HospitalInspections.org

Based on review of policy and procedure, review of facility documents, and interview, it was determined the hospital failed to maintain documentation on their central log that included patients that entered through the emergency department doors seeking help for 1 of 1 patients. (Patient # 0)

Findings include:

Policy titled "Emergency Medical Treatment and Labor Act (EMTALA)", last reviewed 12/2017, requires: "...The hospital to comply with specific obligations and responsibilities, and to ensure all patients presenting to the hospital receive appropriate medical care, within the capability and capacity of the facility...Provide a medical screening examination...to determine the existence of an emergent medical condition; Provide necessary stabilizing treatment...if an emergent medical condition exists to prevent any further clinical deterioration in the patient's...clinical status; Effect an appropriate transfer for a patient who has a medical condition that exceeds the capability and capacity of the facility...arranging for and coordinating the patient transfer by means most appropriate for...condition...A medical screening examination is the process required to reach with reasonable clinical confidence, that point at which it can be determined whether a medical emergency situation does or does not exist...Hospitals are obligated...to provide the necessary stabilizing treatment...for the clinical condition such that, within reasonable medical probability, no material deterioration of the clinical condition is likely to occur...an appropriate patient transfer may be effected...the hospital has the obligation of securing an appropriate mode of transport which is best correlated to meet the needs of the patient respective to their clinical status...."

Policy titled "Transfer of Care", last reviewed 9/2018, requires: "...If ALS (Advanced Life Support) care has been initiated at any level, transfer of care may be handed over tot the same or higher level of care provider but may never be turned over to a lower level of care provider...."

Policy titled "Stop the Line - Patient Safety", last reviewed 7/2016, requires: "...the means and authority for summit employees and healthcare providers to immediately in intervene to protect the safety of a patient, prevent medical error and avert a sentinel event. It is the expectation that all staff and healthcare providers will respond...Imminent Violations of Legally Established Patient Rights that Pose an Immediate Threat to Patient Safety. Includes...Failure to perform screening examination and provide appropriate medical care...transportation to a facility prepared to manage the medical condition...method of intervention chosen should maximize timeliness and effectiveness maintaining patient safety...utilizing the following 'signal words'...'help me understand'...'stop the line'...'time out'...Implement Chain of Command immediately if the response to direct communication with the provider...is inadequate to maintain patient safety...."

ED Director confirmed in interview 10/31/2018, that there was no staff member questioning the decisions made in reference to Patient #0. Additionally there were no incident reports filed by any emergency department personal/staff/or physician.

Facility documents, received from ER Director #11 on 10/30/2018 at 1515 hours, titled "Summit Healthcare Rotor Log", dated 10/10/2018 through 10/17/2018, and "Summit Healthcare Fixed Wing Log", dated 10/11/2018 through 10/21/2018, do not reveal that a patient was "sent out" from Summit Healthcare Regional Medical Center. ER Director #11 confirmed in interview 10/30/2018 at 1515, that Patient #0 was not on the logs for transport/transfer from the hospital.

Facility documents titled "Census screen shot of all patients admitted to ER on 10/15/2018 between 0011 hours and 2347 hours" and "Census 10/15/2018", given to surveyors from ED Director #11, revealed Patient #0 was not registered into the hospital on October 15, 2018. ER Director #11 confirmed in interview 10/30/2018 at 1515, that Patient #0 was not registered into the facility's electronic medical record database.

Facility document described as "Patch Log for October", given to surveyors and described as the documentation done by the ER RN's if an ambulance calls in with a patient report or a patient is going to be transferred into facility from another entity - does not reveal Patient #0's chief complaint, the EMS crew sign in, paramedic name anywhere for the 10/15/2018 date. "Patch Log" was supplied by ED Director #11 who confirmed in interview 10/31/2018, that Patient #0 was not on the "Patch Log" for 10/15/2018.

Policy titled "Patient Registration", policy # AD1007, last reviewed 1/2015, requires: "...It is the policy of the hospital to register all patients receiving services or supplies in a timely, efficient and professional manner...Complete all demographic information...."

