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Based on observation, interview, and record review, the hospital failed to ensure that it was in compliance with the Emergency Medical Treatment and Labor Act (EMTALA) as evidenced by the following:

1. Failure to perform an adequate medical screening examination for one of 24 sampled patients. (Patient 1)

2. Failure to provide stabilizing treatment within the hospital's capabilities for one of 24 sampled patients. (Patient 1)

3. Failure to provide an appropriate transfer for three of 15 transferred patients. (Patients 1, 14, and 18)

These failures had the potential for patients to have delays in receiving needed care and treatment which can result in adverse outcomes including death.

Based on interview and record review, the hospital failed to ensure that one of 24 sampled patients was provided an adequate medical screening examination (MSE) within the capabilities of the hospital's emergency department (ED) to determine whether or not an emergency condition existed (Patient 1) This failure had the potential for a delay in care and treatment that could have resulted in death.

Findings:

On 9/30/14 at 3:15 pm, California Department of Public Health received a complaint regarding an inappropriate transfer of a patient, who sustained injuries from falling off a horse, to Hospital D. The complaint alleged that Patient 1 was seen at the hospital without stabilizing the patient and then transferring to Hospital D which is not a higher level of care.

On 10/6/14, Patient 1's record was reviewed. On 9/29/14 at approximately 9:30 am, Patient 1 was bucked of a horse and suffered head, chest, and back injuries. At 9:34 am, the hospital ambulance responded to Patient 1's accident. It arrived to the accident scene at 9:42 am. First responders on the scene reported that Patient 1 had lost consciousness and demonstrated seizure activity. Registered Nurse (RN) A from the hospital ambulance assessed Patient 1 and found that she had an altered level of consciousness, was combative and confused, had severe pain on her right chest and right hip/pelvis, and had no breath sounds at the base of her right lung. RN A contacted Physician B at the hospital with a report of Patient 1's condition. Physician B directed RN A to take Patient 1 via ambulance to Hospital D (which is approximately 28 miles further than the ambulance base hospital for a total trip of approximately 49 miles) which commenced at 10:02 am.

At 10:05 am, Patient 1 experienced a sudden change in consciousness with a drop in blood pressure and oxygen saturation (the amount of oxygen in the blood), and pain rated at a 10 on a one to ten scale with 10 being the worst pain. At 10:07 am, RN A requested a diversion to the ambulance base hospital because of Patient 1's change in condition. The ambulance arrived at the base hospital at 10:14 am. Physician B was waiting outside and climbed into the ambulance and requested new vital signs be taken which were in the normal range as was the oxygen saturation normal. Physician B stated Patient 1 was stable and directed RN A to resume transport to Hospital D. Ambulance transport was resumed at 10:17 am - three minutes later. At 10:35 am, prior to arriving at Hospital D, Patient 1 had another drop in blood pressure which returned to normal five minutes later.

On 10/6/14, Patient 1's record from Hospital D was reviewed. Patient 1 was evaluated at Hospital D at 10:44 am and found to have a closed head injury, a right-side pneumothorax (when air leaks into the space between the chest wall and lungs causing the lung to collapse), fractured ribs, right-sided shoulder, abdominal, back and hip pain. Hospital D provided diagnostic examination, laboratory testing, x-rays, CT (computerized tomography, a type of x-ray), cardiac (heart) monitoring, intravenous (in the vein), fluids, pain medication, oxygen, chest tube placement (tube inserted between the chest wall and lung to expand a collapsed lung), and arranged for transfer to a higher level of care at Hospital E at 13:20 pm. Patient 1 remained stable during the Hospital D stay.

On 10/6/14, written statements from Emergency Medical Technician (EMT) E and RN A, dated 10/1/14, stated they feared further deterioration of Patient 1's condition during the transport. Both statements indicated that Physician B entered the ambulance and requested another set of vital signs and evaluated the oxygen saturation. EMT E's statement included that Physician B was reported to say, "There's nothing I can do for her. Get her out of here (referring to a transfer to Hospital D)." EMT E stated that Physician B requested an IV, but was told by RN A that a BLS (Basic Life Support) ambulance could not start IVs. Physician B was then reported to leave the ambulance.

