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Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings include:

Based on hospital policy and procedure review, medical record reviews, physician and staff interviews, the hospital's DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for one of 20 reviewed patients who presented to the DED, (Patient #24).

~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2406

Based on hospital policy and procedure, medical record review, medical staff rules and regulations, Emergency Medical Services (EMS) report, diversion status log, Emergency Department census, hospital internal investigation, physician and staff interviews, the hospital's DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for one of 20 reviewed patients who presented to the DED, (Patient #24).

Review of the hospital Medical Staff Rules and Regulations, last revised October 2019 revealed " ... 6.1(a) Screening ... (3) All patients shall be examined by qualified medical personnel, which shall be defined as a physician, nurse practitioner, physician assistant, or certified nurse midwife, or in the case of a woman in labor, a registered nurse trained in obstetric nursing, where permitted under state law and Hospital policy, who may determine true, false or no labor but may not make a medical diagnosis. ... "

Review of the EMTALA Policy titled " Medical Screening and Treatment of Emergency Medical Conditions" last revised 12/02/2021 revealed "... Policy: Any individual who comes to the Hospital Property or Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by a physician or other Qualified Medical Personnel to determine whether or not an Emergency Medical Condition exists. ... Procedures: Facility Policies ... A. General Requirements: Registration, Triage, and Medical Screening Examination. 1. Registration and Log Each such presenting individual must be listed in the Central Log ... Policy ... B. Who May Perform Medical Screening Exam A Medical Screening Examination may be performed by an emergency department physician, another physician, or a non-physician practitioner who is qualified to conduct such examination ...and approved by the Hospital's governing board."

There was no medical record available for review at Campus B for Patient #24.

Review of the EMS (ambulance) run report for Patient # 24 revealed a 59-year-old female who was transported to the Campus B emergency department on 07/16/2022 at 1319 for a chief complaint of dyspnea (shortness of breath) and tracheostomy issue. Review of the EMS run report revealed EMS was dispatched to Patient #24 ' s residence for a chief complaint of " dyspnea and trach issue " on 07/16/2022 at 1126, arrived at the patient ' s residence at 1137, enroute to Campus B at 1220 and arrived at Campus B at 1319. Review of the EMS report revealed Patient #24 was moved to the ambulance via stair chair and stretcher on the scene, placed in fowlers (semi-upright sitting) position on the EMS stretcher and transported to Campus B. Review of incident details on EMS report revealed " ... Response mode: Emergent " to the home residence of a 59 year old female c/o (complaining of) dyspnea. Upon arrival, EMS " found patient sitting in chair on ventilator with tracheostomy. PT (patient) is tachypneic. Family states, ' something broke on her trach ' and her tube has not been changed in months. PT suctioned with no improvement. Unable to drop balloon tube to change tube. PT very anxious. PT has no other complaints. PT 59 Y/O (year old) F (female) conscious, Alert and breathing. GCS (Glasgow Coma Scale) 15, pupils equal and reactive to light. Neck flat no JVD (Jugular Vein Distention). Skin flushed and dry. CV (Cardiovascular) HR (heart rate) 120 to 140 and regular with sinus tachycardia on monitor, with no ectopy. Respiratory rate of 40 and labored. SpO2 (oxygen saturation) 96% on 6L (liters) O2 (oxygen) via tracheotomy. Lungs clear to auscultation. Abdomen soft non tender. No obvious injury or trauma. TX (treatment) as detailed. Scene delay due to extraction from house along with her ventilator. PT and family wanted to be transported to Name (Campus B). On arrival to Name (Campus B) we were turned away due to lack of ventilator and continued transport to Name (Hospital C) with no other change or incident. Report given and car to run (sic) at bedside. " Further review of EMS run sheet revealed Pt #24 had medical history that included tracheostomy. Patient reported no current medications and no known allergies. Review of the EMS report revealed documentation of vital signs at 1146 were heart rate 124, respiratory rate 28, oxygen saturation 99% on 6L via tracheostomy tube and temperature 98.2 with no complaints of pain; at 1215 heart rate 136, respiratory rate 20 and O2 Sat 93%; at 1216 heart rate 137, respiratory rate 20 and O2 Sat 93%; at 1221 blood pressure 149/120, heart rate 141, respiratory rate 21 and O2 Sat 97%; and at 1306 blood pressure 200/174,, heart rate 120, respiratory rate 20 and O2 Sat 91% with no complaints of pain. Review of the " Destination Details " on the EMS run report revealed " Disposition: Transported No Lights/Siren; Transport Due To: Patient ' s Choice; Transported To: Name (Hospital C); Requested By: Family; Destination: Hospital; Department: Emergency Room; Address: Hospital C ' s address; and Condition at Destination: Improved. " Review of the " Incident Times " on the EMS run report revealed EMS 11 was dispatched at 1126, enroute at 1127, on scene at 1137, at Patient at 1140, departed scene at 1220, at destination at 1319 and Pt transferred at 1330. EMS run report revealed Patient #24 ' s personal Philips Ventilator was left with the patient at Hospital C.

