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Based on interviews, medical record review, review of the facility's Emergency Department Log and policy review, the facility failed to comply with 489.20(r)(3), (A 2405) by failure to maintain a central log on each individual who comes to the emergency department and failed to comply with 489.24(a), (A 2406) by failing to provide an appropriate medical screening examination within the capability of the hospital's emergency department to determine whether or not an emergency medical condition exists. The cumulative effects of these systemic practices pose a risk to all patients presenting to the emergency department. The average daily census of the emergency department is 220 patients.

Based on interview, review of Facility A's Emergency department log, and review of Facility A's Logicare OnTrack Essential Tracking System policy, Facility A failed to maintain a central log on each individual who comes to the Emergency department for one (Patient #21) of 21 medical records reviewed.

Findings include:

The medical record for Patient #21 contained an ambulance report from 11/6/14. The Emergency Medical Technician's (EMT) report showed the EMT received a call to transport Patient #21 on 11/6/14 at 6:15 PM. The EMT arrived at Facility A at 6:55 PM and received Patient #21 at 7:00 PM. The EMT's initial assessment of Patient #21 showed Patient #21's blood oxygen level was 84% on room air and 95% on five liters of oxygen. Patient #21 had labored breathing, was short of breath and was wheezing. Patient #21 complained of right shoulder pain which radiated to the neck. The EMT questioned a registered nurse at the facility two times regarding Patient #21's condition who reported Patient #21 was fine.

The EMT documents indicate Patient # 21 was in the squad for transport and several calls had been made to Facility B's supervisor who advised to take Patient # 21 back to the emergency department at Facility A since Patient # 21 was not medically stable. EMT's called Facility A's emergency department where Patient # 21 was then taken and received by the emergency room staff to room #19. A registered nurse took report, placed Patient # 21 on a pulse oximeter and blood pressure machine. The RN reported to the EMT the "nursing supervisor said to throw her on 2 liters and take her to "facility B" and she cannot go here". The EMT documented Patient # 21 was transported to Facility B.

The Emergency Department Log was reviewed on 11/14/14 and did not contain the name of Patient #21 from 11/6/14.

Staff D was interviewed on 11/14/14 at 11:16 AM and reported Patient #21's name did not get placed on the Emergency Department log from the visit on 11/6/14.

Facility A's Logicare OnTrack Essential Tracking System policy was reviewed. The policy stated all patients will be entered into the Essential Tracking System to denote the date and time for their arrival. The daily report from the Logicare OnTrack Essential Tracking System will be utilized as the department's patient log.

This deficiency substantiates Substantial Allegation OH00076979.

Based on interviews, review of the medical record from Facility B and policy review, Facility A failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department to determine whether or not an emergency medical condition exists for one (Patient #21) of 21 medical records reviewed.

Findings include:

During an interview at 11:00 AM on 11/14/14, the Quality Manager reported the facility had recently had an alleged EMTALA violation in which Facility A was researching. Facility A found out about the alleged EMTALA violation on 11/7/14 from the facility the SP was transferred to (Facility B) and a Root Cause Analysis was started on 11/10/14. Facility A started reeducating all of the emergency department staff regarding EMTALA and education is to be completed by the 11/22/14. The Quality Manager reported there was not a physician involved with the alleged EMTALA violation. She/he reported Patient # 21 was discharged and in the process of being transferred to a psychiatric unit at Facility B. Patient # 21 was handed off to the transport team who then assessed Patient # 21's pulse oximeter reading as 80% and at that point transported Patient # 21 directly to Facility A's Emergency department, aborting the transfer to Facility B . Patient # 21's vital signs and pulse oximeter reading were checked by the ED nurse who took Patient # 21 to a room. Oxygen was administered at an undocumented rate. There is no recording of the SP's vital sign results in the emergency department from 11/06/14.

During an interview with the Emergency Department System Medical Director on 11/14/14 at 11:28 AM, she/he reported the emergency department physician working the evening of 11/6/14 was not aware of Patient # 21's arrival in the Emergency department.

