HospitalInspections.org

This Standard is not met as evidenced by:


Based on complainant interview, staff interview, staff ' s signed statement review, Emergency Department (ED) Register review and policy and procedure review, Hospital #1 failed to comply with S489.24 by failing to provide appropriate medical screening exams, necessary stabilizing treatment and appropriate transfer.


Findings include:


1. Cross Refer to C2402 for the facility ' s failure to ensure that EMTALA signs are posted.

2. Cross Refer to C2405 for the facility ' s failure to ensure that an entry into the Central Log was completed to include time of arrival for two (2) patients that arrived on hospital property on 11/07/13.

3. Cross Refer to C2406 for the facility ' s failure to ensure that a Medical Screening Examination was provided for three (3) patients that arrived on the hospital property on11/07/13.

4. Cross Refer to C2407 for the facility ' s failure to ensure that Stabilizing Treatment was provided for three (3) patients that arrived on the hospital property on 11/07/13

5. Cross Refer to C2409 for the facility ' s failure to ensure that appropriate transfer was provided for three (3) patients that arrived on the hospital ' s property on 11/07/13.

Based on observation and staff interview, Hospital #1 failed to ensure that an EMTALA sign was posted within view of patients arriving to the Emergency Department (ED) by ambulance.


Findings include:


On 11/18/13 from 2:15 p.m. to 2:25 p.m. observation made during tour of Hospital #1 ' s ED, accompanied by the ED Manager/ Risk Manager, revealed no EMTALA sign was posted within view of patients arriving by ambulance. Interview with the ED Manager/Risk Manager at that time confirmed this finding. She stated that the sign had been removed so that a plastic sign could be made.

Based on Emergency Department (ED) Register review and staff interview, Hospital #1 failed to ensure that ED Register documentation was complete for Patients #2 and #3.


Findings include:


ED Register log review revealed that Patient #2 and Patient #3 arrived at Hospital #1 ' s ED on 11/07/13. The times that Patient #2 and #3 arrived were not documented in the Central Log.

On 11/18/13 at 2:00 p.m. an interview with the ED Manager/Risk Manager confirmed these findings.

Based on staff interview, Emergency Medical Transportation (EMT) reports, signed statement review, policy review and EMTALA Guidelines review, Hospital #1 failed to ensure that an appropriate Medical Screening Exam (MSE) was provided for three (3) patients who arrived by ambulance onto Hospital #1 ' s property on 11/07/13. Patients #1, #2 and #3.


Findings include:


Review of Hospital #1's "Managing Emergency Department Excess Volume" policy, effective date 01/01/13, revealed: "Diversion Policy. Diversion of Emergency Department patients to outside emergency department will only occur when every option for management of the Emergency Department patients' at this facility has been exhausted. Diversion to another emergency department facility will only occur in compliance with EMTALA regulations. Documentation of a diversion will include information that supports medical judgment for the diversion, clear communications related to the diversion and evidence that the diversion was not financially motivated."


Review of Hospital #1's "EMTALA Guidelines", effective 01/01/13, revealed: "All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic."


An interview with Hospital #1's Emergency Department (ED) Physician (#1) on 11/19/13 from 8:33 a.m. to 8:45 a.m. revealed:
On 11/07/13 ED Registered Nurse (RN) #2 received a call from ambulance staff reporting that they were bringing one (1) patient to Hospital #1 ' s ED. ED RN #2 informed the ambulance staff that the hospital's Computed Tomography (CT) scan was down. Shortly after the first call, Hospital #1 received a second call reporting that a second ambulance was bringing two (2) patients to the ED. RN #2 informed the second ambulance ' s staff that the hospital's CT scan was down. She did not tell the ambulance staff that the ED was on diversion. The first ambulance arrived on hospital property with one (1) patient. The second ambulance arrived behind the first with two (2) patients. ED Physician #1 went to the ambulances and talked with the ambulance paramedics, again telling them that the CT scan was down. He did not examine or treat the three (3) patients. At his direction the patients were transferred by ambulance to other hospitals. The first patient (Patient #1) was transferred to Hospital #2. The other two (2) patients (Patients #2 and #3) were transferred to Hospital #3.


On 11/20/13 from 10:10 a.m. to 10:20 a.m. an interview with Hospital #1's ED Manager/ Risk Manager revealed that the hospital did not have any documented evidence that hospital staff notified anyone of the hospital ' s diversion status.


