HospitalInspections.org

Based on review of the ED central log, ambulance trip report, medical records, Medical Staff Rules and Regulations, policies and procedures, staff interviews, personnel files, and credential files, it was determined that the facility failed to ensure that a patient was entered on the ED central log, generate a medical record, provide an appropriate medical screening (MSE) within the facility's capabilities and provide subsequent stabilizing treatment for one (1) of 20 sampled medical records when Patient #1, diagnosed with COVID-19, was transported via EMS from a skilled nursing facility to the ED (Taylor Regional Hospital) with difficulty breathing.

Findings were:

Cross refer to A-2406, as it relates to failure to provide an appropriate medical screening examination.

Cross refer to tag A-2407 as it relates to failure to provide stabilizing treatment.

Based on review of the ED central log, ambulance trip report, Medical Staff Rules and Regulations, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that a medical record was initiated/generated for one (Patient #1) of 20 sampled records when Patient #1, a COVID-19 positive patient with difficulty breathing arrived via EMS from a skilled nursing facility. Additionally, the facility's EMTALA policies and procedures failed to adequately address maintenance of medical records when patients present to the emergency department.

Findings were:

Cross refer to A-2405, as it relates to failure to enter Patient #1 into the ED central log.

Review of the facility's Emergency Department (ED) log failed to reveal an entry for Patient #1 on 4/14/2020.

A review of the ambulance trip report for Patient #1 from Emergency Medical Services (EMS) Provider #4 documentation revealed that EMS had been dispatched to Facility #3 (Nursing Home) on 4/14/2020 to transport Patient #1 to the ED for complaints of shortness of breath and difficulty breathing. Continued review of the trip report revealed that Patient #1 had tested positive for COVID-19 and had a history of diabetes (disease causing irregular sugar in the blood). Patient #1's vital signs at 10:02 p.m. included: heart rate-84 beats per minute (normal 60 to 100 beats per minute), respiratory rate- 40 breaths per minute (normal 14 to 20 breaths per minute), blood pressure 110/60 (normal 120/80), pulse oximetry 96 % (the amount of oxygen in the blood). Patient #1 was receiving oxygen by mask at 10 Liters/minute. Patient #1 was transported from Facility #3 at 10:14 p.m. Patient #1's vital signs at 11:45 p.m. were: HR- 82 beats per minute; RR-48 breaths per minute; Sats-94%. Patient remained on 10L/min. oxygen. Review of the Outcome/Disposition notes revealed that Patient #1 was originally going to Facility #1 (Taylor Regional Hospital), but EMS crew was advised that they (Facility #1) did not have any available beds. Director FF was notified and advised EMS crew to transport Patient #1 to Facility #2 (Another acute care hospital). Continued review of Outcome/Disposition revealed that no changes were noted in Patient #1 during transport and there were no complications during the transport. Patient #1 arrived at Facility #2 at 12:01 a.m.


Staff Interviews:

Following the entrance conference on 4/27/2020 at 2:00 p.m., an interview with VP AA took place via phone. VP AA explained that the facility had been made aware of a potential EMTALA violation and had conducted a thorough investigation. VP AA explained that at the time of the incident, six of six ED beds were occupied, all ICU beds were occupied, and all COVID-19 overflow designated beds were full. VP AA recalled that she was the administrator on-call and received a call from an ED nurse regarding a patient from a nursing home who was likely COVID-19 positive. The patient had arrived and remained in the ambulance. The ED had one available bed that needed to be cleaned. VP AA instructed the staff member to have the ED room terminally cleaned and ask the EMS to care for the patient in the ambulance until the bed was available. VP AA explained that there was not 'a safe place for the patient to land' when the ambulance arrived but that the room was going to be cleaned. VP AA explained that the ED charge nurse had communicated with the EMS staff. An ED physician (MD EE) obtained vital signs and medical history information from the EMTs. VP AA explained that the ambulance drove off without speaking to the ED staff. VP AA estimated that the ambulance had waited approximately 30 minutes. VP AA explained that the facility staff never told the EMS staff that the facility could not accept the patient. VP AA explained that a medical record was not created for Patient #1 on 4/14/2020.


During the telephone exit conference on 5/1/2020 at 9:30 a.m. CEO DD explained that the facility did not usually generate medical records on patients unless a registration was initiated.

A review of the facility's document #21001 titled 'Medical Staff Rules and Regulations' last revised 06/2019 revealed:
X. MEDICAL RECORDS:
The attending physician shall be held responsible for the preparation of a complete medical record for each patient. The record shall include:
Identification data, chief complaint, provisional diagnosis;
History and Physical. OB records must contain prenatal information;
Diagnostic and therapeutic orders given by Medical Staff members shall be authenticated by the responsible practitioner;
Appropriate informed consent to include the identity of the patient, date, procedure or treatment to be done, name of person performing the procedure or treatment, authorization of anesthesia if indicated, indication that alternate means, risk and complications have been explained."

