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Based on staff interview and in the course of a complaint investigation, it was determined the facility staff failed to comply with the special responsibilities of Medicare hospitals in emergency cases. The facility staff failed to provide evidence of an appropriate medical screening examination for the patient named in the complaint.

The findings include:

As part of the complaint investigation, surveyors requested the Emergency Department (ED) Central Log. The ED Central Log contained no evidence the patient named in the complaint was seen in the ED on September 8, 2011.

The ambulance team that responded to a call related to the patient named in this complaint was interviewed by one Medical Facilities Inspector on September 22, 2011 at 9:15 a.m. The ambulance team responded to the scene which was on the sidewalk directly in front of the hospital named in the complaint (which will be referred to as the initial hospital). When the ambulance team arrived, two local police officers and two employees from the initial hospital were with the patient. One of the initial hospital employees was a security guard and one was with the engineering department. The first ambulance employee said when they arrived, the patient stated he didn't feel well and that he was sick. The patient requested going to the initial hospital but the police officers at the scene said the patient could not go there. The ambulance employee asked the patient his second choice and therefore transported him to that hospital (which will be referred to as the receiving hospital). The ambulance employee stated that he asked the security guard why the patient could not go to the initial hospital and the security guard response was that the patient could not go there. The second ambulance employee was interviewed by one MFI at 9:30 on September 22, 2011 and recalled the patient was sitting on the hospital property about 25 yards from the Emergency Department entrance when they arrived on the scene. The ambulance employee recalled the patient wanting to be seen at the initial hospital. When the MFI asked why the patient was transported to a hospital farther away, the ambulance employee recalled the police officer saying that someone told him (the officer) the patient wasn't allowed to go to the initial hospital. The second ambulance employee acknowledged he did not hear anyone say the patient could not be seen at the initial hospital, but that when he left the scene his impression was that the security guard had told the police officer the patient could be seen there.

Please refer to ?489.24(a) for additional information.

Based on Emergency Department (ED) central log review, staff interviews, and in the course of a complaint investigation, it was determined the facility staff failed to provide evidence of an appropriate medical screening examination (MSE) for the patient named in the complaint.

The findings include:

On September 20, 2011 at 2:00 pm, following an entrance conference and tour of the ED, the facility's Vice President of Quality informed the Medical Facilities Inspectors (MFI) that on September 12, 2011 she received at call from another hospital's risk manager reporting a possible EMTALA violation that occurred on September 8, 2011. The risk manager indicated her hospital (referred to as the receiving hospital) received the patient named in this complaint on September 8, 2011 after an ambulance crew was informed the patient could not be seen at the hospital named in this complaint (referred to as the initial hospital). The Vice President of Quality (of the initial hospital) informed the MFIs that once she was presented with this information, she immediately began her own investigation and self-reported the incident to Office of Licensure and Certification. She provided an e-mail that the facility's Ethics and Compliance Officer sent to everyone at the initial hospital that read in part, "While the main practical impact of EMTALA is in the ER and L&D, EMTALA compliance is actually the responsibility of every employee! Under EMTALA, the hospital has the responsibility to provide a medical screening examination (MSE) to any person who seeks emergency care or any person who is on our property and individual's appearance when observed suggest that the individual may need an exam to determine if an emergency medical condition exits. Our property is defined in the law as the entire hospital campus which is: 'The hospital's main building (sic) 'The physical area immediately next to the hospital's main building 'Other hospital area/structures located within 250 yards of the main building 'Parking lots, sidewalks and driveways (sic) As any hospital employee may encounter as (sic) person seeking care at our facility, please keep the EMTALA regulations in mind and assist the individual with obtaining care at our facility. Assist them in getting to the ER or someone who can provide an MSE, don't just give directions, assume they will get there or ignore them. When in doubt or if you need assistance contact your supervisor or the Nursing Supervisor. If you have any EMTALA questions contact (name, title and phone number of VP of Quality and name of ECO)." The VP of Quality stated the facility had also reviewed their EMTALA policy and procedure and provided evidence of employee training.

As part of the complaint investigation, surveyors requested the Emergency Department (ED) Central Log. The ED Central Log contained no evidence the patient named in the complaint was seen in the ED on September 8, 2011.

