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Based on a review of policies, procedures, and medical staff bylaws and rules and regulations on 8/4/2015 it was determined that:
1) the hospital failed to delineate in the medical staff bylaws/rules and regulations and in policy who may conduct a medical screening examination (MSE), and;
2) the hospital failed to maintain physician competency for EMTALA requirements.


During an onsite investigation related to EMTALA requirements, it was noted that Medical Staff Rules and Regulations fail to delineate who is considered "Qualified medical personnel" and does not mention that Certified Physician Assistants (PA-C) provide medical screening examinations with oversight of the emergency physicians. Review of ED medical records showed numerous instances of the PA-Cs performing the MSE or MSE-equivalent examinations that were co-signed by the physician on duty. Review of hospital bylaws/rules and regulations (revised December 2011) revealed in part, "Article 10 Allied Health Professionals 10.1 Allied Health Professionals fall under the scope of the Hospital's Policy on Allied Health Professionals. Allied Health Professionals are not appointees to the Medical Staff and have no rights granted under these Bylaws."


An expired hospital EMTALA policy (exp. 03/2015) failed to delineate who is qualified to perform a medical screening exam as it contained the statement relative to triage as follows: "All patients who present to the emergency department for evaluation or treatment will have a preliminary medical screening examination performed by the designated screening person (RN with validated Triage Competency, Physician or Physicians ' Assistant). If the medical screening person detects a possible emergency medical condition, the patient is immediately brought back to the emergency department treatment area, where the medical screening examination will continue with the involvement of the emergency physician." The policy then contradicts itself by stating "If the preliminary medical screening examination reveals no emergency medical condition, the patient is deemed stable and may proceed with routine registration procedures." This policy language implies that triage is the equivalent of a MSE and that the triage RN or the PA-C are authorized to perform a medical screening exam and determine if the person presenting is stable and has no emergency medical condition.


Additionally, interview with the head of the Emergency Physician group on 8/4 at approximately 1420 revealed that he gave a presentation on EMTALA in October of 2003; and that the EMTALA training given to emergency physicians occurs when the physicians are recertified by their certification board. Recertification by the American College of Emergency Physicians (ACEP) occurs every 8 years. Additionally, he conveyed that he had an EMTALA algorithm placed on the wall in their offices. Review of a Course Completion Sheet related to competencies for PA-Cs and MDs reveals that only 4 PA-Cs and 4 MDs had completed a competency on EMTALA in the past year. The medical staff who completed the competencies all work on inpatient units. Interview on 8/4 with the new hospital Chief Medical Officer revealed that the hospital does not currently provide any EMTALA training to physicians.


The hospital failed to have a current policy consistent that was consistent with the bylaws to clearly define who can perform a medical screening examination and failed to provide EMTALA training to the ED physicians potentially placing patients at risk of not receiving a medical screening exam as required.

Based on an emergency department (ED) tour of August 4, 2015, it was observed that 1) EMTALA signage in the ambulance bay was inconspicuous to those entering the ED from this entry point, and 2) no signage was found in the main entry regarding Emergency Medical Treatment and Labor Act rights (EMTALA).

Observation on a tour of the ED ambulance bay revealed that from an approximate 10-15 paces from the entry was a sign printed in English, measuring an approximate 11 " x 8 ½ which stated the rights of persons under EMTALA. The signage was so small as to be inconspicuous and unreadable to those entering from the ambulance bay. Additionally, interview with the Director of Emergency Services, at approximately 10 am revealed a community population of primarily English, Spanish and Philippine Tagalog-speaking persons. No other signage was found translated into any language other than English.Continuation of the tour to the main entrance of the ED revealed no EMTALA signage.

Therefore, based on all observations, the hospital failed to inform persons seeking emergency treatment of their rights regarding EMTALA law for an appropriate screening examination, stabilizing treatment, and transfer as necessary.

Based on interview of staff and review of 25 patient records, it was determined that the hospital transferred patient #1 who had a head-injury, to hospital #2 (H2) despite the fact that H2 did not have the capability to provide stabilizing treatment to patient #1 once it was determined that patient #1 had an emergency medical condition.


Based on review of the medical records for patient #1, it was determined that patient #1 was a male in his late sixties who presented at 1240 via ambulance to the ED of H1 with a chief complaint of dizziness. A nursing triage note revealed that patient #1 stated a recent history of "Dizziness x 2 days Reports Falling x 5, some in the yard and in house ...C/O (complained of) migraine HA (headache) 7/10" (pain level 7/10 where 10 is the worst pain). A nursing note of 1328 stated in part, " Pt A/O x 3 ...Hit head during fall in house small cut on RT (right) top head and red streak above RT eyebrow. " A later nursing note of 1523 stated in part, "Required assist to stand and take few steps only. Gait unsteady ..., " and at 1625, "Pt left by ambu (ambulance) to (H2) for CT and will return to (H1)."


This 34 bed hospital has an emergency department and surgical services, but no neurosurgical services. Interview with H1's Risk Manager on 8/4/2015 at approximately 0930 revealed that the hospital CAT scan machine was not working on the day patient #1 presented.


Hospital #2 (H2) has no neurosurgical services and is 110 bed hospital but it had an operational CT. Interview on 8/4/15 at 1115 with the attending physician at H1, revealed that it was his intention to transfer patient #1 to H2 where a CT could be performed.. He stated that he spoke with Dr. __ at H2 who accepted the patient. An ambulance was arranged and patient #1 was transferred at 1626.


