP) providers. Interview revealed he does not countersign the physician's certification for transfer forms. Interview revealed, "No, I don't co-sign, do I have to?" Interview revealed the mid-levels "sometimes call me if they have a question about it and sometimes they just do it (transfer)." Interview revealed "I have no reason not to trust them." Interview revealed the physician's certifications forms signed by PA #2 for Patients #13 and #15 were not countersigned by a physician.

2. Hospital A (transferring facility), closed medical record review on 01/27/2016 for Patient #15 revealed a 19 year old female that presented to Hospital A's DED on 09/05/2015 at 0530 for a chief compliant of "abdominal pain, pregnant." Review revealed the patient was triaged by a RN at 0530. Review revealed "was lying in bed and a pain on the left side started & it continue for 3 hrs (hours) it felt like my mucus plug came out." Review revealed at 0545 initial vital signs were BP 115/76, P 118, R 22, T 98.9 degrees F., SPO2 99%, and pain 6/10 (0 pain free, 10 worse pain). Review revealed the patient was triaged as "Emergent." Review of nursing documentation at 0545 revealed, "fetal heart tones (FHT) per doppler 109." At 0610, "fetal heart tones per doppler 120." At 0725, "Pt is G (gravida) 3, P (para) 1, A (abortions) 1 with and EDC (estimated date of confinement) between 9-26-15 and 10-14-15. C/O pain in RLQ (right lower quadrant) abdomen constant in nature. Pt sees high risk OB clinic because she has PKU (Phenylketonuria). FHT 144. ...reports large amount of mucus discharge a couple of days ago. Resting easy now. States only mild pain along RLQ abdomen now." Review revealed at 0735, "...Transport in to receive pt."

Review of MSE documentation at 0545 by PA #2 (QMP), revealed a Chief Complaint of "Contractions." Review revealed PHYSICAL EXAM - General Appearance: no acute distress, alert... RESP/CVS (Respiratory/Cardiovascular) - no resp (respiratory) distress, breath sounds nml (normal), heart sounds nml. ABDOMEN - soft, non-tender, no organomegaly, no distention, nml bowel sounds, "Gravid." PELVIC EXAM - "OS (cervical opening) closed." SKIN - color nml, no rash, warm, dry, intact. EXTREMITIES - non-tender, nml ROM, no pedal edema. NEURO/PSYCH - oriented x 4 (person, place, time, situation), CN (cranial nerves) nml (2-10) motor nml. Review of PROGRESS revealed "Discussed with Dr. (Physician E) [accepting physician at Hospital C]" Time: (left blank). CLINICAL IMPRESSION: "Active Labor." Disposition Decision Time: 0600 Transfer to Hospital C at 0645.

Review of an untitled (Physician's Certification) form, number "6231227A (Rev 2/2015)" dated 09/05/2015 for Patient #15 revealed in the "PHYSICIAN" section, "I. PATIENT DIAGNOSIS: Labor." Review revealed "[box left blank] The patient is stable so that, within reasonable medical probability, no material deterioration of the patient's condition is likely to result from the transfer. [box left blank] The patient is unstable, but the expected medical benefits of transfer outweigh potential risks associated with the transfer." Review revealed "I certify that I have explained the risks and benefits of transfer to the patient and/or patient's family. On the basis of information available to me at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the patient or, in the case of labor, to the unborn child." Review revealed "Transferring Physician/QMP Signature: (signature of PA #2 handwritten on line) Date/Time: 10/22/15 0600 (handwritten on line)." Review revealed "Physician Countersignature, if applicable: (line left blank) Date/Time: (line left blank). ..."

Reviews of the certification form and record failed to reveal any available documentation that if a physician was not physically present in the emergency department at the time of transfer, the QMP (PA #2) signed the certification after a physician in consultation with the QMP, agreed with the certification and subsequently countersigned the certification within the established time frame according to hospital policies and procedures. Review revealed no countersignature on the certification form 144 days after PA #2 signed the form for Patient #15.

