HospitalInspections.org

Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of §42CFR 489.20 and §42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases.

Findings include:

Hospital policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)", revealed: "...Definition: Capability refers to the hospital's physical space, equipment, supplies, and services (e.g. trauma care, surgery, intensive care, pediatrics, obstetrics, burn unit, neonatal unit or psychiatry), including ancillary services routinely available to the emergency department and emergency services available to inpatients. Capabilities of the staff of a facility means the level of care that the personnel of the hospital can provide within the training and scope of their professional licenses. This includes coverage available through hospital's on-call physician roster. The hospital is responsible go treating the individual within the capabilities of the hospital as a who;e, not necessarily in terms of the particular department at which the individual presented. The hospital is not required to locate additional personnel or require staff at off-campus departments to be on call for possible emergencies...Comes to the Emergency Department means an individual who: has presented at a hospital's dedicated emergency department and requests examination or treatment for a medical condition or has such a request made on his or her behalf...Emergency Medical Condition (EMC) means: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) is serious jeopardy; Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part; or...Hospital Property means the entire main hospital campus as defined in §413.65(b) of this chapter, including the physical area immediately adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings bur which are located within 250 yards of the main buildings, and any other areas that have been determined by CMS to be part of the provider's campus, as well as the parking lots, sidewalks, and driveways,...Medical Screening Examination (MSE) 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...On-Call List refers to the list that a hospital is required to maintain that identify those physicians who are "on-call" duty after the intial MSE to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC. The purpose of the on-call list is to ensure that the emergency department is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide treatment necessary to stabilize individuals with EMCs...General EMTALA Obligations: EMTALA requirements: ...Provide an appropriate medical screening examination by a qualified medical professional, within the capability of the hospital's emergency department, to determine whether or not an emergency medical condition exists, and if an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, or an appropriate transfer...Central Log: The Hospital shall maintain a Central Log on each individual who comes to the Emergency Department seeking assistance. The purpose of the Central Log is to track the care provided to each individual who comes to the Hospital seeking care for an emergency medical condition, and should include all patients presenting to the ED regardless of whether they actually received treatment...If the patient has not provided registration information before he/she leaves, the Hospital should register that patient as John Doe/Jane Doe...Medical Screening: When an individual comes to the emergency department (ED) requesting medical treatment, an appropriate MSE, within the capabilities of the ED (including ancillary services routinely available in the ED), shall be provided to determine whether an emergency medical condition (EMC) exists or , with respect to a pregnant woman having contractions, whether the woman is in labor...The MSE 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 EMC; all medical screenings do not have to be equally extensive...An MSE, stabilizing treatment, or appropriate transfer may not be delayed in order to obtain patient financial information...."

The hospital failed to ensure a patient (Patient #1) who was brought to the Emergency Department (ED) by ambulance was entered into the dedicated ED log.

The hospital failed to provide a Medical Screening Examination (MSE) to a patient (Patient #1) who was taken to the Emergency Department by ambulance. The ambulance was "diverted" by a medical provider to a different hospital (hospital #2).

Patient #1 EMS Runsheet dated 02/28/2023 revealed: "...[PM370] was pulling into the ambulance bay at OVH at this time and diverted to [NWH] (hospital #2)...OVH was informed that [PM370] was on their property with a pt {sic} and OVH diverted [PM370] to [NWH] (hospital #2)...."

Employee #10 confirmed on 04/12/2023 that video of the ambulance bay area revealed the EMS unit with Patient #1 was in the ambulance bay at the time of the medical provider diverted the ambulance to [Northwest] (hospital #2). Employee #10 stated that the EMS unit did not notify the hospital that they were on hospital property or in the ambulance bay at the time of diversion by the medical provider.

Based on review of policies and procedures, hospital documents, medical records and staff interviews, it was determined the hospital failed to ensure a patient (Patient #1) who was brought to the Emergency Department by ambulance was entered into the dedicated ED log.

Findings include:

Hospital policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)", revealed: "...Central Log: The Hospital shall maintain a Central Log on each individual who comes to the Emergency Department seeking assistance. The purpose of the Central Log is to track the care provided to each individual who comes to the Hospital seeking care for an emergency medical condition, and should include all patients presenting to the ED regardless of whether they actually received treatment...If the patient has not provided registration information before he/she leaves, the Hospital should register that patient as John Doe/Jane Doe...."

