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Based on record review and interviews, Hospital #1 failed to ensure that one of twenty patients (Patient #1) received an appropriate medical screening. Patient #1 was evaluated in Hospital #1's Emergency Department (ED) was stabilized and discharged. While enroute back to the Facility (Skilled Nursing Facility, a nursing home) where Patient #1 resided, Patient #1 had seizure activity and the ambulance returned to the Emergency Department. When the ambulance returned to the Emergency Department, ED Physician #1 and the ED Charge Nurse met the ambulance outside the Emergency Department in the ambulance bay. ED Physician #1 looked at Patient #1, determined Patient #1 was stable for transport and sent Patient #1 back to the Facility without conducting an appropriate medical screening.

Findings include:

The Ambulance Run Report, dated 3/30/12, indicated that an ambulance was dispatched to the Facility due to a patient fall with possible seizure activity. The Ambulance Run Report indicated that Patient #1's diagnoses included Seizure Disorder and medications to manage Patient #1's seizure disorder included Dilantin, Valium, and Phenobarbital.

The Ambulance Run Report, dated 3/30/12, indicated that staff reported Patient #1 had an unwitnessed fall in the bathroom and when staff responded to the fall, they observed Patient #1 having grand-mal or tonic/clonic (a grand mal seizure - also known as a tonic-clonic seizure features violent muscle contractions caused by abnormal electrical activity throughout the brain) seizure activity and Valium (antianxiety medication used to treat epileptic seizure activity) was administered. The Ambulance Run Report indicated that the Ambulance attendants observed Patient #1 with seizure activity lasting 2-3 minutes. The Ambulance Run Report indicated that Patient #1's airway was patent and he/she was neurologically within normal limits. The Ambulance Run Report indicated that Patient #1 was boarded and collared, an intravenous line was inserted, oxygen was applied and Patient #1 was then transported to Hospital #1's ED.

The ED Face Sheet, dated 3/30/12, indicated that Patient #1 arrived at Hospital #1's ED at 8:44 P.M. Patient #1 was triaged as an ESI (Emergency Severity Index, priority setting and rapid identification of the patient's needs) Level 3 (2 or more resources required, needs treatment in 1 to 3 hours) and was placed directly into a treatment room in the ED.

The Emergency Physician Record, dated 3/30/12, indicated that ED Physician #1 examined Patient #1 at 9:10 P.M.

The Surveyor interviewed ED Physician #1 on 4/12/12 at 1:00 P.M. ED Physician #1 said he was familiar with Patient #1 from past visits and Patient #1 had a history of petit-mal (Absence seizure involves a brief, sudden lapse of consciousness and may look like he or she is staring into space for a few seconds), and tonic/clonic seizure activity. ED Physician #1 said that when he examined Patient #1, he/she was alert and oriented and was not actively seizing. ED Physician #1 said he ordered diagnostics and a cervical spine CT scan.

The Physician Orders, dated 3/30/12, included a cervical spine CT scan, urinalysis, complete blood count and metabolic panel and Dilantin/Phenobarbital levels.

The cervical spine CT scan Diagnostic Imaging Report, dated 3/30/12, was within normal limits.

The Laboratory Report, dated 3/30/12, indicated that blood testing was essentially within normal limits and the urinalysis was positive for infection.

The ED Physician Orders and Medication Administration Record, dated 3/30/12, indicated that Augmentin (anti-infective agent) was ordered and administered.

The Surveyor interviewed the nurse assigned to Patient #1 (ED Nurse #1) on 4/12/12 at 2:35 P.M. ED Nurse #1 said Patient #1 remained stable, was not actively seizing and was laughing/joking with family members who came in to be with him/her. ED Nurse #1 said that after all the test results returned and Patient #1 was started on Augmentin, ED Physician #1 cleared Patient #1 for discharge. ED Nurse #1 said she called report to a nurse at the Facility and arranged for Patient #1's ambulance transfer back to the Facility. ED Nurse #1 said Patient #1 and his/her family was in agreement with the transfer.

The ED Discharge Date, dated 3/31/12, indicated that Patient #1 was discharged back to the Facility at 1:00 A.M.

The Ambulance Run Report, dated 3/30/12 to 3/31/12, indicated that Patient #1 was transported back to the Facility by the Emergency Medical Technician (EMT)-Paramedic and the EMT-Basic. The Ambulance Run Report indicated that during transport, Patient #1 experienced tonic/clonic seizure activity lasting approximately 1 minute with a post-ictal (altered state of consciousness that a person enters after experiencing a seizure. Usually lasts between 5 and 30 minutes, but sometimes longer in the case of larger or more severe seizures and is characterized by drowsiness, confusion, nausea, hypertension, headache or migraine and other disorienting symptoms) period of 10 minutes. The Ambulance Run Report indicated that an intravenous line was inserted, a cardiac/respiratory monitor was applied and oxygen was applied. The Ambulance Run Report indicated that Patient #1's blood pressure and pulse rate were slightly elevated and his/her oxygen saturation level (SpO2, indicative of the oxygen level in the bloodstream) was within normal limits on 4 liters of oxygen via nasal cannula.

