HospitalInspections.org

Based on hospital policy reviews, Medical Staff bylaws & rules and regulations review, County rescue squad - Patient Care Report (PCR) and Computer Aided Dispatch (CAD) report reviews, Dedicated Emergency Department (DED) central log review, Electronic mail review, Timeline of events review, Medical record reviews, Written statement review, physicians and staff interviews, and County Rescue Squad personnel interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

1. The hospital's DED physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 1 sampled patients who presented via ambulance onto the hospital's property and was diverted by order of the DED physician to another acute care hospital (Patient #21); and the hospital failed to ensure ALL individual(s) determined qualified and who meets the requirements of §482.55 concerning emergency services personnel and direction to provide appropriate MSE was defined by the hospital's Medical Staff bylaws or rules and regulations for 1 of 1 hospital's Medical Staff bylaws, rules and regulations reviewed (Hospital A- Park Ridge Health).

~ Cross refer to 489.24(r) and 489.24(c) Medical Screening Examination - Tag A2406.

Based on hospital policy review, Medical Staff bylaws, rules and regulations review, County rescue squad - Patient Care Report (PCR) and Computer Aided Dispatch (CAD) report reviews, DED central log review, Electronic mail review, Timeline of events review, Medical record review, Written statement review, and interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 1 sampled patients who presented via ambulance onto the hospital's property and was diverted by order of the DED physician to another acute care hospital. (Patient #21); and the hospital failed to comply with §489.24 by failing to ensure ALL individual(s) determined qualified and who meets the requirements of §482.55 concerning emergency services personnel and direction to provide appropriate medical screening examinations (MSE) was defined by the hospital's Medical Staff bylaws or rules and regulations for 1 of 1 hospital's Medical Staff bylaws, rules and regulations reviewed (Hospital A).

The findings include:

1. Review on 07/08/2015 of Hospital A's current policy "ACCESS TO HEALTH CARE" revised 03/04/2015, revealed "It is the policy of his hospital that all individuals presenting for unscheduled treatment or evaluation shall receive a medical screening examination within the capabilities of the emergency department and the ancillary services routinely available to the emergency services of the hospital. The medical screening examination shall include examination, testing, treatment, and the services of appropriate on-call physicians where indicated. ...DEFINITIONS: ...Emergency Medical Condition: A condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in: 1. placing the health of the individual....in serious jeopardy. 2. serious impairment to bodily functions, or, 3. serious dysfunction of any bodily organ or part. ...The scope of this definition is not limited to patients with traditional evaluations of 'emergent' or 'urgent' and may include individuals with traditional designations of 'non-urgent' and possibly 'chronic.' ...Medical Screening Examination: The initial and on-going evaluation of the presenting individual conducted by a physician, including history, physical examination, appropriate testing, completion of appropriate documentation, and evaluation of the patient, within the capabilities of this hospital utilizing those facilities routinely available to the emergency department, including the use of indicated on-call physicians as appropriate, to determine whether a patient has an emergency medical condition....and/or to ensure that the individual does not have an emergency medical condition as defined by law. ...Comes to the Emergency Department: ...4. Is in a ground or air nonhospital-owned ambulance on hospital property for presentation for examination and treatment for a medical condition at a hospital's dedicated emergency department. ...The hospital may direct the ambulance to another facility if it is in 'diversionary status,' that is, it does not have the staff or facilities to accept any additional emergency patients. If, however, the ambulance staff disregards the hospital's diversion instructions and transports the individual onto hospital property, the individual is considered to have come to the emergency department. Property of the Hospital: The property of the hospital is comprised of the hospital and its campus, which includes the parking areas, driveways, sidewalks, grounds, and mobile treatment units located within 250 yards of the main hospital building. ...PROCEDURE: 3. Individuals presenting by ambulance who are not a direct admission to the hospital shall be taken directly to an Emergency Department treatment room, or to the Obstetrics Department, ...6. No individual presenting shall be denied triage or medical screening examination by any employee or medical staff member of this hospital. ...Physician Procedures: 1. The on-duty emergency physician shall provide a medical screening examination to all individuals presenting. ...no individual shall be discharged from the emergency department without being seen by a physician. 2. The medical screening examination may be provided by a private physician in lieu of the emergency physician ...3. The physician providing the medical screening examination shall physically examine the individual ..."