It was determined during review of the facility's Emergency Department EMTALA (ADM 577, titled EMTALA effective 1/31/2001, last reviewed 05/2017) policies and procedures provided by the facility, revealed that medical record initiation and maintaining medical records for patients presenting to ED was not adequately addressed. The facility failed to maintain medical record and other records for patient #1 on 4/14/2020.

Based on review of the ED central log, ambulance trip report, policies and procedures, and staff interviews, it was determined that the facility failed to maintain a central log on each individual who "comes to the emergency department," seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized or discharged for 1 (patient #1) of 20 sampled patient medical records. Additionally, the facility's emergency department EMTALA policies and procedures failed to adequately address maintaining a central log on each individual who comes to the emergency department.


Findings included:


Review of the facility's Emergency Department (ED) log failed to reveal an entry for Patient #1 on 4/14/2020.

A review of the ambulance trip report from Emergency Medical Services (EMS) Provider #4 revealed that EMS had been dispatched to Facility #3 on 4/14/2020 to transport Patient #1 to the ED for complaints of shortness of breath and difficulty breathing. Continued review of the trip report revealed that Patient #1 had tested positive for COVID-19 and had a history of diabetes (disease causing irregular sugar in the blood). Patient #1's vital signs at 10:02 p.m. included: heart rate-84 beats per minute (normal 60 to 100 beats per minute), respiratory rate- 40 breaths per minute (normal 14 to 20 breaths per minute), blood pressure 110/60 (normal 120/80), pulse oximetry 96 % (the amount of oxygen in the blood). Patient #1 was receiving oxygen by mask at 10 Liters/minute. Patient #1 was transported from Facility #3 at 10:14 p.m. Patient #1's vital signs at 11:45 p.m. were: HR- 82 beats per minute; RR-48 breaths per minute; Sats-94%. Patient remained on 10L/min. oxygen. Review of the Outcome/Disposition notes revealed that Patient #1 was originally going to Facility #1, but EMS crew was advised that they (Facility #1) did not have any available beds. Director FF was notified and advised EMS crew to transport Patient #1 to Facility #2. Continued review of Outcome/Disposition revealed that no changes were noted in Patient #1 during transport and there were no complications during the transport. Patient #1 arrived at Facility #2 at 12:01 a.m.

Interviews:

Following the entrance conference on 4/27/2020 at 2:00 p.m., an interview with VP AA took place via phone. VP AA explained that the facility had been made aware of a potential EMTALA violation and had conducted a thorough investigation. VP AA explained that at the time of the incident, six of six ED beds were occupied, all ICU beds were occupied, and all COVID-19 overflow designated beds were full. VP AA recalled that she was the administrator on-call and received a call from an ED nurse regarding a patient from a nursing home who was likely COVID-19 positive. The patient had arrived and remained in the ambulance. The ED had one available bed that needed to be cleaned. VP AA instructed the staff member to have the ED room terminally cleaned and ask the EMS to care for the patient in the ambulance until the bed was available. VP AA explained that there was not 'a safe place for the patient to land' when the ambulance arrived but that the room was going to be cleaned. VP AA explained that the ED charge nurse had communicated with the EMS staff. An ED physician (MD EE) obtained vital signs and medical history information from the EMTs. VP AA explained that the ambulance drove off without speaking to the ED staff. VP AA estimated that the ambulance had waited approximately 30 minutes. VP AA explained that the facility staff never told the EMS staff that the facility could not accept the patient. VP AA explained that patient #1 was not entered into the ED log.


Policies, Procedures

The facility's policy number ADM 557, titled 'EMTALA- Emergency Medical Treatment and Active Labor Act', effective 1/31/2001, last reviewed 05/2017, was reviewed. It was determined in a review of the facilities Emergency Department EMTALA policies and procedures provided by the facility, that central log entries and medical record initiation was not adequately addressed. The facility failed to ensure that on 4/14/2020 came to the hospital's emergency department was entered on the facility's ED log.

Based on review of medical records, ambulance trip report, Medical Staff Rules and Regulations, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency, to determine whether or not an emergency medical condition existed for one (1) (Patient #1) of 20 sampled medical records when Patient #1 arrived to the ED from a skilled nursing facility via ambulance for an evaluation and treatment of a possible emergency medical condition.

Findings:

