HospitalInspections.org

Based on interviews, clinical records and document review, the Transferring Hospital's (TH) noncompliance with the requirements under Emergency Medical Treatment and Labor Act (EMTALA) occurred when:

1.The Transferring Hospital's Emergency Department (TH ED) staff failed to enter Index Patient 100 into the central ED Log (All individual's who come into the ED seeking treatment are entered into a central log). [C2405];

2. TH ED staff did not perform a Medical Screening Exam (MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition) for one of 23 Patients (Index Patient 100) when she presented on the hospital's property seeking medical attention via ambulance. [C2406];

3. The Index Patient was not assessed by qualified medical personnel for a medical emergency condition and provided stabilizing treatment prior to being transported to the Receiving Hospital who had the specialized services she required.(cardiac catherization lab- is an examination room in a hospital or clinic with diagnostic imaging equipment used to visualize the arteries of the heart and the chambers of the heart and treat any stenosis or abnormality found.) [C2407]; and

4. The TH ED did not perform an appropriate patient transfer when transferring Index Patient 100 from the TH's ED to the Receiving Hospital's ED. [2409]

Based on interview and document review the Transferring Hospital's Emergency Department (TH ED) staff failed to enter Index Patient 100 into the central ED Log (All individuals who come into the ED seeking medical attention are entered into a central log). This failure resulted in the inability of the TH ED to know the patient's name in order to follow the patient's care, especially when transferring to a Receiving Hospital (RH).

Findings:

During an interview on 7/20/18 at 9 a.m., ED Staff A stated Emergency Medical Services (EMS ) came up to the Clerk's desk with Index Patient 100. They showed me an EKG rhythm strip (A noninvasive procedure measuring electrical activity of the whole heart) they did in the TH's ambulance bay minutes before they entered here. The strip indicated a STEMI (complete blockage of the heart's artery(ies). The ED Charge Nurse was triaging a patient in a room. He came out. I asked him, "What do you want me to do?" The ED Charge Nurse stated to register the individual, get a 12 lead and a bed.

During the same interview, when the surveyor asked if he was aware the Patient 100 was coming in he stated, "Typically, I am. It was very busy at that time. We had two ambulance here." ED staff A does not recall getting a pink run sheet that gives information about an individual presenting to the ED. It happened fast. [The encounter between EMS and the ED staff.]

Review of the following documentation indicates a listing of times from the EMS [ambulance], videos inside the TH ED and outside in the ambulance bay showing the ambulance arriving, entering and leaving the TH ED:

11:10 -[sic] EKG/ECG Indication: chest pain; Type: 12 lead; Clinician Interpretation:
Normal Sinus Rhythm; Elevation: False; Depression: False; Suspected STEMI: No STEMI; (EMS)

11:17 -sic] EKG/ECG Indication: chest pain; Type: 12 lead; Clinician Interpretation:
Junctional; Ectopy: PVC <6; Elevation: False; Depression: False; Suspected STEMI: No STEMI; (EMS)

11:18 -Pain scale 8 on a scale of 10; (EMS report)

11:22 - [sic] EKG/ECG Indication: chest pain; Type: 12 lead; Clinician Interpretation:
AV Block-1st degree; Elevation: False; Depression: False; Suspected STEMI: Anterior;
(EMS report)

11:23:25 - Entering Ambulance Bay (TH ED's outside ambulance bay video)

11:24:23 - Entering the TH ED's doors (TH ED's outside ambulance bay video)

11:24:55 - In the ED (TH ED's video)

11:25:46 - A conversation between EMS and ED staff (TH ED's video)

11:25:52 - EMS left with Index Patient 100 (TH ED's video)

11:26:06 - EMS coming out the door of the ED (TH ED's outside ambulance bay video)

11:27 - Facility Activation time activated: 7/9/18 11:27 a.m.; Activation Type: STEMI alert (EMS report)

11:29:59 - EMS ambulance drives away (TH ED's outside ambulance bay video)

It took approximately six and half minutes from the time the ambulance entered the TH's ambulance bay; to entering the ED with the individual seeking medical attention; having a conversation between the ED Charge Nurse, ED Staff A and EMS staff; exiting the ED, loading the Index Patient back on the ambulance, and EMS enroute to the Receiving Hospital (RH).

