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Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide triage and medical screening exam (MSE) for 1 patient (P-1) of 20 patients reviewed, resulting in the potential for less than optimal outcomes for all patients seeking emergent care. Findings include:


See tag 2406: Failure to provide MSE

Based on interview and record review, the facility failed to conduct a medical screening exam (MSE) for 1 (P-1) of 20 patients reviewed for care provided after presenting to the emergency room, resulting in delayed care and the potential for less than optimal patient outcomes. Findings include:

Review of the Emergency Department (ED) Discharge Log from Facility-A revealed P-1 was not registered as a patient from 6/1/2024 through 11/20/2024.

On 11/20/2024 at 1230 record review reveals an Emergency Department (ED) Report from Facility-B for P-1 dated 10/6/2024. The ED Report revealed, "the friends took her to the hospital in a pickup truck, EMS decided to bring her to (Facility-B) ER". Review of a Supervision Note from the Emergency Department dated 10/6/2024 reveals "Patient was initially dropped off by friends at (Facility-A), and EMS brought her here."

On 11/21/2024 at 1000 review of a Summary Report found in the record from EMS dated 10/6/2024 at 0435 reveals, "Chief Complaint: Called to a car in the parking lot of (Facility A) for a potential overdose. Friends report pt probably took mushrooms. They also report she might have been sexually assaulted. They reported they found her in the woods with a male. Pt is responsive to pain, not talking. She is staying in the fetal position. Pt is guarding airway well. 2 mg narcan given IV with no change." The full EMS Patient Care Report was reviewed on 11/21/2024 at 1230 and revealed in the Narrative, Section T- "As we were loading her (P-1) (Facility-A) provider walked out from the ER. I advised him that I was thinking of taking her directly to (Facility-B) because she may have been assaulted and he agreed."

On 11/21/2024 at 0940 video review was conducted with the Manager of Safety, Security and Emergency Management (Staff S). The video revealed 2 females presenting to the locked front entrance of Facility-A at 0344 and appeared to use the red security phone located in the lobby area to contact ED staff. At 0348 it is observed an ED RN (Staff V) presents to the front entrance and begins speaking with 2 young females who appear visibly upset. At 0349 it is observed Staff V is using the telephone located near the front entrance. At 0351 an ambulance arrives to the facility ED parking lot and parks next to the truck where P-1 is located. At 0353 EMS personnel are observed removing P-1 from the vehicle onto an EMS stretcher. At 0355 the physician assistant (Staff O) is observed walking towards the ambulance and speaking with the paramedic (Staff R) as P-1 was being loaded into the ambulance. The video reveals the ambulance left the facility parking lot at 0410 with P-1 inside. P-1 did not enter Facility-A and Staff O was not observed evaluating P-1.

During an interview with the ED RN (Staff V) on 11/21/2024 at 1100 it was revealed she was working in the ED on 10/6/2024. Staff V revealed she answered a call from the red "after-hours" emergency phone located in the main entrance. Staff V explained 2 young females were requesting help with getting their unresponsive friend out of a truck located in the ED parking lot, near a tree line and away from the ED entrance. Staff V revealed she did not feel it would be safe to go out into the parking lot by herself, so she called the House Supervisor and was instructed to call EMS to assist with "bringing the patient inside" the facility. Staff V explained she called 911 and requested a "lift assist" to bring P-1 into the ED and went back to "prepare a room". Staff V revealed after some time had passed, she realized EMS never brought P-1 into the facility and later learned she was taken to Facility-B because EMS thought P-1 would need a SANE evaluation due to allegations of assault. When queried why EMS did not bring P-1 into the ED, Staff V revealed "I don't know". Staff V explained she notified her Nurse Manager the following morning about the incident and was told they did not follow EMTALA rules and P-1 should have been brought into the facility prior to transfer.

