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Based on observation, interview, and record review, the hospital failed to comply with the provisions of 42 CFR 489.24 for one of 20 sampled patients (Patient 1) who was brought to the hospital's ED by paramedic ambulance seeking emergency medical treatment. During the transport of the patient (who was in cardiac arrest) to the hospital, the paramedic informed the hospital's base station MICN they were on the hospital's property. The MICN informed the paramedics the ED was on diversion (closed to ambulance traffic during periods of high volume) and rerouted them to Hospital B, 10 minutes away. This resulted in a delay in medical evaluation and treatment for the patient. Cross reference to A 2406.

Based on observation and interview, the hospital failed to ensure the signage was conspicuously posted specifying the rights of individuals under the EMTALA law in places likely to be noticed by all individuals entering the L&D department for triage. This failure could result in individuals to not be aware of their rights to examination and treatment in the event of an emergency medical condition.

Findings:

On 5/9/17 at 0925 hours, a tour of the L&D department was conducted with the Director of Maternal Newborn Services and L&D Manager. Signs specifying the rights for examination and treatment for patients with emergency medical conditions and women in labor were observed posted on the wall in the L&D waiting area; however, there was no signage posted in the triage or treatment areas for obstetric patients waiting for examination and treatment. The Director of Maternal and Newborn services acknowledged the only patient rights signage on the L&D unit was in the waiting area. The Director further acknowledged L&D patients rarely stopped at the waiting area where the signs were posted.

Based on observation, interview, and record review, the hospital (Hospital A) failed to ensure the appropriate medical screening examination and stabilizing treatment were provided for one of 20 sampled patients (Patient 1) who was brought to the hospital's ED by paramedic ambulance seeking emergency medical treatment. During the transport of the patient (who was in cardiac arrest) to the hospital, the paramedic informed the hospital's base station MICN they were already on the hospital's property. The MICN informed the paramedics the ED was in diversionary status (closed to ambulance traffic during periods of high volume) and rerouted the ambulance to Hospital B, 10 additional minutes away. This resulted in a delay in medical evaluation and treatment for the patient.

Findings:

On 3/7/17, Hospital B reported to the Department their facility might have received an improper emergency patient transfer on 3/5/17. The hospital reported the EMS ambulance report showed on 3/5/17 at 2145 hours, the EMS was called to the residence of Patient 1 for his complaint of chest pain and pacer/defibrillator shocking him five times prior to the EMS arrival. At 2148 hours, the EMS arrived on the scene and initially transported the patient to Hospital A. Enroute to Hospital A, the patient became unresponsive and pulseless. The report alleged that "when EMS arrived at [Hospital A's name], while in the ambulance bay, [Hospital A's name] Base contact relayed to the EMS medic that their ED was down for saturation and were told to reroute to [Hospital B's name] with a 10 minute ETA." At 2213 hours, the EMS arrived at Hospital B where CPR continued. However, resuscitation measures were ultimately unsuccessful and the patient was pronounced dead at 2313 hours.

Review of the hospital's P&P titled EMTALA, last reviewed 1/2017 showed:

I. Purpose- to facilitate the appropriate assessment and treatment of individuals who present to the hospital's campus with a potential emergency condition and to comply with State and Federal requirements.
II. Points to Emphasize- EMTALA begins when an individual presents to a dedicated ED or hospital property and requests examination or treatment for what may be an emergency medical condition; has a request made on the individual's behalf for examination or treatment for what may be an emergency medical condition; and a prudent layperson observer would believe, based on the individuals appearance or behavior, that the individual needs examination or treatment for an emergency medical condition.
III. Policy- showed the P&Ps apply to any individual in a ground or air non hospital owned ambulance on hospital property who presents for examination and treatment for a medical condition at the ED of the hospital. The hospital may direct the ambulance to another facility if the hospital is on "Diversionary Status." If, however, the ambulance staff disregards the hospital's instructions and transports the individual onto hospital property, these P&Ps apply to that individual.

The ED was toured on 5/9/17 beginning at 0845 hours, with the ED Director, ED Manager, and Manager Regulatory Compliance.

During an interview with the RN Base Station Coordinator at 0845 hours, the RN stated she was an MICN and responsible for the education, training, and coordination of the hospital's base station MICNs and the county's EMS. The Coordinator demonstrated the emergency phones located at the nurses' station. The Coordinator stated there was always at least one MICN on each shift to monitor the base station calls and coordinate paramedic ambulance traffic in their area of the county.

Observation of the base station room with the Coordinator showed the room was located adjacent to the nurses' station. The room contained a computer/radio and wall maps of the county with locations of the hospitals. The Coordinator demonstrated the alert tone that sounded when a call was coming in for the base MICN. The Coordinator stated the EMS personnel in the field contacted the county for a frequency channel and the county EMS alerted the base station there was a call and on which frequency channel. The base MICN would then establish contact with the EMS personnel or paramedic on the provided frequency.

The Coordinator stated the base station calls were a two way radio system; only one person could talk at a time; you could not break in while the other talked and you had to wait for them to finish. When you heard silence, then it was an open line.

