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Based on observations, record reviews, interviews, review of the hospital's emergency department's Emergency Medical Treatment And Labor Act (EMTALA) policies and procedures, and review of the hospital's Rules and Regulations, the hospital failed to perform a medical screening examination for 1 of 1 patient who presented to the hospital's emergency department with chest pain and the patient had to seek treatment in another hospital. This had the potential to affect all patients that present to the hospital's emergency room whose entrance door to the emergency department was locked and patient's were addressed through an intercom system. (Patient #22)

The findings are:

Cross Reference to C 2406.

Based on video surveillance, Central log, Policy and Procedure review, and interview, the hospital failed to maintain a central log on each individual who comes to the emergency department seeking assistance for complaint of chest pains for 1 of 22 sampled patients who presented to the hospital and found the emergency department door locked, (Patient #22).

The findings are:

Video Surveillance
On 5/14/2020 at 4:15 PM, review of the hospital's video recording, dated 05/09/2020 at 12:07:53 PM showed Male #1 and Patient #22 in a silver car that parked in the emergency department's parking lot. At 12:08:13, Male #1 and Patient #22 walked toward Hospital A's emergency department patient entrance. At 12:10:53, Patient #22 and Male #1 walked away from the hospital's Emergency Department entrance and entered the silver car. At 12:16:26, Male #1 walked toward the Emergency Department entrance while talking on the telephone. At 12:20:16, Male #1 walked from the emergency department entrance while talking on the telephone. At 12:20:20, Male #1 walked toward the silver car. At 12:23:48, an ambulance arrives. At 12:24:06, 2 Emergency Medical Technicians (EMTs) exit the ambulance and talk to Male #1. At 12:24:30, one EMS Technician walked to the rear of the ambulance and gets a stretcher. At 12:26:09, Patient #22 is placed on the stretcher. At 12:26:45, Patient #22 is placed in the back of the ambulance. At 12:27:25, Male #1 walks from the back of ambulance to the silver car. At 12:34:48, the EMT driver gets into the ambulance. At 12:35:07, the ambulance exits the parking lot. Male #1 follows the ambulance in the silver car.

Central Log

On 05/14/2020 at 4:40 PM, the Edgefeild County Emergency Department (ED) central log dated 05/09/2020 was reviewed. The hospital ED log failed to reveal that Patient #22 was listed on the Emergency Department log on 05/09/2020 when she presented to the hospital's ED entrance door complaining of chest pain. The video surveillance dated 05/09/2020 verified Patient #22 presented to the ED and the ED entrance was found to be locked.



Interview
On 05/15/2020 at 11:23 AM, a telephone interview was conducted with Registered Nurse #2 in the conference room. RN #2 verifies he/she was on duty 05/09/2020 when Patient #22 presented to the emergency department entrance and pressed the buzzer and responded that he/she had chest pain. RN #2 reported, "We screen everybody. The patients come to the door and mash the button. We ask the COVID-19 questions over the intercom and then go to door. A patient came up that day and started screaming and yelling at me about answering the questions. Then, she screamed, 'Take me to Augusta'. The patient walked back to the car. I had other patients and went back to one of my rooms." When asked if he/she went to the entrance door, RN #2 reported, "We
don't normally go to the door until after the patient answers the questions. We have to see what Personal Protective Equipment (PPE) we need first. We even screen the ambulance drivers. We have forms and once the questions are filled out, we get correct PPE and meet the patient at the door. We get a temperature on the patient. The patient signs the questionnaire. The questionnaire is scanned to the patient's chart." When RN #2 was asked if any patient record for the visit was completed, RN #2 stated, "No, the patient never got through the screening at the door." RN #2 said, "Sometimes they (patients) get upset but normally they answer the questions. This patient was yelling something about going to Augusta. I am not one hundred percent sure what her complaint was, but I think the patient said, "I need to be seen. I am having chest pain." RN #2 stated, "I did not see the ambulance pull up. I went back to my patient in Room #1. I had no communication with ambulance or 911. I did not go to the door to check on the patient. RN #2 reported, "We have not had training on what to do if someone refuses to answer the questions."