A review of the ED log for 02/28/2023 revealed no documentation that Patient #1 presented to the hospital by ambulance and the ambulance was diverted to another facility prior to the patient receiving a Medical Screening Examination.

Employee #12 confirmed on 04/13/2023 that the hospital had not been provided any patient information by EMS regarding Patient #1. Employee #12 confirmed Patient #1 was diverted to another hospital by the medical provider and was not examined in the ED.

Based on review of policies and procedures, hospital documents and staff interviews, it was determined that the hospital failed to provide a Medical Screening Examination to a patient who presented to the ED for examination and treatment. (Patient #1)

Findings include:

Hospital policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)", revealed: "...Definition: Capability refers to the hospital's physical space, equipment, supplies, and services (e.g. trauma care, surgery, intensive care, pediatrics, obstetrics, burn unit, neonatal unit or psychiatry), including ancillary services routinely available to the emergency department and emergency services available to inpatients. Capabilities of the staff of a facility means the level of care that the personnel of the hospital can provide within the training and scope of their professional licenses. This includes coverage available through hospital's on-call physician roster. The hospital is responsible go treating the individual within the capabilities of the hospital as a who;e, not necessarily in terms of the particular department at which the individual presented. The hospital is not required to locate additional personnel or require staff at off-campus departments to be on call for possible emergencies...Comes to the Emergency Department means an individual who: has presented at a hospital's dedicated emergency department and requests examination or treatment for a medical condition or has such a request made on his or her behalf...Emergency Medical Condition (EMC) means: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) is serious jeopardy; Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part; or...Hospital Property means the entire main hospital campus as defined in §413.65(b) of this chapter, including the physical area immediately adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings bur which are located within 250 yards of the main buildings, and any other areas that have been determined by CMS to be part of the provider's campus, as well as the parking lots, sidewalks, and driveways,...Medical Screening Examination (MSE) 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...On-Call List refers to the list that a hospital is required to maintain that identify those physicians who are "on-call" duty after the intial MSE to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC. The purpose of the on-call list is to ensure that the emergency department is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide treatment necessary to stabilize individuals with EMCs...General EMTALA Obligations: EMTALA requirements: ...Provide an appropriate medical screening examination by a qualified medical professional, within the capability of the hospital's emergency department, to determine whether or not an emergency medical condition exists, and if an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, or an appropriate transfer...Medical Screening: When an individual comes to the emergency department (ED) requesting medical treatment, an appropriate MSE, within the capabilities of the ED (including ancillary services routinely available in the ED), shall be provided to determine whether an emergency medical condition (EMC) exists or , with respect to a pregnant woman having contractions, whether the woman is in labor...The MSE 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 EMC; all medical screenings do not have to be equally extensive...An MSE, stabilizing treatment, or appropriate transfer may not be delayed in order to obtain patient financial information...."

Hospital policy titled' "Triage", revealed: "...Purpose: Provides a standardized systematic method of patient assessment to the appropriate triage category that will determine the priority in which patients are treated for their presenting complaint...Oro Valley Hospital uses the V level Emergency Severity Index (ESI) to establish acuity levels for treatment of Emergency Department patients presenting for medical evaluation...A registered nurse (RN) assesses all patients [resenting to the Emergency Department (ED). A brief history is taken by the RN and a brief Medical Screening Exam (MSE) is done by the ED Physician... The ESI triage category of treatment priority is then assigned according to the individual patient assessment...Placement of patients into the appropriate triage category is determined by both subjective and objective assessments, and evaluation of information such as patient complaint, history, age, vital signs, and physical appearance...The triage nurse identifies patients needing immediate definitive care and initiates appropriate intervention...Triage category: Level 1 - Resuscitation- Requires immediate life-saving intervention;..."

A request was made for a diversion policy or protocol. The facility was unable to provide one.

