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Based on the seriousness of the non-compliance and the effect on patient outcome related to Emergency Services, the facility failed to substantially comply with this condition.

The findings were:

These following standard was cited and shows a systemic nature of non-compliance with regards to Emergency Services as follows:

(482.55(a) Organization and Direction) The facility failed to provide emergency services consistent with standards of practice for emergency care by failing to ensure community ambulances were returned to service in a timely manner for three of three dates observed.

Based on review of facility documents, observations, and staff interviews (EMP), it was determined the facility failed to provide emergency services consistent with standards of practice for emergency care by failing to ensure community ambulances were returned to service in a timely manner for three of three dates observed.

Findings:

Review on November 2, 2022, of the facility document, "EMTALA System Policy," last reviewed May 16, 2022, revealed "Purpose To identify guidelines for providing the appropriate setting for conduction medical screening examinations To identify providers eligible to perform emergency medical screening examinations To comply with the Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C. 1395 and subsequent federal interpretive guidelines and state regulations ... Policy Any person who comes to a facility requesting assistance for a potential emergency medical condition/emergency service will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists Persons with emergency conditions will be treated and their condition stabilized without regard to ability to pay for services. ... Definitions Capability means that an organization provides the requested medical services. Comes to Hospital 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 locations listed. This definition does not apply to admitted inpatients who will be handled pursuant to various treatment processes and protocols within the hospital. Capacity means that the organization has available space and resources to provide the medically necessary emergency care. ... Hospital includes any facility that is defined by state license as such an entity and/or covered with a unique Medicare provider number. Hospital Property or Premises includes the entire main hospital campus, including the parking lot, sidewalk, driveway, and any parts of the hospital that are within 250 yards of the main buildings. ... Procedure A hospital must provide for an appropriate medical screening examination within the capability of the hospital emergency department to any individual who comes to the emergency department and requests examination or treatment. The purpose of this screening examination is to 'determine whether or not an emergency medical condition exists.' If an emergency medical condition exist, then further medical treatment must be provided to stabilize the patient or the patient must be transferred to another facility in accordance with the policy. ..."

Review on November 2, 2022, of the facility Emergency Department Director Job Description Document, last reviewed March 24, 2022, revealed "... Job Profile Name Director Nursing... Job Profile Summary Manages nursing personnel and daily operational related activities. Leads team for assigned units with responsibility for all operational functions of the team. Works in partnership with the Medical Director andPhysician [sic] Liaison of the inpatient unit to provide administrative and medical staff support to the operations of the inpatient unit. Responsible for developing and initiating improvements in the organization and delivery of high quality, cost effective patient care. Job Description... Facilitates a timely problem resolution process for patient and customer related issues. ... Accountable for satisfying all job specific obligations and complying with all organization policies and procedures ..."

Review on November 2, 2022, of the facility Job Profile Name, "Emergency Medical Services Coordinator," last reviewed July 22, 2021, revealed "...Job Profile Summary Supports the local Emergency Medical Services system for the organization. Provides technical support to Emergency Medical Services Programs. Job Description Facilitates communications between the organization and contracted local emergency medical service providers by coordinating medical direction, training and continuing education programs. ... Assumes responsibility for identifying processes or systems that could potentially lead to errors and adverse events. ..."

Review on November 1, 2022, of the facility document, "Hospital Diversion Policy," last reviewed August 2022 revealed "... Purpose The purpose of this policy is to outline process if diversion of ambulance is required. ... Policy Emergency Department Diversion of Ambulance Patients is a serious problem that can reduce access to necessary emergency care. Recognizing its role as a regional referral center, Geisinger Medical Center has never been on ambulance divert. This policy shall govern the unusual instance where diversion may be necessary. Every effort will be made to avoid diversion of ambulance patients from Geisinger. 1. Such decision will be made by the ED Attending Physician in consultation with the Chief Medical Officer (or designate). 2. Diversion decisions regarding trauma patients are communicated to the trauma on-call physician or Trauma Director at the Geisinger accredited trauma centers. 3. Diversion decisions regarding stroke patients are communicated to the Tele-stroke attending on-call, or the Stroke Director (or designate) at Geisinger accredited Stroke Centers. 4. This decision will be communicated to the public service answering points (PSAPs) and 911 centers in the surrounding counties, and surrounding hospital Emergency Departments. 5. The decision to resume accepting patients will also be the Attending Physician in consultation with the CMO (Or designate). ..."

