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Based on interview and document review, the hospital failed to maintain compliance with 42 CFR 489.24 with respect to the Emergency Medical Treatment and Labor Act (EMTALA) for 1 of 20 patients (P3) reviewed.

Findings include:

Based on interview and document review, the recipient hospital failed to ensure care capabilties and capacities between the emergency department (ED) and hospital-provided speciality services (i.e., neurosurgery) were coordinated and available in a timely manner for 1 of 20 patients (P3) reviewed. This resulted in an avoidable, likely unnecessary delay in care when P3 was accepted via emergent transfer from an out-state hospital, arrived to the recipient hospital where it was then discovered P3 would not receive surgery in a timely manner due to their operating room's (OR) known depleted capacity, and P3 had to be transported again to another hospital via LifeLink (i.e., helicopter) to ensure an active emergency medical condition (EMC) was appropriately addressed. See A-2411 for additional information.

Based on observation, interview, and document review, the hospital failed to ensure sufficient signage pertaining to the Emergency Medical Treatment and Labor Act (EMTALA), and corresponding patient rights was posted in all areas as required (i.e., areas waiting for treatment, receiving treatment). This had potential to affect patients presenting to the emergency department (ED) seeking care and/or services.

Findings include:

On 7/5/23 at 10:37 a.m., a tour of the ED was completed with the ED director (EDD) present. The outside of the lobby and reception area, located on a public street, had an over-hanging awning present with red-colored lettering reading, "EMERGENCY." Inside the doors, a reception area contained a security station with two doors present, each on opposite sides of the room, which lead to the admitting area of the hospital or ED, respectively. The ED main waiting room was located through this entrance which had a reception desk a a set of double doors which were badge-access locked. The main lobby had EMTALA signage posted on the wall opposite the reception desk and by these doors. EDD explained patients were then brought into the triage area which consisted of three rooms each being setup "very similar" to each other. However, there was no EMTALA signage posted in these rooms which EDD verified adding the EMTALA signage was posted "just at the main desk."

From the triage area, patients were then brought back into the main ED which consisted of 38 beds and an additional, smaller waiting room located immediately behind the double doors in the main lobby labeled, "Triage Waiting." EDD explained the smaller waiting room was used by patients who needed a smaller, quieter space (i.e., infants, chemotherapy patients). However, this waiting room did not contain any EMTALA signage which EDD verified. Inside the ED, two stabilization rooms (i.e., STAB), five behavioral health rooms and multiple general examination rooms were observed in use. However, none of these treatment rooms had any EMTALA signage posted. In addition, an area EDD described as "rapid care" was observed. The area was located down the hallway from the main ED and consisted of eight rooms used by patients who did not require cardiac monitoring and were, in general, "less acuity" patients. However, again, no EMTALA signage was present in these patient treatment areas. EDD verified the lack of EMTALA signage and explained, to their knowledge, no information was presented about EMTALA to patients upon check-in (i.e. via reception).

On 7/5/23 at 11:10 a.m., registered nurse (RN)-A was interviewed, and explained they worked as both a charge nurse and floor nurse in the ED. RN-A stated it was "hard to say" what, if any, information patients were given about EMTALA in the ED as "everyone's different," but added the rights' for EMTALA and a medical screening were typically only discussed with patients who wanted to leave against medical advice (AMA) or who left without being seen (LWBS). In addition, RN-A explained a labor and delivery (L&D) patient would be handled differently depending on the time of day they presented. RN-A explained if the patient called ahead, they may bypass the ED and go directly to the L&D triage area on the hospital unit depending on their weeks of gestation. RN-A stated there was a separate "OB triage" area, outside of the ED, where those L&D triage rooms were housed.