A review of the ambulance trip report from Emergency Medical Services (EMS) Provider #4 revealed that EMS had been dispatched to Facility #3 on 4/14/2020 to transport Patient #1 to the ED for complaints of shortness of breath and difficulty breathing. Continued review of the trip report revealed that Patient #1 had tested positive for COVID-19 and had a history of diabetes (disease causing irregular sugar in the blood). Patient #1's vital signs at 10:02 p.m. included: heart rate-84 beats per minute (normal 60 to 100 beats per minute), respiratory rate- 40 breaths per minute (normal 14 to 20 breaths per minute), blood pressure 110/60 (normal 120/80), pulse oximetry 96 % (the amount of oxygen in the blood). Patient #1 was receiving oxygen by mask at 10 Liters/minute. Patient #1 was transported from Facility #3 at 10:14 p.m. Patient #1's vital signs at 11:45 p.m. were: HR- 82 beats per minute; RR-48 breaths per minute; Sats-94%. Patient remained on 10L/min. oxygen. Review of the Outcome/Disposition notes revealed that Patient #1 was originally going to Facility #1, but EMS crew was advised that they (Facility #1)
did not have any available beds. Director FF was notified and advised EMS crew to transport Patient #1 to Facility #2. Continued review of Outcome/Disposition revealed that no changes were noted in Patient #1 during transport and there were no complications during the transport. Patient #1 arrived at Facility #2 at 12:01 a.m. Patient #1 arrived to the ED (Hospital #1) from a skilled nursing facility via EMS and remained in the ambulance on the facility property for approximately 30 minutes at the instruction of facility staff, until transported by EMS to another acute care hospital (Hospital #2). The facility failed to ensure that their policy and procedure was followed as evidenced by failing to provide an appropriate medical screening for Patient #1 on 4/14/2020 , who presented to the hospital's ED with an emergency medical condition (Shortness of Breath/difficulty breathing), and the EMS staff informed the staff the patient's condition was deteriorating . Taylor Regional Hospital's ED had the capability to provide an appropriate medical screening examination including ancillary services routinely available to the ED to determine whether or not Patient #1 had an EMC. The facility also failed to ensure that their triage policy was followed as evidenced by failing to triage patient #1 on arrival when he presented to the ED on 4/14/2020.


The medical record from Hospital #2 for patient #1 was reviewed. Review of the "ED Physician Documentation" sheet dated 4/15/2020 at 00:34 revealed that patient #1 was a 65 year old male who presented to the ED via EMS. The patient's chief complaint was listed as "Respiratory Distress and Hypoxia. Per report call in from the Nursing Home staff, the patient tested positive for Covid-19 by the Health Department 6 days ago. The patient was treated with Hydroxychloroquine and Azithromycin. The patient's oxygen level dropped to 69%. The Nursing home staff stated that Patient #1's baseline was ambulatory and verbal. The General Physical Exam (Examination) revealed in part, "Patient arrived obtunded in moderated respiratory distress ...appearance: Febrile 104.2 rectally ...Respiratory ...oxygen saturation of 88 to 90% on full non-rebreather, emergent intubation underway, moderate congestion present in the lungs ...Comments ... Hospitalist kindly agrees to admit ...History and Physical
...Brief Summary- ... The EMS who picked him up headed to Taylor Regional Hospital at first but were then diverted to us here ...Labs came back and were critical. Review of the AICU (Advanced Intensive Care Unit) form revealed that Patient was admitted to the AICU on 4/15/2020 at 0240 hours. Documentation on the AICU form revealed at 4/15/2020 at 05:24 (Patient #1) admitted to the ICU from the ER (Emergency Room) with the following: 1.) Cardiac Arrest, it was PEA (pulseless electrical activity) then changed to V-Fib arrest. Etiology is below. 2.) Acute hypoxemic respiratory failure on MV (mechanical Ventilation). 3.) Septic Shock. 4.) AKI - (Acute Kidney Injury) 5.) Covid-19, and b/l (bilateral) pneumonia ...-Pt (patient) arrest shortly after ICU admission. ACLS lasted for more than 20 minutes but was not successful." Further review revealed that Patient #1 was pronounced dead by the physician on 4/15/2020 at 0534 hours.


INTERVIEWS


Following the entrance conference on 4/27/2020 at 2:00 p.m., an interview with VP AA took place via phone. VP AA explained that the facility had been made aware of a potential EMTALA violation and had conducted a thorough investigation. VP AA explained that at the time of the incident, six of six ED beds were occupied, all ICU beds were occupied, and all COVID-19 overflow designated beds were full. VP AA recalled that she was the administrator on-call and received a call from an ED nurse regarding a patient from a nursing home who was likely COVID-19 positive. The patient had arrived and remained in the ambulance. The ED had one available bed that needed to be cleaned. VP AA instructed the staff member to have the ED room terminally cleaned and ask the EMS to care for the patient in the ambulance until the bed was available. VP AA explained that there was not 'a safe place for the patient to land' when the ambulance arrived but that the room was going to be cleaned. VP AA explained that the ED charge nurse had communicated with the EMS staff. An ED physician (MD EE) obtained vital signs and medical history information from the EMTs. VP AA explained that the ambulance drove off without speaking to the ED staff. VP AA estimated that the ambulance had waited approximately 30 minutes. VP AA explained that the facility staff never told the EMS staff that the facility could not accept the patient.


