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Based on review of facility policies, review of the Emergency Department (ED) central log, review of an Emergency Medical Services (EMS) Patient Care Record, medical record review, review of an EMS incident report, review of a facility investigation, and interview, the facility failed to list one patient (#35) on the ED central log and failed to provide a Medical Screening Examination for one (#35) patient of 35 ED patients reviewed.

For documentation purposes:

Hospital A is Memorial Hospital Chattanooga with 2 campuses with dedicated EDs located in the Chattanooga area.

The Main Campus is Memorial Hospital Chattanooga located at 2525 de Sales Avenue Chattanooga, Tennessee (TN) 37404.

The Hixson Campus is Memorial Hospital Hixson located at 2051 Hamill Road
Hixson, TN 37343 (located 0.50 miles from the location where Patient #35 went into cardiac and respiratory arrest on 1/27/18).

Hospital B is Erlanger Medical Center located at 979 East Third Street, Chattanooga TN 37403 (located 8.1 miles from Hospital A's Hixson Campus).

Review on 3/7/18 of the facility's Investigation, Root Cause Analysis, and Action Plan revealed the facility implemented the following interventions:
1. The investigation revealed the facility had policies and procedures that met EMTALA requirements. The policies and procedures were not followed by an ED Registered Nurse (RN #1) at the Hixson Campus on 1/27/18.
2. On 1/31/18 the facility completed a detailed investigation of Patient #35's visit to the Hixson Campus on 1/27/18 and determined a violation of the facility's EMTALA policies and EMTALA regulations had occurred. The facility discussed the EMTALA violation with Hospital B's Administration and agreed Hospital B would report the EMTALA violations as it was the "receiving" hospital.
3. Review of the facility's investigation and action plan revealed the facility terminated RN #1 on 1/31/18 for failing to follow facility policies and for violation of EMTALA regulations.
4. Review of the facility action plan revealed all ED employees at both campuses were re-educated on EMTALA policies and requirements.
a. All ED employees at both campuses were immediately provided the hospital's EMTALA policies by email with specific instructions regarding the requirement for all patients presenting to receive a Medical Screening Examination (MSE). ED staff were educated on escalation/reporting of patient care concerns to supervisors/management. All staff had to sign confirmations they had read the policies (completed on 1/31/18).
b. Facility administration assessed the current status of EMTALA training for all ED employees and all staff had to complete the appropriate level of EMTALA training by 2/1/18. The training was provided by both staff meetings and by computerized training.
c. Face to face counseling and instructions on EMTALA policies and requirements was immediately done with each ED employee by ED managers (completed 2/28/18).
d. On-going training and reinforcement of previous education is provided by daily Huddle communications (completed by 2/28/18) and a Huddle board was observed in use during the investigation detailing EMTALA requirements in both the EDs.
e. Interviews with ED managers revealed management is monitoring staff for compliance with these interventions by record reviews, random observations of staff, interviews with random staff and patients, and face to face drills with staff during which they are provided EMTALA scenarios to describe how they would manage these scenarios.
f. Interviews with random ED staff at both EDs during the investigation revealed they were knowledgeable of the facility's EMTALA polices and were familiar with EMTALA requirements.

Refer to A-2405 and A-2406.

Based on review of facility policies, Emergency Department (ED) Central Log review, review of an Emergency Medical Services (EMS) Patient Care Record, medical record review, review of an EMS incident report, review of a facility investigation, and interview, revealed the facility failed to include on one patient (#35) on the ED central log out of 35 ED patients reviewed.

The findings included:

Review of facility policy titled "EMTALA GUIDELINES - TREATMENT & TRANSFER OF INDIVIDUALS IN NEED OF EMERGENCY MEDICAL SERVICES" policy number PC-07179, effective date September 2009, revealed "...EMTALA obligations are triggered...requires examination and/or treatment for an EMC [emergency medical condition] although no request for treatment is made...Central Log...A log containing information regarding each individual who 'Comes to the Emergency Department'...The Central Log must contain at minimum, the name of the individual seeking assistance, whether the individual refused treatment, was refused treatment, admitted and treated, admitted and transferred, or discharged..."

Review of Hospital A's Hixson Campus ED central log dated 1/27/18 revealed Patient #35's name, treatment, and/or disposition was not documented on the log.

