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Based on interview, record review and review of the facility's policies and procedures, it was determined the facility failed to ensure compliance with 489.24 relating to its failure to provide a medical screening examination, stabilizing treatment, on-call Physician services and failure to ensure an appropriate transfer.

Based on interview, record review and review of the facility's policies and procedures, internet webpage and Medical Staff By-laws, it was determined the facility failed to provide on-call specialty Physician's services for one (1) of twenty (20) sampled patients (Patient #1) who presented to the facility's Emergency Department (ED) with an emergency medical condition requiring specialized care.

The findings include:

Review of the facility's, "Medical Staff Bylaws", revised May 2011, revealed the basic responsibilities accompanying staff appointment and/or the granting of clinical privileges included participating in the on-call coverage of the emergency services. Per the Bylaws, an "emergency" referred to a condition in which serious or permanent harm might result to a patient, or in which the life of a patient might be in immediate danger, in the event of a delay in administering treatment. Further review of the Bylaws revealed in case of emergency, any medical staff appointee was authorized to do everything possible to save the patient's life or to save the patient from serious harm, to the degree permitted by the appointee's license, but regardless of Department affiliation, staff category or level of privileges. In addition, the Bylaws revealed the practitioner would summon all consultative assistance deemed necessary and arrange for appropriate follow-up.

Review of the facility's policy titled, "System Policy", revised 10/29/09, under the subject titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)" revealed the facility was to have a documented system for providing on-call coverage, so the ED was "prospectively" aware of which Physicians, including specialists and subspecialists, were available to provide screening and treatment necessary to stabilize individuals with emergency medical conditions. Continued review revealed the facility was to establish a process to ensure when a Physician was identified as being "on-call" to the ED for a given specialty, it should be the duty and responsibility of that Physician to assure immediate availability and arrival or response to the ED within a reasonable timeframe.

Review of the facility's policy titled, "Response by Physicians to Emergency Medical Conditions and Emergency Department Patients", dated 08/05/13, revealed the facility's medical staff office would produce a schedule for ED "service call" for each medical specialty category of active Physician staff. Continued review revealed Physicians who took responsibility for the "service call" schedule were required to treat patients at the facility, rather than transfer the patient to another facility for Physician convenience, unless appropriate medical facilities were not available, or in the opinion of the ED Physician there were extenuating circumstances warranting such transfer which were in compliance with the facility's EMTALA policy.

Review of the facility's Physician's orientation education for EMTALA training titled, "Risk Management/Patient Safety Physician, PA, & APRN Guide", revealed the on-call Physician was to respond to a call for assistance from the ED within forty-five (45) minutes of receiving the request for immediate assistance. Continued review revealed the Physician, Physician's Assistant (PA) or Advanced Practice Registered Nurse (APRN) made the decision on which on-call Physician to contact and whether the on-call Physician needed to come to the facility or if a phone consult could be done.

Review of the facility's policy titled, "Emergency Department Treatment Protocols", dated November 2013, revealed the facility's ED "Chest Pain Protocol" stated for a STEMI (segment level elevation Myocardial Infarction, the most dangerous type of heart attack) patient, the protocol included the following: a "STAT 12 Lead EKG" (electrocardiogram); direct hand off to Physician; the ED was to call the "STEMI" Physician "directly on cell phone"; and STAT (immediate) transfer the patient to the cardiac catherization (cath) lab.

Review of the facility's internet webpage revealed the facility's heart attack treatment or " Code AMI protocol " had received multiple quality awards. Continued review revealed the protocols were "built to encourage teamwork on all levels for quality treatment and decreased door-to-procedure time by: accessing an interventional cardiologist and Cath Lab team twenty-four (24) hours a day seven (7) days per week (24/7) with "one-call"; transmitting a digital EKG, from Emergency Medical Services (EMS), a 12-Lead EKG could be digitally sent in seventeen (17) seconds to the cardiologist and emergency department at the facility decreasing time to activation of the Cath Lab team; alerting key personnel including the ED, Cath Lab, and Physicians; and opening the blocked artery within sixty (60) minutes of arrival at the facility or ninety (90) minutes from the patient ' s first medical contact (EMS or referring ED). Further review revealed the facility's goals for cardiac response time were high and exceeded the national standard, and the successes translated into more lives being saved. Per the internet webpage the facility was dedicated to treatment that was rapid and well-coordinated with highly trained professionals from EMS to interventional cardiologists. In addition, review of the internet webpage revealed the facility was the only hospital in Kentucky awarded "GOLD status for Mission Lifeline" heart attack care two (2) years in a row.

Review of the Emergency Medical Services (EMS) "Patient Care Record" for Patient #1 dated 04/04/15 revealed the patient had presented to the EMS station at 11:30 PM, complaining of chest pain and placed on the 12 lead cardiac monitor which showed the patient had a STEMI ( segment level elevation Myocardial Infarction), the most dangerous type of heart attack involving a sudden blockage of one of the three (3) main coronary arteries which supply blood to the heart. Review revealed EMS Paramedics initiated emergency treatment, loaded the patient into the ambulance and transported him/her to the facility's ED and calling report to an ED nurse while enroute. Continued review revealed the ambulance arrived at the facility's ED at 12:06 AM, was unloaded from the ambulance and transported on the stretcher into the ED. Per the "Patient Care Record" the Paramedics were met by a female staff person who told them the ED was on divert for STEMI"s and the Paramedics needed to take the patient "somewhere else". Review revealed the Paramedics returned to the ambulance with Patient #1, loaded the patient back into the ambulance, called report to Facility #2 and transported the patient to there. Further review revealed the ambulance arrived at Facility #2's ED at 12:13 AM where the ambulance was met by ED staff, which included a Cardiologist who confirmed the STEMI. In addition, review revealed the Paramedics with Patient #1 were escorted by the Cardiologist to Facility #2's cardiac cath lab where a team was waiting to perform the cardiac catherization.