During an interview on 7/20/18 at 12:45, the Receiving Hospital's (RH) ED Charge Nurse stated when he spoke with the TH's ED Charge Nurse he [TH's] asked him for the ambulance number. TH's staff obtained the name of Index Patient 100 by calling EMS. Index Patient 100 was never logged into the TH's central log.

During review of TH ED's Policy and Procedure titled, "ED Structure Standards" with a last review date of 11/1/15 indicated, "Log Entry: At arrival the patient gives his or her name to the clerk who enters the patient's name on the computer screen... a 24-hour log is kept on all patients..."

Based on interviews, document review and review of the Transferring Hospital's (TH) policy and procedure the Emergency Department (ED) qualified medical personnel failed to perform a Medical Screening Exam (MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition.) within its' capability for one of 23 Patients (Index Patient 100) when she presented via ambulance on the hospital's property seeking medical attention. This failure had the potential for the presenting individual to not be examined and treated for an emergency medical condition.

Findings:

Review of the Emergency Medical Service (EMS) [ambulance] report titled, "(Name of County) Patient Care Report" dated 7/9/18, stated they brought Index Patient 100 to TH's ED for an initial complaint of sharp chest pain located in the center of the chest and radiating to both shoulders and rated her pain 10/10. She told the EMS she took 3 nitroglycerin (medication used to treat chest pain) prior to their arrival with no relief with one baby aspirin. Patient denied SOB (shortness of breath), dizziness, nausea, or vomiting. Two EKGs (A noninvasive procedure measuring electrical activity all over the heart) were taken on the way to the TH ED which showed no STEMI (complete blockage of a hearts' artery).

The EMS report also indicated that in the TH ED's ambulance bay the third 12 lead EKG "came back with STEMI showing according to the EMS (The documented EKG strips are difficult to read.) From the EMS documentation: [sic] "Upon arrival at TH PT. 12 lead (a representation of the heart's electrical activity recorded from electrodes on the body surface) came back with STEMI showing. [EMS] entered TH ED and advised PT is now showing a STEMI, ER Staff advised us to transport the PT to Receiving Hospital (RH) as they are a STEMI receiving hospital. PT loaded back into ambulance and transported to RH without changes in PT status."

During a phone interview on 7/13/18 at 4 p.m., EMS Paramedic stated the patient complained of chest pain. A 12 lead EKG was done. It was all ok until we arrived at the [TH] ED bay. The 12 lead then showed a STEMI alert. We wheeled the patient into the TH ED. I showed the EKG to the clerk [ED Staff A] - STEMI. The clerk called the RN out of the exam room. The RN came out. I showed him [Charge Nurse] the 12 lead. He said they had to repeat the EKG. Clerk said patient had to be signed in. RN then said you need to take patient to the Receiving (RH), "We are not a STEMI Center." I said ok, we are out of here. I didn't argue. We...went to the RH. I sent the 12 lead to the RH and contacted them by phone.

During an interview on 7/13/18 at 9:35 a.m., TH ED Charge Nurse stated I was in room 10. EMT (Emergency Medical Technician) said EKG at the door [in the TH ED's ambulance bay] indicated a STEMI. The ED Charge Nurse stated she will probably need a cath lab...I knew it might be an EMTALA (Emergency Medical Treatment and Labor Act). A few minutes after they left I called the RH. "I told them the patient left and went to you. I did not know her name."