ER Director #11 confirmed in interview October 31, 2018 that Patient #0 was not registered into the computer system per policy and procedure, was not entered on the "Summit Healthcare Rotor Log", dated 10/10/2018 through 10/17/2018, or "Summit Healthcare Fixed Wing Log", dated 10/11/2018 through 10/21/2018, and was not documented on the "Patch Log for October". ER Director further confirmed that the only "proof" the patient was in the hospital was in the video security surveillance footage provided to the surveyors on 10/30/2018, by Head of Security #19.

EMS Coordinator #13 confirmed in interview on 10/29/2018 at 1515, that video footage supplied to the surveyors was received from the Head of Security #19. Further, EMS Coordinator #13 confirmed that the video footage depicted the ambulance arriving on the hospital campus, pulling up to the helicopter pad, then "after a time" backing up to the ambulance bay, individuals from the EMS crew are seen bringing Patient #0 into hospital, being intercepted by ER DR #2, and leaving the hospital. EMS Coordinator #13 confirmed that the visualization represented in the video confirms that the patient did not receive a medical screening exam, and was directed to leave the hospital interior premises without entering a room.

Based on review of observation on tour, security footage video furnished by facility, interviews, review of facility documents, and review of policy and procedure, it was determined the hospital failed to perform a medical screening examine to determine whether or not an emergency medical condition existed in one of one patients. Failure to ensure that a medical screening exam is completed poses a high risk to the life of a patient and may lead to the death in the event that patient is not determined to be stable.

Findings include:

Observation on Tour revealed that the Emergency Department is facing in a westward direction with the ambulance bay to the "west" side of the building. The ambulance bay is capable of holding a max of three ambulances at one time in the bay area. Across from the ambulance bay road there is a helicopter pad where there are two (2) helicopters. Per review of contracts with [Sunrise and Native Air] there must be available, at all times, one helicopter available for transportation of patients.

Observation upon entrance into the hospital through the ambulance bay, revealed that there is to the right (approximately five (5) feet from the outer door) a small dead end hallway containing four (4) offices. The offices are for the EMS Coordinator #13, the Director of the Emergency Department #11, Pediatric Nurse Liaison #14, and the EMS "office". The EMS office revealed this is where security has video feed monitoring for the approximately 148 (one hundred forty eight) surveillance cameras that record the premises of the hospital. It is also where the EMS personnel are directed to finish their ambulance "runsheet" paperwork and give to the hospital. This is done prior to leaving and going to another call.

[IHS] personnel, flight crew and EMS personnel revealed in interviews prior to onsite survey:
Patient #0 presented to a lower level of care facility [IHS Whiteriver Hospital] with [shortness of breath and urosepsis/septic shock.] This lead to [full respiratory arrest/failure], and Patient #0 was intubated and placed on a ventilator. [IHS] ER RN #27 provided documentation that Patient #0 "...(had a) fentanyl and versed drip as well as bicarb, no pressors, D5NS at 50 ml/hr (milliliters per hour)...labs not improving, conditions worsening...Summit ICU...not willing to accept....", additionally patient was receiving two antibiotics - [Vancomycin and Zosyn] and two (2) liters of Normal Saline.

[IHS] ER RN #27 confirmed that Patient #0 was to be transferred from [White River] hospital to a higher level of care hospital located in Phoenix, Arizona. The weather at [White River] was snow accumulating at approximately six (6) inches at the time of original call for a helicopter - the helicopter was unable to land in [White River] helicopter pad at the hospital. The [White River] EMS ambulance was called to transport Patient #0 to the [Showlow] Airport to meet the helicopter but during transit was diverted to the helicopter pad located at [Summit Healthcare Regional Medical Center] hospital where the patient was to continue transportation with [Native Air] helicopter. EMS paramedic #24, the sending [White River Indian Health Service (IHS)] hospital Emergency Department Registered Nurse #27 ([IHS] ER RN#27) and the driver were aboard the ambulance.