Review of Facility #2's medical record for Patient #1 revealed a Discharge Summary dated 04/11/15, which noted the patient had been taken to the cardiac cath lab and diagnosed with blockages of the coronary arteries. Further interview revealed Patient #1 underwent a five (5) vessel coronary artery bypass surgery and on 04/11/15 the patient was discharged home in stable condition.

Review of the facility's ED "Service Call Schedule", the on-call Physician list for April 2015, revealed on 04/04/15, Cardiologist #1's name was listed for Cardiology and STEMI, and Cardiothoracic (CT) Surgeon #1's name was listed for the on-call CT Surgery.

Interview, on 06/30/15 at 2:03 PM and on 07/01/15 at 5:39 PM, with Cardiologist #1 revealed the weekend of 04/03/15 through 04/05/15, there was no CT Surgeon available for "back up" for the cardiac cath lab, as CT Surgeon #1 no longer performed cardiac open heart surgery. She stated as the Cardiology on-call Physician, she had been available by beeper on the night of 04/04/15, when Patient #1 arrived in the ED, and could have taken any STEMI patient directly to the cardiac cath lab to perform catherization. Cardiologist #1 revealed however, she had never been notified of a STEMI patient arriving in the ED the night of 04/04/15, when she was on-call. Cardiologist #1 stated it was very infrequent a patient had to be taken to surgery from the cardiac cath lab; however, she felt patients deserved to have a CT Surgeon available for "back up" if surgery was determined to be necessary. According to Cardiologist #1, she had discussed with the facility's administration, after seeing the April 2015 On-Call Physician's list, her concern of there being "no CT surgeon" available to "back up" the cath lab the weekend of 04/03/15 through 04/05/15. She stated the facility's administration had made an agreement with Facility #2 to provide CT surgery "back up", but if a patient showed up in the ED needing Cardiology services, she or the other Cardiologist who worked 04/03/15 and 04/05/15, were to see the patient. Further interview revealed a "memo" regarding the agreement with Facility #2 had been sent out by the facility's administration which she had seen as it had been printed out and left on her chair or desk.

Review of an electronic mail (e-mail) dated 03/31/15, revealed "please see the attached memo regarding CT Call coverage for April 3-April 6, 2015...". Review of the attached memo dated 03/31/15, signed by the facility's Chief Medical Officer (CMO) and the Executive Director of Physician Services, revealed "Due to unanticipated CT Surgery Physician coverage issues, there will be no in-house cardiac surgery coverage from Friday April 3, 2015, 7:00 a.m. through Monday, April 6, 2015, 7:00 a.m. During this time period" CT Surgeon #1 would be available to "round on patients, see consultations, and receive calls related to the CT Surgery service". Continued review of the attached memo revealed "any emergent cardiac surgery" would be covered collaboratively with Facility #2 and would necessitate patient transfer to Facility #2 to accommodate the surgery. Further review of the attached memo revealed "please call" a phone number listed on the memo to access Facility #2's CT Surgeon on-call and contact the facility's "Clinical House Supervisor" to arrange transport.

Interview, on 07/02/15 at 3:50 PM, with CT Surgeon #1 revealed he normally provided a "back up" role for the facility's on-call list for his CT Surgeon partners. Per interview, he no longer performed open heart surgeries; however, acted as a "first assistant" during those surgeries. He stated he had not performed any open heart surgeries as the "primary" surgeon since 2001. Continued interview revealed for the weekend of 04/03/15 through 04/06/15, he agreed to take the on-call for CT surgery with the agreement he would not do any open heart surgeries. CT Surgeon #1 stated it was his understanding a memo went out and he believed an agreement was made with Facility #2 to perform any open heart surgery procedures. According to CT Surgeon #1, he was not sure of the exact details to ensure CT Surgery was covered that weekend, even for the patients who were admitted to the facility on the floors who might have needed cardiac surgery. However, further interview revealed he thought the process was to transfer any patients who needed heart surgery to Facility #2.

Interview on 06/30/15 at 2:28 PM, with ED Physician #1 revealed he did not recall receiving an e-mail regarding no CT Surgery available 04/03/15 through 04/06/15 at the facility and patients needing to be transferred to Facility #2. He stated the facility's county had an agreement not to go on diversion except in the event of a catastrophe. Continued interview revealed if a patient came through the ED's doors "we have to see them and stabilize the patient". ED Physician #1 stated a patient shouldn't be "sent away" without receiving stabilizing treatment.

Interview, on 07/01/015 at 4:29 PM, with ED Physician #2 revealed he had been verbally told by the ED Physician who was on shift before him, CT Surgery was not available at the facility that weekend, 04/03/15 through 04/06/15. He stated he did not recall receiving an e-mail however related to this. Per interview, the process that weekend would have been to stabilize and transfer any STEMI patients who had shown up since there were no CT Surgeons available. ED Physician #2 revealed he did not recall a STEMI patient presenting to the ED that weekend however.

Interview, on 07/01/15 at 5:22 PM, with the facility's CMO, who signed the memo dated 03/31/15, revealed the facility had not had CT surgery coverage that weekend, 04/03/15 through 04/06/15. Per interview, arrangements were made with Facility #2 to cover CT Surgery for the facility after the Cardiologists had expressed "some discomfort" related to taking patients to the the cardiac catherization (cath) lab without a CT Surgeon onsite for back up. He stated it should be "infrequent" for the facility to have no CT Surgeon to provide back up, but the facility had experienced difficulty trying to get a temporary back up and therefore, had made the arrangement with Facility #2. According to the CMO, an e-mail communication had been sent to the ED Physicians and "relevant Department Directors" about the agreement made with Facility #2. Continued interview revealed he was not aware of how the information regarding the agreement with Facility #2 would be passes along to ED staff; however, he expected the ED Director to have passed the information along. The CMO stated if a patient presented to the ED the weekend of the agreement with Facility #2, the ED staff were to triage, stabilize and transfer the patient if necessary. Further interview revealed "there was to be a proper assessment of the condition" prior to transfer. In addition, he stated he was not sure there was a written agreement between the facility and Facility #2 for the provision of CT Surgery that weekend. He stated it was "mostly" phone conversations between him and Facility #2's CMO and there might have been e-mail communication.

