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Based on interviews, policy review, document review, and medical record review, the hospital failed to meet the provider's agreement and comply with 42-CFR 489.24 requirements of EMTALA.

There was deficient practice in A-2406, Medical Screening Exam, with an immediate jeopardy for failure to provide a medical screening exam (MSE) that was appropriate for the condition of two individuals that presented to the Emergency Department for treatment of a sample size of 20. In addition, the hospital (H)1 was not able to provide a reason why two hospital's requests to transfer patients for specialized services were denied when the hospital had capability and capacity.

As a result of these deficient practices, patients did not receive the standard medical screening examinations that should have been provided, which had the potential to result in adverse outcomes. If the hospital denies transfers for specialized services, there is delay to obtain the services needed, which may result in adverse outcomes or death.

Findings Include:

1) Cross Reference A-2406- Medical Screening Examination
Two individuals (P1 and P2) out of a sample size of 20 that came to the Emergency Department for treatment were sent (moved) to the Women's Center (WC (another department located within the hospital, that includes labor and delivery)) for the MSE by a Registered Nurse (RN), and were not evaluated by a physician.
The WC RNs are approved by the hospital board and medical staff to provide a labor screening exam (MSE), but are not approved to provide the MSE on patients presenting to the ED with other conditions.

2) Cross Reference A-2411- Recipient Hospital Responsibilities
The hospital was not able to provide sufficient evidence why one patient (P)3 transfer request, of a sample size of 12 for specialized services was denied, when the hospital had the capacity and capability to care for him.. The referral hospital was seeking neurosurgical services, which they did not provide.

Based on interviews, medical record and document review, the facility failed to comply with the EMTALA obligation to provide an appropriate medical screening examination (MSE (determines the presence or absence of an emergency medical condition and must be done in accordance with policy and medical standards)) to two patients (P)1 and P2), of a sample size of 20, that presented to the Emergency Department (ED) for treatment. P1 and P2 were sent (moved) to the Womens Center (WC), but did not receive a medical screening exam by a qualified individual to rule out an emergency medical condition. The nature and extent of this noncompliance created the likelihood there would be a serious adverse outcome of harm or death if not corrected, and resulted in immediate jeopardy.

Findings include:

1) P1 was a 30 year old female who presented to the ED on 03/23/2025 at approximately 07:45 PM for treatment after a motor vehicle accident (MVA). She was approximately 33 weeks pregnant, and reported she was wearing a seatbelt at the time of the accident. On arrival to the ED, she was moved to the WC, where she was assessed by a Registered Nurse (RN), and placed on a fetal heart monitor to measure the heart rate and rhythm of the fetus (baby), to see how the baby was doing. P1 did not see a physician, and was discharged after monitoring on 03/24/2025 at approximately 00:04 AM.

Review of P1's report titled "OB Admission Screen," confirmed there was no face to face MSEI (Medical Screening Examination Initiated) by a Provider. The record included "Chief Complaint: s/p (status after an event) MVA. The "Assessment/Plan," documented by the RN, was "dc (discharge) home. pt (P1) instructed on importance of kick counts, pt given s/s (signs/symptoms) of PTL (preterm labor). pt verbalized understanding. pt to follow up with OB (obstetrician) on April 1st." The written discharge instructions were for preterm labor.

Review of P1's "Obstetrics Procedure" report included the indication for a non stress test (monitoring) "patient was rear ended at a stop light by a car going 10-20 mph (miles per hour); seat belt below gravid (pregnant) abdomen and NO airbag deployed."

Review of the "Nursing Documentation Flowsheet," revealed the following entries:
- "Pain or contractions present ...back pain when walking."
- "Arrived From Emergency Department."
- Obstetrician was notified by phone of P1's arrival and again with results.

There were no ED medical records or triage documentation for P1. She did not see a physician and did not have a standard medical screening examination by an approved qualified individual for a pregnant woman post MVA, which is a high risk event.

