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Based on Hospital #1's Emergency Department (ED) record review, ED physician interview, staff interview, ED staff written report review, ED staff interview, ED log review, document review, policy and procedure review, EMS transcript review, Hospital #2's ED report review, and air EMS transcript review, the facility failed to, within the hospital's capabilities (staff and facilities) comply with 489.20 by failing to provide a Medical Screening Exam (MSE), failing to provide Stabilizing Treatment for an emergency medical condition, and failing to ensure an Appropriate Transfer within its capacity that minimized the health risks of this 14 year old overdose Patient (A).

Findings Include:

A complaint was received at the Regional Office and sent to the State Office for investigation which stated:
"Rescue 5 was requested to rendezvous with ... County EMS in a designated landing zone to intercept a 14 year old female patient for suspected TCA overdose. EMS responded to the patient's home and the patient was extremely combative and confused. IV access was established and the patient was medicated with Versed 4 mg IV and Ativan 2 mg IV. Upon arrival by the flight team, the patient was still extremely combative, confused and tachycardic. Medical decision was made to perform RSI for patient and crew safety. Successful RSI procedure performed and the patient was loaded onto transport equipment and transported to the aircraft. Due to the location of the scene and a strong North headwind which would cause delay, decision was made to transport the patient to (Hospital #1), which was only a 10 minute flight. Blood glucose level checked with result of 95. Dispatch was notified and relayed report to (Hospital #1). Upon landing, the flight team was met at the aircraft by (ED Physician #1 and #2) and informed they were not accepting the patient due to no PICU services available. Crew explained to the physicians that the patient was stable and they were the closest appropriate facility. The physicians again insisted that they were not accepting the patient and at that point the decision was made to transport the patient to (Hospital #2). The patient's vital signs remained stable during flight. However, she continued to require medication for sedation. Status report was called to (Hospital 2) approximately 10 minutes out and landing at that facility was without incident. The patient was transferred onto the ER stretcher and transported into the ER where medical staff were waiting. Report was given and care was transferred at that time with all lines and tubing intact and patent." This is an air ambulance nurse's note and was signed by a Registered Nurse.

Hospital #1 was entered unannounced on 5/1/2018 at 1:40 p.m. The surveyor was shown to a conference room in the Administration offices. At 2:00 p.m. an interview was held with the hospital's COO/Clinical - CNO and the Registered Nurse (RN) Director of Patient Safety and Risk Management. The purpose of the visit was explained and they were given a list of items needed for the survey. We discussed the EMTALA complaint. They both stated they understood why it would be an EMTALA if substantiated. At 2:23 p.m. the Director of Women's and Children's submitted her ED logs.

On 5/1/18 at 2:45 p.m. a tour was done of the hospital's ED with the Director of Patient Safety and Risk Management. EMTALA signage was noted in the waiting area, triage area and all treatment rooms. The RN Manager of the ED and the RN Director of Emergency Trauma Services were met with. The Manager of the ED stated that their ED had 49 treatment rooms. 10 of these rooms are behavioral beds and 39 are acute beds.


The 4/10/18 the ground EMS service report concerning the 14 year old patient (Patient A) was reviewed. EMS picked the patient up at her home. She was confused with altered mental status. Her diagnosis was a self-inflicted possible overdose of Elavil and other unknown substance. She had a known psychiatric history. She was transported to a designated church parking lot and transferred to a helicopter air ambulance.

The air ambulance transported the patient to Hospital #1's helipad to be admitted to their ED.

Review of Hospital #1's 4/10/18 ED log revealed no evidence that this 14 year old overdose patient (Patient A) was brought to their helipad. There is no documented evidence she was registered and/or seen in the hospital's ED, received a Medical Screening Exam, received any stabilizing treatment, or received an appropriate transfer to Hospital #2. There was no documented record by anyone at Hospital #1 of her ever coming to Hospital #1.