Interview was attempted with Facility #2's CMO on 07/02/15 at 4:27 PM, however per the Administrative Assistant the CMO was not in the facility that day and therefore, was unavailable for interview.

Interview, on 07/02/15 at 4:45 PM, with Facility #2's Assistant Hospital Director revealed she would research the agreement referred to by the facility's CMO for CT Surgery coverage on 04/03/15 through 04/06/15.

Review of an e-mail dated 07/06/15 at 2:32 PM, received from Facility #2's Assistant Hospital Director revealed there had been no "formal agreement" between the facility and Facility #2. Per the e-mail, there was "just an oral confirmation" Facility #2 would provide emergent cardiac surgery services via transfer for the brief period of time when the facility was not covered for that specialty, CT Surgery. Further review of the e-mail revealed the oral discussion "merely reiterated our obligation under EMTALA to provide care for patients unable to receive the care they required at another facility".

Based on interview, record review and review of the facility's documents and policies and procedures, it was determined the facility failed to ensure an appropriate medical screening examination (MSE) was provided for one (1) of twenty (20) sampled patients (Patient #1), who presented to the facility's Emergency Department (ED) with an emergency medical condition.

The findings include:

Review of the facility's policy titled, "System Policy", revised 10/29/09, revealed the subject of the policy was "Emergency Medical Treatment and Active Labor Act (EMTALA)". Review of the Policy's purpose revealed it was to ensure the facility complied with the EMTALA requirements and all federal regulations and interpretive guidelines promulgated thereunder. Continued review revealed it was the facility's policy to provide a medical screening examination by a Physician or qualified medical person to any individual who came to the facility's dedicated ED seeking an examination or treatment for a medical condition or who came upon facility property, other than to the ED, seeking examination or treatment for an emergency medical condition. Further review revealed the Policy defined an emergency medical condition as a medical condition which manifested itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment of bodily functions or serious dysfunction of any bodily organ or part.

Review of the facility's policy titled, "Emergency Services", dated 08/01/10, revealed the policy's "Purpose" stated to provide care for individuals who present requesting care for a medical condition. Continued review revealed all individuals requesting treatment in the facility's ED would received a MSE.

Review of the facility's policy titled, "Patient Treatment and Evaluation Process", dated 08/01/10, revealed the "Purpose" stated to assure all patients who presented to the ED received an appropriate MSE. Continued review revealed a patient might be transferred to another facility on their request or the request of a Physician after an appropriate MSE and stabilization were provided.

Review of the facility's policy titled, "Emergency Department Treatment Protocols", dated November 2013, revealed a "Chest Pain Protocol" which noted for a STEMI (segment level elevation Myocardial Infarction, the most dangerous type of heart attack involving a sudden blockage of one of the three (3) main coronary arteries which supply blood to the heart) patient, the protocol was to: do a "STAT 12 Lead EKG" (electrocardiogram); directly hand off to Physician; the ED was to call the "STEMI" Physician "directly on cell phone"; page a code AMI (acute myocardial infarction); administer Plavix (a medication which prevents platelets from clumping together and forming blood clots), Angiomax (a blood-thinning medication used in combination with Aspirin to treat patients with severe chest pain who were to undergo a surgical procedure to unblock clogged arteries), no Unfractionated Heparin, and STAT (immediate) transfer to the catherization (cath) lab.

Review of the Emergency Medical Services (EMS) "Patient Care Record" for Patient #1 dated 04/04/15 revealed at 11:30 PM the patient presented to the EMS station with complaints of chest pain. Review revealed Patient #1 was immediately assessed and placed on the 12 lead cardiac monitor (electrocardiogram {EKG}) which showed the patient was having an acute left inferior infarct with a STEMI, which stands for segment level (a part of an EKG) elevation Myocardial Infarction (heart attack), the most dangerous type of heart attack involving a sudden blockage of one of the three (3) main coronary arteries which supply blood to the heart. Continued review revealed the EMS Paramedics started an intravenous (IV) line, hung Normal Saline (N/S), administered oxygen (O2) at four (4) liters per nasal cannula and administered a Nitroglycerin (a medication used to treat chest pain) one (1) tablet sublingual (under the tongue). Report was called by Paramedic #1 while the ambulance was enroute to the facility to "activate the STEMI protocol" and the staff person at the facility "advised they would be ready when we came". The EMS "Patient Care Record" for Patient #1 revealed the Paramedics administered Aspirin (ASA) three (3) 81 milligram (mg) tablets at 11:50 PM, Zofran (anti-nausea medication) at 11:58 PM and Morphine (a narcotic pain reliever) 4 mg at 11:59 PM. Further review of Patient #1's "Patient Care Record" revealed upon arrival at the facility at 12:06 AM, staff met them after they entered the ED and asked if Patient #1 was the "STEMI alert" and the EMS staff stated "yes". Per review, the ED staff then told the EMS staff the ED was on "divert" for STEMIs and the EMS staff needed to take Patient #1 "somewhere else". In addition, review revealed the EMS staff loaded Patient #1 back onto the ambulance, called report to another facility, Facility #2, that advised they would have a "team" ready upon their arrival and the ambulance left the facility at 12:11 AM to transport the patient to the other facility. The "Patient Care Record" revealed after being loaded back onto the ambulance, Patient #1 was unhappy because the facility would not accept him/her, was "cussing" and he/she had an elevated pulse. Further review revealed upon arrival at Facility #2 at 12:13 AM, ED staff met the ambulance, escorted the EMS personnel with Patient #1 on the stretcher into the ED where a Cardiologist "looked at the 12 lead and agreed it was a STEMI". Additionally, review revealed the Cardiologist walked with Patient #1, who was transported by the EMS staff, to Facility #2's cardiac cath lab where the team was waiting to perform the cardiac cath.

