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Based on hospital policy and procedure reviews, medical record reviews, hospital documents review and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:


1. Based policy and procedure review, DED central log review and staff interview, the hospital failed to maintain an accurate central log on each individual who present to the hospital's DED (dedicated emergency department) seeking assistance as to whether or not he or she refused treatment, or was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged for 4 of 26 sampled patients. (#23, #24, #25 and #26)
~ Cross refer to §489.20(r)(3) Emergency Room Log - Tag A2405

2. Based on hospital policy and procedure review, medical record reviews, physician and staff interview and Emergency Service personnel interviews, the hospital's DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for 4 of 23 reviewed patients who presented to the DED. (#23 #24, #25 and #26).

~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406.

3. Based on hospital policy and procedure review, medical record reviews, physician and staff interview and Emergency Service personnel interviews, the Dedicated Emergency Department (DED) failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize 4 of 23 patients who presented to the DED for treatment. (#23, #24, #25 and #26)

~ Cross refer to §489.24(d)(3) Stabilizing Treatment - Tag A2407.

4. Based on hospital policy and procedure review, medical record reviews, physician and staff interview and Emergency Service personnel interviews, the hospital's Dedicated Emergency Department (DED) physician failed to ensure an appropriate transfer of 4 of 23 patients who presented to the DED for treatment. (#23, #24, #25 and #26)

~ Cross refer to §489.24(e)(2) Appropriate Transfer -Tag A2409.

Based policy and procedure review, DED central log review and staff interview, the hospital failed to maintain an accurate central log on each individual who present to the hospital's DED (dedicated emergency department) seeking assistance as to whether or not he or she refused treatment, or was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged for 4 of 26 sampled patients. (#23, #24, #25 and #26)
Findings include:
Review of hospital policy revealed: Subject: EMTALA, Medical Screening Examination, Stabilization, and Transfer, DATE OF POLICY 12/06/95, POLICY NUMBER IND 2110, REVISED 1/14, SCOPE: Emergency Department Physicians, Emergency Department Personnel, Emergency Patient Registration IV. PROCEDURE: B. All emergency department patients will be pre-registered, however the best interest of the patient and care rendered will always have precedence over registration. For pre-registration purposes the registration clerk will obtain only the patient's name and date of birth.
Review of the hospital's central log revealed Patient #23, #24, #25 and #26 were not registestered on 02/13/2016.
Interview on 03/09/2016 at 1025 with RN #2 revealed Patient #23 was never registered and Patients #24, #25 and #26 were on the ambulance and never registered.

Based on hospital policy and procedure review, medical record reviews, physician and staff interview and Emergency Service personnel interviews, the hospital's DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for 4 of 23 reviewed patients who presented to the DED. (#23 #24, #25 and #26).

The findings include:

Review of hospital policy revealed: Subject: EMTALA, Medical Screening Examination, Stabilization, and Transfer, DATE OF POLICY 12/06/95, POLICY NUMBER IND 2110, REVISED 1/14, SCOPE: Emergency Department Physicians, Emergency Department Personnel, Emergency Patient Registration I. PURPOSE: A. To provide appropriate medical care to ant individual who presents to the emergency department or a request is made on behalf for examination of treatment of a medical condition. B. To provide an appropriate medical screening examination by qualified medical personnel. C. To provide treatment and stabilization of the patient if the medical screening examination reveals an emergency medical condition.... E. To have a policy to include EMTALA requirements related to medical screening examination, stabilization, and transfer of emergency medical conditions.

1. Closed medical record review of Patient #23 on 03/10/2016 revealed a 8 year old female who presented to Hospital A's DED via EMS (emergency medical service). Review of the EMS report revealed "Incident # 2016-2902 Date: 02/13/2016 Patient 1 of 4". Review of the EMS patient care record revealed "The patient is an 8 yr old female. The patient was involved in a minor traffic accident. She was a restrained passenger in the back seat of a vehicle that has slid out of control on black ice. The car hit a guard rail, but was barely damaged. The only visible sign was a scratch on the driver's and back seat doors. No air bags were deployed and no other damage was noted. Two passengers were loaded into the ambulance, none of which was the 8 year old female. While we were obtaining vital signs, we were told we had another patient. It was the 8 year old female. She was complaining of a headache. The patient was answering questions appropriately. She was A&O x 4 (alert to person place time and situation).Another patient was added before we left the scene. Our destination was (Hospital A). While we were assessing the other patients, the 8 yr old female began to get sleepy. She was still answering questions appropriately, but due to the time in morning, it was hard to determine if she was tired or if there was a problem. I continued to assess her and she was responding. We asked the other patients if she had hit her head . They were unsure. Since the only noticeable injury was a laceration to one of the patient's face, we asked if there was a chance they had bumped heads on impact. The adult said, yes she thought they did. The patient with the laceration was on the stretcher. She was ambulatory and with the chance of a head injury, she was moved and secured on the bench seat. The patient was assisted on to the stretcher and secured. Upon palpation of the patient's head, there did not appear to be a hematoma and no bleeding was present. An IV (intravenous line) was established and when the patient did not respond to pain, I asked the first responder to go Code 3 (lights and sirens)... I assessed the patient's pupils. The right pupil was 7mm (millimeters) and the left was 3mm (millimeters). We proceeded to (Hospital A).... Once we arrived the patient was removed from the ambulance, she appeared to be more alert. She sat up and was looking around. When we entered (Hospital A), a physician was there and asked what had happened. The patient had become lethargic again and as the physician started to assess the patient, the patient became combative and loudly crying out. She was reaching toward the right side of her head. The physician said she needed to be transported to (Hospital B- 42 miles away). I told her immediately I would transport. We left the ED and were enroute to (Hospital B), Code 3 (lights and sirens). I notified (Hospital B) we were enroute with a trauma alert. Central was also notified. I gave report and was instructed to take the patient to the trauma bay upon arrival....Vital signs...were continually monitored.. I contacted (Hospital B) via radio to give an update status of the patient. At this point her GCS (Glasgow Coma Scale-15 best response, 8 or less comatose, 3 unresponsive) was 3. She was not responding at all.. She was taken to the trauma bay." Review of Hospital B's trauma flow sheet revealed the patient arrived at 0449 on 02/13/2016. Review revealed vital signs on arrival were BP 130/50, pulse 68, Temp 95.1, O2 saturation 99% and GCS 5. Record review revealed the patient was given Etomidate ( anesthetic) 7.8mg at 0503 and at 0504 succinycholine (paralytic/skeletal muscle relaxant) 52mg (milligrams) then intubated ( breathing tube to protect the airway). Record review revealed the CT scan Final Result: Impression: "Right parietal convexity large-extra-axial acute hematoma has a lenticular morphology suspicious for epidural bleed. (bleeding on the brain). No overlying calvarial fracture. There is 10mm right to left subfalcine herniation. Early obstructive hydrocephalus". Review revealed on 02/13/2016 at 0838 the patient went to the operating room for an emergency craniotomy (surgical removal of part of the bone from the skull to expose the brain)." Review of the record revealed "Discharge Summary: She did well post-operatively... She was taken back to the OR on 02/16/2016 for re-implantation of the bone flap... Her neurological exam is grossly normal and she show no obvious deficits.. Will follow up with Neurosurgery in 7-10 days. The patient was discharged home on 02/21/2016 at 1551".

Interview on 03/09/2016 at 0943 with RN (Registered Nurse) # 1 revealed she was working the night of 02/13/2016. Interview revealed she walked out of a patient's room to the nurses' station and witnessed a pediatric patient saying "the thing" while lying on an EMS stretcher. Interview revealed she heard EMS worker #1 state "the patient's pupils are not equal." Interview also revealed "Dr. said the patient will need pediatric trauma care." and EMS worker #1 said " ok, we are going to (Hospital B)..Let's roll." When asked if she witnessed an assessment of the patient she stated "no". Interview revealed the patient was never placed in a treatment room. Interview confirmed no one tried to stop EMS personnel from leaving.