On 7/5/23 at 11:37 a.m., the OB triage area was toured with EDD present. The area was located inside the main hospital campus and accessed via elevator from the main hospital lobby. A set of locked double doors was present in the hallway off the elevator which was labeled, "OB Triage," and a reception desk was present on the opposite side of the hallway with a patient access representative seated inside. The reception desk had a white-colored EMTALA sign present on the wall, and the representative explained the waiting room for the OB triage was down the hallway on the opposite side. This waiting room was observed with several persons seated inside. However, there was no EMTALA signage posted in the waiting room. Inside the OB triage area, a total of six rooms were inspected. These rooms also lacked any EMTALA signage posted inside of them, however, there was one EMTALA sign posted in the hallway which connected these rooms.

When interviewed on 7/5/23 at 11:50 a.m., the EDD verified the triage rooms, examination rooms, and two of the three waiting rooms observed lacked any EMTALA signage. EDD reiterated the EMTALA signage was posted just "upon patient arrival" (i.e. reception desk), and they expressed if more needed to be added it could be done. EDD added, "We can fix that."

A provided Emergency Medical Treatment and Labor Act (EMTALA) policy, dated 2/2022, identified a purpose of helping to set guidelines to ensure patients would be given a medical screening examination, stabilized, and transferred in accordance with the law. A section labeled, "J. Appropriate Signage," identified EMTALA signage was to be posted conspicuously in any emergency department or place where persons are likely to enter. A series of guidelines were listed including, "It must be posted in an easily seen area which could include an admitting area, an entryway, a waiting room or treatment area." However, the policy lacked specific locations the hospital had decided to post or display such signage on the campus.

Based on interview and document review, the recipient hospital failed to ensure care capabilities and capacities between the emergency department (ED) and hospital-provided specialty services (i.e., neurosurgery) were coordinated and available in a timely manner for 1 of 20 patients (P3) reviewed. This resulted in an avoidable, likely unnecessary, delay in care when P3 was accepted via emergent transfer from an out-state hospital, arrived to the recipient hospital where it was then discovered P3 would not receive surgery in a timely manner due to their operating room's (OR) known depleted capacity, and P3 had to be transported again to another hospital via LifeLink (i.e., helicopter) to ensure an active emergency medical condition (EMC) was appropriately addressed.

Findings include:

P3's Hospital #1 (H1) ED Provider Note, dated 5/29/23, identified P3 was a 76 year old male with dementia who presented to the ED with right-sided weakness which had been present for several days prior, per family. P3 was unable to give meaningful responses to questions, was afebrile, and was uncooperative with attempts to take his temperature. P3 was given medication to help sedate them, and a CT scan was completed which identified a "large head bleed with shift." The ED provider contacted Hospital #2 (H2) and spoke with ED medical doctor (MD)-C who accepted the patient in transfer. P3 was transferred via ambulance after discussion with P3's family.

P3's H2 ED Visit Information note, dated 5/29/23, identified P3 arrived to the H2 ED at 9:10 p.m. via ambulance with a chief complaint listed, "Known Head Bleed." A corresponding H2 ED Provider Note, dated 5/29/23 and authored by MD-C, identified they had accepted P3 from H1, however, then outlined, "I was informed we are on surgical divert since 1630 [4:30 p.m.] until the patient arrived. Informed [MD-A] who obtained accepting with neurosurgical capabilities at [Hospital #3; H3]."