Review on 07/09/2015 of a Patient Care Record (PCR), Incident #: 2015-0870, for Patient #21 from County Rescue Squad (EMS) #1 dated 05/04/2015 provided by Chief #1, revealed an emergency 911 call was received at 1617. Review revealed Medic Unit M24-5 was dispatched at 1618 to Skilled Nursing Facility (SNF) #1. Review revealed "Run Type 911 Response (Emergency)" and "Priority Scene Lights/Sirens." Review revealed "Level of Service Basic Life Support (BLS)." Review revealed "EMD (Emergency Medical Dispatch) Complaint Medical Transport." Review revealed M24-5 was en-route at 1623, on-scene at 1627, at the patient at 1629, and departed scene at 1638. Review revealed M24-5 arrived at Hospital B at 1712 (34 minutes later). Review revealed "Disposition Transported No Lights/Siren." Review revealed "Transport Due To Diversion/ (Hospital A)-ER." Review revealed "Transported To (Hospital B)-ER." Review revealed "Condition at Destination Unchanged." Review revealed Emergency Medical Technician-Basic (EMT-B) #1 was the "Lead" technician and EMT-B #2 was the "Driver." Review revealed the patient's level of consciousness was assessed by EMT-B #1 at 1640 as "V" (Verbal - AVPU [alert, verbal, painful, unresponsive]) and vital signs were assessed as BP (Blood Pressure) 148/73 A [arm], Pulse (P) 93 I [irregular], RR (Respiratory Rate) 20 R [Regular], SPO2 (Pulse Oxygen Saturation) 88%, ETCO2 (End Tidal Carbon Dioxide) 2, Pain 0 (pain free), GCS (Glasgow Coma Score) 14 (15 Best Response, 8 or less comatose, 3 unresponsive). Review revealed "Chief Complaint Dehydration/Dementia" and "Primary Impression Dehydration." Review revealed "Signs & Symptoms Generalized Symptoms - Dehydration." Review of "Narrative" revealed "DISPATCHED TO (SNF #1) FOR A SICK CALL PER EMS (Emergency Medical Service) 4. ARRIVED ON SCENE FOUND PT (patient) LAYING IN BED PER NURSE THEY HAD TRIED TO START AN IV (intravenous) TWICE AND WAS UNSUCCESSFUL SO THEY CALLED PT'S CARE GIVER WHO STATED THEY WANTED PT TAKEN TO THE HOSPITAL DUE TO DEHYDRATION. PER NURSING STAFF PT WAS TO GO TO (Hospital A) SO WE TRANSFERRED PT TO THE STRETCHER AND TRANSPORTED TO THE AMBULANCE. CALLED REPORT INTO (Hospital A) ER (emergency room) AND THEY HAD ALL READY TALKED TO THE NURSING STAFF FROM (SNF #1) AND THEY WOULD SEE US SHORTLY. AS WE WERE TURNING ON TO NAPLES RD (road) CENTRAL CALLED ON THE RADIO AND SAID THAT (Hospital A) HAD CALLED AND SAID THAT THEIR CT (computed tomography) SCAN WAS DOWN AND WE NEED TO DIVERT TO (Hospital B). SO I (EMT-B #1) CALLED EMS SUPERVISOR HE SAID THAT WE NEEDED A DOCTORS ORDER TO DIVERT SO I CALLED (Hospital A) BACK AND TALKED TO DOCTOR (Physician A) AND TOLD HIM WE WERE PULLING IN NOW AND HE TOLD ME THAT WE STILL NEEDED TO DIVERT TO (Hospital B) EVEN THOUGH WE WERE ON THEIR PROPERTY. SO WE DIVERTED TO (Hospital B) ARRIVED AT (Hospital B) ER AND TOOK PT TO ROOM 12. TRANSFERRED CARE OVER TO (Hospital B) NURSING STAFF. COMPLETED CALL." Review of the "Mileage" section revealed the mileage on "Scene (SNF #1)" was "43492.7" and on arrival at "Destination (Hospital B)" was "43508.5" for a total "Loaded Miles (Patient onboard)" of "15.8."

