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Based on review of the facility's ambulance report logs, National EMS audio report transmissions, facility's video recording of the ambulance bay, facility's Central Log, computer query, EMS trip reports, facility's Rules and Regulations for the Medical Staff, Professional Services Agreement, policies and procedures, facility's ED diversion status, staff interviews, interviews with National EMS staff, credential files, and personnel files, it was determined that the facility failed to ensure compliance with CFR 489.24, for two (2) individuals (#17 and #21) of twenty-one (21) sampled patients.

Findings:

1. Cross refer to A2406 as it relates to failure to provide an appropriate Medical Screening Exam (MSE) for patient #17 and #21 on 12/11/2015.

2. Cross refer to A2407 as it relates to failure to provide appropriate stabilizing treatment for patient #17 and #21 on 12/11/2015.

3. Cross refer to A2409 as it relates to failure to ensure that an appropriate transfers was provided for patient # 17 and 21 on 12/11/2015.

Based on review of the facility's policies, computer query, and staff interview, it was determined that the facility failed to generate a medical record for two (2) individuals (#17 and #21) of twenty-one (21) sampled patients.

Findings:

Review of the facility's policy entitled Contents of a Medical Record, 93006, policy number 1179873, last approved November 2014, revealed that each patient record should contain, as applicable, clinical, demographic, and general information. For patients receiving emergency care, treatment and services, the record should contain the following information:
--Time and mode of arrival;
--If the patient left against medical advice; and
--Final disposition, condition, and instructions for follow-up care, treatment, and services.

On 01/05/16, a computer query using the date of service, revealed there was no documented evidence that a medical record was generated for individuals #17 and #21 who arrived at the ambulance bay by ambulance on 12/11/15.

During an interview on 01/06/16 at 11:00 a.m., in the Conference Room, the Chief Nursing Officer (#7 - CNO) confirmed that the facility should have generated a medical record for patients #17 and #21.

Based on review of the facility's policies, Central Log and staff interview,(21) sample it was determined that the facility failed to enter two (2) individuals (#17 and #21) of twenty-one d patients.

Findings:

Review of the facility's policy entitled LL.029 EMTALA (Emergency Medical Treatment and Labor Act) - Central Log, number 662305, last approved 12/05/13, revealed that each hospital that has a Dedicated Emergency Department will maintain a central log to include information on each individual who comes to the Hospital Property or Premises seeking care for an emergency medical condition.

Review of the facility's Central Log from July 01, 2015 through December 31, 2015 revealed there was no documented evidence of patients #17 and #21 being entered into the Central Log on 12/11/15 when these two (2) patients arrived at the facility ' s ambulance bay by ambulance on 12/11/15.

During an interview on 01/06/15 at 11:00 a.m. in the Conference Room, the Chief Nursing Officer (#7 - CEO) confirmed that patients #17 and #21 should have been entered into the Central Log.

Based on review of the facility's ambulance report logs, National EMS audio report transmissions, facility's video recording of the ambulance bay, facility's Central Log, EMS trip reports, facility's Rules and Regulations for the Medical Staff, Professional Services Agreement, policies and procedures, facility's ED diversion status, staff interviews, interviews with National EMS staff, credential files, and personnel files, it was determined that the facility failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital ' s emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists for (2) patients (#17 and #21) when these patients presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 12/11/15.

Findings:

1. Ambulance Report Logs

Review of the facility's ambulance report logs revealed the facility received the following radio transmissions from National Emergency Medical Services (EMS) ambulance attendants on 12/11/15:
--No date or time noted on the log. Ambulance 601 reported on a 42 year old who had been in a head-on motor vehicle crash. This patient complained of bilateral knee pain, abdominal pain with a seatbelt sign, was alert and oriented times three (to person, place, and time), and the vital signs (pulse, respirations, and blood pressure) were within normal limits. Documentation revealed this patient was to be diverted to a trauma center.
--No date or time noted on the log. Ambulance 602 reported on a 79 year old (patient #17) who had also been in the head on motor vehicle crash with airbag deployment. The report noted that the patient was pale and immobilized. Documentation revealed this patient was to be diverted to a trauma center.
--No date, time, or ambulance number. Noted that a 61 year old (patient #21) was immobilized. No additional information.
--Dated 12/11/15 with no time noted. Ambulance 606 reported that they had a 55 year old with injuries to the arm. Documentation revealed this patient was accepted to Rockdale Medical Center for treatment.