2) P2 was a 35 year old female who presented to the ED with complaint of elevated blood pressure (BP) and headache on 04/02/2025 at approximately 05:55 PM. She was five days postpartum. On arrival to the ED, she was moved to the WC for MSE, where she was assessed and monitored by a RN. The RN contacted P2's Obstetrician (OB), who ordered labs. When the lab results returned, the RN contacted the Provider again, and P2 was discharged home at 07:50 PM. She did not see a physician and did not have a standard medical screening examination by an approved qualified individual for this type of complaint.

Review of P2's "Nursing Documention Flowsheet" revealed the following entries:
- Arrival to unit: 04/02/2025 at 05:55 PM
- Pain location: head
- Pain: 4 (scale of 1-10 with 10 being the worst)
- OB notified at 06:14 PM. Orders received for preeclampsia labs (Comprehensive Metabolic Panel, CBC (complete blood count), and urinalysis.
- OB notified at 07:25 PM. Orders received for discharge home with pre-eclampsia precautions.

There were no ED medical records, triage notes, or documentation of a BP taken on arrival to the ED.

On 04/03/2025, at approximately 09:33 PM, P2 presented to the ED again. This encounter, P2 was seen by the ED physician, who completed the MSE to rule out an emergency medical condition.

Reviewed the ED Physician notes dated 04/03/2025, which included, "... presents to ED for elevated blood pressure at home of 162/104. ...Today states her blood pressure was even higher than yesterday. ..." The ED physician ordered additional lab tests, a chest xray, and electrocardiogram to rule out an emergency medical condition, consulted an Obstetrician, and discharged her home.

3) Reviewed the ED policy/procedure titled "Pregnant Patients Presenting to the Emergency Department" last revision date 04/07/2025, which included the following:
- Policy Intent: "To establish guidelines for triaging patients to the Emergency Department or the Birth Center (WC)."
- Policy: Compliance: "A. Any pregnant woman presenting to the Emergency Department for care will have a triage assessment. ...C. Any pregnant woman presenting with symptoms suggestive of non-pregnancy related illness or extensive bleeding will be evaluated in the Emergency Department. D. The "Triage of Pregnant Patient > 20 Weeks" form is part of the medical record and should be sent to the Department of Health Information to scan into the patient record."

- Procedure: D. All pregnant women presenting at greater than 20 weeks gestation with isolated pregnancy-related complaints will be assessed by the Emergency Department triage RN by utilizing the "Triage of Pregnant Patient > 20 Weeks" form... 2. If the triage nurse deems the complaint is not pregnancy related, the patient will be evaluated in the Emergency Department. 3. If the triage nurse deems a pregnancy related complaint, the patient will get a medical screening/assessment in the Birth Center. ...4. If upon evaluation at the Birth Center, it is determined that the patient does not have a pregnancy related problem and needs to be seen in the Emergency Department, the patient will be returned to the Emergency Department for final disposition." 5. If the Emergency Department Physician requests fetal monitoring on a pregnant patient with symptoms of non-pregnancy related illness, the patient remains in the Emergency Department patient until results of fetal monitoring are obtained. a. Birth Center staff will do fetal monitoring in the Emergency Department, or b. Patient is transported to the Birth Center for monitoring. ...d. If upon evaluation at the Birth Center, it is determined that the patient does not have a pregnancy related problem, the patient will be returned to the Emergency Department for final disposition.

4) Reviewed the Systemwide Model Policy number 12119, titled "EMTALA-Medical Screening Exams Labor and Delivery," last review date of 05/17/2024. The policy included:,
- Policy Intent: "A. To ensure that all individuals who Come to the hospital (as defined in the Compliance with EMTALA policy) seeking or in need of Emergency Services and Care, including Labor and Delivery (L&D), receive a appropriate Medical Screening Examination and further examination and Stabilizing treatment in accordance with applicable laws and Hospital policies. B. The Medical Screening Examination will be performed by individuals qualified to perform the Examination to determine if the individual has an Emergency Medical Condition, the Hospital will provide further examination and treatment necessary to Stabilize the Emergency Medical Condition."