Review of an EMS Patient Care Record for Patient #35 dated 1/27/18 at 3:09 PM revealed "...Cardiac Arrest [no heart beat]...Respiratory Arrest [not breathing]...Dispatched to a dialysis center for a patient in full cardiac arrest...He was defibrillated [electrical shock to the heart]...without a pulse...He was moved to the ambulance...without a pulse...he was defibrillated again...Patient was transported to [Hospital A's Hixson Campus]...then diverted to [Hospital B]..." Further review of the EMS record revealed EMS departed the dialysis center with the patient at 3:22 PM and transported the patient to Hospital A (no time documented). Continued review revealed EMS was diverted from Hospital A (no time documented) and arrived at Hospital B at 3:40 PM (18 minutes later). Further review of the EMS record revealed the patient's O2 Saturation levels (amount of oxygen in the blood, normal is 94-99%) were:
44% at 3:27 PM
70% at 3:32 PM
81% at 3:36 PM
92% at 3:41 PM

Medical record review revealed the patient was admitted at Hospital B on 1/27/17 at 3:42 PM.

Medical record review of a Physician's Provider Notes at Hospital B dated 1/27/18 at 4:29 PM revealed "...O2 Saturation 26%...witnessed arrest...Patient was intubated for airway protection, after intubation, patient became hypotensive [low blood pressure]...did not respond and went into PEA [pulseless electrical activity]...CPR [cardiopulmonary resuscitation] performed...Discussed with cardiology who will plan for possible [heart] cath [insertion of a catheter into the heart]..." Further review revealed the patient was admitted to the Intensive Care Unit (ICU) on 1/27/18 and placed on a ventilator (machine used for mechanical breathing) with a diagnosis of Cardiac Arrest. Continued review of the medical record revealed the patient was discharged home in fair condition on 2/3/18.

Review of an EMS incident report dated 1/27/18 revealed "...The call was initially a CPR in progress, however, just prior to transport...[Patient #34] had a ROSC [return of spontaneous circulation]...Upon having the change in pt. status, the crew called to check the availability of a supervisor to perform an RSI [rapid sequence intubation] [placement of a tube in the patients airway to quickly open and secure the patient's airway] on their pt. When determined that the nearest supervisor was greater than 15 min. [minutes] away, they were instructed to transport to [Hospital A's Hixson Campus] due to its close proximity to the call. Upon arriving at [Hospital A's Hixson Campus]...[Emergency Medical Technician (EMT) #1] was met outside as he exited the unit by [Registered Nurse (RN) #1]...[RN #1] advised [EMT #1] that if they had ROSC, then they just needed to transport to [Hospital B] ED...[EMT #1] advised [RN #1] that 'we are already here though,' at which point [RN #1] stated that they just needed to leave and transport the pt. to [Hospital B]. The crew did as instructed...and began transport to [Hospital B]...They were able to maintain their pt. via BVM [bag-mask ventilation] en route, however, an advanced airway wasn't placed. The pt. was ultimately intubated at [Hospital B] ED after the pt. lost a pulse and was revived again...[Hospital A's Hixson Campus] ED did not evaluate this pt. at any point..." Further review of a written statement by EMT #1 dated 1/27/18 at 8:55 PM revealed "...Regarding CPR at dialysis clinic...On this CPR we had a ROSC and called for an RSI...[supervisor] advised [Hospital A's Hixson Campus] is across the street...At which time we transported to [Hospital A's Hixson Campus] and were met in the ambulance bay by [RN#1]...[RN #1] stated if you have a pulse back he [Patient #35] needs to go to [Hospital B]. I stated 'We're already here' to which the reply was, 'it doesn't matter he needs to go to [Hospital B]'...The patient was transported to [Hospital B] at that time..."

Review of a facility investigation at Hospital A Hixson Campus revealed an Email from an EMS manager to Hospital A's ED Manager dated 1/29/18. Further review revealed "...On Saturday [1/27/18] one of my crews responded to a CPR in progress at the dialysis center...the crew was having trouble establishing an advanced airway on the patient...[Hospital A's Hixson Campus] was only a couple of minutes away...they transported the patient to [Hospital A's Hixson campus]. They did a radio call in prior to arrival. But when they arrived in the ambulance bay they were told by [RN #1] that they just needed to transport to [Hospital B] due to obtaining ROSC. The crew member said 'But we are already here'...[RN #1] then told the crew to leave and transport the patient to [Hospital B]. They did as instructed and transported to [Hospital B]..."

Interview with the Vice President of Quality (VPQ) at Hospital A Hixson Campus, in the administration conference room, on 3/7/18 at 3:00 PM revealed the facility was notified on 1/29/18 of a possible EMTALA violation occurring on 1/27/18 at the Hixson Campus. Further interview revealed the VPQ and ED Manager investigated the incident on 1/29/18 and confirmed Patient #35 had arrived by EMS on 1/27/18 at the Hixson Campus ED entrance and was met outside the ED by RN #1 who told EMS to take the patient to Hospital B, which EMS did. Further interview with the VPQ confirmed Patient #35 was not included on the ED central log for 1/27/18.