Review of the Diversion Report Status from April 27, 2022 through September 27, 2022 for Campus A and Campus B revealed no documented diversion status on 07/16/2022.

Review of the ED census revealed there were a total of twenty-two (22) patients registered on 07/16/2022. Further review revealed there were three (3) patients that arrived on 07/15/2022 of which one (1) was discharged on 07/16/2022 at 0045 and two (2) that were transferred to Campus A on 07/16/2022 at 0151 and at 0346. Further review revealed there was one (1) patient that arrived on 07/16/2022 and was Transferred on 07/19/2022 at 1035. Breakdown of the ED census on 07/16/2022 revealed the number of patients that were in the ED by hour:
0000-0100 - four (4)
0100-0200 - three (3)
0200-0300 - four (4)
0300-0400 - four (4)
0400-0500 - two (2)
0500-0600 - none
0600-0700 - none
0700-0800 - two (2)
0800-0900 - one (1)
0900-1000 - one (1)
1000-1100 - three (3)
1100-1200 - four (4)
1200-1300 - six (6)
1300-1400 - five (5)
1400-1500 - six (6)
1500-1600 - seven (7)
1600-1700 - seven (7)
1700-1800 - four (4)
1800-1900 - five (5)
1900-2000 - five (5)
2000-2100 - one (1)
2100-2200 - two (2)
2200-2300 - one (1)
2300-0000 - one (1)
07/17/2022 from midnight (0000) to 0640 - one (1)

Review of internal investigation documented by the CNO of the 07/16/2022 incident revealed "Summary of Event: On Saturday, July 16, 2022, Name EMS called in at approximately 12:20 to Campus B Emergency Department stating they had a patient on home ventilator needing tracheostomy care. At this time, Campus B ED staff were caring for another patient requiring intubation. The charge nurse and respiratory therapist on site at Campus B ED were under the impression only one ventilator was available and after conversation with the ED Director, the Director spoke with Name EMS. After determining the patient was not in any distress, the Director requested the patient be transported to the Campus A ED. The patient remained on EMS transport and was taken to Hospital C with arrival at 1320. Timeline for Saturday July 16, 2022
· Approx. 12:20 - Campus B ED Nurse received call from Name EMS enroute with a patient on a home ventilator requiring tracheostomy care.
· 12:25 - Charge Nurse calls ED Director explaining one patient in Campus B ED currently requiring intubation and EMS enroute with another patient. Respiratory Therapist stated there was only one ventilator.
· 12:30 - Charge nurse on telephone with ED Director and EMS simultaneously arrives on Campus B ED.
· 12:30 - ED Director speaks with EMS and requests if patient is stable to take patient to Campus A ED
· 12:33 - ED Director connects with Director of Laboratory/Respiratory Therapy and requests clarification on ventilator availability at Campus B.
· 12:38 - Manager of Respiratory Therapy confirms there were 2 ventilators on site, but on is set to pediatric settings. ED Director requests a second ventilator be available on Campus B for adult patients.
· Approx. 1300 - ED Director communicates with Campus B ED there is another ventilator set to pediatric setting, but it can be converted and used on adult patients.
· Approx. 1340 - Respiratory Therapist states it is not current practice to manage home ventilators due to unfamiliarity with manufacturer's recommendations and instructions. She was aware of how to convert the second ventilator from neonatal to adult but did not think there was enough time to convert before the patient arrived.

Concerns identified: 1. No medical screening exam performed on patient suffering from emergency medical condition on hospital property.