Hospital document titled, "OVH STEMI Changes", revealed: "...To: EMS partners
Re: Oro Valley Hospital Cath Lab and STEMI Coverage
I am writing to provide an update regarding the types of patients that should be transported to
Oro Valley Hospital in light of the recent changes to Cath Lab services at the hospital including
STEMI coverage.
As was discussed in the previous memo, beginning Friday, August 5, 2022 at 4:30 p.m., the
cath lab at Oro Valley Hospital has been operating during the hours of 7a.m. - 4:30 p.m.,
Monday through Friday, for all inpatient and outpatient elective cardiac procedures. Staff and
physicians will continue to schedule cases as usual within the new hours of operation. This still
stands with no changes.
STEMI patients arriving via EMS should continue to be directed to Northwest Medical Center.
EMS providers should not bring confirmed STEMI patients to Oro Valley Hospital, however,
going forward patients experiencing chest pain of any kind (with the exception of a confirmed
STEMI) can be directed to Oro Valley Hospital as non-interventional Cardiology coverage will
still be available at all times...."

Hospital document titled, OVH Medical Staff Officers Bylaws", revealed: "...Rules and Regulations:...B. Emergency Department:...4. A physician shall be in the Hospital and immediately available for rendering emergency patient care twenty-four (24) hours per day, seven (7) days per week...Patients with conditions whose definitive care is beyond the capabilities of this Hospital shall be referred to the appropriate facility, when in the judgment of the attending Practitioner, the patient's condition permits such a transfer...."

Hospital document titled, "Event Report", revealed: "...OVH received telemetry phone call from [GRFD unit 370] at 1628, [Amanda Poer] RN answered the phone. [370] stated [Paramedic 370] was transporting a [male] patient, unknown age, MVC (motor vehicle collision). Patient is unresponsive, heart rate in the 30's, spo2 40%, externally pacing the patient". At that time [unit 370] requested medical direction and asked, "Can we proceed to your facility?' At this time [Amanda]RN requested [Dr Robert Orava] medical provider to speak with the unit and he immediately instructed the unit to divert to [NMC] (hospital #2) for the potential need of cath lab availability. OVH does not have 24/7 cath lab capabilities and the cath lab was currently closed at the time of the call. At this time the unit diverted, [Dr. Orava] signed the EMS pre hospital runs sheet with [his] instructions to divert to an appropriate facility with full capabilities for this patient. OVH ED was never notified of [unit 370] specific location or that they were ever on site at OVH. It was later noted via ambulance bay cameras that [unit 370] pulled into the OVH ambulance bay at 1630, never stopped, no one exited the ambulance and they kept driving through the ambulance bay area and left...Investigation findings: OVH ED did not have any contact with [unit 370] in person, only via telemetry phone call. OVH ED never received patient information including name or DOB. Patient was diverted per provider medical direction to an appropriate facility with cath lab availability which OVH does not have 24/7. At the time of the call OVH cath lab was closed for the day. [Dr. Orava] (provider) made the appropriate decision to divert [unit 370] and this was in the best interest of the patient based on the presentation provided by [unit 370]. [Unit 370] did not communicate their location with OVH ED or notify them that they were arriving on scene at OVH at 1630. When the call came in at 1628. Ultimately the patient went into cardiac arrest enroute to [NMC] (hospital #2) and OVH ED was not notified of the change in patient status either. OVH ED and provider made the appropriate decision to divert this unit and patient to the appropriate facility with full capabilities...."

A request was made for Patient #1 medical record from Hospital #1. The facility was unable to provide one.

