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1. Based medical reviews and policies and procedures the facility failed to ensure that an appropriate medical screening examination was provided to the individual's presenting signs and symptoms that was within the capability and capacity of the hospital's emergency department, including ancillary services routinely available to the emergency department for 1 (#1) of 20 sampled patients medical records reviewed. Refer to findings in tag A-246.



2. Based on review of medical records, transfer center recordings, transfer center log, bed census reports, policies and procedures and staff interviews, the facility failed to accept the transfer from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who required such specialized services (pulmonologist) capabilities
or facilities if the receiving hospital has the capacity to treat 1 (#18) of twenty (#20) patients sampled patients record reviewed. Refer to findings in Tag A-2411.

Based medical reviews and policies and procedures the facility failed to ensure that an appropriate medical screening examination was provided to the individual ' s presenting signs and symptoms that was within the capability and capacity of the hospital ' s emergency department, including ancillary services routinely available to the emergency department for 1 (#1) of 20 sampled patients medical records reviewed.

Findings:


The hospital ' s Policy and procedure titled " EMTALA -Georgia Medical Screening Examination and Stabilization Policy " Policy number PolicyStatID : 806746, last revised 03/3013, specified in part, " Statement of Purpose: To establish guidelines for providing appropriate medical screening examination (MSE) ...Policy: An EMTALA is triggered when an individual comes to a dedicated emergency department( " DED " ) ...Procedure: ...1. When an MSE is required: A hospital must provide an appropriate MSE within the capability of the hospital ' s emergency department including ancillary services routinely available to the DED, to determine whether or an EMC exists.(i)to any individuals ...who requires such an examination; (ii)an individual who has such a request made on h s or her behalf; or ...a The individual comes to the dedicated emergency department of a hospital and a request is made by the individual ...for examination or treatment for a medical condition, including where: i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition .....Extent of MSE a. Determine if an EMC exists ...b. Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual ' s presenting signs and symptoms and the capability and capacity of the hospital. "

The hospital s policy and procedure titled, "Standards of Triage in the Emergency Department" Original Date 12/96 revised Date: 10/15 was reviewed. The policy specified in part, " Purpose: To provide assessment/reassessment guidelines for initial evaluation, continued monitoring, and/or changes in patient acuity levels according to severity of illness or injury ...Guidelines: All patients presenting to the emergency department room are assessed rapidly to determine the severity of the presenting chief complaint. Acuity is assigned to each patient during the rapid initial assessment ...Definitions: Triage Assessment-The dynamic process of sorting, prioritizing, and assessing the patient is performed by a qualified RN at the time of presentation and before registration ...C. The triage nurse will determine the status of the patient based on the following criteria ...b. Level 2 Triage Category: may include, but not limited to: ...CN (Central Nervous System) Serve headache with high blood pressure, ...altered LOC (Level of Conscious) ... headache ... c. Level 3 Triage Category ... CNS- Headache- severe (mild-moderate distress, pain scale 8-10/10), no LOC vomiting.... II Assessments: ... C. Focused Chief Complaint Assessment/Primary Assessment: 1.) Ongoing Vital signs 2) Ongoing pain Assessment 3) Data pertinent to the clinical presentation/chief complaint 4) documentation of any other complaints 5) Nurse Notes 6) Medications, treatments, and interventions performed on the patient ...III Reassessments/Vital Signs Guidelines A.) Reassessments/Vital Signs guidelines after initiation of the medical screening exam (MSE) are performed by nursing according to acuity ...3. Level (3) Urgent will be performed and documented every hour and more frequently if condition warrants. "

The facilities Policy and Procedure titled "Procedure for Emergency Registration & Admission and ESP Program" reference Number: PARA.PP.PTAC.005 Effective 01/01/2014 was reviewed. The policy specified in part, "Emergency Department Medical Screening Exam for Qualified Medical Person...The non-emergent patient by the Qualified Medical Person(QMP)...Non-Emergent patients who do not pay the required QMP maximum deposit at the time of service may elect to leave the ED to receive care from a family physician or local community resource...Non-emergent patients who pay the required QMP maximum deposit are treated accordingly."

