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Based on staff interviews, patient Emergency Department (ED) medical record reviews and policy and procedure reviews, the hospital failed to comply with the requirements for the Emergency Medical Treatment and Active Labor Act at 42 CFR §489.24 for 1 of 26 sampled patients (#10).

The findings include:

On September 10-12, 2014, a total of 26 Emergency Department patient medical records were reviewed for individuals that presented for evaluation and treatment at the hospital's Emergency Department.

Patient #10, was brought to the hospital's ED via Emergency Medical Services (EMS) transport with complaints of chest pain on August 13, 2014. Enroute to the hospital, two-way radio communication was established with the hospital; treatment (medications administered) and patient's significant cardiac history were relayed. A 12-lead EKG (electrocardiogram) was performed and was electronically transmitted to the hospital for physician review. Based on interpretation of EKG report, the attending ED physician identified that Patient #10 would require interventional treatment, not available at the hospital. Before communication of this information could be relayed to EMS; EMS had arrived at the hospital's Emergency Department (Ambulance bay). Before the patient was taken out of the ambulance, the ambulance was approached by one of the hospital's ED Staff Registered Nurses (RN "L"). RN "L" informed EMS to transport Patient #10 to hospital XXXXX, that could provide 'interventional' treatment. The attending ED physician was not aware the patient had arrived and did not see the patient for a Medical Screening Exam; therefore, the hospital failed to provide an appropriate transfer which includes written physician certification of expected benefits of the transfer outweighs the risk and consent from patient or responsible party to the transfer.

The hospital's policy and procedure entitled "Emergency Medical Treatment and Labor Act ("EMTALA") indicates ..."Any individual who comes to the hospital's Dedicated Emergency Department (DED), including presentation directly to the Labor and Delivery Department by women having contractions, and on whose behalf a request is made for examination or treatment for a medical condition will be provided with: a) an appropriate medical screening examination within the DED's capabilities, including ancillary services routinely available to the DED, to determine whether or not an emergency medical conditions exists; b) any necessary treatment to stabilize an emergency medical condition within the capabilities of the hospital, prior to discharge or transfer; and c) appropriate transfer, if necessary." and indicates - EMTALA does not apply in the following circumstances: "......4. When a member of an ambulance crew contacts the hospital by telephone or telemetry communications and informs the hospital that they want to transport the individual to the hospital for examination and treatment and either the hospital declines or diverts the patient for any reason or the ambulance electively takes the patient to another facility. (However, if the ambulance staff disregards the hospital's instructions and transports the individual onto hospital property, once that ambulance arrives on hospital property, the individual is deemed to have come to the Emergency Department.)

CORRECTIVE ACTION PLAN:

The facility self-reported to CMS on 09/03/2014 the EMTALA violation that occurred on 08/13/2014. Identified in the letter to CMS, the following corrective action: "The nurse involved in the case has received counseling about how to handle patient's presenting in ambulance and to offer that the ED physician see the patient prior to any ambulance leaving premises once they have arrived." The hospital also indicated that they have taken the following action: "Provided additional EMTALA training that includes a focus on how to handle patients in ambulances that present to our hospital. Provided the ED staff with a review of the circumstances concerning this transport as a training example concerning how EMTALA applies to ambulances arriving on campus. Set up a monitoring system to review ED records of ambulances and cardiac patients who present to the ED to assure that patients are offered medical screening examinations and that appropriate transfers are arranged when (the hospital) lacks the capability or capacity to provide specific care (such as STEMI services) needed by emergency patients." In addition, the facility indicated that they "have used our analysis of this case to improve our staff education and processes for monitoring service and compliance."