On 11/20/2024 at 1625 an interview with an ED RN/House Supervisor (Staff Q) was conducted. Staff Q reveals she remembers getting a call from Staff V, who was calling from the hospital main lobby stating that there was a patient that had arrived by private vehicle that required assistance getting into the facility, but she did not feel comfortable walking out into the parking lot alone. Staff Q explained at the time of the incident the provider (Staff O) told her he was unable to assist with getting P-1 out of the vehicle because he had broken ribs, so the decision was made to call 911 for assistance. Staff Q revealed she went back to caring for other patients in the department and and learned that EMS was "just going to take her" to Facility-B. Staff Q explained, "we never refused care". Staff Q revealed the following morning they notified the Manager of Nursing Services (Staff A) what had occurred.

On 11/20/2024 at 1454 an interview with the physician assistant (Staff O) that was the treating provider in the ED at Facility-A on 10/6/2024 was conducted. Staff O revealed he remembered being informed by the nurse that a patient was in the parking lot unresponsive and that they needed assistance with coming into the ED. Staff O recalled it had been reported P-1 had overdosed and was raped. Staff O revealed EMS was called to assist with getting P-1 out of the vehicle because staff did not feel comfortable going out into the parking lot alone to get her. Staff O explained approximately 10 minutes went by and he realized P-1 had not been brought into the facility yet, so he went outside to speak with the paramedic. Staff O revealed the paramedic told him that P-1 needed to go to Facility-B because she would need a SANE examination, and he said "ok". When queried if he had provided a medical screening or evaluated P-1 prior to transfer, Staff O responded, "I looked into the window at her, but that was it".

During an interview on 11/21/2024 at 0909 with the paramedic (Staff R) that transferred P-1 to Facility-B it was revealed he had received a call from his dispatcher that Facility-A had called requesting assistance with a "possible overdose, young girl in a pick-up truck". Staff R revealed it was a 1-minute response time due to the close proximity to Facility-A at the time of the call. Staff R revealed he found a pickup truck parked in Facility-A's ED parking lot with 2 young females outside of the vehicle. Staff R explained he was requested to help a young female located in the backseat who was semi-unresponsive with a GCS of 10. Staff R explained that P-1's friends explained that they were concerned their friend had taken drugs and was raped. Staff R revealed he did not observe any staff from Facility-A in the parking lot until they began wheeling P-1 into the ambulance and that was when he noticed the PA (Staff O) came out of the facility. Staff R explained Staff O was not "giving me any direction", so he told him he was going to "take her to the most appropriate place" for examination and Staff O responded, "sounds good". When queried if he was familiar with EMTALA, Staff R explained, I am a little familiar with it, but we have our own protocols in EMS, and I was following them".

On 11/20/2024 at 1411 an interview with the ED Medical Director (Staff M) was conducted and revealed he was told about the incident involving P-1 the morning of 10/6/2024 by the provider (Staff O). Staff M explained that Staff O was concerned there may have been an EMTALA violation. Staff M revealed he has looked into the incident and spoke with Staff O about the need for a medical screening prior to transfer. Staff O explained the provider did not feel he had "authority" to tell EMS to bring P-1 into the facility and education has been provided. Staff M revealed he has reported the incident to the EMS Medical Director for the region and was told they would be addressing the issue. Staff M explained, "we decided to self-report" and began initiating training for the providers.

During an interview with the Manager of Nursing Services (Staff A) on 11/20/2024 at 1341 it was revealed the facility was made aware of the transfer of P-1 on 10/6/2024 in the morning by Staff Q, Staff O and Staff V. Staff A explained the staff told her they contacted EMS for a "lift assist" to bring P-1 into the facility and when EMS arrived, they decided to take P-1 to Facility-B because she would need a SANE evaluation for possible assault. Staff A revealed the nursing staff explained to her that they were not aware that EMS was not going to bring P-1 into the facility. Staff A revealed EMTALA education has been provided to all staff since the incident.

On 11/21/2024 at 1530 review of policy #15194754, last revised 8/14/2024, titled "...Healthcare EMTALA/Physician On Call Policy" was conducted. Section A, #1 reveals "Medical Screening Examination. If a person comes to the hospital and a request is made (by that person or on behalf of that person) for their examination or treatment for a medical condition...then qualified medical personnel will, within hospital's capability and capacity, conduct and document an appropriate medical screening examination".