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Based on review of video, prehospital care report, medical record, hospital service agreement, hospital logs, interviews, Medical Staff Bylaws and meeting minutes, and policies, it was determined that the facility failed to provide an appropriate medical screening exam to Patient #1, who presented to the hospital seeking emergency services.

Findings:

Refer to C2406.

Based on a review of video footage, pre-hospital care report, and policies, it was determined that the facility (Hospital A) failed to initiate a medical record for Patient #1 who presented to the hospital's Emergency room on 7/14/2020 seeking emergency services.

Findings:

A review of the hospital's video surveillance from 7/14/2020 regarding Patient #1's disposition was done on 9/14/20 at 2:02 PM in the office of the Chief Executive Officer (CEO DD) with two qualified surveyors, the Director of Nursing (DON EE) and the CEO.

The review revealed that an ambulance backed up to the entrance of the Emergency Department (ED) on 7/14/20 at 1:43:56 a.m. At 1:46:05 a.m., Emergency Medical Technician (EMT JJ) got out of the truck, keyed the entrance code into the keypad, and walked directly into the ED. It was observed on the video that EMT JJ had his hands out to his side and in the air with his palms facing upwards. He walked into the ED and out of view of the camera. At 1:48:00 a.m., EMT JJ was still out of view of the camera and there was no activity noticed from the ambulance. CEO DD explained that an internal investigation by the hospital had revealed that the ambulance driver was talking to the ED Medical Doctor (MD BB) off-camera. The video further revealed that the Licensed Practical Nurse (LPN GG) sat down at the nurses' station at 1:46:56 a.m. CEO DD stated that LPN GG witnessed the conversation between MD BB and the driver. CEO DD said that a Registered Nurse (RN FF) was the Charge Nurse at that time and had "heard everything". At 1:49:20 MD BB entered the camera view and appeared to be heading towards the ambulance entrance and parking lot door. As he was standing at the exit keypad, he turned towards the camera and was observed talking to someone out of camera range.

AT 1:49:40, EMT JJ entered the camera view and was observed in conversation with MD BB. At 1:49:48 MD BB walked out and turned to the right (towards the parking lot). EMT JJ exited the ED at 1:49:53, went to the ambulance, and opened the patient compartment doors of the ambulance. At 1:50:53 a.m., the driver closed the back door of the ambulance and walked to the driver's side of the ambulance. The ambulance pulled away from the facility at 1:53:20 a.m.

A review of the Pre-hospital Care Report (PCR) dated 7/14/2020, received from neighboring county Emergency Medical Services (EMS), revealed that Patient #1 was picked up by the county EMS ambulance from a private residence. On 7/14/2020, the ambulance was dispatched at 12:35 a.m. and arrived at a private residence at 12:51 a.m. The narrative note revealed that upon EMS arrival Patient #1's oxygen level was 90 % (normal range is greater than 95%) on room air. Patient #1 was having trouble answering questions.

The narrative of the PCR further revealed that MD BB continued to advise EMT JJ that from what EMT JJ has told MD BB, Patient #1 needed a higher level of care than Hospital A was able to provide. MD BB said the ambulance crew needed to seek a higher level of care. MD BB suggested they talk to Patient #1 and see if there was another location he could go to. MD BB told EMT JJ to tell Patient #1 that he needed to seek a higher level of care.

MD BB walked out of the ambulance entrance doors and headed to his car. EMT JJ opened the patient compartment door and told Patient #1 and EMT II that the hospital would not accept him. He asked Patient #1 if he would agree to be transported to Hospital B and Patient #1 nodded yes. EMT JJ informed his central dispatch (where assignments are made) that Hospital A would not accept Patient #1 and that the ambulance was en route to Hospital B. The ambulance arrived at Hospital B at 2:08 a.m. on 7/14/2020.

A review of Patient #1's medical record from Hospital B revealed that he was brought in by ambulance and admitted to the Emergency Department on 7/14/2020 at 2:19 a.m. Patient # 1 was admitted to Hospital B on 7/14/2020 at 10:15 a.m.

POLICIES

Review of the EMTALA (Emergency Medical Treatment and Labor Act) policy, effective 4/16/18, revised 7/16/19 revealed that medical records of individuals transferred to or from the hospital must be retained in their original or legally reproduced format for no less than 5 years from the date of transfer. A patient encounter number is created which will trigger the patient being put on the central log and creation of a medical record. The medical record will reflect an ongoing assessment of the individual's condition. Monitoring of the individual will continue until the individual is stabilized, admitted to the hospital, appropriately transferred, the individual requires care and treatment that exceeds the hospital's capabilities, or the individual is discharged or expires.