Review on 07/09/2015 of a "CAD (Computer Aided Dispatch) Call Information Detail" report dated 07/08/2015 for Medic Unit 24-5 provided by Chief #1, revealed on 05/04/2015 a 911 call for "SICK PERSON." Review revealed at 16:17:39 (call received); 16:23:07 (en-route to scene); 16:27:19 (on-scene); 16:38:45 (left scene). Review of "Narrative" revealed at 16:58:55, "24-5 PER (Hospital A) DIVERT TO (Hospital B)." Further review revealed 17:12:34 (arrived Hospital B).

Note: SNF #1 is located approximately 9.43 miles or 18 minutes from Hospital A.
Hospital A is located approximately 6.98 miles or 12 minutes from Hospital B.

Review on 07/08/2015 of Hospital A's DED central log revealed no log entries on 05/04/2015 for Patient #21.

Interview on 07/09/2015 at 1338 with EMT-B #2, revealed he was a member of County Rescue Squad #1. Interview revealed he was a credentialed EMT-Paramedic. Interview revealed he had been a paramedic for one month and was an EMT-Basic prior, for one year. Interview revealed County Rescue Squad #1 operated at an EMT-Intermediate level with paid part-time and volunteer staff. Interview revealed he recalled the 911 call involving Patient #21 on 05/04/2015. Interview revealed he was the driver of the ambulance. Interview revealed the ambulance was a Basic Life Support (BLS) unit. Interview revealed "I remember the run due to the confusion with the destination (Hospitals)." Interview revealed they picked up the patient at SNF #1. The patient's family had requested for the patient to go to Hospital A. Interview revealed he had heard "through the grape vine" or on the CAD that the CT scanner was down at Hospital A. Interview revealed "without thinking we headed to Hospital A." Interview revealed he had no direct communication with the hospital. Interview revealed EMT-B #1 called report from "miles away, about 5-10 minutes out." Interview revealed the ED staff stated they were ready to take the patient. Interview revealed "we get onto South Naples Road approximately 4/10 of a mile from the hospital (Hospital A) when we were contacted by central dispatch and were told the CT scanner at Hospital A was down and we needed to go to Hospital B." Interview revealed EMT-B #1 called the EMS Supervisor to tell him about their location and to ask what to do. Interview revealed "by the time EMT-B #1 spoke with the supervisor and called the hospital back, we had already turned onto Hospital Drive and were on the hospital's property." Interview revealed he recalled EMT-B #1 reporting by telephone to Hospital A's ED staff that they were already in the parking lot with the patient. Interview revealed he turned the ambulance around in the guest parking lot in-front of the hospital's entrance; then left the property and transported the patient to Hospital B's DED. Interview revealed he recalled the patient having altered mental status and dementia, but the dementia was normal. Interview revealed he did not recall or witness a blood glucose being obtained by EMT-B #1. Interview revealed the PCR was "an accurate account of the run."

