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Based on review of the EMTALA policies, review of emergency department (ED) log sheets, and interviews with hospital and ambulance staff, the ED physician failed to provide a medical screening examination and ED staff failed to enter patient information in the ED logbook, as directed by their policies for 1 of 1 patients presenting to the ED by ambulance for treatment on 10/16/14 (Patient # 6). The patient sample included 25 ED cases and 5 OB cases for review. The ED at the hospital furnished care to an average of 100 patients daily.

The failure of the ED physician to complete a medical screening exam in the ED or in the ambulance for Patient #6 resulted in a delay of treatment. The patient was taken by ambulance to another hospital 75 miles away for a medical screening exam and stabilizing care. At the time the patient left Great River Medical Center (GRMC) for the other hospital, the patient ' s heart rate had increased and the patient complained of nausea. The failure allowed the patient ' s condition to continue to deteriorate.

Findings include:

1. Review of the hospital's "EMTALA" policies and procedures on 10/21/14 revealed the policies were in compliance with the requirements of EMTALA at 42 CFR 489.24.

2. During an interview on 10/21/14 at 12:25 PM, Staff G, Vice President of Nursing verified the nursing home contacted their ED on 10/16/14 at approximately 3:00 AM and said they were sending a patient by ambulance to their hospital for hematuria (blood in the urine). She said paramedic staff called the hospital while in route and Practitioner A, the ED physician, told them to divert. Staff A reported the ambulance pulled into their ED ambulance garage at approximately 3:30 AM and stayed 30 minutes before leaving for the receiving hospital. She verified the patient did not receive a medical screening exam and the patient's information was not entered in the ED log as directed by hospital policy.

3. A review of the ED log dated 10/16/14 revealed approximately 32 patients presented requesting treatment between 7:00 PM on 10/15/14 and 7:00 AM on 10/16/14. The ED log lacked evidence that showed Patient #6 presented to the ED requesting treatment on 10/16/14.

Refer to A 2405 and A2406 for additional information.

Based on document review and staff interview, the hospital's Emergency Department (ED) staff failed to maintain a central log and add the name of 1 of 33 patients (Patient #6) who presented to the ED requesting emergency care between 7:00 PM on 10/15/14 and 7:00 AM of 10/16/14. Patient #6 arrived at the hospital by ambulance at about 3:30 AM on 10/16/14. The surveyor selected 25 ED patients and 5 obstetric patients for the sample.

Failure to enter the the information for Patient #6 into the hospital's central log was not in compliance with the Hospital's EMTALA policy and is a violation of EMTALA

Findings include:

1. Review of the facility's EMTALA Policy, last reviewed 7/14 revealed the following information. The policy required the ED at Great River Medical Center (GRMC) to "maintain a central log containing information of each individual who comes the on the GRMC campus requesting assistance...the emergency department log contains: Patient name...time and nature of the complaint, through the computerized registration process."

2. Review of the ED log showed 32 patients were listed on the log from 7:00 PM on 10/15/14 and 7:00 AM on 10/16/14. Information regarding the presence of Patient #6 in the hospital's ED log was missing.

Patient #6 came to the hospital by ambulance and arrived in the hospital's ambulance garage at 3:30 AM and left in the ambulance to the receiving hospital about 30 minutes later. The patient never left the ambulance and never received a medical screening exam to ascertain whether the patient had an emergency medical condition. The hospital did not have a medical record for Patient #6 on 10/16/14.

3. During an interview with Staff G, the Vice President of Nursing, on 10/21/14 at 12:25 PM, Staff G verified the ED staff failed to follow the hospital's EMTALA policy when they did not register Patient #6 into the central log.

Refer to A2406 for additional information.

Based on a review of interviews with hospital staff, parmedics, and a physician at the receiving hospital, the Emergency Department (ED) staff failed to provide a medical screening examination for 1 (of 1 patients) who presented to the ED by ambulance for emergency care on 10/16/14 (Patient # 6). The patient was sent to another hospital without leaving the ambulance or receiving a medical screening exam. The ED nursing director reported the ED furnished care to an average of 100 patients per day.