Based on a review of video, prehospital care report, central logs, and policies, it was determined that the facility failed to include Patient #1 on the central log when presented to the hospital for emergency services on 7/14/2020. This affected Patient #1 and had the potential to affect all patients served.

Findings:

A review of the hospital's video surveillance from 7/14/2020 regarding Patient #1's disposition was done on 9/14/20 at 2:02 PM in the office of the Chief Executive Officer (CEO DD) with two qualified surveyors, the Director of Nursing (DON EE) and the CEO.

The review revealed the arrival of an ambulance to the entrance of the Emergency Department (ED) on 7/14/20 at 1:43:56 a.m. At 1:46:05 a.m., Emergency Medical Technician (EMT JJ) got out of the truck, keyed the entrance code into the keypad, and walked directly into the ED.
It was observed on the video that EMT JJ had his hands out to his side and in the air with his palms facing upwards. He walked into the ED and out of view of the camera. At 1:48:00 a.m., EMT JJ was still out of view of the camera and there was no activity noticed from the ambulance. CEO DD explained that an internal investigation by the hospital had revealed that the ambulance driver was talking to the ED Medical Doctor (MD BB) off-camera. The video further revealed that the Licensed Practical Nurse (LPN GG) sat down at the nurses' station at 1:46:56 a.m. CEO DD stated that LPN GG witnessed the conversation between MD BB and the driver. CEO DD said that a Registered Nurse (RN FF) was the Charge Nurse at that time and had "heard everything". At 1:49:20 MD BB entered the camera view and appeared to be heading towards the ambulance entrance and parking lot door. As he was standing at the exit keypad, he turned towards the camera and was observed talking to someone out of camera range.

AT 1:49:40, EMT JJ entered the camera view and was observed in conversation with MD BB. At 1:49:48 MD BB walked out and turned to the right (towards the parking lot). EMT JJ exited the ED at 1:49:53, went to the ambulance, and opened the patient compartment doors of the ambulance. At 1:50:53 a.m., the driver closed the back door of the ambulance and walked to the driver's side of the ambulance. The ambulance pulled away from the facility at 1:53:20 a.m.

A review of the facility's Emergency Department Central Log from 6/1/20 through 9/10/20 failed to reveal Patient #1's name on the central log.

Review of the EMTALA (Emergency Medical Treatment and Labor Act) policy, effective 4/16/18, revised 7/16/19 revealed that the hospital is required to maintain a central log tracking the care of all individuals who come to the emergency department.

The policy further revealed that a central log must be maintained and include, directly or by reference, individual logs from all departments of the hospital including the emergency department when an individual presents for emergency services. A patient encounter number is created which will trigger the patient being put on the central log and creation of a medical record. The log must contain the name of the individual and whether the individual was refused treatment, refused treatment, was transferred, was admitted and treated, was stabilized and transferred, and/ was discharged. The policy defines a central log as: 'Log that a Hospital is required to maintain on each individual who "comes to the emergency department" seeking assistance that documents whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, Stabilized and transferred or discharged. The purpose of the Central Log is to track the care provided to each individual where EMTALA is triggered. The Central Log includes, directly or by reference, logs from other areas of the Hospital that may be considered DEDs, such as labor and delivery where an individual might present for emergency services or receive an MSE instead of the "traditional" emergency department; as well as individuals who seek care for an EMC in other areas located on the Hospital Property other than a DED.'

Based on review of video, prehospital care report, medical record, hospital service agreement, hospital logs, interviews, Medical Staff Bylaws and meeting minutes, and policies, it was determined that the facility failed to provide an appropriate medical screening exam to Patient #1, who presented to the hospital seeking emergency services.

Findings:

