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Based on hospital policy and procedure reviews, Emergency Medical Services (EMS) documentation review, medical record review, Dedicated Emergency Department (DED) Central Log review, staff and physician interviews the hospital's DED staff failed to comply with 42 CFR 489.24 by failing to ensure an appropriate Medical Screening Examination (MSE) was provided by Qualified Medical Personnel (QMP) within the capabilities of the hospital for 1 of 31 patients (#31) who presented to the hospital's DED with an emergency medical condition (EMC) and was diverted to another Hospital for evaluation and treatment.

The findings include:

1. ~ cross refer to 489.24(r) 489.24(c) Medical Screening Exam, Tag A2406.

Based on hospital policy and procedure reviews, Emergency Medical Services (EMS) documentation review, medical record review, Dedicated Emergency Department (DED) Central Log review, staff and physician interviews the hospital's DED staff failed to ensure an appropriate Medical Screening Examination (MSE) was provided by Qualified Medical Personnel (QMP) within the capabilities of the hospital for 1 of 31 patients (#31) who presented to the hospital's DED with an emergency medical condition (EMC) and was diverted to another Hospital for evaluation and treatment.

The findings include:

Review of current hospital policy "Medical Screening Exam" Policy Number: 7098-408.00, revised 05/2013, revealed "Policy: Any individual presenting to the Emergency Department requesting care is to receive a medical screening exam (MSE) to determine whether or not an emergency medical condition (EMC) exists. The MSE is to be done by an emergency physician or PA-C under the supervision of an emergency department physician credentialed to practice at (Hospital A). The MSE consists of whatever testing the provider deems necessary and within the capability of the hospital, including ancillary services available to the emergency department, in order to determine the existence of an EMC and the stability of the person's condition. If an emergency medical condition is determined to exist, the provider will provide any necessary stabilizing treatment, arrange an appropriate transfer or consult for further treatment. Procedure: 1. Individuals presenting with a request for care are quickly registered by name, social security and/or date of birth. 2. Individuals with conditions of a life or limb threatening nature are processed to the first available treatment space. 3. Other individuals are assessed and treated in accordance with the (Hospital A) ED Triage Policy. ..."

Review on 07/24/2014 of an EMS Patient Record dated 06/22/2014 for Patient #31 revealed an emergency 911 call was received by the local EMS service at 2359 on 06/21/2014. Review revealed the call was dispatched at 0004 on 06/22/2014 and was "Dispatched As: Assault." Review revealed EMS Medic 3 responded to a residence and arrived on scene at 0013 and found Patient #31. Review of a Chief Complaint (Category: Assault) revealed "Pain to the head and face." Review of History of Present Illness (HPI) revealed "Pt stated that he was assaulted by 3 males, kicked, punched, and stomped. Pt stated that he wanted to be evaluated." Review of neurological exam documentation revealed level of consciousness: alert; no loss of consciousness; neurological present: normal; mental present: oriented-person, place, and time. Review of initial physical findings revealed head: normal, pain, swelling, tenderness and face: normal, pain, swelling, tenderness. Review revealed an impression/diagnosis of "traumatic injury." Review revealed "Scene Information Description ...Pt was assisted to unit ...pt was transported. U/A (upon arrival) to (Hospital A - Satellite Campus B) EMS was advised that the CT (computed tomography) machine was down and pt would have to transported to another facility. Pt was then placed back on bench seat and transported to (Hospital B). ...U/A to (Hospital B) pt was placed in triage and pt care was released to triage nurse." Review of activity documentation by Medic 3 staff revealed at 0031 "Medic 3 enroute to (Hospital A - Satellite Campus B)"; at 0049 "Medic 3 on scene at (Hospital A - Satellite Campus B)"; 0059 "Medic 3 enroute to (Hospital B)"; 0119 "Medic 3 on scene at (Hospital B)"; and at 0150 "Medic 3 clear and available."

Hospital B closed DED record review on 07/24/2014 for Patient #31 revealed the patient presented to the DED via EMS on 06/22/2014 at 0124 (35 minutes after presentation to Hospital A's Satellite Campus B DED). Review revealed a chief complaint of "Assault." Review revealed a MSE was performed at 0229 by a QMP. Review revealed a Complete Blood Count, Lumbar Spine X-Ray, CT of Head and Cervical Spine, and CT of Pelvis was performed. The patient was subsequently discharged at 0752 in stable condition with a diagnosis of Alleged Assault, Contusion - Head, Hip, Back.

