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Based on medical record review, Emergency Medical Services (EMS) document review, Adverse Incident Report review, review of Policy and Procedure, and interview the facility failed to meet its obligation at 42 Code of Federal Regulations part 489.24.

The findings include:
1. The facility failed to provide screening and stabilizing treatment within the scope of its abilities to one individual (Patient #1) with an emergency medical condition who came to Hospital #1 by ambulance for examination and treatment. See the citation in this report at A2406.

2. The facility failed to appropriately transfer one individual (Patient #1) with an emergency medical condition. Patient #1 had not received medical treatment to minimize the risk to the patient's health prior to transfer from Hospital #1 and the Emergency Department physician had not signed a certificate summarizing the risk and benefits of transfer to the patient with a statement that the medical benefits outweighed the increased risks to the patient. See the citation in this report at A2409.

Based on medical record review, Emergency Medical Services (EMS) document review, Adverse Incident Report review, review of Policy and Procedure, and interview the facility failed to provide screening and stabilizing treatment within the scope of its abilities to one individual (Patient #1) with an emergency medical condition who came to Hospital #1 by ambulance for examination and treatment. A patient with a medical emergency was brought to the Hospital #1 Emergency Department (ED) by EMS for medical treatment. The Emergency Department physician refused to examine and treat the patient.

The findings include:

A review of the Hospital #1 Policy and Procedure: Medical Screening Exam, approved 4/27/21 reads: "Policy 1. Patients presenting to Hospital #1 under Emergency Medical Treatment and Active Labor Act (EMTALA) will receive a medical screening exam (MSE) by a qualified medical professional as defined by Hospital #1 bylaws."

A review of the EMS "Patient Care Record" dated 9/12/21 reads, "The patient (Patent #1) is a 30-year-old male who is physically disabled. Patient has a tracheostomy, home ventilated, and bed bound. The tracheostomy was accidentally dislodged causing damage to the inside of the throat leading to profuse bleeding and continuous airway obstruction... The family was made aware that we had to transport the patient to [Hospital #1] being the closest appropriate facility due to the patient's critical condition and immediate need to be properly stabilized. Hospital #1 was contacted with an explicit report and the [Hospital #1] person on the radio acknowledged our impending arrival with no attempt to divert us in route... Upon arrival at the [Hospital #1] ED at 7:28 p.m., the hospital staff denied us the ability to transfer the patient to a room and told us we needed to leave and take the patient to another hospital...The doctor and nursing staff continued to refuse the patient and willfully made no attempt to evaluate or intervene in any patent care whatsoever. In the interest of patient care, we continued caring for the patient and transported the patient to (Hospital #2) at 7:35 p.m." The EMS report shows the patient went into bradycardia (slow heart rate) 4 minutes after leaving the hospital and went asystole (without pulse) at 7:42 p.m. while still being transported to the second emergency department.

The only Hospital #1 documentation of the encounter for Patient #1 is the EMS report obtained from EMS by the Ward Clerk. The Ward Clerk documented the time was 7:25 p.m., the patient's age was 30 years-old, the patient needed a ventilator, the patient's heart rate at the time of the EMS report was 37, and his blood oxygen saturation was 91%. Patient #1 was not screened or provided stabilizing medical treatment at Hospital #1 but was placed back in the ambulance and taken to another hospital, Hospital #2. There is no documentation of an exam or treatment by the Hospital #1 ED physician.