Observation of security video footage obtained by the surveyor revealed the following:

1. Upon arrival to the helicopter pad (helipad), at 1614 hours, the flight crew are seen on video entering the ambulance of Patient #0,

2. [Native Air] helicopter crew entered the hospital emergency department,

3. Patient #0 was in the ambulance with the EMS crew and the [Native Air] flight crew from time of helicopter grounding at 1615, approximately, until entrance into the hospital at 1706 hours. Patient #0 entered the hospital at 1706 hours with the [White River] EMS Paramedic #24, [IHS] ER RN #27, and [Native Air] Flight RN #26 and pilot,

5. Patient #0 and "crews" were intercepted by ER DR #2 twenty-one (21) seconds after entrance through ambulance bay doors as noted on surveillance video,

6. Surveyor observed, per video time stamp, ER DR #2 spent one minute thirty-five seconds (00:01:35) talking with EMS crew and [IHS] ER RN #27 about patient. It can be observed in video that the doctor appears to be leaning into look at settings on machines that are on the patient and is being explained the drips by [IHS] ER RN #27 - the nurse is talking and holding an intravenous bag up to show physician . The physician is handed a phone by a "female nurse" at approximately this time and is seen talking on it then walking away from Patient #0. ER DR #2 does not return again to the area in the video footage. ER DR #2 total time with the patient and the "crew" was one minute and thirty five seconds, leaves the patient/area while talking on a phone, and never returns - time is 1708 hours,

7. EMS, Flight Crew and sending hospital [IHS} ER RN are noted to be standing with the patient until 1715 hours in the hallway before turning gurney around and leaving the hospital and returning to the ambulance with the patient.

8. EMS personnel and ER RN #27 stayed with the patient in the ambulance parked to the side of the helicopter pad from video timestamp of 1732 hours until 1810 hours, then departed hospital grounds.

[IHS}ER RN #27 confirmed in interview October 24, 2018 at 0800, the [IHS] charge RN, at the direction of the sending ER MD, initially instructed him/her to return the patient to [White River IHS], the sending hospital. However, [IHS] Charge RN #25, sending [IHS] physician, EMS personal, and [IHS] ER RN #27 determined that for safety reasons, with sleet and snow accumulating in [White River], that it was safer for the patient to stay at the [Summit] hospital area until a fixed wing aircraft was able to fly into a nearby town called Taylor, Arizona. The fixed wing was coming from El Paso, Texas with an estimated arrival of two (2) hours.

Facility document titled "Medical Staff Rules and Regulations", last revised 6/2018 requires: "...Section 7. Rules Regarding Emergency Services...Emergency services will be rendered any patient presenting at the Emergency Department...Every patient will be assessed by a physician and will receive appropriate emergency treatment...Justification for Admission...Except in emergency circumstances, patients shall not be admitted to the hospital until a valid reason...for admission has been stated. In the case of an emergency, such statement is recorded as soon as possible...Medical Staff Professional Code of Conduct...Will commit to create an atmosphere of respect, compassion, and ethical behavior toward our patients...It is expected that all members of the Medical Staff...adhere to the Medical Staff Bylaws, Rules and Regulations, Credentialing Procedures Manual, and Hospital policies and procedures...E.D. Medical Records...An appropriate medical record shall be kept for every patient receiving emergency service and be incorporated in the patient's hospital record if such exists. The record shall include: i. Adequate patient identification; ii. Information concerning the time of the patient's arrival, means of arrival and by whom transported; iii. Pertinent history of the injury or illness including place of occurrence and physical findings including the patient's vital signs and details relative to first aid or emergency care given prior to arrival at the hospital; iv. Clinical observations, including results of treatment v. Diagnostic impression vi. Treatment given vii. Condition of the patient on discharge or transfer; this shall be stated in terms permitting specific measurable comparison, not "improved", "good", etc. viii. Final disposition including instructions given to patient or family regarding necessary follow up care. When relevant, the discharge summary should reflect instructions regarding medications, diet and physical activity. ix. Whether the patient left against medical advise...."