2. Audio EMS Recordings
On 01/07/16 the audio EMS recordings from National EMS were reviewed regarding the radio transmissions on 12/11/15. The recordings were as follows:
--1:00:36 p.m., Confirmation of the site of scene address.
--1:15:08 p.m., Ambulance 606 calls Rockdale Medical Center's ED.
--1:16:37 p.m., Ambulance 606 gives report on a patient. (This was patient #15 who was transferred to Rockdale Medical Center, treated, and admitted.)
--1:40:08 p.m., Ambulance 601 radioed in regarding the 42 year old patient. After describing the patient's injuries the attendant was informed that due to the patient's injuries which included abdominal pain, bruising, increased heart rate, and significant damage to the vehicle, the patient was to be diverted to a trauma center. (This patient was transferred from the scene to the trauma center).
--1:44:41 p.m., Ambulance 602's communication is not audible.
--1:44:57 p.m., Ambulance 602 is told that the patients are to be diverted.
--1:45:20 p.m., Ambulance 602 is told that the physician recommends that the patients go to another facility due to their injuries.
--1:48:16 p.m., Nurse #6 states the patients need to go to another facility due to their injuries.
--1:51:36 p.m., Ambulance 602 notifies the EMS communication center that they are being diverted to the _______Trauma Center and asked that the communication center confirm that the trauma center can accept patients #17 and #21. Report is given to the trauma center.
--1:56:17 p.m., Communication center gives report to trauma center and informs them that the estimated time of arrival is 30 minutes.
--2:10:13 p.m., Ambulance 602 reports that the 79 year old patient's (#17) condition has changed and that the patient is now not alert or oriented to person, place, or time, and that their priority is now a 1.
--2:11:01 p.m., Communication center notifies the trauma center that the patient's GCS is now a 10.
--2:11:48 p.m., Communication to ambulance attendant, verified GCS is now a 10.
--2:12:44 p.m., Communication notifies 602 that trauma center is awaiting arrival and 602 responds inaudibly. Communication asked, a surgeon on standby can you elaborate?
--2:13:42 p.m., Ambulance 602 states to disregard last transmission.
--2:21:27 p.m., Communication calls trauma center regarding unit 601 and gives report of 42 year old patient that was in the same motor vehicle accident. Review of the EMS radio transmissions revealed the 42 year old patient was transferred from the scene of the accident to the Atlanta Trauma Center in ambulance 601.
--2:26:22 p.m., Ambulance 602 reports out at trauma center.


3. Video Recording
On 01/06/16 at 12:10 p.m., the facility's video recording of the ambulance bay on 12/11/15 was reviewed with the Director of Facility Operations and Security Services in his/her office. The Director explained that the time on the video recording was not accurate. The video revealed 1 ambulance parked in the ambulance bay at 2:44 p.m. (incorrect time) and what was identified as ambulance 602 pulled into the ambulance bay and parked. A male nurse who was identified as nurse (#6) went to the passenger side of the first ambulance and spoke with someone, then went around to the driver's side of the second ambulance. The nurse is seen coming to the back of the ambulance, partially opening the door, and speaking with someone inside. After the nurse goes back inside the facility the second ambulance (602) leaves the facility at 2:49 (time on the video but the Director stated it was actually 1:28 p.m.). There was no audio associated with this video.