Interview on 03/09/2016 at 1025 with RN # 2 revealed she remembers the events of the night of 02/13/2016. Interview revealed they received a call on the radio that they were going to receive 4 (four) patients from a wreck - 2 adults and 2 pediatric. Interview revealed EMS reported both adults were wearing c-collars and one of them had a laceration over the left eye. Interview revealed EMS also reported that the youngest of the pediatric patients was stable and had a complaint of neck pain while the 8 year old patient was lethargic but responsive with a complaint of head pain. Interview revealed as she was preparing the room for the patients arrival, the secretary alerted her to go look at the patient at the front desk. Interview revealed when she arrived at the desk, ER Physician #1 was on one side of the stretcher and both EMS personnel were on the other side doing a patient assessment. Interview revealed the patient had "sporadic jerking movements of her arms and legs as well as was hitting herself on the side of her head" saying "the thing". Interview revealed she and ER Physician #1 started listing out things the patient was going to need like CT and MRI. Interview revealed they were trying to figure out what was going on because per EMS no one spoke English. Interview revealed ER Physician #1 stated the patient needed a trauma work up. Interview revealed EMS personnel wanted to know where was the closest trauma center and was told Hospital B. Interview revealed EMS worker stated "let's roll" and left the DED. Interview confirmed no one tried to stop EMS personnel from leaving.

Interview on 03/09/2016 at 1900 with ER Physician #1 revealed the ER received a call on 02/13/2016 about getting 4 (four) patients from an accident. Interview revealed EMS brought in the little girl first (Patient #23). Interview revealed the patient was in and out of consciousness and her pupils were unequal. Interview revealed she stated the patient will need trauma and neurosurgeon. Interview revealed per EMS worker # 1 "we got all 4 of them, we are not going to break them up." Interview revealed when asked if she completed a MSE, she replied "all I did was listen to her chest". Interview revealed nurses stated that we will keep her (the patient). Interview revealed EMS worker #1 stated "we are not going to break them up, let's roll". Interview revealed she stated "we will keep her... EMS worker #1 replied "I am just going to take her to (Hospital B)". Interview confirmed no one tried to stop EMS personnel from leaving.

Interview on 03/09/2016 at 1045 with EMS worker #1 revealed after introduction she stated "Is this about the Dr. refusing to assume care of the patient?" Interview revealed she remembers the series of events. Interview revealed she responded to a MVC (motor vehicle collision) dispatch approximately at 0300 on 02/13/2016. Interview revealed the First Responders (Fire Fighters) said they had 2 patients both in c-collars and one with a laceration under left eye. Interview revealed while she was doing her assessment the backdoor opened and the First Responders said you have 2 (two) more patients. Interview revealed the little girl patient was acting sleepy and upon assessment the right pupil was larger than the left. Interview revealed the pediatric patient was answering question and sat up with eyes wide open. Interview revealed upon arrival to Hospital A, ER Physician #1 looked at the child and said "she needed to go to (Hospital B)". Interview revealed "I feel like that doctor saved that child's life". "I said yes, we will transport, we will take her right now." Interview confirmed no one tried to stop EMS personnel from leaving.

Interview on 03/09/2016 at 1125 with EMS worker # 2 revealed she remembers responding to MVC call. Interview revealed one patient complaining of neck pain and the other patient with a laceration under the left eye. Interview revealed when they were notified on the scene of 2 patients she requested a driver. Interview revealed while doing assessment on the two patients, there was a knock on the door and First Responder (FireFighter) stated "we want this guy to go". Interview revealed it was the male pediatric patient. Interview revealed another knock on the door, it was the First Responders with the female pediatric patient (Pt #23) stating Dad wanted her to go get checked out. Interview revealed she noticed there was something "not right" with the little girl. Interview revealed she was whinning. Interview revealed upon arrival to Hospital A, EMS worker #1 and First Responder took (Pt #23) into the DED via stretcher as she went to get a wheelchair for the other patients. Interview revealed before she took any other patient out of the ambulance, EMS worker #1 was walking out of the DED with the patient and First Responder. Interview revealed she stated EMS work #1 stated "Don't get them out, we go to go to (Hospital B). This doctor said she wasn't going to touch her, she needed to go to (Hospital B)." Interview confirmed no one tried to stop EMS personnel from leaving.


Interview on 03/09/2016 at 1520 with FireFighter #1 revealed he volunteered to drive ambulance to Hospital A since they had 4 (four) patients. Interview revealed he was told " we are going to (Hospital A) emergency traffic (lights and sirens), she appears to have a head injury." Interview revealed the female pediatric patient was not acting the same as she was on the scene of the accident. Interview revealed once they entered Hospital A's DED and gave report, ER Physician #1 said "she will have to go to (Hospital B)." Interview revealed EMS worker #1 asked for clarification along the lines of "are you sure you want us to go and not stay?" Interview revealed the ER Physician replied "yes". Interview confirmed no one tried to stop EMS personnel from leaving.


2. Closed medical record review of Patient #24 on 03/10/2016 revealed a 6 year old male who was involved in a motor vehicle accident. Review of the EMS report revealed "Incident # 2016-2902 Date: 02/13/2016 Patient 3 of 4". Review of the EMS patient care record revealed "The patient was a passenger in the back seat of this vehicle accident. He was restrained. ..Patient walked to the ambulance. The patient was secured in his booster seat with the seat belt to the bench seat. The patient was transported to (Hospital B) with the trauma already in the truck. Patient has no other complaints but a headache. Patient was pointing to the top of his head stating that was where his head hurt... Patient was placed in triage at Hospital B. Report was given to the ED nurse. Patient was with his mother in the triage area." Record review revealed the patient was examined by a physician in Hospital B's DED at 0642 diagnosed with a "Headache" and discharged at 0709.

Interview on 03/09/2016 at 1025 with RN # 2 revealed she remembers the events of the night of 02/13/2016. Interview revealed they received a call on the radio that they were going to receive 4 (four) patients from a wreck - 2 adults and 2 pediatric. Interview revealed EMS reported both adults were wearing c-collars and one of them had a laceration over the left eye. Interview revealed three (3) patients were never taken out of the ambulance at Hospital A.

Interview on 03/09/2016 at 1900 with ER Physician #1 revealed the ER received a call on 02/13/2016 about getting 4 (four) patients from an accident. Interview revealed EMS brought in the little girl first (Patient #23). Interview revealed the other patients remained on the ambulance without examination or treatment. Interview confirmed the EMS personnel departed Hosptial A's property with 4 (four) patients.

Interview on 03/09/2016 at 1045 with EMS worker #1 revealed after introduction she stated "Is this about the Dr. refusing to assume care of the patient?" Interview revealed she remembers the series of events. Interview revealed she responded to a MVC (motor vehicle collision) dispatch approximately at 0300 on 02/13/2016. Interview revealed the First Responders (Fire Fighters) said they had 2 patients both in c-collars and one with a laceration under left eye. Interview revealed while she was doing her assessment the backdoor opened and the First Responders said you have 2 (two) more patients. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1125 with EMS worker # 2 revealed she remembers responding to MVC call. Interview revealed one patient complaining of neck pain and the other patient with a laceration under the left eye. Interview revealed when they were notified on the scene of 2 patients, she requested a driver. Interview revealed while doing assessment on the two patients, there was a knock on the door and First Responder (FireFighter) stated "we want this guy to go". Interview revealed it was the male pediatric patient (Patient # 24) Interview revealed another knock on the door, it was the First Responders with the female pediatric patient (Patient #23) stating Dad wanted her to go get checked out. Interview revealed while she was getting wheelchairs to assist the other patients in to the DED she was stopped by EMS worker #1 and told not to get anyone off the ambulance. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1520 with FireFighter #1 revealed he volunteered to drive ambulance to Hospital A since they had 4 (four) patients. Interview revealed 3 of the patients never got off the ambulance and were not treated by Hospital A's staff. Interview confirmed 4 (four) patients were transported from Hospital A to Hospital B.