P3's subsequent H2 ED Provider Note, dated 5/29/23 and authored by MD-A, identified P3 arrived to H2 ED for evaluation of a head bleed. P3 was recorded as having, " ... a large left cerebral convexity subdural hematoma with midline shift and herniation," with P3's baseline being unknown. A physical examination was completed which recorded P3 as slumped over to the right, elderly and demented appearing, and moaning. The note continued, " ... [P3] had declined over the past couple of days ... was excepted [sic] by my colleague [MD-C] earlier in the day and transferred via ground here at [H2] shortly after the start of my shift ... colleague was aware of the patient's arrival and was already talking with neurosurgery [MD-B] ... was told by my colleague that the OR [operating room] is on surgical divert. Neurosurgery was in the middle of the case and could not care for this patient and recommended transfer. I immediately arrange[d] for a helicopter for transfer ... colleagues started to Dick [sic] for more information regarding this OR divert as the ER was unaware. The ER charge nurse, house supervisor, and trauma surgeon were unaware that we are on OR divert per my colleagues ... I anticipated that his [P3] condition is going to decline and we would need to fly him for further definitive neurosurgical management. Patient was subsequently intubated ... started on Cardene for blood pressure control. Propofol for sedation. Fentanyl was given for pain ... was given 3% hypertonic saline for his intracranial bleed." The note concluded with dictation outlining P3's family had been updated, agreed to intubation, and were told the OR was on divert and "neurosurgery is unavailable at this time ... They are given directions to [H3] and started to head that way. I discussed the case with the emergency department there at [H3] who agreed to accept the patient in transfer." P3's H2 corresponding Flowsheets, dated 5/29/23, identified P3's completed diagnostic tests, evaluations, and nursing assessments. This included a Glasgow Coma Scale (GCS) of "9" at 9:14 p.m.

P3's H2 completed Transfer Consent, dated 5/29/23, identified P3 did not request a transfer but rather listed a reason for the transfer as, "Unable to Provide Services." The consent outlined H3 accepted the transfer via helicopter and P3's vital signs prior to departure were recorded as 191/89 (blood pressure) and 16 respirations per minute. The consent concluded with dictation which outlined the patient may be at risk for deterioration from or during transfer due to an intracranial bleed, but the risks of transfer " ... are outweighed by the benefits reasonably anticipated from proper care at the receiving facility." The consent was electronically signed by MD-A on 5/29/23 at 10:10 p.m.

On 7/5/23 at 2:02 p.m., P3's medical record was reviewed with H2 ED registered nurse (RN)-B and H2 ED director (EDD) present. EDD explained P3 presented to the H2 ED via ambulance with a head bleed after the H2 ED physician, MD-C, accepted the patient. When P3 arrived, there was a change of shift so MD-A then assumed the care. P3 had a GCS on arrival of "nine" which meant P3 was considered a "high acuity patient." RN-B and EDD both reviewed the ED medical record, including physician notes, and acknowledged P3 was then transferred to another hospital for care which RN-B described as "weird" given they would typically keep a head bleed patient and perform surgery or care onsite. RN-B and EDD both verified the H2 campus had neurosurgical capabilities on both routine and emergent basis, and RN-B explained a potential reason was the inpatient bed availability or if they were on "divert," however, expressed they were unsure the circumstances for the transfer at the time. EDD explained the weekend, and for this particular case being at night, the staffing for the neurosurgery department typically would just consist of "one neuro team" and surgeon so, as a result, if they were unable to complete surgery timely then the hospital would likely elect to transfer them. EDD added the documentation supported, "We did everything we could beside the surgery."

On 7/6/23 at 8:39 a.m., MD-A was interviewed via telephone. MD-A recalled the case involving P3 on 5/29/23, and explained they had been working the night shift when P3 presented to the H2 ED via ambulance. MD-A stated they were just going to see P3 when another physician voiced neurosurgery was in another case and unable to provide care, so P3 would need to be transferred. MD-A stated P3 presented with paralysis on one side, an altered mental status and "did not appear to be with it" and "was not tracking at all." This caused suspicion the head bleed was worsening and, as a result, they contacted H3 whom accepted the patient. MD-A then intubated P3 and started the process to transport them via air. MD-A stated that "was kind of it from my end" for care provided but verified they felt P3's condition and diagnosis constituted an EMC. MD-A explained there had been situations in the past, which were similar, where a specialty service was unable to address an emergent patient care need timely resulting in transfer. MD-A stated there was only one neurosurgeon scheduled during night hours to their understanding and if, for example, neurosurgery was involved in a case and more patients presented, then the hospital was left with "too many cases at the same time." MD-A verified they had been unaware neurosurgery, or the OR in general, was on diversion until their colleague had voiced such prior to seeing P3 after he arrived to the ED describing the moment as learning "second hand" from them. MD-A stated they intubated P3 for concerns about secretion management and his airway, so it was done in effort to ensure P3 was "stable to fly and maintain his airway." MD-A expressed they were unsure what, if any, contingency plans were in place to address emergent neurosurgery staffing needs but added there had been "conversations" about it to their knowledge. Further, MD-A stated they felt there had been no violation of EMTALA in P3's care as the hospital had capability to perform the needed care but "in the moment" just not the capacity due to the OR diversion.

