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Based on document review and interview, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to post EMTALA signs in areas likely to be noticed by all individuals that visit the emergency department (ED), see A 2402; and the failure to ensure an adequate medical screening exam was performed by a qualified medical professional as appointed in the Bylaws, see A 2406 and failure to accept an unstable patient (patient #1) from a rural hospital and provide stabilizing treatment, see A 2411. See specific tags.

Based on observation and interview the facility failed to post EMTALA signs in areas likely to be noticed by all individuals that visit the emergency department (ED). Findings include:

On 5/27/15 at approximately 0915 it was revealed during a tour of the ED, that patients entering the facility via ambulance would not be able to see EMTALA signs. Ambulance traffic enters through the ambulance bay, which does not pass the EMTALA signs posted in the waiting room.

On 5/27/15 at approximately 0916 during an interview with staff A it was asked by this surveyor "How do the patients that enter by ambulance see the EMTALA signs?" Staff A stated, "They don't, we don't have a sign posted there. We can get that fixed."

Based on document review and interview, it was determined that the facility failed to ensure a medical screening exam (MSE) was performed by a qualified medical professional, as specified in the Hospital Bylaws resulting in the potential for patients to be screened by an unqualified/unapproved medical professional. Findings include:

On 5/27/15 at approximately 1630 during review of the Hospital Bylaws, no evidence could be found of which providers were considered qualified to conduct a MSE.

On 5/28/15 at approximately 0915 during an interview with staff K, chief medical officer, it was confirmed that the hospital bylaws did not currently indicate which providers were qualified to conduct a MSE.

Based on document review and interview, Hospital A failed to receive and provide stabilizing treatment for a patient, (Pt.) #1, who was initially accepted as a transfer in an unstable condition from another outlying hospital, Hospital B. Patient #1 had presented to Hospital B with a "leaking abdominal aortic aneurysm" and later, exhibited symptoms of shock; with low blood pressure and vomiting. Hospital A failed to receive the patient, who had been transferred by fix wing transport (airplane) to the local airport, and provide stabilizing treatment. The Hospital's failures posed an immediate threat to Patient #1's health and safety and had the potential to effect ALL patients that present to the ER with an emergency medical condition. The immediate jeopardy is cited at 42 CFR 489.24(f) A 2411. A total of twenty two patients were included in the sample. These findings resulted in the finding of an Immediate Jeopardy. Findings include:
On 5/27/15 at 1430 a review of the medical record from [Hospital B] revealed that the patient arrived at Hospital B, the initial hospital on 5/1/15 at 1857 by ambulance with abdominal pain and a history of a previous repair of an abdominal aortic aneurysm (AAA) (tear in a major blood vessel). At 2107 a computerized tomography (CT) was completed and the films were sent to [Hospital A] tel-radiology. At 2116, Hospital A was contacted via the "one-call" system, a recorded method of communication/consultation between physicians/providers. Staff H, an ED physician from Hospital A, accepted patient #1 at 2116. At 2116 a unit of packed red blood cells was transfused. At 2119 the diagnostic computerized tomography image was interpreted by a radiologist as a "rupturing AAA with failure of previous graft." CT images were sent to [Hospital A] on 5/1/15 at 2130. On 5/1/15 at 2145 dopamine (medication used to treat shock and low blood pressure) was initiated and at 2200 a second unit of blood was initiated. At 2205 the patient was loaded into the ambulance for transfer to the airport and fixed wing (airplane) transport to Hospital A.

A summary of activities that took place after patient #1 was accepted by and en route to the recipient hospital at 2205 are as follows. At 2215 the referring hospital (Hospital B), received a call from the recipient hospital (Hospital A) indicating that Patient #1's destination may not be Hospital A but another, yet to be named hospital. At 2240 the referring hospital tried to call ED nurse to nurse report to the recipient hospital and was told that the patient may not be coming to the original recipient hospital. After patient #1 had left the transferring hospital, the vascular surgeon staff L, from the recipient hospital was looking for another recipient hospital to perform the specialized surgical repair for patient #1's failed AAA graft. Attempts were made to redirect patient #1 to a second recipient hospital 435.7 miles from the original recipient hospital ' s airport location; an additional facility under consideration was another hospital located in another state to the south, which was 307.83 miles from the airport where the patient was originally expected to land. At 2320 the ED nurse at the transferring hospital received a call from the recipient hospital indicating a new recipient hospital destination in another state, 307.83 miles away. The plane, carrying patient #1 was approaching the recipient hospital airport (Hospital A) at 2256, and calling in the patient's status (unstable palpable blood pressure) to staff H, who was relaying the patient #1 status information to staff L. There was no ambulance from the recipient hospital, Hospital A at the scene when the plane landed. Patient #1 was sitting at the airport in the city of recipient hospital, Hospital A, on the plane with the flight crew; a paramedic and the nurse with the plane's engines running, awaiting a destination from the original recipient hospital. At 2315, the flight crew received orders to take the patient to the facility in another state located due south, an estimated 307.83 miles away from their current location. At 2335, while en route to the second recipient hospital, (Hospital C), the patient suffered a cardiac and respiratory arrest. Resuscitative efforts were initiated and the patient was intubated and manually provided respiratory support. The plane landed immediately in Green Bay, Wisconsin at 0005. Patient #1 was taken by ambulance to the closest facility's, [Hospital D] emergency department where resuscitative efforts failed and the patient expired.
On 5/21/15 at 1315 an interview with the emergency department (ED) physician, staff AA from [Hospital B] took place. Staff AA that he had called on the one-line system and spoke with staff H, the ED physician at the referral center, [Hospital A], who after conferring with a vascular surgeon, who happened to be in the ED, agreed to accept the patient (patient #1). Staff AA stated, "in the middle of the flight, [Hospital A] wanted to divert the patient to another facility. I told them that the patient will never make it, he is unstable and needs to go to the closest hospital."

On 5/28/15 at 0830 an interview with staff H, from [Hospital A] took place. When asked if he accepted patient #1, he replied, "Yes. I took the phone call and staff L, the vascular surgeon happened to be in the ED that night, and I asked him if we could accept, he agreed to accept this patient (patient #1)". Staff H continued, "After we pulled up the CT images (for patient #1), staff L indicated that the repair was going to be more complicated than originally expected, I asked if we needed to contact the doctor at the sending facility and he said 'no'". Staff H was asked why the patient was not brought to [Hospital A] for a medical screening exam and stabilization, to which he replied, "The patient would have been better served by being transported directly to a hospital with the specialized surgical capability required for this type of aneurysm." When asked whether the patient could have been stabilized if taken to [Hospital A], he replied, "There was nothing more I could have done that they (paramedics) weren't already doing, he needed the surgical repair."