Review on 01/27/2016 of Hospital A's DED Provider schedule for the month of September 2015 revealed PA #2 was the one (1) QMP scheduled to work on 09/04/2015, the day shift (0800 to 2000) and night shift (2000 to 0800) for a 24 hour shift in the DED (Patient #15 was transferred on the night shift). Review revealed no physicians scheduled on-duty in the DED on 09/04/2015.

Telephone interview on 01/27/2016 at 1620 with PA #2 revealed he was an employee of Hospital A's contracted DED provider company. Interview revealed he had been on-staff for 3 years. Interview revealed the last EMTALA training he was provided was in 2013. Interview revealed when transferring patients, he calls Hospital C's transfer center and they agree if the transfer is appropriate. Then a transport service is found to transport the patient. Interview revealed he completes the transfer form (physician's certification). Interview revealed he discusses risks and benefits with the patient and/or guardian and makes sure all questions are answered. Interview revealed he was not required to document the specific risk and benefits of the patient's EMC on the form. Interview revealed "usually it's required to check the boxes" on the form. Interview revealed, "Yes, I will write something there sometimes." Interview revealed he signs the physician's certification form. Interview revealed a physician is not required to countersign the physician's certification form. Interview revealed he does not have to consult with a physician on-staff at Hospital A to transfer patients. Interview revealed "No, I am qualified to make that judgment to transfer in North Carolina." Interview revealed Physician A was his supervising physician and the Medical Director. Interview revealed Physician A "is available to me if I need to call him." Interview revealed he has "never" needed to call Physician A prior to transferring a patient. Interview revealed there was not an on-call physician's list available for staff use in the ED. Interview revealed Hospital C supplies the needed specialty physicians.

Telephone interview on 01/27/2016 at 1455 with PA #1 revealed MSEs are performed by mid-levels (PA, NP), or physicians in the ED. Interview revealed Physician A was his supervising physician. Interview revealed the mid-levels sign the physician's certification for transfer form. Interview revealed "as far as I know, I don't believe it needs a co-signature." Interview revealed "I don't know if the forms are signed at a later point by a physician." Interview revealed most of the transfers go to Hospital C. Interview revealed if he transfers a patient, he contacts the transfer center at Hospital C. The transfer center takes the patient's information and calls back with a physician on the line who accepts the patient for transfer. Interview revealed he speaks with an accepting physician prior to transfer. Interview revealed he does not consult with a physician on-staff at Hospital A prior to transferring a patient. Interview revealed "none" of the transfers are performed in consultation with a physician from Hospital A. They involve talking with the accepting physician. Interview revealed there is "no" on-call physicians list for the hospital's ED. Interview revealed if I need a specialty consult I will call Hospital C to ask for a consult. Interview revealed Hospital A has "limited resources." Interview revealed he had not received EMTALA training through Hospital A nor the contracted DED provider company.

Interview on 01/26/2016 at 1400 with PA #3 during tour of the DED revealed he was the QMP on-duty in the DED. Interview revealed he was an employee and owner of the hospital's contracted DED provider group. Interview revealed Physician A was his supervising physician. Interview revealed the mid-levels on-duty sign the physician's certification for transfer form. Interview revealed the mid-levels can sign the form without consultation of a physician on-duty at Hospital A. Interview revealed the certification did not have to be countersigned by a physician. Interview revealed there is not a specific EMTALA course offered to the mid-levels. Interview revealed there have been discussions related to EMTALA in the past.

Interview on 01/27/2016 at 1645 with Physician A revealed he was the ED Medical Director, Chief of Staff, and Chief Medical Officer for Hospital A. Interview revealed he was the supervising physician for "all" mid-level (PA, NP) providers. Interview revealed he does not countersign the physician's certification for transfer forms. Interview revealed, "No, I don't co-sign, do I have to?" Interview revealed the mid-levels "sometimes call me if they have a question about it and sometimes they just do it (transfer)." Interview revealed "I have no reason not to trust them." Interview revealed the physician's certifications forms signed by PA #2 for Patients #13 and #15 were not countersigned by a physician.

NC00113833