3. Closed medical record review of Patient #25 on 03/10/2016 revealed a 40 year old female who was involved in a motor vehicle accident. Review of the EMS report revealed "Incident # 2016-2902 Date: 02/13/2016 Patient 2 of 4". Review of the EMS patient care record revealed " The patient was a front seat passenger in this vehicle that hit some black ice on I-40...Patient stated her neck hurt so she was placed in a c-collar. Patient was secured to the bench seat and transported to (Hospital B) where her daughter was taken from this same accident to trauma. Patient was placed in stretcher triage. Report was given to ED nurse..This patient spoke no English. There was another patient on board that was capable of translating." Record review revealed the patient was examined by a physician in Hospital B's DED at 0637 diagnosed with "Strain of the muscle and tendon of back wall of thorax" and discharged at 0720.

Interview on 03/09/2016 at 1025 with RN # 2 revealed she remembers the events of the night of 02/13/2016. Interview revealed they received a call on the radio that they were going to receive 4 (four) patients from a wreck - 2 adults and 2 pediatric. Interview revealed EMS reported both adults were wearing c-collars and one of them had a laceration over the left eye. Interview revealed three (3) patients were never taken out of the ambulance at Hospital A.

Interview on 03/09/2016 at 1900 with ER Physician #1 revealed the ER received a call on 02/13/2016 about getting 4 (four) patients from an accident. Interview revealed EMS brought in the little girl first (Patient #23). Interview revealed the other patients remained on the ambulance without examination or treatment. Interview confirmed the EMS personnel departed Hosptial A's property with 4 (four) patients.

Interview on 03/09/2016 at 1045 with EMS worker #1 revealed after introduction she stated "Is this about the Dr. refusing to assume care of the patient?" Interview revealed she remembers the series of events. Interview revealed she responded to a MVC (motor vehicle collision) dispatch approximately at 0300 on 02/13/2016. Interview revealed the First Responders (Fire Fighters) said they had 2 patients both in c-collars and one with a laceration under left eye. Interview revealed while she was doing her assessment the backdoor opened and the First Responders said you have 2 (two) more patients. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1125 with EMS worker # 2 revealed she remembers responding to MVC call. Interview revealed one patient complaining of neck pain and the other patient with a laceration under the left eye. Interview revealed when they were notified on the scene of 2 patients, she requested a driver. Interview revealed while doing assessment on the two patients, there was a knock on the door and First Responder (FireFighter) stated "we want this guy to go". Interview revealed it was the male pediatric patient (Patient # 24) Interview revealed another knock on the door, it was the First Responders with the female pediatric patient (Patient #23) stating Dad wanted her to go get checked out. Interview revealed while she was getting wheelchairs to assist the other patients in to the DED she was stopped by EMS worker #1 and told not to get anyone off the ambulance. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1520 with FireFighter #1 revealed he volunteered to drive ambulance to Hospital A since they had 4 (four) patients. Interview revealed 3 of the patients never got off the ambulance and were not treated by Hospital A's staff. Interview confirmed 4 (four) patients were transported from Hospital A to Hospital B.


4. Closed medical record review of Patient #26 on 03/10/2016 revealed a 27 year old female who was involved in a motor vehicle accident. Review of the EMS report revealed "Incident # 2016-2902 Date: 02/13/2016 Patient 4 of 4". Review of the EMS patient care record revealed "Patient was a restrained passenger in the back seat of the vehicle that hit a patch of ice and then struck the guard rail....Patient had 2 inch laceration under her left eye. This occurred from the small child sitting to the patient's left at the time the vehicle hit the black ice this child's head hit this patient in the face. The laceration was not bleeding upon EMS arrival. Patient was given an ice pack to place on the injury. Patient was also complaining of neck pain so she was placed in a c-collar. Patient did not have any back pain at the time... Patient was secured to the bench seat and transported to (Hospital B) with the trauma child. Patient was placed in triage bed #7. Report given to ED nurse." Record review revealed the patient was examined by a physician at Hospital B's DED. Record review revealed Xrays and CT scan were ordered which were negative. Record review revealed laceration repair was performed and the patient diagnosed with "Laceration without foreign body of left cheek, Contusion of left knee, Contusion of right knee, Headache, Other chest pain and Cervicalgia" and discharged at 0905.

Interview on 03/09/2016 at 1025 with RN # 2 revealed she remembers the events of the night of 02/13/2016. Interview revealed they received a call on the radio that they were going to receive 4 (four) patients from a wreck - 2 adults and 2 pediatric. Interview revealed EMS reported both adults were wearing c-collars and one of them had a laceration over the left eye. Interview revealed three (3) patients were never taken out of the ambulance at Hospital A.

Interview on 03/09/2016 at 1900 with ER Physician #1 revealed the ER received a call on 02/13/2016 about getting 4 (four) patients from an accident. Interview revealed EMS brought in the little girl first (Patient #23). Interview revealed the other patients remained on the ambulance without examination or treatment. Interview confirmed the EMS personnel departed Hosptial A's property with 4 (four) patients.

Interview on 03/09/2016 at 1045 with EMS worker #1 revealed after introduction she stated "Is this about the Dr. refusing to assume care of the patient?" Interview revealed she remembers the series of events. Interview revealed she responded to a MVC (motor vehicle collision) dispatch approximately at 0300 on 02/13/2016. Interview revealed the First Responders (Fire Fighters) said they had 2 patients both in c-collars and one with a laceration under left eye. Interview revealed while she was doing her assessment the backdoor opened and the First Responders said you have 2 (two) more patients. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1125 with EMS worker # 2 revealed she remembers responding to MVC call. Interview revealed one patient complaining of neck pain and the other patient with a laceration under the left eye. Interview revealed when they were notified on the scene of 2 patients, she requested a driver. Interview revealed while doing assessment on the two patients, there was a knock on the door and First Responder (FireFighter) stated "we want this guy to go". Interview revealed it was the male pediatric patient (Patient # 24) Interview revealed another knock on the door, it was the First Responders with the female pediatric patient (Patient #23) stating Dad wanted her to go get checked out. Interview revealed while she was getting wheelchairs to assist the other patients in to the DED she was stopped by EMS worker #1 and told not to get anyone off the ambulance. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1520 with FireFighter #1 revealed he volunteered to drive ambulance to Hospital A since they had 4 (four) patients. Interview revealed 3 of the patients never got off the ambulance and were not treated by Hospital A's staff. Interview confirmed 4 (four) patients were transported from Hospital A to Hospital B.

Based on hospital policy and procedure review, medical record reviews, physician and staff interview and Emergency Service personnel interviews, the Dedicated Emergency Department (DED) failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize 4 of 23 patients who presented to the DED for treatment. (#23, #24, #25 and #26)


The Findings include:


Review of hospital policy revealed: Subject: EMTALA, Medical Screening Examination, Stabilization, and Transfer, DATE OF POLICY 12/06/95, POLICY NUMBER IND 2110, REVISED 1/14, SCOPE: Emergency Department Physicians, Emergency Department Personnel, Emergency Patient Registration I. PURPOSE: A. To provide appropriate medical care to ant individual who presents to the emergency department or a request is made on behalf for examination of treatment of a medical condition. B. To provide an appropriate medical screening examination by qualified medical personnel. C. To provide treatment and stabilization of the patient if the medical screening examination reveals an emergency medical condition.... E. To have a policy to include EMTALA requirements related to medical screening examination, stabilization, and transfer of emergency medical conditions.

