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On the days of the EMTALA (Emergency Medical Treatment And Labor Act) investigation based on observations, patient record reviews, interviews, review of the hospital's policies and procedures, the hospital failed to ensure that a patient was registered on the hospital's central log upon presentation to the hospital, failed to ensure the hospital created and maintained a medical chart for the patient upon presentation to the hospital, and failed to ensure a medical screening examination was provided to determine whether or not an emergency medical condition existed for an individual when a request was made on his/her behalf and failed to ensure stabilizing treatment for a patient presenting with abnormal changes on the Electrocardiogram performed by the Emergency Services Crew, and failed to ensure an appropriate transfer process for 1 (Patient #15) of 21 sampled patients who presented to the hospital's emergency department.


The findings are:


Cross Reference to A 2402: The hospital failed to post a sign in places likely to be noticed by all individuals entering the emergency departments specifying the rights of individuals with respect to examination and treatment of emergency medical conditions and women in labor.

Cross Reference to A 2403: The hospital's emergency department failed to ensure that when a patient presented to its emergency department for care that a medical chart for the patient was created for 1 of 21 patients presenting to the hospital's emergency department for care. (Patient 15)

Cross Reference to A 2405: The hospital failed to ensure the central log was completed with the required information for patients for (Patient 15 and Patient 23)

Cross Reference to A 2409: The hospital failed to ensure that patients presenting to its emergency department requiring transfer to another facility has to meet the standards and its own policies and procedures required for an appropriate transfer for 1 of 1 patient who presented to the hospital's emergency department and was transferred to another hospital. (Patient 15)

Based on observations, interview, and review of the hospital's emergency department policy and procedure, the hospital failed to post a sign in places likely to be noticed by all individuals entering the emergency departments specifying the rights of individuals with respect to examination and treatment of emergency medical conditions and women in labor.


The findings are:

Observations during a tour of the hospital's emergency department at 4:30 p.m. on 11/27/2017 revealed there was no sign specifying patients rights at the entrance where patients arrive by Emergency Medical Services (EMS) to the emergency room (ER). During an interview with Registered Nurse(RN) 2 at 5:15 p.m. on 11/27/2017, RN 2 verified there was no sign posted at the EMS entrance for individuals entering the emergency department, and stated, "Cabinets and shelves had been put up where the sign use to be."

Hospital policy, titled, "EMTALA(Emergency Medical Treatment And Labor Act) Policy", reads, "The Hospital shall post conspicuously....all areas in which individuals routinely present for treatment...signs...that specify rights of an individual under the law with respect to examination and treatment for emergency medical conditions and of woman who are pregnant and having contractions".

Based on record reviews and interviews, the hospital's emergency department failed to ensure that when a patient presented to its emergency department for care that a medical chart for the patient was created for 1 of 21 patients presenting to the hospital's emergency department for care. (Patient 15)


The findings are:


On 11/27/2017 at 4:10 p.m., review of Patient 15's chart revealed Patient 15 presented to the hospital's emergency department via Emergency Transport Services (EMS) for complaint of shoulder pain. When Patient 15's chart was requested for review, the hospital's Compliance Officer stated, "There was no medical chart made for the patient on the evening(11/06/2017) that the patient arrived to the hospital. The (Patient 15) chart was made this morning (11/27/2017)." When the medical chart created for Patient 15 on 11/27/2017 was requested and reviewed for care and services, the patient's chart revealed the chart was created on 11/27/2017 at 11:25 a.m. and included a note authenticated by the emergency department's physician(Physician 1) on 11/6/2017 at 1930 (07:30 p.m.)