On 5/2/18 at 9:25 a.m. an interview with the Director of Patient Safety and Risk Management revealed that one of the physicians that went out to the helipad on 4/10/18, ED Physician #2 was out of the country working, so was unavailable for interview.

During an interview with RN Manager of the ED on 5/2/18 from 9:27 a.m. to 9:43 a.m. Medical Screening Exams, stabilizing treatment, appropriate transfers, and patient dumping were discussed. She stated that she was not on duty on 4/10/18, that they had received EMTALA training/in-service in October of 2017. She also agree that she would write a statement of what she was told happened and what she knows regarding the incident.

On 5/2/18 at 9:55 a.m. an interview was held with ED Physician #1. The physician stated that he was one of the two ED physicians who met the life flight (on 4/10/18) on the heli pad. He stated he had received a call from life flight describing an agitation, fighting, intubated, sedated patient. "I called dispatch to inform them we have no Peds ICU (Pediatric Intensive Care Unit). During discussion with them and (Physician #2) the heli (helicopter) landed although we had not accepted the patient. We assessed and did a MSE (Medical Screening Exam) for the patient in the helicopter. The vital signs were normal. We failed to document any of this. I spoke with the (Hospital #2) MD (Pediatrician) and they accepted the patient. None of this was documented. We thought delay of care was not warranted, but on hind sight I wish we had documented. I'm not sure why, but the heli passed up (another area hospital) with the same capabilities." ED Physician #1 stated that his last EMTALA training was in October of 2017. He also confirmed that ED Physician #2 was the second physician that went out to the heli pad on 4/10/18 and she was now working out of the country.

On 5/2/18 at 11:37 a.m. the RN Manager of the ED presented a handwritten statement which stated, "On the morning of 4-12-18 at 0545 am, I was informed by (ED lead RN/Flow RN) that on the previous night (sometime around 2230) Rescue 5 (air ambulance) was in bound with an intubated 14 y/o overdose (Elavil and alcohol). Later that morning around 0830 am, I called and spoke with (Operations Manager of Rescue).
(ED lead RN/Flow RN) relayed to me that a report was called from the EMS dispatch. The ED staff attempted to call the helicopter in bound but it did not complete communication before landing. It was a 7 minute transport to (Hospital #1) from the lower Stone County/upper Harrison County area (picked up from a residence).
(ED lead RN/Flow RN) stated that upon helicopter arrival, (ED Physician #2 and #1) went to the helipad, assessed the patient and instructed the flight paramedic that they should travel on to (Hospital #2).
(Operations Manager of Rescue) relayed to me that the flight paramedic called (Operations Manager of Rescue) at the time of the physician assessment. (Operations Manager of Rescue) relayed to me that he advised the Rescue 5 staff to go on to (Hospital #2). (Operations Manager of Rescue) stated this was based on the physician assessment and direction. He stated that they would later review the case.
(ED lead RN/Flow RN) informed me that (ED Physician #1) came inside post assessing the patient and called (Hospital #2) to give them a heads up to inform them that the patient was enroute. (ED lead RN/Flow RN) advised me that (ED Physician #2) stated that she gave report and talked to a Pediatric Intensivist at (Hospital #2).
(Operations Manager of Rescue) said to me "The flight paramedic told him that they elected to go to our ED because it was 7 minutes versus 30 minutes with an unstable 14 year old."
(ER lead RN/Flow RN) stated that the ER physicians (ED Physician #2 and #1) stated that the vital signs were stable when the helicopter landed. (ED lead RN/Flow RN) informed me that (ED Physician #2 and #1) assessed the patient including listening to breath sounds, looking at EKG/current cardiac monitor."

During an interview on 5/3/18 at 9:25 a.m. the hospital Administrator discussed the hospital's ED physicians refusing to take the patient and sending the life flight helicopter with the 14 year old overdose patient onto (Hospital #2) on 4/10/18. "I think they did what was best for the child. The fact that one of the physician's was talking to dispatch when the helicopter landed, meant our physicians did not have time to turn them around in the air. We don't take vented children." He agreed that they probably should have documented something.