During an interview on 7/20/18 at 9 a.m., ED Staff A stated EMS came up to the clerk's desk with Index Patient 100. They showed me an EKG rhythm strip they did in the TH's ambulance bay minutes before they entered [TH ED]. It indicated a STEMI. The charge nurse was triaging a patient in a room. I called him, he came out. I asked him, "What do you want me to do?" The medic asked us, "What do you want me to do and he questioned the charge nurse, too." The ED Charge Nurse stated to register the individual, get a 12 lead and a bed.

During the same interview, when asked by the surveyor if he ED Staff A was aware the patient was coming in he stated, "Typically, I am. It was very busy at that time. We had two ambulances here." ED Staff A does not recall getting a pink run sheet which gives information about the patient. It happened fast [the encounter]. When asked if ED Staff A heard any of the conversation between EMS and the charge nurse he stated, "yes". The ED Charge Nurse stated, "Go to the Receiving Hospital."

During a review of the ED inside video on 7/18/18 followed by an interview on 7/20/189 at 10:45 a.m., it indicated shortly after Patient 100 left the ED, the ED Charge Nurse and ED Staff Nurse B were seen conversing. ED Staff Nurse B stated the ED Charge Nurse told him, I think I may have done it wrong. They discussed what should be done. The ED physician, the manager, and the RH were called. The was no ED physician involvement in this encounter.

Review of the following documentation indicates a listing of times from the EMS [ambulance], videos inside the TH ED and outside in the ambulance bay showing the ambulance arriving, entering and leaving the TH ED:

11:10 -[sic] EKG/ECG Indication: chest pain; Type: 12 lead; Clinician Interpretation:
Normal Sinus Rhythm; Elevation: False; Depression: False; Suspected STEMI: No STEMI; (EMS)

11:17 -sic] EKG/ECG Indication: chest pain; Type: 12 lead; Clinician Interpretation:
Junctional; Ectopy: PVC <6; Elevation: False; Depression: False; Suspected STEMI: No STEMI; (EMS)

11:18 -Pain scale 8 on a scale of 10; (EMS report)

11:22 - [sic] EKG/ECG Indication: chest pain; Type: 12 lead; Clinician Interpretation:
AV Block-1st degree; Elevation: False; Depression: False; Suspected STEMI: Anterior;
(EMS report)

11:23:25 - Entering Ambulance Bay (TH ED's outside ambulance bay video)

11:24:23 - Entering the TH ED's doors (TH ED's outside ambulance bay video)

11:24:55 - In the ED (TH ED's video)

11:25:46 - A conversation between EMS and ED staff (TH ED's video)

11:25:52 - EMS left with Index Patient 100 (TH ED's video)

11:26:06 - EMS coming out the door of the ED (TH ED's outside ambulance bay video)

11:27 - Facility Activation time activated: 7/9/18 11:27 a.m.; Activation Type: STEMI alert (EMS report)

11:29:59 - EMS ambulance drives away (TH ED's outside ambulance bay video)
It took approximately six and half minutes from the time the ambulance entered the TH's ambulance bay; to entering the ED with the individual seeking medical attention; having a conversation between the ED Charge Nurse, ED Staff A and EMS staff; exiting the ED, loading the Index Patient back on the ambulance, and EMS enroute to the Receiving Hospital (RH).

During review of TH ED's Policy and Procedure titled, "ED Structure Standards" with a last review date of 11/1/15 indicated, "Triage/Medical Screening Exam: It is the policy of the TH to ensure that individuals coming to the hospital for emergency services receive a prompt Medical Screening Exam..."

Based on interviews, document review and review of the Transferring Hospital's (TH) policy and procedure the Emergency Department (ED) staff, for one of 23 Sampled individuals presenting to the TH ED, failed to ensure stabilizing treatment ("Stabilized" means that within reasonable medical certainty, "no material deterioration" should occur from or during the transfer) was given to the individual before transferring to a Receiving Hospital (RH) with specialized services. This failure did not allow the ED's qualified personnel to provide a medical screening exam (MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not) and determine what stabilizing treatment was necessary before the individual was transferred to a higher level of care.