4. EMS Trip Report for Patient #17

Review of the EMS trip report for patient #17 revealed the 79 year old patient was the driver in a head-on motor vehicle crash with airbag deployment. The report indicated that upon arrival the patient had removed himself/herself from the vehicle and was on the side of the road. The report noted that the patient had shoulder/hip pain and bleeding. Documentation revealed the patient was taking Atenolol to treat high blood pressure. The assessment revealed the patient's glascow coma scale (GCS) was a 15. (The glascow coma scale (GCS) is a scoring system which determines the state of consciousness. A score of 3 is no response to eye opening, verbal response, or motor response. A score of 15 occurs when a patient can open their eyes spontaneously, is alert and oriented times three, and can respond appropriately to commands (such as squeeze my hand)). In addition, the patient's initial vital signs were pulse 86 (normal 60 - 100), respirations 16 (normal 12 - 20), blood pressure 124/72 (normal 110-130/60-80), oxygen saturation 98% (normal 95 - 100%), In addition, documentation revealed the patient was immobilized. The report revealed the ambulance pulled into Rockdale Medical Center's EMS parking lot and that a nurse (#6) came out to the ambulance and told the attendants that the facility was refusing to service the patient at the ED. Documentation revealed the ambulance went back into service at 1:28 p.m. enroute to the Atlanta Trauma Center. Further documentation revealed this patient's condition deteriorated while enroute to the trauma center. Documentation revealed that at 1:50 p.m., the patient was alert and oriented to nothing, pulse was 124, respirations were 12, blood pressure was 62/30, and oxygen saturation had dropped to 86%. A repeat of the patient's vital signs revealed the pulse was 114, respirations 12, blood pressure was 86/52, and oxygen saturation was 97%. The notes revealed the patient's GCS dropped to 7, that the patient was placed on 15 liters of oxygen via a non-rebreather mask (a device used in medical emergencies, allows for delivery of higher concentration of oxygen), and that fluids were administered intravenously (into a vein). Documentation revealed the ambulance arrived at the trauma center at 2:26 p.m. and that report was given to the ED physician.
5. Medical Record Review for patient #17 -Trauma Center
Patient #17 ' s medical record from the trauma center was reviewed. A review of the medical record revealed that Patient #17 arrived to the ambulance bay at 2:29 p.m. Documentation in the medical record revealed that on 12/11/2015 at 2:34 p.m., Patient #17 a 79 year old presented to the emergency department after a motor vehicle collision. EMS reported, Pt (patient) was initially alert and oriented, became confused, cool and diaphoretic. " Further review revealed that an arterial blood gas test (a test where blood is drawn and measured for oxygen content) was ordered, urinalysis, complete type and screen only for blood (lab test done to determine a person ' s blood type), PT with INR (blood test on how long it takes blood to clot), Ethanol serum (Blood Alcohol concentration in the blood), Chemistry 8, metabolic panel (blood tests that measures glucose level, electrolytes, fluid balance and kidney function), CBC, platelet count, troponin -1 level, White blood cell with Differential, Chest and pelvis x-rays, Cat Scan (a picture inside of a part of the body that is made by a computerized machine.) of the trauma chest, abdomen, pelvis, and brain. Further review revealed that at 5:02 PM the patient ' s GCS was 7 on ED presentation, hypotensive (low BP) ST depression on EKG (electrocardiogram-a record display of a person ' s heartbeat). The patient also received 2 units of uncross matched blood. They were also awaiting for further trauma evaluation and a repeat EKG. Documentation in the medical record revealed that after the patient came from CT scan, trauma placed a chest tube in for a pneumothorax (Collapsed Lung), cordis (large bore vascular catheter device for rapid fluid and blood administration in trauma settings) and an arterial line. The patient was thereafter found to be bradying (slowing of the heart rate) down, then cardiac arrest. After several rounds of shock and epi (epinephrine- increases blood pressure, heart rate and cardiac output) and other medications, code was called. Family was present during resuscitation and was kept updated throughout ...Pt time of death 1618 (4:18 PM) pronounced by Dr. (Physician name) and (Physician Name) trauma. "

6. EMS Trip Report for Patient #21

Review of the EMS trip report for patient #21 revealed the 61 year old patient (#21) was a passenger in the head-on motor vehicle crash. The report noted that upon arrival the patient was on the side of the road. Documentation revealed the patient complained of neck and chest pain. The patient's history and home medications were noted. The patient's initial GCS was 15, the patient was alert and oriented to person, place, time, and situation. The patient's initial vital signs were pulse 101, respirations 14, blood pressure 145/80, and oxygen saturation was 98% on room air. The patient's vital signs were repeated twice with no significant changes. Documentation revealed the patient was immobilized and that the patient denied chest pain or shortness of breath but that the patient had severe pain to the upper spine when palpated (touched). In addition, documentation revealed there was bruising to the right shoulder and upper right breast. Documentation revealed the ambulance rolled into the Rockdale Medical Center parking lot and was turned away by nurse (#6) who informed the ambulance staff that the facility would not see the patient there and to take the patient to a trauma center. Documentation revealed the ambulance left Rockdale Medical Center at 1:28 p.m. and arrived at the trauma center at 2:26 p.m.

