HospitalInspections.org

Based on review of policy an procedures, video recording, ambulance trip report, medical records video surveillance, incident report and investigation, and staff interviews, it was determined that the facility failed to provide a Medical Screening Exam (MSE) to one patient (P) (P#1) of 20 sampled patients, when P#1 arrived to the emergency department (ED) for complaints of severe back pain on 4/29/25 and was denied assistance getting from the personal vehicle to the facility entrance.

Findings:

Cross refer to A2406 as it relates to the facility's failure to ensure that P#1 received a medical screening examination.

Based on review of policy and procedures, video recording, ambulance trip report, medical records video surveillance, incident report and investigation, staff interviews and review of facility policies and procedures, it was determined that the facility failed to provide a Medical Screening Exam (MSE) to one patient (P) (P#1) of 20 sampled patients, when P#1 arrived to the emergency department (ED) for complaints of severe back pain on 4/29/25 and was unable to transfer to a wheelchair. Facility staff refused to assist with a stretcher and instructed the driver of the personal vehicle to go off of hospital property and call 911 if they needed assistance with a stretcher.

Findings:

A review of the facility's "Emergency Medical Treatment and Labor Act - EMTALA" policy, Policy #LD-108, last reviewed 5/6/22 revealed, the policy of Wellstar Health System to comply with the Emergency Medical Treatment & Active Labor Act (EMTALA) 42 CFR § 489.24, 42 CFR § 489.20 and subsequent federal interpretive guidelines and state regulations. If a patient "Comes to the Emergency Department" The Hospital will provide an appropriate medical screening examination within the capability of the Hospital's Dedicated Emergency Department, including ancillary services routinely available, to determine if an "emergency medical condition" exists.

A review of video surveillance recording of ED entrance dated 4/29/25 with a timestamp of 11:37 a.m. revealed the following:
11:38:11 P#1 and female driver arrive in personal vehicle, gray SUV to the ED entrance
11:38:32 Female driver, wearing blue t-shirt and blue shorts, walks into ED entrance and speaks to Ambassador (AMB) DD
11:39:04 AMD DD walks over to the triage desk and speaks with RN II and US CC
11:39:09 Female driver joins AMB DD at triage desk and speak with Registered Nurse (RN) II and Unit Secretary (US) CC
11:39:40 AMB DD walks away from the conversation and returns outside
11:40:10 Female driver returns to her car; RN II and US CC follow behind and AMB DD brings wheelchair to the car
11:40:19 Female driver opens the back door of her car
11:40:29 Security Officer (SO) EE walks out of the ED entrance
11:40:30 Female driver stands at her car doorway speaking with RN II and US CC; AMB DD remains on the scene during the beginning of the conversation
11:40:55 AMB DD walks away; SO EE remains on the scene during the conversation between RN II, US CC and female driver.
11:43:24 SO EE walks away from the scene and back through the ED entrance
11:43:44 SO EE walks back out of the ED and stands at the ED entrance doors as the conversation continues
11:44:37 Female driver closes the back door of her car; RN II removes the wheelchair, and US CC remained standing next to the car
11:44:53 Female driver and P#1 drive away

A review of the Emergency Medical Services (EMS) Trip Report revealed that the ambulance arrived at the scene at 12:07 p.m. on 4/29/25. Continued review revealed that the ambulance arrived at the facility's ED at 12:43 p.m. A review of the Trip Report 'Narrative' revealed that Metro Unit 205 dispatched to business for reports of a male pt CC (chief complaint) non-traumatic back pain immediate response from crew. Upon EMS arrival, P#1 was lying left lateral recumbent in the backseat of a car. 41 Y/O (year old) M (male) with non-traumatic back pain. P#1 states today, he is unable to bear any weight on his left side without unbearable pain. He states the only way he is pain-free is when lying left lateral recumbent, and states he is unable to seat [sic] in a wheelchair. P#1's wife drove him to {the facility}, they were unable to get him out of the car into triage and told them to leave the hospital property and call 911. P#1 ambulatory with assistance on scene, assisted to stretcher and placed left lateral recumbent with side rails up and 5-point harness in place. At destination, P#1 taken to ED room and moved from stretcher to bed via sheet slide.