When interviewed on 7/6/23 at 11:02 a.m., MD-B explained they were the neurosurgeon working on 5/29/23 when P3 presented to the H2 campus' ED. MD-B stated they had reviewed P3's medical record but were "not really" involved in his care adding they had never personally seen or examined the patient while at H2 campus. MD-B explained they were first contacted about P3 when they arrived to the ED on 5/29/23, and MD-B had been doing "back to back cases" for from early in the day to nearly midnight (5/30/23). MD-B verified they had not been contacted about P3 prior to their arrival in the ED adding, "Not that I recall." MD-B explained a head bleed would likely often require surgical intervention and, from their recall, they were already in the OR working on another case when P3 presented. MD-B verified H2 campus' only had one neurosurgeon on-call to address all cases during weekend hours, and any other neurosurgery providers (i.e., physician assistant) would have been in surgery with them. MD-B stated they were unable to recall when, or even if, the OR was ever officially declared to be on diversion adding they were unsure how such information gets communicated to the ED physicians or staff. MD-B stated a head bleed could be an EMC but depended on the "nature of the hemorrhage" adding if a patient' neurological status was clearly worsening then such would "typically be the cases which are an emergency and need surgery." MD-B stated there had been similar situations like this, with patients presenting and unable to get timely neurosurgical services, but felt it was "not often." MD-B stated they were unsure what, if any, actions or discussions had been had since this incident happened to address potential solutions, if any, adding they "haven't been aware of it [them]." Further, MD-B stated it was important to "highlight" there is one neurosurgeon available during weekend, holiday or night hours and if they were "inundated" and unable to provide care, then decisions to balance patient condition and needs (i.e., keep or transfer) were left to the ED physicians adding, "The judgement falls with them."

On 7/6/23 at 11:32 a.m., an interview was held with the vice president of acute care (VPAC) and registered nurse accreditation personnel (RN)-C. VPAC explained they had looked into the situation involving P3 on 5/29/23 and had "a few insights" regarding what potentially happened. MD-B had a "very busy day" on 5/29/23, and had multiple cases "added on" as the day progressed which, at some point, got pushed back in the day and resulted in MD-B being in the OR from approximately 12:00 p.m. until nearly midnight (5/30/23). These cases were all considered more acute and at approximately 4:30 p.m. (on 5/29/23) a decision was made the OR was "at capacity," but not necessarily at the point of diversion yet. VPAC stated it was possible P3 was accepted by H2 for care prior to the decision of capacity and "backlog" of cases presented itself, and went on to explain the OR is tracked in "real time" in the ED using a "status board," and ED physicians were able to visualize scheduled and in-progress surgeries there. VPAC explained when a decision to "divert" is made, there is typically a series of notifications which are sent to operators, nursing supervisors, and specialty surgeries as a result. This was done to help determine whether or not patients could be accepted, however, it did not always preclude them from taking new patients, either. VPAC verified they were not sure exactly when P3 had been accepted from H1 for care as the electronic medical record (EMR) system didn't have a "definitive acceptance button" a person could select and record such information; however, expressed regardless P3 was accepted and ended up at H2 for care. VPAC explained H2 had a policy which outlined if neurosurgery is unavailable or in the OR, then the staff should transfer a patient to a Level I trauma center for care which is likely how the decision to transfer had been made. VPAC explained given H2's Level II trauma center designation, they only had one on-call neurosurgeon scheduled over weekend and night-time hours adding there wasn't a "backup in place" as it was not required to their understanding. VPAC expressed they were unsure what, if any, follow-up or after-action events had been done since the incident involving P3 on 5/29/23, to review and potentially address the situation.

