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Based on policy review, document review, audio recording review, medical record review, observation and interviews, the hospital failed to ensure each patient who presented to the Emergency Department (ED) seeking examination and/or treatment received an appropriate medical screening exam (MSE) within the hospital's capabilities and according to hospital policy in order to determine if a medical emergency condition existed for 1 of 21 (Patient #21) sampled patients.


The findings included:

1. The hospital failed to accept a patient who was brought to the hospital's ED by emergency medical services (EMS) who was seeking examination and/or treatment to determine if an emergency medical condition existed.

Refer to A2406

Based on policy review, critical advisory report document review, audio recording review, medical record review, observation and interviews, the hospital failed to ensure each patient who presented to the hospital's Emergency Department (ED) received an appropriate medical screening exam (MSE) according to hospital policy to determine if a medical emergency condition existed for 1 of 21 (Patient #21) sampled patients.

The findings included:

1. Review of the facility's "Screening, Stabilization, Treatment and Transfer of Individuals in Need of Emergency Medical Services - EMTALA (Emergency Medical Treatment and Labor Act)" policy revealed, "...Definitions...c. "Diversionary status" generally means that Hospital does not have the staff (capability) and/or facilities (capacity) to accept additional emergency patients at all or of a certain type of condition...e. "Hospital Property" means the entire main Hospital campus (including the physical area owned by Hospital that is immediately adjacent to Hospital's main buildings, other areas and structures owned by Hospital that are not attached to Hospital's main buildings but are located within 250 yards of Hospital's main buildings, including parking lots, sidewalks, driveways, and hospital departments (if any)...C. Community Ambulances Previously Diverted that Present on Hospital Property...An individual in a community ambulance that arrives on Hospital Property is considered to have come to the Hospital's emergency department, even if Hospital personnel attempted to divert the ambulance prior to arrival or if the Hospital is on diversion or critical advisory status, the individual should be provided an MSE [Medical Screening Exam] and any EMC [Emergency Medical Condition] stabilized and/or the individual should be appropriately transferred as applicable under EMTALA, unless the patient refuses...".

2. Review of the facility's "Critical Advisory for Patients Arriving to the Emergency Department" policy revealed, "...Critical advisory may be requested only after the hospital has exhausted all internal resources to meet the current patient load, including any necessary call-backs of staff, expedited discharges, opening of "virtual" beds, and similar mechanisms to address patient load...Critical advisory is a plan to temporarily limit the hospital or Emergency Department to ambulance traffic when safe patient care becomes a concern. This may be due to fluctuations in patient acuity and census, ED overcrowding, staffing shortages, lack of critical care, specialty, or even general beds, to the extent that the ED is unable to provide quality care or protect the health or welfare of the patients is serves...While on critical advisory, hospitals must make every attempt to maximize bed space, screen and defer elective admissions or procedures, and use all available personnel and facility resources to minimize the length of critical advisory status...CRITICAL ADVISORY OVER-RIDE...An EMS [Emergency Medical Services] crew in the field is authorized to declare a 'critical advisory over-ride' and proceed to the hospital currently on ED Critical Advisory at their discretion for the safety and request of any patient...".

3. Review of the hospital's Critical Advisory Report presented to the survey team on 7/6/2020 at 11:45 AM revealed the hospital was on Critical Advisory from 6/14/2020 at 3:42 PM until 6/15/2020 at 6:23 AM.

4. Review of an audio recording provided by the Regional Medical Communications Center (RMCC - a communication center that connects EMS services with Hospital EDs) revealed Paramedic #1 contacted the RMCC and reported their EMS Unit 433 was leaving the scene of Patient #21's residence in Memphis in route to Hospital #1 [Methodist South] with Patient
#21. The Communication Center informed Paramedic #1 that Hospital #1 had been on critical advisory for days. The Communication Center stated he could still connect the Paramedic through to the Hospital #1 and was simply informing of the critical advisory status of Hospital #1.
The recording revealed the Communication Center contacted Hospital #1 and informed Hospital #1 that EMS Unit 433 needed to give a report on Patient #21, and that the EMS crew had been advised of the critical advisory status. A staff member at Hospital #1 stated the Hospital was still on critical advisory. The staff member was later identified by the surveyor as a Hospital Operator. The Communication Center told the hospital Operator "They [EMS unit 433] still wants to give report."
Next on the recording, Hospital #1's ED Nurse #1 answered the Communication Center call and was connected with the EMS Unit 433. Paramedic #1 informed ED Nurse #1 they were in route with a 42 year old female (Patient #21) who had complaints of chest pain and shortness of breath, worsening the past couple of days with a current systolic blood pressure 190 (the diastolic blood pressure could not be heard on the audio), heart rate 92, respirations 20, and oxygen 98% on room air, showing normal sinus rhythm.
Paramedic #1 reported the unit was 2-3 minutes away from Hospital #1's ED.
ED Nurse #1 asked "Are you able to send us [transmit to ED before arrival with patient] an EKG [electrocardiogram- evaluates the mechanical activity of the heart]?"
Paramedic #1 stated they were unable to send the EKG prior to the patient's arrival.
ED Nurse #1 stated, "Hold on a second." ED Nurse #1 came back to the call and stated, "...since we don't have the ability to see the EKG, uh according to our ER doctor [ED Physician #1], we need y'all to divert to an area that has cardiac."
The RMCC (who was listening on the call during the entire time) then informed Paramedic #1 that 4 other hospitals in the area were also on critical advisory.
Paramedic #1 stated she would talk to Patient #21 and find out where she wanted to go. The call ended.