Policy and Procedure

Hospital policy and procedure, titled, Central Log Requirements", established January 2007, reads, " 11.
11.1 ECH (Edgefeild Community Hospital) maintains a central log to include information on each individual who comes to the dedicated emergency room seeking examination or treatment for a medical condition, or comes to other areas on the hospital property requesting evaluation or treatment, or appears to be requesting treatment for what may be an EMC (Emergency Medical Condition).

11.1.1. The central log, which includes the emergency room patient log, admission log and ECH incident report log, must contain at a minimum the name of the individual who comes to the dedicated emergency room seeking emergency medical care; and whether each individual:
a. refused treatment
b. was refused treatment
c. was transferred
d. was admitted and treated
e. was stabilized
f. was discharged

11.1.2. The central log must be retained for EMTALA purposes for a minimum of five (5) years from the date of screening.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to maintain a central log on Patient #22 when she came to the hospital's dedicated emergency room seeking emergency medical care for the complaint of chest pain on 05/09/2020.

Based on medical record reviews, video surveillance review, written statement review, EMTALA ( Emergency Medical Treatment And Labor ACT policy and procedures review, Emergency Medical Transport (EMT) team's run report review, and review of the hospital's Medical Staff By-Laws for EMTALA, and interviews, the facility failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's Emergency Department (ED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency an emergency medical condition exists for 1 of 22 sampled patient who presented for a chief complaint for chest pain to the hospital's emergency department entrance and found the entrance door locked, (Patient #22).

The findings are:

Video Surveillance
On 5/14/2020 at 4:15 PM, review of the hospital's video recording, dated 05/09/2020 at 12:07:53 PM showed Male #1 Patient #22 in a silver car parked in the emergency department's parking lot. At 12:08:13, Male #1 and Patient #22 walked toward Hospital A's emergency department patient entrance. At 12:10:53, Patient #22 and Male #1 walked away from the hospital's Emergency Department entrance and entered the silver car. At 12:16:26, Male #1 walked toward the Emergency Department entrance while talking on the telephone. At 12:20:16, Male #1 walked from the emergency department entrance while talking on the telephone.
At 12:20:20, Male #1 walked toward the silver car. At 12:23:48, an ambulance arrives. At 12:24:06, 2 Emergency Medical Technicians (EMTs) exit the ambulance and talk to Male #1. At 12:24:30, 1 EMT walks to the rear of the ambulance and gets a stretcher. At 12:26:09, Patient #22 is placed on the stretcher. At 12:26:45, Patient #22 is placed in the back of the ambulance. At 12:27:25, Male #1 walks from the back of ambulance to the silver car. At 12:34:48, the EMT driver gets into the ambulance. At 12:35:07, the ambulance exits the parking lot. Male #1 follows the ambulance in the silver car. The video surveillance verified that the patient's only contact with the Emergency Department personnel was through an intercom system (Patient #22). The patient stated Chest Pain was the reason for his/her visit, but no staff appeared at the emergency department door or opened the emergency department door for the patient according to staff interviews because the patient did not answer COVID - 19 questions. According to video surveillance, the patient and spouse were present in the emergency room's parking lot for approximately 20 to 30 minutes but no emergency department staff was observed to approach the patient during this period.

EMS Run Sheet (5/09/2020)
"Chief complaint chest pain, back pain, and arm pain. Duration: three days. Medic was dispatched to (Hospital A) for a patient with chest pain sitting in a silver car at the ER entrance. On our arrival, we found a 48-year-old female sitting in the passenger seat of a silver car. Patient stated she had went to the door and rang the bell and informed the staff she was having chest pain. They told the patient they were at max(Maximum) capacity and couldn't see her. Then her husband called 911. We did an assessment of the patient and moved her to our stretcher and secured. She was then moved to the unit and secured. V/S (Vital signs) assessed and a 12 lead (Electrocardiogram) was done. It showed a normal sinus rhythm. Patient did relate to an increase in pain on movement and taking a deep breath. We then went en-route to Hospital B... non-emergent for chest wall pain. Patient has no other complaint during transport. V/S monitored throughout transport. Hospital B - ER was notified via radio and given a radio report and a 7 minute ETA (Estimated Time Arrival). We transported the patient to ER Room 13 and an oral report was given to the staff and care was turned over to them. Our unit was placed available.
Vital signs were: 12:20 PM - Blood Pressure(BP) 147/92, Heart Rate (HR) 78, Oxygen Saturation(O2) 98, Respirations: 16.
12:34 PM- BP 122/76, HR 77, O2 98,
12:44 PM- BP 121/84, HR 75, O2 100, Respiration 11
12:53 PM- HR 80, Respirations 16 ".