Review of the facility's ED log for the date of 04/04/15 revealed no documented evidence of Patient #1's name, date of arrival, arrival time, departure time or disposition.

Review of Patient #1's medical record from Facility #2, revealed the patient arrived at 12:12 AM, complaining of chest pain. Review of Patient #1's Discharge Summary, dated 04/11/15, revealed the patient had been diagnosed with a STEMI on arrival to Facility #2, was taken to the cardiac cath lab where the catherization was performed. Per the Discharge Summary, Patient #1's cardiac cath revealed the right coronary artery had a complete occlusion (blockage), severe disease in the "circumflex" branch of the left coronary artery and "around" a 70% mid left anterior descending artery lesion. Continued review of the Discharge Summary revealed Patient #1 required coronary artery bypass surgery times five (5) vessels and was discharged home in stable condition on 04/11/15.

Interview, on 06/29/15 at 11:08 AM, with EMS Paramedic #1 revealed she had been present when Patient #1 presented to the EMS station on 04/04/15 at 11:30 PM. Paramedic #1 stated when she and Paramedic #2 assessed the patient via a 12 lead EKG, an elevation was noted which indicated a STEMI. Per interview, Patient #1 was transported to the facility immediately and at about eight (8) to ten (10) minutes from the facility she called to give report to an ED nurse. Continued interview revealed report was given and the ED nurse said "see you when you get here". She stated upon arrival at the facility she and Paramedic #2 offloaded Patient #1's stretcher, went through the ED's two (2) sets of doors and then were met by a female staff person who told the Paramedics the ED was on "divert for STEMI's" and they would have to transport the patient to another facility. Paramedic #1 stated she looked at Paramedic #2, after being told this, and stated to Paramedic #2, "I didn't think you could go on divert for STEMI's" to which Paramedic #2 replied, "I didn't think so either". According to Paramedic #1, the staff person stated she had tried to call Paramedic #1 back three (3) times to tell the EMS staff the ED was on "divert for STEMI's"; however, had not gotten an answer. She stated she looked at her phone and there were no missed calls. Per Paramedic #1, she and Paramedic #2 returned Patient #1 to the ambulance, called Facility #2 to give report to their ED and the Paramedics were told someone would meet them in the ED. Paramedic #1 revealed Patient #1 was "very upset" over being not being treated at the facility and he/she had an elevated pulse when assessed after being loaded back into the ambulance. Further interview revealed Patient #1 was transported to Facility #2's ED where they were met by a Physician who escorted them with the patient "straight up to the cath lab".

A post-survey interview conducted with Paramedic #2, on 07/06/15 at 8:42 AM, revealed he had been present also when Patient #1 presented to the EMS station on 04/04/15, complaining of chest pain. Per interview, he and Paramedic #1 hooked Patient #1 up to the 12 lead EKG and noted the patient had a STEMI. He stated they immediately transported Patient #1 to the facility, and Paramedic #1 had called report to a facility ED nurse. Paramedic #2 revealed when they took Patient #1 through the facility's ED doors a female staff person came and was waving her hands at them, and said "we are on divert for STEMI's". Continued interview revealed the nurse said she had tried to call them three (3) times to tell them, but had not gotten an answer. He stated he asked Paramedic #1 if she had any missed calls and she said "no". Paramedic #2 reported they loaded Patient #1 back into the ambulance, called Facility #2 to give report and transported the patient to Facility #2's ED where they were met by a Physician who escorted them "straight to the cath lab". According to Paramedic #2, he later learned Patient #1 ended up having a "five (5) vessel bypass" surgery.

Interview, on 06/26/15 at 2:00 PM, with the ED Nurse Manager revealed the county in which the facility was located there was an agreement with acute care facilities, not to go on diversion. She stated if a STEMI patient arrived in the ED, there was a protocol for staff to follow; and there was an on-call STEMI Physician who would be notified so the patient could be taken to the cardiac cath lab. Per interview, if a patient was brought to the ED in an ambulance who was a "field STEMI" (a STEMI assessed per a 12 lead EKG prior to arrival at the ED), the EMS personnel usually bypassed the ED and took the patient straight to the cardiac cath lab.

