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Based on interview and record review, the facility failed to ensure staff followed its facility policy and procedure titled "Triage" for 1 of 16 patients (Patient 20) who presented to the Emergency Department (ED) for emergency care, when staff triaged Patient 20 at priority level 3 (Urgent) but did not attempt to re-assess the patient for five hours. This failure resulted in Patient 20 leaving the hospital without receiving a Medical Screening Examination (MSE), which caused a delay in emergency medical care and services.

Findings:

During a concurrent interview and record review with Manager M on 9/02/21, at 10:41 a.m., Patient 20 was identified in the facility's Central Log as having left the emergency department without being seen (did not receive an MSE). The ED Summary Report, dated 2/20/21, indicated Patient 20 was an 18-year-old female who arrived in the ED at 10:24 a.m., and was triaged as priority 3 at 10:37 a.m., with a chief complaint of "Reproductive" concerns. The report indicated Patient 20 presented with abdominal pain lasting for one month. Patient 20 was previously diagnosed with an ovarian cyst that had raptured. Patient 20 was still experiencing upper abdominal pain and nausea with diarrhea and bloody stools for two weeks. On presentation, Patient 20 had the following vital signs: heart rate was 85 beats per minute, respiration (breathing) rate was 15 breaths per minute, blood pressure was 154/89 mm Hg (unit of pressure equal to the pressure exerted by a column of mercury 1 millimeter high). The report indicated Patient 20 was not in the lobby at 3:34 p.m. when ED staff returned to re-assess Patient 20's needs. Manager M stated the facility had 18 patients in the ED rooms when Patient 20 was in the ED.

During an interview on 9/02/21, at 1:54 p.m., Nurse L stated the role of the Triage nurse included reassessing ED patients waiting to be seen by a physician, by checking patient vital signs and neurological status for any material changes. For reassessing patients with a priority level 3, Nurse L stated, these patients were reassessed every two hours. When asked if the triaged nurse documented the reassessment, Nurse L stated, "Absolutely."

During an interview on 9/02/21, at 3:53 p.m., Manager M verified Patient 20's ED record contained no other notes regarding Patient 20 from the time of her triage at 10:37 a.m. until 3:34 p.m.

Review of the facility policy and procedure titled "Triage," approved 8/01/21, indicated patients identified as a level 3 priority should be reassessed by a nurse hourly or sooner. The policy indicated the triage nurse or designated registered nurse was responsible for reassessing patients waiting to be seen and for documenting reassessment in the Nurse's Notes. "The nurse is responsible for determining the need for vital signs as an element of patient reassessment, based upon his/her evaluation of the patient's presenting condition and potential for deterioration."

Review of the facility policy and procedure titled "EMTALA- Screening, Stabilization And Transfer of Individuals With Emergency Medical Conditions All Departments & Locations," dated 3/23/21, indicated a "... MSE should be performed to the extent sufficient to determine within reasonable medical probability whether an EMC [Emergency Medical Condition] exists."

Based on interview and record review, the facility (Hospital 1) did not follow its policy when managing the emergency medical condition of one patient (Patient 1) who required specialized services and an intensive level-of-care, when Hospital 1 did not accept the request for Patient 1's emergent transfer despite having the capacity to receive the patient as well as the specialized service on-call. This failure resulted in the undue delay of emergency care for Patient 1, who had suffered a hemorrhagic stroke (e.g., when a blood vessel breaks and bleeds into the brain, and surrounding brain cells begin to die within minutes; also called intracerebral hemorrhage). Patient 1 eventually died an hour after arriving to another, more-distant facility (Hospital 4) for stabilizing care and treatment.

Findings:

On 4/16/21, the Department received a complaint regarding Patient 1, a patient who received care through Hospital 2's emergency department (ED) on 4/13/21 due to an intracerebral bleed. The complaint indicated Hospital 2 attempted to transfer Patient 1 to Hospital 1, but Hospital 1's neurosurgeon did not accept the patient for lack of a neurologist on-call. Hospital 2 then sought to have Patient 1 admitted to Hospital 3. The complaint indicated: "Upon hearing that the neurosurgeon at [Hospital 1] refused to accept the patient because there was no neurologist there, the neurosurgeon at [Hospital 3] refused to accept the patient as well, contending that the [Hospital 1] neurosurgeon was not justified in refusing the transfer."