On 09/10/2014 at approximately 12:20pm during an interview with the ED Unit Manager she stated she was immediately informed, after EMS departure, of the violation on 08/13/2014. She reviewed the specifics of the incident and then contacted Risk Management. She looked at the training piece that was currently out there and made sure all was correct. A web-ex training for the next 4 months had already been posted (for EMTALA) prior to this incident. The nurse involved was made to go over the policy, released of charge nurse duties, and instructed to go over the 'web-ex', which was completed on 08/28/2014 per sign in sheet. The Unit Manager indicated the training performed on 08/28/2014 was a 'web-ex' that was done in groups. EMS (Emergency Medical Services) was contacted and the issues were identified (should the patient have been brought here and why they just left without seeing a physician). The Medical Director was informed. Information regarding the incident was brought to an ED staff meeting (08/21/14) - in which, was pointed out something had occurred and what not to do. ED Staff were given verbal education, nothing was documented in writing of this or other action(s) immediately taken.

The Quality Assurance (QA) Director, stated per interview on 09/10/2014 at approximately 2:45pm that QA monitoring activities following this incident, were not organization-wide, but Unit specific. The UM, who was also present, along with the Risk Manager, indicated an incident/occurrence report was NOT generated. The UM indicated, once again, that staff were verbally educated on EMTALA, and that all staff are to be trained on EMTALA not just the RNs (referencing the monthly EMTALA training schedule "Required ER RN Classes"). She stated that these classes had already been scheduled, prior to the incident on 08/13/14 and that there were still some staff that had not gone through a formal training on EMTALA, but had received verbal education following this incident. The UM, stated that EMTALA was brought up in staff meeting held on Monday, and EMTALA is also discussed in "huddle" meetings which occur daily (Risk Manager indicated that this is a brief meeting held with Department Heads daily). The facility does not document "Huddle" meetings. The UM was not able to immediately provide minutes for the Monday meeting, indicating the minutes were on her home computer and she had forgotten her password. A staff Member in the ED was selected to look at all patients with chest pain and transfers, this information would be collected monthly beginning this month (September). There was no data available at this time. Also stated that they were looking at EMTALA forms to make sure everything coincides and to make sure a MSE (Medical Screening Exam) was performed. There was nothing in writing presented by the UM to indicate active monitoring efforts at this time (on 9/10/14).

On 09/12/2014, just prior to survey exit at approximately 1:20pm, written evidence of monitoring and action plan implementation was presented. The hospital had completed 4 transfer/ EMTALA forms since 09/01/2014. The minutes to the "Monday" meeting [ED staff meeting] were also presented. A review of the meeting minutes and sign in sheet, dated 08/21/2014 identified a total of 6 (of 38) staff members in attendance. Meeting minutes indicated "EMTALA - Reviewed the importance of ensuring the physician is notified of when an EMS arrives in order to complete the MSE (Medical Screening Exam). This is the expectation when the EMS arrives on our property. This ensures that the physician has determined appropriate treatments and or transfers occur properly in accordance with EMTALA rules. In addition, the CHS EMTALA webex classes were posted. Reminder that this has been updated for all of ER staff to attend one class. ........ This is a mandatory requirement......" The UM - also indicated she spoke with the Supervisor of EMS- she was not sure what communication he had after that (with his staff).

Based on staff interview, physician interview, patient Emergency Department record review and the hospital's policy and procedure, the hospital failed to ensure the provision of an appropriate Medical Screening Examination for every patient that presented to the hospital's Dedicated Emergency Department for 1 of 26 sampled patients. (Patient #10)

The findings include:

Patient #10, was brought to the hospital's Emergency Department (ED) via Emergency Medical Services (EMS) transport with complaints of chest pain on August 13, 2014. Enroute to the hospital, two-way radio communication was established with the hospital; treatment (medications administered) and patient's significant cardiac history were relayed. A 12-lead EKG (electrocardiogram) was performed and was electronically transmitted to the hospital for physician review. Based on interpretation of the EKG report, the attending ED physician identified that Patient #10 would require interventional treatment, not available at the hospital. Before communication of this information could be relayed to EMS; EMS had arrived at the hospital's Emergency Department (Ambulance bay). Before the patient was taken out of the ambulance, the ambulance was approached by one of the hospital's ED Staff Registered Nurses (RN "L"). RN "L" informed EMS to transport Patient #10 to hospital XXXXX, that could provide 'interventional' treatment. The attending ED physician was not aware the patient had arrived to the Emergency Department and did not see the patient to conduct a Medical Screening Exam.