The medical record for patient #1 was reviewed. Review of the form titled "Emergency Patient Record," revealed that patient #1 presented to the facility on 12/13/2015 at 9:18 p.m. Documentation by the Emergency Department (ED) Nurse specified Patient#1 stated and chief complaint was listed as "Ingestion." Patient #1 ' s ESI (Emergency Severity Index) was listed as " 3/Urgent." Further documentation by the ED nurse revealed in part in the section titled, "Assessments " revealed in part, "Subjective Assessments: " Pt. (patient) states a friend gave her what she thought was a goodie powder and a short time later she states she blacked out and could not remember things." The patient ' s Vital signs were listed as: Blood Pressure 180/110 (normal blood Pressure 120/80); Temperature: 98.0; Respirations: 18; and Oxygen saturation (measurement of oxygen the blood is carrying as a percentage)99%. Documentation by the ED nurse revealed in part,"... 2158 (9:58 PM) Patient Tearful, had headache, states asked for goodie powder, given by roommate sister's boyfriend, Patient Anxious, asked to repeat tem (temperature), the same. C/O (complain/of) neck pain, headache, face, left shoulder, states sinus headache before med (medication). Believes she was given something else. . 10:00 p.m. ... " Presenting Signs and Symptoms: HEADACHE, FACE PAIN, " FEEL FUNNY " ....2205 (10:05 PM) {ED physician name] stated has seen patient, no assault, sexual assault, ...Patient still crying and wants something for pain 2214 (10:14 PM) Patient vomited small amt (amount), food , not paying to be seen, asking for Tylenol for pain, ambulates well, steady gait, escorted to friends room. 22:15 PM (10:15 PM) ...Pain Scale: Numeric Intensity: 7(Pain scale 0-10 with 10 being the highest) ...physically leaves the ED ...22: 35 (10:35 PM) " The ED physician documented in part, " HPI (History of Present Illness) ... Context- related history: Took medication then left. Did drink some alcohol (1 shot) ...Phy (Physical) Exam (examination)- General Med ...General : Alert, oriented X3, cooperative, distress (Mild distress) ...Disposition- ...Clinical Impression ...Substance intoxication. "

Review of the form in the medical record entitled, "Doctor's Hospital MSE (Medical Screening Determination) dated 12/13/2015 revealed in part, QMP (Qualified Medical Personnel) " ____MEDICAL SCREENING COMPLETE: Immediate medical attention not necessary, no acute symptoms of sufficient severity ....no immediate serious impairment or dysfunction of body functions or organs is reasonably expected ... Triage Nurse____ patient received medical screening exam. No emergency medical condition found per qualified medical personnel. Patient declined further medical treatment at the facility and has left. Registration provided a listing of community resources to the patient for follow-up care for the patient ' s non-emergent medical condition." Patient #1 left Doctor ' s Hospital and went to Hospital B, another acute care hospital, where the patient was appropriately treated and discharged.

The hospital failed to ensure that an appropriate medical screening examination was provided for patient #1 on 12/13/2015 that was within the capability and capacity of the hospital's ED. This was evidenced by the based on the patient's inability to pay for further treatment to include ancillary services (urine drug screen, laboratory test routinely available related to the patients presenting signs of ingestion of unknown powdery substance. The facility triaged patient #1 as a level 3 (Urgent). According to the facility's policy, levels four and five are non-emergent patient. According to the patient ' s complaints of ingestion of an unknown substance as well as loss of consciousness, there was no documentation in the medical record to indicate the patients VS were taken every hour, despite an elevated blood pressure initially, and no vital signs were completed upon discharge from the ED. The patients presenting signs and symptoms of ingestion of an unknown substance as well as reported loss of consciousness the patient should have been triaged as a level 2 as stated in the facility ' s triage policy. There was no re assessments of the patient complaint of pain and no treatment nor interventions were provided for patient #1 on 12/13/2015.

Based on review of medical records, transfer center recordings, transfer center log, bed census reports, policies and procedures and staff interviews, the facility failed to accept the transfer from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who required such specialized services capabilities
or facilities if the receiving hospital has the capacity to treat 1 (#18) of twenty (#20) patients sampled patients medical records reviewed.


Findings include:


Review of PolicyStat 807019, EMTALA- Transfer Policy, approved and revised 03/2013, revealed that a hospital with specialized capabilities or facilities (including, but not limited to burn units, shock-trauma units, neonatal intensive care units or with respect to rural areas, regional referral centers) shall accept from a transferring hospital an appropriate transfer of an individual with an EMC who requires specialized capabilities if the receiving hospital has the capacity to treat the individual. The transferring hospital must be within the boundaries of the United States.


Review of recorded Transfer Center telephone calls from 12/13/15 revealed that physician (MD #9) was contacted by another facility's ER physician on 12/13/15 to request transfer of an 84-year-old patient (#18) with high blood sugar of 696 - (normal range is less than 140 two [2] hours after eating), pneumonia and high blood sodium of 154 (normal range is 135-145) to this facility. After the ER physician provided details on the patient's condition and the treatment rendered, MD #9 (on call physician at Doctors Hospital ) could be heard stating "can't you handle the glucose?" and that he/she did not see a reason for him/her to admit the patient, and that he/she thought the patient could be managed over there. MD #9 could be heard further making treatment suggestions and instructed the ER MD to telephone him/her back if the patient did not improve. The MD further stated that he/she was not going to do anything differently than what the ER MD was doing over there and that was the only reason he/she did not want to take the patient.