Findings:

Review of the Emergency Medical Service (EMS) [ambulance] report titled, "(Name of County) Patient Care Report" dated 7/9/18, stated they brought Index Patient 100 to TH's ED for an initial complaint of sharp chest pain located in the center of the chest and radiating to both shoulders and rated her pain 10/10. She told the EMS she took 3 nitroglycerin (medication used to treat chest pain) prior to their arrival with no relief with one baby aspirin. Patient denied SOB (shortness of breath), dizziness, nausea, or vomiting. Two EKGs (A noninvasive procedure measuring electrical activity all over the heart) were taken on the way to the TH ED which showed no STEMI (complete blockage of a hearts' artery).

The EMS report also indicated that in the TH ED's ambulance bay the third 12 lead EKG "came back with STEMI showing according to the EMS (The documented EKG strips are difficult to read.) From the EMS documentation: [sic] "Upon arrival at TH PT. 12 lead (a representation of the heart's electrical activity recorded from electrodes on the body surface) came back with STEMI showing. [EMS] entered TH ED and advised PT is now showing a STEMI, ER Staff advised us to transport the PT to Receiving Hospital (RH) as they are a STEMI receiving hospital. PT loaded back into ambulance and transported to RH without changes in PT status."

During a phone interview on 7/13/18 at 4 p.m., EMS Paramedic stated the patient complained of chest pain. 12 lead EKG. It was all ok until we arrived at the [TH] ED bay. 12 lead then showed STEMI alert. We wheeled the patient in. I showed the EKG to the clerk [ED Staff A] - STEMI. The clerk called the RN out of the exam room. The RN came out. I showed him [ED Charge Nurse] the 12 lead. He said they had to repeat the EKG. Clerk said patient had to be signed in. RN then said you need to take patient to the RH, "We are not a STEMI Center." I said ok, we are out of here. I didn't argue. We...went to the RH.

During an interview on 7/13/18 at 9:35 a.m., TH ED Charge Nurse stated I was in room 10. EMT (Emergency Medical Technician) said EKG at the door [in the TH ED's ambulance bay] indicated a STEMI. The ED Charge Nurse stated she will probably need a cath lab..." I knew it might be an EMTALA (Emergency Medical Treatment and Labor Act). A few minutes after they left I called the RH. "I told them the patient left and went to you. I did not know her name."

During an interview on 7/20/18 at 9 a.m., ED Staff A stated EMS came up to the clerk's desk with Index Patient 100. They showed me an EKG rhythm strip they did in the TH's ambulance bay minutes before they entered [TH ED]. It indicated a STEMI. The charge nurse was triaging a patient in a room. I called him, he came out. I asked him, "What do you want me to do?" The medic asked us, "What do you want me to do and he questioned the charge nurse, too." The charge nurse stated to register the individual, get a 12 lead and a bed.

When asked by the surveyor if he [ED staff] was aware the patient was coming in he stated, "Typically, I am. It was very busy at that time. We had two ambulances here." ED staff does not recall getting a pink run sheet which gives information about the patient. It happened fast [the encounter]. When asked if ED staff heard any of the conversation between EMS and the charge nurse he stated, "yes". The charge nurse stated, "Go to [the Receiving Hospital]."

During a review of the ED inside video on 7/18/18 followed by an interview on 7/20/189 at 10:45 a.m., it indicated shortly after Patient 100 left the ED the ED Charge Nurse and ED Staff Nurse B was seen conversing. ED Staff Nurse B stated the ED Charge Nurse told him, I think I may have done it wrong. They discussed what should be done. The ED physician, the manager, and the RH were called. The was no ED physician involvement in this encounter.