A review of the hospital's video surveillance from 7/14/20 regarding Patient # 1's disposition was done on 9/14/20 at 2:02 PM in Chief Executive Officer's (CEO) (DD) office with two qualified surveyors, the Director of Nursing (DON) (EE) and CEO (DD). The review revealed that an ambulance backed up to the entrance of the Emergency Department (ED) on 7/14/20 at 1:43:56 a.m. At 1:46:05 a.m., Emergency Medical Technician (EMT) JJ got out of the truck, keyed entrance code into keypad, and walked directly into the ED. It was observed on the video that EMT JJ had his hands out to his side and in the air with his palms facing upwards. He walked into the ED and out of view of the camera. At 1:48:00 a.m., EMT JJ was still out of view of the camera and there was no activity noticed from the ambulance. CEO DD explained that from their investigation the found the ambulance driver was talking to the ED Medical Doctor (MD) (BB) off-camera. The video further displayed Licensed Practical Nurse (LPN) GG sat down at the nurses' station at 1:46:56 a.m. CEO DD stated that LPN GG witnessed the conversation between MD BB and the driver. CEO DD said that Registered Nurse (FF) was the Charge Nurse and had "heard everything." At 1:49:20 Medical Doctor (MD) BB entered the camera view and was heading towards the ambulance entrance and parking lot door. As he was standing at the exit keypad, he turned towards the camera and was observed talking to someone out of camera range. AT 1:49:40, EMT JJ entered the camera view and was observed in conversation with MD BB. At 1:49:48 ME BB walks out and turns to the right (towards the parking lot). EMT JJ exited the ED at 1:49:53, went to the ambulance and opened the patient compartment doors of the ambulance. At 1:50:53 a.m., the driver closed the back door of the ambulance and walked to the driver side of the ambulance. The ambulance pulled away from this hospital at 1:53:20 a.m.

A review of the Prehospital Care Report (PCR) dated 7/14/20, received from neighboring county Emergency Medical Services (EMS), revealed Patient # 1 was picked up by their ambulance from a private residence. On 7/14/20, the ambulance was dispatched at 12:35 a.m. and arrived at a private residence at 12:51 a.m. The narrative note revealed Patient # 1 was found sitting upright in a kitchen chair. Upon arrival his oxygen level was 90 % (normal oxygen levels are greater than 95%) on room air and he was having trouble answering questions. Patient # 1's family advised he had just returned from a hospital in Atlanta on 7/13/20 after receiving treatment for Covid-19. Family advised he seemed fine when he went to bed at 9:00 p.m. but woke up at 12:00 a.m. and was having difficulty breathing. The family advised that Patient # 1 was not acting like himself. The initial assessment at 1:06 a.m. revealed Patient # 1's heart rate was 94 (normal 60-100), Respirations were 18 (normal 12-20), Blood sugar was 329 milligrams/deciliter (mg/dl) (units of measurement) (normal blood sugar is 70-140), and his oxygen concentration in his blood was 91% (normal is greater than 95). The narrative report revealed Patient # 1 was oriented, smiled, interacted, and obeyed commands. EMT's loaded Patient # 1 into the ambulance at 1:12 a.m. and left the residence in route to the hospital. At 1:22 a.m. Patient # 1's heart rate was 91, respirations were 18 and normal, and his oxygen concentration was 98%. Patient # 1 was confused at 1:22 a.m. Continued review of the narrative revealed the EMTs started Patient # 1 on 6 liters of oxygen by nasal cannula (plastic tubing inserted in the nose openings to deliver oxygen) and his condition improved. The narrative report revealed that when the ambulance was approximately 5 minutes from the hospital, EMT II called report and was told the hospital was on diversion. EMT II advised that this was the patient's and family's choice and they would be arriving in approximately 5 minutes. MD BB got on the phone and asked about Patient #1 and again said they were on out of county diversion. At 1:35 a.m. as the ambulance was passing the hospital, EMT JJ, who was driving the ambulance, phoned the hospital and asked who the physician was who advised them to divert. At 1:37 a.m., EMT JJ called the neighboring hospital and talked to their ED charge nurse to request acceptance. The narrative continues and revealed the ambulance pulled over on the side of the road. The charge nurse at the second hospital advised him they were on diversion also. The charge nurse suggested they turn around and go back to the initial destination and if they refused Patient # 1, to call her and she would make arrangements to accept the patient. The ambulance turned around and went to the original hospital. EMT JJ went in the hospital and talked with MD BB. The narrative of the PCR continued and revealed MD BB continued to advise EMT JJ that from what he had tole him, Patient # 1 needed a higher level of care than this hospital is able to provide. MD BB said the ambulance crew needed to seek a higher level of care. He suggested they talk to Patient # 1 and see if there is somewhere else he can go. MD BB told EMT JJ to tell Patient # 1 that he needs to seek a higher level of care. MD BB walked out the ambulance entrance doors and headed to his car. EMT JJ opened the patient compartment door and told Patient # 1 and EMT II that the hospital would not accept him. He asked Patient # 1 if he would agree to be transported to the other hospital and Patient # 1 nodded yes. EMT JJ informed his central dispatch (where assignments are made) that the original hospital would not accept the patient and they were in route to the final destination hospital. The ambulance arrived at the final destination hospital at 2:08 a.m.