In an interview on 9/20/21 at 10:30 a.m., Respiratory Therapist (RT) Staff C said that on 9/12/21 he had gotten a call from the ED saying a ventilator patient was in route to the hospital via EMS. He said he had obtained a ventilator and had it in the ED treatment room at the time of EMS' arrival. He said there was himself, EMS staff and three or four other people in the room that Patient #1 was assigned. RT Staff C said he observed EMS staff ventilating the patient nasally by an oxygenated Ambu bag. RT Staff C said he asked the EMS staff if the patient had a patent air way, and he was told they did not. The RT said there was a large amount of blood coming from the stoma (opening) of the patient's tracheostomy. RT Staff C said the ED physician came to the door of the room as EMS staff were in the process of transferring the patient from their stretcher to the ED bed. RT Staff C said he heard the ED physician tell the EMS staff the patient could not stay at the hospital and needed to be transferred to another hospital because they did not have a pulmonologist and they did not treat trauma. RT Staff C said he heard the ED physician say to the EMS staff: "The patient cannot stay here. Do not load him in our bed. We cannot take care of this patient he needs to go to a trauma hospital".

In an interview on 9/20/21 at 11:15 a.m., ED Physician Staff A said he observed the EMS staff member suctioning a lot of blood from the stoma of the patient. He said he believed the patient had a lot of blood in his lungs. ED Physician Staff A said there were so many people in the room that he could not get into the room, so he stood at the doorway. ED Physician Staff A said EMS had not reported to hospital staff that the patient was a trauma patient. ED Physician Staff A said he told the EMS staff the patient would be better off at a hospital with a trauma surgeon or an ear, nose, and throat specialist. ED Physician Staff A said he was not aware the EMS staff reported to the RT they did not have an airway or the patient's heart rate was 37 beats per minute. ED Physician Staff A said he arrived late so he may have missed some of the conversation. ED Physician Staff A said he did not intend for the EMS staff to transport the patient without any care. ED Physician Staff A said after telling the EMS staff the patient needed to be transported to another hospital he went and sat down. ED Physician Staff A said the EMS staff transported the patient before he could get back to care for the patient.

In an interview on 9/20/21 at 12:00 p.m., Registered Nurse (RN) Supervisor Staff B said she was acting as house supervisor on 9/12/21. RN Supervisor Staff B said a nurse from the ED had called her for a medication when she saw EMS bringing Patient #1 into the ED. The RN Supervisor said the ED physician kept saying we need to transfer the patient out of here. RN Supervisor Staff B said EMS staff were ignoring the ED physician. She said she told the EMS staff they needed to listen to the ED physician. The RN Supervisor Staff B said EMS staff replied to her that they needed to stabilize the patient before transport. RN Supervisor Staff B said that as she was walking away from the area, she told the Registered Nurse responsible for the patient (RN Staff E) and the ED physician that they needed to stabilize the patient before he was transported.

A review of the Hospital #1 incident report document finds a witness statement dated 9/12/21 at 8:00 p.m. titled "Statement from [RN Staff E]" which reads: "[RN Staff E] stated that he witnessed the physician and the house supervisor tell the EMS staff that 'this is a trauma patient, we cannot take care of this patient'. EMS took the patient back to the EMS vehicle and drove away."

Based on medical record review, Emergency Medical Services (EMS) document review, Adverse Incident Report review, review of Policy and Procedure, and interview the facility failed to appropriately transfer one individual (Patient #1) with an emergency medical condition. Patient #1 had not received medical treatment to minimize the risk to the patient's health prior to transfer from Hospital #1 and the ED (Emergency Department) physician had not signed a certificate summarizing the risk and benefits of transfer to the patient including a statement that the medical benefits outweighed the increased risks to the patient.

The findings include:

A review of the Hospital #1 Policy and Procedure: EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act, approved 1/22/19 reads: "Procedure 6. Transfers: Both stable and un-stable individuals may be transferred safely and systematically to another facility. They all require the following:
a. The transferring hospital must within its capability, provide treatment to minimize the risks to the health of the individual.
In addition, if the individual has not yet been stabilized there needs to be, A Certification for Transfer signed by the physician listing the risks and benefits stating that the medical benefits outweigh the increased risk to the individual."

