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Based on policy review, medical record review, staff and physician interviews, the facility failed to comply with 42 CFR §489.20 and §489.24.

Findings include:

1. Based on review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) log, medical record review, emergency medical services (EMS) report review, facility document reviews, and interviews, the facility failed to provide a medical screening exam to determine whether or not an emergency medical condition existed for one (1) of 22 emergency department patients records reviewed, (Patient #6).

2. Based on facility policy review, medical record review, staff and physician interviews, the hospital's medical providers failed to provide an appropriate transfer by failing to document the certification of the risks and benefits at the time of transfer in 6 of 6 patients who transferred to another medical facility (Patient #19, 11, 23, 15, 17, and 16).

~ Cross refer to A2406 and A2409.

Based on review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) log, medical record review, emergency medical services (EMS) report review, facility document reviews, and interviews, the facility failed to provide a medical screening exam to determine whether or not an emergency medical condition existed for one (1) of 22 emergency department patients records reviewed, (Patient #6).

The findings included:

Review of the hospital's central EMTALA log for 08/23/2022 failed to reveal Patient #6's arrival at Hospital A.

Medical record review for Patient #6 revealed there was no medical record available for review at Hospital A.

Review of the EMS (emergency medical services) run report for Patient #6 revealed an 86-year-old female who was transported to the Dedicated Emergency Department (DED) of Hospital A on 08/23/2022 at 0919 with a chief complaint of Rectal Bleeding. Review of the EMS run report revealed EMS was dispatched to Patient #6's Extended Care Facility on 08/23/2022 at 0848. Review of the EMS report revealed, " ... Scene Information: ... Pt (patient) found laying in bed Alert to her normal. Pt was being cleaned up by staff. Pt had large amounts of stool with dark and bright red blood noted ... 0906 - 96 (Heart Rate), 112/52 (Blood Pressure), 97 (Pulse Oximetry), 16 (Respirations), normal sinus rhythm, 4/5/6 (GCS- Glasgow Coma Scale - describes consciousness, 15 means responsive), 142 (glucose/blood sugar), 2/10 (Pain) ... 0915 - ALS alert sent by (named EMS) via Radio. Possible GI bleed, RM 1 given but does not have GI available. 0919 - EMS arrived on scene. (named Hospital A) ER Doctor came out to the unit and states Pt needs to be transported to another hospital. 0924 - Pt being transported to (named Hospital B). Medic (named) called Captain (named) and informed her of the incident. 0931 - 94 (Heart Rate), 119/57 (Blood Pressure), 97 (Pulse Oximetry), 18 (Respirations), 4/5/6 (GCS- Glasgow Coma Scale) ... 0934 - ALS alert sent by (named EMS) via Radio. Rectal bleeding, possible GI Bleed. 0937 - Arrived (Hospital B) Pt taken to rm (room) 13 with report given ..."

Review of Hospital A's Diversion Log failed to reveal documentation of diversion status on 08/23/2022.

Review of the ED Tracker Board Screenshots for Hospital A on 08/23/2022 revealed there were six patients awaiting transfers to outside facilities, eight patients were roomed and being treated, and four patients were triaged and waiting in the waiting room.

Review of the Adverse Event Log revealed one incident dated 08/23/2022 related to Patient #6 being directed away from the DED ambulance entrance.

Interview on 10/20/2022 at 1400 with the Quality Director #1 revealed the facility was notified via EMS personnel that Patient #6 had been turned away from the ambulance entrance. Interview revealed that the leadership team gathered to take statements from the employees involved. Interview revealed the facility made a self-report on 08/23/2022. Interview revealed they determined the physician involved was new and they were unsure of the EMTALA training received prior to joining the facility. Interview revealed that the facility leadership determined EMTALA education was a contributing factor to this event, so they started reeducation immediately. Interview revealed that they updated the facility policy to include pathways to report potential violations before they occurred. Interview revealed that the facility monitored education completion and the incident reports. Interview revealed that the facility had not had additional events related to failure to provide a MSE to a patient who presented to the facility.

Interview on 10/21/2022 at 1011 with Medical Doctor (MD) #1 revealed he was the sole provider in the DED on the morning of 08/23/2022. Interview revealed that the DED was boarding two patients with GI bleeds and the GI physician was not in house. Interview revealed that when EMS radioed that another GI bleed (Patient #6) was in route, MD #1 was unsure if they had the resources available to manage the patient. Interview revealed that EMS had switched their radio off, so when they arrived onsite MD #1 met them in the ambulance bay. Interview revealed Patient #6 appeared pale, awake, and stable enough to transfer to Hospital B. Interview revealed the ED Medical Director called MD #1 after the EMS truck left to make him aware of the potential violation. Interview revealed that MD #1 had started his role at the facility on 07/28/2022. Interview revealed that MD #1's experiences with transfers was limited due to being at a large facility with multiple specialties available. Interview revealed MD #1 had received reeducation on EMTALA and providing care to any person that presents to the facility. Interview revealed that MD #1 felt the culture had shifted with additional EMTALA training and staff had familiarity with reporting before a potential violation occurred.