1. Closed medical record review of Patient #23 on 03/10/2016 revealed a 8 year old female who presented to Hospital A's DED via EMS (emergency medical service). Review of the EMS report revealed "Incident # 2016-2902 Date: 02/13/2016 Patient 1 of 4". Review of the EMS patient care record revealed "The patient is an 8 yr old female. The patient was involved in a minor traffic accident. She was a restrained passenger in the back seat of a vehicle that has slid out of control on black ice. The car hit a guard rail, but was barely damaged. The only visible sign was a scratch on the driver's and back seat doors. No air bags were deployed and no other damage was noted. Two passengers were loaded into the ambulance, none of which was the 8 year old female. While we were obtaining vital signs, we were told we had another patient. It was the 8 year old female. She was complaining of a headache. The patient was answering questions appropriately. She was A&O x 4 (alert to person place time and situation).Another patient was added before we left the scene. Our destination was (Hospital A). While we were assessing the other patients, the 8 yr old female began to get sleepy. She was still answering questions appropriately, but due to the time in morning, it was hard to determine if she was tired or if there was a problem. I continued to assess her and she was responding. We asked the other patients if she had hit her head . They were unsure. Since the only noticeable injury was a laceration to one of the patient's face, we asked if there was a chance they had bumped heads on impact. The adult said, yes she thought they did. The patient with the laceration was on the stretcher. She was ambulatory and with the chance of a head injury, she was moved and secured on the bench seat. The patient was assisted on to the stretcher and secured. Upon palpation of the patient's head, there did not appear to be a hematoma and no bleeding was present. An IV (intravenous line) was established and when the patient did not respond to pain, I asked the first responder to go Code 3 (lights and sirens)... I assessed the patient's pupils. The right pupil was 7mm (millimeters) and the left was 3mm (millimeters). We proceeded to (Hospital A).... Once we arrived the patient was removed from the ambulance, she appeared to be more alert. She sat up and was looking around. When we entered (Hospital A), a physician was there and asked what had happened. The patient had become lethargic again and as the physician started to assess the patient, the patient became combative and loudly crying out. She was reaching toward the right side of her head. The physician said she needed to be transported to (Hospital B- 42 miles away). I told her immediately I would transport. We left the ED and were enroute to (Hospital B), Code 3 (lights and sirens). I notified (Hospital B) we were enroute with a trauma alert. Central was also notified. I gave report and was instructed to take the patient to the trauma bay upon arrival....Vital signs...were continually monitored.. I contacted (Hospital B) via radio to give an update status of the patient. At this point her GCS (Glasgow Coma Scale-15 best response, 8 or less comatose, 3 unresponsive) was 3. She was not responding at all.. She was taken to the trauma bay." Review of Hospital B's trauma flow sheet revealed the patient arrived at 0449 on 02/13/2016. Review revealed vital signs on arrival were BP 130/50, pulse 68, Temp 95.1, O2 saturation 99% and GCS 5. Record review revealed the patient was given Etomidate ( anesthetic) 7.8mg at 0503 and at 0504 succinycholine (paralytic/skeletal muscle relaxant) 52mg (milligrams) then intubated ( breathing tube to protect the airway). Record review revealed the CT scan Final Result: Impression: "Right parietal convexity large-extra-axial acute hematoma has a lenticular morphology suspicious for epidural bleed. (bleeding on the brain). No overlying calvarial fracture. There is 10mm right to left subfalcine herniation. Early obstructive hydrocephalus". Review revealed on 02/13/2016 at 0838 the patient went to the operating room for an emergency craniotomy (surgical removal of part of the bone from the skull to expose the brain)." Review of the record revealed "Discharge Summary: She did well post-operatively... She was taken back to the OR on 02/16/2016 for re-implantation of the bone flap... Her neurological exam is grossly normal and she show no obvious deficits.. Will follow up with Neurosurgery in 7-10 days. The patient was discharged home on 02/21/2016 at 1551".

Interview on 03/09/2016 at 0943 with RN (Registered Nurse) # 1 revealed she was working the night of 02/13/2016. Interview revealed she walked out of a patient's room to the nurses' station and witnessed a pediatric patient saying "the thing" while lying on an EMS stretcher. Interview revealed she heard EMS worker #1 state "the patient's pupils are not equal." Interview also revealed "Dr. said the patient will need pediatric trauma care." and EMS worker #1 said " ok, we are going to (Hospital B)..Let's roll." When asked if she witnessed an assessment of the patient she stated "no". Interview revealed the patient was never placed in a treatment room. Interview confirmed no one tried to stop EMS personnel from leaving.

Interview on 03/09/2016 at 1025 with RN # 2 revealed she remembers the events of the night of 02/13/2016. Interview revealed they received a call on the radio that they were going to receive 4 (four) patients from a wreck - 2 adults and 2 pediatric. Interview revealed EMS reported both adults were wearing c-collars and one of them had a laceration over the left eye. Interview revealed EMS also reported that the youngest of the pediatric patients was stable and had a complaint of neck pain while the 8 year old patient was lethargic but responsive with a complaint of head pain. Interview revealed as she was preparing the room for the patients arrival, the secretary alerted her to go look at the patient at the front desk. Interview revealed when she arrived at the desk, ER Physician #1 was on one side of the stretcher and both EMS personnel were on the other side doing a patient assessment. Interview revealed the patient had "sporadic jerking movements of her arms and legs as well as was hitting herself on the side of her head" saying "the thing". Interview revealed she and ER Physician #1 started listing out things the patient was going to need like CT and MRI. Interview revealed they were trying to figure out what was going on because per EMS no one spoke English. Interview revealed ER Physician #1 stated the patient needed a trauma work up. Interview revealed EMS personnel wanted to know where was the closest trauma center and was told Hospital B. Interview revealed EMS worker stated "let's roll" and left the DED. Interview confirmed no one tried to stop EMS personnel from leaving.

Interview on 03/09/2016 at 1900 with ER Physician #1 revealed the ER received a call on 02/13/2016 about getting 4 (four) patients from an accident. Interview revealed EMS brought in the little girl first (Patient #23). Interview revealed the patient was in and out of consciousness and her pupils were unequal. Interview revealed she stated the patient will need trauma and neurosurgeon. Interview revealed per EMS worker # 1 "we got all 4 of them, we are not going to break them up." Interview revealed when asked if she completed a MSE, she replied "all I did was listen to her chest". Interview revealed nurses stated that we will keep her (the patient). Interview revealed EMS worker #1 stated "we are not going to break them up, let's roll". Interview revealed she stated "we will keep her... EMS worker #1 replied "I am just going to take her to (Hospital B)". Interview confirmed no one tried to stop EMS personnel from leaving.

Interview on 03/09/2016 at 1045 with EMS worker #1 revealed after introduction she stated "Is this about the Dr. refusing to assume care of the patient?" Interview revealed she remembers the series of events. Interview revealed she responded to a MVC (motor vehicle collision) dispatch approximately at 0300 on 02/13/2016. Interview revealed the First Responders (Fire Fighters) said they had 2 patients both in c-collars and one with a laceration under left eye. Interview revealed while she was doing her assessment the backdoor opened and the First Responders said you have 2 (two) more patients. Interview revealed the little girl patient was acting sleepy and upon assessment the right pupil was larger than the left. Interview revealed the pediatric patient was answering question and sat up with eyes wide open. Interview revealed upon arrival to Hospital A, ER Physician #1 looked at the child and said "she needed to go to (Hospital B)". Interview revealed "I feel like that doctor saved that child's life". "I said yes, we will transport, we will take her right now." Interview confirmed no one tried to stop EMS personnel from leaving.