Interviews
Face-to-face interview with ED Manager - May 14, 2020 at 1:29 PM
"I found out about this late yesterday. I called the nurse this morning that was working. She's working tomorrow. She was talking through the intercom system to the patient. There is a script with three initial questions to ask. This determines whether to give the patient a mask or put them in a negative pressure room. We have five rooms in the triage room. On that day, patients were here that had been here since 8:00 AM and 9:00 AM that morning, and they were still there. This particular day, the doctor was slow turning them around. Chest pain and abdominal pain are triggers to bring patients back. We have five rooms and a stretcher. They don't use the stretcher if they don't have to. Room 2, we try to leave open for chest pain or suturing. The nurse was on the intercom with a patient (#22). She was getting up to talk to her, and the patient was walking to the car. She had another patient with chest pain that she was working up."

Emergency Medical Technician (EMT) #1- May 14, 2020 at 3:30 PM
On 05/14/2020 at 3:30 PM, a telephone interview in the conference room was conducted with the EMT #1 who verified that he/she was dispatched to ..... (Hospital A) on 05/09/2020. EMT #1 reported an ambulance was called to ..... (Hospital A) by a patient's significant other on 05/09/2020 at approximately 12:10 PM. EMT #1 reported, "The call came in as chest pain in parking lot of ..... (Hospital A). When we arrived to the ER parking lot of Hospital A, the patient was in the car and the significant other was still very upset." The complainant stated, "We went to the door, rang bell and they told us they were at full capacity." EMT 1 reported, "We ended up taking her to ..... (Hospital B's - ER(Emergency Room). The patient refused to go to ..... (Hospital A) ER."

Interview Medical Director - May 14, 2020 at 3:49 PM
On 05/14/2020 at 3:49 PM, an interview was conducted in the conference room with the Medical Director. The Medical Director reported that he/she is one of two medical directors at this hospital and he/she has been employed since 1997. The Medical Director reported that " if someone complains of chest pain, it becomes more emergent for consideration. Usually, the nurse and physician would go to the door." When asked what the ER's procedure is when a patient presents with chest pain and the hospital's ER is full, the ER Medical Director reported, "If someone could be moved, we would move them. We would try to get room number two, the code room, but we can move to room number one if room number two was not available." When asked who in the ER answers the buzzer at the door to the ER, the Medical Director replied, "The nurse absolutely." When asked what the ER's system was for patient's presenting to the ER, the Medical Director reported, ""They (patients) come to the door and ring the buzzer. Staff asks questions while the patient is outside. There is a script they follow. With the appropriate mask, a staff member goes outside to get a temperature on the patient. Once inside, we ask the questions again and normal history and physical questions." When asked if the hospital has had any problems with the COVID-19 screening process, the Medical Director stated, "Sometimes the patient gets a little huffy, but in general, everyone understands we don't have a choice." The Medical Director reported that he/she was made aware of the incident on 05/09/2020 in the ER because "MD #1 emailed both medical directors to let us know of the incident."