- Policy: Compliance: "...b. Provide a Medical Screening Examination by a physician, clinical nurse midwife or a registered nurse authorized to provide a Medical Screening Examination to any pregnant woman who comes to Labor and Delivery (WC) seeking examination or treatment."
- Procedure: "2a. A Medical Screening Examination is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an individual is, or is not, experiencing Labor or another Emergency Medical Condition. ...c. The Hospital and Medical Staff will determine the categories of Qualified Medical Persons who may perform the Medical Screening Examinations. The Medical Staff bylaws or rules and regulations, as approved by the Hospital governing body, will designate the categories of Qualified Medical Persons in L&D who are authorized to perform the Medical Screening Examination. A Qualified Medical Person who is authorized to perform a Medical Screening Examination in L&D must: i. Practice within the scope of his/her license issued by the state in which the Hospital is located; ii. Demonstrate his/her current competence in performance of Medical Screening Examinations, within the authorized scope of his/her health profession; and iii. As applicable, perform the Medical Screening Examination in accordance with protocols standardized procedures or other policies as may be required by law or approved by the Hospital governing body and the Medical Staff. ..."4. Non -Labor Related Condition. If it is determined that the patient is not in labor, but has a presenting complaint, signs or symptoms (such as abdominal pain) that is beyond the scope of the nurses license or authorized practice in the Hospital, or of a Qualified Medical Person treating the patient, the nurse or Qualified Medical Person will arrange for the completion of the Medical Screening Examination by requesting a physician to come to L&D in a timely manner to examine the patient, or arrange to have the patient taken to the Emergency Department."

5) Reviewed the Hospital Rules and Regulations, which included: P/14.000, "Medical Screening Examinations shall be performed on all individuals who come to the Medical Center requesting examination or treatment to determine the presence of an emergency medical condition. The Medical Executive Committee designated who is qualified to perform medical screening examinations. Currently: Physician members of the medical staff with privileges in the Emergency Department. A qualified labor and delivery nurse shall provide a labor screening exam to any patient assigned to a medical staff member with obstetrical privileges. Disposition of the patient shall be determined by the attending physician. The obstetrics on-call physician will provide a labor screening exam to any woman who is not a patient of our medical staff with obstetric privileges.

The Hospital Rules and Regulations approve WC RN's to do Medical Screening Exams for labor only, when present to the ED for treatment.

6) On 04/11/2025 at 10:00 AM, interviewed one of the WC Nurses (RN)1, who said the WC works closely with the ED, and recently participated in their skills fair to share information on "OB emergencies." She said the WC created a reference binder for the ED nursing staff, which included information on post partum hemorrhage and hypertension. Inquired if there had been any updates to policies regarding triaging or moving patients that present to the ED with post partum high BP, or after a MVA, she replied no. RN1 said the WC RNs have competencies for screening for labor. When inquired if they had competencies to conduct MSE for post partum preeclampsia, or other nonrelated pregnancy conditions, she replied no. RN1 said she took the call from the ED RN the day P2 came for treatment of a headache and high blood pressure. She recalled the ED RN mentioned the ED skills fair education and asked if they were able to take this patient, rather than go through the ED, and she told the RN they could bring the patient to the WC.

On 4/11/2025 at 11:30 AM, conducted an interview in the conference room with the WC Nurse Manager (NM). She said the Hospital had been preparing for new CMS regulations on "OB emergency readiness (initiative to prepare to respond to emergencies that my cause or contribute to maternal mortality)," and the WC recently had a station at the ED skills fair, where they shared information and resources including an algorithm to identify OB emergencies. The UM went on to say if someone came to the ED and had already delivered, they usually go through the ED. She said the process for triage and moving patients to WC had not changed. The UM said the ED should do their MSE, and then consult the OB provider if needed. She said the WC MSE was focused on labor, and if someone had been sent to WC, and found to have a nonpregancy related condition, she would expect the staff to contact the hospitalist to examine the patient, or send the patient to the ED.

On 04/11/2025 at 12:00 PM, conducted an interview in the conference room with the Obstetrics Nurse Educator (NE). She said she was not familiar with the ED specific policies, but if a patient presents in active labor, or to rule out active labor, the ED would send the patient to WC. The NE said she would expect all others to get a MSE in the ED, and consult the OB provider as needed. The NE went on to say the WC had a station at the ED skills fair about OB emergencies that the ED might see, and that she created a reference binder for them. The NE said the focus was on early recognition of OB emergencies and early OB consult. She acknowledged anyone presenting to the ED post partum with headache and concerns about high blood pressure should be triaged in the ED, have vitals taken immediately, and be seen by the ED physician.