Interview on 03/09/2016 at 1125 with EMS worker # 2 revealed she remembers responding to MVC call. Interview revealed one patient complaining of neck pain and the other patient with a laceration under the left eye. Interview revealed when they were notified on the scene of 2 patients she requested a driver. Interview revealed while doing assessment on the two patients, there was a knock on the door and First Responder (FireFighter) stated "we want this guy to go". Interview revealed it was the male pediatric patient. Interview revealed another knock on the door, it was the First Responders with the female pediatric patient (Pt #23) stating Dad wanted her to go get checked out. Interview revealed she noticed there was something "not right" with the little girl. Interview revealed she was whinning. Interview revealed upon arrival to Hospital A, EMS worker #1 and First Responder took (Pt #23) into the DED via stretcher as she went to get a wheelchair for the other patients. Interview revealed before she took any other patient out of the ambulance, EMS worker #1 was walking out of the DED with the patient and First Responder. Interview revealed she stated EMS work #1 stated "Don't get them out, we go to go to (Hospital B). This doctor said she wasn't going to touch her, she needed to go to (Hospital B)." Interview confirmed no one tried to stop EMS personnel from leaving.


Interview on 03/09/2016 at 1520 with FireFighter #1 revealed he volunteered to drive ambulance to Hospital A since they had 4 (four) patients. Interview revealed he was told " we are going to (Hospital A) emergency traffic (lights and sirens), she appears to have a head injury." Interview revealed the female pediatric patient was not acting the same as she was on the scene of the accident. Interview revealed once they entered Hospital A's DED and gave report, ER Physician #1 said "she will have to go to (Hospital B)." Interview revealed EMS worker #1 asked for clarification along the lines of "are you sure you want us to go and not stay?" Interview revealed the ER Physician replied "yes". Interview confirmed no one tried to stop EMS personnel from leaving.


2. Closed medical record review of Patient #24 on 03/10/2016 revealed a 6 year old male who was involved in a motor vehicle accident. Review of the EMS report revealed "Incident # 2016-2902 Date: 02/13/2016 Patient 3 of 4". Review of the EMS patient care record revealed "The patient was a passenger in the back seat of this vehicle accident. He was restrained. ..Patient walked to the ambulance. The patient was secured in his booster seat with the seat belt to the bench seat. The patient was transported to (Hospital B) with the trauma already in the truck. Patient has no other complaints but a headache. Patient was pointing to the top of his head stating that was where his head hurt... Patient was placed in triage at Hospital B. Report was given to the ED nurse. Patient was with his mother in the triage area." Record review revealed the patient was examined by a physician in Hospital B's DED at 0642 diagnosed with a "Headache" and discharged at 0709.

Interview on 03/09/2016 at 1025 with RN # 2 revealed she remembers the events of the night of 02/13/2016. Interview revealed they received a call on the radio that they were going to receive 4 (four) patients from a wreck - 2 adults and 2 pediatric. Interview revealed EMS reported both adults were wearing c-collars and one of them had a laceration over the left eye. Interview revealed three (3) patients were never taken out of the ambulance at Hospital A.

Interview on 03/09/2016 at 1900 with ER Physician #1 revealed the ER received a call on 02/13/2016 about getting 4 (four) patients from an accident. Interview revealed EMS brought in the little girl first (Patient #23). Interview revealed the other patients remained on the ambulance without examination or treatment. Interview confirmed the EMS personnel departed Hosptial A's property with 4 (four) patients.

Interview on 03/09/2016 at 1045 with EMS worker #1 revealed after introduction she stated "Is this about the Dr. refusing to assume care of the patient?" Interview revealed she remembers the series of events. Interview revealed she responded to a MVC (motor vehicle collision) dispatch approximately at 0300 on 02/13/2016. Interview revealed the First Responders (Fire Fighters) said they had 2 patients both in c-collars and one with a laceration under left eye. Interview revealed while she was doing her assessment the backdoor opened and the First Responders said you have 2 (two) more patients. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1125 with EMS worker # 2 revealed she remembers responding to MVC call. Interview revealed one patient complaining of neck pain and the other patient with a laceration under the left eye. Interview revealed when they were notified on the scene of 2 patients, she requested a driver. Interview revealed while doing assessment on the two patients, there was a knock on the door and First Responder (FireFighter) stated "we want this guy to go". Interview revealed it was the male pediatric patient (Patient # 24) Interview revealed another knock on the door, it was the First Responders with the female pediatric patient (Patient #23) stating Dad wanted her to go get checked out. Interview revealed while she was getting wheelchairs to assist the other patients in to the DED she was stopped by EMS worker #1 and told not to get anyone off the ambulance. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1520 with FireFighter #1 revealed he volunteered to drive ambulance to Hospital A since they had 4 (four) patients. Interview revealed 3 of the patients never got off the ambulance and were not treated by Hospital A's staff. Interview confirmed 4 (four) patients were transported from Hospital A to Hospital B.



3. Closed medical record review of Patient #25 on 03/10/2016 revealed a 40 year old female who was involved in a motor vehicle accident. Review of the EMS report revealed "Incident # 2016-2902 Date: 02/13/2016 Patient 2 of 4". Review of the EMS patient care record revealed " The patient was a front seat passenger in this vehicle that hit some black ice on I-40...Patient stated her neck hurt so she was placed in a c-collar. Patient was secured to the bench seat and transported to (Hospital B) where her daughter was taken from this same accident to trauma. Patient was placed in stretcher triage. Report was given to ED nurse..This patient spoke no English. There was another patient on board that was capable of translating." Record review revealed the patient was examined by a physician in Hospital B's DED at 0637 diagnosed with "Strain of the muscle and tendon of back wall of thorax" and discharged at 0720.

Interview on 03/09/2016 at 1025 with RN # 2 revealed she remembers the events of the night of 02/13/2016. Interview revealed they received a call on the radio that they were going to receive 4 (four) patients from a wreck - 2 adults and 2 pediatric. Interview revealed EMS reported both adults were wearing c-collars and one of them had a laceration over the left eye. Interview revealed three (3) patients were never taken out of the ambulance at Hospital A.

Interview on 03/09/2016 at 1900 with ER Physician #1 revealed the ER received a call on 02/13/2016 about getting 4 (four) patients from an accident. Interview revealed EMS brought in the little girl first (Patient #23). Interview revealed the other patients remained on the ambulance without examination or treatment. Interview confirmed the EMS personnel departed Hosptial A's property with 4 (four) patients.

Interview on 03/09/2016 at 1045 with EMS worker #1 revealed after introduction she stated "Is this about the Dr. refusing to assume care of the patient?" Interview revealed she remembers the series of events. Interview revealed she responded to a MVC (motor vehicle collision) dispatch approximately at 0300 on 02/13/2016. Interview revealed the First Responders (Fire Fighters) said they had 2 patients both in c-collars and one with a laceration under left eye. Interview revealed while she was doing her assessment the backdoor opened and the First Responders said you have 2 (two) more patients. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1125 with EMS worker # 2 revealed she remembers responding to MVC call. Interview revealed one patient complaining of neck pain and the other patient with a laceration under the left eye. Interview revealed when they were notified on the scene of 2 patients, she requested a driver. Interview revealed while doing assessment on the two patients, there was a knock on the door and First Responder (FireFighter) stated "we want this guy to go". Interview revealed it was the male pediatric patient (Patient # 24) Interview revealed another knock on the door, it was the First Responders with the female pediatric patient (Patient #23) stating Dad wanted her to go get checked out. Interview revealed while she was getting wheelchairs to assist the other patients in to the DED she was stopped by EMS worker #1 and told not to get anyone off the ambulance. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1520 with FireFighter #1 revealed he volunteered to drive ambulance to Hospital A since they had 4 (four) patients. Interview revealed 3 of the patients never got off the ambulance and were not treated by Hospital A's staff. Interview confirmed 4 (four) patients were transported from Hospital A to Hospital B.