Review of Hospital A's DED Central Log on 07/23/2014 revealed no available documentation of a log entry for Patient #31 who presented via EMS Medic 3 on June 22, 2014 at 0049.

Telephone interview on 07/23/2014 at 1705 with DED RN #1 revealed she was the Charge Nurse on-duty in the DED of Hospital A's Satellite Campus B on the 7PM to 7AM shift when Patient #31 presented to the DED via EMS (June 22, 2014). Interview revealed "around midnight, the CT tech (technician) came over and reported that CT was down because it was too hot in the room and the room needed to cool down before a CT could be done." Interview revealed "CT was going to be down for an unknown amount of time." Interview revealed "Dr. (Physician A) came out and overheard the conversation. He stated if anyone came in or we were aware a patient may need a CT scan, to go ahead and divert the patient to another hospital." Interview revealed "I did not verify, but assumed he meant EMS." Interview revealed EMS usually will call ahead to the hospital and notify the staff of the patient and complaint. Interview revealed "EMS did not call in this time for the patient." Interview revealed "EMS walked in with the patient ambulating behind them." Interview revealed they entered through the ambulance bay and came to the nursing station. Interview revealed EMS reported the patient had been assaulted. Interview revealed the patient had been hit in the head. Interview revealed the patient was holding an ice pack to his head. Interview revealed "I informed EMS that CT was down and Dr. (Physician A) would like the patient to be diverted elsewhere." Interview revealed "they (EMS) made a comment, that the patient didn't need a CT." Interview revealed "they (EMS) turned around and left and the patient followed." Interview revealed this was the "only episode" to her knowledge of any patient being diverted after arrival to the DED. Interview revealed the hospital did have a diversion protocol in place. Interview revealed the DED was not on official diversion when Patient #31 presented. Interview revealed "I was iffy on the protocol." Interview revealed "I was a little uneducated on that process." Interview revealed she had been a registered nurse for two years. Interview revealed she had worked in the DED since August 2013. Interview revealed she was new to the Charge Nurse role. Interview revealed she has received re-education and training on the EMTALA policy and procedures, diversion guidelines and protocols. Interview revealed Physician A was unaware the patient had presented to the DED and was diverted elsewhere. Interview revealed "we should have done a medical screening exam on the patient." Interview confirmed Patient #31 was not registered as a patient in the DED. Interview confirmed Patient #31 was not evaluated by a physician or other QMP on June 22, 2014.

Interview on 07/23/2014 at 1515 with Administrator #1 revealed she is the Administrator for Hospital A's Satellite Campus B. Interview revealed she was made aware of the incident involving Patient #31. Interview revealed she was notified by risk management regarding "a potential EMTALA violation." Interview revealed "I tried to pull the patient's record to review, but there was no record to review." Interview revealed "the patient should have been registered, placed in a room, evaluated by a physician, treated, discharged or transferred if necessary." Interview revealed "We did not screen the patient and should have." Interview revealed "we should have done something different." Interview revealed the "EMTALA Policy was not followed." Interview confirmed no available documentation of a DED record for Patient #31 who presented via EMS Medic 3 on June 22, 2014 at 0049.

Interview on 07/24/2014 at 1100 with Physician B revealed he is the DED Assistant Medical Director at Hospital A's Satellite Campus B. Interview revealed he was made aware of the incident involving Patient #31 by Hospital Administration. Interview revealed the local EMS Medical Director also notified him of the incident. Interview revealed there appeared to have been communication issues and the unavailability of CT scan when Patient #31 presented via EMS. Interview revealed he spoke with administration to get an understanding regarding the CT issue. Interview revealed he spoke with staff involved and reviewed the incident with the on-duty physician (Physician A). Interview revealed Physician A was unaware the patient had presented and been diverted to another hospital. Interview revealed the DED was not on diversion status. Interview revealed "the patient should have never left." Interview revealed "the patient was brought onto the campus and regardless of what conversations occurred, the patient left the campus without a medical screening examination being performed." Interview revealed "it should not have happened." Interview revealed "there were a whole bunch of actions that could have taken place to prevent the patient from leaving. That did not happen." Interview revealed "Yes" it was an EMTALA violation. Interview revealed he was unaware of any other similar incidents occurring since Hospital A's Satellite Campus B DED opened in October 2013.

NC00098468