Telephone interview with EMT-B #1 on 07/09/2015 at 1408, revealed he was a member of County Rescue Squad #1. Interview revealed he was a credentialed EMT-Basic. Interview revealed he had been an EMT-B for 10+ years. Interview revealed he had a copy of the PCR to review during the interview. Interview revealed on 05/04/2015, they received a call from the EMS Supervisor for a routine call to take a patient to Hospital A for evaluation. They were dispatched to a nursing home to pick up the patient. The nursing home staff were unable to start an IV on the patient due to dehydration and the patient needed to be transported to the hospital for evaluation. Interview revealed he was the patient care provider (Lead) on the call for Patient #21. Interview revealed the nursing home staff called Hospital A and gave report. Interview revealed they loaded the patient into the ambulance and were enroute to Hospital A. Interview revealed after leaving SNF #1 he checked the patient's vital signs and they were stable. Interview revealed he checked the patient's blood glucose and the meter "showed low" so he rechecked the blood glucose and it "showed low" again. Interview revealed "I can ' t see where I wrote them (blood glucose checks) down either." (Surveyor verified during interview EMT-B #1 obtained two (2) separate blood glucose checks that read low, but did not document the results on the PCR.) Interview revealed he was unable to administer oral glucose because the patient was unable to swallow. Interview revealed the ambulance was operating as a BLS unit. Interview revealed the ambulance carried other medications to treat low blood sugars, but as an EMT-B he could only administer oral glucose. Interview revealed no one on the ambulance was credentialed to administer other medications. Interview revealed "5 minutes" from Hospital A, he called report to the ED. Interview revealed the ED staff stated they were expecting the patient and would see them in a few minutes. Interview revealed the ambulance was on "Naples Road crossing over the interstate (I-26)" when dispatch called and told them they needed to divert to Hospital B because CT was down at Hospital A. Interview revealed the EMS Supervisor was called and stated they needed to get an "order" to divert from Hospital A, since the ambulance was "so close to the hospital." Interview revealed he called Hospital A and spoke with Dr. (Physician A). Interview revealed he gave report that the patient was from SNF #1 and had altered mental status and the physician replied "Well do you have a CT on your truck?" Interview revealed he told the physician, "We are in your parking lot now" and the physician replied "I don't care." Interview revealed he reported the blood glucose as low to the physician. Interview revealed the physician did not say anything. Interview revealed Physician A gave the order to divert and the ambulance turned around in the parking lot and went to Hospital B. Interview revealed the parking lot was located in-front of the hospital, off Hospital drive. Interview revealed when they arrived at Hospital B he reported the low blood glucose to ED staff and turned patient care over to them. Interview revealed ED staff checked and verified the blood glucose was low.

Telephone interview on 07/08/2015 at 1544 with Physician A revealed, he was a DED attending physician at Hospital A. Interview revealed he worked for the hospital's contracted emergency physicians group. Interview revealed he had been on-staff at Hospital A since July 2009. Interview revealed he recalled the incident involving Patient #21 on 05/04/2015. Interview revealed a nurse picked up the EMS phone and was receiving report and made the comment they (EMT) needed to talk to the doctor. Interview revealed he spoke with the EMT over the phone. Interview revealed he does not recall the age of the patient, but it was a nursing home patient with altered mental status. Interview revealed the patient's vital signs were stable. Interview revealed the ED was on "CT diversion." Interview revealed he "thought" the patient needed a CT scan and needed to go over to Hospital B. Interview revealed there was "no indication they were on hospital property." Interview revealed he was "made aware a couple days later" the ambulance had presented onto hospital property with the patient. Interview revealed if he had been aware the ambulance was on hospital property he would have advised them to come into the ED. Interview revealed he did not recall any issues with the patient's blood glucose being reported by the EMT. Interview confirmed Physician A gave the order for the ambulance to divert to Hospital B.

Review on 07/08/2015 of "Electronic Mail" documentation from Hospital A's Diagnostic Imaging (DI) Director #1 to Hospital A's Risk Manager (RM) #1 dated 07/08/2015 at 1208, revealed "Subject: 2015 CT down times." Review revealed the hospital's CT scanner was out of service on the following dates: 01/11/2015; 01/25/2015; 03/26/2015; 04/10/2015; 05/04/2015 (Date Patient #21 presented on Hospital A's Property and was diverted to Hospital B); 05/24/2015; 06/06/2015; and 06/10/2015.