4. Closed medical record review of Patient #26 on 03/10/2016 revealed a 27 year old female who was involved in a motor vehicle accident. Review of the EMS report revealed "Incident # 2016-2902 Date: 02/13/2016 Patient 4 of 4". Review of the EMS patient care record revealed "Patient was a restrained passenger in the back seat of the vehicle that hit a patch of ice and then struck the guard rail....Patient had 2 inch laceration under her left eye. This occurred from the small child sitting to the patient's left at the time the vehicle hit the black ice this child's head hit this patient in the face. The laceration was not bleeding upon EMS arrival. Patient was given an ice pack to place on the injury. Patient was also complaining of neck pain so she was placed in a c-collar. Patient did not have any back pain at the time... Patient was secured to the bench seat and transported to (Hospital B) with the trauma child. Patient was placed in triage bed #7. Report given to ED nurse." Record review revealed the patient was examined by a physician at Hospital B's DED. Record review revealed Xrays and CT scan were ordered which were negative. Record review revealed laceration repair was performed and the patient diagnosed with "Laceration without foreign body of left cheek, Contusion of left knee, Contusion of right knee, Headache, Other chest pain and Cervicalgia" and discharged at 0905.

Interview on 03/09/2016 at 1025 with RN # 2 revealed she remembers the events of the night of 02/13/2016. Interview revealed they received a call on the radio that they were going to receive 4 (four) patients from a wreck - 2 adults and 2 pediatric. Interview revealed EMS reported both adults were wearing c-collars and one of them had a laceration over the left eye. Interview revealed three (3) patients were never taken out of the ambulance at Hospital A.

Interview on 03/09/2016 at 1900 with ER Physician #1 revealed the ER received a call on 02/13/2016 about getting 4 (four) patients from an accident. Interview revealed EMS brought in the little girl first (Patient #23). Interview revealed the other patients remained on the ambulance without examination or treatment. Interview confirmed the EMS personnel departed Hosptial A's property with 4 (four) patients.

Interview on 03/09/2016 at 1045 with EMS worker #1 revealed after introduction she stated "Is this about the Dr. refusing to assume care of the patient?" Interview revealed she remembers the series of events. Interview revealed she responded to a MVC (motor vehicle collision) dispatch approximately at 0300 on 02/13/2016. Interview revealed the First Responders (Fire Fighters) said they had 2 patients both in c-collars and one with a laceration under left eye. Interview revealed while she was doing her assessment the backdoor opened and the First Responders said you have 2 (two) more patients. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1125 with EMS worker # 2 revealed she remembers responding to MVC call. Interview revealed one patient complaining of neck pain and the other patient with a laceration under the left eye. Interview revealed when they were notified on the scene of 2 patients, she requested a driver. Interview revealed while doing assessment on the two patients, there was a knock on the door and First Responder (FireFighter) stated "we want this guy to go". Interview revealed it was the male pediatric patient (Patient # 24) Interview revealed another knock on the door, it was the First Responders with the female pediatric patient (Patient #23) stating Dad wanted her to go get checked out. Interview revealed while she was getting wheelchairs to assist the other patients in to the DED she was stopped by EMS worker #1 and told not to get anyone off the ambulance. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1520 with FireFighter #1 revealed he volunteered to drive ambulance to Hospital A since they had 4 (four) patients. Interview revealed 3 of the patients never got off the ambulance and were not treated by Hospital A's staff. Interview confirmed 4 (four) patients were transported from Hospital A to Hospital B.

Based on hospital policy and procedure review, medical record reviews, physician and staff interview and Emergency Service personnel interviews, the hospital's Dedicated Emergency Department (DED) physician failed to ensure an appropriate transfer of 4 of 23 patients who presented to the DED for treatment. (#23, #24, #25 and #26)

The Findings include:

Review of hospital policy revealed: Subject: EMTALA, Medical Screening Examination, Stabilization, and Transfer, DATE OF POLICY 12/06/95, POLICY NUMBER IND 2110, REVISED 1/14, SCOPE: Emergency Department Physicians, Emergency Department Personnel, Emergency Patient Registration I. PURPOSE: A. To provide appropriate medical care to ant individual who presents to the emergency department or a request is made on behalf for examination of treatment of a medical condition. B. To provide an appropriate medical screening examination by qualified medical personnel. C. To provide treatment and stabilization of the patient if the medical screening examination reveals an emergency medical condition.... E. To have a policy to include EMTALA requirements related to medical screening examination, stabilization, and transfer of emergency medical conditions.

1. Closed medical record review of Patient #23 on 03/10/2016 revealed a 8 year old female who presented to Hospital A's DED via EMS (emergency medical service). Review of the EMS report revealed "Incident # 2016-2902 Date: 02/13/2016 Patient 1 of 4". Review of the EMS patient care record revealed "The patient is an 8 yr old female. The patient was involved in a minor traffic accident. She was a restrained passenger in the back seat of a vehicle that has slid out of control on black ice. The car hit a guard rail, but was barely damaged. The only visible sign was a scratch on the driver's and back seat doors. No air bags were deployed and no other damage was noted. Two passengers were loaded into the ambulance, none of which was the 8 year old female. While we were obtaining vital signs, we were told we had another patient. It was the 8 year old female. She was complaining of a headache. The patient was answering questions appropriately. She was A&O x 4 (alert to person place time and situation).Another patient was added before we left the scene. Our destination was (Hospital A). While we were assessing the other patients, the 8 yr old female began to get sleepy. She was still answering questions appropriately, but due to the time in morning, it was hard to determine if she was tired or if there was a problem. I continued to assess her and she was responding. We asked the other patients if she had hit her head . They were unsure. Since the only noticeable injury was a laceration to one of the patient's face, we asked if there was a chance they had bumped heads on impact. The adult said, yes she thought they did. The patient with the laceration was on the stretcher. She was ambulatory and with the chance of a head injury, she was moved and secured on the bench seat. The patient was assisted on to the stretcher and secured. Upon palpation of the patient's head, there did not appear to be a hematoma and no bleeding was present. An IV (intravenous line) was established and when the patient did not respond to pain, I asked the first responder to go Code 3 (lights and sirens)... I assessed the patient's pupils. The right pupil was 7mm (millimeters) and the left was 3mm (millimeters). We proceeded to (Hospital A).... Once we arrived the patient was removed from the ambulance, she appeared to be more alert. She sat up and was looking around. When we entered (Hospital A), a physician was there and asked what had happened. The patient had become lethargic again and as the physician started to assess the patient, the patient became combative and loudly crying out. She was reaching toward the right side of her head. The physician said she needed to be transported to (Hospital B- 42 miles away). I told her immediately I would transport. We left the ED and were enroute to (Hospital B), Code 3 (lights and sirens). I notified (Hospital B) we were enroute with a trauma alert. Central was also notified. I gave report and was instructed to take the patient to the trauma bay upon arrival....Vital signs...were continually monitored.. I contacted (Hospital B) via radio to give an update status of the patient. At this point her GCS (Glasgow Coma Scale-15 best response, 8 or less comatose, 3 unresponsive) was 3. She was not responding at all.. She was taken to the trauma bay." Review of Hospital B's trauma flow sheet revealed the patient arrived at 0449 on 02/13/2016. Review revealed vital signs on arrival were BP 130/50, pulse 68, Temp 95.1, O2 saturation 99% and GCS 5. Record review revealed the patient was given Etomidate ( anesthetic) 7.8mg at 0503 and at 0504 succinycholine (paralytic/skeletal muscle relaxant) 52mg (milligrams) then intubated ( breathing tube to protect the airway). Record review revealed the CT scan Final Result: Impression: "Right parietal convexity large-extra-axial acute hematoma has a lenticular morphology suspicious for epidural bleed. (bleeding on the brain). No overlying calvarial fracture. There is 10mm right to left subfalcine herniation. Early obstructive hydrocephalus". Review revealed on 02/13/2016 at 0838 the patient went to the operating room for an emergency craniotomy (surgical removal of part of the bone from the skull to expose the brain)." Review of the record revealed "Discharge Summary: She did well post-operatively... She was taken back to the OR on 02/16/2016 for re-implantation of the bone flap... Her neurological exam is grossly normal and she show no obvious deficits.. Will follow up with Neurosurgery in 7-10 days. The patient was discharged home on 02/21/2016 at 1551".

