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Based on interview and a review of the Emergency Department's registration logbook, it was determined the facility failed to ensure one (1) of twenty-one (21) sampled patients (Patient #1) was registered in the facility's Emergency Department registration logbook. Patient #1 presented to the grounds of the Emergency Department (ED) on 07/07/15 but left without receiving a medical screening. There was no evidence patient #1 was logged into the ED registration logbook (refer to A2405).

Based on interview, incident report, and a review of the facility's policy it was determined the facility failed to ensure a medical screening was provided for one (1) of twenty-one (21) patients (Patient #1) that presented to the grounds of the facility's Emergency Department (ED) on 07/07/15 seeking treatment. Interview revealed Patient #1 was transported by emergency medical services (EMS) to the facility's emergency room on 7/7/15 with complaints of difficulty breathing. Patient #1's family member was present along with EMS personnel when staff told EMS that the facility could not accommodate the patient due to the patient's weight/size. The facility failed to provide a medical screening/assessment for patient #1 and told EMS to transport the patient to a facility that could accommodate bariatric patients. (Refer to A2406).

Based on interview and a review of the Emergency Department's registration logbook, it was determined the facility failed to ensure one (1) of twenty-one (21) sampled patients (Patient #1) was registered in the facility's Emergency Department registration logbook. Patient #1 presented to the grounds of the Emergency Department (ED) on 07/07/15 but left without receiving a medical screening. There was no evidence patient #1 was logged into the ED registration logbook.

The findings include:

Review of the facility policy titled "Emergency Room Records" revealed the facility had a policy to ensure that necessary systems were in place to record a complete and legible emergency department record. Further review of the policy revealed a control register was continuously kept and included at least the following information on each patient: 1. Patient Identification. 2. Time/Means of arrival 3. Person(s) transporting patient. 4. History of present complaints and physical finding.

Interview with the Emergency Medical Technician (EMT) on 07/21/15 at 12:40 PM revealed Patient #1 presented by ambulance to the facility on 07/07/15 at approximately 7:20 PM. According to the EMT, the closest hospital diverted care and told EMS they could not accommodate the patient due to the patient's size/weight. The EMT stated a call was then dispatched to the above facility who agreed to accept the patient. The EMT stated patient #1 remained in the ED parking lot on the floor of the ambulance while facility staff came in/out for over an hour. The EMT stated information was provided to the facility to register the patient.

Review of the EMS (Emergency Medical Service) transportation record dated 07/07/15 and the audio recording of the 911 call confirmed that the EMS dispatch had contacted the facility regarding Patient #1 and staff at the faciity had agreed to accept the patient. According to the EMS report, EMS staff transported the patient to the facility's ED for treatment. Continued review of the EMS report revealed ED staff refused to accept the patient due to the patients weight.

Review of the ED registration log dated 07/07/15 revealed no evidence that patient #1 was ever logged into the ED registration logbook.

Interview with the registration clerk (#1) who was working at the time of the incident stated staff could not get Patient #1 out of the ambulance due to the patient's weight/size. Registration Clerk #1 stated patients who presented to the ED were normally logged into the ED registration logbook. Registration Clerk #1 stated patient #1 was not logged in "but I guess we should have."

The Director of Nursing (DON) on 07/21/15 at 10:45 AM stated it was facility policy to maintain the ED logbook with at least the patient's name, date of birth, and complaint until more information could be obtained. The DON gave no explanation why patient #1 was not logged on the ED registration logbook.

Based on interview, incident report, and a review of the facility's policy it was determined the facility failed to ensure a medical screening was provided for one (1) of twenty-one (21) patients (Patient #1) that presented to the grounds of the facility's Emergency Department (ED) for treatment. Interview revealed Patient #1 was transported to the facility's emergency room on 7/7/15 by emergency medical services (EMS) with complaints of difficulty breathing. Patient #1's family member was present along with the EMS personnel when staff told EMS that the facility could not accommodate the patient due to the patients weight/size. The facility failed to provide a medical screening/assessment for patient #1 and told EMS to transport the patient to a facility that could accommodate bariatric patients.

The findings include:

A review of the facility's policy titled "EMTALA Policy" undated, revealed the facility provided appropriate medical screening examinations to individuals who presented to the ED and to individuals who presented on the campus property who requested examination or treatment of an emergency condition, and if one exists, either to stabilize the emergency condition or to transfer the individual appropriately and in conformity with legal and regulatory requirements.

Review of the facility's contracts revealed an agreement had been signed between EMCARE Physician Services and the facility effective April, 2015 to provide twenty-four (24) hour emergency Physician Services to the members of the community who required immediate medical and hospital service through the Hospital's Emergency Department.

Interview with the Emergency Medical Technician (EMT) on 07/21/1 at 12:40 PM revealed Patient #1 was transported to the facility's emergency room on 7/7/15 by emergency medical services (EMS) with complaints of difficulty breathing. According to the EMT, the facility agreed to accept the transport; however, upon arrival staff told EMS the facility could not accommodate the patient due to the patients weight/size. The EMT stated patient #1 remained on the floor of the ambulance for over an hour before EMS found a receiving hospital which was more than a hundred (100) miles away. The EMT stated patient #1 did not receive a medical screening at the above facility and there was a "heated discussion" when staff told EMS the patient needed to be transported to a bariatric hospital.

Interview with Patient #1's family member on 07/23/15 at 10:00 AM revealed the mother was present along with the EMS personnel when staff told EMS the facility could not accommodate the patient due to the patients weight/size. The family member stated,"the hospital should be equipped to handle bariatric patients." According to the family member, patient #1 weighed 650 lbs.

An interview was conducted on 07/21/15 at 6:30 PM with the House Patient Care Manager (HPCM) who was working on 07/07/15 at the time of the incident. The HPCM stated she received a phone call from the ED Nurse (Nurse #1) who reported EMS had transported a bariatric patient and the facility did not have a stretcher to support the patient's weight. The HPCM stated the ambulance was in the ED parking lot and the patient was lying on the floor of the ambulance. The HPCM requested another bariatric stretcher from the local County EMS but their stretcher was not wide enough to support the weight of the patient either. The HPCM stated she asked the ED Physician to go outside and assess patient #1 but the ED Physician refused. The HPCM stated she notified the DON but the ED Physician continued to refuse to go out and assess the patient.

Interview with Nurse #1 on 07/22/15 at 9:30 AM revealed she was working when the ambulance arrived at the ED parking lot on 07/07/15. Nurse #1 stated her shift ended at 7:00 PM but she stayed over until 8:45 PM trying to help with the situation. Nurse #1 stated it was her understanding when she left work that EMS and facility staff was going to transfer the patient to a hospital bed so the patient could be seen in the emergency room by the ED Physician.

The ED Physician stated in interview on 07/23/15 at 9:30 AM that patient #1's reported weight was approximately 900 lbs., and there was no success getting the patient out of the ambulance. The ED Physician stated the facility bariatric bed only held 450 lbs. and the bed was not an option. When asked why the ED Physician did not assess the patient or conduct a medical screening of the patient outside in the ambulance, the ED Physician stated, "Looking at the patient in an ambulance would not constitute a medical screening."

Review of Patient #1's medical record from the second facility revealed when the patient presented to the second hospital on 07/07/15 at 10:49 PM, the patient received a medical screening and was admitted. Further review revealed the patient was medically screened at the second facility and diagnosed with Acute Chest Pain, Acute Renal Failure, Hypotension, Morbid Obesity, and Left Leg Mass.