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Based on interview and record review, the facility failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) as evidenced by:

1. The facility failed to provide a medical screening exam (MSE) for Patient 1. (Refer to C 2406)

2. The facility failed to ensure the ED log included the names of all patients who presented for treatment. (Refer to C 2405)

Based on interview and record review, the hospital failed to maintain a central log in which each patient presenting for emergency care was listed along with all of the information required by CFR 489.24 and hospital policy. The Emergency Department (ED) log failed to include the name for one of 21 sampled patients (Patient 1).

This failure had the potential to result in the facility's inability to accurately track the care given to each patient.

Findings:

The facility's policy titled, "Transfer of Individuals - Emergency," dated 4/19/18, was reviewed. It read, under Central Log: "1. Logs will be maintained on each person who comes seeking emergency care, including labor and delivery. Documentation on: a. Patient disposition (i.e. admitted, treated and discharged, treated and transferred). b. Patient refusal to further examination, treatment admission and/or transfer. c. The logs will be maintained for a minimum of ten years and according to policy. d. Per California State Law the following additional data will be kept in the central log: Means of arrival, age, sex, and medical record number."

On 1/30/19 at 2:35 pm, the California Department of Public Health (CDPH) received a fax from the Chief Nursing Officer (CNO) at this hospital (Hospital A). CNO reported that Patient 1, who presented to their ED on 1/26/19, was encouraged to drive to Hospital B (about 45 to 60 minutes away) by ED physician (MD) A, so Patient 1 went to Hospital B. CNO reported that no medical record was open for Patient 1.

On 3/20/19, the ED log for 1/26/19, was reviewed and did not included the name of Patient 1 or other necessary information as required by regulation and facility policy.

During an interview on 3/20/19 at 10:10 am, the Quality Improvement Director confirmed Patient 1 had not been signed into the ED log when he presented to the ED, on 1/26/19.

Based on interview and record review, the facility (Hospital A) failed to provide an emergency medical screening (MSE) to determine if an Emergency Medical Condition (EMC) existed, for one of 21 sampled patients (Patient 1), when Patient 1 presented to the Emergency Department (ED) complaining of fever and possible wound infection. Patient 1 then went to Hospital B where he was treated, for fever and wound infection with antibiotics, and discharged home.

This failure led to a delay in the assessment and treatment of Patient 1 and a potential decline in his overall health including a worsening of the infection and possible sepsis (a life threatening complication of an infection).

Findings:

The facility's "Cobra and Emergency Medical Treatment and Active Labor Act (EMTALA) Guidelines for Emergency Department Patients" policy, dated 8/30/18, was reviewed. It read: "All patients presenting to to the hospital for a non-scheduled visit and seeking care must be accepted and evaluated regardless of the patient's ability to pay. a. Hospital property is defined as: i. The physical area immediately adjacent to the hospital's main buildings; ii. Other areas and structures that are part of the hospital and are not strictly contiguous to the main building, but are located within 250 yards of the main building; and iii. Any other areas that are determined by the Centers for Medicare/Medi-cal Services (CMS) regional office on an individual basis to be part of the hospital campus. iv. Hospital property included sidewalks, driveways and parking lots that are part of the main campus but does not include areas and structures within 250 yards of the main building that are not part of the hospital."
"b. Presenting to the emergency department is defined as: i. An individual who presents to a dedicated emergency department or presents on hospital property (other than a dedicated emergency department) and; 1. Requests examination or treatment for a medical condition; or 2. Has a request made on the individual's behalf for examination or treatment for a medical condition."
"2. All patients shall receive a MSE that includes providing all necessary testing and on-call services within the capability of the Hospital to determine whether an EMC exists. d. A MSE: i. Will be offered to any individual who comes to the ED. The MSE must be provided within the capability of the dedicated ED, including ancillary services routinely available to the dedicated ED. This MSE must be the same appropriate examination that the Hospital would perform on any individual with similar signs and symptoms, regardless of the individual's ability to pay."

The facility's policy title, "Transfer of Individuals - Emergency," dated 4/19/18, was reviewed. Under MSE it read: "4. The initial MSE will consist of: a) an interview to obtain information related to the patient's current condition; b) information related to the patient's history; c) vital signs; d) physical exam relative to the chief complaint; e) other tests and services as needed and within the capability of the Hospital; f) a determination on whether an EMC exists."

On 1/30/19 at 2:35 pm, the California Department of Public Health (CDPH) received a fax from the Chief Nursing Officer (CNO) at Hospital A. CNO reported that Patient 1, who presented to their ED parking lot on 1/26/19, was encouraged to drive to Hospital B (about 45 to 60 minutes away) by ED physician (MD) A, so Patient 1 went to Hospital B.