Interview, on 06/29/15 at 8:22 PM, with Registered Nurse (RN) #1, the ED nurse who took report from Paramedic #1 on 04/04/15, revealed on Friday, 04/03/15, the ED Charge Nurse had told staff the ED was on diversion for STEMI's; however, she stated she did not know it was supposed to be for the "entire weekend" which included 04/04/15 and 04/05/15. RN #1 stated none of the ED nurses working the night of 04/04/15, had been aware the ED was still on divert for STEMI's. Per interview, she received a phone call from EMS staff on 04/04/15 about a STEMI patient they were transporting to the facility's ED, and after report she told the EMS staff person she talked to, "okay, we'll see you when you get here". Continued interview revealed she then reported the incoming STEMI patient information to RN #2/Charge Nurse, and he told her they couldn't take the patient. She stated as she continued to talk to RN #2/Charge Nurse and request assistance on what to do, he kept telling her over and over they couldn't take the patient, but did not provide with any guidance on what to do. Per RN #1, she thought they should "stabilize, then transfer" the STEMI patient (Patient #1). She revealed she had tried to get guidance from other staff and from the ED Physicians working that night; however, no on provided guidance to her. According to RN #1, since she had not obtained the name of the city the EMS staff were transporting Patient #1 from, she started calling the local and some of the surrounding county's EMS stations. RN #1 stated she was never able to locate where the STEMI patient (Patient #1) was coming from though, in order to relay the information regarding the ED being on divert for STEMI's, so the patient could be transported to another facility. She stated the ambulance with Patient #1 arrived and the patient was off loaded and brought into the facility's ED. Further interview revealed she told the EMS staff what RN #2/Charge Nurse had told her about the ED being on divert for STEMI's and that they couldn't "take the patient" there. In addition, RN #1 revealed she had worked in the facility's ED for about one (1) year but had only received a "quick read through" five (5) minute information session during her orientation on EMTALA. She stated she had not received any additional training and "just didn't know about EMTALA" to ensure the patient received an appropriate MSE.

Interview, on 06/29/15 at 5:22 PM and on 07/01/15 at 4:09 PM, with RN #2/Charge Nurse revealed he had worked the weekend of 04/03/15 through 04/05/15. He stated he had been told on Friday, 04/03/15, by the Charge Nurse "going off" for the previous shift, the ED was on divert for STEMI's as there were "no cardiac cath lab operators" available and because no cardiologists were available. According to RN #2/Charge Nurse, he knew he had told staff on 04/03/15, Friday night, during the meeting held before shift started, of the ED being on divert for STEMI's. He stated however, he could not recall if he reminded staff during the pre-shift meeting on Saturday, 04/04/15, of the ED still being on divert, and did not remember if RN #1 was in the meeting or not. Per interview, he knew the ED was on divert for STEMI's for two (2) nights in a row but could not recall which nights. RN #2/Charge Nurse stated he could not recall if he informed the ED Physicians regarding the ED being on divert for STEMI's or not. Continued interview revealed he had only been informed verbally of the diversion, and didn't recall ever getting an email about the ED being on divert for STEMI's. He revealed when RN #1 told him about receiving the phone report from EMS personnel regarding transporting a STEMI to the facility's ED, he told her to call them back and tell them the ED was on divert for STEMI's because there were no "cardiac cath lab operators available". Per RN #2/Charge Nurse, he did not remember if RN #1 asked for assistance from him that night; however, he stated as Charge Nurse he should have provided assistance obviously. He stated when the ambulance arrived at the facility, RN #1 informed the EMS staff to "divert for patient safety to the facility closest with a cath lab". RN #2/Charge Nurse stated it wasn't the plan however, to tell EMS staff to transport Patient #1 somewhere else, because if a patient made it onto the facility's property he/she should should have received an appropriate MSE. Further interview by turning the patient away without receiving an appropriate MSE first was an EMTALA violation and should never occur.

Interview, on 06/29/15 at 4:45 PM, with RN #4 revealed she recalled a weekend maybe in April 2015 when a patient was "turned away" one (1) night because the facility did not have the "service" available to treat the patient. She stated however, that should never happen because once a patient was in the ED they were supposed to treat prior to transferring the patient. RN #4 stated she did not recall being informed of the ED being on divert for STEMI's by RN #2/Charge Nurse. Per interview, she had only received a "little" EMTALA training during her orientation a few months before, and was not aware of all the requirements, but knew a patient should be treated before being transferred.

Interview, on 06/29/15 at 5:39 PM, with RN #3 revealed when she started work a few months before she had received some training on EMTALA requirements in orientation. Per interview, she had just received additional training in the past month or so related to what had happened in April 2015 when a patient was "turned away" from the ED. She stated she had worked the night that incident occurred and RN #1 had been "upset" because she'd had to turn the patient away after being told to do so by RN #2/Charge Nurse. RN #3 revealed a message had been sent out that weekend which RN #2/Charge Nurse had received that the ED was on divert for STEMI's. She stated she and the other nurses had thought it was only for one (1) night, Friday night; however, learned later on it had been for the whole weekend. According to RN #3, "communication hadn't been great" that weekend, and it was important for everyone to know important information, such as, being on divert for STEMI's. RN #3 stated RN #1 had not been aware of the ED being on divert for STEMI's when she took report from the ambulance personnel, and had accepted the patient. Per interview, when RN #1 reported the incoming STEMI patient to RN #2/Charge Nurse, he told her the ED "couldn't handle that patient" and to call the ambulance personnel back to tell them. She stated RN #1 had not obtained information of where the ambulance was coming from, attempted phoning EMS stations, but never got the correct one. Further interview revealed the ambulance arrived at the facility's ED where the EMS personnel were told by RN #1 "they would have to go on" to another facility. RN #3 stated no patient should ever be "turned away" from the ED and should receive an appropriate MSE. In addition, she stated she sure wouldn't want her family "done that way".

Interview, on 06/29/15 at 5:00 PM, with ED Technician (EDT) #2 revealed he had worked in April 2015, the weekend the ED was on divert for STEMI's because there was no on call Physician to take a STEMI patient. He stated RN #2/Charge Nurse had "mentioned" the ED being on divert for STEMI's the first night, Friday night during "huddle", the meeting held prior to shift starting. EDT #2 revealed he thought RN #2/Charge Nurse might have "mentioned" it on the second night, Saturday night during "huddle" also; however, could not recall for certain if staff were told on the second night or not. Continued interview revealed all ED staff did not attend the "huddle" meetings held prior to shift beginning and therefore, might not have known the ED was on divert for STEMI's that weekend. He stated the only way for people to know important information like that was through "huddle" or if other staff passed the information along. According to EDT #2, information was not posted in the ED anywhere except maybe in where the ED Physicians sat. Further interview revealed EDT #2 reported never having received EMTALA training prior to April 2015, but had recently received EMTALA training in the last month which he did not know what had "brought it about".