Policy titled "Emergency Medical Treatment and Labor Act (EMTALA)", last reviewed 12/2017, requires: "...The hospital to comply with specific obligations and responsibilities, and to ensure all patients presenting to the hospital receive appropriate medical care, within the capability and capacity of the facility...Provide a medical screening examination...to determine the existence of an emergent medical condition; Provide necessary stabilizing treatment...if an emergent medical condition exists to prevent any further clinical deterioration in the patient's...clinical status; Effect an appropriate transfer for a patient who has a medical condition that exceeds the capability and capacity of the facility...arranging for and coordinating the patient transfer by means most appropriate for...condition...A medical screening examination is the process required to reach with reasonable clinical confidence, that point at which it can be determined whether a medical emergency situation does or does not exist...Hospitals are obligated...to provide the necessary stabilizing treatment...for the clinical condition such that...no material deterioration of the clinical condition is likely to occur...an appropriate patient transfer may be effected...the hospital has the obligation of securing an appropriate mode of transport which is best correlated to meet the needs of the patient respective to their clinical status...."

Policy titled "Emergency Medical Treatment, Screening, and On-call", last reviewed 9/2018, requires: "...All Patients presenting to the Emergency Department are seen by an Emergency Department Provider...is provided with a medical screening examination to determine if that individual is experiencing an emergency medical condition...an "emergency medical condition" is one manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment...or serious jeopardy to the health of the individual...."

Policy titled "Stop the Line - Patient Safety", last reviewed 7/2016, requires: "...the means and authority for Summit employees and healthcare providers to immediately in intervene to protect the safety of a patient, prevent medical error and avert a sentinel event. It is the expectation that all staff and healthcare providers will respond (to)...Imminent Violations of Legally Established Patient Rights that Pose an Immediate Threat to Patient Safety. Includes...Failure to perform screening examination and provide appropriate medical care...transportation to a facility prepared to manage the medical condition...method of intervention chosen should maximize timeliness and effectiveness maintaining patient safety...utilizing the following 'signal words'...'help me understand'...'stop the line'...'time out'...Implement Chain of Command immediately if the response to direct communication with the provider...is inadequate to maintain patient safety...."

Policy titled "Transfer of Care", last reviewed 9/2018, requires: "...If ALS (Advanced Life Support) care has been initiated at any level, transfer of care may be handed over to the same or higher level of care provider but may never be turned over to a lower level of care provider...."

EMS Paramedic #24 confirmed in interview, 10/23/2018 at 0823 hours, that the patient and the "crews" were inside the hospital and were approximately 50 feet from the entrance hallway at the "fork" when they were approached by ER DR #2. EMS Paramedic #24 confirmed in interview, ER DR #2 was remembered as saying "What's going on? I don't know this patient", report was being given by [HIS] ER RN #27, and about half way through the report doctor said "Patient #0 needs ICU (Intensive Care Unit)" and the s/he can't do anything else for the patient.

Additionally, EMS Paramedic #24 stated, approximately 15 feet from ambulance entrance - a door opened and a "nurse" came out and said "this is an EMTALA violation." (This was determined to be Pediatric Nurse Liaison #14 - as noted being seen approximately one minute twenty five seconds into surveillance video provided to the surveyors by Summit Security. Pediatric Nurse Liaison #14 was observed handing a phone to ER DR #2.) EMS Paramedic #24, further stated the ER DR #2 "agreed" with the "EMTALA" and told ambulance crew they could not remain in the hospital.

