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Based on interviews, review of the facility's (Facility #1) Emergency Department (ED) registration log book and policies, and review of a medical record from Facility #2, it was determined the facility failed to provide a medical screening examination to determine whether an emergency medical condition existed for one (1) of twenty-one (21) sampled patients (Patient #1) who presented to the facility.

On 12/28/18, EMS brought Patient #1 to the Emergency Department (ED) via Emergency Medical Services (EMS) with leg pain. Physician #1 told the patient that he/she would have to be transferred for any needed x-rays because the facility's Diagnostic Imaging (x-ray) equipment was not functioning properly. Physician #1 initated an examination of the patient; however, EMS left the facility with Patient #1 and transported the patient to Facility #2 (twenty-seven miles away). There was no documented evidence that the facility conducted a medical screening exam for Patient #1 or attempted to arrange the patient's transfer. Patient #1 was diagnosed with "Pain in both lower extremities and Chronic Obstructive Pulmonary Disease" at Facility #2.

Furthermore, the facility failed to ensure that patients who presented to the ED were documented on the ED's registration logbook. Patient #1's presentation to the ED on 12/28/18 was not logged in the facility's ED logbook.

Refer to 42 CFR 489.24 (a) and (c) Medical Screening Exam (A2406) and 42 CFR 489.20 (r)(3) Emergency Room Log (A2405).

Based on interview and review of the Emergency Department's (ED's) registration log book, it was determined the facility failed to ensure that patients who presented to the ED for treatment were logged into the ED registration log book.

The findings include:

Review of the facility's policy titled, "EMTALA-Central Log," reviewed 10/14/08, revealed the facility must maintain a central log to include information on each patient who came to the dedicated emergency department seeking examination or treatment for a medical condition or who came onto the hospital property requesting evaluation or treatment for what may be an emergency medical condition.

Interview with Registered Nurse (RN) #3 on 01/15/19 at 1:40 PM revealed EMS brought Patient #1 to the facility (Facility #1) on 12/28/18 with lower extremity pain. Physician #1 told the patient that if imaging (x-rays) was required, he would have to transfer Patient #1 to another facility. RN #3 stated Physician #1 began examining Patient #1; however, EMS Personnel #1 stated she would take Patient #1 to another facility and left the facility with Patient #1.

Review of the ED log dated 12/28/18 through 12/29/18 revealed at the time Patient #1 presented to Facility #1, the facility had one (1) patient registered. Continued review of the ED log revealed there was no documented evidence that Patient #1 had presented to the facility and requested treatment for his/her emergency medical condition.

Interview with the ED Manager on 01/14/19 at 1:30 PM revealed that it was her understanding that it was the responsibility of the ED registration clerk to enter and update all patient information in the ED registration log book. The ED Manager stated that since Patient #1 did not register, the patient did not get entered on the ED log book. The ED Manager stated all patients that presented to the facility for evaluation needed to be recorded in the ED registration log book.

Based on interviews, review of the facility's (Facility #1) policies and investigations, and review of a medical record from Facility #2, it was determined the facility failed to provide a medical screening examination to determine whether an emergency medical condition for one (1) of twenty-one (21) sampled patients (Patient #1), who presented to the facility (Facility #1). On 12/28/18, the facility notified EMS that patients who required Diagnostic Imaging Services (x-rays, etc.) were being "diverted" because their equipment was not functioning properly. Interviews revealed Patient #1 presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 12/28/18 with complaints of leg pain for two (2) days. Physician #1 told Patient #1 that the Diagnostic Imaging Services Department was "down," and the patient would have to be transferred if an x-ray was needed. EMS Personnel were reporting on the patient's condition and stated they would transfer the patient and left the facility. EMS transferred Patient #1 to Facility #2 (twenty-seven miles away) where the patient was diagnosed with "Pain in both lower extremities and Chronic Obstructive Pulmonary Disease."

The findings include:

Review of the facility's "EMTALA-Stabilization" policy reviewed 10/14/08, revealed the facility was to provide such medical treatment as was necessary to assure, within reasonable medical probability, that no material deterioration of the patient's condition was likely to result from, or occur during, the transfer of the individual from the facility. Continued review of the policy revealed the facility would deem a patient stabilized if the treating physician attending to the individual in the hospital's dedicated emergency department has determined, within reasonable clinical confidence that the emergency medical condition has resolved.

Review of the facility's policy titled, "EMTALA-Transfer," reviewed 10/14/08, revealed the facility provided medical examination and treatment, including hospitalization, if necessary, as required to stabilize the medical condition within the capabilities of the staff and facilities available at the hospital; or to transfer to another more appropriate or specialized facility after provision of treatment necessary to minimize the risks to the health of the individual or in the case of a pregnant female, to the unborn child. Further review of the policy revealed any legally responsible person acting on the patient's behalf must first be fully informed of the risks of a transfer, the alternatives to transfer, and of the facility's obligations to provide further examination and treatment sufficient to stabilize the patient's Emergency Medical Condition. The policy stated that to provide an appropriate transfer, the following was required: the transferring facility must, within its capability, provide treatment to minimize the risks to the health of the individual or unborn child; the receiving facility must have available space and qualified personnel for the treatment of the individual and must have agreed to accept the transfer and provide appropriate treatment; and the transferring facility must send copies of all available medical records pertaining to the individual's emergency condition to the facility where the patient is being transferred.