A review of Patient 1's record from Hospital B indicated he arrived on 1/26/19 at 11:34 pm, complaining of a post-operative wound infection and fever. He was treated with oral antibiotics, had lab tests, and was discharged on 1/27/19 at 5:48 am, with prescriptions for two antibiotics. Patient 1 was admitted to Hospital B as an inpatient and underwent surgery, the next day, on 1/28/19, for debridement (removal of dead or contaminated tissue) of the wound and discharged on 2/4/19.

During an interview on 3/5/19 at 10 am, Patient 1's family member (FM) B explained Patient 1 had surgery on his right foot on 12/5/18 at Hospital B. After the cast was taken off Patient 1 had a wound and was being followed by a Home Health Nurse (HHN) who advised her and Patient 1 that they should be concerned if he developed a fever of 102 degrees. FM B said on 1/26/19, Patient 1 started shivering and had a fever of 102. She called Hospital A's ED and spoke to MD A who advised her to take Patient 1 to Hospital B because that was where he had the initial surgery. FM B said she went to Hospital A because they had emergency services available. Patient 1 remained in the truck, in the parking lot, and did not come inside the ED but MD A came out and looked at Patient 1 through the opened door of the truck. FM B said no one took Patient 1's temperature or blood pressure, examined him or looked at his wound. FM B said she was told it was better for her to take Patient 1 to Hospital B because that was where he had his surgery. FM B took Patient 1 to Hospital B that night (1/26/19) where he was given antibiotics, given a prescription and discharged home the next morning on 1/27/19. The next day on 1/28/19, HHN saw Patient 1 and said the wound was worse and he needed to be admitted so she called Patient 1's surgeon (from Hospital B) and he was admitted as an inpatient to Hospital B and had surgery later that day.

During an interview on 3/20/19 at 4 pm, HHN confirmed she saw Patient 1 on 1/28/19 and his wound had worsened. She called his surgeon's office and advised the surgeon it was necessary to admit Patient 1. His surgeon agreed to do this and Patient 1 was admitted as an inpatient to Hospital B on 1/28/19.

During an interview on 3/4/19 at 10:45 am, MD A said FM B called the ED on 1/26/19 around 8:30 pm and said Patient 1 had a fever relating to a surgical procedure he had the prior month at Hospital B. MD A advised her that Hospital B was closed to transfers from Hospital A, but if she drove directly to the ED at Hospital B, then Patient 1 would be seen. About a half hour later FM B arrived with Patient 1 to their ED parking lot. Patient 1 remained in the truck while FM B came inside the ED. MD A said he called and spoke to a nurse at Hospital B's ED who said they were on "advisory" which meant they would only accept transfers from other hospitals if the patients were trauma, stroke, or STEMI (heart attack) patients. MD A went out to the truck and saw Patient 1 who was a little shaky but was not having shortness of breath, not sweating, and did not look to be in a toxic state. MD A said he explained to FM B that he would not refuse to see Patient 1 but it would be advisable for her to take Patient 1 to Hospital B. MD A confirmed he did not complete a MSE, or get anyone to take vital signs. MD A confirmed this was an EMTALA violation as the rules were written but felt the best thing for Patient 1 was to be seen at Hospital B where a surgical consult was available.

During an interview on 3/4/19 at 10:20 am, Family Nurse Practitioner (FNP) B said he treats inpatients only. He said he received a call from MD A to ask if he would treat Patient 1. He and MD A went to the truck and saw Patient 1. After hearing of Patient 1's history and complaint, FNP B said he would not treat Patient 1 there (at Hospital A) because he thought the patient needed a MRI (magnetic resonance imaging that creates a detailed images of organs and tissues) and a surgical consult (not available at Hospital A).

During an interview on 3/21/19 at 9:20 am, ED technician (EDT) said FM came into the ED lobby, while Patient 1 remained in the vehicle and she advised MD A of this. EDT overheard MD A tell FM B, that Patient 1 could be seen and treated here but it would be best if she took him directly to Hospital B. EDT confirmed Patient 1 did not enter the ED.

During an interview on 3/4/19 at 1:45 pm, MD C (ED Medical Director) confirmed he had discussed this case with MD A. Since Hospital B was essentially closed to transfers except for trauma, heart attack, and stroke patients, MD A advised FM B if Patient 1 had a problem requiring hospitalization it was better to go to Hospital B where his surgeon was located. MD C said, although MD A did what he thought was in the best interests of the patient, this was an EMTALA violation.