HospitalInspections.org

Based on interviews and review of patient medical records, the hospital failed to ensure compliance with 489.24(a) in that 1 of 1 patients was not provided a medical screening examination when the patient was brought to the hospital via EMS.

Findings:

A. In an interview with emergency medical services (EMS) staff #11 at 3:36pm on November 27, 2017 via telephone who alleged the emergency room physician told him twice (over the radio when the EMS was in the ambulance bay and when EMS staff physically walked into the emergency room to tell emergency physician they would be violating EMTALA if they did not accept this patient), that they would not accept the patient.

B. Interviewed hospital staff #5, emergency room physician via telephone at 2:40pm on November 14, 2017. Staff #5 was the emergency room physician that was on that evening 7pm October 28 to 7am October 29th. It was explained that the emergency room received a call from EMS around 2:30am in the morning saying they had a patient, a 21 year old female who was found naked at a residential area. The reporter said the patient had altered mental status (AMS). Staff # 5, MD informed the ambulance crew that the hospital was on diversion due to the CT scanner being down. A patient with an altered mental status will need a CT scan of head/brain to rule out a stroke. It was suggested that it would be better for the patient to be seen immediately at the other facility who had at that time the higher level of care by having the capabilities of a working CT scanner and can immediately rule out a stroke. Staff #5, MD explained she was thinking about what would be best for the patient at that time and did not want to waste any critical time in this situation. The other hospital was close enough. The emergency room had been on diversion status since early afternoon on October 28, 2017 and this fact was well communicated to the community. The EMT paramedic came to the emergency room alone without the patient and was "hot and angry." Staff #5, said she was really surprised by EMS staff behavior, threatening an EMTALA violation if the patient was not seen here. MD #5 said "I never told EMS staff that we would not accept the patient but was trying to explain to the current situation especially for a patient with altered mental status is going to need a CT. The EMS staff did not want to hear what would be best for the patient, but seemed to be thinking of himself and being able to unload this patient. " To avoid wasting more time the EMS staff was told since he already brought the patient to our ambulance bay we might as well see her. " EMS staff turned around and walked out of the emergency room. Staff #5, MD said she thought he was going to go out to bring the patient in and he basically walked out and left with the patient who was still in the ambulance. Staff #5, MD said she never told EMS staff that she would not see the patient.

C. The patient had an emergency medical condition and was not provided an appropriate medical screening examination. Although the hospital did not have a working CT scan and was on diversion for any condition that would require a CT scan, the patient did arrive at the hospital via EMS but did not receive a medical screening examination.

In the EMTALA guidelines, it states that "if any ambulance (regardless of whether or not owned by the hospital) disregards the hospital's instructions and brings the individual on to hospital campus, the individual has come to the hospital and the hospital has incurred an obligation to conduct a medical screening examination for the individual."

D. In the review of emergency room treatment records, there were 2 walk-in patients who were sent to another hospital for a CT scan during the time the hospital was on divert. The 2 patients were provided a medical screening.

E. Policies
1. Facility Policy: Medical Screening Exam:

"Medical Screening Examination (MSE):
A. Resolute Health shall provide a medical screening examination to any individual who comes to the Emergency Department.
B. The MSE is the examination of the patient by the Qualified Medical Person required to determine within reasonable clinical confidence whether and emergency medical condition does or does not exist. The examination should be tailored to the patient's complaint and depending on the presenting symptoms, the medical screening examination may represent a spectrum ranging from a simple process involving only a brief history and physical examination, to a complex process that also involves performing ancillary studies and procedures.
C. The MSE must be provided in a non-discriminatory manner. The examination provided to an individual must be the same MSE that the hospital would provide to any individual coming to the Hospital's dedicated emergency department with those signs and symptoms, regardless of ability to pay. ...

The purpose of the MSE is to:
1. Assess the patient for the presence of an EMC; and
2. Assess the patient's stability for transfer, if appropriate ...."

2. Facility Policy: EMTALA Compliance Policy:
Page 1 under Definitions:
"B. Comes to the Emergency Department: "An individual is deemed to have come to the emergency department if the individual:"

..... 3. Is in a ground or air non hospital owned ambulance on Hospital Property for presentation or examination for a medical condition at the hospital dedicated emergency department;..
C. Dedicate Emergency Department: is defined as any department or facility of the hospital regardless of if it is located on or off the main Hospital campus that meets at least on for the following requirements:"

3. CFR 489.24 Special Responsibilities of Medicare hospitals in emergency cases under definition:
"Comes to the emergency department means, with respect to an individual who is not a patient ..., the individual:

(4) Is in a ground or air nonhospital -owned ambulance on hospital property for presentation for examination and treatment for a medical condition at a hospital's dedicated emergency department. However an individual in a nonhospital-owned ambulance off hospital property is not considered to have come to the hospital's emergency department, even if a member of the ambulance staff contacts the hospital to telephone or telemetry communications and informs the hospital that they want to transport the individual to the hospital for examination and treatment. The hospital may direct the ambulance to another facility of it is in "diversionary status," that is, it does not have the staff or facilities to accept any additional emergency patients. If however, the ambulance staff disregards the hospital's diversion instructions and transports the individual onto hospital property, the individual is considered to have come to the emergency department."

E. The patient was brought to the emergency department even after the ambulance staff disregarded the hospital's diversion instruction. A medical screening examination which was the hospitals incurred obligation once the patient was on hospital campus was not provided to the patient.