Review of the following documentation indicates a listing of times from the EMS [ambulance], videos inside the TH ED and outside in the ambulance bay showing the ambulance arriving, entering and leaving the TH ED::

11:10 -[sic] EKG/ECG Indication: chest pain; Type: 12 lead; Clinician Interpretation:
Normal Sinus Rhythm; Elevation: False; Depression: False; Suspected STEMI: No STEMI; (EMS)

11:17 -sic] EKG/ECG Indication: chest pain; Type: 12 lead; Clinician Interpretation:
Junctional; Ectopy: PVC <6; Elevation: False; Depression: False; Suspected STEMI: No STEMI; (EMS)

11:18 -Pain scale 8 on a scale of 10; (EMS report)

11:22 - [sic] EKG/ECG Indication: chest pain; Type: 12 lead; Clinician Interpretation:
AV Block-1st degree; Elevation: False; Depression: False; Suspected STEMI: Anterior;
(EMS report)

11:23:25 - Entering Ambulance Bay (TH ED's outside ambulance bay video)

11:24:23 - Entering the TH ED's doors (TH ED's outside ambulance bay video)

11:24:55 - In the ED (TH ED's video)

11:25:46 - A conversation between EMS and ED staff (TH ED's video)

11:25:52 - EMS left with Index Patient 100 (TH ED's video)

11:26:06 - EMS coming out the door of the ED (TH ED's outside ambulance bay video)

11:27 - Facility Activation time activated: 7/9/18 11:27 a.m.; Activation Type: STEMI alert (EMS report)

11:29:59 - EMS ambulance drives away (TH ED's outside ambulance bay video)

It took approximately six and half minutes from the time the ambulance entered the TH's ambulance bay; to entering the ED with the individual seeking medical attention; having a conversation between the ED Charge Nurse, ED Staff A and EMS staff; exiting the ED, loading the patient back on the ambulance, and EMS enroute to the Receiving Hospital (RH).

During review of TH ED's Policy and Procedure titled, "Transfer: Provision of Emergency Services and Care Prior to Patient Transfer (COBRA/EMTALA" with a last review date of 11/1/15 indicated, 'Transfers of Unstablilized Individuals.' "An individual whose medical condition is not stabilized may not be discharged or transferred for any reason unless one of the following conditions are met: 1. On[patient] request... or 2. With Physician Certification..." Neither of these two conditions were met.

Based on interviews, document review and review of the Transferring Hospital's (TH) policy and procedure, the Emergency Department (ED) staff, for one of 23 sampled individuals presenting to the TH ED, failed to ensure Index Patient 100 was transferred appropriately from the Transferring Hospital (TH) to a Receiving Hospital (RH) that offered specialized care when the following was not done:

1. A. medical screening exam by qualified personnel to establish if the individual had a medical emergency with stabilizing treatment;

2. Signed certification that the individual would require specialized services not offered at the TH;

3. TH Physician to RH Physician communication with acceptance of the individual; and

3. Medical records related to the emergency condition for which the individual has presented was sent to the RH.

These failures had the potential for the individual's medical condition to worsen while in transit.

Findings:

Review of the Emergency Medical Service (EMS) [ambulance] report titled, "(Name of County) Patient Care Report" dated 7/9/18, stated they brought Index Patient 100 to TH's ED for an initial complaint of sharp chest pain located in the center of the chest and radiating to both shoulders and rated her pain 10/10. She told the EMS she took 3 nitroglycerin (medication used to treat chest pain) prior to their arrival with no relief with one baby aspirin. Patient denied SOB (shortness of breath), dizziness, nausea, or vomiting. Two EKGs (A noninvasive procedure measuring electrical activity all over the heart) were taken on the way to the TH ED which showed no STEMI (complete blockage of a hearts' artery).