A review of Patient # 1's medical record from the final destination hospital revealed that he was brought in by ambulance and admitted to the Emergency Department on 7/14/20 at 2:19 a.m. Triage of Patient # 1 at 2:45 a.m. revealed Patient # 1 was short of breath and that the patient was not talking by choice. The review of systems was limited as Patient # 1 was not talking. Patient # 1 had a prior history of high blood pressure and heart disease. He had been diagnosed COVID (Corona Virus and Disease or severe respiratory illness) positive. He was released from a hospital on 7/12/20 after treatment for COVID. Triage notes revealed Patient # 1 was in no apparent distress. A medical screening exam was performed at 2:45 p.m. and revealed Patient # 1 as alert and oriented to person, place, and time. He had no fever. His condition was stable. A chest x-ray (test used to show pictures of the inside parts of the body) was performed and the results were bilateral (both sides) infiltrates (substance denser than air visible on a chest x-ray) with a COVID appearance. Physician documentation at 6:23 a.m. revealed plans to discharge to home with follow up with primary care provider or to return to the Emergency Department if symptoms worsened. Further Physician documentation revealed at 7:46 a.m., the nurse noted Patient # 1's oxygen saturation (percentage of oxygen in blood) was declining and he had voided on himself. Possible seizure activity was considered. Plan was then to admit Patient # 1 to the hospital and follow up with a Magnetic Resonance Imaging (technique used in x-ray to form pictures of the organs in the body and how they are working). At 9:41 a.m., the Physician spoke with Patient # 1's wife who advised the Physician that Patient # 1 had stopped talking at 9:00 p.m. the previous night. The Physician ordered the MRI and admittance to the hospital intensive care unit for stroke symptoms. Patient # 1 was admitted to the hospital at 10:15 a.m.

A review of actual hospital bed census on 7/14/20 at 12:02 a.m. revealed 24 of 25 beds in the hospital were occupied.

A review of the Ambulance Diversion Log revealed that the Emergency Department went on diversion status ( the current emergency patient load exceeds the Emergency Department's ability to treat additional patients promptly) on 7/13/20 at 3:00 p.m. and went off diversion status on 7/14/20 at 8:22 a.m.

Review of the facility's Services Agreement, revealed Emergency Department provider coverage was to be 24 hours a day 365 days a year. The agreement revealed the providers agreed to comply with the policies, bylaws, rules and regulations of the Medical Staff; all applicable federal, state, and local laws and regulations, including but not limited to, those provisions of federal law commonly referred to as (Emergency Medical Treatment and Labor Act) EMTALA.

During a telephone interview in the Administration Conference Room on 9/15/20 at 12:00 p.m. with the Medical Doctor (MD) (BB) and two surveyors. MD BB said that the evening of 7/14/20, "had gone crazy" with 14 patients in the Emergency Department (ED) waiting room; the exam rooms were full, and there were 3-4 patients being held in the ED for a bed to become available in the hospital. MD BB said that the hospital Administration was called, and Administration said to go on out-of-county diversion (patients from other counties would be taken to a different hospital.) MD BB said that the information about diversion was "put out" to all Emergency Medical Services (EMS) directors to inform them that the hospital was on diversion. MD BB said their hospital does not go on diversion but 3-4 times a year. MD BB said that when the neighboring county's EMS called, the secretary answered the phone. MD BB said that after the secretary notified EMS of the diversion, EMS was still coming to the ED with a COVID positive patient who was short of breath. BB said that he went to the phone and asked EMS why they were insisting. MD BB said that EMS said it was because the patient had requested that hospital. BB said that he asked EMS to inform the patient that the hospital did not have Intensive Care Unit (ICU) beds, the hospital does not have specialists, and were on diversion. MD BB said he felt that a patient who had received treatment for COVID and was having complications needed a higher level of care than this hospital could provide. MD BB said that EMS told him they would inform the patient, and that was the last MD BB heard of it until EMS arrived at the ambulance entrance shortly after the phone call. BB said that one Emergency Medical Technician (EMT) JJ came into the ED without the patient and said he was not sure what to do. MD BB said EMT JJ told him that his EMS Dispatch had advised him to go where the patient wanted to go. MD BB said that he was yelling at EMT JJ but then apologized. MD BB said that he understands EMS code about going where the patient wants to go. MD BB said that he told EMT JJ the next time, try to inform the patient of resources so the patient can make an informed decision. MD BB said that he was going to his car and assumed EMS was going to bring the patient in, because they were there at the ED. MD BB said that when he saw the ambulance leave, "My heart just hit the floor; that's wrong, you can't do that." MD BB said he thought he was going to throw up. MD BB said that he never told EMS to leave or that they could not come to the ED. MD BB said that "They suddenly left which shocked everybody." MD BB further stated, "We know that once they get to our property it is our responsibility to assess and stabilize." MD BB said that he got on the phone to try to contact the ambulance to tell them to return to the ED, but the county dispatch said the EMT's would not answer the phone. MD BB said that he told Dispatch to keep trying to get them; "they are not supposed to leave when a patient is on the property." MD BB said that Dispatch called back and said the ambulance was at a different hospital's emergency room. MD BB said that he told dispatch to inform the ambulance that they needed to bring the patient back, but the EMT's were refusing to bring the patient back. MD BB said that Charge Nurse (FF) called the other hospital ED's charge nurse and again requested that the ambulance come back; they still refused to come back. MD BB said he never told EMS that they could not come and never told them to leave. MDBB said that the physician's staffing agency does annual training on EMTALA. MD BB said he was required to go through and completed special Emergency Medical Treatment and Labor Act (EMTALA) courses. MD BB said that transferring a patient to a different hospital during this state of emergency has been difficult. He said there have been a few occasions where the patients had to be transferred out of state.