Review of a signed statement provided by Hospital #1's ED Physician #1 on 11/20/13 at 9:45 a.m. revealed: "November 7, 2013 came my first 'real time' opportunity to utilize my obtained knowledge of EMTALA, and to do the right thing(s) to both protect the patient(s), and to avoid any EMTALA violation(s). I failed to do that, I bear responsibility for this EMTALA violation. Had the thought of EMTALA ever entered my mind that day, I would definitely not have requested transfer of this patient (#1) without a thorough history and physical exam. What I witnessed was an MVC (motor vehicle collision) victim in the back of Paramedic (#1's) ambulance, who was alert and had no distress, and had a good airway. However, this patient was on a long board with a c-collar (cervical collar) on, and had a complaint of a headache. At that moment, since our CT scanner was down, I really did feel like the ambulance transfer of (Paramedic #1's patient) to (Hospital #2) was in the patient ' s best interest. Prior to Paramedic's ambulance arrival with this patient, I heard, (ED RN #1) plainly and with emphasis tell the ambulance personnel that we had no CT capability at present because our scanner was inoperative. Indeed, (ED RN #1) did not use the word 'divert'. They knew to divert merely upon hearing that our CT scanner was down, even though to my knowledge the actual word ' divert ' was never used."


Review of the facility ' s Emergency Medical Transporter (EMT) Paramedic #1's Comprehensive Report regarding Patient #1 revealed that the patient was a 38 year old that was involved in a multi-car motor vehicle collision (MVC) on 11/07/13. The patient was alert and oriented. Cervical-spine (C-spine) precautions were in effect. The patient reported that he had a medical history of Hypertension, Cerebral Vascular Accident and Seizures. On arrival to Hospital #1's ED at 12:12 p.m. the ambulance crew was met in the parking lot by ED Physician #1 and nurses. Hospital #1's ED staff stated they could not accept the patient due to the fact that their CT scanner was in-operative. ED Physician #1 made patient contact in the ambulance and advised the Paramedic to transport the patient to another hospital. The patient was transported to Hospital #2 by ambulance. Review of Patient #1 ' s ED Record from the receiving hospital revealed that the patient arrived at Hospital #2's ED on 11/7/13 at 12:39 p.m. and was triaged Level 3 at 1:19 p.m. The patient complained of neck and right shoulder pain. Pain level was rated by Patient #1 as an eight (8) on a scale of 0-10. A MSE was completed. X-rays of the patient's shoulder and cervical spine were negative. Clinical Impression: "Contusion right arm and Motor Vehicle Accident." A sling was applied to the patient's right arm and he was discharged home from Hospital #2 at 3:05 p.m. with discharge instructions The patient reported pain level on departure as a six (6) on a scale of 0-10.


Review of Hospital #1's EMT Paramedic #2 ' s Comprehensive Report revealed that Patient #2 arrived at Hospital #1's ED parking area on 11/07/13 at 12:36 p.m. following a MVC with complaints of head, neck, and back pain. The patient reported a past medical history of Hypertension, Anxiety, and Depression. The patient was experiencing anxiety and her arms were shaking. Upon arrival to Hospital #1's ED parking area, the ambulance staff was met in the ED entrance by ED Physician #1. ED Physician #1 reported to the ambulance staff that the hospital's CT scanner was down and asked the paramedic if he had protocol to go to another facility. The patient agreed to a transport to Hospital #3. The patient was transferred by the ambulance to the receiving hospital without incident. Review of the
patient 's ED record from Hospital #3 revealed that Patient #2 arrived at their ED on 11/07/13 at 2:09 p.m. alert and fully oriented. The patient complained of headache, moderate chest and lower back pain. A MSE was provided. The patient had mild mid-sternal chest tenderness and exhibited tenderness to the thoracic spine and lumbar spine areas. X-rays of the head, chest, pelvis, spine, and chest were negative. The impression was: "No acute fracture dislocation of the pelvis; Mild degenerative disease of the hips and lower lumbar spine." The patient was discharged home from Hospital #3 with discharge instructions at 5:46 p.m. on 11/07/13.

Review of Hospital #1's EMT Paramedic #3's Comprehensive Report regarding Patient #3 revealed that Unit 3 ambulance arrived at Hospital #1's ED parking area on 11/07/13 at 12:36 p.m. The Paramedics were met in the parking lot to the ED by ED Physician #1 and were told that the hospital's CT scanner was down. The Paramedic was instructed by Physician #1 to take the patient to another hospital. The patient was informed of the situation and agreed to transfer to Hospital #3. Patient #3 was transported by ambulance to Hospital #3 without incident. Review of the ED record at Hospital #3 revealed that Patient #3 arrived at their ED on 11/7/13 at 1:52 p.m. and was triaged as Urgent. The patient ' s past medical history included Hypertension, Diabetes Mellitus, and End Stage Renal Disease requiring dialysis. Patient #3 complained of right lower back/flank pain. A MSE was provided. An abrasion was noted to the patient's right lower back and right knee. Midline lumbar tenderness was also noted. A CT scan of the patient ' s abdomen/pelvis without contrast was performed. "Impression: 1. Acute fracture right transverse process of lumbar three (3). 2. Lack of intravenous contrast limits evaluation for solid abdominal organ injury. However, no significant free fluid/hematoma is demonstrated throughout the abdomen/pelvis. If there is high clinical concern for injury, contrast examination can be obtained with a short-term follow dialysis in this patient with known renal failure. 3. Small right pleural effusion which appears simple with a sliver of pericardial fluid noted. 4. Patchy areas of ground-glass opacity in both lung bases are likely to congestive failure." Review of Hospital #3's ED physician's note revealed that the patient continued with superficial pain across abrasion area, "but believes feels well enough to go home." The physician discussed the results of the CT scan with Patient #3 and explained that a non-contrast scan does not rule out solid organ injury, however, it is less likely. On 11/07/13 at 6:29 p.m. Patient #3 was discharged home from Hospital #3 in stable condition with discharge instructions. The patient ' s final diagnoses included MVC; Lumbar transverse process fracture; back abrasion; End Stage Renal Disease on dialysis and Hypertension.