Interview with the ED Manager at Hospital A Hixson Campus, in the ED Break Room, on 3/8/18 at 10:00 AM revealed she was notified on 1/29/18 of the alleged EMTALA violation involving Patient #35 on 1/27/18. Further interview revealed the ED Manager was notified of the allegation by an Email from an EMS manager on 1/29/18. Continued interview revealed the ED Manager interviewed RN #1 who admitted to meeting EMS outside the ED and telling them to take Patient #35 to Hospital B since ROSC had been obtained. Further interview confirmed the patient arrived at Hospital A Hixson Campus ED on 1/27/18 and was not included on the ED central log for 1/27/18.

Telephone interview with RN #2 at Hospital A Hixson Campus on 3/8/17 at 9:30 AM confirmed he was the charge nurse at the Hixson Campus ED on 1/27/18. Further interview revealed ED staff had been notified of Patient #35's pending arrival and were prepared to care for the patient. Continued interview revealed RN #2 was busy with other patients and did not know RN #1 had met EMS outside the ED and told them to go to Hospital B. Further interview confirmed patients were never to be sent away, and when he learned what happened he told RN #1 "...she should not have done that..."

Interview with Physician #1 at Hospital A Hixson Campus on 3/8/18 at 9:35 AM, in the ED Consultation Room, revealed he was the ED Physician on 1/27/18. Further interview revealed Physician #1 was notified EMS was bringing Patient #35 to the ED and he expected to see the patient. Continued interview revealed Physician #1 was busy treating other ED patients when the patient arrived and did not know RN #1 had sent EMS away with the patient.

Based on review of facility policies, review of an Emergency Medical Services (EMS) Patient Care Record, medical record review, review of an EMS incident report, review of a facility investigation, and interview, the facility failed to provide a medical screening examination (MSE) for one (#35) patient who presented to the Emergency Department (ED) out of 35 ED patients reviewed.

The findings included:

Review of facility policy titled "EMTALA GUIDELINES - TREATMENT & TRANSFER OF INDIVIDUALS IN NEED OF EMERGENCY MEDICAL SERVICES" policy number PC-07179, effective date September 2009, revealed "...EMTALA obligations are triggered when...requires examination and/or treatment for an EMC [emergency medical condition] although no request for treatment is made...The hospital will provide to any individual...an appropriate Medical Screening Examination ('MSE') within the capability of the Hospitals DED [dedicated emergency department]...to determine whether or not an EMC exists..."

Review of facility policy titled "MEDICAL SCREENING OF EMERGENCY PATIENTS," policy number MS-04005, effective date November 2001, revealed "...all patients presenting in the Emergency Department must have a medical screening...The Emergency department physician...mid-level practitioner shall provide a medical screening for any patient presenting in the emergency department..."

Review of the ED central log for Hospital A's Hixson Campus revealed no documentation Patient #35 was provided a MSE on 1/27/18.

Review of an EMS Patient Care Record for Patient #35 dated 1/27/18 at 3:09 PM revealed "...Cardiac Arrest [no heart beat]...Respiratory Arrest [not breathing]...Dispatched to a dialysis center for a patient in full cardiac arrest...He was defibrillated [electrical shock to the heart]...without a pulse...He was moved to the ambulance...without a pulse...he was defibrillated again...Patient was transported to [Hospital A's Hixson Campus]...then diverted to [Hospital B]..." Further review of the EMS record revealed EMS departed the dialysis center with the patient at 3:22 PM and transported the patient to Hospital A (no time documented). Continued review revealed EMS was diverted from Hospital A (no time documented) and arrived at Hospital B at 3:40 PM (18 minutes later). Further review of the EMS record revealed the patient's O2 Saturation levels (amount of oxygen in the blood, normal is 94-99%) were:
44% at 3:27 PM
70% at 3:32 PM
81% at 3:36 PM
92% at 3:41 PM

Medical record review revealed Patient #35 was admitted at Hospital B on 1/27/17 at 3:42 PM by EMS.

Medical record review of a Physician's Provider Notes at Hospital A Hixson Campus dated 1/27/18 at 4:29 PM revealed "...O2 Saturation 26%...witnessed arrest...Patient was intubated for airway protection, after intubation, patient became hypotensive [low blood pressure]...did not respond and went into PEA [pulseless electrical activity]...CPR [cardiopulmonary resuscitation] performed...Discussed with cardiology who will plan for possible [heart] cath [insertion of a catheter into the heart]..." Further review revealed the patient was admitted to the Intensive Care Unit (ICU) on 1/27/18 and placed on a ventilator (machine used for mechanical breathing) with a diagnosis of Cardiac Arrest. Continued review of the medical record revealed the patient was discharged home in fair condition on 2/3/18.