On 5/4/2018 an Exit Interview was held with hospital's COO/Clinical - CNO and the RN Director of Patient Safety and Risk Management. No further information was submitted for review.


Review of the 4/10/18 Air Transport Medical Record for Patient A revealed Rescue 5 air ambulance met a ground ambulance to receive the patient on 4/10/18 at 21:46 (9:46 p.m.). The patient was loaded onto an aircraft stretcher and placed in 5 point harness. The chief complaint was documented as TCA overdose/Altered Mental Status. At 21:55 (9:55 p.m.), prior to take off, the medical decision was made to orally intubate the patient for her safety and the fight crew safety.
History of Present Illness/Injury:
Rescue 5 was requested to rendezvous with .... County EMS in a designated landing zone to intercept a 14 year old female patient for suspected TCA overdose. EMS responded to the patient's home and the patient was extremely combative and confused. IV access was established and the patient was medicated with Versed 4 mg (milligram) IV (intravenous) and Ativan 2 mg IV. Upon arrival by the flight team, the patient was still extremely combative, confused and tachycardic. Medical decision was made to perform RSI (oral intubation) for patient and crew safety. Successful RSI procedure performed and the patient was loaded onto transport equipment and transported to the aircraft. Due to the location of the scene and a strong North headwind which would cause delay, decision was made to transport the patient to (Hospital #1), which was only a 10 minute flight. Blood glucose level checked with result of 95. Dispatch was notified and relayed report to (Hospital #1). Upon landing, the flight team was met at the aircraft by (Hospital #1's ED Physician #1 and #2) and informed they were not accepting the patient due to no PICU services available. Crew explained to the physicians that the patient was stable and they were the closest appropriate facility. The physicians again insisted that they were not accepting the patient and at that point the decision was made to transport the patient to (Hospital #2). The patient's vital signs remained stable during flight. However, she continued to require medication for sedation. Status report was called to (Hospital #2) approximately 10 minutes out and landing at that facility was without incident. The patient was transferred onto the ER stretcher and transported into the ER where medical staff were waiting. Report was given and care was transferred at that time with all lines and tubing intact and patent." This report was signed by the RN flight crew member.

Review of Hospital #2's 4/10/18 ED report for Patient A revealed she was received via air ambulance to their ED, stabilized and moved to their PICU:
"Admission Information:
14 yo brought in via EMS for intentional ingestion resulting in intubation. Per EMS the police were called to the scene when she was fighting with boyfriend around 2 hours prior to arrival. She was cleared at that time. Later EMS and police responded to a call that she had taken an unknown amount of Elavil and was being combative. Pt had to be intubated en route to hospital due to being extremely agitated and combative. Originally taken to (Hospital #1) that refused secondary to no PICU but prior to stabilization. Upon arrival here she was about 1.5 hours from pick up. On the way they originally were concerned for an arrhythmia but no medications were needed and she was stabilized to sinus tach. She received 300 cc (cubic centimeters) of NS (Normal Saline) and multiple doses of sedation/roc. CMP, CBC and EKG reassuring in the ED.
Hospital Course:
Upon admission to PICU patient was found vitally stable but intubated. Her blood work was reassuring (Negative pregnancy test, normal kidney and liver function, no markers of infection, acetaminophen and salicylate levels normal, EKG no acute changes). She remained under sedation drips overnight and was extubated at the following morning to room air. Upon further history taking family disclosed long-standing hx of depression and anxiety, psychiatry outpatient monthly follow up, as well as previous hx of inpatient care for suicidal ideation within the last 6 months. Psychiatry was consulted and evaluated her case. She met criteria for unspecified derepression. Psychiatry recommended patient to be admitted to an inpatient facility for stabilization of mood, but family and patient both decline at this time. It was considered the option of having the courts involved, but parents report that they will be watching her 24/7 (mother stays at home and pt is home schooled). They report they have already locked up all the medication at home, OTC and rx. Family denies having guns in home. I advised patient that if she becomes suicidal, homicidal, beings hallucination, or if anything feels out of the ordinary to take her to the nearest ER or call 911. Given that family appears appropriate, that mother will be home with patient 24/7, and that she already has outpatient providers who family will contact today, we will forego involving the courts at this time. She has appointments with both the psychologist and psychiatrist on April 17, but family will try to move these appointments up if she does not eventually get admitted to the inpatient unit. Patient was advised to abstain from all drugs, nicotine, and alcohol."