7. Medical Record Review for Patient #21- Trauma Center
The medical record from the trauma center revealed that patient #21 arrived to the Trauma Center on 12/11/2015 at 2:32 PM. The patient ' s admission status was listed as " Emergency. " The Emergency Medicine Provider Note was reviewed. The patient ' s Chief Complaint was Motor Vehicle Crash. The History of Present Illness (HPI) revealed in part, " HPI Comments: 61 y/o (year/old) ...restrained passenger s/p (status/post) highway MVC. Minor intrusion, no LOC (loss of consciousness), positive airbag deployment. Self-extricated with bystander assistance. Now complains of neck and chest pain ...Review of Systems ...Cardiovascular: positive for chest pain ...Musculoskeletal: Positive for neck pain. Initial Vital signs: Temp (temperature): 36.7 (98.1) Heart Rate: 74 Resp (respirations): 20 B/P (Blood Pressure): 154/74 Spo2 100%...Physical Exam (Physical Examination) ...Disability: PERRL (Pupil equal reactive round to light), GCS 15 ... Musculoskel (Musculoskeletal): C/T (cervical/thoracic) spine tenderness. Abrasion and ecchymosis to right shoulder and mid chest with TTP (thrombotic thrombocytopenia purpura- is a blood disorder that causes blood clots to form in small blood vessels) MEDICAL DECISION MAKING: ..7:03 PM CT head/ c spine neg (negative) CT C/AP (Cervical/Anterior/posterior) with minimally displaced fracture of the left lower sacrum and possibly the right lower scrum with small presacral and Oblique non displaced sternal fracture. Trauma paged. 8:31 PM Trauma will accept patient to floor after EKG normal. EKG w/o (with/out) arrhythmia. Trauma requested Ortho (Orthopedics-medical specialty concerned with corrections of deformities or functional impairments of the skeletal system) eval (evaluation) for sacral fracture. Will place bed request for tele (telemetry-transmission of cardiac signals to receive location where they are displayed for monitoring) bed ... Disposition: ...Diagnoses: Sternal Fracture , Sacral, Fracture MVC ...Condition: Stable Disposition: Admit. "
8. Medical Staff Rules and Regulations

Review of Rockdale Medical Center's Rules and Regulations for Medical Staff, policy #1219939, last approved December 2011, revealed in the Emergency Medical Screening, Treatment (MSE), Transfer, and On-Call Roster Policy, section 6.1 Screening, Treatment, and Transfer,
6.1 (a) Screening,
A. Any individual who presents to the ED of this hospital for care shall be provided with a MSE to determine whether that individual is experiencing an emergency medical condition (EMC).
C. All patients shall be examined by qualified medical personnel, which shall be defined as a physician; or a Licensed Independent Practitioner/Allied Health Professional with appropriate training and privileges as permitted by State law and authorized by his or her supervising physician, if any; or, in the case of a woman in labor, a registered nurse (RN) trained in obstetric nursing pursuant to hospital policy who may determine true, false or no labor but may not make a medical diagnosis.
D. Services available to ED patients shall include all ancillary services routinely available to the ED, even if not directly located in the department. The Rules and Regulations were signed on 08/07/14 by the Chief of Staff, Board of Trustees Chairperson, and the Chief Executive Officer.

9. Professional Services Agreement
Review of the Professional Services Agreement between Rockdale Medical Center (facility) and Emerginet (Contractor), entered into on July 1, 2010, and required Contractor's Representatives to comply with the facility's Medical Staff bylaws, Rules and Regulations.