[IHS] ER RN #27 confirmed, in interview 10/24/2018 at 0800, that upon entrance to the emergency department, ER DR #2 yelled: "...'Stop, I don't know this patient'...." Further, when [IHS] ER RN #27 attempted to give report on Patient #0 to the physician, s/he was interrupted multiple times and was being asked: "Is the patient stable? You have a stable intubated patient, there is nothing we can do here. Take the patient back to [sending hospital]". [IHS] ER RN #27 additionally stated that the receiving hospital physician was refusing Patient #0 stating: " s/he had not "received a doctor to doctor report" from the sending hospital. [IHS] ER RN #27 stated that ER DR #2 refused to listen to anyone from the flight crew, hospital personal (ER Charge RN #16 and House Supervisor #12), or self ([IHS] ER RN #27), when attempting to tell ER DR #2 that the sending hospital physician would give report.

[IHS] Charge ER RN #25, confirmed in interview 10/23/2018 at 0800, that [IHS] ER RN #27 spoke to the [IHS] sending hospital physician and [IHS] Charge ER RN #25, and explained the hospital's refusal of the patient. It was reported to the [IHS] Charge ER RN #25 that the ambulance staff were told: "[IHS] can do more, could take care of the patient, and could continue to do so, go back to [White River]". It was initially determined, in the best interest of care/patient, to return Patient #0 to the sending hospital and "wait out the weather". Due to danger to the EMS crew and patient due to weather, this was changed to wait for the flight to arrive in Taylor airport, and stay near the hospital.

Further, [IHS] Charge ER RN #25 confirmed that the [IHS] sending hospital has twenty four (24) medical / surgical beds, nine (9) emergency department beds, and no critical care capabilities other than to "stabilize and ship" a patient to higher level of care. [IHS] Charge ER RN #25 stated that to return the patient to the [reservation] hospital would be a decrease in the level of care that Summit hospital was capable of supplying. The (sending hospital) has no critical care capability, other than in the Emergency Department, and that is only to stabilize.

Document titled "Map of events for patient transport on 10/15/2018, to Summit Rotor which was canceled", provided to surveyor from [IHS] ER RN #27, traced back to an email from [IHS]. Document identifies the timeline presented by [IHS] as to events documentation. Document revealed: "...Arrived at Summit 16:15. NAA RN (Native Air Ambulance Registered Nurse) and medic boarded ambulance to start transfer of patient to helicopter, reported 2000 foot ceiling...NAA RN/Medic transferred out tubing (for bicarb only) and BP (blood pressure) cuff changed over and at approx. 10 min later, pilot for NAA arrived and reported the ceiling collapsed and the flight was a 'No go'...Flight RN approached Summit ED and spoke with (ER DR #2)...initially said...would take patient if worst case scenario...they were under impression they would accept the patient. Flight RN and crew not wanting to return patient to (sending hospital name) as was lower level of care. Patient then taken into ED...(ER DR #2) at doctor station, stated 'Stop, you cannot come in'... indicated...did not know about the patient and did not get report...(Pediatric Liaison RN #14) came out to tell them that by them bringing the patient in was an EMTALA violation, as they know nothing about the patient...([IHS] ER RN #27) attempted to give report at that time, however, (ER DR #2) did not want to hear it, told him to stop, and that they could not do anything that we (IHS) could do for the patient...(ER DR #2 and Pediatric Liaison RN #14) both stated the best thing to do is take the patient back to (name of sending hospital)...([IHS] ER RN #27) Called [IHS White River ER Charge Nurse #28] regarding refusal of Summit ER to accept patient. After ([IHS] ER RN #27) got off the phone (with IHS ER Charge RN #28 s/he) spoke to (IHS White River House Supervisor #29) who then called (Summit House Supervisor #12)...while...crew were returning the patient to the ambulance. (Summit House Supervisor #12) then went to ED advocating for patient to await flight in Taylor...was in agreement that returning the patient to (sending hospital) was not in the patient's best interest...Pressures fluctuating - concern that patient may need pressors at some point in near future. MAP 68 (mean arterial pressure)...([IHS] ER RN #27) requested additional drip tubing and pressors to have on hand just in case the patient's blood pressures bottomed out...was given tubing but was told that Summit ED would have to accept patient to arrange for pressors...([IHS] ER RN #27) then asked the Flight RN if they could provide pressors if they were needed. Then flight crew called their supervisor to make the request and they too were told that they would have to assume care in order to release it to them...ambulance pulled out of ER Bay...parked in Summit parking lot to await flight, did not leave until they had to, in case patient deteriorated. Flight crew offered to help if needed. Flight RN instructed ([IHS] ER RN #27) to take patient to ED if MAP < 65...ambulance left Summit at 1820...Arrived at Taylor at 1920...."]