On 11/28/17 from 2:25 p.m. to 2:40 p.m., an interview was conducted with Registered Nurse(RN) 3 and the night shift ED Charge Nurse was present. RN 3 stated, "I was not aware of the patient coming in that night(11/06/2017) until it was all said and done. I remember hearing the radio traffic, but I'm not sure who took the report and assigned the room to the patient. I was up front in the triage and I do remember both Registrars were up front too because it was a little busy. By the time I got to the back and asked the doctor about the patient, the doctor told me that the patient had been taken to the other hospital and a medical chart was never made for the patient. He told me the patient was never taken off of the EMS's(Emergency Medical Services) stretcher and the physician reviewed the EKG(Electrocardiogram) that the medic had gotten on the patient. There was not an EKG done in our ER. It was then decided to transfer the patient to the other hospital. "

In an interview with Hospital #1's Compliance Officer, the Compliance Officer stated, "There was no chart made for the patient on the evening the patient arrived to our hospital(11/06/2017). The (patient's )chart was made this morning(11/27/2017)." Further review of Patient 15's chart revealed the patient's record was in fact created on 11/27/17 at 11:25 a.m., and there was a progress note written by Emergency Department Physician 1 dated 11/6/17 at 1930(7:30 p.m.). There was no other documentation in the patient's chart.

On 11/28/17 from 1:00 to 1:40 p.m., an interview with the Director of the hospital's emergency department was conducted. The ED Director stated, "When EMS is bringing a patient to our ED, either a nurse or the doctor will take the radio report and will typically assign them(patient) a room. That night (11/06/2017), this patient was assigned to go to room 5, which is to the left, right inside the EMS bay. No one can recall who took the actual radio report. Since the patient was never registered, the patient's information fell off the tracker board.

Hospital policy and procedure, titled, Chart for the Emergency Department, originally adopted 11/04 and last revised 4/14, reads, "Purpose: All patients presenting for care will have their care documented on an ED chart. ED staff will complete charts accurately.
Policy statement: The Emergency department chart will be a complete reflection of the care and services provided to the patient while in the ED at ....Hospital.
Procedure:
1. The patient's chart will be initiated on arrival to the ED either by registration or by the emergency room nurse. T sheets will be utilized by nursing in cases of downtime and can be obtained by contacting the Nursing Supervisor.
2. Patient's will be assessed by a Registered Nurse and will have a Medical Screening Exam (MSE) initiated by the MD (Medical Doctor), before any attempt is made to obtain billing and/or insurance information from the patient. 3. Patient information obtained by registration on arrival includes:
a. Name - legal full name with middle initial
b. Social Security number
c. Date of birth
d. Other names used by patient
e. Chief complaint
f. Mode of arrival
g. Emergency contacts.

Based on review of the hospital's emergency department central log, interview, and review of the hospital's emergency department's policies, the hospital failed to ensure the central log was completed with the required information for patients for (Patient 15 and Patient 23)


The findings are:


On 11/27/17 at 4:10 p.m., review of the hospital's ED Central Log revealed Patient 15 who was identified in the allegation was not listed on the hospital's emergency department log when the patient presented to the hospital's emergency department on November 6, 2017. In an interview with the hospital's Compliance Officer, the Compliance Officer stated, "When the patient presented to the emergency department on November 6, 2017, there was no patient chart created for the patient on the evening the patient arrived to our hospital. The patient's chart was created this morning, and the patient's visit was added to the hospital's emergency department central log at 11:16 a.m. on 11//27/17. "




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On 10/29/2017 at 10:00 a.m., review of the hospital's emergency department (ED) central log revealed Patient 23 presented to the hospital's ED on 11/3/2017, but the patient's disposition was blank.

The hospital's policy and procedure, titled, "EMTALA", reads, ...." C. 1. The Hospital must maintain a central log of individuals who "come to the emergency department," and include in such log whether such individuals refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE....".

Hospital policy and procedure, titled, Central Log, reads, "Purpose: To maintain a permanent, easily, accessible, computerized record of all patients seen in the Emergency Department.
Policy Statement: The Central Log will be used to maintain statistical records of the number of patients seen, types of illnesses/injuries and final disposition in the Emergency department.
Procedure:
2. The register will contain at least the following information:
a. Identification of patient, including E.D. record number, name, age, and sex
b. Date and Time of arrival
c. Mode of transportation
d. Nature of complaint
e. Time of departure
f. Disposition

Based on review of patient records, interviews, and review of the hospital's policies, the hospital failed to ensure that patients presenting to its emergency department requiring transfer to another facility has to meet the standards and its own policies and procedures required for an appropriate transfer for 1 of 1 patient who presented to the hospital's emergency department and was transferred to another hospital. (Patient 15)