Review on 07/09/2015 of a "Timeline of Events" provided by Hospital A's Chief Nursing Officer (CNO) #1, revealed:
05/3/2015 at 0700 CT Scanner down. Initial report was that it would be down for approximately 24 hrs.
05/04/2015 at 1415 Requested DI (Diagnostic Imaging) Director to look at the cost of obtaining a new CT scanner.
05/04/2015 at 1626 DI Director reports that CT scanner will not be coming back up until at least midnight.
05/04/2015 at 1628 Requested DI Director to explore obtaining backup CT scanner for emergent down-time.
05/05/2015 at 0000 CT Scanner back up.
05/08/2015 CNO #2 at Hospital B called to speak with me. I was not in the office that day....arranged for me to call her on Monday 05/11/2015.
05/11/2015 at 0930 Called CNO #2 at Hospital B. She informed me about the situation (Patient #21) and suggested a meeting ASAP.
05/13/2015 at 1300 Meeting with Hospital B. Attendees: CNO #1, Physician D, ED Director #2, DI Director #1, CNO #2, ED Director #1, and Physician B. Discussed circumstances and identified things at both organizations that needed to be addressed in order to prevent the situation from happening again.
06/02/2015 Received revised policies from Hospital B: "Transfers from Other Hospitals" and "Transfer of Patients from Other Hospitals for Diagnostic Imaging MI-Ra05."

Interview on 07/08/2015 at 1503 with Hospital A's CNO #1, revealed the hospital has only one CT scanner available for use. Interview revealed the CT scanner had been down for approximately 36 hours on 05/04/2015 due to a power supply issue. Interview revealed if the CT scanner goes down, the house supervisor notifies EMS, medical transport services, Hospital B's ED, and Hospital C's ED. Interview revealed when CT is down, the physicians want EMS to avoid coming to the hospital for any patients having head symptoms. Interview revealed he received a telephone call from CNO #2 (Hospital B) who requested a meeting regarding "a potential EMTALA issue" their hospital would have to report. Interview revealed he attended the meeting at Hospital B. Interview revealed because of HIPAA laws, the patient's name, medical records, and EMS PCR were not provided to them. Interview revealed they discussed the situation that occurred when the CT scanner was down. Interview revealed there was confusion with policies, the House Supervisor had only contacted EMS and not County Rescue Squad #1. Interview revealed policy changes were implemented and the hospital has started to keep run sheets and has checked into the cost of putting a recording system in the ED. Interview revealed "I think the patient got the right care but not from an EMTALA perspective." Interview revealed "When Dr. (Physician A) found out about the patient, he thought the patient had a hot belly and needed to be taken to Hospital B for a CT." Interview revealed "Dr. (Physician A) didn't understand the patient was here on hospital property when he told them to divert to Hospital B." Interview revealed communication between the hospital and ambulance was over the phone or radio, not face-to-face. Interview revealed "If an ambulance rolls onto our property they cannot be turned away." Interview revealed "if they did arrive on the hospital's property it would have been a potential violation." Interview revealed Hospital A had no available documentation, ED medical record, ED central log entry, or witnesses the ambulance arrived on hospital property on 05/04/2015 with Patient #21.