Interview Emergency Medical Doctor(MD) #1 - May 14, 2020 at 4:22 PM On 05/14/20 at 4:22 PM- Telephone
MD #1 verified that he/she was a third year resident who was working in the hospital's ER on 05/09/2020. MD #1 reported that he/she has worked at ..... (Hospital A) for one and a half years. MD #1 stated, "The current protocol is to ask screening questions outside once someone hits the buzzer. The patient had no distress when talking. The nurse started asking the questions, and the patient became very upset. The patient went to her vehicle and EMS showed up." When asked if the nurse who answered the buzzer told the patient that the ED was full, MD #1 stated, "I don't recall the nurse saying we were full. I was sitting at the computer, and the buzzer intercom is within a few feet." When asked if he/she at any time went to the door to lay eyes on the patient, MD #1 replied, "No." When asked if he/she had written a statement about the incident, MD #1 replied, "Yes, I wrote it this morning." When asked about any training in Emergency Medical Treatment and Labor Act (EMTALA), MD #1 replied, "Sure. I learned about EMTALA throughout my residency and training." MD #1 reviewed his/her typed unauthenticated written statement that MD #1 verified that he/she had authored that morning (May 14, 2020). MD #1's written statement, reads, "Patient presented to the ER door. She stated she was having chest pain. She was asked CoVid screening questions. She refused to answer questions and became angry and stated she was leaving and going to another facility. We told patient we would be happy to see her, however, we needed her to answer the questions and she refused. She left the door and went to her vehicle. It appears she called EMS from her car. EMS came to the parking lot and picked up patient and took her not emergent to the hospital. She never came back to the door of the ER after going to her vehicle."

Registered Nurse #1 - May 15, 2020 at 09:45 AM
On 05/15/2020 at 9:45 AM, a face to face interview was conducted in the conference room with RN #1. RN #1 verified that he/she was on duty when the incident happened on 05/09/2020. When asked, RN #1 reported that he/she had not written a statement concerning the incident dated 05/09/2020 when a patient was transferred from the hospital's parking lot to another hospital. RN #1 reported that he/she has been employed at the hospital for twenty years. RN #1 stated that on 05/09/2020 at approximately 12:08 PM he/she heard, "I overheard the intercom system. They were going through the COVID-19 questionnaire. The patient was saying something about having chest pain. Then, the patient started cursing and saying take her to another hospital. More patients are behind the patient with chest pain. I hear RN (RN #2) talking with the patient with chest pain, but the patient wouldn't answer the questions. The patient with chest pain started yelling and screaming. I did not see the patient with chest pain. I was called into Room #4. When I came out, there was another patient and a child at the door. I answered the intercom for them." RN #1 reported, "The Sheriff's office called the ER asking about a call made from the ER's parking lot. The dispatcher wanted to know if the ER still needed an ambulance to come to the parking lot. I told the dispatcher "no ma'am, a while ago, we had a patient who refused to answer the COVID-19 questions, and they must have called 911. If they would like to be seen, we can see them. When the Sheriff's Office called, the Tech(Technician) called me out of the room I was in. I did not see anyone in the parking lot. I saw the ambulance pull up while I was on the phone with Sheriff's office. I was waiting on a response, and I never got a call back from the ambulance driver or the Sheriff's office. I did not see the ambulance driver load the patient. At the time of the event, I had every room full except Room #2. We had four patients in the ER and one open room. If she came in, she would have went to Room #2." When asked, "If the ER is full, where would a new patient go?, RN #1 stated, "We have a stretcher and could possibly move another patient to make room for a new patient. We do have to get the room cleaned and it takes time."

RN #1 stated, "It is preferred one of the nurses answer the intercom, but sometimes it is a doctor or technician." When RN #1 was asked about the procedure if someone refuses to answer the COVID-19 questions, he/she stated, "Typically with COVID, we have been doing this procedure through the intercom. Once we are in appropriate mask and gown, we would get a temperature. This process helps us determine where we put the patient. Everywhere you go, you have to answer questions. We do not have a specific procedure to follow if the patient refuses to answer the questions." When asked about Emergency Medical Treatment and Labor Act (EMTALA) training, RN #1 replied, "We do computer training and fill out forms. I have had training here yearly and other places over the years."