The provided Neurosurgeon Coverage for Trauma Patients policy, dated 8/2022, identified a purpose which read, "To provide continuous coverage of a neurosurgeon 24 hours a day, 7 days a week," along with several lettered policy points. These outlined the rotating call schedule would have the name of the neurosurgeon available, timeframes for their response to the hospital campus, and the neurosurgeon on-call would decide when it was necessary to call for back-up coverage, if needed. The policy included, "In the instance that he/she is in the OR a transfer agreement/bypass to the Level I Trauma Center has been established with Level 1 trauma centers." However, the policy lacked any information or guidance on what, if any, procedures were in place to ensure such information ( i.e., surgeon in the OR; unavailable) was communicated to other hospital areas (i.e., ED).

On 7/6/23 at 12:18 p.m., a subsequent interview was held with EDD, and they explained the process for physician and staff notification of OR diversion would likely be a question best answered by the physicians. EDD expressed the communication between the OR and ED, in general, "isn't great" adding it was "maybe how we got ourselves into this position." EDD explained the typical process for the ED is to accept a patient and then contact the OR after they arrive and have had an evaluation; however, the OR schedule is "ever changing" which can make it difficult. EDD stated if communication "doesn't occur" then the ED physicians likely didn't know or realize the OR was on diversion until P3 arrived, adding they had visited with both MD-A and MD-C about this incident the previous day (on 7/5/23) and both expressed they were unaware or had not been told of the diversion status before P3 arrived. As a result, EDD stated they had just had a conversation with the OR manager on the process for accepting patients and ensuring OR availability adding, currently, there was no "backup plan" in place for weekends or after-hours to help prevent this from happening again. EDD expressed the ED was "kind of caught in the middle sometimes" due to being unable to divert certain patients from their ED (i.e., stroke, heart attack) but then discovering the lack of OR capacity and having to transfer patients right back out. EDD expressed the situation with P3 on 5/29/23 may "have slipped through the cracks" adding while they believed all EMTALA requirements were met, there needed to be discussion and response from the hospital to help prevent a similar situation from happening again.

A telephone call and message was place on 7/6/23 at 12:52 p.m., in attempt to interview P3. However, no return call was received.

On 7/6/23 at 1:19 p.m., MD-C was interviewed via telephone and recalled P3 and the events of 5/29/23, expressing it was a "pretty infuriating case" from their perspective. MD-C explained the H2 ED typically takes transfer calls and accepts all patients from the local, surrounding hospital systems and if a patient, like P3, had a known head bleed then it would be reasonable to assume they'd need neurosurgical services "sooner rather than later." MD-C explained they had taken the transfer call from H1 on 5/29/23 around 7:00 p.m. and, at that time, they were unaware the OR was on diversion as nobody had told the ED physicians of such information. MD-C stated they learned of the OR diversion when visiting with neurosurgery "couple hours later" on an unrelated case who mentioned the OR had been on diversion since 4:30 p.m. MD-C stated, "That was three hours at that point!" MD-C stated they never should have accepted P3 from H1 given the hospital was on a known OR diversion but added, "The ER had no idea [of the diversion]." MD-C verified themselves, the other working ED physicians, nor the charge nurse were aware of the OR diversion until several hours after it had been supposedly implemented (i.e., 4:30 p.m.) which MD-C reiterated was "very frustrating." MD-C explained a similar situation happened again, just a few weeks prior, where an OR diversion was in process and "no one told the ER again," however, this time it involved a trauma case. MD-C stated they never personally examined or saw P3 when they arrived to H2, as MD-A had assumed care, so they were unsure of P3's condition upon presentation to H2. MD-C stated they felt there should be "a protocol" or decision making tool in place to help ED physicians decide if some of these patients should be accepted and if the hospital has available resources to care for them prior adding, "We have no decision tool to help make that [call]." This resulted in physicians, at times, relying on their "gut" when they accept a patient or not. MD-C acknowledged both the ED and OR did not seem to coordinate their care delivery and, as a result, seemingly work independently of each other and this situation could have contributed to a delay in P3 getting needed care (i.e., could have been flown immediately to H3 from H1). MD-C stated after the 5/29/23 incident, themselves and MD-A visited with the ED medical director about the situation who expressed the situation was "frustrating," and voiced they maybe should have called the OR prior to accepting P3 for care. However, there had not been other systemic actions discussed or made to help prevent a similar occurrence. MD-C stated the ED physicians were supposed to have a real-time OR schedule but added "sometimes we do, sometimes we don't" which MD-C explained they are then told "never believe the end times [of surgeries]," which felt like "why even look" at it then. MD-C reiterated their frustration with the incident involving P3 on 5/29/23, and expressed, "Maybe we can't accept everyone."