Interview on 10/21/2022 at 1050 with ED Nurse Leader #3 revealed she was involved in the reeducation efforts. Interview revealed that within an hour of the event happening, the leadership had gathered, determined what happened, and started education efforts. Interview revealed the EMTALA policy was reviewed, and a paper attestation was signed until they were able to make the training electronic.

Interview on 10/21/2022 at 1110 with EMS #4 revealed she was the paramedic who transported Patient #6 on 08/23/2022. Interview revealed that EMS #4 radioed Hospital A to let them know the truck was enroute with Patient #6. Interview revealed when the truck pulled into the ambulance entrance, EMS #4 received a radio call to contact Hospital A's DED before they went into the building. Interview revealed EMS #4 was notified that there were six patients awaiting transfer in the DED. Interview revealed that EMS #4 proceeded to open the truck and get Patient #6 out of the back of the ambulance when MD #1 was standing in the door. Interview revealed MD #1 asked EMS #4 to take Patient #6 to another facility that had GI available. Interview revealed EMS #4 felt that this was an issue, but did not want to argue in front of the patient. Interview revealed EMS #4 called her supervisor notified them about the situation. Interview revealed Patient #6 was routed to Hospital B's DED. Interview revealed after handoff EMS #4 had received multiple phone calls from Hospital A's leadership to determine what happened. Interview revealed the facility staff had received updated EMTALA training and would speak up if presented with potential violations in the future.

Interview on 10/21/2022 at 1120 with EMS Director #5 revealed he was alerted to the situation within an hour of the event happening. Interview revealed the information escalated up the EMS chain of command and the EMS Director met with Hospital leadership to form a plan of correction. Interview revealed the facility policies and procedures were reviewed and updated. Interview revealed that re-education on EMTALA was performed for all of the staff and providers. Interview revealed that there had not been any additional instances of patients not receiving a medical screening exam upon facility presentation.

In summary, Patient #6 presented by via EMS with complaints rectal bleeding and dark stools. The patient called 911. EMS came to the home and there was a large amount of dark stool with bright red blood noted. An IV was started and the patient was transported to the hospital. The EMS unit called the facility for possible G.I. bleed and the facility said they did not G.I. available. On arrival to the emergency department, the emergency department provider came out to the ambulance unit and stated that the patient to be transported to another facility. EMS crew left the facility and drove to Hospital B. Patient #6 presented to the emergency department at Hospital A with complaints of rectal/GI bleeding. The pt. was not triaged upon arrival. The patient did not have a medical screening exam. The patient was not seen at the emergency department.

Based on facility policy review, medical record review, staff and physician interviews, the hospital's medical providers failed to provide an appropriate transfer by failing to document the certification of the risks and benefits at the time of transfer in 6 of 6 patients who transferred to another medical facility (Patient #19, 11, 23, 15, 17, and 16).

The findings included:

Review of the facility policy, Emergency Medical Treatment and Labor Act (EMTALA), last revised 08/23/2022, revealed, " ... It shall be the policy ... to: - Perform a medical screening exam when an individual (including a minor) comes to, or a request is made on the individual's behalf, for examination or treatment at GHS for a potential emergency medical condition. A medical screening exam shall be performed within the capability of the facility ... - Initiate stabilization treatment if it has been determined that the patient has an emergency medical condition, contact a specialist from the hospital's on-call medical staff roster if appropriate, and/or arrange for transfer of the patient to a facility where appropriate treatment may be obtained ... Procedures for EMTALA transfers: ... Patient or representative must be informed in writing of the risks and benefits of the transfer ..."

1. Closed medical record review of Patient #19 revealed a 29-year-old female who presented to the facility's DED (dedicated emergency department) on 10/13/2022 with complaints of pressure and contractions. Medical record review revealed Patient #19 was 35 and 1/7 weeks pregnant (G2P1 (gravida- number of pregnancies/para-number of births)). Review revealed Patient #19 was routed to the OB (obstetrics) area and triage began at 0927. Review revealed the OB provider transferred Patient #19 to a higher level of care. Medical record review revealed Patient #19 was transferred from the facility at 1328. Review of the Physician Assessment and Certification Transfer form dated 10/13/2022 failed to reveal the documentation of risks, benefits, and time of the certification of transfer.

Interview on 10/20/2022 at 1530 with OB Nurse Manager #6 revealed the staff did concurrent review on the completion of transfer forms. Interview revealed the nursing staff reviewed in the moment to ensure that all the form spaces were filled out. Interview revealed that the facility was not monitoring incomplete transfer paperwork.