Paramedic #1 made a second call to the RMCC requesting to speak with Hospital #1's ED. The Communication Center contacted Hospital #1's operator and asked if he could speak with the ED nurse again.
ED Nurse #2 answered the call and the Communication Center stated,
"The Patient [Patient #21] is requesting your facility, they will be there [Hospital #1] probably in about 30 seconds."
Paramedic #1 can then be heard saying their EMS Unit was pulling into the hospital parking lot at that moment.
ED Nurse #2 can then be heard saying, "It doesn't matter what the patient is requesting..." The Communication Center stated, "well they [EMS Unit 433] are on your property now". ED Nurse #2 replied "We don't have a cath lab [area with diagnostic imaging equipment used to visualize the arteries of the heart and the chambers of the heart and treat any stenosis or abnormality found] or a cardiac unit to help the patient..."
ED Nurse #2 then asked if the EMS Unit 433 was on the phone and Paramedic #1 replied, "Yes, I am here."
ED Nurse #2 stated, "Okay so per our ER Doc [ED Physician #1] we can't accept the patient because we don't have.." Paramedic #1 spoke over ED Nurse #2 and asked if they were refusing the patient. ED Nurse #2 stated she was unable to hear Paramedic #1's question. The RMCC then asked "Who is the doctor refusing the patient?"
ED Nurse #2 asked the Communication Center to repeat the question more than once and then stated she could not hear him.
Next on the audio recording, ED Nurse #2 handed the phone to the Nursing Supervisor. The Nursing Supervisor identified herself and the Communication Center asked, "Who is the doctor refusing...the unit is on your property."
The Nursing supervisor responded, "they [EMS Unit 433] are not on our property". Paramedic #1 stated "We are pulling in the drive."
The Nursing Supervisor stated she was looking at the drive and the EMS Unit 433 was not there and stated, "it doesn't matter what the patient is requesting, we don't have the appropriate level of care for them".
The Communication Center can be heard saying, "the argument is not with me". The ED Nursing Supervisor responded, "Well that's our statement."
Paramedic #1 asked for the name of the physician refusing the patient, and the Nursing Supervisor named ED Physician #1.
The Nursing Supervisor stated, "That is fine if they [EMS Unit 433] are truly pulling in the driveway we will have a discussion with their supervisor, but this is per [named ED Physician
#1]". The call then became inaudible and ended a few seconds later.


5. Review of the Patient Care record from EMS Unit 433 revealed the EMS Unit was dispatched to Patient #21's home on 6/15/2020 at 12:12 AM for complaints of breathing problems. EMS documented they arrived at the home at 12:33 AM and Patient #21 complained of chest pain, shortness of breath and vomiting blood.
At 12:44 AM Patient #21's blood pressure was 170/119, pulse 102 and O2 saturation 100% on room air. The patient was alert and oriented. The record revealed Patient #2's chest pain had gotten worse the past couple of days. Patient #21 reported stabbing pain at mid-sternum area and rated it 9 on a scale of 1-10 (with 10 being the worst pain you can imagine). The patient reported shortness of breath when walking and vomiting bright red blood the past two days. Patient #21 was in normal sinus rhythm on the cardiac monitor. Patient #21 stated Hospital #1 was her hospital of choice.
The EMS Patient Care Record revealed Paramedic #1 contacted the RMCC while in route to Hospital #1 to give report to Hospital #1's ED staff.
Paramedic #1 documented, "...after report was given [to Hospital #1 ED] nurse informs myself and dispatch [named ED Physician #1] refuses to treat patient and states she should be transported to a facility with cardiology receiving services."
The EMS record further documented, the RMCC had informed Hospital #'1s ED Nurse the EMS Unit was pulling into the driveway of Hospital #1.
Paramedic #1 documented, "...the Nurse states well out [our] ER doctor will take it up with your supervisor but our doctor is not going to treat the patient.
Paramedic #1 asked 'So you are refusing to treat my patient?'...While still on the phone with dispatch patient was asked if she would be willing to go to another facility. Patient was very upset and states guess I will go to [Hospital #2], that's bullshit they are not suppose to refuse to see you..".
When ED Physician #1 refused to accept Patient #21, the EMS unit left Hospital #1 and diverted to Hospital #2.