The findings are:


Hospital EMTALA Policy
Transfer of Emergency Department Patient, originally adopted 11/04 and last reviewed 5/11, reads,
"Purpose: To ensure an expedient and safe transport of patients requiring transfer from Coastal Carolina Hospital to other facilities under the EMTALA guidelines.
Policy Statement: Patients occasionally require treatment at other facilities for various. The Emergency Department will be capable of instituting essential lifesaving measures and implementing emergency procedures that will minimize further compromise of the condition of any infant, child, or adult being transported.
Procedures:
1. Unless extenuating circumstances are documented in the patients' record, no patient will be arbitrarily transferred to another hospital if the patient is initially seen here and this hospital has the means of providing adequate care. Patients will be transferred to other facilities for the following reasons:
1. Special medical/surgical needs of the patient in which .....Hospital is not able to meet the specific needs (example: specialized diagnostic studies and/or surgical procedures, geographical preference of the patient, etc.)
2. Bed availability- as when .....Hospital is unable to provide an appropriate bed (example: no empty beds in the hospital or no available bed in the ICU/CCU/PCU or other specialty areas for a patient requiring the level and/or specialty of care).
3. The patient or his agent requested the transfer.

2. The patient willnot be transferred until the receiving organization has consented to accept the patient and the patient is considered sufficiently stabilized for transport.

3. Responsibility for the patient during transfer will be established with the patient or his agent when the consent to transfer form is signed. All pertinent medical information will accompany the patient being transferred wither personally and/or by fax.

4. A physician must order the transfer and the nurse and physician will complete and sign the appropriate forms as indicated by the specific type of transfer(see attached forms):
a. Nursing Transfer Information Sheet (Form #1)
b. Physician Transfer Summary (Form #2)
c. Physician Certification/ Patient Transfer Acknowledgement(Form #3)
d. Patient refusal of transfer (Form#4).....
5. The patient being transferred or his representative must sign all forms used as appropriate to the circumstances surrounding the transfer.
6. The transferring physician will communicate the following information to the RN (Registered Nurse) coordinating the transfer.
1. The name of the facility to which the patient is being transferred.
2. The town in which that facility is located.
3. The name of the accepting physician.
4. The mode of transport (i.e. ground ambulance, air ambulance, private auto, commercial plan, etc.).
5. The specific time from in which the transfer is to occur.
6. The type of personnel needed during the transport.
7. The portions of the medical record to be sent with the patient.
7. The physician/RN must sign the EMS Inter- facility Transport Form indicating the medications and IV's to be continued during transport.
8. The registered nurse caring for the patient will contact the nursing supervisor and communicate the above information as ordered by the physician. ....

On 11/27/17 at 4:10 p.m., review of the Patient 15's medical record presented by the hospital revealed the hospital created the medical record for Patient 15 on 11/27/2017 although Patient 15 presented to hospital's emergency department on 11/06/2017 via EMS transport for shoulder pain. The only documentation in Patient 15's chart that was created on 11/27/2017 was a progress note dated 11/06/2017 at 07:30 p.m. revealed the physician recorded, "38 y/o (year /old) male obese, sleep apnea, +F.H. Paramedics arrive Pt (Patient) c/o (complained of) R (Right) shoulder pain? EKG STEMI? ST elevation Reciprocal changes. Paramedics offered to transfer to our cath lab facility. In light of benefits to patient, this should be considered an Anginal Equivalent; symptoms and changes on EKG. Medical Screening Exam: Clear lungs CORR S152 NO S3 Abd (Abdomen ) soft, nontender No rebound Ext. supple, no edema N/V (neuro/vascular) intact Neuro intact Airways - patent and stable To appropriate facility within our system with ST elevation/Reciprocal changes. Should have initially been directed to HH (Hospital 2)". There was no other documentation in Patient 15's chart for the patient's presentation to the hospital's emergency department on 11/6/2017.