The patient's record from the receiving hospital was obtained and reviewed on September 20, 2011. The record verified the patient was transported by ambulance from the scene in front of the initial hospital to the receiving facility's ED on September 8, 2011.

The ambulance team that responded to a call related to the patient named in this complaint was interviewed by one Medical Facilities Inspector on September 22, 2011 at 9:15 a.m. The ambulance team responded to the scene which was on the sidewalk directly in front of the hospital named in the complaint (which will be referred to as the initial hospital). When the ambulance team arrived, two local police officers and two employees from the initial hospital were with the patient. One of the initial hospital employees was a security guard and one was with the engineering department. The first ambulance employee said when they arrived, the patient stated he didn't feel well and that he was sick. The patient requested going to the initial hospital but the police officers at the scene said the patient could not go there. The ambulance employee asked the patient his second choice and therefore transported him to that hospital (which will be referred to as the receiving hospital). The ambulance employee stated that he asked the security guard why the patient could not go to the initial hospital and the security guard response was that the patient could not go there. The second ambulance employee was interviewed by one MFI at 9:30 a.m. on September 22, 2011 and recalled the patient was sitting on the hospital property about 25 yards from the Emergency Department entrance when they arrived on the scene. The ambulance employee recalled the patient wanting to be seen at the initial hospital. When the MFI asked why the patient was transported to a hospital farther away, the ambulance employee recalled the police officer saying that someone told him (the officer) the patient wasn't allowed to go to the initial hospital. The second ambulance employee acknowledged he did not hear anyone say the patient could not be seen at the initial hospital, but that when he left the scene his impression was that the security guard had told the police officer the patient could be seen there.

The ambulance's patient care report was reviewed on September 20, 2011. It documented the ambulance crew responded to a call involving the patient named in this complaint on September 8, 2011. The location's proper address was documented and found to be directly in front of the facility named in this report. The ambulance crew documented their primary impression as, "Alcoholic Intoxication" and within the narrative the crew wrote in part, "Unknown the reason but (hospital named) Security informed (local police) that the pt (patient) was not allowed to go to (hospital named)." The report documented no visible physical abnormalities or bleeding and included, "Pt c/o (complained of) 'feeling sick.' Pt denied any CP (chest pain), SOB (shortness of breath), or Abd (abdominal) pains. Pt has ETOH (alcohol) on his breath and was uneasy on his feet. Pt denied any alcohol consumption today but states he has (sic) some last night." The report noted in part, "Pt was able to stand and walk, w/(with) assistance, into the ambulance. Pt was secured to the stretcher. Pt was transported w/o (without) incident or change in condition to (receiving hospital) ER bed 10.

One of the two local police officers who responded to 911 call relating to a male lying outside of the facility named in this complaint was interviewed via phone by one Medical Facility's Inspector (MFI)on September 21, 2011 at 12:55 pm. The officer recalled responding to the location outside of the facility where a male was sitting or lying on the ground. The officer stated he didn't remember the exact words that were said, but recalled the male telling the officer that he had a medical condition and needed to go to the hospital. The officer said, "I asked security, 'Do you guys want him?' and he said, 'No'." The officer recalled the ambulance crew asking why the patient was not going to the facility closest to their location and the police officer said he responded, "They said they didn't want him." The police officer was unable to describe the security officer he spoke with at that time. When asked if he'd ever had this facility deny taking a patient in the past, the officer stated, "I've worked this precinct for 12 years and I've never had a problem with (name of facility) or any hospital refusing a patient."

The other police officer who responded was not interviewed by the MFIs. He told the Office of Licensure and Certification's (OLC) Complaint Unit Supervisor he did not recall talking with anyone about where to send the male.