Registered Nurse #2 - May 15, 2020 at 11:23 AM
A telephone interview was conducted with RN #2 on 05/15/2020 at 11:23 AM in the conference room. RN #2 verified that he/she remembers the incident that occurred on 05/09/2020 regarding a patient with chest pain. RN #2 reported, "We screen everybody. The patients come to the door and mash the button. We ask the COVID-19 questions over intercom, and then go to door. A patient came up that day and started screaming and yelling at me about answering the questions. Then she was screaming, "Take me to Augusta". The patient walked back to the car. I had other patients and went back to one of my rooms. We don't normally go to the door until after the patient answers the questions. We have to see what Personal Protective Equipment (PPE) we need first. We even screen the ambulance drivers. We have forms and once the questions are filled out, we get correct PPE and meet the patient at the door. We get a temperature on the patient, and the patient signs the questionnaire. The questionnaire is scanned to the chart." RN #2 was asked if any record of the patient with chest pain presentation at the ER's door on 05/09/2020 was recorded. RN #2 stated, "No. The patient never got through the screening at the door." RN #2 stated, "Sometimes they get upset, but normally they answer the questions. This patient was yelling something about going to Augusta. I am not one hundred percent sure what her complaint was, but I think the patient said, "I need to be seen. I am having chest pain." RN #2 was asked if anyone in the ER told the patient that the ER was full, and RN #2 replied, "No ma'am." RN #2 stated, "I did not see the ambulance pull up. I went back to my patient in Room #1. I had no communication with ambulance or 911. I saw the patient walk back to the car. I did not go to the door to check on the patient. Another RN (RN #1), Technician (Technician #1) and Medical Doctor(MD #1) were all right there at the nurse station when this happened. So far, all patients have answered the COVID-19 questions. We have not had training on what to do if someone refuses to answer the questions." RN #2 verified he/she has been employed at the hospital for two years. RN #2 reported that he/she had Emergency Medical Treatment and Labor Act (EMTALA) training when she started and yearly.

Emergency Room Technician #1 - May 15, 2020 at 1:40 PM
A telephone interviewed was conducted on 05/15/2020 at 1:40 PM with ER Technician #1. ER Technician #1 verified that he/she was on duty in the ER when the incident occurred on 05/09/2020. ER Technician #1 reported, "I worked that day, and I remember something out of the ordinary in that the Sheriff's office called us. That is the first time I can remember that happening. I remember that patient. She was mad. She did not want to answer those questions." ER Technician #1 reported, "The patient said, 'I am going to go to Augusta.' The telephone rang a few minutes after the patient with chest pain. I got the RN (RN #1) and let the RN(RN #1) know it was the Sheriff on the telephone." ER Technician #1 was asked what he/she recalled with the patient with chest pain, and stated, "The patient was cursing and mad. The patient walked away. I don't remember if we were full, but there were a good many patients that day, and we were busy. I never talked to the patient or saw the patient. I'm not sure if anyone went to the door. I was going in another room. I didn't see anyone go out there."

Policies and Procedures
Hospital policy and procedure, titled, "ECH Emergency Room EMTALA Policy," reads, "2. RESPONDING TO AN INDIVIDUAL/PATIENT/VISITOR WHO PRESENTS WITH AN EMERGENCY MEDICAL CONDITION ON HOSPITAL PROPERTY
DEFINITIONS:
2.1 Presents: An individual presents when they:
1. Arrive at the dedicated emergency room and request examination or treatment, or if a request is made on behalf of the individual, or if a prudent layperson would believe, based on the individual's appearance, that the individual needs emergency treatment or examination;
2. Arrive on hospital property other than the emergency room and request an examination or treatment for what may be an emergency medical condition or such a request is made on the individual's behalf, or if a prudent layperson observer would believe, based on the individual's appearance that the individual needs emergency treatment or examination.
3. Arrives in a ground or air ambulance on hospital property as defined below for medical examination and treatment in the emergency room.

2.2 Emergency medical condition: an emergency medical condition(EMC) is a medical condition manifesting itself by acute symptoms of sufficient severity ( including severe pain or altered mental status) such that the absence of immediate medical attention could reasonably be expected to result in:
1. Placing the individual (or with regard to a pregnant woman and/or her unborn child) in serious jeopardy;
2. Serious impairment to bodily functions; or
3. Serious dysfunction of any bodily organ or part; or
4. With respect to a pregnant woman having contractions delivery before reaching the receiving hospital or a threat to the health or safety of a pregnant woman and/or her unborn child.
5. With respect to psychiatric/mental health a person has an emergency medical condition (EMC) and they expressed suicidal or homicidal ideation and are a threat to themselves and/or others.