Based on staff interview, facility EMTALA Guidelines review, staff statement review and policy and procedure review, Hospital #1 failed to ensure that stabilizing treatment was provided for Patients' #1, #2 and #3. The three (3) patients arrived on Hospital #1 ' s property in ambulances on 11/07/13.


Findings include:



Review of Hospital #1's EMTALA Guidelines, effective 01/01/2013, revealed:
"(Hospital #1) may not transfer or discharge a patient who may be reasonably at risk to
deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to
deteriorate due to the natural process of their medical condition, they are legally unstable as per EMTALA."
"(Hospital #1) may not transfer patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient. A transfer of a potentially unstable
patient to another facility may only be for reason of medical necessity."



On 11/13/13 at 6:56 p.m. Hospital #1"s Administrator self reported by fax to the State Agency the following EMTALA violations:
On November 7, 2013 the C.T. (Computed Tomography) scanner at the facility was put out of service while awaiting repair. The Emergency Department (ED) and Emergency Medical System (EMS) Ambulance Service were notified of this by the Director of Radiology Services. Patients with the need for CT imaging to rule out or diagnose neurological defects, CVAs (strokes) spinal injuries, etc, would need to be transferred to other hospitals capable of providing this service. Hospital #1's EMS Ambulances were dispatched to the scene of an MVC (Motor Vehicle Collision) on the interstate, where they packaged three (3) patients for transport with spinal immobilization in place. At the professional opinion of Paramedics #1, #2 and #3 a decision was made to transport to Hospital #1. When the report was called to the Nursing staff, the paramedics were advised that the hospital's CT imaging equipment was still not functioning. The EMS ambulances arrived in Hospital #1's ED loading area. At this time ED Physician #1 approached one of the ambulances and entered the patient compartment area. He explained to the patient and the paramedic that he could not "clear the cervical spine" and the patients should be taken to other hospitals. ED Physician #1stated they should take one to (Hospital #2) and the other two (2) patients to (Hospital #3). ED Physician #1 reported that he did not complete a MSE (Medical Screening Examination) or document any findings.



An interview with Hospital #1's ED Manager/ Risk Manager, on 11/20/13 from 10:10 a.m. to 10:20 a.m., revealed that the hospital did not have any documented evidence that anyone was notified of diversion status due to the CT scan not functioning.

Based on staff interview, facility EMTALA Guidelines review and policy and procedure review, Hospital #1 failed to ensure that appropriate transfers were provided for Patient #1, #2 and #3, who arrived on hospital property by ambulance on 11/07/13 after a Motor Vehicle Collision (MVC).


Findings include:


Review of Hospital #1's EMTALA Guidelines revealed: "If a patient is to be transferred for medical necessity the following guidelines must be followed:
"A physician certification that the risks of transferring the patient are outweighed by the potential benefits. The individual risks and benefits must be documented and the patient's medical record must support these, or the patient requests a transfer in writing. In addition to the following:
The receiving hospital must give acceptance in advance. The acceptance must be documented in the medical record; including the name of the Physician accepting the patient and the person/persons receiving verbal report regarding the transfer. Copies of the medical record, x-rays and laboratory tests will accompany the patient when transferred. In the event copying the records could jeopardize the patient, the records may be sent on a STAT basis to the receiving facility as soon as completed."


Patients #1, #2, and #3 arrived at Hospital #1's Emergency Department (ED) parking area in ambulances following a multiple MVC on 11/07/13. Patient #1 was in the first ambulance and Patients #2 and #3 were in the second ambulance. The patients remained in the ambulances until they were transferred to other hospitals at the instructions of ED Physician
#1. Patient #1 was transferred to Hospital #2's ED, located in a nearby town. Patients #2 and #3 were transferred to Hospital #3's ED, also located in another town.


An interview with Hospital #1's ED Manager/ Risk Manager, on 11/18/13 from 11:45 a.m. to11:50 a.m., revealed that the facility did not have ED records for Patients #1, #2 or #3. She stated that the only documentation the facility had on these three (3) patients was the paramedics' reports. There was no documented evidence that a physician at Hospital #3's ED had accepted the transfer of Patients #2 and #3 from Hospital #1. Physician interview at Hospital #3's ED revealed that their staff was not aware that the patients were transferred from Hospital #1's ED.