A review of the EMS "Patient Care Record" dated 9/12/21 reads, "The patient (Patent #1) is a 30-year-old male who is physically disabled. Patient has a tracheostomy, home ventilated, and bed bound. The tracheostomy was accidentally dislodged causing damage to the inside of the throat leading to profuse bleeding and continuous airway obstruction. Upon arrival at the [Hospital #1] (ED) at 7:28 p.m. the hospital staff denied us (EMS staff) the ability to transfer the patient to a room and told us we needed to leave and take the patient to another hospital...The doctor and nursing staff continued to refuse the patient and willfully made no attempt to evaluate or intervene in any patent care whatsoever. In the interest of patient care, we continued caring for the patient and transported the patient to (Hospital #2) at 7:35 p.m."

In an interview on 9/20/21 at 10:30 a.m., Respiratory Therapist (RT) Staff C said on 9/12/21, he had gotten a call from the ED saying a ventilator patient was in route to the hospital via EMS. He said he had obtained a ventilator and had it in the ED treatment room at the time of EMS' arrival. RT Staff C said the ED physician came to the door of the room as EMS staff were in the process of transferring the patient from their stretcher to the ED bed. RT Staff C said he heard the ED physician tell the EMS staff the patient could not stay at the hospital and needed to be transferred to another hospital because they did not have a pulmonologist and they did not treat trauma. RT Staff C said he heard the ED physician say to the EMS staff: "The patient cannot stay here. Do not load him in our bed. We cannot take care of this patient he needs to go to a trauma hospital".

In an interview on 9/20/21 at 11:15 a.m., ED Physician Staff A said he observed the EMS staff member suctioning a lot of blood from the opening in the throat of the patient. He said he believed the patient had a lot of blood in his lungs. ED Physician Staff A said there were so many people in the room that he could not get into the room, so he stood at the doorway. ED Physician Staff A said EMS had not reported to hospital staff the patient was a trauma patient. ED Physician Staff A said he told the EMS staff the patient would be better off at a hospital with a trauma surgeon or an ear, nose, and throat specialist. ED Physician Staff A said he was not aware the EMS staff reported to the RT they did not have an airway or the patient's heart rate was 37 beats per minute. ED Physician Staff A said he arrived late so he may have missed some of the conversation. ED Physician Staff A said after telling the EMS staff the patient needed to be transported to another hospital he went and sat down. ED Physician Staff A said the EMS staff transported the patient before he could get back to care for the patient.

The only Hospital #1 documentation of the encounter for Patient #1 is the EMS report obtained from EMS by the Ward Clerk. The Ward Clerk documented the time was 7:25 p.m., the patient's age was 30 years-old, the patient needed a ventilator, the patient's heart rate at the time of the EMS report was 37, and his blood oxygen saturation was 91%. There is no documentation of an exam or treatment by the ED physician. There is no documentation of a Transfer Risk/Benefit Certification completed by the ED physician.

In an interview on 9/20/21 at 12:00 p.m., Registered Nurse (RN) Supervisor Staff B said she was acting as house supervisor on 9/12/21. RN Supervisor Staff B said she saw EMS bringing Patient #1 into the ED. The RN Supervisor said the ED physician kept saying we need to transfer the patient out of here. The RN Supervisor Staff B said EMS staff replied to her that they needed to stabilize the patient before transport. RN Supervisor Staff B said that as she was walking away from the area, she told the Registered Nurse responsible for the patient (RN Staff E) and the ED physician that they needed to stabilize the patient before he was transported.

A review of the Hospital #1 incident report document finds a witness statement dated 9/12/21 at 8:00 p.m. titled "Statement from [RN Staff E]" which reads: "[RN Staff E] stated that he witnessed the physician and the house supervisor tell the EMS staff that 'this is a trauma patient, we cannot take care of this patient'. EMS took the patient back to the EMS vehicle and drove away."

There was no treatment provided to Patient #1 by Hospital #1 personnel, doctors or clinical staff, to stabilize the patient or minimize the risk to the patient's health during transfer to another hospital.