During an interview on 9/14/20 at 5:50 p.m. in the Administrative Conference Room with two surveyors and the Charge Nurse Registered Nurse (RN) (FF), RN FF stated that she "pretty much remembers the situation." RN (FF) said she had been the Charge Nurse in ED for over a year. She said she remembers the incident and that the Emergency Department (ED) got a phone call from the neighboring county's Emergency Medical Service (EMS). RN (FF) said that she did not hear the call, but she knew it was EMS. RN (FF) said that the Unit Secretary (US) (HH) gave the phone to Medical Doctor (MD) (BB). RN (FF) said the only thing she heard in passing was that MD BB diverted the patient to a higher level of care because of what was going on with the patient. RN (FF) said that the next thing she knew, the ambulance was backing up to the ambulance entrance door and one of the Emergency Medical Technicians (EMT), EMT (JJ), walked in by himself. RN (FF) said that MD (BB) and the EMT (JJ) started "having an exchange of words." RN (FF) said she could not hear everything that was spoken. RN (FF) said that she did hear EMT (JJ) say that that everybody was on diversion and they did not have anywhere else to go. RN (FF) said that MD (BB) told EMT (JJ) that the hospital did not have Intensive Care Unit (ICU) capability. She said EMT (JJ) came back with, "Just transfer him then." RN (FF) said that MD (BB) told EMT (JJ) that the problem with COVID-19 is that there is nowhere to transfer people, everybody is on diversion. RN (FF) said that the hospital had transferred people to Pensacola, Orlando, and Kentucky, and it was difficult for the families to travel that far. RN (FF) said that she did not have a room open; the ED was full; the waiting room was full. Charge Nurse, RN (FF), said that she told EMT (JJ) that he could bring the patient in and the patient would have to "go on the wall." (Going on the wall means that the patient would have to wait for a room along the ED wall. EMS would stay with the patient until there was a room available.) RN (FF) explained that when the patient would have been on the wall, she would have brought out a non-critical patient and turned the room over (cleaned and prepared the room for the next patient.) "really quickly." RN (FF) said that she would either put the non-critical patient in the hallway or in one of two internal waiting rooms. The internal waiting rooms are rooms that are normally used for families if someone dies or the physician needed to speak to a family. RN (FF) said that only one patient at a time would be put into an internal waiting room. RN (FF) said that EMT (JJ) left the ED, and she thought he was going to get the patient. RN (FF) said that when she looked up, there was no patient and the ambulance was gone. RN (FF) stated that she called the EMS Dispatch and asked them to tell the ambulance to come back. RN (FF) said that Dispatch told her that they would radio the ambulance, but the ambulance did not come back.