Interview, on 06/29/15 at 3:44 PM, with RN #5/Charge Nurse revealed she had never known of the facility's ED to be on a cardiac divert and if the patient arrived on the facility's property he/she would have to be seen for an appropriate MSE. Per interview, every patient had to have an appropriate MSE if they were on the property, prior to being transferred elsewhere.

Interview, on 06/30/15 at 1:45 PM, with EDT #1 revealed she did not remember the facility's ED ever being on divert for anything because she thought the ED could never be on divert. She stated all patients are always seen first by an ED Physician, then if the Physician thought the patient needed to be transferred the transfer was arranged. Per interview, she had "read a bunch of stuff" during orientation ten (10) months earlier about EMTALA, but had not received any recent EMTALA training.

Interview, on 06/30/15 at 2:28 PM and 2:51 PM, with ED Physician #1, who worked the night of 04/04/15, revealed he couldn't remember if it was a Friday or Saturday, but did recall the ED there not being a Cardiothoracic (CT) Surgeon being available one (1) weekend possibly in April. He stated he did not recall being informed of a possible STEMI patient coming to the ED on that weekend, but if a STEMI had arrived he would have seen the patient. Per interview, he recalled overhearing RN #2/Charge Nurse telling someone the ED didn't "have such and such" and therefore could not take a patient; however, did not recall overhearing it was a STEMI patient. Continued interview revealed in the facility's county there was an agreement between all the acute care facilities not to go on diversion except during a catastrophe. According to ED Physician #1, if a patient comes onto the facility's property or through the ED doors, the patient had to be seen for an appropriate MSE and stabilization, and should never be sent away without receiving that.

Interview, on 07/01/15 at 4:29 PM, with ED Physician #2, who worked the night of 04/04/15, revealed there was a weekend when the facility had no CT Surgeons available to do surgery, but was not aware of the ED being on diversion. He stated this information was verbally reported to him by the ED Physician who was on the previous shift, and he did not recall receiving any written documentation regarding this. Per interview, he did not recall ever being informed of a STEMI patient coming to the ED and being turned away. Continued interview revealed if a STEMI patient showed up the patient should have been seen for a MSE, stabilized then transferred if there was no CT Surgeon available.

Interview with the ED Medical Director was attempted; however, he was on vacation overseas and unavailable. Interview, with ED Physician #3, who was temporarily overseeing the ED in the ED Medical Director's absence, revealed the ED process should always ensure patients were seen for an appropriate MSE, stabilization and then transfer if necessary. Per interview, this should always be the process no matter what.

Based on interview, record review and review of the facility's documents and policies and procedures, it was determined the facility failed to ensure patients who presented to the facility's Emergency Department (ED) and was determined to have an emergency medical condition received further medical examination and treatment to stabilize the medical condition or arranged for transfer of the patient to another medical facility for one (1) of twenty (20) sampled patients (Patient #1).

The findings include:

Review of the facility's policy titled, ""System Policy", revised 10/29/09, revealed the subject of the policy was "Emergency Medical Treatment and Active Labor Act (EMTALA)". Continued review revealed if a patient presented to the facility's ED with an emergency medical condition the patient was to receive the medical treatment necessary to "assure within reasonable medical probability" no "material" deterioration of the condition was likely to result from being transferred or if the Physician or other qualified medical person attending to the patient had determined within "reasonable clinical confidence" the emergency medical condition had resolved.

Review of the Emergency Medical Services (EMS) "Patient Care Record" for Patient #1 dated 04/04/15 revealed at 11:30 PM, he/she had come to the EMS station with complaints of chest pain, was placed on the 12 lead cardiac monitor which showed an acute left inferior infarct, a segment level (a part of an EKG) elevation Myocardial Infarction, a "STEMI" (heart attack). Review revealed EMS staff loaded Patient #1 into the ambulance, continued to assess the patient and provided treatment enroute to the facility. Continued review revealed report was called to the facility and the patient was accepted. Review revealed the ambulance arrived at the facility at 12:06 AM, where the EMS staff unloaded Patient #1 from the ambulance and wheeled him/her into the facility's ED on a stretcher. The "Patient Care Record" revealed the EMS staff were met by a facility staff person who told them the ED was on "divert" for STEMI's and they needed to take the patient to another facility. Per the "Patient Care Record, the EMS staff returned to the ambulance with Patient #1, loaded the patient back into it, called report to Facility #2, and were told a "team" would be ready when they arrived. Further review revealed the ambulance arrived at 12:13 AM with Patient #1, were met by ED staff who escorted the EMS personnel with Patient #1 on the stretcher into the ED where a Cardiologist observed the 12 lead and agreed the patient had a STEMI. In addition, the Cardiologist escorted the patient and EMS personnel to Facility #2's cardiac catherization (cath) lab where a "team" was waiting to perform a cardiac catherization.

Review of the facility's ED log dated 04/04/15 revealed no documented evidence Patient #1 was brought to the ED, received a medical screening examination (MSE) and was stabilized prior to being transferred to Facility #2.

Review of Patient #1's medical record from Facility #2, of the Discharge Summary dated 04/11/15, revealed Patient #1 had received the cardiac catherization which had shown blockage of coronary arteries which resulted in the patient having coronary artery bypass survey times five (5) vessels. Further review revealed Patient #1 was discharged home in stable condition on 04/11/15.