On 04/11/2025 at 12:45 PM, conducted an interview with the Director of Education and Workforce Development (DE) and the ED Clinical Nurse Educator in the conference room. The DE confirmed the WC station at the skills fair and that there were no policy changes. She said it was "informative education for staff," but no process change.

On 04/11/2025 at 01:12 PM, had a phone interview with the ED Medical Director. He said patients that present with pregnancy related complaint, would be sent to L&D for MSE. If not pregnancy related, they would stay in the ED. At that time reviewed the scenario of P1 and P2, who presented to the ED for treatment and moved to WC. The MD said a headache postpartum, is "kind of a grey zone if associated with pregnancy or not, and would be reasonable to triage, and could send to OB in nature, but currently there had not been any policy changes." He went on to say a MVA in pregnant women (P1) is at increased risk due to the pregnancy, and should be triaged into the ED for the MSE.

On 4/14/25 at 07:30 AM, conducted a telephone interview with WC RN2, who cared for P1. Her recall was that the ED called saying they had a pregnant lady from a car accident and were sending her over for monitoring. RN2 said she "did not know if P1 had been seen in the ED by a physician or not."

Based on interviews, medical records and document review, the hospital (H)1 was not able to provide sufficient evidence why one patient (P)3 transfer request of a sample size of 12 was denied for neurosurgical specialized services, when the receiving hospital had the capacity and capability to care for them. As a result of this deficiency, P3 did not receive the specialized services timely. After his conditioned deteriorated, several days later, he was accepted for transfer by H4. If patients do not receive the specialized services needed in a timely manner, there is a high probability of serious adverse outcomes.

Findings include:

1) The Office of Healthcare Assurance received notice of approval to investigate an anonymous complaint that H1 refused to accept a transfer of a patient that needed specialty neurosurgical services from an outer island hospital (H2) that does not provide that service.

During the investigation, reviewed the log, titled "Med/Surg Patient Transfer Requests," for the period of October 1, 2024, through March 31,2025, which is maintained by the House Supervisors (HS). The log revealed a request for transfer from H2 for neurosurgical services for P3. The log indicated H1 had the capability and capacity at the time the request for transfer was made. Review of the On-call schedule provided by Medical Staff Office revealed a neurosurgeon (NMD) was scheduled on call at the time of the request.

2) On 01/28/2025 H2 requested to transfer P3 to H1 for neurosurgical services they did not provide. Reviewed the form the House Supervisor (HS) at H1 initiated on 01/28/2025 at 06:50 PM, that documented the transfer request. The form included: "Patient Diagnosis: Septic knee/possible spinal epidural abscess." "Specialty Need: Neuro surg/ID (infectious disease)." Type of bed request: "Med/Surg (medical/surgical)." Part II: "Criteria to determine whether the request is for an EMTALA or non-EMTALA transfer." "1. Is the patient in an emergency department or labor & delivery?" The box was checked "Yes." "2. Has there been a determination that the patient has an "emergency medical condition?" The Box was checked "Yes." "3. Has there been a determination as to whether the emergency medical condition is "stabilized" or not?" The box marked said "stabilized."
"4. What are the reasons for transfer?" The box marked was "Specialized care." "5. Does the sending facility have the present capability & capacity to provide the services needed?" The box was checked "No." Part III: "Determine hospital capability and capacity to accept the transfer." "1. Does AHCS (H1) have an appropriately staffed bed that is expected to be available at the time of the patient's arrival; ..." The box was marked "Yes." "2. Is the Emergency Department expected to have the capacity to examine, treat & monitor the patient pending assignment ...?" The box was marked "Yes." "3. Does AHCS expect to have service capacity at the time of this patient's arrival or within clinically required timeframes) to provide the level of care required for the patient?" The box was marked "Yes." "4. Is there an appropriate medical staff physician who will accept responsibility for the patient?" The HS wrote "NO" next to the box, "Does patient need specialty services not provided at AHC?" The HS also wrote "No," next to the box "Is there accepting coverage for any specialty services?" Part IV: "Time requesting physician called specialist: 19:50 PM (07:50 PM)." "Part V. Documentation if Transfer Not Accepted." This section has eight reasons that can be checked to explain the reason for denial. These included: Not an emergency medical condition, Emergency medical condition stabilized, Patient does not require specialized services at AHCS, AHCS does not have a bed, services or emergency department capacity (document the reasons below), On-call physician is not available to accept the patient (document the reasons) below, Transfer is for insurance reasons, Transfer is a lateral transfer (level of care available at transferring hospital at time of transfer), and Other (document below). The box "On-call physician is not available to accept the patient (document the reason below)" was checked. "Other information/Issues with Transfer:" The HS wrote "NMD declined the request, doesn't meet spine admission criteria."