A phone interview with EMS Director (Director) FF took place on 4/27/2020 at 2:45 p.m. Director FF recalled that he had been informed approximately one day prior to this event that Facility #1 would accept COVID-19 patients and this information was conveyed to all EMS staff. Patient #1 was the first patient from Facility #3 with suspected COVID-19 that his EMS service had transported, and that Patient #1 was in critical condition during transport. Director FF recalled that he spoke with staff from Facility #1 as well as staff from the facility that Patient #1 was eventually admitted to (Facility #2). Director FF explained that he had also talked with the two EMS crew members that transported Patient #1. Upon arrival to Facility #1, EMS GG was greeted by an ED registration clerk and informed that they had to 'find a room' and to 'stay in the truck'. Director FF further explained that at some point later, a House Supervisor informed EMS GG that the facility 'didn't have a room for this patient'. EMS GG notified Director FF and Director FF recalled that he directed EMS GG to transport Patient #1 to Facility #2. Director FF explained that the EMS crew was not told to wait on a room to be cleaned. Director FF explained that EMS GG reported seeing open ED beds in Facility #1. Director FF explained that Facility #2 was approximately 36 miles from Facility #1 and Patient #1 expired soon after arrival to Facility #2. Director FF stated that per EMS GG and EMS HH, a physician did not inquire about Patient #1, only an unidentified House Supervisor. Director FF explained that Patient #1 expired after arrival to Facility #2..


A phone interview with ED Registered Nurse (RN) II took place 4/28/2020 at 6:45 p.m. RN II recalled the incident with Patient #1. RN II recalled that when the ambulance arrived with Patient #1, there was a patient in the ED's only negative pressure room. RN II instructed the receptionist to inform the EMT's that a patient needed to be transported to ICU, then that room needed cleaning before the patient could be brought into the ED. RN II recalled that she transported a patient to the ICU and returned to the ED. In the meantime, someone had called to get the negative pressure room cleaned. EMT came to ambulance door to inquire about room status and informed ED staff that Patient #1 'was not doing good'. MD EE had overheard this conversation and went out to speak to the EMT's.


A telephone interview with Emergency Department Physician (MD) EE took place on 4/29/2020 at 7:45 a.m. MD EE recalled the incident with Patient #1. MD EE explained that to the best of her recollection, the ED had been busy and there were two RN's working. When the ambulance arrived with Patient #1, the ED was full and already had two COVID-19 patients. MD EE recalled having a few minutes lead time prior to Patient #1's arrival and Patient #1 was one of two COVID-19 patients en route. MD EE recalled that the nurses were overwhelmed and were 'doing the best they could'. MD EE explained that the EMT's had been informed that a room needed to be cleaned and it would be a few minutes. MD EE recalled that one of the EMT's appeared 'ancy', was 'pacing and sighing'. After approximately ten minutes, one of the EMT's approached the door to the ED and asked for the status. The EMT told MD EE that they had bypassed two hospitals already because the hospitals were on 'COVID diversion'. MD EE asked the EMT's the status of Patient #1 and was told that he was 'holding his own'. MD EE did not recall specific vital signs. MD EE recalled that she explained to the EMT's that she did not have a room for Patient #1 now and it was not safe to have the patient wait in the hallway. MD EE recalled that she told the EMT that she was not turning the patient away, they just needed a few minutes to get the room cleaned. MD EE recalled telling the EMT 'please don't leave'. MD EE explained that if the EMT's had expressed concern about Patient #1's condition, she would have donned (put on) personal protective equipment (PPE) (supplies used to prevent the spread of infection such as gloves, masks, gowns) and got into the ambulance to assess the patient. After a few minutes, MD EE recalled that another ambulance arrived and when she went to the door to ask the second ambulance to wait, she noted that the ambulance with Patient #1 was gone. The crew of the second ambulance informed MD EE that the ambulance with Patient #1 said they were going to another hospital. MD EE recalled that on the evening of the incident, the ICU was full, and the overflow beds were full.



A telephone interview took place with the emergency medical service (EMS) crew (EMS GG, EMS HH) on 4/29/2020 at 9:30 a.m. EMS GG explained that he had been the driver of the ambulance. EMS GG explained that they had been dispatched to Facility #3 (a skilled nursing facility) to pick up Patient #1 and take him to Facility #1's ED. Facility #3 had notified Facility #1 of pending arrival. EMS GG explained that Patient #1 was COVID-19 positive. EMS GG recalled that Facility #1 was called from the ambulance a few minutes from arrival. It took approximately 36 minutes to go from Facility #3 to Facility #1 EMS GG recalled that upon arrival to Facility 1, a 'young lady' probably a registration clerk or tech came out to the truck and instructed crew to 'hold up in the truck' because a room wasn't available. EMS HH recalled that Patient #1 had been deteriorating and was 'critical'. After several minutes, EMS GG recalled that he went back to the ED door and spoke with the same staff member. The facility staff member told EMS GG that a COVID-19 positive patient had just been transferred out of an ED room and the room needed to be cleaned. EMS GG recalled telling the facility staff that Patient #1 was also COVID-19 positive and there was no need to clean the room. EMS GG recalled telling the staff member that Patient #1 was deteriorating. The staff member told EMS GG that she was going to call her 'supervisor'. EMS GG explained that he thought she was referring to the House Supervisor. EMS GG went back to the door after a few minutes and was greeted by the House Supervisor. House Supervisor told EMS GG that the facility 'could not turn them away' but there wasn't a bed available. EMS GG explained that at this point, he called Director FF and was instructed to take Patient #1 to Facility #2.. EMS HH estimated that their total time at Facility #1 had been a little over 30 minutes.