Interview with EMS Paramedic #1 on 06/29/15 at 11:08 AM, revealed she and Paramedic #2 had been present on 04/04/15 at 11:30 PM, when Patient #1 came to the EMS station with complaints of chest pain. She stated they put the patient on the 12 lead EKG, and there was an elevation indicating Patient #1 was having a STEMI. Paramedic #1 revealed Patient #1 was taken by ambulance to the facility, and report was called to an ED nurse who accepted the patient. Continued interview revealed when the ambulance arrived at the facility with Patient #1, the Paramedics unloaded the patient on the stretcher, went into the ED where a female staff person informed them the ED was on "divert for STEMI's". She stated she and Paramedic #2 were told they would have to transport Patient #1 to another facility. According to Paramedic #1, they then returned to the ambulance with Patient #1, called report to Facility #2's ED and were informed ED staff would meet them upon arrival. She stated Patient #1 was "very upset" over not receiving treatment at the facility and when she assessed his/her pulse, it was elevated. Further interview revealed when the ambulance arrived at Facility #2's ED, staff met them and a Physician escorted them with Patient #1 on the stretcher to the cardiac cath lab.

A post-survey interview on 07/06/15 at 8:42 AM, with Paramedic #2 revealed he and Paramedic #1 had been present when Patient #1 came to the EMS station complaining of chest pain on 04/04/15. He stated Patient #1 was hooked up to the 12 lead EKG which showed the patient was having a STEMI. Per interview, Patient #1 was loaded into the ambulance and transported to the facility's ED. Paramedic #2 stated during the transport, Paramedic #1 called report to the facility's ED and accepted the patient. He revealed when they arrived at the ED, they unloaded Patient #1 on the stretcher, went into the ED where they were met by a female staff person who informed them the ED was "on divert for STEMI's", and would have to take the patient to another facility. Continued interview revealed he and Paramedic #1 returned to the ambulance with Patient #1 on the stretcher, loaded the patient back into the ambulance, called Facility #2 to give report and transported the patient to Facility #2's ED. Paramedic #2 stated a Physician met them when they unloaded Patient #1 at Facility #2 and escorted them to the cardiac cath lab. In addition, Paramedic #2 reported he was later told the patient had to have a "five (5) vessel bypass" surgery.

Interview with Registered Nurse (RN) #1 on 06/29/15 at 8:22 PM, the ED nurse on 04/04/15 who received the report from Paramedic #1, revealed she was not aware the ED was on divert for STEMI's on 04/04/15. She stated therefore, when she received the report from Paramedic #1, she had told the Paramedic she would see her when they arrived with Patient #1. RN #1 stated however, when she informed RN #2/Charge Nurse she had a patient coming in with a STEMI, he had told her the ED couldn't take the patient and to call the EMS back to tell them this. According to RN #1, she did not agree with this and thought the STEMI patient should be stabilized in the ED then transferred. RN #1 revealed she tried to call Paramedic #1 back, but had not obtained the county where the EMS station was located, and never was able to call them. Per the RN, when the ambulance arrived, the EMS personnel brought Patient #1 into the ED and she told the EMS staff what RN #2/Charge Nurse had told her regarding the ED being on divert for STEMI's and that they couldn't take the patient there. Further interview revealed the EMS personnel left with Patient #1 after she told them that information.

Interview with RN #2/Charge Nurse on 06/29/15 at 5:22 PM and on 07/01/15 at 4:09 PM, revealed he had been told the ED was on divert for STEMI's due to there being "no cardiac cath lab operators" or cardiologists available. He stated RN #1 had informed him of her receiving report from EMS personnel related to a STEMI patient being transported to the facility's ED. Continued interview revealed he told RN #1 to call the EMS personnel back to tell them the ED was on divert for STEMI's; however, he revealed he did not provide her with any guidance and was busy with another patient when the ambulance arrived. According to RN #2/Charge Nurse, when the EMS staff brought the STEMI patient (Patient #1) into the ED she told them they needed to "divert for patient safety to the facility closest with a cath lab". Further interview revealed however, the patient should have received a MSE and stabilizing treatment in the ED prior to being transferred to another facility. He revealed without providing the MSE and stabilizing treatment, it was an EMTALA violation which should not have occurred.

Interview with ED Physician #1, on 06/30/15 at 2:28 PM and 2:51 PM, who was working in the ED the night of 04/04/15, revealed if a patient presented to the ED or onto the facility's property, the patient had to be seen for an appropriate MSE and stabilization, and should never be sent away without receiving those first.

Interview with ED Physician #2, on 07/01/15 at 4:29 PM, who was also working in the ED the night of 04/04/15, revealed if a STEMI patient presented to the ED, the patient should have been seen for a MSE, been stabilized and then transferred.

Interview on 07/02/15 at 4:51 PM with ED Physician #3, who was temporarily responsible for the ED in the ED Medical Director's absence, revealed patients who came to the ED should always have a MSE, be stabilized and then transferred if necessary.

Based on interview, record review and review of the facility's documents and policies and procedures, it was determined the facility failed to ensure patients who presented to the facility's Emergency Department (ED) with an emergency medical condition received a medical screening examination (MSE), stabilizing treatment, had the risks and benefits of transfer explained and a Physician signed a certification indicating the transfer was necessary with the risks and benefits of transfer documented for one (1) of twenty (20) sampled patients (Patient #1). Patient #1 arrived at the facility Emergency Department (ED) with an emergency medical condition; however, the patient was provided no emergency treatment prior to being transferred to another facility.


The findings include:

Review of the facility's policy titled, "System Policy", revised 10/29/09, under the subject section titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" revealed patients who presented to the ED would receive a MSE and stabilizing treatment. Continued review revealed prior to being transferred, the risks versus benefits must be explained to the patient and a Physician was to sign a certification noting the medical benefits of the transfer to another medical facility outweighed the risks for the patient.

Review of the facility's policy titled, "Emergency Services", dated 08/01/10, revealed patients would be transferred to another facility only after a MSE, evaluation and appropriate stabilization. Continued review revealed EMTALA guidelines would be followed for all transfers.