Reviewed P3's "ED Provider (EDMD) notes" from H2, dated 01/28/2025, which included the following:
Medical Decision Making: "This 67-year-old male PMH (pertinent medical history) of HTN (hypertension) and DM (Diabetes) presents to the ED for left shoulder pain, right knee pain and continued back pain. ...His knee shows a large effusion without erythema (redness). Mild warmth ...Although the knee does not appear septic, will obtain synovial fluid (in joint cavity) to evaluate for septic arthritis. MRI (Magnetic Resonance Imaging) ...to evaluate for possible spinal epidural abscess (infection that can cause rapidly deteriorating neurological functioning due to compression).
03:10 PM: Knee arthrocentesis (fluid drawn from joint) performed.
06:15 PM: "...Pending orthopedic consultation and MRI read (results)."
06:30 PM: "...MRI shows ...collection along the posterior aspect of the right L4/5 (lumbar) facet joint. This potentially represents abscess formation. This extends into the spinal canal along the posterior aspect of the canal. The patient has ...septic arthritis (infection of one or more joints) and possible abscess draining into his spinal canal. ... Additional liter of fluids (intravenous) ordered as the patient is slightly tachycardic (increased heart rate). He was placed on 2 L (liters) of oxygen due to mild hypoxia (low oxygen level) ..."
06:37 PM: "Call placed to H4 but they are over capacity and cannot accept at this time."
06:39 PM: "Called H5, pending call back."
06:40 PM: "Call placed to H1. Requested MRI images beamed (to be sent) first."
07:21 PM: "Pt (P3) declined from H5"
07:25 PM: "I (ED physician) spoke with NMD (H1 spine) who felt that the patient's lumbar MRI findings were more consistent with a synovial cyst."
Clinical Impression included bacteremia (bacteria in the blood stream)..., pyrogenic (infection) arthritis of right knee joint and infection of lumbar spine.

EDMD Provider notes dated 01/28/2025 at 09:23 PM: "Patient signed out to me by previous provider for follow-up on disposition. NMD at H1 does not think that this is infectious, he states that he thinks that this is a synovial cyst and can be treated outpatient however will consult if patient transferred per previous provider. patient [sic] does show signs of infectious etiology particularly the knee, however, is very possible that patient is bacteremic and has also seeded his spine (rare condition called a spinal cord abscess). When discussed with NMD again he still declines transfer. ..."
01/29/2025: "ADDENDUM: MRI cervical spine and lumbar spine overread this morning: ...T2 (thoracic area) hyperintense lesion dorsal epidural space at the L4-5 level, concerning for phlegmon (localized inflammation or infection)/developing abscess (well defined pocket filled with pus). ...Radiologist discussed with MD2 who is attempting to obtain additional Neurosurgery consultation."

P3 was admitted at H2 for IV antibiotic therapy and monitoring. He had progressive decline in clinical status including worsening weakness in his left upper extremity and bilateral lower extremities. He was accepted for transfer to H4 on 02/04/2025 where he had surgery 02/06/2025.

Reviewed P3's H4 "Operative Report" dated 02/06/2025, which included the following:
Postoperative Diagnosis:
1. Incomplete quadriplegia due to cervical discitis and epidural abscess, C5-C6 and C6-C7.
2. Cervical spinal stenosis, C5-T1.
3. L4-:5 spinal stenosis (narrowing of spinal canal) likely due to epidural abscess.