During an interview on 4/22/21 at 9:53 a.m., Physician H stated he cared for Patient 1 at Hospital 2 on 4/13/21. Physician H stated Patient 1 needed a higher level of care. Physician H stated Patient 1 needed intensive care and a neurosurgeon. Physician H stated Patient 1 had a CT (computerized tomography, a medical scan that shows detailed images of internal organs) of the head and was diagnosed with a large bleed. Physician H described Patient 1's CT results as "devastating." After reviewing the results, Physician H started to arrange for Patient 1's transportation, and contacted the transfer center of the closest hospital (Hospital 1) to request transfer. Physician H stated Hospital 1 refused Patient 1's transfer. Physician H stated Hospital 1's staff stated it was the hospital policy to not take stroke patients without a neurologist on-call. Physician H stated he requested Patient 1's transfer to Hospital 3 through the same transfer center, but was informed Hospital 3 had also refused Patient 1. Physician H stated he eventually obtained Hospital 4's acceptance for Patient 1's transfer. To reach Hospital 4, Physician H stated Patient 1 had to travel by ambulance and by air. Physician H stated Patient 1 arrived at Hospital 4 after 3:00 a.m. the following morning and died one hour later.

Review of Patient 1's medical record from Hospital 2 indicated Patient 1 was seen in the ED on 4/13/21, after being found unresponsive by his wife. The record indicated Physician H was Patient 1's physician. A CT scan of the head, performed on 4/13/21 at 6:53 p.m., indicated Patient 1 suffered a left frontoparietal (in the area of the front and middle lobes of the brain) intra-axial (in the brain itself) hemorrhage measuring 8 cm (centimeters) x 5.3 cm x 6.2 cm, with a midline shift (a shift in the bring that occurs when the pressure exerted blood and swelling around the damaged brain tissues is powerful enough to push the entire brain off-center) rightward measuring 7 millimeters. The record indicated Patient 1's blood pressure was 207/120, at 6:55 p.m. After Patient 1 was placed on mechanical ventilator (a machine that moves air in and out of the lungs), at 7:38 p.m., the patient's blood pressure decreased to 156/98. Patient 1 was administered mannitol (medication to keep the pressure down in his head) intravenously. The record indicated Patient 1's transfer to a higher level of care at Hospital 4 was initiated "about 1 a.m.," and involved ambulance transport to a fixed-wing aircraft, which would continue Patient 1's transfer to the distant receiving hospital.

Review of collected audio recordings of telephone calls coordinated by the Transfer Center (TC), dated 4/13/21 and beginning at 7:11 p.m., indicated Physician H called the Transfer Center (TC) and informed the TC Coordinator that Patient 1 was in Hospital 2's emergency room with a large hemorrhagic stroke. Physician H requested Patient 1's transfer to Hospital 1 for the specialized service of neurosurgery and an intensive care unit (ICU) bed. Review of the audio recording, beginning at 7:28 p.m., indicated the charge nurse for Hospital 1's ED called the TC Coordinator and informed the TC Coordinator to speak with the neurosurgeon before the ED could accept the patient. Review of the audio recording, beginning at 7:34 p.m., indicated the TC Coordinator spoke with Physician Assistant C, for Hospital 1's on-call neurosurgeon (Physician A). The TC Coordinator offered to connect Physician Assistant C with Physician H to discuss Patient 1, but Physician Assistant C declined. Review of the audio recording, beginning at 7:44 p.m., indicated Physician Assistant C called the TC Coordinator to inform the TC Coordinator that she had spoken to Physician A about Patient 1. The audio recording indicated Physician Assistant C informed the TC Coordinator that Physician A had recommended Patient 1 be transferred to Hospital 3, as it had broader services than Hospital 1 and that, statistically, most hemorrhagic strokes were non-surgical and there was no neurologist on call at Hospital 1 to manage Patient 1 if he did not need surgery.

Continued review of collected audio recordings, dated 4/13/21 and beginning at 7:48 p.m., indicated the TC Coordinator called Physician H to inform him that neurosurgery at Hospital 1 did not accept Patient 1 and recommended Hospital 3, which had neurology, because most hemorrhagic strokes were non-surgical. The recording indicated Physician H stated he just intubated (a procedure where a tube is inserted down the throat and into the windpipe to make it easier to get air into and out of the lungs) Patient 1 and the patient did not have a good chance of making it that far. Physician H agreed to try to transfer Patient 1 to Hospital 3 since Hospital 1 was not accepting the patient.

Continued review of collected audio recordings, dated 4/13/21 and beginning at 8:29 p.m., indicated the TC Coordinator called Physician Assistant C at Hospital 1 and stated, "I don't know. I'm just kind of lost--at a loss right now." The TC Coordinator stated Hospital 3's neurosurgeon had declined transfer for Patient 1 because neurology was not needed for a hemorrhagic stroke and that Hospital 1 should be able to take Patient 1. Physician Assistant C stated, "Well, you know, we're not accepting the patient. If you wanna--again, uh, if you contact the ED and they want to accept him, that's fine. We'd be happy to consult but, um, those were just [Physician A]'s recommendations. It's not--it's not us refusing, it was just [Physician A]'s recommendation."