10. Policies and Procedures
Review of facility policy entitled EMTALA (Emergency Medical Treatment and Labor Act), 93133, policy #1209363, last approved December 2014, revealed any individual who comes to the Hospital Property or Premises requesting examination or treatment is entitled to and shall be provided an appropriate MSE performed by a physician or other Qualified Medical Personnel to determine whether or not an EMC exists. This policy defined the facility's campus as the physical area immediately adjacent to the main Hospital, other areas and structures that are not strictly contiguous to the main Hospital buildings but are located within 250 yards of the main buildings. This policy further instructed in section C. Special Circumstances: Ambulances, A Hospital may deny access to patients when it is in "diversionary" status because it does not have the staff or facilities to accept any additional emergency patients at that time. Hospitals may not divert on a case-by-case basis, but may only divert when on formal diversionary status. However, if an ambulance disregards the Hospital's instructions regarding diversion and brings the individual to the Hospital, the individual has come to the Hospital, and the Hospital's EMTALA duties are triggered.

11. Diversion status December 11, 2015 through December 12, 2015
The facility's diversion status that was uploaded to the Georgia EMS website from July 1, 2015 through December 31, 2015 was reviewed. This data revealed that from December 11, 2015 through December 12, 2015 the facility was not on ED diversion.

12. Interviews
During an interview with the ED physician (#1) on 01/05/16 at 2:25 p.m. in the Conference Room, the physician confirmed that he/she remembered the situation that occurred on 12/11/15. The physician explained that he/she was at the nurses' station when a radio transmission came in from an ambulance and that since there were no nurses available, he/she took the call. The physician said he/she was informed that there were 2 patients, the first patient had obvious deformity to the upper extremity and the second patient had bruising to the abdomen and increased heart rate. The physician stated he/she informed the ambulance attendant that the second patient needed to go to a trauma center. The physician said another radio transmission came in and nurse #6 took the call because the ED Charge Nurse was not available. The physician said he/she could overhear the transmission and that there were 2 patients and that he/she could not remember the details but that he/she had informed the nurse that those 2 patients also needed to go to a trauma center. The physician confirmed that 3 of the 4 patients were to be diverted to a trauma center. The physician said he/she assumed both ambulances were going to the trauma center. The physician said he/she went back to seeing patients and was later informed that 1 of the ambulances had presented to the facility and that nurse (#6) had gone out and told the ambulance attendants to take the patient to a trauma center. The physician confirmed that he/she had not told the nurse to go out and speak with the ambulance attendants and that he/she was unaware of the episode until after the ambulance had left the property. The physician said he/she later spoke with nurse #6 and informed the nurse that once patients were on the facility's property the facility was required to provide any needed medical treatment. The physician said he/she also informed the Charge Nurse (#5) and a few days later spoke with the Chief Nursing Officer (#7). The physician said he/she received EMTALA training once every 2 years which was provided by the contracted ED physicians' group.

During an interview with the RN (#6) on 01/06/16 at 9:50 a.m. in the Conference Room, the nurse confirmed that he/she remembered the situation that occurred on 12/11/15. The nurse explained that he/she was the Manager of the Medical/Telemetry Unit and had been down in the ED to help move a patient to his/her unit. The nurse said that he/she was at the nurses' station when the ED physician (#1) was taking a report from an ambulance. The nurse said a second call came in from ambulance #602 and that since none of the ED nurses were available he/she took the report. The nurse said the report was for 2 patients, and that he/she was unsure which patient but that 1 of the patients had a seat belt sign and abdominal pain. The nurse said the physician could over hear the transmission and had requested this patient be diverted to a trauma center. The nurse said that as the ambulance attendant started the second patient's report the nurse was informed that the ambulance was driving into the ambulance bay. The nurse said he/she told the ambulance attendant that due to the patients' injuries they both needed to go to a trauma center. The nurse said he/she wondered why the ambulance was on the facility's property when the patients needed a trauma center and that Rockdale Medical Center did not have a trauma surgeon. The nurse said he/she then went out to the ambulance bay and saw 2 ambulances. The nurse said he/she asked the ambulance attendant in the first ambulance if they were 602 and was pointed to the second ambulance. The nurse said he/she then went around the driver's side of 602 and then to the back and opened the door slightly. The nurse said he/she informed the ambulance attendant that the patients had been diverted to a trauma center. In addition, the nurse said he/she never assessed either patient in the ambulance. The nurse stated the ED physician (#1) had not told the nurse to go out and speak with the ambulance attendants and that the physician had probably not even been aware that the ambulance was on the facility's property. The nurse confirmed that he/she had EMTALA training annually and stated he/she had previously been the ED Director. The nurse stated he/she had 18-20 years of ED experience. The nurse went on to say that at the time of the occurrence, he/she had not thought about the 250 yards requirement that his/her concern had been getting the patients to the appropriate facility that could render the care the patients needed. The nurse said that after this occurrence no one at the facility had spoken to him/her about the episode.