Facility A's Emergency Department Log from 11/6/14 was reviewed and it did not contain Patient # 21's name. Staff H was unable to produce a copy of Patient #21 ' s emergency department encounter on 11/6/14.

The medical record for Patient #21 contained an ambulance report from 11/6/14. The Emergency Medical Technicians (EMT) report showed the EMT received a call to transport Patient #21 on 11/6/14 at 6:15 PM. The EMT arrived at Facility A at 6:55 PM and received Patient #21 at 7:00 PM. The EMT's initial assessment of Patient #21 showed Patient #21's blood oxygen level was 84% on room air and 95% on five liters of oxygen. Patient #21 had labored breathing, was short of breath and was wheezing. Patient #21 complained of right shoulder pain which radiated to the neck. The EMT questioned a registered nurse at the facility two times regarding Patient #21's condition who reported Patient #21 was fine.

The EMT documents indicate Patient # 21 was in the squad for transport and several calls had been made to Facility B's supervisor who advised to take Patient # 21 back to the emergency department at Facility A since Patient # 21 was not medically stable. EMT's called Facility A's emergency department where Patient # 21 was then taken and received by the emergency room staff to room #19. A registered nurse took report, placed Patient # 21 on a pulse oximeter and blood pressure machine. The RN reported to the EMT the "nursing supervisor said to throw her on 2 liters and take her to "facility B" and she cannot go here". The EMT documented Patient # 21 was transported to Facility B. The medical record did not contain a medical screening examination from 11/6/14.

An email from Staff A was reviewed. Staff A documented after reading the EMS chart, it appears that Patient #21 was taken back into the facility's Emergency department Room #19. An "eye ball" exam from the emergency department RN supervisor, who then states that the EMS crew can put her on two Liters of oxygen and take her to Facility B, does not constitute an appropriate MSE (medical screening examination). Facility B's registered nurse's complaint that the patient wasn't "medically stable" is poorly worded in the EMS chart, but the claim is valid. The normal MSE wasn't performed and the patient wasn't "declared" stable for transfer by a physician or physician or physician assistant. From the EMS chart, it doesn't sound as if the patient was seen by an emergency department physician or physician assistant. Regardless, however, from what I have read so far, (only the EMS chart), it would appear that one can easily argue that the EMTALA rule was in play for this patient, and that Facility A clearly failed to perform an appropriate MSE. That alone makes it an EMTALA violation. From the information I have reviewed, however, it would appear Facility A did violate EMTALA with respect to the care provided for this specific patient.

Facility A's Emergency department Physician Assessment Responsibilities policy was reviewed. The policy stated any patient regardless of diagnosis, race, color, financial status, national origin, or handicap who presents himself/herself to the emergency department will be seen by an emergency department provider. All patients will undergo an appropriate medical screening exam and be offered stabilizing treatment either by the emergency department provider or an attending physician that is a qualified member of the medial staff.

The medical record of Patient #21 from Facility B was reviewed on 11/19/14. The record showed Patient #21 arrived at Facility B by EMS on 11/6/14 at 9:37 PM. An emergency physician documented Patient #21 was brought to Facility B from Facility A. Patient #21 was supposed to be a direct admission but when the EMS got to Facility A to transfer Patient #21, the EMS noted Patient #21 was lethargic, weak, complaining of right sided chest pain and diaphoretic. The emergency department physician wrote the EMS took Patient #21 to the emergency department at Facility A but the hospital staff refused to readmit Patient #21. Patient #21 was brought to Facility B for medical clearance before admission to the psychiatric unit. A computed tomography scan of the chest was performed on 11/7/14 at 12:58 AM and the results showed Patient #21 had bilateral pulmonary embolisms (obstructions of a blood vessel in the lungs, usually due to a blood clot) with a saddle embolism (a large thrombus lodged at an arterial bifurcation, where blood flows from a large-bore vessel to a smaller one). Patient #21 was admitted to the intensive care unit at Facility B.

This deficiency substantiates Substantial Allegation OH00076979.