Continued review of collected audio recordings, dated 4/13/21 and beginning at 9:08 p.m., indicated Physician B called the TC Coordinator and stated he was the chief medical officer of Hospital 1 and called to check-on the status of the hemorrhagic stroke patient seeking transfer to Hospital 1. The TC Coordinator summarized the calls she had made, including her call to Physician Assistant C, and then stated, "so I was just confused 'cause she kept saying well we'll accept the consult, but this is what we're recommending, the patient needs to go somewhere with neurology . . . ." Physician B asked if Physician Assistant C had spoken with Physician A, and the TC Coordinator stated no. The TC Coordinator stated she had offered Physician Assistant C a doctor-to-doctor conversation with Physician H, but Physician Assistant C declined. Physician B stated he did not have an ICU bed at that time, but he would check on the ICU bed, call Physician A, and call the TC back.

Continued review of collected audio recordings, dated 4/13/21 and beginning at 10:39 p.m., indicated TC Coordinator called Hospital 2's ED to inquire if the facility had found a facility to accept Patient 1. Hospital 2's ED staff informed the TC Coordinator that Patient 1 was going to Hospital 4's ICU.

During an interview on 7/29/21 at 11:11 a.m., Physician A stated he had been a neurosurgeon at Hospital 1 for 30 years. He stated hemorrhagic strokes were seen primarily by neurology. Physician A stated he was absolutely capable of managing a hemorrhagic stroke surgically, but not medically. He stated maybe 5% of hemorrhagic strokes needed surgery. Physician A stated that without neurology available, he could not accept a hemorrhagic stroke patient. When asked about hemorrhagic stroke patients that come into the ED, Physician A stated he would consult on the patient, and then the hospitalist decided if they could manage the patient medically. When asked how he decided if a patient with a hemorrhagic stroke was a surgical candidate, Physician A stated he looked at the studies (images of the brain) or talked to the ED doctor. He stated a description of the hemorrhage would be enough.

During an interview on 8/31/21 at 11:14 a.m., Director F and Director G described the process for transferring a patient from an outside hospital into Hospital 1. Director G stated the TC staff would check with the house supervisor for bed availability. She stated if a bed was available, TC staff would connect the specialist with the transferring doctor for a doc-to-doc conversation. Director F stated bed availability was always confirmed before the doctors were involved.

During an interview on 8/31/21 at 2:25 p.m., Physician J stated as a neurologist she saw patients with multiple conditions, including strokes, seizures, delirium, some spinal cord cases. Physician J stated she and her partner only covered half the month, so if a patient arrived to Hospital 1 during the time there was no coverage, the patient may need to go to another facility (with neurology coverage). Physician J confirmed there were between 14-to 17-days each month with no neurology coverage. Physician J stated hemorrhagic stroke patients required a neurosurgeon. Physician J stated she would consult, but would not be involved in the decision to transfer.

During a record review and concurrent interview on 9/1/21 at 9:10 a.m., Nurse Manager K stated the ICU had 12 beds, and Hospital 1 had only one ICU. Nurse Manager K stated the hospital's ICU took mixed patients, including traumas, neuro, surgical recovery, cardiovascular, and medical. Nurse Manager K reviewed the facility document titled "ICU Assignment Sheet" for the NOC shift (6 p.m. to 6 a.m.), dated 4/13/21, and stated the census in the ICU was 10 patients, with one charge nurse, six nurses, and one nurse on orientation. Nurse Manager K stated the charge nurse for the ICU was also charge nurse for the intermediate care unit, which had a census of six patients with two nurses scheduled the night of 4/13/21.

During an interview on 9/1/21 at 9:30 a.m., Physician D stated he was the hospitalist working on the night of 4/13/21. Physician D stated he always accepted transfers if it was safe for the patient. He stated that if a physician was requesting transfer, it was probably because they were uncomfortable with what was going on with the patient and needed a specialist to focus on whatever needed to be done for the patient. Physician D stated he was board certified in internal medicine and could manage a hemorrhagic stroke, but he could not know until he actually laid hands on a patient. He stated the subject matter expert, the specialist, would determine the patient's needs, "it's not like they're going to sign off." Physician D stated he usually told the TC: "If you can get the specialist to agree to consult, we'll work this out." He stated the doc-to-doc was usually with the specialist because they knew the ins and outs of what to do about the patient, such as whether to administer steroids (medication to reduce inflammation) based on the patient's specialized condition.