On 10/1/14 at 2:30 pm, EMT E stated that Physician B did not do an examination of Patient 1 in the ambulance.

On 10/6/14, the hospital policy, titled, "Cobra/EMTALA (Emergency Medical Treatment and Labor Act) Transfer Policy/Protocols," dated 8/8/12, read, "It is the policy of Surprise Valley Hospital to provide appropriate medical response, screening, and stabilization to determine the nature and extent of any injury, medical condition, and /or pregnancy within its capabilities...All persons presenting to the hospital campus requesting treatment shall be provided a medical screening exam for the purpose of determining whether they suffer from an emergency medical condition... Screening will include necessary testing to rule out any condition with potential health risks... The medical screening exam shall be conducted by a physician...." The policy further defined an emergency medical condition as, "Any medical condition manifesting itself by acute problems of sufficient severity, including sever pain, such that the absence of immediate medical care could reasonably be expected to result in: 1) Placing the patient's health...in serious jeopardy, 2) Serious impairment to bodily functions, 3) Serious dysfunction of any bodily organ or part... 4) Any one or more of the above."

On 10/7/14 at 4:05 pm, Physician B stated that he was approached by the hospital Chief Executive Officer immediately after Patient 1 left the hospital regarding concerns for EMTALA violations in Patient 1's transfer. Physician B stated he acknowledged that Patient 1 did not receive an adequate MSE prior to leaving the hospital.

Based on interview and record review, the hospital failed to ensure that one of 24 sampled patients received further medical evaluation and treatment within the capabilities and capacity of the hospital to stabilize her emergency condition. (Patient 1)

This failure had the potential for patients' conditions to deteriorate and could have resulted in serious health impairment including death.

Findings:

1. On 10/1/14, Patient 1's record was reviewed. Patient 1 sustained injuries from falling off a horse. Patient 1 presented to the hospital Emergency Department with altered level of consciousness, was combative and confused, had severe pain on her right chest and right hip/pelvis, and had no breath sounds at the base of her lungs. Patient 1 was transferred from the hospital to Hospital D for care. Refer to C 2406 for further information. Patient 1's record did not contain evidence that further medical evaluation or treatment was provided to stabilize Patient 1's emergency medical condition.

The hospital participates in a community call system for trauma (a serious bodily injury or shock, as from violence or an accident.). The policy for the trauma system provided by the Director of Nurses (DON) on 10/6/14, titled, "Trauma Triage and Activation Policy," dated (revision) 6/21/11, read, "When the Base Hospital deems it necessary to transport a patient to the "nearest" Receiving Facility for stabilization, it is IMPERATIVE for healthcare providers to understand that a Critical Trauma Patient is a surgical emergency and requires early definitive care....The entire trauma system is driven by the tenet that severely injured trauma patients should be triaged to the closest appropriate trauma facility."

On 10/8/14, the hospital policy, titled, "Cobra/EMTALA Transfer Policy/Protocols," dated 8/8/12, read, "No person suffering from an emergency medical condition shall be transferred from this hospital until the patient's condition has been stabilized... unless in the medical judgement of the responsible physician, this facility is not capable of providing reasonably necessary or anticipated care for the patient... to maintain the stability of the patient."

On 10/8/14, the hospital policy, titled, "Stabilizing Orders," undated, instructed nurses that for patients who had altered level of consciousness the following orders were considered standard and should be performed: IV, labs (Complete Blood Count [CBC-an analysis of blood cells], Basic Metabolic Panel [BMP-test for kidney function and electrolytes], Urine Test [UA-analysis of urine], oxygen administration, heart monitoring, Finger Stick-Glucose [FSG- tests sugar in blood]).

On 10/1/14 at 3 pm, the DON reviewed Patient 1's record and acknowledged that Patient 1 met the definition for a trauma patient. DON acknowledged that Patient 1 had an emergency condition that was not stabilized while at the hospital. The DON confirmed that the hospital had the same capabilities of Hospital D with the exception of the availability of CT scan (computerized tomography, a type of x-ray). The DON further confirmed that an intravenous (IV) line could have been established to provide fluids and medications such as pain medication (Patient 1 had severe pain rated 10 out of a scale of 10), laboratory testing, x-rays, a chest tube (to re-expand the lung), and a urinary catheter could all have been provided at the hospital. The DON acknowledged that Patient 1 should have been transferred to a higher level of care rather than to Hospital D, that had similar capabilities and capacity to treat Patient 1's emergency condition.