Documentation received from [Native Air] Regional Director #22 and Regional Clinical Manager #23 titled "Summary of Flight Request #152780" and "Timeline of events taken from [Air com] Notes, and statement submitted by (Flight RN #26) revealed: "...At one point the Summit ER stated they would accept the patient, then declined when patient was brought in...."

Documentation further revealed the following in the timeline of events:

"...1630 (hours) Flight RN...went into Summit ER to see if patient could be accepted there. (ER DR #2) and Charge Nurse...were contacted separately, each agreeing that if all other options were exhausted that patient should be brought into Summit ER. (ER DR #2) asserted that every effort should be made, however, to get the patient to (receiving hospital name in Phoenix) and the physician accepting care at that facility...

1631 (hours)...clinicians made patient contact and were packaging patient when pilot entered ambulance and informed them the weather had deteriorated and they could not complete the transport...

1646 (hours- Flight crew) advised that if cannot secure FW (fixed wing - plane) that they have already spoken to Summit Hospital to take the patient inside until weather clears for FW...

1647 (hours) Administrator on Call patched to (flight crew) for further discussion regarding possibility of transporting patient by ground. (Flight Crew) advised not comfortable with going by ground with rain and sleet and less than 3 mile visibility. Also re-affirmed that Summit Hospital willing to take patient until weather clears...

1703 (hours - Flight crew) advises Summit is going to take the patient until weather clears...

1715 (hours) Per Flight RN...arrived in ER hallway to find (ER DR #2, ER Charge RN #16, and House Supervisor #12) engaged with the (EMS team) explaining that the team's decision to bring the patient into the ER constituted an EMTALA violation...that the ER was already working up a septic patient and its resources would be taxed by another septic patient. If the patient could not be taken to Phoenix (EMS team) was obliged to return to [White River IHS] with (Patient #0), they asserted. ([HIS] ER RN #27) contacted ([HIS] ER Charge #28 in [White River] ), who agreed that if patient could not be transported to Phoenix and Summit would not accept (him) the team should bring...back to (sending hospital)...

1716 (hours)...(Sending hospital MD) wants the patient brought (back) and not turned over to Summit...

1718 (hours) [Native Air advised that Lifeguard flight FW available with arrival in 2 hours]...

1749 (hours - Flight Crew) has been released by (sending hospital) to go home and they will call back if they need us...

1800 (hours - Flight Crew contacted) about Levophed in the event that the patient's hemodynamics deteriorated...(flight crew and EMS crew) discussed advisability of ambulance remaining near Summit Healthcare in Show Low until their drive time and arrival at Taylor airport would coincide with (arriving fixed wing name). Under such circumstances, it was reasoned; if patient's status deteriorated it would be a short trip back to Summit ER...

1900 (fixed wing name) arrived at Taylor airport for patient pick up...

2210 (hours) Flight to Phoenix completed and was uneventful...."]

EMS Coordinator #13 confirmed in interview on 10/30/2018 that Pediatric Nurse Liaison #14 was the one who called EMS Coordinator #13 at home on 10/15/2018 at 1705 hours, regarding the incident about the flight crew initially asking if the patient could be brought in to the hospital. EMS Coordinator #13 confirmed that Pediatric Nurse Liaison #14 was stating there were some issues regarding the patient was "stable", vented, but no doc to doc had been done. EMS Coordinator #13 stated that according to his/her phone (personal cell) that s/he called ER DR #2 at 10/15/2018 at 1705 hours. Further stating the conversation with the ER DR #2 was that s/he ER DR #2 "was too busy to address the issue right now, would I (EMS Coordinator #13) talk to ([IHS]ER RN #27)". I (EMS Coordinator #13) told the [HIS] ER RN #27 "my concerns that a doctor to doctor report had not been given and possible EMTALA violations and you may need to transport the patient back to [name of sending hospital]." EMS Coordinator #13 confirmed that s/he should have put more of the decision making on (ER DR #2) that doctor to doctor report is a courtesy. EMS Coordinator #13 confirmed that s/he was unaware that the EMS personal and Patient #0 were sitting in the parking lot after phone call.