2.3 Hospital property: Hospital Property means the entire hospital facility, including the parking lots, sidewalks, driveways, and any buildings owned by a within 250 yards of the main hospital building as designated in the ECH property map. Hospital property does not include other areas are structures physically external to the hospital such as physicians offices or other healthcare providers that operate independently of a under a separate Medicare provider number.
Hospital property: hospital property means the entire hospital facility, including the parking lots, sidewalks, driveways, and any buildings owned by ECH within 250 yards of the main hospital building as designated in the ECH property map. Hospital property does not include other areas or structures physically external to the hospital such as physician offices or other healthcare providers that operate independently of ECH under a separate Medicare provider number.
Dedicated emergency room: the emergency department at ECH.

3. Appropriate Medical Screening and Stabilization
3.1 Screen and stabilize patients: a medical screening exam is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether a medical emergency exists or not. Triage is not equivalent to an MSE. If the exam does not reveal the patient has an EMC(Emergency Medical Condition), the EMTALA obligations of ECH end. If the exam reveals that the patient does have an EMC, the patient should be stabilized, or transferred if appropriate ....".

Hospital policy and procedure, titled, "Triage and Re-triage Policy", reads, "Triage is a continuous process of assessment and priority-setting which begins at the time of the patient's presentation to the Emergency Department, and continues until discharge or transfer in order to:
1. Provide immediate and appropriate assessment and intervention to all patients in the Emergency Department for emergency medical condition.
2. Promote a timely and orderly flow of patients through the emergency department.
3. Oversee the activity of the waiting area.
4. Ensure patient safety and well-being while they are waiting to be seen by a provider.
Procedure:
All patients presenting to the Emergency Department will be seen by a registered nurse in a triage capacity.
A brief triage will be conducted by the nurse who will determine the priority of care and the appropriate area for further evaluation and treatment.
All patients will receive a Medical Screening Exam by the Emergency Department Provider (MD - Medical Doctor or ANP - Advanced Nurse Practitioner). This exam will occur after triage ....".

Medical Screening Examination (MSE)
The hospital's policy and procedure, titled, "Medical Emergencies, Screening and Transfer", reads, " ....Medical Screening: A screening process to determine with reasonable clinical confidence whether an emergency condition does or does not exist. The exam is conducted by a physician or by a Nurse Practitioner. Triage is not a medical screening: it is the method of determining the location and priority order of further examination and treatment ....".

Criteria for Review of Non-Traumatic Chest Pain
1. Onset and Duration
2. Location - Onset and Presently: Radiation
3. Character and Intensity
4. Associated signs and symptoms
5. Pertinent Medical History
6. Vital signs and General Appearance
7. Cardiopulmonary examination
8. Chest wall and Abdominal examination
9. Peripheral circulatory examination including edema and tenderness
10. EKG (Electrocardiogram)as indicated
11. ABG's (Arterial Blood Gas) as indicated
12. Chest x-ray as indicated
13. CBC, (Complete blood count) isoenzymes and other lab and x-ray as indicated.
14. IV, monitor, O2 (oxygen) as indicated
15. Appropriate medications as indicated
16. Specialty referral and/or consultation
17. Instructions to patient
18. Follow up and/or referral for after-care.


MEDICAL STAFF BYLAWS
On 5/15/2020 at 9:00 AM, review of the hospital's Medical Staff Bylaws, revealed, "Outpatient and Emergency Services ....2.
ECH's Emergency Department will provide an appropriate medical screening exam to every patient presented in the ED. If it determined that an emergency medical condition exists, ECH will either stabilize the condition, or if unable to stabilize the individual, ECH will transfer the patient to a hospital that is capable of stabilizing the medical condition ....".

The facility failed to ensure that their Policies and Procedures, and Medical Staff bylaws were followed as evidenced by failing to ensure that an appropriate medical screening examination was provided on 5/9/200 by a physician or Nurse Practitioner when the patient presented to the hospital's property. Additionally, the facility failed to triage and failed to follow their chest pain protocol for the patient.