On 10/7/14 at 4:05 pm, Physician B acknowledged that further examination and treatment should have been provided to stabilize Patient 1's emergency condition prior to transferring Patient 1 to a higher level of care.

Based on interview and record review, the hospital failed to ensure that three of 15 transferred patients met the qualifications for an appropriate transfer, as follows:

1. Patient 1's transfer was not provided to an appropriate receiving facility, and with qualified personnel and transportation equipment;

2. Patient 18 was discharged with an emergency medical condition and transfer to an appropriate medical facility was not arranged; and

3. Patient 14 was transferred without the receiving facility receiving all medical records related to the emergency condition.

These failures had the potential for miscommunication and inability to provide needed care which could have resulted in serious health impairment including death.

Findings:

1. On 10/1/14, Patient 1's record was reviewed. Patient 1 sustained injuries from falling off a horse. Patient 1 presented to the hospital Emergency Department with altered level of consciousness, was combative and confused, had severe pain on her right chest and right hip/pelvis, and had no breath sounds at the base of her lungs. Registered Nurse (RN) A contacted Physician B at the hospital with a report of Patient 1's condition from the accident scene. Physician B directed RN A to take Patient 1 via ambulance to Hospital D (which is approximately 28 miles further than the ambulance base hospital for a total trip of approximately 49 miles) which commenced at 10:02 am.

On 10/1/14 at 2:30 pm, EMT Stated RN A was certified to drive the ambulance and EMT E (not certified to drive) was in the back with Patient 1.

At 10:05 am, Patient 1 experienced a sudden change in consciousness with a drop in blood pressure and oxygen saturation (the amount of oxygen in the blood), and pain rated at a 10 on a one to ten scale with 10 being the worst pain. At 10:07 am, RN A requested a diversion to the ambulance base hospital because of Patient 1's change in condition and fear of further deterioration. The ambulance arrived at the base hospital at 10:14 am. Physician B was waiting outside and climbed into the ambulance and requested new vital signs be taken which were in the normal range as was the oxygen saturation normal. Physician B stated Patient 1 was stable and directed RN A to resume transport to Hospital D. Ambulance transport was resumed at 10:17 am - three minutes later.

On 10/6/14, written statements from Emergency Medical Technician (EMT) E and RN A, dated 10/1/14, stated Physician B entered the ambulance and requested another set of vital signs and evaluated the oxygen saturation (amount of oxygen in the blood). EMT E's statement included that Physician B was reported to say, "There's nothing I can do for her. Get her out of here (referring to a transfer to Hospital D)." EMT E stated that Physician B requested an IV (intravenous-in the vein), but was told by RN A that a BLS (Basic Life Support) ambulance could not start IVs. Physician B then left the ambulance. The ambulance proceeded Code 3 to Hospital D. (Code 3 is a mode of travel in which simultaneous use of lights and sirens is required in order to achieve a rapid response in traffic).

Basic life support as defined in the California Health and Safety Code, Section 1797.50- 1797.97 means emergency first aid and cardiopulmonary resuscitation procedures which, as a minimum, include recognizing respiratory and cardiac arrest and starting the proper application of cardiopulmonary resuscitation to maintain life without invasive techniques until the victim may be transported or until advanced life support is available.

Advanced life support as defined in the California Health and Safety Code, Section 1797.52-1797.97 means special services designed to provide definitive emergency medical care, including, but not limited to, cardiopulmonary resuscitation, cardiac monitoring, cardiac defibrillation (shock, advanced airway management, intravenous therapy, administration of specified drugs and other medical preparations, and other specified techniques and procedures administered by authorized personnel under the direct supervision of a base hospital as part of a local EMS system at the scene of an emergency, during transport to an acute care hospital, during interfacility transfer, and while in the emergency department of an acute care hospital until responsibility is assumed by the emergency or other medical staff of that hospital.