ER DR #2 confirmed in interview on 11/5/2018 at 1302 hours, remembers stating to flight crews: "I don't know anything about this patient and I can't set up plan without report - no one told me about patient." When ER DR #2 was asked if s/he recalled a nurse or the flight crew trying to talk about the patient, stated: "All I know is that (EMS Coordinator #13) was on the phone stating: 'this is an EMTALA violation, we haven't accepted the patient.' I handed the phone to (flight crew). I knew we had no ICU beds available, knew the patient had a bed in the valley, knew hospitalist hadn't accepted, and thought (EMS Coordinator #13) took care of everything". ER DR #2 stated he never got a call from (name of sending hospital) for report, believes it was (flight crew's) patient. Further ER DR #2 states [IHS] ER RN #27 never gave report, if needed "...my help would have asked - No one asked me to take patient...."

ER Medical Director/Physician #3 confirmed in interview on 11/5/2018, that s/he was out of state at time of incident. ER Medical Director/Physician #3 replied when asked "If a patient presents to the hospital and the weather is bad and plans have to change, who is responsible for the patient?" ER Medical Director/Physician #3 stated that the EMS personnel can follow protocols if necessary and if all else fails, they can transfer to the nearest Emergency Department. Further, s/he stated that they are unaware of rooms being "lended" until weather clears and the patient continuing on transfer - stating "It is a sticky situation because of the EMTALA violation ( physician named sending facility)."

CMO #1 confirmed in interview November 1, 2018 at 1300, that the patient was the "hospital's patient as soon as (s/he) entered the door, a medical screening exam should have been completed" and the patient registered. Additionally, entering the doors, even for weather reasons, implies that the crew needs assistance and help with the patient. Further, CMO #1 stated that s/he did not hear of the incident until the "Quality People" told him/her about it on approximately October 19, 2018. No reporting of incident was done at this time to CMS (Centers for Medicare & Medicaid Services). Per CMO #1, the "self reporting of incident" was done on 10/23/2018 by Chief Compliance and Risk Management Officer #3.

Based on review of facility documentation, interview, and review of policy and procedure, it was determined the hospital failed to accept 1 of 1 patients Patient # 0) from another hospital entity with limited resources and no critical care capabilities. The patient was being transported to a higher level of care by emergency medical services ambulance, and due to inclement weather and denial by all forms of aircraft (fixed wing and rotor) the patient was stranded at this facility's helicopter pad. There is a high possibility of harm/death to a patient if the recipient hospital does not accept a patient from an emergency medical services crew coming from a rural entity.

Findings include:

Facility incident report titled "Professional Conduct Event (220)", dated 10/23/2018, [authored by Quality RN #30] revealed: "...was told that (ER DR #2) met the ambulance and patient in the hallway outside ED4 (Trauma bay #4) stating stop you cannot bring this patient here this is an EMTALA violation. Pt (patient) was held in Summit parking lot for close to three hours as (ER DR #2) refused to take care of the pt in our ED (Emergency Department). I called (ER DR #2) to ask...what occurred. He told me the ED was 'chaos' crazy busy. All (s/he) know was there was a patient from (name of sending hospital) and (s/he) did not have a doc to doc report on this patient and felt it was an EMTALA violation. Someone had called (EMS Coordinator #13) and (EMS Coordinator #13) told (him/her) it was an EMTALA violation and...would take care of it...I (ER DR #2) then continued to work in my very busy ED and take care of my patients. I (ER DR #2) never saw the patient...(Day Charge RN #16 and House Supervisor #12) stated ED on that day was very slow, so slow the second doc was sent home. (IHS ER RN #27) stated (ER DR #2) stopped them outside room 4 when they were rolling the patient into the ED on the gurney and stated...knew nothing about the patient, (IHS ER RN #27) tried to give (ER MD #2) report and [he] kept 'cutting [him] off' and saying take (Patient #0) back I don't have a doc to doc report...."