A review of P#1's medical record 'Visit Information' revealed that P#1 arrived at 4/29/25 at 12:33 p.m. with a chief complaint of nontraumatic back pain, not ambulatory. An "ED Provider Note' at 1:18 p.m. revealed that P#1 review of systems was positive for back pain. The 'Physical Exam' comments revealed that P#1 was uncomfortable appearing, lying on his left side. Unable to lie supine due to pain and unable to comply with physical exam due to pain. A continued review of the medical record 'Physician Receiving Sign out Note' dated 4/29/25 at 7:09 p.m. revealed that a review of the MRI was reassuring; the patient was able to ambulate and will be placed on low back pain care pathway. P#1 and spouse agreed with discharge.

A review of the facility incident report #512687 dated 4/29/25 completed by Emergency Department Director (EDD) AA revealed that the event type was "Treatment Related. Failure to obtain appropriate assistance for ED patient". Continued review revealed that immediate interventions that were put in place to prevent recurrence included staff educated/coached.

A review of Incident Investigation #13875 dated 4/29/25, Summary of Investigation for Compliance Event #13875, revealed that P#1 arrived via EMS and had been picked up at a gas station. Wellstar Kennestone Hospital physician, received from a medic with Marietta Fire regarding the call Marietta Fire received from P#1 and his wife at the gas station. Continued review revealed that Assistant Vice President (AVP) BB spoke with P#1's spouse on the day of the event that concluded with P#1's wife stating that she was advised by facility staff that the policy of the facility was that only cardiac patients were assisted with a stretcher and that if the patient needed a stretcher, the patient could be transported off property and call 911. Continued review revealed AVP BB interviewed facility staff involved.

An interview was conducted with Emergency Department Director (EDD) AA on 5/6/25 at 12:50 p.m. in the Risk Management conference room. EDD AA recalled the situation involving P#1 arriving to the Emergency Department (ED) on 4/29/25 with his wife via their personal car and had been notified by Assistant Vice President (AVP) BB. He continued to explain that he was told that P#1's wife drove the patient to the hospital ED entrance, got out the car and spoke to RN II and US CC. He continued to explain that he was told that P#1's wife asked for assistance getting her husband out of her car and that he was in pain and unable to sit or ambulate. EDD AA continued to explain that he was told that the two nurses and unit secretary went to P#1's car with a wheelchair to assist in getting him out of the car and into the wheelchair. He continued to say that P#1's wife asked for a stretcher because her husband was in pain and could not sit up. He continued to explain that he was told that security officer (SO) EE came outside to intervene and attempt to resolve the issue when P#1 and his wife drove off. EDD AA stated that he was not privy to the conversation between RN II and P#1's wife. He continued to explain that AVP BB had the conversation with RN II regarding the situation. EDD AA confirmed that stretchers can be brought out to the ED drop off for any patient who needs one. He confirmed that stretchers are not only used for cardiac patients. EMTALA training is required to be completed as part of employee annual training.

An interview was conducted with Assistant Vice President of Emergency Services (AVP) BB on 5/6/25 at 1:49 p.m. in the Risk Management conference room. AVP BB recalled that she had been alerted to a situation on 4/29/25 in the afternoon. AVP BB recalled that the information received was that P#1 had presented to the ED entrance and was not rendered assistance. AVP BB reviewed the ED tracking board and noting that P#1 was still in the ED, went to speak with P#1 and spouse. P#1's wife explained what happened and that she felt she had no other choice but to go off-site and call 911 because the ED nurse would not get a stretcher for her husband who could not sit down. AVP BB stated that she did speak with RN II whose account was a little different from the wife's however, she stated that RN II reported that P#1's wife insisted on having a stretcher for her husband. She continued to explain that RN II stated that she advised P#1's wife that she needed to assess her husband first and that P#1's wife just got upset and drove off and that she did not have time to stop her. AVP BB stated that RN II should have got a stretcher from the ED where we keep the stretchers for situations like this, not only for cardiac patients. AVP BB stated that an internal investigation was completed and additional EMTALA training was developed to add to the existing EMTALA training. AVP BB confirmed that stretchers are available in the ED for any patient that requires or requests one for their medical treatment.