The initial Web anonymous complaint, included that H1's NMD, "refusal to transfer for neurosurgery evaluation but stated multiple times if the pt was already on oahu [sic] and at their hospital they would consult. ..."

3) On 04/14/2024 at 10:15 AM, interviewed the Medical Staff Officer (MSO) in the administrative conference room. He said he reviews the quality data on transfer requests monthly, to identify trends and opportunities. The MSO said he will sometimes discuss a case with the specialist, for additional information regarding the reason for denial. Brought to MSO's attention that the reason for denial of transfer for P3 was "doesn't meet spine admission criteria." When asked what the facility spine admission criteria was, he said they did not have any specific spine criteria. The MSO said he had a discussion with NMD about the denial, and recalled NMD told him after he looked at the x-rays, he felt the issue was a septic knee, and needed orthopedic consult.

On 04/15/2025 at 03:30 PM had a telephone interview with NMD. Inquired if he recalled the request from H2 to transfer P3. He said when he spoke with the ED doctor and with the information he had at that time, he felt the priority would be to have an orthopedic specialist assess the patient for the obvious knee infection, and that he recommended further workup to differentiate the spinal involvement and diagnosis. NMD said he felt the spinal issue could have been a synovial cyst or septic arthritis, rather than an epidural abscess, needing immediate neurosurgical consult/treatment. He went on to say the "ER physician was exacerbated" with him and was not open to the recommendation of further workup at H2 with additional consult after receiving results. NMD said he felt he left it open for the ER doctor to call him back if needed after further work up.

4) Reviewed H1's policy/procedure number 1200, titled "Model Policy: EMTALA - Acceptance of Emergency Transfers," with last review date of 01/22/2024. The policy included the following: 1. Acceptance of Transfers.
a. A hospital with specialized capabilities or facilities will accept the Transfer of an individual with an Unstabilized Emergency Medical Condition if the individual requires the specialized services of facilities of the Hospital ... "
b. If another hospital requests acceptance of Transfer of an individual who does not have an Emergency Medical Condition, or Emergency Medical Condition is Stabilized, the Transfer will be reviewed for medical necessity, the level of acuity, the capability of the Hospital to manage the patient's condition, the availability of staff, beds and other resources, an accepting physician and other factors, ..."
2. Hospital Process for the Acceptance Transfers.
a. Responsibility for the Acceptance of Transfer requests. ...ii. If a member of the medical staff, including an On-call specialist, is contacted directly by the transferring hospital or physician to accept a Transfer, the physician should notify staff assisted to handle Transfers, and provide pertinent information as to the patient, his/her clinical status and needs and other information to the requested transfer,"
g. Refusal to Accept Transfer.
- i. Except where the Hospital is required to accept a Transfer under applicable state law or its contractual obligations (including Transfer agreements and health plan contracts), the Hospital may refuse to accept a Transfer of an individual with an Unstabilized Emergency Medical Condition of anyone if the following conditions exist I. The individual does not require the specialized capabilities and facilities of the Hospital at the time of the Transfer; II. The Hospital does not have the Capacity at the time of the Transfer to provide the specialized services required for the individual; III. The transferring facility had the present Capability and Capacity to provide the specialized services required for the individual; or IV. The transferring facility provides the same level of specialized services that are present at the Hospital at the time of the Transfer. Lateral Transfers between facilities of comparable resources are not required by EMTALA because they do not offer enhanced care benefits to the individual except where there is a mechanical failure of equipment, no beds or staff available at the transferring hospital, or similar circumstances.
- ii Reporting of Denial of Transfer Request if the Receiving Physician declines a Transfer, he/she will immediately report the denial of the Transfer to the house nursing supervisor on duty. If the Receiving Physician declines a transfer, he/she will submit a written report to [click here and insert name] within 24 hours. The written report will include the name of the patient's condition and need for care, the reason given for the Transfer and the reason that the physician or house nursing supervisor declined the Transfer.

The model policy provided was not revised to include the name of individual to submit written report of a transfer that was declined,and that process was not in place.