Review of the facility's ED log dated 04/04/15 revealed no documented evidence Patient #1 had entered the ED seeking treatment, received a medical screening examination (MSE) and was stabilized prior to being transferred to Facility #2.

Review of the Emergency Medical Services (EMS) "Patient Care Record" for Patient #1 dated 04/04/15 revealed the patient presented to the EMS station at 11:30 PM, complaining of chest pain. A 12 lead electrocardiogram (EKG) revealed the patient had a segment level elevation Myocardial Infarction, STEMI (heart attack). Review revealed Patient #1 was loaded into the ambulance with treatment provided by a Paramedic and transported to the facility. Report was called to the facility's ED while enroute and a ED nurse accepted the patient. Upon arrival at the facility's ED at 12:06 AM however, after unloading the patient's stretcher and entering the ED, Paramedic #1 and Paramedic #2 were informed by ED staff the ED could not accept the patient as the ED was on "divert" for STEMI's and the Paramedics needed to transport the patient to another facility. The "Patient Care Record revealed the Paramedics returned Patient #1 to the ambulance, called report to Facility #2 who accepted the patient and told the Paramedics a "team" would be ready on their arrival. Further review revealed the ambulance arrived at Facility #2 with Patient #1 at 12:13 AM, and a Cardiologist reviewed the 12 lead EKG confirming the patient had a STEMI. In addition, Patient #1 was immediately taken to the facility's cardiac catherization (cath) lab for cardiac catherization.

Review of Patient #1's medical record of the Discharge Summary dated 04/11/15, from Facility #2, revealed the patient's cardiac catherization revealed coronary artery blockage. Continued review of the Discharge Summary revealed Patient #1 had coronary artery bypass survey times five (5) vessels, and was discharged home in stable condition on 04/11/15.

Interviews with EMS Paramedic #1 on 06/29/15 at 11:08 AM and a post-survey interview on 07/06/15 at 8:42 AM, with Paramedic #2 revealed Patient #1 had arrived at their EMS station on 04/04/15 at 11:30 PM with complaints of chest pain. Per interview, a 12 lead EKG was performed and showed the patient had an elevation which was indicative of a STEMI. The Paramedics reported Patient #1 was loaded into the ambulance with emergency care provided and report called to the facility's ED while enroute. Per Paramedic #1 she spoke to an ED nurse who took report and accepted the patient. Continued interview revealed however, when they arrived at the facility's ED, unloaded Patient #1 and took him/her into the ED, they were met by a female staff person who told them the ED was on "divert for STEMI's". According to the Paramedics, the female staff person told them they would have to transport Patient #1 to another facility and therefore, they returned with the patient to the ambulance. They stated report was called to Facility #2 who accepted the patient and told them ED staff would be awaiting their arrival. Paramedic #1 stated Patient #1 was "very upset" about not being treated in the facility's ED, and the patient's pulse was elevated when his/her vital signs were assessed after being returned to the ambulance. Paramedic #2 stated when the ambulance arrived at Facility #2, a Physician met them and escorted them to the cardiac cath lab. Paramedic #2 revealed he later learned Patient #1 had been taken to surgery for a "five (5) vessel bypass".

Interview, on 06/29/15 at 8:22 PM, with Registered Nurse (RN) #1, the ED nurse on 04/04/15 who received the report from Paramedic #1, revealed on the night of 04/04/15 she had not been aware the ED was on diversion for STEMI's, therefore, when she received report from Paramedic #1 she said she'd see them when they got to the ED. According to RN #1, she told RN #2/Charge Nurse about the STEMI patient being transported to the ED, and he told her the ED couldn't take the patient and she should call the EMS Paramedic back to inform them of this. She stated she didn't agree with RN #2/Charge Nurse and thought the STEMI patient should be seen and stabilized in the ED before being transferred somewhere else. Per interview, she did attempt to call the EMS Paramedics back, but had not obtained the county they were coming from, but tried the facility's county and some surrounding counties. She stated she was not able to contact them and the ambulance arrived at the ED with the patient who was transported into the ED by EMS staff. Continued interview revealed she relayed to the EMS staff what her Charge Nurse had said about the ED being on divert for STEMI's and they couldn't take the patient. RN #1 revealed the EMS staff then returned to the ambulance with the patient and left the facility.

Interview, on 06/29/15 at 5:22 PM and on 07/01/15 at 4:09 PM, with RN #2/Charge Nurse revealed he had been told the ED was on divert for STEMI's due to there being "no cardiac cath lab operators" or cardiologists available. RN #2/Charge Nurse revealed therefore, when RN #1 told him she had received report from EMS staff of a STEMI patient being transported to the facility's ED, he had told her to call the EMS personnel back to tell them the ED was on divert for STEMI's. Per interview, he did not provide guidance to RN #1 however, as he was busy with another patient. He revealed when the EMS personnel arrived in the ED with the patient RN #1 told them they needed to "divert for patient safety to the facility closest with a cath lab". Continued interview revealed this should not have happened and the patient should have received a MSE and stabilizing treatment in the ED prior to being transferred elsewhere, as without those it was an EMTALA violation.

Interviews on 06/30/15 at 2:28 PM and 2:51 PM with ED Physician #1, and on 07/01/15 at 4:29 PM, with ED Physician #2 revealed they both had worked the night of 04/04/15 when Patient #1 was transported to the facility's ED. Both ED Physicians revealed the patient should have received a MSE and stabilization in the ED prior to being transferred to another facility.

Interview, on 07/02/15 at 4:51 PM, with ED Physician #3, who was temporarily responsible for the ED in the ED Medical Director's absence, revealed all patients coming to the ED should have a MSE and be stabilized prior to being transferred somewhere else if necessary.