The security officer who responded to a dispatch regarding a man lying in front of the facility on the morning of September 8, 2011 was interviewed by one MFI on September 21, 2011. The security officer, the facility's Vice President of Quality, and one MFI walked outside the facility to reconstruct the security officer's experience on September 8, 2011. The security officer said after getting the call from dispatch there was a man down in front of the hospital, he and another employee walked down one street to the corner and looked down the adjacent street to see a man sitting on a short retaining wall, lying back on the grass in front of the hospital. The local police were present and talking with the man who was obviously intoxicated but not belligerent and had his pants down. The security officer told the MFI that although they walked toward the police, he knew that since the police were onsite, it was their investigation. After 3-5 minutes, the ambulance crew arrived and when the crew members approached the scene, the security officer returned to the hospital. He denied having a conversation with the officers saying, "I thanked them for their service. They didn't ask me anything." The security officer acknowledged he was wearing a shirt that identified him as security as well as his badge. He did not recognize the ambulance crew or the police officers. When asked whether he knew why the man would not have been transported to his facility's ED, he said that when he left the scene, he did not know whether the man would be going to the hospital or going to jail for public intoxication.

The facility's engineering department employee who responded with the security guard was interviewed on September 22, 2011 by one MFI. He said when they arrived at the scene, the police department was already there. He described an old man that appeared "drunk" but said he did not get close enough to smell alcohol. He also stated, "his pants were down." The employee said the ambulance arrived within 5 minutes of them reaching the scene. When asked if he could explain how the man ended up at another hospital rather than the initial hospital he said, "I assumed the ambulance was going to take the patient around the block to our emergency department bay." He added, "If I had heard the police department tell the ambulance guys you can't go to this hospital, I would have said 'why not?'." MFI asked the engineering employee if he heard anyone say that the patient could not come to their hospital and the employee said that although he could not make out every word, the only communication he saw between the security guard and police officers was when the security guard asked the officers if he could help them get the patient's pants back on.

The initial hospital's Director of Emergency Department was interviewed on September 20, 2011 at 3 p.m. She said the hospital's Associate Chief Nursing Officer informed her of a possible EMTALA violation and she verified the patient named in this complaint had never been registered in their ED on September 8, 2011. She informed the MFIs the patient was well known to the initial hospital's ED staff and then stated, "It just sounds odd, he was here on the 5th, the 11th and the 13th." (of September 2011).

The Vice President of Quality stated on September 21, 2011 that her investigation revealed the patient had been seen in their ED over 50 times during the year of 2011 and at least twice since this incident. The MFI's verified the patient had been seen in the initial facility's ED on both September 11, 2011 and September 13, 2011 by reviewing the patient's ED records from both dates.

Based on Emergency Department (ED) central log review, staff interviews, and in the course of a complaint investigation, it was determined the facility staff failed to provide evidence of an appropriate medical screening examination (MSE) for the patient named in the complaint.

The findings include:

On September 20, 2011 at 2:00 pm, following an entrance conference and tour of the ED, the facility's Vice President of Quality informed the Medical Facilities Inspectors (MFI) that on September 12, 2011 she received at call from another hospital's risk manager reporting a possible EMTALA violation that occurred on September 8, 2011. The risk manager indicated her hospital (referred to as the receiving hospital) received the patient named in this complaint on September 8, 2011 after an ambulance crew was informed the patient could not be seen at the hospital named in this complaint (referred to as the initial hospital). The Vice President of Quality (of the initial hospital) informed the MFIs that once she was presented with this information, she immediately began her own investigation and self-reported the incident to Office of Licensure and Certification. She provided an e-mail that the facility's Ethics and Compliance Officer sent to everyone at the initial hospital that read in part, "While the main practical impact of EMTALA is in the ER and L&D, EMTALA compliance is actually the responsibility of every employee! Under EMTALA, the hospital has the responsibility to provide a medical screening examination (MSE) to any person who seeks emergency care or any person who is on our property and individual's appearance when observed suggest that the individual may need an exam to determine if an emergency medical condition exits. Our property is defined in the law as the entire hospital campus which is: 'The hospital's main building (sic) 'The physical area immediately next to the hospital's main building 'Other hospital area/structures located within 250 yards of the main building 'Parking lots, sidewalks and driveways (sic) As any hospital employee may encounter as (sic) person seeking care at our facility, please keep the EMTALA regulations in mind and assist the individual with obtaining care at our facility. Assist them in getting to the ER or someone who can provide an MSE, don't just give directions, assume they will get there or ignore them. When in doubt or if you need assistance contact your supervisor or the Nursing Supervisor. If you have any EMTALA questions contact (name, title and phone number of VP of Quality and name of ECO)." The VP of Quality stated the facility had also reviewed their EMTALA policy and procedure and provided evidence of employee training.