6. Review of Hospital #2's ED record for Patient #21 revealed the patient was transported to Hospital #2 on 6/15/2020 where she received a MSE in the ED at 1:59 AM. (This was 1 hour and 15 minutes after initially being picked up at home by EMS). The MSE revealed the patient presented with complaints of chest pain, shortness of breath and vomiting dark red blood. The patient rated her pain at a 9 on a scale of 0-10 (10 being the worst pain you can imagine). The patient's EKG showed no sign of Myocardial Infarction (heart attack), however, review of the patient's lab work revealed the following abnormalities:
Low Red Blood Cell (RBC) count of 3.91 (4.2-5.4 is normal range for females).
Hemoglobin (HgB) critically low at 5.4 (12.0-15.5 is normal range for females).
Hematocrit (Hct) critically low at 19.8% (36%-48% is normal range for females).

The patient was admitted to Hospital #2 on 6/15/2020 at 4:53 AM. During the patient's admission, she received 3 blood transfusions and also had an Esophagogastroduodenoscopy (EGD) and colonoscopy, which revealed 2 small polyps. The patient was found to have vaginal bleeding during her admission, and had an endometrial biopsy performed (results not known before discharge from the hospital). The patient had uncontrolled Hypertension (high blood pressure) during her admission and was treated with multiple medications.

Review of the patient's discharge summary revealed discharge diagnoses that included Upper Gastrointestinal (GI) bleeding, episode of heavy vaginal bleeding, Chest Pain and Hypertension.

7. In an interview in the conference room on 7/6/2020 at 11:50 PM, Hospital #1's Risk Manager (RM) verified the hospital was not on critical advisory at the time of the call from EMS Unit 433 related to Patient #21 on 6/15/2020. The RM stated Hospital #1's House Supervisor had canceled the critical advisory but failed to notify RMCC.
When asked if Hospital #1 had a policy allowing an ED physician to make a decision about medical care over the telephone and direct a patient to a higher level of care without a medical screening exam the RM stated "no" that is not a hospital policy.
The Risk Manager verified Hospital #1 had a cardiac catheterization unit (cardiac catheterization - the insertion of a catheter into a chamber or vessel of the heart for diagnostic purposes) open during the daytime Monday through Friday. The RM verified if a patient needed a cardiac catheterization after hours or weekends they were seen by a physician and transferred to a higher level of care if needed.

The Risk Manager walked with the surveyors outside of the hospital on 7/6/2020 at 12:00 PM to observe the area where EMS Unit 433 had parked adjacent to the driveway entrance to the Hospital #1's ED ambulance bay. She stated EMS Unit 433 was there for several minutes while on the phone with the Communication Center and Hospital #1.

In an interview in the conference room on 7/6/2020 at 12:34 when the surveyors asked for an interview with ED Physician #1, the Risk Manager stated ED Physician #1 had resigned and no longer worked at the hospital. The survey team attempted to call ED Physician #1 on 7/6/2020 at 2:28 PM and on 7/7/2020 at 12:20 PM to conduct a telephone interview. The survey team was unable to make contact with ED Physician #1.

In a telephone interview on 7/6/2020 at 12:53 PM, ED Nurse #2 stated she had worked in Hospital #1's ED for over 2 years. She verified she took a call from EMS Unit 433 about Patient #21 on 6/15/2020. She stated she answered the call when EMS called back a second time because the patient had again requested Hospital #1. She stated ED Physician #1 said to divert the patient since the EMS could not transmit an EKG to the ED and determine patient stability. She stated the local county owned EMS company have the capability to send an EKG to the hospital while they are in route.
When asked where the ambulance was located when the call was made, ED RN #2 stated that she had later learned EMS Unit 433 was on the hospital property but she was unaware when she was speaking with Paramedic #1. (This is contradictory to the audio recording referenced above).