During an interview on 9/1/21 at 1:05 p.m., Physician B stated his role in transfers from other hospitals was to take calls in the escalation process. Physician B stated he was there for support if there was a question, or if a physician declined a patient he would call the physician to determine if capability was an issue. When asked about his expectation regarding the doc-to-doc conversation, Physician B stated the primary goal of the conversation was to determine capability. He stated, "It's critical," the transferring physician should be able to speak with the accepting physician to make that determination. When asked about capacity for transfers, Physician B stated capacity was usually determined first, capability can come first, not necessarily in that order. When asked about his expectation of specialists when they were communicating whether or not they were accepting a patient for transfer, Physician B stated the specialist should be clear about accepting or not accepting the patient.

During an interview on 9/1/21 at 5:25 p.m., Physician Assistant C stated she did not always do a doc-to-doc conversation when presented with transfer patients. Physician Assistant C stated she did not remember being presented with a hemorrhagic stroke patient at Hospital 2 on 4/13/21. When asked about her statement to the Transfer Center on 4/13/21 that Physician A was not accepting the patient but not refusing the patient, Physician Assistant C stated that if the statement was unclear, then the TC Coordinator should have asked for clarification.

During an interview on 9/2/21 at 8:17 a.m., Supervisor E stated she was the first point of contact for transfers into Hospital 1. She stated she did not want a patient to have a bad outcome because we could not get them in. Supervisor E stated she would first contact the TC to reach out to the specialist, and if the specialist accepted the patient, then she would look for beds. She stated, "If the patient needed surgery, I would just make it happen." Supervisor E stated they "got a lot of bleeds [in Hospital 1's locale]," they would not survive a trip to [Hospital 3], so "we have to get them in." Supervisor E stated they had no neurology on call for half of the month. Supervisor E stated the lack of an on-call provider impacted what Hospital 1 could accept, but the hospital accommodated most hemorrhagic stroke requests. Supervisor E stated the neurosurgeons had accepted "bleeds" without neurology in the past.

During an interview on 9/2/21 at 9:11 a.m., Physician H stated he and his staff did not fax any reports with the severity or location of Patient 1's intracerebral bleed to Hospital 1. He stated he did describe the bleed to the house supervisor, but the reason they gave him for refusing Patient 1 was there was no neurology.

During an interview on 9/2/21 at 1:05 p.m., when asked what a specialist was required to say when accepting or declining a patient for transfer, the TC Coordinator stated the specialist needed to state "I accept the patient" or "I decline the patient." When asked how she would interpret a specialist who stated both "I am not accepting the patient" and "I am not refusing the patient", the TC Coordinator stated if it was unclear, she would escalate it and then ask for clarification. The TC Coordinator described her role in the transfer process: She stated she first made sure there was a bed with the house supervisor, and then checked the on-call list for the specialist needed. The TC Coordinator stated she contacted the specialist and then got them on a three-way call with the sending physician.

During a review the TC's Computer-Assisted Dispatch (CAD, an information repository in which all communications regarding a transfer request are documented) system, on 9/1/21 at 3:47 p.m., the CAD record pertaining to Patient 1 indicated the record was created on 4/13/21, at 7:12 p.m. The CAD record indicated Hospital 2 was Patient 1's transferring facility, and further indicated Hospital 1 had bed available at 7:24 p.m., when Physician H initiated his transfer request.

In response to a request for policies and procedures for Transfer Center staff, a document titled "Bed Availability Determination" was provided, not dated. Director F stated the document was developed 4/9/20, and has been in practice ever since. Review of the document indicate: "Transfer staff contacts the House Supervisor, provides the following information, and asks for bed availability within 15 minutes of receiving request . . . . Note: Do not reach out to any MDs (physicians) until House Supervisor confirms an available bed."

Review of facility policy "EMTALA - Screening, Stabilization And Transfer of Individuals With Emergency Medical Conditions All Departments & Locations," revised 1/23/17, indicated, "To the extent that the Hospital has specialized capabilities or facilities (e.g., neonatal intensive care) that are not available at another facility that has asked the Hospital to accept the Transfer of an individual needing those capabilities or facilities, the Hospital shall accept the appropriate Transfers of such individuals if the Hospital has the Capacity to treat the individual."

Review of Critical Care journal article "The critical care management of spontaneous intracranial hemorrhage: a contemporary review" de Oliveira Manoel et al. (https://ccforum.biomedcentral.com/articles/10.1186/s13054-016-1432-0), dated 9/18/16, revealed, "According to the AHA/ASA (American Heart Association/American Stroke Association) guidelines and the Emergency Neurological Life Support protocols, spontaneous intracranial hemorrhage is a medical emergency and should be managed accordingly."