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Based on interview and record review the facility failed to maintain a central log on each individual who comes to the emergency department, when a patient presenting to the facility's Pediatric emergency department seeking treatment was not recorded, preventing the tracking of the hospital care provided. (Patient #1)

Findings include:

During a telephone interview on 7/13/17 at 10:00 a.m., the EMS Supervisor stated, "...the ambulance arrived at North Austin Medical Center at 1:45 a.m. and cleared at 2:21 a.m ...."

Review of the facility provided EMTALA Log reflected Patient #1 was logged into the Adult ER on 5/14/17 at 2:08 a.m. The initial arrival time to the Pediatric ER was not documented.

During an interview on the morning of 7/11/17 in the administrative conference room, when asked why there was no record of Patient #1 on the Pediatric ER log, Staff #15, Director of Adult ER stated, "...she wasn't logged into the Pediatric ER; she was logged in when she arrived at Adult ER..."

Review of the Facility provided EMTALA-Definitions and General Requirements Policy (Dated 10/15/2016) "Central Log is a log that a hospital is required to maintain on each individual who comes to the emergency department seeking assistance that documents whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged. The purpose of the Central Log is to track the care provided to each individual where EMTALA is triggered. The Central Log includes, directly or by reference, logs from other areas of the hospital that may be considered DEDs (Dedicated Emergency Department), such as labor and delivery where an individual might present for emergency services or receive an MSE (Medical Screening Exam) instead of the "traditional" emergency department; as well as individuals who seek care for an EMC (Emergency Medical Condition) in other areas located on the hospital property other than a DED...."

Based on interview and record review the facility failed to determine whether or not an emergency medical condition existed when an examining physician(s) or other qualified medical personnel of the hospital did not provide a medical screening examination (MSE) to a patient arriving by ambulance to the facility's Pediatric Emergency Room, the ambulance was sent to the Adult ER across the campus. (Patient #1)

Findings include:

Review of Patient #1's Adult Emergency Physician's note reflected, "...Initial Greet Date/Time 05/14/17 0216 (2:16 a.m.) Presentation Chief Complaint Breathing problem...18 y/o female h/o of ADENYLOSUCCINATE LYASE DEFICIENCY, central hypoventilation syndrome, epilepsy, cerebral palsy, presents with hypoxia. Mother states she [sic] normally on CPAP at night and presents with episodes of hypoxia. Pt required increased duration of ventilation via Bag valve mask per mother this evening. Pt had 3 episodes of desaturation to 60% on pulse ox requiring bagging via BVM. Mother denies any fevers, + rhinnorhea, no productive cough. No vomiting, diarrhea, no wheezing, no hemoptysis....Reports: Seizure disorder, Stroke/TIA.
Additional Medical History hypothyroid, epilepsy - requiring extensive medication, cerebral palsy, SIADH, sleep apnea with hypoventilation, ADENYLOSUCCINATE LYASE DEFICIENCY, FUNGAL VENTRICULITIS, CYCLICAL VOMITING SYNDROME Additional Surgical History Neurosurgical ablation procedure to left sided "scar" on 1/22/16 by team at Texas Children's. VNS. G-TUBE.

Review of the Patient #1's EMS Patient Care Report dated 5/14/17 reflected, "...Called for a female with difficulty breathing and decreased oxygen saturation. AOS TF a female pt lying in bed. 1. Is alert to her normal state per family. They informed crew that for the last several hours pt. has had to have ventilation assist by BVM multiple times to maintain oxygen saturation. Pt saturation would drop to the 60s without ventilation support. Family did tell crew that pt. relies on Non- Invasive Ventilation while she sleeps but can be on room air when awake. As pt became more awake and awake. Saturation improved and pt. was able to maintain saturation of 96-100% on NRM. Crew observed pt. for several minutes to insure that pt. was going to maintain Saturation prior to moving to Unit. Pt. secured to Stretcher and moved to ambulance. While loading pt. into ambulance, she had a brief full body seizure that was stopped by VNS. Pt. did not have a postictal period after and returned to normal baseline rapidly. Pt. placed on 4 lead ekg which showed Sinus Tach. ETC02 WNL, Crew did note that pt CO was slightly elevated at 11-12. CO reading did come down WNL continued oxygen therapy. During transport pt experienced 5 more seizures that were quickly stopped by VNS. Further assessment unremarkable. Transported without incident. Upon arrival at NAMC care to RN with report Bed 6..."