Medical Staff Rules and Regulations

A review of the facility's document #21001 titled 'Medical Staff Rules and Regulations' last revised 06/2019 revealed:
VII. Emergency Services
A physician was available 24 hours per day to render emergency patient care. An appropriate ED log was kept, listing all persons who presented or was brought to the ED for treatment or care and a notation about treatment or transfer.

Hospitalist and specialty physicians were available for on-call coverage of the ED. Specific duties were established by the Medical Executive Committee (MEC) as necessary and appropriate to sustain and insure the adequacy of physician coverage for the department. The on-call physician must be able to respond by telephone within 20 minutes or must be physically present within 30 minutes of contact, if requested by the ED physician, or staff.

The hospital must provide an appropriate medical screening exam (MSE) within the capability of the hospital's ED including ancillary services routinely available to the dedicated ED (DED), to determine whether or not an emergency medical condition (EMC) existed (i) to any individual, including a pregnant woman having contractions, who requested an examination, (ii) an individual who had such a request made on his or her behalf, or (iii) an individual whom a prudent layperson observer would conclude from the individual's appearance or behavior was in need of a MSE. An MSE was provided to determine whether the individual was experiencing an EMC.
Only the following individuals could perform an MSE in the ED:
1. A qualified physician with appropriate privileges


Policies and Procedures

A review of the facility's policy number ADM 557, titled 'EMTALA- Emergency Medical Treatment and Active Labor Act', effective 1/31/2001, last reviewed 05/2017, revealed that the purpose of the policy was to comply with EMTALA regulations. Further review revealed that the policy applied to all employees and medical staff members.
Continued review of the policy revealed that if any individual (regardless of Medicare eligibility or ability to pay) came alone or with another person to the ED and a request was made on the individual's behalf for an examination or treatment of a medical condition by a qualified medical person, or a prudent layperson observer believed that the individual presented with an EMC, the hospital provided an appropriate MSE within the capability of the ED including ancillary services routinely available to the ED to determine whether or not an EMC existed.

Definitions included:
Capacity- the ability of the hospital to accommodate the individual requesting the examination or treatment of the transferred individual. Capacity encompassed things such as number and availability of qualified staff, beds and equipment and the hospital's past practices of accommodation of additional patients in excess of occupancy limits.
Comes to the ED- with respect to an individual who requested an examination or treatment that the individual was on hospital property. Property meant the entire main hospital campus, including the parking lot, sidewalk, and driveway as well as any organization that was located off the main campus but was a department of the hospital. Property included ambulances owned and operated by the hospital, even if it was not on hospital grounds.

Emergency Medical Condition (EMC)- a medical condition manifested by acute symptoms of enough severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
A. Placing the health of the individual in serious jeopardy;
B. Serious impairment to bodily functions;
C. Serious dysfunction of any bodily organ or part

Stabilize- with respect to EMC, no material deterioration of the condition was likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility. Stable for transfer did not require final resolution of the EMC.

If an individual (regardless of Medicare benefits) came to a hospital and the hospital determined that the individual had an EMC, the hospital provided either:
A. Within the capabilities of the staff and facilities available at the hospital, for medical examination and treatment as required to stabilize the medical condition;
B. For transfer of the individual to another medical facility in accordance.
Delay in examination or treatment- the hospital did not delay an appropriate MSE or further medical examination and treatment in order to inquire about the individual's method of payment or insurance.

Continued review of the policy revealed that regarding transfer to another medical facility, transfer was only appropriate in cases in which:
A. The transferring hospital provided medical treatment within its capacity that minimized the risks to the individual's health.
B. The receiving facility had available space and qualified personnel for the treatment of the individual and agreed to accept transfer to provide appropriate medical treatment.
C. The transferring hospital sent the receiving hospital all available medical records (or copies) related to the EMC that the individual presented.
D. The transfer was affected through qualified personnel and transportation equipment, such as required, including the use of necessary and medically appropriate life support measures during the transfer.

If a hospital failed to meet COBRA, anti-dumping requirements, CMS could terminate the provider agreement.

A review of the facility's work instructions titled 'Emergency Department Triage', effective 02/1995, last revised 03/2017 revealed that the purpose of the policy was to provide a standardized system whereby patients presenting to the Emergency Department were triaged and treated in order of priority based upon acuity using the Emergency Severity Index (ESI) Five level triage system.

Strategy included:
All persons that presented to the Emergency Department received an immediate appropriate evaluation without regard to method of payment or insurance status.
1. An RN triaged all patients who arrived at the Emergency Department to identify life-threatening conditions and to "sort" or prioritize patients according to acuity.
2. All patients were triaged within 10 minutes of hospital arrival. Triage was generally done at bedside,
except during peak census periods, then the triage room was utilized. An electronic form was chosen
based on the patient's complaint.
3. The process of acuity determination was accomplished by using a five-tiered system of triage acuity
categories.
4. Only the assessment necessary to accurately assign a triage level based on the ESI system was
performed in triage and the patient appropriately assigned to a location.