ED Director #11 confirmed in interview 10/31 at 1142, that the census at the time Patient #0 entered the emergency department (ER) was twelve (12) patients, with two (2) of those being discharged and one (1) of those was an admit to the hospital inpatient units. There were no patients in the hallway "beds", no patients in triage, and one (1) patient in the waiting room being registered. The total capacity of the ER is thirty (30) beds - six (6) of the beds are disposition chairs (where care can be started prior to bed placement such as in the actual beds are full). (In addition there are six (6) beds located in the ER observation area and are used if a patient needs <23 hour care but does not meet the standards for a full admit. The patient can be registered to this area and in times of saturation these beds are also used as "regular" ER beds and ER staff take care of the patients assigned to this area). Further, ED Director #11 confirmed that there were two physicians and two physician assistants on at the time Patient #0 was brought to the hospital. Surveyor was provided with a "grid" printed off the "T System Census" by ED Director #11 on 10/31/2018 at 1130 hours that documents this information by the "computer" accessing the information of the hospital electronic medical record system.

Policy titled "Emergency Medical Treatment, Screening and On-Call", Policy #ED1017, last reviewed 9/2018, requires: "...All Patients presenting to the Emergency Department are seen by an Emergency Department Provider...Any individual who presents to the Emergency Department is provided with a medical screening examination to determine if the individual is experiencing an emergency medical condition...."

Policy titled "Interfacility Transport", Policy #BH8002GL, last revised 9/2018, requires: "...if the receiving facility is also a certified emergency center, care of the patient and direct communication with paramedics rendering that care may be transferred to the receiving medical control authority...."

Policy titled "Emergency Medical Treatment and Labor Act (EMTALA)", Policy #HW1109, last reviewed 12/2017, requires: "...A patient will be deemed stabilized if the attending emergency physician has determined with reasonable clinical confidence that the emergent medical condition has been treated...The hospital has the obligation of securing an appropriate mode of transport which is best correlated to meet the needs of the patient respective to their clinical status...the desired outcomes, within reasonable medical probability, to prevent any further deterioration in the patient's...clinical status. When the hospital has exhausted all of its capabilities and capacities in attempting to resolve an emergent medical condition, it will arrange an appropriate transfer of the patient...the hospital must secure a mode of transport that is best suited to meet the clinical needs of the patient...."

[IHS] ER RN #27 confirmed in interview 10/24/2018 at 0800, that all methods of safely transporting the patient to a higher level of care had been exhausted. Further, no fixed wing or rotor (helicopter) was capable of landing in [White River IHS] facility or the town of [Show Low] airport or hospital helipad. It was determined, in the best interest of the patient, in order to not expose this patient to the "elements" which could further deteriorate the patient's condition, the only option available was to enter the Summit hospital for their assistance.

[IHS] ER RN #27 confirmed on 10/24/2018 at 0800, the hospital did not treat the patient, did not assess if there were any further stabilizing procedures/actions that could have be done. [IHS] ER RN #27 confirmed s/he was unable to give report to ER DR #2 about Patient #0, and was unable to inform the physician that the sending hospital [WHITERIVER PHS INDIAN HOSPITAL] emergency room physician was willing to give report on Patient #0.

Chief Nursing Officer #4 confirmed in interview on 10/29/2018 at 1130, that Summit Healthcare Regional Medical Center is the only hospital for the rural area extending in all directions capable of providing critical care. Additionally, there is "No patient turned away, we are unable to divert, we are the only hospital for this rural community".