Interview on 10/20/2022 at 1713 with OB Provider #7 revealed she was the provider that transferred Patient #19 on 10/13/2022. Interview revealed that OB Provider #7 did not recall Patient #19 but knew she would have discussed risks and benefits before transfer, even though it was not documented on the transfer form. Interview revealed the benefits in this instance were delivery at a facility that offered care for premature infants and the risks were delivery in route. Interview revealed that OB Provider #7 had received training on EMTALA within the last year but was unsure if the training covered the completion of transfer paperwork. Interview revealed the completion of paperwork was a shared responsibility between the nursing staff and providers. Interview revealed OB Provider #7 completed the certification form once she had evaluated a patient and deemed them stable for transfer. Interview revealed if the patient condition changes while awaiting transfer, then nurse would notify the provider to reevaluate the patient. Interview revealed the time between certification and the patient's departure from the facility varied from minutes to hours.



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2. Closed DED record review of Patient #11 revealed a 63 year-old female that presented to the hospital's DED on 10/09/2022 at 0858 via EMS (emergency transport) with a chief complaint of "seizure per EMS." Review of the record revealed a medical screening examination was started by MD #8 at 0906 that recorded the patient had a history of diabetes, hypertension, drug abuse, with no known history of seizure. Review revealed a disposition plan to transfer Patient #11 to Hospital C with a clinical impression of "Status epilepticus" and "Hyperglycemia (elevated blood sugar)." Review of the "Physician Assessment and Certification" form signed by MD #8 on 10/09/2022 with no time documented, revealed the "Benefits" of transfer were listed as, "Higher level of care." There were no risks of transfer documented. Further review of the DED record revealed no documentation of the risks of transfer. Review of the record revealed the patient was transported via air transport to Hospital C and departed on 10/09/2022 at 1657.

Interview on 10/21/2022 at 1050 with MD #8 revealed he was the EDP that treated Patient #11 on 10/09/2022. The EDP stated he remembered the patient and stated she had required multiple rounds of medication to stop her seizures and she required intubation. The physician stated the patient was having status epilepticus and needed EEG capability (monitoring of brain activity) which was not available at Hospital A and was available at Hospital C. When asked about the risks of transfer, the EDP stated the patient could have more seizure activity, aspiration, pull her NGT (Nasogastric tube) out, or die. The EDP was unable to locate documentation of the risks of transfer in the patient's DED medical record. The EDP reported there was no time documented for the certification of the patient's condition on the signed form.

3. Closed DED record review of Patient #23 revealed a 66 year-old male that presented to the hospital's DED on 08/22/2022 at 1546 via EMS (emergency transport) with a chief complaint of "generalized weakness, unsteady gait." Review of the EDP notes at 2115 recorded, "...due to multiple factors including GI not available at this facility today, SBO (small bowel obstruction) with previous anastomosis (surgical connection between parts), septic shock on pressors (medication to raise the blood pressure), she (Hospitalist) feels that this patient is not appropriate to stay at this facility due to his critical condition. Will discuss with (name of transferring hospital). Review of the EDP clinical impression recorded a primary impression of "septic shock" and a secondary impression of "anemia, atrial fibrillation, pneumonia, small bowel obstruction" with a plan to transfer Patient #23 to Hospital D. Review of the "Physician Assessment and Certification" form signed by MD #8 on 08/23/2022 with no time documented, revealed the "Benefits" of transfer were listed as, "Services that are not available at this hospital." There were no risks of transfer documented. Further review of the DED record revealed no documentation of the risks of transfer. Review of the record revealed the patient was transported via air transport to Hospital D and departed on 08/24/2022 at 0306.

Interview on 10/21/2022 at 1050 with MD #8 revealed he was the EDP that treated Patient #23 on 08/23/2022. The EDP stated he did not remember the patient and had reviewed the DED record. The physician stated there was no GI services available at Hospital A and GI services were available to Hospital D. When asked about the risks of transfer, MD #8 stated the patient was a potential GI bleed and the risks of transfer included, "tenuous blood pressure, decompensation, alcohol withdrawal, major bleeding event, possible bowel obstruction." The EDP was unable to locate documentation of the risks of transfer in the patient's DED medical record. The EDP reported there was no time documented for the certification of the patient's condition on the signed form.

4. Closed DED record review of Patient #15 revealed a 53 year-old male that presented to the hospital's DED on 07/05/2022 at 2330 with a chief complaint of "abdominal pain." Review revealed a disposition plan to transfer the patient to Hospital E. Review of the "Physician Assessment and Certification" form signed by MD #9 on 07/06/2022 with no time documented, revealed the "Benefits" of transfer were listed as, "Surgical Services." There were no risks of transfer documented. Further review of the DED record revealed no documentation of the risks of transfer. Review of the record revealed the patient was transported via ground transport to Hospital E and departed on 07/06/2022 at 0416.