Further review of the 12/13/15 Transfer Center telephone calls revealed that the transfer center contacted Doctors Hospital Bed Control Supervisor to advise of the physician's transfer request denial. The Bed Control Supervisor could be heard stating "well, that's what we have to go with".

Further review of the 12/13/15 Transfer Center telephone calls revealed that the revealed that the transfer center contacted Doctors Hospital facility Administrator on Call to advise of the physician's transfer request denial. After the transfer center provided details of the situation, the Administrator on call could be heard asking "how did they take it?" After the transfer center's response, the Administrator on call stated that he/she thought "that sounds appropriate", and "okay, I agree" (with the denial).



The Transfer Center Pre-Admit Sheet dated 12/13/2015 for patient #18 was reviewed. The patient ' s diagnosis #1 was listed as pneumonia, hypernatremia (Elevated Sodium level); History of Present illness: ICU (Intensive Care Unit) Bed unresponsive. Review revealed that the Emergency Department physician from Hospital B called on 12/15/2015 at 10:34 " Spoke to (MD NAME) - " LOOKING TO TRANSFER TO HOSPITALIST. " The section of this form titled " Accepting Services and Provider Service: Pulmonary Critical Care Medicine ...Physician ' s Name (#9) ...Acceptance Status: Denied. Date and time of decision: 12//134/2015 11:04 Explanation: PHYSICIAN REFUSAL...Notes: ...12/13/2015 11:04 DR TO DR-84 YO (year old) NURSING HOME PATIENT HAS HYPERGLYCEMIA IS 698 ON ARRIVAL HYPERNATREMIC IS DNR (Do not resuscitate) IS UNRESPONSIVE ON FEEDING TUBE. PT COULD BE MANAGED OVER THERE HAS PNA (pneumonia), STATED ANTIBIOTICS DOES NOT REQUIRE ANY DIFFERENT CARE THAN ALREADY BEING DONE ...12/13/2015 11:09:CALLED LEFT MESSAGE FOR AOC (administrator on call) ...on denial of patient ...Notes: 12/13/2015 10:46 (House Supervisor) ...ICU GOOD ...12/1/3/2015 11:13:CALLED LEFT MESSAGE-FOR AOC ...ON DENIAL OF PATIENT AND CALLED HOUSE SUPERVISOR. House Supervisor AND ADVISED OF DENIAL OF PT (patient) WHO STATED WOULD STAND BY DRS (doctors) DECISION ...12/13/2015 11:39 AOC ...CALLED BACK. I ADVISED HER OF DENIAL AND THE DRS RESPONSES SHE STATED SHE AGREED WITH DECISION. PLACEMENT ...Placement ... Notes 12/13/2015 10:55: CHECKED ICU BEDS -OK. "

Review of the hospital's bed census for the ICU dated 12/13/2015 revealed the hospital census for the unit was 13. The hospital's ICU Bed capacity is 24.


Interview with the ER Medical Director on 12/30/15 at 10:40 AM in the conference room revealed an acknowledgement of the transfer denial by MD #9 on patient #18. The ER Medical Director explained that MD #9 may not have believed that the patient needed to go to the ICU (Intensive Care Unit) or may not have known that he/she needed to accept the patient, even if the hospitals provided the same level of care. The ER Medical Director stated "if we have a bed, we have to take them." Review of the hospital ' s bed census verified that on 12/13/2015 the hospital had a bed (capacity) to accept patient #18 on 12/13/2015 when the request was made by the ED physician from the referring hospital.

Telephone interview with MD #9 on 12/30/15 at 12:20 PM revealed that he/she recalled the telephone conversation with another facility's ER MD regarding their request to transfer patient #18 to this facility. The MD stated that he/she had not accepted the patient because the patient had pneumonia, high blood sugar, and high sodium, all of which could be managed on a medical floor. MD #9 further explained that the patient had already received antibiotics and intravenous fluids and that he/she would not have consulted with any specialist, such as a pulmonologist or a nephrologist. He/she stated that he/she believed the referring hospital had the capability to provide the necessary services to the patient. MD #9 further stated that he/she had worked as a Hospitalist at this facility for nearly one (1) year, and, believed that he/she had received EMTALA training on hire. Doctors Hospital had the capability to accept patient #18 on 12/13/2015 when the ED physician from Hospital A called and requested a transfer.