On 11/28/17 from 3:40 to 3:50 p.m., a telephone interview was conducted with Paramedic 1 that transported Patient 15 to the hospital's Emergency Department on 11/6/17. Paramedic 1 reported that when the EMS unit arrived, Patient 15 complained of right shoulder pain, appeared a bit Tachypnea, but denied chest pain. Paramedic 1 stated, "I was thinking he either had a PE(Pulmonary Embolus) or was having an MI(Myocardial Infarction). I felt as though he needed a Heparin drip or Nitroglycerin started, so I took him to the closest hospital which is literally right across the street. I took him there for definitive care, but I knew he should have gone to ..... Hospital B. I placed bilateral IV's(Intravenous), one in each arm, and I completed the 12-lead EKG(Electrocardiogram - a machine to measure the electrical activity of the heart). I had him to .....(Hospital 1) in a matter of minutes, and I sat him down in the first room on the left." When asked what was meant by "sitting him down", Paramedic 1 stated, "The patient was taken off of the EMS stretcher and placed on the hospital bed." Paramedic 1 stated, "I spoke with Dr. .... (ED Physician 1) about the patient and showed him my 12-lead, and he agreed there were subtle V3 and V4 changes and elevation. The doctor recommended at that time that we need to transport the patient to .....(Hospital 2). The physician did not give me any orders for Aspirin, Nitroglycerin, or Heparin. At that point, I specifically asked the doctor if he was concerned at all about an EMTALA, and he said to go ahead and take the patient. My partner and I loaded the patient back onto our stretcher and transported the patient to .....(Hospital 2). I feel Dr. .....(ED Physician 1) was legitimately concerned about the patient."

On 11/28/17 from 3:00 to 3:20 p.m., in an interview with ED Physician 1, he/she revealed, "When EMS arrived with the patient, he(the patient) did not appear to be in distress. He was a middle-aged guy who had right shoulder pain. He wasn't the poster child for angina equivalent, and he didn't even complain of chest pain. Typically for a MSE, serial EKG's are critical, but I had already decided he needed to go to the cath lab for subtle EKG changes. The paramedic said he would take care of the patient, and he took the patient to the other hospital. I had all intents of calling the other hospital, but I got busy with things coming at me, and I remembered it at the end of the night. The call(to the admitting hospital - Hospital 2) was never made. I did, however, write a progress note later that night and had kept it on my desk in case it was needed. I gave it to the ED Director the next day." ED Physician 1 revealed, "When EMS arrived with the patient, he did not appear to be in distress. He was a middle-aged guy who had right shoulder pain. He wasn't the poster child for angina equivalent, and he didn't even complain of chest pain. Typically for a MSE, serial EKG's are critical, but I had already decided he needed to go to the cath lab for subtle EKG changes. I guess I did do the MSE, but it just wasn't put on paper in a medical record."

On 11/28/17 from 2:25 to 2:40 p.m., an interview with RN 3, and the night ED Charge Nurse was conducted. RN 3 stated, "I was not aware of the patient coming in that night until it was all said and done. I remember hearing the radio traffic, but I'm not sure who took the report and assigned the room. I was up front in triage and I do remember both Registrars were up front because it was a little busy. By the time I got to the back and asked the doctor about the patient, I was told the patient had been taken to the other hospital and a chart was never made. He(ED Physician 1) told me the patient was never taken off of the EMS stretcher and the EKG that the medic had gotten on the patient was reviewed. There was not an EKG done in our ER. It was decided to transfer the patient to ..... hospital (Hospital 2)." RN 3 stated, "The transfer process is to make sure an MD has screened the patient, drawn labs, get EKG's, and then the potential receiving hospital is called, the transfer packet is made up, and then the secretary gets the receiving physician on the phone so the sending doctor can give a report, and then the patient is sent usually by ambulance if necessary."

In an interview with Hospital #1's Compliance Officer, the Compliance Officer stated, "There was no chart made on the evening the patient arrived to our hospital. The chart was made this morning." Further review of Patient 15's chart revealed the record was in fact created on 11/27/17 at 11:25 a.m., and there was a progress note written by the Emergency Department Physician 1 on 11/6/17 at 1930(7:30 p.m.).

There was documentation to support that the hospital followed its own policies and procedures to effect an appropriate transfer for Patient 15 who was sent to another hospital on 11/06/2017 after presenting to to Hospital 1's emergency department.