During an interview with the Unit Secretary (US) (HH) at 7:25 a.m. at 9/15/20 in the Administrative Conference Room, Unit Secretary (HH) said that she has been employed as Unit Secretary since June 17, 2019. US HH said that when Emergency Medical Services (EMS) calls, she will listen and write down everything EMS tells her about the patient. US HH said that she does not really remember the type of patient EMS called about on 7/14/20, but she remembers trying to divert. Unit Secretary HH said Medical Doctor (MD) (BB) came over to "the radio" and let them know they needed to divert because of the level of care the patient needed. Unit Secretary HH said, "We thought they were going to divert, but they came here anyway." Unit Secretary HH said that she does not remember if the call was over the radio or telephone, and that she "barely remembers." Unit Secretary HH said that from what she remembered, it was a radio call; when EMS started saying the chief complaint, MD BB told them to divert. Unit Secretary (HH) said that once EMS comes there, "it is our patient." Unit Secretary HH stated that, "We never actually saw the patient, because when Emergency Medical Technician (EMT) JJ got here, he came in and talked to (MD) BB. Unit Secretary HH said it looked like EMT JJ came in just to say what he wanted to say about being diverted; almost came in and picked a fight; came in without the patient and came in to have words with (MD) BB." The Unit Secretary (HH) said that when the EMT JJ went out, she thought EMT JJ was bringing the patient in. Unit Secretary HH stated, "We didn't think they were leaving." Unit Secretary (HH) said that after she saw the ambulance pull away, MD BB came back (into the ED from outside) and told her to try to reach them. Unit Secretary HH said that she tried several times to contact EMS. She said EMS would not answer their phones. Unit Secretary HH said that she tried to call over the radio, and somebody else picked up the phone and called the county dispatch; that is when dispatch said the ambulance was going to the neighboring county's hospital. The Unit Secretary (HH) stated, "We asked them to come back, because once they are here, they are supposed to come inside." Unit Secretary HH said that she tried the radio twice and they (EMS) would not answer. When the surveyor asked the Unit Secretary how she knew about EMTALA, she stated, "I've been doing it since 1997, Unit Secretary for a long time, so every time I transition to a new job, I get retrained." Unit Secretary HH said that she had a lot of computer classes in a different facility, but since she had been at the current hospital, "I haven't really had to do classes, I do annual care learning, but not sure if EMTALA is included."

During a telephone interview on 9/15/20 at 12:20 p.m. in the Administrative Conference Room with two surveyors and the Emergency Medical Technician (EMT) JJ, EMT JJ said he remembers the incident. He said that Patient #1 had a high blood sugar and was on 6 liters (measure) of oxygen. EMT JJ said when they first got to Patient # 1, Patient # 1 was on 6 liters of oxygen a minute, but the tubing was really long. EMT JJ explained that the longer the tubing, the less concentrated the oxygen that gets to the patient. The patient's family requested that the patient be taken to this hospital, since it was the closest. EMT JJ said his partner, EMT II, was in the back of the ambulance providing care to the patient. EMT JJ said that he told his partner, EMT (II), to call the hospital to give report (a description of the patient's status given to the nurse or doctor regarding the patient.) EMT JJ said that when EMT II called the hospital, she was put on hold. While on hold, EMT II told EMT JJ that the hospital was on diversion (not receiving patients.) EMT JJ said that the patient and the patient's family had requested this hospital. EMT JJ said he had been trained to take the patient to the requested hospital. EMT JJ said that he did not know what to do. EMT JJ said that when he was 1 mile from the hospital, he called an alternative Emergency Department (ED) that was 8 miles further away; told the charge nurse that he had a patient who had been in transit for 25 minutes and needed an elevated level of care immediately. EMT JJ said that the charge nurse at the alternate ED told him that they were on out-of-county diversion and to turn around and go back to the other hospital; if that hospital did not accept the patient, then they would find a bed at the alternate hospital. EMT JJ said he had already passed the original hospital. He said he turned around and went back about a mile to the original destination. EMT JJ said he told EMT II not to take patient # 1 in the hospital until he could talk to the Medical Doctor. EMT JJ explained that he did not want to take a COVID positive patient into an emergency department if they were not going to see him. EMT JJ said that when he backed the ambulance up to the ED, he could see the MD (BB) through the glass doors and wanted to tell the MD (BB) that he had to come there (to the ED). EMT JJ said that he went into the ED without the patient. He said that when he approached MD BB, he apologized and told MD BB he had to come there because it was what the family requested. EMT JJ said that he told MD BB Patient # 1's findings (blood sugar, vital signs, oxygen level, etc.) to let MD BB know the patient was critical. EMT JJ said MD BB told him Patient # 1 needed a higher level of care, the hospital was not equipped to provide the services, they did not have any beds, and asked EMT JJ "what the fuck do you want me to do?" He said MD BB immediately apologized. EMT JJ said that MD BB told him that he did not have room for any more patients and that JJ should tell the patient that he needs to seek an elevated level of care. EMT JJ said that MD BB asked him, "What part of diversion do you not understand?" EMT JJ said that MD BB never told him not to bring the patient in. EMT JJ said that he has been an EMT for 2 ½ years and was still learning. My instructor told me that once my tires touch the hospital ground that is where the patient goes. EMT JJ said that he did not ask, "Doctor, are you refusing my patient?" EMT JJ said that he told MD BB that he would "hold the wall" (wait) for as long as necessary for someone to provide higher care than and EMT could; that is when MD BB said, "Sir, you need to go and seek an elevated level of care." EMT JJ said that is when he made the decision to leave. EMT JJ said that MD BB said that it was time for his "tea break" and walked to the door. EMT JJ said that he thought MD BB was going to look at the patient, but MD BB went a different direction after leaving the ED. EMT JJ said that he went to the door of the ambulance and told Patient #1, "Sir, they're not accepting anyone right now, can I take you to another facility?" EMT JJ said that Patient #1 nodded since he was not able to speak, and EMT JJ took that as the patient giving consent. EMT JJ said that he called the charge nurse at the other ED, told her what happened, and the Charge Nurse told him to bring the patient to their ED. About a mile from the alternate ED, JJ said that he heard Central Dispatch saying that the hospital had called asking where the ambulance went and to tell the ambulance to come back. EMT JJ said that he was only a mile from the alternate ED and was not going to turn around. EMT JJ said he knew he should not leave but he did anyway.