During an interview with the ED Director (#4) on 01/05/16 at 12:00 p.m. in the Conference Room, the ED Director stated he/she was informed about the occurrence by the ED Charge Nurse (#5) on 12/11/15. The Director stated he/she addressed the issue with the physician (#1), the nurse (#6), and the Charge Nurse (#5), and informed them that patients on property should never be turned away. In addition, the Director said that the facility has a meeting scheduled on Thursday, January 2016 with the ED physicians, ED Leadership, ED Educator, and National EMS.

During an interview with the ED Charge Nurse (#5) on 01/05/16 at 12:30 p.m. in the Conference Room, the Charge Nurse explained that he/she had been informed of the occurrence after it had already happened. He/she stated ED staff receive EMTALA training annually. In addition, he/she said that following the occurrence the ED Director (#4) and ED Educator met with him/her to discuss how to improve communications with the EMS.

During an interview with the National EMS Paramedic (#8) on 01/05/16 at 4:00 p.m. in the Conference Room, the Paramedic stated that on 12/11/15 ambulance 602 responded to a 2 car motor vehicle crash. The Paramedic explained that ambulance 602's radio transmission was in process as they arrived at the ED door. The Paramedic confirmed that ambulance 602 had the 79 year old patient (#17) and a 61 year old patient (#21) on-board as they arrived. The Paramedic explained that a nurse (#6) came out and informed the EMS that they could not come into the facility and that the 2 patients had not been accepted. The Paramedic said he/she notified his/her supervisor and that the ambulance left the facility at 1:28 p.m. enroute to the trauma center. The Paramedic said that upon arrival to Rockdale Medical Center both patients' condition had been stable and that both patients' GCS had been 15. The Paramedic said the 79 year old's condition declined enroute and that upon arrival to the trauma center the 79 year old had been unresponsive. The Paramedic stated there had never been any problems with the facility accepting patients.

During an interview with the National EMS Emergency Medical Technician (EMT - #9) on 01/05/16 at 4:30 p.m. in the Conference Room, the EMT stated he/she remembered the episode that occurred on 12/11/15. The EMT stated he/she gave report on the 79 year old (#17) and 61 year old (#21) patients and was told that the patients were being diverted to a trauma center. The EMT said nurse (#6) came out and told us that the ED physician (#1) didn't want to see the patients and that the patients needed to go to a trauma center. The EMT said the Paramedic called their supervisor and they then took the patients to the trauma center. The EMT said that upon arrival to Rockdale Medical Center both patients were stable but that the 79 year old's condition had declined while enroute to the trauma center.

During a telephone interview with the National EMS Chief Operating Officer (COO - #10) on 01/07/16 at 12:30 p.m., the COO confirmed that on 12/11/15 3 ambulances responded to a 2 vehicle motor vehicle crash. The COO also confirmed that ambulance 606's 55 year old patient (#15) was received for treatment at Rockdale Medical Center and that ambulance 601 transported a 42 year old patient from the scene of the accident to the trauma center. In addition, the COO confirmed that ambulance 602 transported the 79 year old (#17) and 61 year old (#21) patients to Rockdale Medical Center where the 2 patients were refused services. The COO stated this was very unusual and that the facility had never refused to accept patients in the past.

During an interview with the Chief Nursing Officer (#7) on 01/06/16 at 11:00 a.m., the CNO confirmed that the facility should have provided a MSE for both patient #17 and #21.

Review of 3 Credential files and 3 personnel files revealed all 6 files contained evidence of EMTALA training.