Interview on 03/09/2016 at 0943 with RN (Registered Nurse) # 1 revealed she was working the night of 02/13/2016. Interview revealed she walked out of a patient's room to the nurses' station and witnessed a pediatric patient saying "the thing" while lying on an EMS stretcher. Interview revealed she heard EMS worker #1 state "the patient's pupils are not equal." Interview also revealed "Dr. said the patient will need pediatric trauma care." and EMS worker #1 said " ok, we are going to (Hospital B)..Let's roll." When asked if she witnessed an assessment of the patient she stated "no". Interview revealed the patient was never placed in a treatment room. Interview confirmed no one tried to stop EMS personnel from leaving.

Interview on 03/09/2016 at 1025 with RN # 2 revealed she remembers the events of the night of 02/13/2016. Interview revealed they received a call on the radio that they were going to receive 4 (four) patients from a wreck - 2 adults and 2 pediatric. Interview revealed EMS reported both adults were wearing c-collars and one of them had a laceration over the left eye. Interview revealed EMS also reported that the youngest of the pediatric patients was stable and had a complaint of neck pain while the 8 year old patient was lethargic but responsive with a complaint of head pain. Interview revealed as she was preparing the room for the patients arrival, the secretary alerted her to go look at the patient at the front desk. Interview revealed when she arrived at the desk, ER Physician #1 was on one side of the stretcher and both EMS personnel were on the other side doing a patient assessment. Interview revealed the patient had "sporadic jerking movements of her arms and legs as well as was hitting herself on the side of her head" saying "the thing". Interview revealed she and ER Physician #1 started listing out things the patient was going to need like CT and MRI. Interview revealed they were trying to figure out what was going on because per EMS no one spoke English. Interview revealed ER Physician #1 stated the patient needed a trauma work up. Interview revealed EMS personnel wanted to know where was the closest trauma center and was told Hospital B. Interview revealed EMS worker stated "let's roll" and left the DED. Interview confirmed no one tried to stop EMS personnel from leaving.

Interview on 03/09/2016 at 1900 with ER Physician #1 revealed the ER received a call on 02/13/2016 about getting 4 (four) patients from an accident. Interview revealed EMS brought in the little girl first (Patient #23). Interview revealed the patient was in and out of consciousness and her pupils were unequal. Interview revealed she stated the patient will need trauma and neurosurgeon. Interview revealed per EMS worker # 1 "we got all 4 of them, we are not going to break them up." Interview revealed when asked if she completed a MSE, she replied "all I did was listen to her chest". Interview revealed nurses stated that we will keep her (the patient). Interview revealed EMS worker #1 stated "we are not going to break them up, let's roll". Interview revealed she stated "we will keep her... EMS worker #1 replied "I am just going to take her to (Hospital B)". Interview confirmed no one tried to stop EMS personnel from leaving.

Interview on 03/09/2016 at 1045 with EMS worker #1 revealed after introduction she stated "Is this about the Dr. refusing to assume care of the patient?" Interview revealed she remembers the series of events. Interview revealed she responded to a MVC (motor vehicle collision) dispatch approximately at 0300 on 02/13/2016. Interview revealed the First Responders (Fire Fighters) said they had 2 patients both in c-collars and one with a laceration under left eye. Interview revealed while she was doing her assessment the backdoor opened and the First Responders said you have 2 (two) more patients. Interview revealed the little girl patient was acting sleepy and upon assessment the right pupil was larger than the left. Interview revealed the pediatric patient was answering question and sat up with eyes wide open. Interview revealed upon arrival to Hospital A, ER Physician #1 looked at the child and said "she needed to go to (Hospital B)". Interview revealed "I feel like that doctor saved that child's life". "I said yes, we will transport, we will take her right now." Interview confirmed no one tried to stop EMS personnel from leaving.

Interview on 03/09/2016 at 1125 with EMS worker # 2 revealed she remembers responding to MVC call. Interview revealed one patient complaining of neck pain and the other patient with a laceration under the left eye. Interview revealed when they were notified on the scene of 2 patients she requested a driver. Interview revealed while doing assessment on the two patients, there was a knock on the door and First Responder (FireFighter) stated "we want this guy to go". Interview revealed it was the male pediatric patient. Interview revealed another knock on the door, it was the First Responders with the female pediatric patient (Pt #23) stating Dad wanted her to go get checked out. Interview revealed she noticed there was something "not right" with the little girl. Interview revealed she was whinning. Interview revealed upon arrival to Hospital A, EMS worker #1 and First Responder took (Pt #23) into the DED via stretcher as she went to get a wheelchair for the other patients. Interview revealed before she took any other patient out of the ambulance, EMS worker #1 was walking out of the DED with the patient and First Responder. Interview revealed she stated EMS work #1 stated "Don't get them out, we go to go to (Hospital B). This doctor said she wasn't going to touch her, she needed to go to (Hospital B)." Interview confirmed no one tried to stop EMS personnel from leaving.


Interview on 03/09/2016 at 1520 with FireFighter #1 revealed he volunteered to drive ambulance to Hospital A since they had 4 (four) patients. Interview revealed he was told " we are going to (Hospital A) emergency traffic (lights and sirens), she appears to have a head injury." Interview revealed the female pediatric patient was not acting the same as she was on the scene of the accident. Interview revealed once they entered Hospital A's DED and gave report, ER Physician #1 said "she will have to go to (Hospital B)." Interview revealed EMS worker #1 asked for clarification along the lines of "are you sure you want us to go and not stay?" Interview revealed the ER Physician replied "yes". Interview confirmed no one tried to stop EMS personnel from leaving.


2. Closed medical record review of Patient #24 on 03/10/2016 revealed a 6 year old male who was involved in a motor vehicle accident. Review of the EMS report revealed "Incident # 2016-2902 Date: 02/13/2016 Patient 3 of 4". Review of the EMS patient care record revealed "The patient was a passenger in the back seat of this vehicle accident. He was restrained. ..Patient walked to the ambulance. The patient was secured in his booster seat with the seat belt to the bench seat. The patient was transported to (Hospital B) with the trauma already in the truck. Patient has no other complaints but a headache. Patient was pointing to the top of his head stating that was where his head hurt... Patient was placed in triage at Hospital B. Report was given to the ED nurse. Patient was with his mother in the triage area." Record review revealed the patient was examined by a physician in Hospital B's DED at 0642 diagnosed with a "Headache" and discharged at 0709.

Interview on 03/09/2016 at 1025 with RN # 2 revealed she remembers the events of the night of 02/13/2016. Interview revealed they received a call on the radio that they were going to receive 4 (four) patients from a wreck - 2 adults and 2 pediatric. Interview revealed EMS reported both adults were wearing c-collars and one of them had a laceration over the left eye. Interview revealed three (3) patients were never taken out of the ambulance at Hospital A.

Interview on 03/09/2016 at 1900 with ER Physician #1 revealed the ER received a call on 02/13/2016 about getting 4 (four) patients from an accident. Interview revealed EMS brought in the little girl first (Patient #23). Interview revealed the other patients remained on the ambulance without examination or treatment. Interview confirmed the EMS personnel departed Hosptial A's property with 4 (four) patients.