Review on November 1, 2022, of the facility policy, "Diversion Policy," last reviewed August 31, 2022, revealed "... Purpose The purpose of this policy is to ensure the proper protocol is followed to prevent any unnecessary diversion. Persons Affected All Geisinger Staff Policy This explicitly does not refer to diversions of pre-hospital or EMS patients; no patient will be diverted from pre-hospital or EMS services. Consideration of "Divert status" is the primary responsibility of the Chief Medical Officer (or designate) after consultation with the Bed Coordinator/Nursing Supervisor and ER physician. After the divert decision has been determined and activated, the Bed Coordinator/Nursing Supervisor will notify the appropriate staff. A. The Emergency Room must continue to provide medical command despite status change. B. The Medical Command Physician shall assign an individual to notify Geisinger Placement Services at 570-214-9104 and Geisinger Administrator On-Call of the diversion. C. No hospital will divert an ambulance that is transporting a cardiac arrest patient. D. Despite any divert status, the hospital must provide an appropriate medical screening examination for any individual who comes to the Emergency Department and who requests examination or treatment for a medical condition. E. The Nursing Supervisor and the Emergency Department Physician, in consultation with the Hospital Administrator On-Call, shall determine the return to normal operating conditions at the earliest possible time. An individual shall be assigned to notify Geisinger Placement Services at 570-214-9104 of the return to normal operation conditions. F. The decision of a hospital to go on divert (either total or a lower level) when the diversion is for 8 continuous hours or for more than 12 hours in a 24-hour period is a Chapter 51, reportable event to the Department of Health. (Note: notification of your Regional EMS Council does not substitute for notification of the Department of Health.) The written report of the event must contain the date and the time when the hospital went on divert, date and time went off divert, the reasons and what the hospital did to avoid divert status. ... Definitions Diversion - an inability to admit a patient in transfer from another healthcare facility. This explicitly does not refer to diversions of pre-hospital or EMS patients; no patient has been or will be diverted from pre-hospital or EMS services. Types of Divert: Total Care Diversion - When a hospital can no longer accommodate inpatient admissions. Critical Care Divert - No more monitored beds are available. ED Divert - When the ED is no longer able to accommodate inter-facility transfers but will continue to accept patients from EMS and pre-hospital services. ..."

Review on November 1, 2022, of the facility security camera video from September 13, 2022, at approximately 1900 revealed three ambulances parked in the ED ambulance bay. The street beyond the ambulance bay was not visible.

Interview on November 1, 2022, with EMP10 and EMP11, at approximately 1130 confirmed security camera video footage showed three ambulances parked in the ED ambulance bay on September 13, 2022, at 1900 and the street beyond the ambulance bay was not visible by camera. EMP10 and EMP11 confirmed there was no way of knowing if additional ambulances were parked on the street.

Review on November 1, 2022, of the facility security camera video from September 29, 2022, at approximately 1913 revealed five ambulances parked in the ED ambulance bay. The street beyond the ambulance bay was not visible. Security camera footage of the ED ambulance bay hallway revealed five patients on ambulance stretchers lined up in the hallway with EMS crews at their side. EMS crews were observed waiting for extended periods time.

Interview on November 1, 2022, with EMP10 and EMP11, at approximately 1140 confirmed security camera footage showed five ambulances parked in the ED ambulance bay on September 29, 2022. EMP10 and EMP11 confirmed there was no way of knowing if additional ambulances were parked on the street. EMP10 and EMP11 confirmed there were five patients on ambulance stretchers lined up in the hallway with EMS crews at their side. EMP10 confirmed ambulance drop offs were often backed up and EMS crews had to wait for extended periods of time at the facility.

An observation tour of the ED ambulance bay was completed on November 1, 2022, at approximately 1200. There were four ambulances parked under the ambulance bay and four additional ambulances parked on the street adjacent to the ambulance bay. Ambulance six, ambulance seven, and ambulance eight were holding patients waiting to drop off patients inside.

Interview on November 1, 2022, with EMP12, at approximately 1205, revealed it was common for EMS to wait in line for an hour and half to unload patients at the facility ED.

Interview on November 1, 2022, with EMP13, at approximately 1205, confirmed it was common for EMS crews to wait for one hour and 30 minutes or more to unload patients at the facility ED. EMP13 confirmed this resulted in the EMS crews delay in caring for additional community patients.

Interview on November 1, 2022, with EMP21, at approximately 1207, confirmed it was common practice to EMS crews to wait at least one hour to unload patients at the facility ED.

Review on November 2, 2022, of MR4 ambulance trip report dated September 13, 2022, revealed MR4 arrived via EMS at the facility at 1053 and EMS was back in service at 1220.

Interview on November 2, 2022, with EMP9, at approximately 1430 confirmed MR4 EMS drop off was approximately one hours and twenty-seven minutes.

Review on November 2, 2022, of MR14 ambulance trip report dated September 29, 2022, revealed MR14 arrived via EMS at the facility at 1728 and EMS was back in service at 2049. There ambulance trip report contained documentation MR14 was picked up from a facility with a symptomatic blood glucose of 46. There was documentation the EMS crew arrived at the facility ED and wheeled the patient into the EMS staging area. There was documentation after a three hour wait the patient was assisted from the ambulance stretcher to a facility stretcher.

Interview on November 2, 2022, with EMP9, at approximately 1435 confirmed MR14 EMS drop off was approximately 3 hours and twenty-one minutes.

Review on November 2, 2022, of MR15 ambulance trip report dated September 29, 2022, revealed MR15 arrived via EMS at the facility 1628 and EMS was back in service at 1728. There was documentation MR15 was picked up at home via 911 for blood sugar level over 800. There was documentation upon MR15's arrival to the ED there was an extended wait for an ED bed.

Interview on November 2, 2022, with EMP9, at approximately 1440 confirmed MR15 EMS drop off was approximately one hour and 14 minutes.

Interview on November 1, 2022, with EMP9, at approximately 1210, revealed EMP9 did not feel there was an issue with EMS patient unload wait times. When asked how the facility safely cared for patients waiting in long EMS lines EMP9 stated the facility does not utilize diversion and that the patients want to come to the facility. EMP9 was not knowledgeable hospitals must not deliberately delay EMS crews by the practice of parking ambulances at the facility. EMP9 asked where such EMTALA guidance could be found.

Interview on November 1, 2022, with EMP2, at approximately 1212, revealed EMP2 was not knowledgeable hospitals must not deliberately delay EMS crews by the practice of parking ambulances at the facility. EMP2 stated it was not EMP2's problem.