As part of the complaint investigation, surveyors requested the Emergency Department (ED) Central Log. The ED Central Log contained no evidence the patient named in the complaint was seen in the ED on September 8, 2011.

The patient's record from the receiving hospital was obtained and reviewed on September 20, 2011. The record verified the patient was transported by ambulance from the scene in front of the initial hospital to the receiving facility's ED on September 8, 2011.

The ambulance team that responded to a call related to the patient named in this complaint was interviewed by one Medical Facilities Inspector on September 22, 2011 at 9:15 a.m. The ambulance team responded to the scene which was on the sidewalk directly in front of the hospital named in the complaint (which will be referred to as the initial hospital). When the ambulance team arrived, two local police officers and two employees from the initial hospital were with the patient. One of the initial hospital employees was a security guard and one was with the engineering department. The first ambulance employee said when they arrived, the patient stated he didn't feel well and that he was sick. The patient requested going to the initial hospital but the police officers at the scene said the patient could not go there. The ambulance employee asked the patient his second choice and therefore transported him to that hospital (which will be referred to as the receiving hospital). The ambulance employee stated that he asked the security guard why the patient could not go to the initial hospital and the security guard response was that the patient could not go there. The second ambulance employee was interviewed by one MFI at 9:30 a.m. on September 22, 2011 and recalled the patient was sitting on the hospital property about 25 yards from the Emergency Department entrance when they arrived on the scene. The ambulance employee recalled the patient wanting to be seen at the initial hospital. When the MFI asked why the patient was transported to a hospital farther away, the ambulance employee recalled the police officer saying that someone told him (the officer) the patient wasn't allowed to go to the initial hospital. The second ambulance employee acknowledged he did not hear anyone say the patient could not be seen at the initial hospital, but that when he left the scene his impression was that the security guard had told the police officer the patient could be seen there.

The ambulance's patient care report was reviewed on September 20, 2011. It documented the ambulance crew responded to a call involving the patient named in this complaint on September 8, 2011. The location's proper address was documented and found to be directly in front of the facility named in this report. The ambulance crew documented their primary impression as, "Alcoholic Intoxication" and within the narrative the crew wrote in part, "Unknown the reason but (hospital named) Security informed (local police) that the pt (patient) was not allowed to go to (hospital named)." The report documented no visible physical abnormalities or bleeding and included, "Pt c/o (complained of) 'feeling sick.' Pt denied any CP (chest pain), SOB (shortness of breath), or Abd (abdominal) pains. Pt has ETOH (alcohol) on his breath and was uneasy on his feet. Pt denied any alcohol consumption today but states he has (sic) some last night." The report noted in part, "Pt was able to stand and walk, w/(with) assistance, into the ambulance. Pt was secured to the stretcher. Pt was transported w/o (without) incident or change in condition to (receiving hospital) ER bed 10.

One of the two local police officers who responded to 911 call relating to a male lying outside of the facility named in this complaint was interviewed via phone by one Medical Facility's Inspector (MFI)on September 21, 2011 at 12:55 pm. The officer recalled responding to the location outside of the facility where a male was sitting or lying on the ground. The officer stated he didn't remember the exact words that were said, but recalled the male telling the officer that he had a medical condition and needed to go to the hospital. The officer said, "I asked security, 'Do you guys want him?' and he said, 'No'." The officer recalled the ambulance crew asking why the patient was not going to the facility closest to their location and the police officer said he responded, "They said they didn't want him." The police officer was unable to describe the security officer he spoke with at that time. When asked if he'd ever had this facility deny taking a patient in the past, the officer stated, "I've worked this precinct for 12 years and I've never had a problem with (name of facility) or any hospital refusing a patient."

The other police officer who responded was not interviewed by the MFIs. He told the Office of Licensure and Certification's (OLC) Complaint Unit Supervisor he did not recall talking with anyone about where to send the male.

The security officer who responded to a dispatch regarding a man lying in front of the facility on the morning of September 8, 2011 was interviewed by one MFI on September 21, 2011. The security officer, the facility's Vice President of Quality, and one MFI walked outside the facility to reconstruct the security officer's experience on September 8, 2011. The security officer said after getting the call from dis