In an telephone interview with ED Nurse #1 on 7/6/2020 at 1:02 PM, ED Nurse #1 verified she worked in the ED at Hospital #1 and confirmed she took the first call from the EMS Unit 433 on 6/15/2020 regarding Patient #21.
ED Nurse #1 stated EMS Unit 433 reported Patient #21 had chest pain, shortness of breath and elevated blood pressure and she asked if the EMS crew could send an EKG to the hospital prior to the patient's arrival so they would know of the patient was having a stemi (heart attack) and the EMS crew stated they could not send an EKG.
ED Nurse #1 stated since the EMS crew were unable to send a EKG, ED Physician #1 advised they transport the patient to a higher level of care that had cardiac catheterization capability 24 hours a day. She stated it was standard protocol and at the discretion of the ED physician if they were unable to get an EKG to send the patient to a higher level of care. (This was contradictory to the Risk Manager's interview).

In an interview in the conference room with the Interim ED Nursing Director on 7/6/2020 at 3:10 PM, the Nursing Director stated she was made aware of the incident with Patient #21 on 6/16/2020. The Nursing Director stated she was unaware of this happening before. The Nursing Director stated ED Physician #1 should have been communicating with the EMS personnel if he was making a decision to send the patient to a higher level of care, not her nursing staff. She verified EMS Unit 433 still had the right to bring Patient #21 to Hospital #1's ED.

In an telephone interview on 7/7/2020 at 12:41 PM, Hospital #1's Nursing Supervisor stated her role was to supervise all areas of Hospital #1 and act as a resource for nursing.
The Nursing Supervisor stated she just happened to be in the ED at the time of the call between EMS Unit 433 and Hospital #1's ED on 6/15/2020.
The Nursing Supervisor stated she took the telephone call from ED Nurse #2 because ED Nurse #2 was having a difficult time hearing the EMS personnel and the Communication Center.
The Nursing Supervisor stated she was unaware of the location of EMS Unit 433 at the time of the call. (This is contradictory to the audio recording referenced above).
The Nursing Supervisor stated ED Physician #1 was standing right in front of her in the ED and stated he was diverting the patient to a higher level of care.
The Nursing Supervisor stated the ED nurses were taking direction from ED Physician #1.

In a telephone interview with the ED Medical Director on 7/7/2020 at 12:50 PM, the ED Medical Director stated he was notified of the incident with Patient #21 being diverted to another hospital in an email from ED Physician #1 on 6/15/2020.
The Medical Director stated ED Physician #1 reported to him that he was unaware the EMS unit was on the hospital property. The ED Medical Director stated if ED Physician #1 had known EMS was on the property he should have treated the patient (The audio recording verifies the Hospital ED Nurses were informed the EMS unit was on Hospital #1's property).
The ED Medical Director verified a patient's request of a specific hospital should not be dismissed.
The ED Medical Director stated his expectation is that the ED physicians speak directly to EMS and not rely on second party information.

In an interview in the Director of Hospital Security's office on 7/7/2020 at 1:25 PM, while watching video recording of the outside of Hospital #1's ED on the night of 6/15/2020, the Risk Manager verified the ambulance was within 250 yards of hospital property when it was parked adjacent to the ambulance entrance bay of Hospital #1. There was no time stamp or reference on the video recording.

In a telephone interview on 7/7/2020 at 3:34 PM, Paramedic #1 verified she was told by both ED Nurse #1 and #2 the physician would not see Patient #21 because the EKG could not be sent prior to the patient's arrival, and the patient needed cardiac services.
Paramedic #1 stated she has transported patients to this hospital in the past, and never experienced a problem prior to 6/15/2020.
Paramedic #1 stated she was "shocked" at what the ED nurses were telling her.
Paramedic #1 verified the EMS unit had arrived on Hospital #1's property and were in the hospital's ambulance bay when they were told by the Nursing Supervisor the ED physician that they would not accept or treat Patient #1.
Paramedic #1 verified again they were on hospital property when the Patient #21 was declined ED hospital services.

In a telephone interview on 7/7/2020 at 3:47 PM, the emergency medical technician (EMT) #1 for EMS Unit 433 stated she was driving the EMS unit on 6/15/2020 with Patient #21.
The EMT stated, "[named Paramedic #1] is soft spoken and I could hear her repeating 'So you are refusing my patient?'"
EMT #1 verified she had parked adjacent to Hospital #1's ambulance bay while Paramedic #1 was on hold with the hospital's ED.
EMT #1 stated she then drove onto Hospital #1's property at the ambulance bay entrance, but when she arrived there, Paramedic #1 advised her Hospital #1 had refused to see the patient.

The survey team attempted to reach Patient #21 on 7/6/2020 at 2:26 PM. The survey team left a message for Patient #21 with a family member. Patient #21 did not return the survey teams call.