Hospital B, closed DED record review on 07/08/2015 for Patient #21 revealed a 75 year old male presented via ambulance to the DED on 05/04/2015. Review revealed the patient was triaged by a Registered Nurse (RN) at 1728. Review revealed a "Chief Complaint" of altered mental status ANS-(abnormal change in a person's responsiveness and awareness, ranges from confusion to complete unresponsiveness)and a "Stated complaint" of hypoglycemia, UTI (urinary tract infection) and metabolic encephalopathy. Review revealed a past medical history of hypoglycemia, dementia, hypertension, congestive heart failure, gastroesphogeal reflux disease, kidney disease et al. Review of ED Primary Assessment revealed the patient's level of consciousness was assessed as drowsy and arousable to verbal stimuli. The patient's orientation was to person and self. Speech pattern was hesitant and behavior was fatigued. Respiratory effort was non-labored and lung sounds were clear. Cardiovascular was assessed as rhythm regular, strength normal and heart tones clear. ED Neurological Assessment revealed a GCS score of 14. Pupils were bilateral, reaction brisk, and equality PEARL. All extremities with normal strength. The patient was assessed as unable to comprehend, memory was impaired and mood flat. Review of ED Rapid Triage documentation at 1757 revealed "PER RESCUE SQUAD, PT SENT TO ED FOR DEHYDRATION AND AMS. SYMPTOMS FOR UNKNOWN LENGTH OF TIME." Review revealed vital signs (VS) were assessed as temperature (T) 97.8 degrees Fahrenheit (F); Pulse (P) 57; Respirations (R) 16; blood pressure (BP) 127/77; and Pulse Oxygen Saturation (SpO2) 93% on oxygen. Pain was assessed as an "N" (no). The patient was assigned an ESI (emergency severity index) Priority 2 (1 most severe, 5 least severe). Review of nursing documentation at 1728 revealed "PT TOP [SIC] ROOM VIA EMS STRETCHER. EKG (ECG - electrocardiogram) DONE. FINGERSTICK GLUCOSE DONE (13 mg/dl) (Fingerstick Glucose reference range for hospital was 70-115 md/dl). RESULTS TO DR. (Physician B). At 1735 "INT (intravascular access device) PLACED AND BLOOD DRAWN AND SENT TO LAB." At 1745 "DR. (Physician B) TO ROOM." At 1800 "...TO ROOM TO DO STRAIGHT CATH." At 1805 ED Continuous Pulse Ox. At 1810 ED Cardiac Monitor Sinus Rhythm. At 1830 VS were reassessed as BP 172/96, P 78; SpO2 97% on 2 lpm (liters per minutes) oxygen (O2). At 1837 "ATTEMPTED TO CALL (SNF #1). NO ANSWER." At 1838 ED Foley Indwelling placed. At 1851 "SPOKE WITH....RN AT (SNF#1). SHE STATES PT WAS SENT TO ED FOR AMS AND DEHYDRATION. SHE HAS NO OTHER COMMENT. ..." At 1900 VS were reassessed as BP 133/76, P 64; SpO2 96%. At 1939 "portable xray done at this time." At 2020 "BC (Blood Culture) drawn..." At 2028 "BC #2 drawn..." At 2046 VS were reassessed as BP 147/79, P 68; SpO2 100% on 2 lpm O2. At 2104 "paperwork faxed to the floor for admission." At 2109 "Repeat BS (Blood Sugar), 286. Dr. (Physician C) aware..." At 2115 "Pt to the floor..." Review revealed "Primary Impression" Hypoglycemia and "Secondary Impression" Acute renal failure and UTI. Disposition: admitted as inpatient. Review of physician's orders revealed a Complete Blood Count, Comprehensive Metabolic Panel, Magnesium, Urinalysis, Urine Culture, Blood Culture, ECG, and CXR were obtained as ordered by Physician B. Review of Medication Administration Record (MAR) revealed the patient received the following medications as ordered by Physician B at: 1. 1750 - NS (normal saline) 1,000 ml (milliliters) IV(intravenous) at 500 ml/hr (hour); 2. 1750 - Dextrose 50% - 25 gm (grams) IV; 3. 1820 - Dextrose 50% - 25 gm IV; 4. 1850 - D5-NS (Dextrose 5% - Normal Saline) 1,000 ml at 250 ml/hr; 5. 1859 - Dextrose 50% - 25 grams IV; and 6. 