During a telephone interview from the Administrative Conference Room on 9/15/20 at 11:45 a.m. with Advanced Emergency Medical Technician (EMT) (II) and two surveyors, EMT (II) said that she was in the back of the ambulance the evening of 7/14/20 and made the initial call to the Emergency Department (ED) regarding Patient #1. EMT (II) said she was told that the ED was on out-of-county diversion. EMT (II) said that she told the person who answered the phone that the hospital was where the patient and family wanted him to go. EMT (II) said that MD (BB) took the phone and EMT (II) told him that that the hospital was the patient and family's choice. The EMT (II) said that the MD (BB) asked for the patient's Chief Complaint and was told difficulty breathing and COVID positive. EMT II said MD BB asked how the patient could request that facility if he was having difficulty breathing. EMT II said she told MD BB the patient had asked before his breathing got worse. EMT II said EMT JJ was on the phone with another hospital's emergency department when her call with MD BB was dropped. EMT (JJ) said that he was calling the other hospital's ED to see if they would accept the patient. EMT (II) said that when the ambulance pulled into the first hospital, EMT (JJ) got out and told her he would be back. EMT II could see EMT JJ and MD BB talking through the glass doors of the ED. EMT II said she saw EMT JJ coming out the door and MD BB was following him. EMT (II) said that she thought MD (BB) was coming out to check on the patient. EMT II said MD (BB) went to his car. EMT (II) said that EMT (JJ) told he her ED would not accept the patient and they were going to the hospital in the next county. EMT (II) said that when they were almost to the next county's ED, the hospital started calling the ambulance wanting them to bring the patient back. EMT (II) said that she did not answer the phone, because she was talking to the patient. EMT (II) said the ambulance was almost at the next hospital and the EMT's did not want to delay patient care anymore. EMT (II) said that Patient # 1 was alert and oriented and wanted to know why that hospital would not accept him. EMT (II) said that when they got to the next ED, there was a room ready for the patient. EMT (II) further said that she has been an Advanced EMT for about a year, and she is half-way through Paramedic school.

An interview with Charge Nurse, Registered Nurse (RN) CC was initiated during the tour of the Emergency Department on 9/14/20 at 12:00 p.m. RN CC said that the emergency department does not go on diversion very often. She said she remembers July was an unusual month in that they did go on diversion several times. RN CC explained that when they go on diversion, it had to be approved by the Administrator on call. She said either the Charge Nurse or the Physician would call and explain the situation to the Administrator. RN CC said she does not know of any time, they have refused to allow diversion. RN CC said when diversion was approved, either the Charge Nurse or the Unit Secretary would call all the neighboring counties to let them know the hospital was on diversion and why the hospital was on diversion. She said when the hospital comes off diversion, those counties are called to let them know the hospital is off diversion. RN CC said they have a list and contact numbers to call for five neighboring Emergency Medical Service Agencies. RN CC said there is also a state agency where diversions are reported.

