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Based on clinical record review, interviews and document reviews, the facility failed to ensure compliance with EMTALA requirements at 42 CFR 489.24: Special Responsibilities of Medicare Hospitals in Emergency Cases.

The facility staff failed to accept a patient for a Medical Screening Examination (MSE) who had presented by EMS (Emergency Medical Services Ambulance) for evaluation after a motor vehicle accident.

The hospital staff informed the EMS, after their arrival on hospital property that they could not accept the patient and the patient would have to be taken to a trauma center.

Please refer to 2406 for further information.

Based on clinical record review, interviews and document review, the facility staff failed to provide a Medical Screening Examination (MSE) for one patient (Patient #19) who presented to the Emergency Department (ED) Hospital campus requesting an evaluation after a motor vehicle accident (MVA).

Patient #19 was transported to the facility via EMS (Emergency Medical Services) ambulance and upon arrival the EMS staff was told to take the patient to another trauma facility approximately 30 (thirty) miles away.

The findings include:

According to the information documented in the EMS "Prehospital Care report" dated September 26, 2024 at 3:01 a.m., the EMS had been dispatched and arrived on the scene of a motor vehicle accident (MVA). The document read, in part: "...complains of head pain...left hip aching a little...hit head in car but did not loose consciousness...could move feet and all extremities...does not complain of any neck or back pain...stated was wearing seatbelt...secondary exam found small bump on the top of patients head, no other injuries found...as (ambulance) began to transport to SMH (Shenandoah Memorial Hospital) priority 3 (non emergent condition that requires medical treatment but not on an emergency basis) reassessed vitals as noted. Called report to SMH as we were in the parking lot and was informed they (hospital ED) could not take and (patient) needed to go to a trauma center. (EMS Ambulance) redirected to (another hospital trauma center) pri (priority) 3..."

There was no record of Patient #19 being seen in the facility's Emergency Department on September 26, 2024. However, the Emergency Department of the "sister" facility (Trauma Center) had a record of Patient #19 receiving care following a MVA on September 26, 2024 at 4:04 a.m.

On November 12, 2024 at 11:25 a.m. during a tour of the emergency Department (ED), Staff Member #3 indicated that when a call comes in from EMS regarding a patient in transport, the charge nurse takes the call and assigns a room. Staff Member #3 further explained that "according to EMTALA regulations" any person who comes on to the hospital campus seeking help must be seen in the ED. "The campus is the entire hospital buildings, clinics and parking lot." Staff Member #3 indicated that EMS calls received over the radio were recorded, but if they came through the "CISCO portable phones" they would not be recorded. The surveyors requested to review recorded calls for the previous two (2) months.

At 2:45 p.m. on November 12, 2024, the surveyors were provided and listened to recordings of calls to the ED in the past 2 months. There were no EMS calls related to the MVA for the dates November 25 or November 26, 2024. Staff Member # 9 indicated that the call must have come through the portable phone and was not recorded. Staff member #3 explained "there is not" a log of incoming calls to the ED kept.

The facility policy and procedure "Transfer of Patients - EMTALA (Emergency Medical Treatment and Labor Act) last revised 04/2023" was reviewed and evidenced, in part: "...POLICY: A. Any person who comes to a VHS (Valley Health System) hospital requesting assistance for a potential emergency medical condition/emergency services will receive a medical screening examination performed by a qualified provider to determine whether an emergency medical condition exists. B. Persons with emergency medical conditions will be treated with their condition stabilized within the scope of the facilities capability...C. Definitions...3. Comes to hospital a. refers to any individual requesting emergent examination and treatment arriving on any hospital property or premises. This includes sidewalks, driveways, parking lots and parking garages for the VHS hospital locations...5. Hospital Property a. Includes any facility that the hospital covers with its unique Medicare provider number, including the main hospital campus. the parking lot, sidewalk, and driveway of departments within 250 yards of the hospital..."

According to information provided by the facility the "Prehospital Care Report" had been amended on September 28, 2024 to include the information that the EMS had been turned away by the facility when arrived "in the parking lot". The surveyor interviewed OI #1 (Outside Interview/Non-Staff) on November 12, 2024 at 4:43 p.m. who explained that reports go through a "peer review" process as soon as possible after the event, "usually within twenty-four hours". OI #1 indicated the crew who responded to this accident were relatively new at that time, and the incident was discussed and the documentation was reviewed by the captain (Fire and Rescue Captain). The crew was directed to edit the report and and include all pertinent information regarding the event that had not been included in the first report. "This is standard protocol because as you know, documentation is very important and must be accurate.." Both reports were available for review and evidenced the editing date.

Review of an email statement by OI #2 (EMS) dated September 26, 2024 at 10:21 a.m. revealed, in part: "As we got off the exit I called SMH to give report. After sharing the patient's info I was transferred to the charge and explained that I have a patient who was in MVC (motor vehicle crash) and only had head pain and minor hip pain. We parked in front of the hospital doors as I was still talking to the charge nurse which is when I heard (charge nurse) talking to someone in the background and then telling me they can't take (patient). (Charge) said they don't have the equipment and that (patient) needs to go to a trauma center. I explained that we are already at SMH but (charge) still said they can't take, (patient) needs to go to a trauma center...We then diverted to (trauma center)."

The surveyors requested to interview the ED Physician who was on duty at the time of the event. The surveyors were informed the physician was out of the country and could not be reached for an interview.

The surveyors reviewed the ED schedule for charge nurse staff who were on duty on November 25 and November 26, 2024.

Staff Member #11 (Registered Charge Nurse) indicated in an interview on November 12, 2024 at 3:00 p.m. that they were not aware of an EMS call in September in which a patient was turned away. "That has not happened when I was in charge".

At 3:15 p.m. on November 12, 2024, Staff Member # 12 (RN Charge) was interviewed and indicated they did not recall this incident, however stated, "if I told them that it would have been because I referred to the doctor and was instructed to give that message; but I do not recall this ever happening."

OI #3 was interviewed on November 13, 2024 at 12:00 p.m. (Emergency Medical Technician/Driver) and indicated they were the ambulance driver at the time of the incident and not aware the facility refused to take the patient until they had pulled outside the ED doors underneath the canopy. OI #3 recalled they had gotten out of the ambulance, went around to the back, opened the doors and were told by the patient that the facility refused to take them. OI #3 added that OI #2 was still on the phone with the ED and was telling them they were right outside the doors. OI #3 explained that after that they transported patient to the ED of the nearest trauma center.

On November 13, 2024 at 1:30 p.m. OI #2 (Emergency Medical Technician) was interviewed and validated that they were in the back of the ambulance monitoring Patient #19. OI #2 indicated they had notified the ED that they were en-route with the patient who had stable vital signs and was only complaining of some head pain and mild side pain, possibly from the seatbelt. OI #2 recalled that they had pulled onto the hospital property and were getting ready to ark when the charge nurse in the ED told (OI #2) they "could not accept the patient because they did not have the resources for a patient with a possible major head trauma and the patient needed to be taken to a trauma center". OI #2 further indicated that at they informed the charge nurse they were right outside the doors to the ED doors under the canopy with Patient #19 in ambulance. The charge nurse told them the ED could not take the patient and to take (patient) to a trauma center. OI#2 stated they had called their dispatch, explained the situation and transported the patient to the nearest a trauma center, 34 miles away.

The surveyors made multiple attempts to contact Patient #19 on November 12 and 13, 2024, without success at the time of the report.

The findings and concerns were discussed on November 12, 2024 at 3:45 p.m. with facility Administration in an exit conference.