An interview was conducted with Unit Secretary (US) CC on 5/6/25 at 1:45 p.m. in the Risk Management conference room. US CC recalled the incident involving P#1 when his wife brought him to the hospital to be seen last week. He continued to explain that he was at the front desk with RN II when AMB DD came in from outside and stated that there was a patient outside who needed a stretcher. He continued to explain that he and RN II went outside with a wheelchair to assist the patient in getting out of the car. He stated that often times he is called upon to help patients get in and out of wheelchairs and brought into the ED or out to their car. He continued to explain that when he and RN II approached P#1's car, his wife was standing with the backdoor open and blocking our access to her husband. US CC stated that P#1's wife stated that her husband needed a bed and could not sit in a wheelchair. He continued to explain that P#1's wife stated that she drove 1.5 (one and half) hours away to come to this hospital and was told over the phone that there will be a stretcher available for him. He continued to explain that P#1's wife and RN II were outside going back and forth for approximately eight or nine minutes and that RN II basically said we are not bringing a stretcher out here. US CC stated that after a few minutes SO EE came outside where we were and asked if he could help, RN II told SO EE that we were trying to help P#1 get out of the car. He continued to explain that he did see P#1 in the back seat, and he appeared to be hurt but he could not see his face because he was lying face down and did not say anything while we were standing at his car. He continued to explain that P#1's wife seem to get frustrated after going back and forth and just left.

An interview was conducted with Ambassador (AMB) DD on 5/6/25 at 2:10 p.m. in the Risk Management conference room. AMB DD stated that she is a contract employee through Cornerstone Parking. She continued to explain that it is her responsibility to assist patients that are arriving to the ED by providing a wheelchair, assisting the patient out of the car, into the lobby and put them in the triage line to be seen. AMB DD recalled the incident involving P#1 and his wife who arrived to the ED in the personal vehicle. She continued to say that P#1's wife asked her for a stretcher for her husband. AMB DD stated that she offered a wheelchair and P#1's wife stated that her husband could not sit in a wheelchair and needed a bed. She continued to explain that she went inside to the front desk and told RN II that the patient outside is requesting a stretcher. AMB DD stated that is when RN II and US CC came outside to assist P#1 and his wife heard RN II tell P#1's wife that stretchers were not provided unless there was a cardiac risk situation, and right now he (P#1) would need to get in the wheelchair. She continued to explain that she heard RN II tell the wife that she could call 911 but, she had to go off campus to do that. She continued to explain that she heard P#1's wife say what do you expect me to do, my husband is in pain and needs to be seen. AMB DD stated she did not hear RN II's response to P#1's wife's question because another car drove up and she walked away after that. AMB DD stated that she did not hear the interaction SO EE had with the patient or with RN II. AMB DD stated that she had not received EMTALA training with her company or with this facility.