The following steps occurred when making the triage decision.
A). The triage assessment included the incorporation of at least one of the following to help assign an
appropriate ESI level:
-Assessment: General appearance, airway status, breathing status, circulatory status and disability (neurological) status and chief complaint. Generally, a brief one-line statement or phrase in the patient's own words described the reason for seeking emergency care.
-Triage assessment: Perform focused assessment of chief complaint. Includes the collection of subjective and objective data.
(a) Subjective data included, but was not limited to onset and progression of symptoms,
location and description of problem, mechanism of injury, treatment prior to arrival and
response and pain assessment.
(b) Objective data included observations (appearance), data measured (vital signs), and
data discerned (localized examination).
c) Collection of in depth medical/surgical, TB and/or infectious disease history, along with a detailed medication list, to include name of their pharmacy, names of medications, routes, dosages, last
dosage administered, and allergies.

Continued review of the policy revealed that the facility considered worst case scenarios, pose hypotheses, and collected data to narrow the range of possibilities. Consider current condition, potential for deterioration, speed of flow within the department and the availability of resources.
-Determine the acuity category
-Reassess and reassign acuity as necessary.

B) Determine the amount of resources needed. The list of approved resources included:
Labs, ABG's Respiratory Treatments, EKG, X-rays, CT/MRI/Ultrasound, IV fluids, IV/IM medications, Specialty Consultations, Simple procedures: laceration repair, Foley catheter insertion, Complex procedures (2 points awarded) conscious sedation.

Five-Tier Acuity Categories were:
1. Level 1-Imminent:
a) Definition: Any condition that presented as an immediate threat to life or limb requiring immediate interventions to save a life or prevent irreversible damage.
b) Time to treatment: Immediate
c) Presentation example: Unresponsive, intubated, apneic, pulseless

***When a Level 1 condition was identified, the triage process stops, the patient was taken directly to a room and immediate physician intervention was requested.

2. Level 2-Emergent:
a) Definition: Potentially life or limb threatening and could worsen without intervention
b) Time to treatment: Immediate
c) Presentation: High risk situations, new onset confusion, lethargy or disorientation, severe pain or distress, patients requiring two or more resources, HR, RR or Oxygen saturation in the danger zone.

***When a Level 2 condition was identified, the triage process stops, the patient was taken directly to a room and immediate physician intervention was required. ***

Based on review of medical records, ambulance trip report, review of Medical Staff Rules and Regulations, review of policies and procedures, and staff interviews, it was determined that the facility failed to ensure that stabilizing treatment was provided for one (1) (Patient #1) of 20 sampled medical records when Patient #1 arrived to the ED from a skilled nursing facility via ambulance for an evaluation and treatment of a possible emergency medical condition.

Findings included:


A review of the ambulance trip report from Emergency Medical Services (EMS) Provider #4 revealed that EMS had been dispatched to Facility #3 on 4/14/2020 to transport Patient #1 to the ED for complaints of shortness of breath and difficulty breathing. Continued review of the trip report revealed that Patient #1 had tested positive for COVID-19 and had a history of diabetes (disease causing irregular sugar in the blood). Patient #1's vital signs at 10:02 p.m. included: heart rate-84 beats per minute (normal 60 to 100 beats per minute), respiratory rate- 40 breaths per minute (normal 14 to 20 breaths per minute), blood pressure 110/60 (normal 120/80), pulse oximetry 96 % (the amount of oxygen in the blood). Patient #1 was receiving oxygen by mask at 10 Liters/minute. Patient #1 was transported from Facility #3 at 10:14 p.m. Patient #1's vital signs at 11:45 p.m. were: HR- 82 beats per minute; RR-48 breaths per minute; Sats-94%. Patient remained on 10L/min. oxygen. Review of the Outcome/Disposition notes revealed that Patient #1 was originally going to Facility #1, but EMS crew was advised that they (Facility #1) did not have any available beds. Director FF was notified and advised EMS crew to transport Patient #1 to Facility #2. Continued review of Outcome/Disposition revealed that no changes were noted in Patient #1 during transport and there were no complications during the transport. Patient #1 arrived at Facility #2 at 12:01 a.m. The facility failed to provide stabilizing treatment within its capability as required for patient #1 on 4/14/2020 when he presented to the hospital's ED via ambulance with complaint of shortness of breath/difficulty breathing.

Interviews:

A telephone interview took place with the emergency medical service (EMS) crew (EMS GG, EMS HH) on 4/29/2020 at 9:30 a.m. EMS GG explained that he had been the driver of the ambulance. EMS GG explained that they had been dispatched to Facility #3 (a skilled nursing facility) to pick up Patient #1 and take him to Facility #1's ED. Facility #3 had notified Facility #1 of pending arrival. EMS GG explained that Patient #1 was COVID-19 positive. EMS GG recalled that Facility #1 was called from the ambulance a few minutes from arrival. It took approximately 36 minutes to go from Facility #3 to Facility #1. EMS GG recalled that upon arrival to Facility #1, a 'young lady' probably a registration clerk or tech came out to the truck and instructed crew to 'hold up in the truck' because a room wasn't available. EMS HH recalled that Patient #1 had been deteriorating and was 'critical'. After several minutes, EMS GG recalled that he went back to the ED door and spoke with the same staff member. The facility staff member told EMS GG that a COVID-19 positive patient had just been transferred out of an ED room and the room needed to be cleaned. EMS GG recalled telling the facility staff that Patient #1 was also COVID-19 positive and there was no need to clean the room. EMS GG recalled telling the staff member that Patient #1 was deteriorating. The staff member told EMS GG that she was going to call her 'supervisor'. EMS GG explained that he thought she was referring to the House Supervisor. EMS GG went back to the door after a few minutes and was greeted by the House Supervisor. House Supervisor told EMS GG that the facility 'could not turn them away' but there wasn't a bed available. EMS GG explained that at this point, he called Director FF and was instructed to take Patient #1 to Facility #2. EMS HH estimated that their total time at Facility #1 had been a little over 30 minutes.