An interview was conducted with Registered Nurse "L" (RN "L") on 9/10/14 at approximately 3:44 pm. RN "L" confirmed that she was the one that instructed EMS to transfer patient #10 to another hospital, while the ambulance and patient were still in the ambulance bay, and the patient was not given a medical screening exam by the physician. She further indicated that she was the charge nurse on the shift at that time, and knew that she had made a mistake, but it was too late to do anything about it when she realized it.

An interview was conducted with the Health Unit Coordinator, Staff "M," on 9/11/14 at approximately 10:45 am. Staff M confirmed the charge nurse instructed the EMS personnel to transfer patient #10 to another hospital while the ambulance was still in the ambulance bay, and the patient had not been brought inside the hospital for a medical screening examination.

An interview was conducted with the Emergency Department Physician, physician "K," on 9/11/4 at approximately 11:30 am. Physician "K" was the emergency department physician on duty at the time of the transfer of patient #10. The physician stated he was made aware of the patient's EKG results transmitted by EMS to the hospital, and a short time later, he was made aware of the patient's medical history. When he found out that the patient had a history of multiple cardiac stents, and previous myocardial infarcts, he instructed staff to send the patient to a hospital with the capability to perform cardiac interventional procedures. He stated he was not aware that EMS had already arrived on the hospital property when he made the decision to send the patient to a cardiac hospital. He stated he was not informed that EMS had arrived on hospital property until after EMS had already departed for the receiving hospital.

On 09/10/14 at approximately 11:20am, an interview was conducted with the Unit Manager of the ED regarding the ED visit process. She stated that patients will be quick registered when they arrive (name, date, birthdate and gender), then triaged by Registered Nurse (RN) to determine if they go to "fast track." After that the Physician or Physician Assistant (PA) sees the patient - ..... nothing else can happen until the doctor performs the MSE. The UM references the incident that occurred on 08/13/14 - stating the physician said to bypass, this didn't happen by the time ambulance pulled up. The UM stated that the physician didn't even know the ambulance had arrived - EMS had called a report and it was ugly (significant cardiac history). The patient needed a cardiac hospital. Then the secretary said "hold on", opening door - grabbed charge nurse instead of doctor and charge nurse relayed only information doctor had told her (patient needed cardiac hospital.) The patient and his wife were enroute to the hospital in private vehicle when EMS intercepted.

On 09/10/2014 at 2:50pm, a phone interview was conducted with the Medical Director for the Emergency Department. He stated that Medical Screening Examinations are either conducted by one of the physicians or a midlevel practitioner (Physician Assistant or Nurse Practitioner) to determine if the patient has a medical emergency. He confirmed the hospital has an obligation to provide a medical screening exam and ensure that the patients' gets to the place that treats their problem. He stated that ER physicians receive EMTALA training as part of Emergency Medicine, and that there was a module he is supposed to look at next month. He was made aware of the event that occurred on 08/13/14 and stated that he made sure all nurses know that if a patient arrives to the ED, they have to be seen by a physician; no other way to do it. He was not sure if the physician on duty on 08/13/14 saw patient #10. The Medical Director stated that the physicians know they should see all patients that present to the ED. He indicated he sent out a message to ED physicians on how to transfer patients.