Telephone interview on 10/20/2022 at 1640 with MD #9 revealed he was the EDP that treated Patient #15 on 07/06/2022. The EDP stated he remembered the patient and stated he had bladder cancer and a molder, and he had a small bowel obstruction. MD #9 reported that he talked with the patient's surgeon at Hospital E who accepted the patient for transfer to Hospital E. When asked about the risks of transfer, the EDP stated the patient could have
an ischemic bowel, ultimately leading to death. The EDP stated, "We talked about it. I don't have it documented. He has been in a couple of times with surgical problems." The EDP was unable to locate documentation of the risks of transfer in the patient's DED medical record. The EDP reported there was no time documented for the certification of the patient's condition on the signed form.

5. Closed DED record review of Patient #17 revealed an 84 year-old male that presented to the hospital's DED on 09/25/2022 at 1258 via EMS (emergency transport) with a chief complaint of "coughing up blood and blood in stool x 3 months per Home Health Aide." Review revealed a plan to transfer the patient to a tertiary care facility for IVC filter placement. Review revealed the anticoagulant medication was continued and the patient was monitored for bleeding, with a plan to transfuse blood as needed. Review revealed the patient was accepted for transfer to Hospital F on 09/26/2022 at 0424. Review of the "Physician Assessment and Certification" form signed by MD #10 on 09/26/2022 with no time documented, revealed the "Benefits" of transfer were listed as, "Advance Care." There were no risks of transfer documented. Further review of the DED record revealed no documentation of the risks of transfer. Review of the record revealed the patient was transported via ground transport to Hospital F and departed on 09/26/2022 at 0908.

Telephone interview on 10/20/2022 at 2000 with MD #10 revealed he was the EDP that treated Patient #17 on 09/26/2022. The EDP stated he was unable to remember the patient and had reviewed the patient's DED record. MD #10 reported the patient had an upper and lower GI bleed and a DVT in his lower extremity. Interview revealed the patient needed an IVC filter and the procedure could not be done at Hospital A (transferring hospital). MD #10 reported the benefit of transfer was access to interventional radiology. When asked about the risks of transfer, the EDP stated the patient could have worsening DVT leading to a pulmonary embolus in the chest. The EDP was unable to locate documentation of the risks of transfer in the patient's DED medical record. The EDP reported there was no time documented for the certification of the patient's condition on the signed form. MD #10 stated he went off duty at 0700 and the certification of the patient's condition would have been documented before he left at 0700. Interview revealed the patient departed at 0908 (2 hours and 8 minutes after MD #10 departed the DED).

6. Closed DED record review of Patient #16 revealed a 61 year-old male that presented to the hospital's DED on 08/07/2022 at 0939 via EMS (emergency transport) with a chief complaint of "rectal pain." Review of an EDP note timed at 1825 recorded that the Hospitalist service had evaluated the patient at the bedside and spoken with the patient's wife. The note stated "Wife is requesting that we transfer the patient to (Hospital C) because she wants further investigation performed as to why her husband is having such severe pain out of proportion to CT findings." Review of the EDP's notes at 1845 recorded that patient was accepted for transfer to Hospital C. Review of the EDP note at 1900 revealed Patient #16 was signed out to the oncoming DED physician, MD #2. Review of the DED record revealed no DED notes documented by MD #2. Review of the "Physician Assessment and Certification" form signed by MD #2 on 08/08/2022 with no time documented, revealed the "Benefits" of transfer were listed as, "oncology services." There were no risks of transfer documented. Further review of the DED record revealed no documentation of the risks of transfer. Review of the form revealed a section to document "Patient Request for Transfer" which was marked out with a line struck through that section. Review of the record revealed the patient was transported via ground transport to Hospital C and departed on 08/08/2022 at 0228.

Interview on 10/21/2022 at 1000 with MD #2 revealed he was the EDP that treated Patient #16 on 08/08/2022. The EDP stated he "vaguely remembered" the patient and stated the reason for transfer was "bowel obstruction."
MD #2 reported that he "did not have much meaningful clinical interaction" with Patient #16. He stated the EDP wanted the patient transferred to Hospital C due to no oncology services were available at Hospital A (transferring hospital). MD #2 stated he didn't remember anything mentioned about the patient or his wife requesting transfer. MD #2 reported the patient was stable in the DED and he provided pain management and did a "peripheral check on the patient." MD #2 stated, "I didn't document" any notes on the patient. When asked about the risks of transfer, the EDP stated the patient could decompensate in route, have a bowel perforation or ischemia. The EDP was unable to locate documentation of the risks of transfer in the patient's DED medical record. The EDP reported there was no time documented for the certification of the patient's condition on the signed form.