Leadership Timeline:
7/16/2022 - ED Director and Manger of RT confirm two ventilators are available on Campus B. Confirmed RT on staff on Campus B was able to locate tubing and equipment needed to convert second ventilator to adult settings. Confirmed RT staff on Campus B was capable and knowledgeable of how to convert a ventilator from pediatric settings to adult settings.
7/18/2022 - ED Director notifies Administration of issue that occurred on 7/16/2022 and the resolution to prevent this issue from happening again.
7/20/2022 - Name, EMS Director, called Name, Executive Director of Operations at Campus B to notify her of a potential violation that occurred on July 16, 2022. He informed her that he had reported us for an EMTALA violation.
7/21/2022 at 8:45 a.m. - TEAMS call with CNO, Director Emergency Departments, Executive Director Operations Campus B and Director of Compliance, Privacy & Risk to review the circumstances surrounding this incident and to determine next steps.
7/22/2022 - Chief Nursing Officer and Director of Compliance, Privacy & Risk interviewed staff about the incident on July 16, 2022. (see interviews included with EMTALA packet)
7/22/2022 at 1:30 p.m. - TEAMS call with CEO, CNO, Executive Director Operations Campus B, LifePoint Assistant Vice President, Regulatory & Accreditation Services, and Director Compliance, Privacy & Risk to discuss next steps. Decision made to self-report to NCDHHS.
7/22/2022 - Notification to ED Medical Director.
7/22/2022 - Chief Nursing Officer and Director Compliance, Privacy & Risk contacted NCDHHS and spoke to Name (employee in the intake unit) and provided the information she requested. (1-800-624-3004)

Interview on 09/27/2022 at 1040 with the CNO, Director of Quality & Patient Safety and the CMO revealed a potential EMTALA violation incident occurred on 07/16/2022 at Campus B. Interview revealed the hospital self-reported the incident to NCDHHS (North Carolina State Survey Agency) on 07/22/2022. Interview revealed the incident was investigated by hospital leadership which included staff interviews, EMTALA education for staff and providers, review of policies and monitoring of EMS arrivals, MSE ' s and Central Log began in August 2022 with 100% compliance.

Interview on 09/27/2022 at 1625 with the Director of the ED revealed the Director received a phone call from the charge nurse at Campus B around lunch on Saturday, July 16, 2022. Interview revealed the charge nurse stated the staff/Provider were currently intubating a patient in the Campus B ED and EMS was bring in a patient with a home ventilator. Interview revealed the Director informed the charge nurse that there were two (2) ventilators at Campus B, however the Respiratory Therapist had informed the charge nurse that there was only one (1) ventilator at Campus B. The charge nurse informed the Director that they were unable to care for the EMS patient in the ED as they were busy intubating a patient and Respiratory Therapy was unable manage the home ventilator due to lack of familiarity and training. The charge nurse then stated that EMS was backing up at the ambulance entrance and the Director asked the charge nurse to let her speak with the EMS personnel. The ED Director spoke with EMS to inquire about the patient's condition. EMS stated the patient was stable and in no distress. The Director explained that they only had one ventilator available and asked the EMS personnel to transport the patient to Campus A. Interview revealed the EMS personnel stated " Okay, we will take care of it. " Interview revealed the Director stated that she immediately contacted the Director of Respiratory Therapy to obtain a second ventilator at the Campus B facility. Interview revealed the Director also contacted Biomed to get another ventilator for the Campus B facility. Interview revealed that per the Respiratory Therapy Manager that Campus B had two ventilators however one of the ventilators was set up for Pediatric patients and would require the Respiratory Therapist to convert the ventilator to adult settings before it could be used on an adult patient. Interview revealed the ED Director notified hospital administration on 07/18/2022 of the incident that occurred on 07/16/2022. Interview revealed the Executive Director of Operations at Campus B was contacted by the EMS Director on 07/18/2022 and notified that he reported the incident to the state agency.

Interview on 09/28/2022 at 1832 with the ED Provider working in the ED at Campus B on 07/16/2022 revealed he had just recently learned about the EMTALA concern. Interview revealed that Provider #1 stated "I may have heard about the incident in passing, but no details until today" (09/28/2022). Interview revealed that he was not made aware of a patient waiting in the EMS truck and he did not perform a medical screening examination. Interview revealed that ED Provider #1 had completed EMTALA education related to the incident in August 2022.