A review of the hospital's policy and procedure entitled "Medical Screening / Stabilization" defines "MEDICAL SCREENING/ STABILIZATION General Requirements" to include .... "the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital (including ancillary services routinely available in the Dedicated Emergency Department and emergency services offered at outpatient department or facilities) to determine whether an Emergency Medical Condition exists, or with respect to a pregnant woman having contractions...... and, if necessary, the Hospital must execute an Appropriate Transfer according to the guidelines of EMTALA and these policies." The policy identifies "The Location in Which the Medical Screening Examination Should be Performed:" "The Medical Screening Examination and other emergency services need not be provided in a location specifically identified as an emergency room or Dedicated Emergency Department. If an individual arrives at a facility and is not technically in the Dedicated Emergency Department, but is on the premises of the Hospital and requests emergency care, he or she is entitled to a Medical Screening Examination...." Medical Screening Examination Requirements indicate "...3. Individuals coming to the Dedicated Emergency Department must be provided a Medical Screening Examination. Triage is not equivalent to a Medical Screening Examination. Triage merely determines the "order" in which patients will be seen, not the presence of absence of an Emergency Medical Condition. 4. The Medical Screening Examination includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an Emergency Medical Condition..... 6. The Medical Screening Examination must be the same Medical Screening Examination that the Hospital would perform on any individual coming to the Hospital's Dedicated Emergency Department with those signs and symptoms, regardless of the individual's ability to pay for medical care......10. A Hospital that is not in diversionary status may not refuse or fail to accept a telephone or radio request for Transfer or admission. Such failure or refusal could represent a violation of the Hospital's obligations under EMTALA. Even when on diversionary status, if a patient arrives on camps, Hospital must provide a Medical Screening Examination within its Capacity and Capability, as well as Stabilizing Treatment. 11. Once a patient presents to the Dedicated Emergency Department of the hospital, whether by ambulance or otherwise, the hospital has an obligation to see the patient. A hospital's EMTALA obligations begin when the patient presents at the hospital's Dedicated Emergency Department on hospital property, or is picked up by a Hospital-owned ambulance, and a request is made for examination or treatment of an emergency medication condition. Patients arriving via ambulance meet this requirement when ambulance staff request treatment from hospital staff. Ambulance Parking is not appropriate and could result in an EMTALA violation."

Based on staff interviews, physician interview, patient Emergency Department record reviews and the hospital's policy and procedure, the hospital failed to provide a Medical Screening Examination for every patient that presented to the hospital's Dedicated Emergency Department, in order to determine if an emergency medical condition was present. The hospital failed to identify the stability of the patient and provide for an appropriate transfer for 1 of 26 patient medical records reviewed. (Patient #10)

The findings include:

Patient #10, was brought to the hospital's Emergency Department (ED) via Emergency Medical Services (EMS) transport with complaints of chest pain on August 13, 2014. Enroute to the hospital, two-way radio communication was established with the hospital; treatment (medications administered) and patient's significant cardiac history were relayed. A 12-lead EKG (electrocardiogram) was performed and was electronically transmitted to the hospital for physician review. Based on interpretation of EKG report, the attending ED physician identified that Patient #10 would require interventional treatment, not available at the hospital. Before communication of this information could be relayed to EMS; EMS had arrived at the hospital's Emergency Department (Ambulance bay). Before the patient was taken out of the ambulance, the ambulance was approached by one of the hospital's ED Staff Registered Nurses (RN "L"). RN "L" informed EMS to transport Patient #10 to hospital XXXXX, that could provide 'interventional' treatment. The attending ED physician was not aware the patient had arrived to the Emergency Department and did not see the patient to conduct a Medical Screening Exam. The stability of the patient was not determined by the physician prior to the patient being transferred. The EMS transport left before an appropriate transfer could be initiated by physician.

On 09/10/2014 at approximately 2:50pm, a telephone interview was conducted with the Medical Director of the ED. He stated it was the hospital's obligation to provide a Medical Screening Examine and to ensure that the patients' gets to the place that treats their problem. Stability of a patient is determined by Physician judgement. There is no particular protocol. If unstable and the hospital has something to help then the hospital has an obligation to treat. If the patient is unstable and the needs treating, sometimes it is best to get them to another place for treatment.

An interview was conducted with RN "L" on 9/10/14 at approximately 3:44 pm. RN "L" confirmed that she was the one that instructed EMS to transfer patient #10 to another hospital, while the ambulance and patient were still in the ambulance bay, and the patient was not given a medical screening exam by the physician. She further indicated that she was the charge nurse on the shift at that time, and knew that she had made a mistake, but it was too late to do anything about it when she realized it.