A telephone interview with Emergency Department Physician (MD) EE took place on 4/29/2020 at 7:45 a.m. MD EE recalled the incident with Patient #1. MD EE explained that to the best of her recollection, the ED had been busy and there were two RN's working. When the ambulance arrived with Patient #1, the ED was full and already had two COVID-19 patients. MD EE recalled having a few minutes lead time prior to Patient #1's arrival and Patient #1 was one of two COVID-19 patients en route. MD EE recalled that the nurses were overwhelmed and were 'doing the best they could'. MD EE explained that the EMT's had been informed that a room needed to be cleaned and it would be a few minutes. MD EE recalled that one of the EMT's appeared 'ancy', was 'pacing and sighing'. After approximately ten minutes, one of the EMT's approached the door to the ED and asked for the status. The EMT told MD EE that they had bypassed two hospitals already because the hospitals were on 'COVID diversion'. MD EE asked the EMT's the status of Patient #1 and was told that he was 'holding his own'. MD EE did not recall specific vital signs. MD EE recalled that she explained to the EMT's that she did not have a room for Patient #1 now and it was not safe to have the patient wait in the hallway. MD EE recalled that she told the EMT that she was not turning the patient away, they just needed a few minutes to get the room cleaned. MD EE recalled telling the EMT 'please don't leave'. MD EE explained that if the EMT's had expressed concern about Patient #1's condition, she would have donned (put on) personal protective equipment (PPE) (supplies used to prevent the spread of infection such as gloves, masks, gowns) and got into the ambulance to assess the patient. After a few minutes, MD EE recalled that another ambulance arrived and when she went to the door to ask the second ambulance to wait, she noted that the ambulance with Patient #1 was gone. The crew of the second ambulance informed MD EE that the ambulance with Patient #1 said they were going to another hospital. MD EE recalled that on the evening of the incident, the ICU was full, and the overflow beds were full.

A phone interview with ED Registered Nurse (RN) II took place 4/28/2020 at 6:45 p.m. RN II recalled the incident with Patient #1. RN II recalled that when the ambulance arrived with Patient #1, there was a patient in the ED's only negative pressure room. RN II instructed the receptionist to inform the EMT's that a patient needed to be transported to ICU, then that room needed cleaning before the patient could be brought into the ED. RN II recalled that she transported a patient to the ICU and returned to the ED. In the meantime, someone had called to get the negative pressure room cleaned. EMT came to ambulance door to inquire about room status and informed ED staff that Patient #1 'was not doing good'. MD EE had overheard this conversation and went out to speak to the EMT's. MD EE informed the EMT's that 'they (Facility #1) cannot refuse patient' but they needed to get a room. RN II recalled that she returned outside to help transport Patient #1 inside and the ambulance was gone. RN II explained that she tried to locate the EMT's and Patient #1 and was informed that the EMT's decided to take Patient #1 to Facility #2. RN II was not sure if the ED had been aware that Patient #1 was en route.

Following the entrance conference on 4/27/2020 at 2:00 p.m., an interview with VP AA took place via phone. VP AA explained that the facility had been made aware of a potential EMTALA violation and had conducted a thorough investigation. VP AA explained that at the time of the incident, six of six ED beds were occupied, all ICU beds were occupied, and all COVID-19 overflow designated beds were full. VP AA recalled that she was the administrator on-call and received a call from an ED nurse regarding a patient from a nursing home who was likely COVID-19 positive. The patient had arrived and remained in the ambulance. The ED had one available bed that needed to be cleaned. VP AA instructed the staff member to have the ED room terminally cleaned and ask the EMS to care for the patient in the ambulance until the bed was available. VP AA explained that there was not 'a safe place for the patient to land' when the ambulance arrived but that the room was going to be cleaned. VP AA explained that the ED charge nurse had communicated with the EMS staff. An ED physician (MD EE) obtained vital signs and medical history information from the EMTs. VP AA explained that the ambulance drove off without speaking to the ED staff. VP AA estimated that the ambulance had waited approximately 30 minutes. VP AA explained that the facility staff never told the EMS staff that the facility could not accept the patient.