The Surveyor interviewed the EMT-Paramedic on 4/11/12 at 10:20 A.M. The EMT-Paramedic said when they picked up Patient #1 from Hospital #1's ED for transport, Patient #1 was alert and oriented and was not actively seizing. The EMT-Paramedic said approximately 10 minutes into transport, Patient #1 began to have tonic/clonic movements. The EMT-Paramedic said Emergency Medical Services protocol required them to return Patient #1 back to Hospital #1 because Patient #1's condition changed during transport. Note: Actually, the standard is not under the Protocols, but rather under the EMS System regulations, 105 CMR 170.000, that requires EMS to take emergency patients only to acute care hospitals with emergency departments. This patient did fit the definition of "emergency" in 105 CMR 170.000]. The EMT-Paramedic said he told the EMT-Basic to return to Hospital #1's ED. The EMT-Paramedic said he called the ED, started an intravenous line and applied oxygen. The EMT-Paramedic said that when they got closer to Hospital #1, he called again with an update and the Charge Nurse told him a physician would meet them out in the ambulance bay.

The ED Charge Nurse said she took the initial call regarding Patient #1's seizure activity and that the ambulance was returning to Hospital #1's ED. The Charge Nurse said she told ED Physician #1 that Patient #1 was returning due to seizure activity and ED Physician #1 said there was no need for that. The Charge Nurse said when the EMT-Paramedic called again, she told him that Patient #1 had a known seizure disorder and that she would meet them in the ambulance bay. The Charge Nurse said when the ambulance arrived, she and ED Physician #1 went to the ambulance bay to look at Patient #1.

ED Physician #1 said he was told by the Charge Nurse that Patient #1 was returning to the ED due to seizure activity. ED Physician #1 said when the ambulance arrived in the bay, the Charge Nurse told him to come with her to look at Patient #1. ED Physician #1 said when he examined Patient #1 in the ambulance, Patient #1 was alert and oriented, seizure-free and able to follow commands. ED Physician #1 said he told the EMT-Paramedic that Patient #1 was stable and safe to return to the Facility.

Review of the ED record, dated 3/30/12, indicated that documentation regarding ED Physician #1's re-examination of Patient #1 outside the ED in the ambulance bay was not written until 4/3/12 at which time ED Physician #1 wrote an addendum note indicating that he examined Patient #1 in the ambulance bay and cleared Patient #1 for return to the Facility.

The Charge Nurse said ED Physician #1 looked at Patient #1 and said Patient #1 was at baseline and there was no need for Patient #1 to be at the ED. The Charge Nurse said the EMT-Paramedic looked worried, so she offered to call the Facility. The Charge Nurse said she went into the ED, called the Facility, spoke with a nurse and explained what had happened to Patient #1 during transport. The Charge Nurse said she asked the nurse if the Facility would accept Patient #1 back and the nurse said they would as long as Patient #1 was not in status epilepticus (a state of continuous seizure activity).

The Facility Nursing Note, dated 3/30/12, indicated that the ED Charge Nurse called and informed the Facility about Patient #1's seizure activity while in transport, that the ambulance had returned to the ED and they had met the ambulance at the ED door. The Nursing Note indicated that the Charge Nurse asked if the Facility could handle Patient #1's seizures and was told the Facility could as long as the seizure activity did not continue because the Facility did not have the capability of administering large doses of anti-seizure medication and properly monitor Patient #1.

The Charge Nurse said after she hung up from speaking with the Facility nurse, she informed the EMT-Paramedic that Patient #1 could return to the Facility.

ED Physician #1 said that at the time, he did not consider this action as an EMTALA violation.

Review of the ED's Corrective Action Plan, dated 4/6/12, included: immediate verbal education to ED physicians and nurses regarding medical screening requirements (completed 4/6/12), mandated education to ED physicians regarding medical screening requirements and EMTALA regulations (completed 4/11/12), counseling of the Chief of Medical Services regarding reporting EMTALA violations (4/11/12) and review of the case in detail during the ED Physician's Meeting (4/11/12).

Pending at the time of the survey was review of the Physician Certification form to determine if changes are needed and case study presentations on EMTALA issues by Hospital #1's legal department. As part of ongoing monitoring for compliance, the Chief will review 30 random cases for compliance with EMTALA requirements until there is 100% compliance for 3 months. Noncompliance will be reviewed with the physician involved and may result in disciplinary action.