Failure to provide a medical screening examination in the ED or in the ambulance to determine if an emergency medical condition existed resulted in a prolonged delay of treatment for Patient #6 who was transported to the receiving hospital, 75 miles away from Great River Medical Center (GRMC).


Findings include:

1. Review of the ED log dated 10/16/14 revealed 32 patients presented to the ED requesting treatment between 7:00 PM on 10/15/14 and 7:00 AM on 10/16/14 and appeared in the central log. The ED log lacked documentation of Patient #6's presentation to the hospital's ambulance garage for for a medical emergency on 10/16/14 at 3:30 AM.

2. Review of a "Patient's Data" sheet for Patient #6, dated 10/21/14, revealed the patient was in GRMC's ED on 4 separate occasions from 5/31/13 to 10/28/13 and received care for an emergency condition and was admitted to the hospital on 8 separate occasions between 6/14/13 to 12/17/13. During an interview on 10/22/14 at 8:00 AM Staff C, Hospital Compliance Officer, verified that the hospital staff was familiar with Patient #6.

3. Review of GRMC "Equipment List" dated 10/14 revealed the following equipment was immediately available for use on 10/16/14. Two specialized chairs for bariatric patients 850 pounds or less were available. There was a bariatric bed available but the staff was unable to locate it on 10/16/14 for Patient #6. It was available for patient care at the time. A document provided on 10/21/14 included an analysis of the bed situation on 10/16/14. It showed there actually was a bariatric bed available for the patient but the environmental services staff were unaware of the process of obtaining a bariatric bed after normal hours.

4. During an interview on 10/22/14 at 8:00 AM, Staff C, the hospital's Compliance Officer, acknowledged ED staff failed to utilize the equipment immediately available for use to provide a medical exam and treatment to Patient #6. Staff C confirmed their hospital had the capability and resources on 10/16/14 to provide emergency services to the patient.

5. The following interviews were consistent with the events related to the arrival and the departure of the ambulance from the hospital ambulance garage and the failure of the hospital staff's failure to comply with the EMTALA requirements as directed by hospital policy.

a. During an interview on 10/21/14 at 12:25 PM, Staff G, Vice President of Nursing said the nursing home, where Patient # 6 resided, contacted their ED on 10/16/14 at approximately 3:00 AM and reported they were sending a patient by ambulance to their hospital for hematuria. She said Paramedic I called their hospital while en route but Practitioner A, (the ED physician on duty) told them to divert. The ambulance was only two minutes away so they continued to the hospital. Staff G said the ambulance pulled into their ED ambulance garage at approximately 3:30 AM and stayed about 30 minutes. Staff G acknowledged Practitioner A failed to complete a medical screening exam.

b. During an interview on 10/22/14 at 7:00 AM, Staff E, The RN House Supervisor on duty on 10/16/14, reported the following information. Practitioner A called her, on 10/16/14 at approximately 3:00 AM, and said he had instructed Paramedic I to divert Patient #6 from their ED because they did not have a bariatric bed. Staff E said she went to the ED and told Practitioner A if they didn't have a bariatric bed, they did have a bariatric chair to use to examine the patient. Practitioner A did not believe that would allow him to properly examine the patient. Staff E told Practitioner A that the patient had to be examined and that this could be and EMTALA violation. Staff E confirmed she learned later that there was a bariatric bed in the hospital available to use for the patient and acknowledged they failed to follow EMTALA policies.

c. During an interview on 10/21/14 at 9:10 AM, Staff A, ED RN, reported the following. She received a call from Paramedic I on 10/16/14 between 3:00 to 4:00 AM. She was informed there was a patient en route to the ED that would need a bariatric bed. Staff A, Staff B (ED RN), and Practitioner A discussed the situation and options to examine the patient. Staff A confirmed Practitioner A did not feel comfortable examining Patient #6 if there wasn't a bariatric bed. He instructed her to contact Paramedics and tell them they were diverting the patient. She contacted Paramedic but they were pulling up to the hospital's ambulance garage then.

d. During an interview on 10/22/14 at 10:00 AM, Staff B, ED RN, reported the following information. She received the initial call from Patient #6's nursing home on 10/16/14 at approximately 3:00 AM. They told her they were sending a patient to their ED, the patient had hematuria and required a bariatric bed. Shortly after that phone call ended, they received a call from Paramedic I saying they were bringing Patient #6 to GRMC by ambulance.