On 10/1/14 at 2:30 pm, EMT E stated that Physician B did not perform an examination of Patient 1 in the ambulance.

The hospital participates in a community call system for traumas. The policy for the trauma system provided by RN A in her role as Director of Nurses (DON) on 10/1/14, titled, "Trauma Triage and Activation Policy," dated (revision) 6/21/11, read, "When the Base Hospital deems it necessary to transport a patient to the "nearest" Receiving Facility for stabilization, it is IMPERATIVE for healthcare providers to understand that a Critical Trauma Patient is a surgical emergency and requires early definitive care....The entire trauma system is driven by the tenet that severely injured trauma patients should be triaged to the closest appropriate trauma facility."

On 10/6/14, the hospital policy, titled, "Cobra/EMTALA Transfer Policy/Protocols," dated 8/8/12, read, "It is the policy of this hospital that all patients being transferred while suffering from emergency medical conditions and not being deemed stabilized shall receive a medically appropriate transfer to a facility capable of providing the care necessary to the health and safety of the patient.... No patient shall be transferred ...until the responsible physician.. has determined the necessary level of medical care personnel and life support equipment required for the patient's reasonable anticipated care and reasonably foreseeable complications during transport and secured such personnel, medications, and equipment to accompany the patient."

On 10/1/14 at 3 pm, the DON reviewed Patient 1's record and acknowledged that Patient 1 met the definition for a trauma patient. DON acknowledged that Patient 1 had an emergency condition, a closed head injury and severe right side pain, that was not stabilized while at the hospital. The DON confirmed that the hospital had the same capabilities of Hospital D with the exception of the availability of CT scan (computerized tomography, a type of x-ray). Refer to 2406 for further information. The DON acknowledged that Patient 1 should have been transferred to a higher level of care rather than to Hospital D, which had the similar capability and capacity to treat Patient 1's emergency condition. DON further stated that Patient 1 should have been transported with an ALS ambulance or air transfer to facilitate IV fluids and medications to address her pain and foreseeable complications related to her head injury.

On 10/7/14 at 4:05 pm, Physician B stated he had completed the transfer paperwork after the ambulance had left the hospital and that he had faxed it to Hospital D later in the day. Physician B stated he had contacted the Physician C at Hospital D to report on Patient 1's condition. Physician B acknowledged that he had spoken with the hospital Chief Operating Officer in regards to the transfer and EMTALA regulations, and had agreed that it would not happen again.

2. On 10/8/14, Patient 18's record was reviewed. Patient 18 presented to the Emergency Department (ED) with thoughts of killing herself and harming others. Patient 18's record contained evidence that she was medically cleared and needed a psychiatric evaluation. Patient 18's record indicated she was discharged. Patient 18's record did not indicate who had resumed medical supervision for Patient 18's emergency medical condition nor that the emergency condition nor longer existed or had been stabilized. Patient 18's record contained no evidence of an appropriate transfer.

On 10/8/14 at 9:45 am, DON reviewed Patient 18's record and acknowledged that the hospital policy had not been followed for Patient 18's emergency medical condition.

On 10/8/14 at 11:45 am, Physician B acknowledged that he had not arranged for a transfer of Patient 18.

3. On 10/7/14, Patient 14's record was reviewed. Patient 14 presented to the ED, on 6/28/14 at 1:20 pm, with left shoulder pain after a fall. Patient 14 was later transferred to another hospital for definitive care at 3:45 pm. The record did not indicate that Patient 14's medical records had been sent to the receiving hospital.

On 10/6/14, the hospital policy, titled, "Cobra/EMTALA Transfer Policy/Protocols," dated 8/8/12, indicated that no patient shall be transferred until the responsible physician had provided transport personnel with copies of the patient's medical records, lab testing, radiologist films, consultation reports reflecting all examinations and treatment performed at the hospital to be delivered to the receiving facility.

On 10/8/14 at 11:45 am, DON reviewed Patient 14's record and acknowledged that there was no evidence that records had been sent to Patient 14's receiving hospital.