An interview was conducted with Security Officer (SO) EE on 5/6/25 at 2:50 p.m. in the Risk Management conference room. SO EE recalled the incident that involved P#1 and had observed RN II and US CC outside the ED entrance having a loud discussion at P#1's car door. He continued to explain that he walked outside to see if there was anything he could do to assist the staff in resolving the issue. SO EE stated that when he approached the P#1's wife, RN II and US CC at the car he could hear P#1's wife continuously asking for a stretcher and she stated that her husband could not sit down in a wheelchair. He continued to explain that he heard RN II trying to explain the P#1's wife that if you let us try and get him out of the car we can get him treated but the wife continued to ask for a stretcher. SO EE stated that he heard RN II say to P#1's wife that the first part of treatment is to get him out of the car, get him to triage and once he is assessed then we'll be able to better understand his next course of treatment. SO EE stated that P#1's wife wanted P#1 to be placed on a stretcher and to go straight to the back and she did not want to wait in the waiting room. He continued to explain that he heard a comment made that stretchers were used for cardiac arrest patients or gunshot victims and wheelchairs were used for patients in regular pain. He stated that he was not sure if it was RN II or US CC who made the statement. He continued to explain that RN II and P#1's wife continued going back and forth for a few minutes and he could see P#1 lying face down in the back seat, but he did not say anything during the interaction. SO EE continued to say that RN II stated to P#1's wife let's just try and get him in the chair and that is when P#1's wife stated that she will drive off and call 911 and they will put him in a bed. He continued to explain that RN II stated to P#1's wife if that's what you want to do, that's fine but we prefer you to put him in the wheelchair. He continued to say that P#1's wife stated that if he gets into the wheelchair how long will he have to sit in the lobby and RN II stated that she could not answer that question because he has not been assessed yet. SO EE recalled that P#1's wife closed the car door and drove off after that. SO EE stated that he is familiar with EMTALA from his employment at this facility and other facilities. He stated that he has completed EMTALA training at this facility.

A telephone interview was conducted with Nurse Manager (NM) FF on 5/7/25 at 10:28 a.m. NM FF stated that she was aware of the possible EMTALA violation concerning P#1. NM FF explained that EMTALA was constantly talked about in meetings and included in other training, as well as annual training and that stretchers were readily available in the ED for any patient who required one or asked for one. She continued to explain that she had brought out a stretcher for patients in the past and they were not restricted to cardiac patients. NM FF stated that the comment Registered Nurse (RN) II made to P#1 and his wife about stretchers only being available for cardiac patients was not true. She continued to say that she was on duty the day of the incident and RN II did not escalate the issue to leadership for resolution in order to provide care to the patient.

An interview was conducted with Registered Nurse (RN) GG on 5/7/25 at 10:52 a.m. in the Risk Management conference room. RN GG recalled P#1 arrived via Emergency Medical Services (EMS) through our ambulance bay last week. She continued to explain that the ambulance crew explained to her that the patient initially arrived via personal car to the front of the ED and requested a stretcher because of his pain. P#1's wife left the facility and went to a gas station across the street and called 911 for an ambulance to come to the hospital. RN GG continued to explain that she never spoke to P#1's wife during this time. She continued to say that she began her assessment of the patient, and his vitals were within normal range; however, he was unable to sit upright. RN GG stated that after the assessment it was determined that he could not go to the waiting room was placed in a EMS room for further treatment.

A telephone interview was conducted with Registered Nurse (RN) II on 5/7/25 at 11:15 a.m. RN II recalled P#1 and his wife when they arrived at the ED last week. She had been sitting at the desk and AMB DD came in and stated that the patient who just pulled up needs a stretcher. She recalled that she and US CC walked outside with a wheelchair to assess what was going on. P#1 was lying face down in the backseat of their car and his wife was standing at the door blocking our access to her husband. She continued to explain that P#1's wife would not give her an opportunity to access her husband to determine why she was asking for a stretcher. RN II recalled that she tried to convince P#1's wife to allow them to try and to get him in the wheelchair and get him in the hospital to be assessed for treatment. She continued to explain that P#1's wife was insistent on a stretcher and would not allow her to assess P#1. RN II recalled that P#1's wife stated that she would call 911 for an ambulance. She continued to explain that she advised P#1's wife that she could not tell her what she can or cannot do; however, an ambulance would not come to the hospital to pick up your husband. RN II recalled that once P#1's made this remark she (RN II) turned to call the charge nurse for assistance. P#1's wife got in the car and drove away. RN II stated that she did not advise P#1's wife to call 911 and she did not tell P#1's wife that stretchers were only used for cardiac patients. She stated that she has been a nurse for over 20 years and would never tell a patient something like that. RN II stated that she understands what EMTALA is and has completed EMTALA training and feels she tried to assist P#1 the best way she could.