2040 - Levofloxacin 750 mg IVPB (intravenous piggyback) at 100 ml/hr. Review of MSE documentation by Physician B revealed the patient was seen at 1729. Review revealed "Chief Complaint: dehydration." Review revealed "Source of history: Patient, Paramedic, Nursing home (NH)." Review of HPI (history of present illness) revealed "Pt sent from NH as he was refusing to take po (by mouth) today. Had planned IV and IVF (intravenous fluids) but unable to start IV and send to ED. Pt is unable to give any hx (history) secondary to dementia. Only hx available is from EMS and NH notes. Attempted to speak with NH but no one available to give hx. No other hx available. EMS found FSBS (finger stick blood sugar) of 16, no rx (treatment) given." Review revealed "Severity: Currently is Moderate, Maximum is Moderate." Review of PMH revealed CHF, Hypertension, Dementia, Kidney Disease and (Chronic renal insufficiency). Review of Physical Exam revealed, General/Constitutional: No acute distress, Well-developed, Well-nourished, Cooperative, Well hydrated. Head/Eyes: Atraumatic, Normocephalic, PERRL (pupils equal round reactive to light), EOMI (extra-ocular movement intact), No periorbital redness, No scleral icterus. ENT (ears, nose, throat): Atraumatic, Normal Oropharynx, Mucous membranes moist, Tympanic membranes normal. Neck: Atraumatic, Supple, No meningismus, Full range of motion, No adenopathy, No swelling, Non-tender, No masses. Respiratory/Chest: Atraumatic, Breath sounds normal, No respiratory distress, No rales, No rhonchi, No wheezing. Cardiovascular: Heart rate normal, regular rhythm, Heart sounds normal, capillary refill normal, peripheral circulation normal. Abdomen: Atraumatic, Soft, Non-tender, No guarding. No rebound, bowel sounds normoactive. No distention. Back: Atraumatic, Normal inspection, Non-tender, No Costovertebral angle tenderness. Extremities: Atraumatic, Normal inspection, Non-tender, No swelling, No edema, Neurovascular intact, No clubbing/cyanosis. Skin: Atraumatic, Normal color, No rash, Warm, Dry, Normal turgor, No swelling. Neurologic: Alert, No motor deficits, and No sensory deficits. Review of laboratory tests results at 1745 revealed a glucose level of 24 mg/dl [deciliter] (reference range 70-115), blood urea nitrogen 70 mg/dl (reference rage 6-20), creatinine 6.0 mg/dl (reference range 0.5-1.2), carbon dioxide level 18.4 mmol/l (reference range 21.0-31.0), hemoglobin 11.8 g/dl (reference range 13.5-18.0), hematocrit 36.1% (reference range 40.0-52.0), and platelet count 112 K/cmm (reference range 130-450). Review of urinalysis results at 1830 revealed urine appearance - hazy and urine bacteria moderate. Review of bedside glucose levels revealed: at 1734 a bedside glucose level of 13 mg/dl (reference range 70-110 mg/dl); at 1811 a bedside glucose level of 11 mg/dl; at 1845 a bedside glucose level of 22 mg/dl; and at 1910 a bedside glucose level of 212 mg/dl. Review of ECG interpretation results at 1730 revealed Normal sinus rhythm, No acute ischemic changes, normal QRS, normal axis, and normal intervals. Review of chest x-ray interpretation revealed no acute disease. Review of re-evaluation/progress documentation at 1929, revealed "Status: Improved." Further review revealed "Pt rx (treated) with a total of 3 amps D50 with improvement of hypoglycemia (increased to 213), rx initially with NS bolus the [sic] D5NS at 250 ml/h. No change in MS (mental status) with resolution of hypoglycemia. SNF contacted by nursing staff, no other hx or old labs available. Will admit. Consultation: Consultant called: hospitalist....Consultant: Accepts patient. Clinical Impression: Primary Impression: Hypoglycemia Additional Impressions: Acute renal failure, UTI (lower urinary tract infection) Disposition: ADMITTED AS INPATIENT. ..." Review of an Admissions History and Physical dictated 05/05/2015 at 0521 by Physician C for Patient #21 revealed and admission date of 05/04/2015. Review revealed "HISTORY OF PRESENT ILLNESS: He was sent there [sic] as he was refusing to take oral intake, oral medications or food today. They had planned to give him IV fluids to see if he improved, but were unable to start an IV and the patient was sent to the emergency room. ...EMS found a fasting blood sugar of 16 en route. No Rx was given. He was initially taken to (Hospital A) but was diverted to the (Hospital B) emergency room. On arrival to the (Hospital B) emergency room his glucose was 13. ..." Review revealed "IMPRESSION 1. Persistent hypoglycemia. ...2. Urinary tract Infection. ..." The patient was discharged from Hospital B on 05/14/2015 (10 days later).