Based on review of the facility's ambulance report logs, National EMS audio report transmissions, facility's video recording of the ambulance bay, facility's Central Log, EMS trip reports, facility's Rules and Regulations for the Medical Staff, Professional Services Agreement, policies and procedures, facility's ED diversion status, staff interviews, interviews with National EMS staff, credential files, and personnel files, it was determined that the facility failed to provide stabilizing treatment for two (2) patients #17 and #21 when these patients presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 12/11/15.

Findings:

Cross refer to A2406 as it relates to failure to provide an appropriate Medical Screening Exam (MSE) and stabilizing treatment for all patients.

Review of Rockdale Medical Center's Rules and Regulations for Medical Staff, policy #1219939, last approved December 2011, revealed in the Emergency Medical Screening, Treatment (MSE), Transfer, and On-Call Roster Policy, section 6.1 (b) Stabilization, Any individual experiencing an emergency medical condition (EMC) must be stabilized prior to transfer or discharge.

Review of facility policy entitled EMTALA (Emergency Medical Treatment and Labor Act), 93133, policy #1209363, last approved December 2014, revealed that a MSE was not an isolated event, but rather an on-going process. The policy required documentation of on-going monitoring and diagnostic testing according to patients' needs. This policy defined stabilized in respect to an EMC as no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility. A patient will be deemed stabilized if the treating physician of the individual with the EMC has determined, within reasonable clinical confidence, that the EMC has been resolved.

During an interview with the Chief Nursing Officer (#7) on 01/06/16 at 11:00 a.m., the CNO confirmed that the facility should have provided stabilizing treatment for both patient #17 and 21 on 12/11/2015.

Based on review of the facility's ambulance report logs, National EMS audio report transmissions, facility's video recording of the ambulance bay, facility's Central Log, EMS trip reports, facility's Rules and Regulations for the Medical Staff, Professional Services Agreement, policies and procedures, facility's ED diversion status, staff interviews, interviews with National EMS staff, credential files, and personnel files, it was determined that the facility failed to provide an appropriate transfer for two (2) patients (#17 and #21) when these patients presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 12/11/15.

Findings:

Cross refer to A2406 as it relates to failure to provide an appropriate Medical Screening Exam (MSE) and an appropriate transfer for all patients.

Review of Rockdale Medical Center's Rules and Regulations for Medical Staff, policy #1219939, last approved December 2011, revealed in the Emergency Medical Screening, Treatment (MSE), Transfer, and On-Call Roster Policy, section 6.1 (c) Transfer, (A.) Qualified medical personnel as defined in Section 6.1 (a) (3) [as a physician, Licensed Independent Practitioner/Allied Health Professional with appropriate training and privileges as permitted by State law and authorized by his or her supervising physician, if any] shall obtain the consent of the receiving facility before the transfer of an individual. Said person or other ED personnel, as appropriate, shall make arrangements for the patient transfer with the receiving hospital. (B.) The condition of each transferred individual shall be documented in the medical records by the physician responsible for providing the MSE and stabilizing treatment. (C.) Upon transfer, the ED shall provide a copy of appropriate medical records regarding its treatment of the individual including, but not limited to, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any tests, informed written consent or transfer certification, and the name and address of any on-call physician who has refused or failed to appear within a reasonable period of time in order to provide stabilizing treatment. (D.) All reasonable steps shall be taken to secure the written consent or refusal of the patient (or the patient's representative) with respect to the transfer. The ED Physician must inform the patient (or the patient's representative) of the risks and benefits of the proposed transfer.

Facility policy entitled EMTALA (Emergency Medical Treatment and Labor Act), 93133, policy #1209363, last approved December 2014, documented that a MSE was not an isolated event, but rather an on-going process. The policy required documentation of on-going monitoring and diagnostic testing according to patients' needs. This policy defined stabilized in respect to an EMC as no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility. A patient will be deemed stabilized if the treating physician of the individual with the EMC has determined, within reasonable clinical confidence, that the EMC has been resolved.

During an interview with the Chief Nursing Officer (#7) on 01/06/16 at 11:00 a.m., the CNO confirmed that the facility should have provided an appropriate transfer for patient #17 and #21 on 12/11/2015.