Review of an EMS incident report dated 1/27/18 revealed "...The call was initially a CPR in progress, however, just prior to transport...[Patient #34] had a ROSC [return of spontaneous circulation]...Upon having the change in pt. [patient] status, the crew called to check the availability of a supervisor to perform an RSI [rapid sequence intubation] [placement of a tube in the patients airway to quickly open and secure the patient's airway] on their pt. When determined that the nearest supervisor was greater than 15 min. [minutes] away, they were instructed to transport to [Hospital A's Hixson Campus] due to its close proximity to the call. Upon arriving at [Hospital A's Hixson Campus]...[Emergency Medical Technician (EMT) #1] was met outside as he exited the unit by [Registered Nurse (RN) #1]...[RN #1] advised [EMT #1] that if they had ROSC, then they just needed to transport to [Hospital B] ED...[EMT #1] advised [RN #1] that 'we are already here though,' at which point [RN #1] stated that they just needed to leave and transport the pt. to [Hospital B]. The crew did as instructed...and began transport to [Hospital B]...They were able to maintain their pt. via BVM [bag-mask ventilation] en route, however, an advanced airway wasn't placed. The pt. was ultimately intubated at [Hospital B] ED after the pt. lost a pulse and was revived again...[Hospital A's Hixson Campus] ED did not evaluate this pt. at any point..." Further review of a written statement by EMT #1 dated 1/27/18 at 8:55 PM revealed "...Regarding CPR at dialysis clinic...On this CPR we had a ROSC and called for an RSI...[supervisor] advised "[Hospital A's Hixson Campus] is across the street...At which time we transported to [Hospital A's Hixson Campus] and were met in the ambulance bay by [RN#1]...[RN #1] stated if you have a pulse back he [Patient #35] needs to go to [Hospital B]. I stated 'We're already here', to which the reply was, 'it doesn't matter he needs to go to [Hospital B]'...The patient was transported to [Hospital B] at that time..."

Review of a facility investigation at Hospital A Hixson Campus revealed an Email from an EMS manager to Hospital A's ED Manager dated 1/29/18. Further review revealed "...On Saturday [1/27/18] one of my crews responded to a CPR in progress at the dialysis center...the crew was having trouble establishing an advanced airway on the patient...[Hospital A's Hixson Campus] was only a couple of minutes away...they transported the patient to [Hospital A's Hixson campus]. They did a radio call in prior to arrival. But when they arrived in the ambulance bay they were told by [RN #1] that they just needed to transport to [Hospital B] due to obtaining ROSC. The crew member said 'But we are already here'...[RN #1] then told the crew to leave and transport the patient to [Hospital B]. They did as instructed and transported to [Hospital B]..."

Interview with the Vice President of Quality (VPQ) at Hospital A Hixson Campus, in the administration conference room, on 3/7/18 at 3:00 PM revealed the facility was notified on 1/29/18 of a possible EMTALA violation occurring on 1/27/18 at the Hixson Campus. Further interview revealed the VPQ and ED Manager investigated the incident on 1/29/18 and confirmed Patient #35 had arrived by EMS on 1/27/18 at the Hixson Campus ED entrance and was met outside the ED by RN #1 who told EMS to take the patient to Hospital B, which EMS did. Further interview with the VPQ confirmed Patient #35 was not included on the ED central log for 1/27/18.

Interview with the ED Manager at Hospital A Hixson Campus, in the ED Break Room, on 3/8/18 at 10:00 AM revealed she was notified on 1/29/18 of the alleged EMTALA violation involving Patient #35 on 1/27/18. Further interview revealed the ED Manager was notified of the allegation by an Email from an EMS manager on 1/29/18. Continued interview revealed the ED Manager interviewed RN #1 who admitted to meeting EMS outside the ED and telling them to take Patient #35 to Hospital B since ROSC had been obtained. Further interview confirmed patients should never be sent away from the ED without being provided a MSE and stabilizing treatment if needed.

Telephone interview with RN #2 at Hospital A Hixson Campus on 3/8/17 at 9:30 AM confirmed he was the charge nurse at the Hixson Campus ED on 1/27/18. Further interview revealed ED staff had been notified of Patient #35's pending arrival and were prepared to care for the patient. Continued interview revealed RN #2 was busy with other patients and did not know RN #1 had met EMS outside the ED and told them to go to Hospital B. Further interview confirmed patients were never to be sent away, and when he learned what happened he told RN #1 "...she should not have done that..."

Interview with Physician #1 at Hospital A Hixson Campus on 3/8/18 at 9:35 AM, in the ED Consultation Room, revealed he was the ED Physician on 1/27/18. Further interview revealed Physician #1 was notified EMS was bringing Patient #35 to the ED and he expected to see the patient. Continued interview revealed Physician #1 was busy treating other ED patients when the patient arrived and did not know RN #1 had sent EMS away with the patient. Further interview confirmed Physician #1 did not provide a MSE to Patient #35 and he was not aware the patient had arrived at the ED until after the patient had left.