Interview on 09/29/2022 at 1140 with Respiratory Therapist (RT) revealed she was made aware of EMS transporting a patient to the Campus B ED that had a home ventilator. Interview revealed RT communicated with the Provider and RN in the room where they were bagging another patient and preparing for intubation. Interview revealed Campus B ED only had one (1) ventilator available and that the ventilator had been set up for the patient they were currently intubating. Interview revealed RT informed the nurse in the room with her that they only had one ventilator currently. Interview revealed Campus B had two (2) ventilators but the one was set up for neonatal patients and the other one was set up for adult patients. Interview revealed that in order to convert the ventilator from neonatal to adult settings required disassembly and set up of adult settings that would take approximately 10-15 minutes. Interview revealed this would have required the RT to be pulled out of the current intubation process. Interview revealed RT had already set up the ventilator in the patient ' s room but had not programmed. Interview revealed the RT did not see that patient that arrived by EMS, but just knew they were on the way. Interview revealed the Provider in the patient room was just aware of a patient being brought in by EMS. Interview revealed the Provider asked if we had another ventilator and "I told him would have to disassemble and put back together."

Interview on 09/29/2022 at 1150 with the Charge RN revealed the nursing staff and ED Provider were intubating another patient in the ED when EMS called in report of a patient with a trach on a home ventilator that would require a ventilator in the ED. Interview revealed the charge nurse had been informed by RT that the facility only had one ventilator. Interview revealed the charge nurse was not certain how they could accept the patient that needed a ventilator if they only had one ventilator available, so she asked EMS to " hold on, didn ' t want them to drop patient off. " Interview revealed the charge nurse contacted the ED Director via phone for direction, as EMS had not yet arrived at the facility. Interview revealed EMS was directed to transport the patient to Campus A, as Campus B only had one ventilator and they were currently intubating a patient that would need the ventilator. Interview revealed as the charge nurse was talking with the Director EMS arrived at the " back door " . Interview revealed the charge nurse informed the Director that EMS had just "pulled up" and the Director asked to speak with the EMS personnel. Interview revealed "I had no further involvement." Interview revealed that Campus B was not on diversion status.

Interview on 10/03/2022 at 1558 with the ED Medical Director revealed the expectation for ED staff was that they should make the provider aware if there was a patient waiting in the EMS truck outside the ED. Interview revealed the Medical Director would expect the nursing staff and/or respiratory therapy to let the provider know what was going on when EMS was enroute to the ED.

Interview on 10/04/2022 at 1620 with Paramedic #1 revealed he was the Paramedic in the back of the truck with the patient. Interview revealed Paramedic #1 called report to the ED via radio and was instructed that " Directions upon arrival. " Interview revealed the patient was having issues with her tracheostomy tube, on a home ventilator and respiratory distress. Interview revealed the patient and family requested to be transported to Campus B. Interview revealed EMS was met at the ambulance entrance by a nurse and was asked not to take the patient out of the ambulance and that the ED Director wanted to talk with him. Interview revealed the 2nd Paramedic (driver) assumed responsibility for the patient and he went into the ED to speak with the ED Director by phone. Interview revealed the ED Director informed him that the facility did not have a second ventilator and that they were unable to use the patient's ventilator. Interview revealed the ED Director requested that EMS transport the patient Campus A. Interview revealed Paramedic #1 walked back to the truck and informed the patient that they would need to transport to another hospital. Interview revealed the patient requested to go to Hospital C. Interview revealed Paramedic #1 did not recall if Campus A was offered to the patient. Interview revealed "I may have said Name (Hospital C), because that's what I am familiar with." Interview revealed Paramedic #1 discussed with the EMS Director and contacted his supervisor immediately after the event. Interview revealed the EMS staff had received EMTALA training via email, after the incident that included: "don't leave, when you arrive at the facility the patient needs to be evaluated at the facility." Interview revealed the incident with additional training had been discussed in the EMS meeting.

Summary of Hospital C's Medical Record for Patient #24:

Review of the Hospital C medical record for Patient #24 revealed the patient arrived on 07/16/2022 at 1335 with a chief complaint of shortness of breath and trach concerns. ENT (Ear, Nose, Throat) services paged at 1336. Patient #24 was placed in an ED bed at 1337 and triaged at 1339. Triaged as an acuity level of "2". Review of the medical record revealed Patient #24 was admitted from the ED to Hospital C on 07/16/2022 at 1922.