Interview on 03/09/2016 at 1045 with EMS worker #1 revealed after introduction she stated "Is this about the Dr. refusing to assume care of the patient?" Interview revealed she remembers the series of events. Interview revealed she responded to a MVC (motor vehicle collision) dispatch approximately at 0300 on 02/13/2016. Interview revealed the First Responders (Fire Fighters) said they had 2 patients both in c-collars and one with a laceration under left eye. Interview revealed while she was doing her assessment the backdoor opened and the First Responders said you have 2 (two) more patients. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1125 with EMS worker # 2 revealed she remembers responding to MVC call. Interview revealed one patient complaining of neck pain and the other patient with a laceration under the left eye. Interview revealed when they were notified on the scene of 2 patients, she requested a driver. Interview revealed while doing assessment on the two patients, there was a knock on the door and First Responder (FireFighter) stated "we want this guy to go". Interview revealed it was the male pediatric patient (Patient # 24) Interview revealed another knock on the door, it was the First Responders with the female pediatric patient (Patient #23) stating Dad wanted her to go get checked out. Interview revealed while she was getting wheelchairs to assist the other patients in to the DED she was stopped by EMS worker #1 and told not to get anyone off the ambulance. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1520 with FireFighter #1 revealed he volunteered to drive ambulance to Hospital A since they had 4 (four) patients. Interview revealed 3 of the patients never got off the ambulance and were not treated by Hospital A's staff. Interview confirmed 4 (four) patients were transported from Hospital A to Hospital B.



3. Closed medical record review of Patient #25 on 03/10/2016 revealed a 40 year old female who was involved in a motor vehicle accident. Review of the EMS report revealed "Incident # 2016-2902 Date: 02/13/2016 Patient 2 of 4". Review of the EMS patient care record revealed " The patient was a front seat passenger in this vehicle that hit some black ice on I-40...Patient stated her neck hurt so she was placed in a c-collar. Patient was secured to the bench seat and transported to (Hospital B) where her daughter was taken from this same accident to trauma. Patient was placed in stretcher triage. Report was given to ED nurse..This patient spoke no English. There was another patient on board that was capable of translating." Record review revealed the patient was examined by a physician in Hospital B's DED at 0637 diagnosed with "Strain of the muscle and tendon of back wall of thorax" and discharged at 0720.

Interview on 03/09/2016 at 1025 with RN # 2 revealed she remembers the events of the night of 02/13/2016. Interview revealed they received a call on the radio that they were going to receive 4 (four) patients from a wreck - 2 adults and 2 pediatric. Interview revealed EMS reported both adults were wearing c-collars and one of them had a laceration over the left eye. Interview revealed three (3) patients were never taken out of the ambulance at Hospital A.

Interview on 03/09/2016 at 1900 with ER Physician #1 revealed the ER received a call on 02/13/2016 about getting 4 (four) patients from an accident. Interview revealed EMS brought in the little girl first (Patient #23). Interview revealed the other patients remained on the ambulance without examination or treatment. Interview confirmed the EMS personnel departed Hosptial A's property with 4 (four) patients.

Interview on 03/09/2016 at 1045 with EMS worker #1 revealed after introduction she stated "Is this about the Dr. refusing to assume care of the patient?" Interview revealed she remembers the series of events. Interview revealed she responded to a MVC (motor vehicle collision) dispatch approximately at 0300 on 02/13/2016. Interview revealed the First Responders (Fire Fighters) said they had 2 patients both in c-collars and one with a laceration under left eye. Interview revealed while she was doing her assessment the backdoor opened and the First Responders said you have 2 (two) more patients. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1125 with EMS worker # 2 revealed she remembers responding to MVC call. Interview revealed one patient complaining of neck pain and the other patient with a laceration under the left eye. Interview revealed when they were notified on the scene of 2 patients, she requested a driver. Interview revealed while doing assessment on the two patients, there was a knock on the door and First Responder (FireFighter) stated "we want this guy to go". Interview revealed it was the male pediatric patient (Patient # 24) Interview revealed another knock on the door, it was the First Responders with the female pediatric patient (Patient #23) stating Dad wanted her to go get checked out. Interview revealed while she was getting wheelchairs to assist the other patients in to the DED she was stopped by EMS worker #1 and told not to get anyone off the ambulance. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1520 with FireFighter #1 revealed he volunteered to drive ambulance to Hospital A since they had 4 (four) patients. Interview revealed 3 of the patients never got off the ambulance and were not treated by Hospital A's staff. Interview confirmed 4 (four) patients were transported from Hospital A to Hospital B.


4. Closed medical record review of Patient #26 on 03/10/2016 revealed a 27 year old female who was involved in a motor vehicle accident. Review of the EMS report revealed "Incident # 2016-2902 Date: 02/13/2016 Patient 4 of 4". Review of the EMS patient care record revealed "Patient was a restrained passenger in the back seat of the vehicle that hit a patch of ice and then struck the guard rail....Patient had 2 inch laceration under her left eye. This occurred from the small child sitting to the patient's left at the time the vehicle hit the black ice this child's head hit this patient in the face. The laceration was not bleeding upon EMS arrival. Patient was given an ice pack to place on the injury. Patient was also complaining of neck pain so she was placed in a c-collar. Patient did not have any back pain at the time... Patient was secured to the bench seat and transported to (Hospital B) with the trauma child. Patient was placed in triage bed #7. Report given to ED nurse." Record review revealed the patient was examined by a physician at Hospital B's DED. Record review revealed Xrays and CT scan were ordered which were negative. Record review revealed laceration repair was performed and the patient diagnosed with "Laceration without foreign body of left cheek, Contusion of left knee, Contusion of right knee, Headache, Other chest pain and Cervicalgia" and discharged at 0905.

Interview on 03/09/2016 at 1025 with RN # 2 revealed she remembers the events of the night of 02/13/2016. Interview revealed they received a call on the radio that they were going to receive 4 (four) patients from a wreck - 2 adults and 2 pediatric. Interview revealed EMS reported both adults were wearing c-collars and one of them had a laceration over the left eye. Interview revealed three (3) patients were never taken out of the ambulance at Hospital A.

Interview on 03/09/2016 at 1900 with ER Physician #1 revealed the ER received a call on 02/13/2016 about getting 4 (four) patients from an accident. Interview revealed EMS brought in the little girl first (Patient #23). Interview revealed the other patients remained on the ambulance without examination or treatment. Interview confirmed the EMS personnel departed Hosptial A's property with 4 (four) patients.

Interview on 03/09/2016 at 1045 with EMS worker #1 revealed after introduction she stated "Is this about the Dr. refusing to assume care of the patient?" Interview revealed she remembers the series of events. Interview revealed she responded to a MVC (motor vehicle collision) dispatch approximately at 0300 on 02/13/2016. Interview revealed the First Responders (Fire Fighters) said they had 2 patients both in c-collars and one with a laceration under left eye. Interview revealed while she was doing her assessment the backdoor opened and the First Responders said you have 2 (two) more patients. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1125 with EMS worker # 2 revealed she remembers responding to MVC call. Interview revealed one patient complaining of neck pain and the other patient with a laceration under the left eye. Interview revealed when they were notified on the scene of 2 patients, she requested a driver. Interview revealed while doing assessment on the two patients, there was a knock on the door and First Responder (FireFighter) stated "we want this guy to go". Interview revealed it was the male pediatric patient (Patient # 24) Interview revealed another knock on the door, it was the First Responders with the female pediatric patient (Patient #23) stating Dad wanted her to go get checked out. Interview revealed while she was getting wheelchairs to assist the other patients in to the DED she was stopped by EMS worker #1 and told not to get anyone off the ambulance. Interview revealed 3 (three) patients never got off the ambulance and 4 (four) patients were transported from Hospital A to Hospital B.

Interview on 03/09/2016 at 1520 with FireFighter #1 revealed he volunteered to drive ambulance to Hospital A since they had 4 (four) patients. Interview revealed 3 of the patients never got off the ambulance and were not treated by Hospital A's staff. Interview confirmed 4 (four) patients were transported from Hospital A to Hospital B.


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