Interview with Registered Nurse (RN) #2 on 01/15/18 at 10:00 AM revealed she was working in the ED at Facility #1 on 12/28/18. She stated the facility's x-ray machines were down and she notified EMS that the facility was on "divert" for all radiology services. RN #2 stated she saw EMS bring Patient #1 into the ED, but she was with another patient at the time and only witnessed RN #3 and Physician #1 speaking with the patient and EMS staff.

Interview with RN #3 on 01/15/18 at 1:40 PM revealed she was working at Facility #1 on 12/28/18 when EMS brought Patient #1 into the ED. RN #3 stated that EMS Personnel #1 reported that patient had pain in one of his/her lower extremities for two days. RN #3 stated while EMS was giving report, Physician #1 came to the patient's stretcher and informed EMS Personnel #1 and Patient #1 that all of the Diagnostic Imaging Services (x-rays) at Facility #1 were "down." The physician stated that if imaging was required, he would have to transfer Patient #1 to another facility. RN #3 stated that Physician #1 spoke with Patient #1, looked at the patient's leg, and EMS Personnel #1 reported the patient's vital signs. Continued interview with RN #3 revealed, at that point EMS Personnel #1 stated she had misunderstood the reason the facility was on "divert." She stated she thought the facility's CT machine was down, not x-ray machines. RN #3 stated EMS Personnel #1 then stated she would take Patient #1 to another facility, and left the facility with Patient #1. RN #3 stated EMS did not report where they were transporting Patient #1, and the facility was not aware where the patient was until Physician #1 received a text message from a physician at Facility #2.

Interview with EMS Personnel #1 on 01/15/19 at 12:40 PM revealed on 12/28/18 she transported Patient #1 to Facility #1, then "made the call" to leave Facility #1 and transport the patient to Facility #2. EMS Personnel #1 stated Facility #1 had notified them that they were on "divert" but she understood it was only for CT services, not for all Imaging Services. EMS Personnel #1 stated at no time did Physician #1 refuse to treat Patient #1 or ask them to leave Facility #1. EMS Personnel #1 stated when Physician #1 informed them that because Patient #1 would need an X-Ray, he would have to transfer Patient #1, she told Physician #1 that "this was my (EMS) fault" and she would take the patient to another facility, and left Facility #2 with Patient #1. She stated when they arrived at Facility #2, the facility complained because they had transported Patient #1 to their facility. EMS Personnel #1 stated it was nothing unusual for Facility #2 to complain because they were very difficult to work with.

Interview with Physician #1 on 01/15/18 at 6:45 PM revealed on the morning of 12/28/18, Facility #1 was having problems with the servers in the radiology department and was unable to upload images for the radiologist to read. The physician stated they had notified EMS that they were on divert for Imaging Services. Physician #1 stated when EMS brought Patient #1 into the ED and was giving report to RN #3, he got up to go assist. Continued interview revealed when EMS Personnel #1 informed him of the patient's pain in lower leg. He stated he spoke with the patient, looked at the patient's leg, and obtained report of the patient's vital signs from EMS staff. Physician #1 stated that he felt it was only fair that he inform the patient that he/she would need an x-ray and would need to be transferred. At that point, EMS Personnel #1 stated, "Oh my bad. I thought it was just your CT down. No problem we'll just go ahead and take [Patient #1] to another facility." Physician #1 stated EMS then left the facility with Patient #1 and he "did not know what had just happened." Further interview revealed approximately forty-five (45) minutes later, he received a text message from a physician at Facility #2 that stated he had just violated EMTALA, and she hoped he was fined 50,000 dollars. Physician #1 stated at no time did he refuse to treat the patient or request that they leave Facility #1.

Interview with the Risk Manager on 01/14/18 at 12:00 PM revealed Facility #2 notified them of the incident and they began an investigation. The Risk Manager stated they began re-educating all ED staff regarding the facility's EMTALA policy. She stated education was initiated with RNs on 01/07/19, administration staff on 01/02/19, and the Medical Director had counseled Physician #1. The Risk Manager stated that all employees were trained annually on EMTALA and the Physicians were trained by the medical group that employed them. She stated she contacted the medical group when the incident occurred and they began re-educating all the physicians on EMTALA.

Review of the facility's investigation dated 12/31/18 revealed the "suspected underlying cause" was the facility had no diversion policy on how to initiate a diversion plan, and the physician and nursing staff did not follow the facility's EMTALA policy.

Review of Patient #1's medical record from Facility #2 revealed Patient #1 presented to Facility #2 on 10/17/18 at 6:05 AM via EMS with a complaint of leg pain. According to the record, the patient stated he/she "was not evaluated" at Facility #1 "and that upon arrival the physician in the ER said they didn't have enough equipment so EMS was instructed to take patient to" Facility #2. Patient #1 had a Medical Screening Exam at 11:01 AM at Facility #2 and the facility provided medical treatment that included a Venous Doppler Study of the patient's lower legs (an ultrasound that shows if there are blockages in veins). Facility #2 discharged Patient #1 on 12/28/28 at 4:25 PM with diagnoses of "Pain in both lower extremities and Chronic Obstructive Pulmonary Disease."