Patient #1 EMS runsheet dated 02/28/2023 revealed: "...Decision was made to transport the pt {sic} to OVH. Once in [PM370], the pt {sic} began breathing slower at 8 per minute and was no longer responsive. The pts{sic}color began to turn pale/blue. Carotid pulse was present, but slow. [EMT Schobel] placed pads on the pt while [CEP Thorson] started an IV in the pts {sic} left EJ (external jugular vein), successful, flushed easily. Once on the pads, the pt {sic} was found to be in a 3rd degree block. [CEP Thorson] began pacing the pt {sic} at a rate of 80, with 90 milliamp's. Capture was shown on the monitor and mechanical capture was found by radial pulse. Pt{sic} still breathing at 8-10 per minute. At this time, [CEP Port] called OVH to inform them of the paced pt in a 3rd degree block. The receiving nurse asked [CEP Port] to talk to a doctor, who informed [CEP Port] they could not take a 3rd degree block, and [PM 370] needed to divert to [NWH] (hospital #2). [PM370] was pulling into the ambulance bay at OVH at this time and diverted to [NWH] ( hospital #2). [CEP Thorson] was preparing to place the pt {sic} on oxygen via NRB (non rebreather mask) when the pt {sic} began having agonal respirations . Pacing was stopped to check a carotid pulse. Carotid pulse was absent, and the pt {sic} was apneic (not breathing). CPR (cardiopulmonary resuscitation) was initiated by [EMT Schobel]. [CEP Thorson] inserted an I-Gel into the pts {sic} airway successfully and began bagging the pt {sic} at 10/minute. BVM (bag-valve-mask) was used at 10/minute throughout. [CEP Port] administered 1mg of Epi 1:10 via the EJ IV. Rhythm checks 1, 2, and 3 were v fib with a shock administered and CPR immediately resumed. 4th rhythm check was asystole ( no heart rhythm), CPR resumed. [NWH] (hospital #2) was notified that [PM370] was coming to their facility with a cardiac arrest. Pt {sic} was moved from [PM370] into [NWH] ( hospital #2) room [7]. CPR and mechanical ventilation were both done while pt {sic} was being moved into [NWH] (hospital #2). Pt {sic} was disconnected from [PM370] monitor and moved onto the bed in room [7]. CPR was resumed by ED staff, report and pt{sic} care given to RN [April D]. E: Pt {sic}did not receive 2nd dose of epi or amiodarone due to being moved out of [PM370] and into [NWH] (hospital #2) during the time both medications would've been given. ETCO2 was not used due to the proper equipment not being available. [CEP Thorson] was unable to find the pts home address. OVH was informed that [PM370] was on their property with a pt {sic}, and OVH diverted [PM370] to [NWH] (hospital #2)...."

Patient #1 Pre-Hospital EMS Communication from hospital #2 dated 02/28/2023 at 1635 revealed: "...ETA (estimated time of arrival) 5 min...chief complaint: cardiac arrest, was initially unstable 3rd degree block and was diverted by Oro Valley, Pt, {sic} immediately coded. Crew bypassed Oro Valley...."

Patient #1 ED Triage note dated 02/28/2023 revealed: "...triage time: 1645...Chief complaint: Drove off the road at [Oracle and Wilds road in Catalina], Upon EMS arrival pt{sic} was altered and in complete heart block then patient immediately started coding...

Patient #1 ED physician admission note dated 02/28/2023 from hospital #2 revealed: "...diagnosis: NSTEMI (non-ST elevated myocardial infarction); cardiac arrest; Forehead laceration...I did initiate STEMI protocol based on the patient's multiple episodes of ventricular fibrillation and ventricular tachycardia likely suggesting a cardiac arrest. I spoke with the cardiologist [Dr. Rathore] who does not recommend initiating STEMI protocol and will not take the patient to the cardiac catherization lab at this time...The patient was admitted after discussion with [Dr Alnajaar] (ICU Hospitalist) for further evaluation and management of [his] postcardiac arrest care in critical condition...."

A random sample of an additional nineteen (19) ED patient clinical records were reviewed of patients arriving by EMS from January through March 2023. Three (3) patients arrived to the ED in cardiac arrest and with CPR being actively performed. One (1) patient arrived via helicopter for a myocardial infarction. Five (5) patients were brought in via EMS with chest pain. Documentation in those records revealed the patients received MSE's with no delays in treatment.

Tour of the Emergency Department was conducted on 04/12/2023. Observation revealed the ambulance bay entrance was visible from the main hall of the Emergency Department. Observation of the telemetry phone revealed the ambulance bay entrance was not visible from the telemetry phone location.

Employee #10 confirmed on 04/12/2023 that the ED staff did not know that EMS was in the ambulance bay with Patient #1. Employee #10 confirmed that the provider made the decision to divert the patient and EMS thinking that the patient needed a higher level of care than what was offered at OVH. Employee #10 stated "if we had known they were outside we would have treated the patient.

Employee #12 confirmed on 04/12/2023 that the hospital was not made aware that EMS was on hospital property with Patient #1 when the provider diverted the patient until the receiving hospital notified OVH the next day. Employee #12 confirmed that the hospital conducted an investigation into the incident with Patient #1 and determined that the provider had made appropriate decision in diverting the patient since the cath lab was not available.