Interview was attempted at Hospital B on 07/08/2015 with Physician B (performed MSE on Patient #21 on 05/04/2015). The DED physician was unavailable for interview.

Telephone interview at Hospital B on 07/08/2015 at 0955 with Physician C, revealed she was the Hospitalist who admitted Patient #21 to Hospital B on 05/04/2015. Interview revealed the patient's initial blood glucose was 13 in the ED. Interview revealed she was told by the charge nurse and from reading the EMS notes that the patient was initially taken to Hospital A then diverted to the ED at Hospital B. Interview revealed the patient was not given any treatment until he arrived at Hospital B's ED. Interview revealed she was told Hospital A had turned away the patient on the ramp and that they were going to report it as an EMTALA violation. Interview revealed she does not recall who told her. Interview revealed an "EMC existed" when the patient arrived in the ED. Interview revealed the patient was admitted. Interview revealed the patient had a chest x-ray, labs, urinalysis, EKG performed and was administered dextrose. Interview revealed a CT scan was not ordered on the patient while he was hospitalized. Interview revealed the patient's EMC had resolved upon admission and changes in his mental status had improved, but had not resolved. Interview revealed the patient was back to baseline at discharge according to the discharge physician's notes.

Review on 07/08/2015 of a "Written Statement" signed and provided by Hospital B's ED Director #1 revealed "(Hospital B) - Emergency Department Documentation of concerns regarding (Hospital A) diversion of patients 5/3-4/2015." Further review revealed "On 5/4/2015 upon arrival to the ED, I was notified....that (Hospital A) was 'sending us all their patients that required CT' as their CT scanner was down. ...At approximately 1730 hours, while rounding in the ED, I was approached by (County Rescue Squad #1) personnel regarding a patient (Patient #21) that they were bringing to the ED for care. He stated that they had been dispatched for a 'sick person' with abdominal pain, to be transported to (Hospital A). They had notified (Hospital A) of their pending arrival and after arriving on their property, were given an order by the ED physician (Dr. [Physician A]) to divert the patient to (Hospital B) due to their CT scanner being out of service. Upon arrival to our ED, the patient's blood glucose (BG) was 13 mg/dl; when reported to (County Rescue Squad #1), they stated they had noted a BG of 16 mg/dl but did not think that value was correct. This patient was treated and admitted to our facility. Please see (County Rescue Squad #1) patient care record for documentation. ..."

Interview at Hospital B on 07/08/2015 at 0935 with ED Director #2, revealed she was notified on Monday morning (05/04/2015) when she came to work that Hospital A's CT scanner had been down since Sunday (05/03/2015) and Hospital B had started receiving patients from Hospital A. Some patients were being transferred from Hospital A's DED and others were being sent over for outpatient CT only. Interview revealed she was present in the DED on 05/04/2015 when Patient #21 presented to Hospital B. Interview revealed Patient #21 presented by ambulance. Interview revealed the ambulance was with County Rescue Squad #1. Interview revealed the EMS staff's name was "EMT-B #1 or EMT-B #2." Interview revealed "I think it was EMT-B #1 and he told me he felt there had been an EMTALA violation." He reported the details of the events involving Patient #21. Interview revealed he reported EMS was dispatched to a nursing home for a sick person with abdominal pain, that was to be sent to Hospital A's ED for evaluation. He called report in to Hospital A and the ED staff were aware and expecting the patient. After arrival on Hospital A's property the ambulance was given an order by the ED physician to take the patient to Hospital B, because the CT scanner was down at Hospital A. The order was by radio or phone communication and not face-to-face. The patient was not off-loaded from the ambulance at Hospital A. Interview revealed the patient arrived at Hospital B and was triaged at bedside by RN #1. Interview revealed EMT-B #1 reported that he checked the patient's blood glucose and it was 16, but did not report the blood glucose to Hospital A because he felt it was incorrect and did not document the result on the PCR. Interview revealed the patients' blood glucose was rechecked