When asked about the procedure for accepting the patients brought in by the EMS ambulance when the hospital was in diversionary status, the Coordinator stated the ambulance would be diverted to another appropriate hospital able to accept them. When asked about the procedure if the ambulance was already on hospital property, the Coordinator stated they would have to accept them in the ED. The Coordinator stated because of the close proximity of several skilled nursing facilities and medical buildings to the hospital, the ambulances were often on the hospital's property before the initial contact was made by radio.

An audio recording between the paramedic caring for Patient 1 and the hospital's base station MICN on 3/5/17, was made available for review by the hospital on 5/9/17. Review of the recording showed the EMS paramedics were on the scene at the patient's home for approximately six minutes. The ETA to the hospital was approximately one minute. When the EMS first made contact with the hospital that they had already been on the hospital's grounds. In listening to the recording, neither the MICN nor EMS had to ask to repeat information due to static on the line.

Review of the audio recording showed the initial contact between the base MICN and EMS occurred at 2159 hours on 3/5/17. The EMS reported Patient 1's complaint of his defibrillator going off more than two times prior to their arrival. The patient contact time was reported as 2153 hours. The EMS stated, "we actually have ETA less than 1 min to [Hospital A's name]." The EMS reported the patient's defibrillator going off more than seven times since contact. The EMS stated, "we are pulling up to the back of your facility. Our patient is going in and out of consciousness." There was then a 13 second break in recording.

The EMS then again stated, "[Hospital A's name] we are pulling up in back of your facility. The patient is running an occasional V Fib then his defibrillator will go off then knock him back into another sinus tach rhythm. The patient is going in and out of consciousness" (three seconds break in recording).

The MICN informed the EMS she was trying to contact them and stated, "we are down to ED Stat, have been trying to break thru to you, we are down to ED Sat, we are a wave off, we cannot take this patient" (15 seconds break).

The EMS acknowledged but stated they were "30 seconds....actually we are at the back of the hospital" and stated they would reroute to Hospital B with an ETA of 10 minutes.

The MICN informed the EMS "I have been trying to tell you we are on ED SAT but the transmission continued, go ahead and start from ABCs (airway, breathing and cardiac assessment), give the vitals and will call" Hospital B.

The EMS proceeded to give a report of the patient's condition to the MICN. They reported when the patient was loaded into the ambulance, he was going in and out of consciousness, and now the patient was in V Fib, pulseless, and not breathing. The ETA to Hospital B was four more minutes. In another minute the EMS reported Patient 1 now had a pulse, was breathing, and regaining consciousness. The patient arrived at Hospital B at 2210 hours. The total transmission time was 11 minutes.

Review of Patient 1's medical record obtained from Hospital B showed the patient arrived to the ED at 2213 hours on 3/5/17. An IV medication to treat the V-fib/V-tach was given on arrival and the patient was intubated (flexible tube inserted into the airway through the throat to assist breathing). The patient was in a V Tach rhythm. At 2220 hours, the CPR was initiated. The patient was in and out of V Tach. The patient expired at 2313 hours.

RN 1 was interviewed on 5/9/17 at 1240 hours. RN 1 confirmed she was the MICN assigned to the base station on 3/5/17, coordinating the ambulance run for Patient 1 with the EMS. The MICN stated she worked the day shift, usually going home at 1900 hours; however, she stated she stayed overtime as the ED was extremely busy and they were saturated with patients on 3/5/17. RN 1 stated they were also holding two Intensive Care Unit level patients in the ED who were waiting for beds in the hospital. RN 1 stated the hospital was in diversionary status for several hours at the time of the call.

RN 1 was asked to describe the call between her and the EMS on 3/5/17 beginning at 2159 hours. RN 1 stated she answered the call and was told the patient had an ICD that fired several times. RN 1 stated she pushed the button, acknowledged contact with the EMS, and then the EMS started to talk. RN 1 stated they informed her they had a patient in full arrest (no heartbeat or breathing), coming to the hospital as they were the closest facility. RN 1 stated, "they kept talking and talking."

RN 1 stated she popped her head out of the room and called for the charge nurse, RN 2, to come into the room. RN 2 listened to the radio call with her. RN 1 stated she asked RN 2 if they could accept the patient and was told "no." RN 1 stated the EMS kept talking and she could not break through. RN 1 stated when she finally was able to break in she told them to go to Hospital B.

RN 1 was asked what she heard the EMS personnel say before she was able to talk to them. RN 1 stated she did not hear the EMS say they were on the hospital grounds, just that they were nearby. RN 1 further stated, "when they said they were at the back door, I thought they were at the intersection just off the hospital entrance." RN 1 stated she had no idea the EMS was in the ambulance bay of the hospital. However, when asked if she tried to clarify the location of the EMS ambulance when the EMS reported three different times they were at the back of the hospital, RN 1 stated she did not.

When asked about the hospital's policy for accepting ambulance runs when the ED was in diversionary status, RN 1 stated, "diversion is a request," and "if a patient comes on the property we have to take them."