During a telephone interview on 7/13/17 at 10:00 a.m. Staff#16, EMS Supervisor stated, "...the ambulance arrived at North Austin Medical Center on 5/14/17 at 1:45 a.m. and cleared at 2:21 a.m...."

During a telephone interview on 7/13/17 at 12:00 p.m. Staff #17, Emergency Services Crew member that transported Patient #1 to NAMC, stated, "...We encoded directly to the Pediatric Emergency Room... the staff met us at the door and instructed us to go to the Adult ER, we didn't take her off the ambulance ...we stayed at the Pediatric ER bay for a while, the mother was trying to contact her physician; she was trying to get her daughter admitted into the Pediatric ER, she didn't want her in the Adult ER ...the mother was deciding if she should go somewhere else...the patient seized nine times during the transport and had an acute condition...It made sense for her to go to the Pedi ER. " When asked why the EMS report did not include being sent to the Adult ER after presenting to the Pediatric ER, Staff #17 stated, "...we didn't think anything was wrong with it, they didn't refuse care...We were focused on providing care to the patient..."

During an interview on the afternoon of 7/11/17, in the administrative conference room, Staff #2, Chief Medical Officer confirmed the Pediatric Physician did not conduct a medical screen in the ambulance while it was in the Pediatric ER bay.

During an interview on the morning of 7/11/17 in the administrative conference room Staff #1, Chief Nursing Officer stated, "...The patient had turned 18 years old two weeks before....The staff tried to call the ambulance to direct them to the Adult ER, they couldn't contact them...We didn't think to report it...We were not turning them away...."
Review of the facility provided policy EMTALA - Texas Medical Screening Examination and Stabilization (Revision date 07/05/2017) reflected, "... An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED") and:

1. the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition; or

2. a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition.
Internal Distribution Such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition ("EMC"). Further, if a prudent layperson observer would believe that the individual is experiencing an EMC, then an appropriate MSE, within the capabilities of the hospital's DED.... ii. The individual arrives as a transfer from another hospital or health care facility.
Upon arrival of a transfer, a physician or qualified medical person ("QMP") must perform an appropriate MSE. The physician or QMP shall provide any additional screening and treatment required to stabilize the EMC. The MSE of the individual must be documented. This type of screening cannot be performed by the triage nurse. If an EMC is determined to exist and the hospital admits the individual as an inpatient for further treatment, the hospital's obligation under EMTALA ceases.... iii. Transporting to other hospital property: The facility may direct individuals to other hospital-based facilities that are on hospital property and operated under the hospital's provider number. However, the hospital should not move an individual to a hospital-based facility located off-campus, such as a rural health clinic or physician office, for an MSE or other emergency services. Individuals should only be moved to the hospital-based on-campus facility when the following conditions are met:

o all persons with the same medical condition are moved to this location regardless of their ability to pay for treatment,

o there is a bona fide medical reason to move the individual, and

o QMP accompany the individual ... iii. Transporting to other hospital property: The facility may direct individuals to other hospital-based facilities that are on hospital property and operated under the hospital's provider number .... Individuals should only be moved to the hospital-based on-campus facility when the following conditions are met:

o all persons with the same medical condition are moved to this location regardless of their ability to pay for treatment,

o there is a bona fide medical reason to move the individual, and

o QMP accompany the individual... 5. No Delay in Medical Screening or Examination ...

c. EMS. A hospital has an obligation to see the individual once the individual presents to the DED whether by EMS or otherwise. A hospital that delays the MSE or stabilizing treatment of any individual who arrives via transfer from another facility, by not allowing EMS to leave the individual, could be in violation EMTALA and the Hospital CoP for Emergency Services. Even if the hospital cannot immediately complete an appropriate MSE, the hospital must assess the individual's condition upon arrival of the EMS service to ensure that the individual is appropriately prioritized based on his or her presenting signs and symptoms to be seen for completion of the MSE...."