She contacted the environmental services staff to look for a bariatric bed but they were unable to locate one. She told Practitioner A that Patient #6 was coming by ambulance to their ED. Practitioner A instructed her to contact Paramedic I and tell him to divert the patient because they didn't have a bariatric bed. She reminded the physician that there was a bariatric chair available to allow Practitioner A to exam the patient but the physician continued to insist on diverting the patient to another hospital.

e. During an interview on 10/22/14 at 10:45 AM, Practitioner B, the ED Medical Director, acknowledged Practitioner A failed to perform a medical screen for Patient #6 on 10/16/14. Practitioner B said once the ambulance arrived to their ambulance bay, they were obligated, under EMTALA, to complete a medical screening examination.

f. During an interview on 10/22/14 at 11:55 AM, Practitioner A acknowledged he failed to complete a medical screening exam on 10/16/14 for Patient #6. He confirmed the patient arrived at the hospital by ambulance. He did not go out to the ambulance to the examine the patient even after the the request of the paramedic to do so. He admitted instructing them to divert the patient. He acknowledged he failed to consider the other options.

g. During an interview on 10/22/14 at 12:40 PM, Staff F, ED Nursing Director reported becoming aware of the situation that occurred on 10/16/14 around 10:00 AM the next morning. Staff F told Practitioner A that once the ambulance pulled into their ED garage, they were obligated under EMTALA to complete a medical screening exam for Patient #6.

h. During an interview on 10/22/14 at 1:45 PM, Paramedic I reported the following information. They were contacted by a nursing home around 3:00 AM on 10/16/14. A bariatric patient needed to be transported to the GRMC ED with new onset of hematuria. When they arrived at the nursing home, Patient #6 was awake, alert, able to stand to transfer from a bench to the bariatric ambulance cot. The patient appeared anxious, was extremely pale, and the patient's urine was dark red with clots of blood in the catheter tubing. After the patient was in the ambulance, they started to go to GRMC. They had contacted the ED earlier and were advised it was "OK" but then the ED staff called back about 15 minutes later after and advised them to divert the patient because they didn't have a bariatric bed. They were only 2 minutes away from the hospital and he alerted them they would be pulling into the ambulance garage.

i. Paramedic J provided the following information on 10/22/14 at 2:30 PM. He went into the ED and observed GRMC - Staff A, Staff B, and Practitioner A at the nurses station. They told him they had a bariatric chair but did not have a bed and they did not want to assume the liability for providing care to the patient. When requested by the paramedic to contact the receiving hospital, Practitioner A responded that it was not his responsibility to contact another hospital. The paramedic reported he went back into the ED and asked Practitioner A if they could bring the patient into the ED with the ambulance's bariatric cot, they would be willing to leave the cot at the hospital for as long as needed. This would allow Practitioner A to exam the patient. Practitioner A declined this option and said they were going to divert the patient.

The ambulance had been in the hospital's ambulance garage at for about 35 minutes. The paramedic made arrangements for transfer to the receiving hospital. The patient's condition had deteriorated with an increased heart rate and complaints of nausea. When they left GRMC they determined the patient's condition had worsened so the ambulance's lights and sirens were activated for the trip to the receiving hospital. At the time they arrived at the receiving hospital, it had been 3 hours since they picked their patient up at the nursing home and the problems at GRMC caused a huge delay in treatment.


6. Review of Patient #6's ED record from the receiving hospital on 10/16/14 revealed the following information. Upon presentation to ED, the patient feels short of breath with a heart rate 188 and a low blood pressure of 90/70. Cardiac testing revealed atrial fibrillation and the patient was admitted to the Intensive Care Unit. During an interview on 10/23/14 at 11:00 AM, Practitioner C, the ED provider at receiving hospital, said the patient was very ill and had abnormal vital signs upon arrival so this could have been life threatening. Practitioner C concurred the potential outcome of the delay in treatment allowed the patient's condition to worsen and become life-threatening.