The transfer was to complete a medical screening examination (MSE) to determine if an emergency medical condition (EMC) was present, such as bleeding in the brain, and if so, the patient was to receive care at H2. However, H2 also lacked the capacity to treat patient #1 if such a condition was found to be present. The attending physician stated that while the ambulance was enroute to H2, H2 recanted on their acceptance of patient #1 stating they would perform a CAT scan. The CAT scan was done once the patient arrived at H2 and Patient #1 was then transferred back to H1 prior to the reading of his scan. While the patient was enroute back to H1, the Radiologist at H2 called H1 to state that patient #1 had a hemorrhage in his brain from the head injury, an emergency medical condition requiring immediate intervention.


After patient #1's arrival back to H1, he was subsequently flown out to a hospital with a higher level of care including neurosurgery. The total time for patient #1 from presentation at H1 to the time of transfer to a higher level of care was 7 hours. Based on all documentation, it is determined that H1 delayed definitive treatment for patient #1 when he was transferred for an outpatient CAT scan to a hospital which could not meet his the treatment needs. This interim transfer also caused a delay in determining that patient #1 had an emergency medical condition.

Based on interview, and review of 25 emergency department records, and other documentation, it is determined that when the hospital (H1) lacked the capability to determine if patient #1 had an emergency medical condition, he was transferred to hospital #2 (H2) for a needed CAT (computer assisted tomography) scan instead of being transferred to a higher level of care that could both determine an emergency medical condition and provide stabilizing treatment.


Based on review of the medical records it was determined that patient #1 is a male in his late sixties who presented at 1240 via ambulance to the ED of H1 with a chief complaint of dizziness. A nursing triage note revealed that patient #1 stated a recent history of, " Dizziness x 2 days Reports Falling x 5, some in the yard and in house ...C/O (complained of) migraine HA (headache) 7/10 " (pain level 7/10 where 10 is the worst pain). A nursing note of 1328 reveals in part, " Pt A/O x 3 ...Hit head during fall in house small cut on RT (right) top head and red streak above RT eyebrow. " A later nursing note of 1523 reveals in part, " Required assist to stand and take few steps only. Gait unsteady ..., " and at 1625, Pt left by ambu (ambulance) to (H2) for CT and will return to (H1). "


The 34 bed hospital has an emergency department and surgical services, but no neurosurgical services. Interview with H1 Risk Manager on 8/4/2015 at approximately 0930 revealed that the hospital's CAT scan machine was not working on the day patient #1 presented.


Hospital #2 (H2) is a 110 bed hospital and a certified Primary Stroke Center, but has no neurosurgical services. Interview on 8/4/15 at 1115 with the attending physician at H1, revealed that he intended to transfer patient #1 to H2 where patient #1 would be able to get a CAT scan. He stated that he spoke with Dr. __ at H2 who accepted the patient.


An ambulance was arranged, and patient #1 signed a printed consent for transfer at 1555. The printed consent stated transfer for " Medical Indication, Needs CT (not functioning at (H1)). " The box for "Stable Patient" was checked. An electronic, untimed "Patient transfer Out Form" stated a destination of (H2's) ER (emergency room). It further designates a Specialty of "Neurology/Neurosurgery for a Chief Complaint of dizziness, and a diagnosis of " Unsteady Gait: R/O (rule out) CVA (cerebrovascular accident)." Patient #1 was transferred at 1626.


The transfer was to complete a medical screening examination (MSE) to determine if an emergency medical condition (EMC) was present, such as a hemorrhage in the brain, and if so, the patient was to receive care at H2. However, H2 lacked the capacity to treat patient #1 if such a condition was found to be present. The attending physician stated that while the ambulance was enroute to H2, H2 recanted on their acceptance of patient #1, but stated they would perform a CAT scan. The CAT scan was done once the patient arrived at H2. Patient #1 was then transferred back to H1 prior to the reading of his CAT scan. While the patient was enroute back to H1, the Radiologist at H2 called H1 to state that patient #1 had a hemorrhage in his brain from the head injury; an emergency medical condition requiring immediate intervention.


At 1830, the oncoming physician wrote in part, "Received call from Dr, __ imaging on call. Pt with 2.5 cm subdural hemorrhage with 2 cm of midline shift ...transport team reached and advised of patient ' s condition and advised to return lights and sirens. ETA approximately 20 min." At 1858, the physician wrote, Pt returned to the ED. On exam, he has a nonfocal neurologic exam, complaining only of mild headache. Dr. __ at (H3) contacted for transfer and pt accepted ...Will continue to monitor 158/95, HR 68, R18, ox 100." An appropriate transfer consent was signed and patient #1 was air-lifted to a higher level of care at 1957


Patient #1 was subsequently flown out to a hospital with a higher level of care including neurosurgery. It is noted that the distance from H1 to a trauma center which could have completed the medical screening exam and stabilizing treatment is 18.7 miles, which is 1.5 miles closer to H1 than H2. Additionally, there are other area hospitals with higher levels of care within 25 miles of H1 by land and air. However, no other higher level of care hospital was queried for possible transfer. Therefore, over the course of 7 hours under the care of H1, patient #1 was transferred twice, and then transferred for a third time by air transport to a higher level of care. Of note is that patient #1 subsequently had an emergency right craniotomy to evacuate the subdual hematoma, and recovered in an acute rehabilitation facility.


Based on all documentation, it is determined that H1 delayed definitive treatment for patient #1 when he was transferred for an outpatient CAT scan to a hospital which could not meet his treatment needs. This interim transfer also caused a delay in determining that patient #1 had an emergency medical condition.