CONCLUSION:
The complaint regarding Patient A not receiving a Medical Screening Exam, Stabilizing Treatment or an Appropriate Transfer while in a helicopter on Hospital #1's helipad were substantiated and EMTALA violations were cited for the facility's failure to ensure this patient received a Medical Screening Exam (MSE), Stabilizing Treatment, or an Appropraite Transfer from a physician during the time she was on the facility's grounds.
A2406 - Medical Screening Exam
A2407 - Stabilizing Treatment
A2409 - Appropriate Transfer

Based on Hospital #1's Emergency Department (ED) record review, ED physician interview, staff interview, ED staff written report review, ED staff interview, ED log review, document review, policy and procedure review, EMS transcript review, Hospital #2's ED report review, and air EMS transcript review, the facility failed to, within the hospital's capabilities (staff and facilities) provide a Medical Screening Exam (MSE) for Patient A, a 14 year old overdose patient with an emergency medical condition.

Findings include:

Cross Refer to A2400 for the facility's failure to ensure Patient A received a Medical Screening Exam on 4/10/18 when the air ambulance she was in landed at their helipad in an attempt to get her attention for an emergency medical condition.


CONCLUSION:
The complaint regarding Patient A not receiving a Medical Screening Exam while in a helicopter on the hospital's helipad was substantiated and EMTALA violations were cited for the facility's failure to ensure this patient received a Medical Screening Exam (MSE) for an emergency medical condition from a physician during the time she was on the facility's grounds.

Based on Hospital #1's Emergency Department (ED) record review, ED physician interview, staff interview, ED staff written report review, ED staff interview, ED log review, document review, policy and procedure review, EMS transcript review, document review, Hospital #2's ED report, and air EMS transcript review, the facility failed to, within the hospital's capabilities (staff and facilities) provide Stabilizing Treatment for an emergency medical condition within its capacity that minimized the health risks of Patient A, a 14 year old overdose patient.

Findings Include:

Cross Refer to A2400 for the facility's failure to provide Stabilizing Treatment for an emergency medical condition within its capacity that minimized the health risks of Patient (A), a 14 year old overdose patient.


CONCLUSION:
The complaint regarding Patient A not receiving Stabilizing Treatment while in a helicopter on Hospital #1's helipad was substantiated and EMTALA violations were cited for the facility's failure to ensure this patient received Stabilizing Treatment for an emergency medical condition from a physician during the time she was on the facility's grounds.

Based on Hospital #1's Emergency Department (ED) record review, ED log review, ED physician interview, staff interview, ED staff written report review, ED staff interview, ED log review, document review, policy and procedure review, EMS transcript review, Hospital #2's ED report, and air EMS transcript review, Hospital #1 failed to ensure Patient A received an appropriate transfer to Hospital #2.

Findings Include:

Cross Refer to A2400 for the facility's failure to ensure Patient A received an appropriate transfer to Hospital #2.


CONCLUSION:
The complaint regarding Patient A not receiving an Appropriate Transfer to Hospital #2 while in a helicopter on Hospital #1's helipad were substantiated and EMTALA violations were cited for the facility's failure to ensure this patient, with an emergency medical condition, received an Appropriate Transfer to Hospital #2 from a physician during the time she was on the facility's grounds.