The EMS report also indicated that in the TH ED's ambulance bay the third 12 lead EKG "came back with STEMI showing according to the EMS (The documented EKG strips are difficult to read.) From the EMS documentation: [sic] "Upon arrival at TH PT. 12 lead (a representation of the heart's electrical activity recorded from electrodes on the body surface) came back with STEMI showing. [EMS] entered TH ED and advised PT is now showing a STEMI, ER Staff advised us to transport the PT to Receiving Hospital (RH) as they are a STEMI receiving hospital. PT loaded back into ambulance and transported to RH without changes in PT status." Review of the following documentation indicates a listing of times from the Emergency Medical Service (EMS) [ambulance], videos inside the TH ED and outside in the ambulance bay showing the ambulance arriving, entering and leaving the TH ED:

11:10 -[sic] EKG/ECG Indication: chest pain; Type: 12 lead; Clinician Interpretation:
Normal Sinus Rhythm; Elevation: False; Depression: False; Suspected STEMI: No STEMI; (EMS)

11:17 -sic] EKG/ECG Indication: chest pain; Type: 12 lead; Clinician Interpretation:
Junctional; Ectopy: PVC <6; Elevation: False; Depression: False; Suspected STEMI: No STEMI; (EMS)

11:18 -Pain scale 8 on a scale of 10; (EMS report)

11:22 - [sic] EKG/ECG Indication: chest pain; Type: 12 lead; Clinician Interpretation:
AV Block-1st degree; Elevation: False; Depression: False; Suspected STEMI: Anterior;
(EMS report)

11:23:25 - Entering Ambulance Bay (TH ED's outside ambulance bay video)

11:24:23 - Entering the TH ED's doors (TH ED's outside ambulance bay video)

11:24:55 - In the ED (TH ED's video)

11:25:46 - A conversation between EMS and ED staff (TH ED's video)

11:25:52 - EMS left with Index Patient 100 (TH ED's video)

11:26:06 - EMS coming out the door of the ED (TH ED's outside ambulance bay video)

11:27 - Facility Activation time activated: 7/9/18 11:27 a.m.; Activation Type: STEMI alert (EMS report)

11:29:59 - EMS ambulance drives away (TH ED's outside ambulance bay video)
During a phone interview on 7/13/18 at 4 p.m., EMS Paramedic stated the patient complained of chest pain. 12 lead EKG. It was all ok until we arrived at the [TH] ED bay. 12 lead then showed STEMI alert. We wheeled the patient in. I showed the EKG to the clerk [ED Staff A] - STEMI. The clerk called the RN out of the exam room. The RN came out. I showed him [ED Charge Nurse] the 12 lead. He said they had to repeat the EKG. Clerk said patient had to be signed in. RN then said you need to take patient to the RH, "We are not a STEMI Center." I said ok, we are out of here. I didn't argue. We...went to the RH.

During an interview on 7/20/18 at 9 a.m., ED Staff A stated Emergency Medical Services (EMS ) came up to the Clerk's desk with Index Patient 100. They showed me an EKG rhythm strip (A noninvasive procedure measuring electrical activity of the whole heart) they did in the TH's ambulance bay minutes before they entered here. The strip indicated a STEMI (complete blockage of the heart's artery(ies). The charge nurse was triaging a patient in a room. He came out. I asked him, "What do you want me to do?" The ED charge nurse stated to register the individual, get a 12 lead and a bed.

During the same interview when the surveyor asked if he was aware the Patient 100 was coming in he stated, "Typically, I am. It was very busy at that time. We had two ambulance here." ED staff does not recall getting a pink run sheet that gives information about an individual presenting to the ED. It happened fast. [The encounter between EMS and ED staff.]

During a review of the ED inside video on 7/18/18 followed by an interview on 7/20/189 at 10:45 a.m., it indicated shortly after Patient 100 left the ED the ED Charge Nurse and ED Staff Nurse B was seen conversing. ED Staff Nurse B stated the ED Charge Nurse told him, I think I may have done it wrong. They discussed what should be done. The ED physician, the ED manager, and the RH were contacted. The was no ED physician involvement in this encounter.

During review of TH ED's Policy and Procedure titled, "ED Structure Standards" with a last review date of 11/1/15 indicated, "Transfers from the ED will be made in accordance with EMTALA regulations. ALL transfers will be reviewed to assure the standard of care is met..."