A phone interview with EMS Director (Director) FF took place on 4/27/2020 at 2:45 p.m. Director FF recalled that he had been informed approximately one day prior to this event that Facility #1 would accept COVID-19 patients and this information was conveyed to all EMS staff. Patient #1 was the first patient from Facility #3 with suspected COVID-19 that his EMS service had transported, and that Patient #1 was in critical condition during transport. Director FF recalled that he spoke with staff from Facility #1 as well as staff from the facility that Patient #1 was eventually admitted to (Facility #2). Director FF explained that he had also talked with the two EMS crew members that transported Patient #1. Upon arrival to Facility #1, EMS GG was greeted by an ED registration clerk and informed that they had to 'find a room' and to 'stay in the truck'. Director FF further explained that at some point later, a House Supervisor informed EMS GG that the facility 'didn't have a room for this patient'. EMS GG notified Director FF and Director FF recalled that he directed EMS GG to transport Patient #1 to Facility #2. Director FF explained that the EMS crew was not told to wait on a room to be cleaned. Director FF explained that EMS GG reported seeing open ED beds in Facility #1. Director FF explained that Facility #2 was approximately 36 miles from Facility #1. Director FF stated that per EMS GG and EMS HH, a physician did not inquire about Patient #1, only an unidentified House Supervisor. Director FF explained that Patient #1 expired soon after arrival to Facility #2.

Medical Staff Rules and Regulations

A review of the facility's document #21001 titled 'Medical Staff Rules and Regulations' last revised 06/2019 revealed:
VII. Emergency Services
A physician was available 24 hours per day to render emergency patient care. An appropriate ED log was kept, listing all persons who presented or was brought to the ED for treatment or care and a notation about treatment or transfer.

Hospitalist and specialty physicians were available for on-call coverage of the ED. Specific duties were established by the Medical Executive Committee (MEC) as necessary and appropriate to sustain and insure the adequacy of physician coverage for the department. The on-call physician must be able to respond by telephone within 20 minutes or must be physically present within 30 minutes of contact, if requested by the ED physician, or staff.

The hospital must provide an appropriate medical screening exam (MSE) within the capability of the hospital's ED including ancillary services routinely available to the dedicated ED (DED), to determine whether or not an emergency medical condition (EMC) existed (i) to any individual, including a pregnant woman having contractions, who requested an examination, (ii) an individual who had such a request made on his or her behalf, or (iii) an individual whom a prudent layperson observer would conclude from the individual's appearance or behavior was in need of a MSE. An MSE was provided to determine whether the individual was experiencing an EMC.
Only the following individuals could perform an MSE in the ED:
1. A qualified physician with appropriate privileges


Policies and Procedures

A review of the facility's policy number ADM 557, titled 'EMTALA- Emergency Medical Treatment and Active Labor Act', effective 1/31/2001, last reviewed 05/2017, revealed that the purpose of the policy was to comply with EMTALA regulations. Further review revealed that the policy applied to all employees and medical staff members.
Continued review of the policy revealed that if any individual (regardless of Medicare eligibility or ability to pay) came alone or with another person to the ED and a request was made on the individual's behalf for an examination or treatment of a medical condition by a qualified medical person, or a prudent layperson observer believed that the individual presented with an EMC, the hospital provided an appropriate MSE within the capability of the ED including ancillary services routinely available to the ED to determine whether or not an EMC existed.

Definitions included:
Capacity- the ability of the hospital to accommodate the individual requesting the examination or treatment of the transferred individual. Capacity encompassed things such as number and availability of qualified staff, beds and equipment and the hospital's past practices of accommodation of additional patients in excess of occupancy limits.
Comes to the ED- with respect to an individual who requested an examination or treatment, that the individual was on hospital property. Property meant the entire main hospital campus, including the parking lot, sidewalk, and driveway as well as any organization that was located off the main campus but was a department of the hospital. Property included ambulances owned and operated by the hospital, even if it was not on hospital grounds.

Emergency Medical Condition (EMC)- a medical condition manifested by acute symptoms of enough severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
A. Placing the health of the individual in serious jeopardy;
B. Serious impairment to bodily functions;
C. Serious dysfunction of any bodily organ or part

Stabilize- with respect to EMC, no material deterioration of the condition was likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility. Stable for transfer did not require final resolution of the EMC.

If an individual (regardless of Medicare benefits) came to a hospital and the hospital determined that the individual had an EMC, the hospital provided either:
A. Within the capabilities of the staff and facilities available at the hospital, for medical examination and treatment as required to stabilize the medical condition;
B. For transfer of the individual to another medical facility in accordance.
Delay in examination or treatment- the hospital did not delay an appropriate MSE or further medical examination and treatment in order to inquire about the individual's method of payment or insurance.

Continued review of the policy revealed that regarding transfer to another medical facility, transfer was only appropriate in cases in which:
A. The transferring hospital provided medical treatment within its capacity that minimized the risks to the individual's health.
B. The receiving facility had available space and qualified personnel for the treatment of the individual and agreed to accept transfer to provide appropriate medical treatment.
C. The transferring hospital sent the receiving hospital all available medical records (or copies) related to the EMC that the individual presented.
D. The transfer was affected through qualified personnel and transportation equipment, such as required, including the use of necessary and medically appropriate life support measures during the transfer.