During the entrance conference on 9/14/20 at 11:00 a.m., Chief Executive Officer (CEO) DD said they were expecting us. CEO DD said she had self-reported the incident because they knew it could be a possible violation. CEO DD said the Emergency Department Charge Nurse, Registered Nurse (RN) FF, had called her at 1:30 in the morning to inform her of the situation.

A subsequent interview was done with Chief Executive Officer (CEO) DD on 9/15/20 at 2:00 p.m. in the administrative conference room. CEO DD explained that she had self-reported because the ambulance had arrived on their property with a patient that they never saw. The hospital administration has been in contact with the Emergency Department (ED) Contract Physicians Group. CEO DD said remedial and advanced Emergency Medical Treatment and Labor Act (EMTALA) training was completed by MD BB within 2 weeks of the incident. She confirmed that the hospital is looking into getting someone with a legal background to come talk to all the hospital employees about EMTALA regulations. CEO DD said administration has interviewed all the staff from that night, and they were all shocked that the ambulance just left. CEO DD confirmed that the hospital was on diversion at that time. CEO DD said anytime a patient came to the emergency department regardless of the diversion status, the patient would be seen. She said all the neighboring counties had been notified but that the hospital had failed to notify the state Emergency Medical Services agency that was usually notified. CEO DD said that even when the state agency was notified of a diversion, the Charge Nurse would notify surrounding counties. CEO DD said COVID positive and patients under suspicion of COVID every day in the Emergency Department. She said COVID positive patients are admitted or stabilized and transferred to a higher level of care if indicated. CEO DD confirmed they do not have a specified Intensive Care Unit in the hospital. CEO DD said a lot of the beds that were usually used for swing beds were now being used for COVID patients.

Review of the Medical Staff Rules and Regulations revealed that the hospital shall accept all patients for care and treatment within its capacity. Only practitioners granted staff appointment shall admit patients, except during a disaster. Each practitioner must assure timely, adequate professional care for his patients in the hospital by being available by presence or telephone or having an available alternate. The Medical Director of the Emergency Department (ED) shall have the overall responsibility for emergency care. Emergency services policies and procedures shall be approved by the Medical Executive Committee and the Board. The Medical Director shall be responsible for the continuous evaluation of the quality and appropriateness of patient care in the ED. Patients with conditions whose definitive care is beyond the capabilities of this hospital shall be referred to the appropriate facility, when in the judgement of the attending practitioner, the patient's condition permits such a transfer. The hospital's procedures for patient transfers to other facilities shall be followed. The Emergency physician director through the emergency service committee shall make certain that emergency service procedures are properly coordinated with the hospital's disaster plan, especially as they pertain to the care of mass casualties. All patients who arrive at the Emergency Department for evaluation or care are required under EMTALA law to have a medical screening exam done and have stabilizing treatment, if unstable. Medical screening exams in the ED must be done by a physician, nurse practitioner, or a physician assistance under the supervision of a physician.

Review of the 8/12/20 MEC Committee closed meeting minutes draft (not approved until the next MEC meeting) revealed that the Medical Director (AA) and the Chief Executive Officer (CEO) DD advised the committee of an incident that occurred in the Emergency Department (ED) on July 14, 2020. The incident involved Medical Doctor (MD) (BB) confronting a neighboring county's Emergency Medical Services (EMS) about bringing a patient to the hospital while the hospital was on diversion. The minutes revealed that the Emergency Medical Technician (EMT) (JJ) got upset and left the hospital with the patient. The EMT (JJ) never unloaded the patient, however, the ambulance was in the bay. Further review revealed that the hospital had self-reported and submitted the following requirements for the physicians staffing group: MD (BB) would complete the staffing group's EMTALA course prior to coming to campus for his next shift. The staffing group would require all providers coming to the hospital to complete an EMTALA course no later than 7/31/20. MD (BB) would meet with the hospital's Corporate Compliance Officer regarding EMTALA. MD (BB) would work no more than 3 shifts in a row. If another incident occurred, the staffing agency would ensure MD (BB) was no longer on the schedule. MD (BB) was required to complete any compliance course the hospital may require in the future. Continued review of the MEC minutes revealed that MD (BB) had cooperated fully and completed all the request action items. The August MEC meeting minutes further revealed that Medical Director (AA) had a general discussion with the MEC regarding ED physicians' responsibility in responding to rapid response calls and codes.

POLICIES

Review of the EMTALA (Emergency Medical Treatment and Labor Act) policy, effective 4/16/18, revised 7/16/19 re