An interview was conducted with the Health Unit Coordinator, Staff "M," on 9/11/14 at approximately 10:45 am. Staff M confirmed the charge nurse instructed the EMS personnel to transfer patient #10 to another hospital while the ambulance was still in the ambulance bay, and the patient had not been brought inside the hospital for a medical screening examination.

An interview was conducted with the Emergency Department Physician, staff "K," on 9/11/4 at approximately 11:30 am. Staff "K" was the emergency department physician on duty at the time of the transfer of patient #10. The physician stated he was made aware of the patient's EKG results transmitted by EMS to the hospital, and a short time later, he was made aware of the patient's medical history. When he found out that the patient had a history of multiple cardiac stents, and previous myocardial infarcts, he instructed staff to send the patient to a hospital with the capability to perform cardiac interventional procedures. He stated he was not aware that EMS had already arrived on the hospital property when he made the decision to send the patient to a cardiac hospital. He stated he was not informed that EMS had arrived on hospital property until after EMS had already departed for the receiving hospital.

A review of the hospital's policy and procedure entitled "Emergency Medical Treatment and Patient Transfer, effective December 1998 and revised in September 2013, indicates under the heading "Appropriate Transfer ..1) the transferring Hospital provides medical treatment within its Capacity and Capability that minimizes the risks to the individual's health .... 4) the Transfer is effected through Qualified medical personnel and appropriate transportation and equipment ... ..." "Comes to the Emergency Department with respect to an individual requesting examination and treatment means the individual is on the Hospital Property (including parking lot, campus, ambulance bay, and other departments of the Hospital) ..." "Medical Screening Examination is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists .... Such screening must be done within the Hospital's Capacity and Capability and available personnel, including on-call physicians. The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either Stabilized or Appropriately transferred ...." "Qualified Medical Personnel refers to those individuals defined by the Hospital's Medical staff Bylaws, Rules and Regulations and approved by the Hospital's governing board to perform the initial Medical Screening Examination for those individuals who come to the Dedicated Emergency Department and request examination or treatment."
"Stabilized/ Stabilization: With respect to an Emergency Medical Condition, to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is like to result from or occur during the transfer of the individual from a facility ... ...4. If a Hospital has screened a patient and found the patient to have an Emergency Medical Condition, and admits that patient in good faith in order to Stabilize the Emergency Medical Condition, the Hospital has satisfied its special responsibilities under EMTALA with respect to that patient........"

Based on staff interview, physician interview, patient Emergency Department record reviews and the hospital's policy and procedures, the hospital failed to meet the requirements for an "appropriate transfer" as a result of failing to perform a Medical Screening Exam (MSE) to determine the presence of an emergency medical condition (EMC) for 1 of 26 sampled patients. (Patient #10)

The findings include:

Patient #10, was brought to the hospital's Emergency Department (ED) via Emergency Medical Services (EMS) transport with complaints of chest pain on August 13, 2014. Enroute to the hospital, two-way radio communication was established with the hospital; treatment (medications administered) and patient's significant cardiac history were relayed. A 12-lead EKG was performed and was electronically transmitted to the hospital for physician review. Based on interpretation of EKG report, attending ED physician (physician "K") identified that Patient #10 would require interventional treatment, not available at the hospital. Before communication of this information could be relayed to EMS; EMS had arrived at the hospital's Emergency Department (Ambulance bay). Before the patient was taken out of the ambulance, the ambulance was approached by one of the facility's ED Staff Registered Nurses (RN "L"). RN "L" informed EMS to transport Patient #10 to hospital XXXXX, that could provide 'interventional' treatment. The attending ED physician was not aware the patient had arrived and did not see the patient for a Medical Screening Exam - therefore, the requirement obligations for EMTALA failed to be met for an appropriate transfer. Requirements include written physician certification of expected benefits of transfer outweighs the risk and consent from patient or responsible party are aware of this risks and benefits of the transfer. The resident was subsequently transferred without incident or adverse outcome, however, the receiving hospital was not aware of the request to transfer from the hospital in question.