On 7/5/23 at 12:40 p.m., a telephone call and message was placed to H3. A return call was provided on 7/7/23 at 8:45 a.m., and H3 patient safety coordinator (PSC)-A was interviewed. PSC-A explained P3 arrived via LifeLink to the hospital campus on 5/29/23, and the physician team there was "very concerned" with P3's condition upon arrival. P3 had a significant brain bleed and a GCS of "three" upon arrival and was almost completely unresponsive. P3 had, apparently, been transported to H2 for care but then were told their surgical capabilities were "on divert" so P3 had be transferred again to H3. PSC-A stated P3 remained hospitalized at their campus currently and had likely sustained "permanent harm" from the events on 5/29/23, with P3 now being a DNR (do not resuscitate) due to their condition.

P3's corresponding H3 Emergency Medicine Stabilization Room Note, dated 5/29/23, identified P3 presented to the hospital with a reported subdural hematoma. The note outlined P3 had originally been transferred to H2 for neurosurgery to address the situation, however, " ... but due to their operative diversion status he was sent to [H3]." The note continued, "[P3] reportedly arrived to the initial facility [H1] following commands with noted right sided deficits, but needed sedation for imaging. In [H2] was intubated for airway protection prior to transport here due to declining mental status, unclear if from sedation vs progression of his symptoms ... Despite no sedative drips he has not done anything purposeful for medics since they picked him up." The note concluded with a series of bullet points which outlined steps and/or actions taken by H3 upon arrival including obtaining another CT which verified an acute bleed, obtaining laboratory work, and "Discussed operative plan with SICU [surgical intensive care unit] - at this time okay to wait until morning based on imaging and current exam ... Plan to admit patient to SICU. Report called to admitting team."

A provided Emergency Medical Treatment and Labor Act (EMTALA) policy, dated 2/2022, identified a purpose of helping to set guidelines to ensure patients would be given a medical screening examination, stabilized, and transferred in accordance with the law. The policy included several definitions to help guide compliance with the law including, "Emergency Transfer: The transfer of a patient suffering from an emergency medical condition from which the patient is at risk of deteriorating from or during transport, but where the benefits of transfer outweigh the risks." A section labeled, "Addendum A; St Cloud Hospital Specific," included a procedure for acceptance of transfers. This identified hospital' policy was to accept patients for inter-hospital emergency transfers who are having an EMC and in need of stabilizing treatment with the capabilities and capacity of the hospital. The policy outlined physicians receive requests for transfers from referring physicians and " ... determine their ability to accept the patient for medical care and follow-up," adding, "In the event that medical staff has been notified of hospital capacity issues and prior to patient acceptance by a medical staff member, including an on-call specialist, the accepting physician should immediately verify with the involved unit, admitting department or the administrative nursing supervisor that this facility has capacity to accept the patient. Upon acceptance of the patient, the accepting physician should immediately notify the house supervisor of the patient's acceptance, the condition of the patient, the necessary bed, equipment, and surgical requirements for the patient and the estimated time of arrival." The addendum included, "Physicians at St Cloud Hospital are notified if there is a bed or staffing capacity situation that would need to be considered for incoming admissions of all types," however, lacked specific information on how this process would be accomplished or completed.