An interview was conducted with Registered Nurse "L" (RN "L") on 9/10/14 at approximately 3:44 pm. RN "L" confirmed that she was the one that instructed EMS to transfer patient #10 to another hospital, while the ambulance and patient were still in the ambulance bay, and the patient was not given a medical screening exam by the physician. She further indicated that she was the charge nurse on the shift at that time, and knew that she had made a mistake, but it was too late to do anything about it when she realized it.

An interview was conducted with the Health Unit Coordinator, Staff "M," on 9/11/14 at approximately 10:45 am. Staff M confirmed the charge nurse instructed the EMS personnel to transfer patient #10 to another hospital while the ambulance was still in the ambulance bay, and the patient had not been brought inside the hospital for a medical screening examination.

An interview was conducted with the Emergency Department Physician, physician "K," on 9/11/4 at approximately 11:30 am. Physician "K" was the emergency department physician on duty at the time of the transfer of patient #10. The physician stated he was made aware of the patient's EKG results transmitted by EMS to the hospital, and a short time later, he was made aware of the patient's medical history. When he found out that the patient had a history of multiple cardiac stents, and previous myocardial infarcts, he instructed staff to send the patient to a hospital with the capability to perform cardiac interventional procedures. He stated he was not aware that EMS had already arrived on the hospital property when he made the decision to send the patient to a cardiac hospital. He stated he was not informed that EMS had arrived on hospital property until after EMS had already departed for the receiving hospital.

On 09/10/2014 at approximately 10:35am, an interview was conducted with the Nurse Manager for the ED. She stated that patient transfers are made by physician determination with that patient and that sometimes the patient requests a transfer, or (facility) may transfer if not able to provide service to the patient. She stated, that the physician will have a conversation and make the determination for transfer with the patient. The physician informs the Unit Secretary regarding who to notify. The facility is contacted and starts the transfer process. The ED physician has a one on one conversation with receiving doctor - then they proceed with paperwork. They call and give report, contact EMS Transport service and the transfer occurs. This is a written process (EMTALA Transfer form) that the physician initiates to begin the transfer process.

A review of the hospital's policy and procedure entitled "EMTALA - Emergency Transfers" Section "6. Emergency Transfer. A hospital may not Transfer a patient with an Emergency Medical Condition unless (a) the Transfer is pursuant to a physician's order with an appropriate Physician Certification, or (b) the patient, or a legally responsible person acting on the patient's behalf, requests the Transfer, after being informed of the Hospital's obligations under EMTALA and of the risks and benefits of the Transfer. The request must be in writing and must include the following: - the request must contain a statement of the Hospital's obligations under EMTALA and the benefits and risks that were outlined to the person signing the request. - any Transfer of a patient with an Emergency Medical Condition must be initiated by either a written request for Transfer or a Physician Certification. If both are provided, as is often the case, the individual must still be informed of the risks versus benefits of the Transfer. - The request must be made part of the individual's medical record, and a copy of the request should be sent to the receiving Hospital when the patient is transferred. ......An emergency Appropriate Transfer to another Hospital will be appropriate only in those cases in which: The patient has an Emergency Medical Condition and has not been Stabilized for Discharge. - The patient is Stable for Transfers as defined by EMTALA. A patient is Stable for Transfer if the treating physician has determined, within reasonable clinical confidence, that the patient is expected to leave the Hospital and be received at a second facility, with no material deterioration in his/her medical condition; and the treating physician reasonably believes the receiving facility has the capability to manage the patient's medical condition and any reasonably foreseeable complication of that condition..... .....The Hospital, through its designated personnel and/or emergency department physicians, must obtain the consent of the receiving or recipient Hospital before the Transfer of the patient and must make the appropriate arrangements for the patient Transfers with an authorized representative of the receiving Hospital. 8. Physician Certification To meet the legal requirements for an Appropriate Transfer, for a patient who has not been Stabilized for Discharge, a physician must have signed a certification that, based on the information available at the time of Transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another Hospital outweigh the increased risks to the individual ........ - An express written Physician Certification is required. A Physician Certification cannot be implied from the findings in the patient medical record and the fact that the patient was transferred.