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Based on current policies and procedures, ambulance trip report review, Dedicated Emergency Department (DED) medical record review, audio tape review, and physician and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

The hospital's DED medical staff failed to provide an appropriate medical screening examination within the capability of the hospital's DED for an individual who presented for evaluation for an emergency medical condition in 2 of 25 sampled patients (Patient #24 and #25).

~ Cross refer to §489.24(a) and (c) Medical Screening Exam, Tag A-2406.

Based on policies and procedures review, ambulance trip report review, DED medical record reviews, audio tape review, physician and staff interviews, it was determined the hospital's DED medical staff failed to provide an appropriate medical screening examination within the capability of the hospital's DED for individuals who were found unresponsive, and transported by the hospital's owned and operated ambulances and presented for evaluation for an emergency medical condition for 2 of 25 sampled patients (Patient #24 and #25).

Findings included:

Policy and Procedure

Review of the hospital's "EMTALA-Medical Screening Examination and Stabilization" policy revised 11/2015 revealed "... An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and: 1. A request is made by the individual or on the individual's behalf for an examination or treatment for a medical condition ... Further, if an individual presents elsewhere on hospital property and requests examination or treatment for an emergency medical condition (EMC) or if a prudent layperson observer would believe that the individual is suffering from an EMC, then an appropriate MSE, within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of the on-call physicians), shall be performed by an individual qualified to perform such examination to determine whether an EMC exists ... An individual MUST receive an MSE, within the capabilities of the hospital's DED, to determine whether or not an EMC exists, ... and whether or not the treatment requested is explicitly for an emergency condition if: ... d. An individual is in a ground or air ambulance for purposes of examination and treatment for a medical condition at a hospital's DED, and the ambulance is either: i. owned and operated by the hospital, even if the ambulance is not on hospital grounds ..."

Audio Tape

Review on 08/29/2018 at 1505 of an audio tape of the radio call placed to the DED on 08/14/2018 revealed RN #3 stated, "If you think they meet flight criteria that would be great because we don't have any ICU beds here."


1. Ambulance Trip Report #24

Review of a ground ambulance trip report revealed Patient #24, a 38 year old male patient was found unresponsive in a vehicle in a private parking lot on 08/14/2018. Review revealed there was also a female patient in the vehicle. Review of the EMS trip report revealed , "Chief Complaint: Overdose". History of Present Illness: PD [Police Department] has found subjects in their vehicle. It is not known how long they have been there. [PD] has used Narcan [a drug to reverse the effects of opioid overdose] on the male pt inside the vehicle." Review revealed at 2228, EMS arrived on the scene and the crew split to initiate care of both patients in the vehicle. Review revealed the patient was breathing 4-6 (normal respiratory rate 14-20) times per minute and had a GCS of 3 (Glasgow Coma Scale range is 3-15 with 3 indicating coma) with a blood pressure of 194/124 and a heart rate of 78. Review revealed the crew initiated an intravenous (IV) line in the male patient and 2mg (milligrams) of Narcan was given without change in responsiveness. Review revealed the patient's airway was unstable and a nasopharyngeal airway was placed at 2232. Review revealed 1mg Narcan was given at 2223 with no change in responsiveness at the same time the patient was being bagged (manually ventilated) and loaded into Ambulance #1. Review revealed at 2235 1mg Narcan was given. Review revealed also at 2235, "ALS [Advanced Life Support] Notification alert sent by [EMT #1] via radio. Contacted [Hospital A DED] via handheld to inform of pending situation with two patients requiring high dose Narcan. Advised [Hospital A DED- Harris Regional Hospital ] does not have capability to treat patients long term, advised to fly if patients require possible intensive care. Contacted Dispatch to obtain 2 helicopters." Review revealed at 2240 an IO [Intraosseous line to be used to infuse medication or fluid directly into the bone marrow] was obtained. At 2245, 2mg Narcan was given without change in responsiveness. At 2249, 2mg Narcan was given with no change in responsiveness. At 2251, an attempt to intubate (insert a breathing tube to protect the airway) was unsuccessful. At 2256, intubation was attempted again and was successful. At 2300, the ambulance departed for the loading zone at Hospital A, arriving at 2302. Upon arrival at the loading zone, blood pressure was 167/115, heart rate was 89, and the patient was intubated and manually ventilated. At 2305, Helicopter #1 was landing. Crew aboard Helicopter #1 assumed care of the patient at 2315 and were then en route to Hospital B.

Medical Record #24 Hospital B

Review of the air ambulance trip report for Patient #24 revealed Hospital B's flight crew was dispatched at 2240 to Hospital A and arrived on scene at 2306. Review of the EMS patient assessment recorded at 2309 revealed " ... Upon our arrival, the patient is unresponsive, intubated orally with a 7.5 ETT (endotracheal tube) secured at 26 cm's (centimeters). Current V/S (vital signs): B/P (blood pressure) 176/118 HR (heart rate) 80's SPO2 (oxygen saturation) 94% ETCO2 (ETT carbon dioxide) 35-45. Pupils pinpoint. Patient received 1000 ml (milliliters) NS IV (intravenous) total. The patient is assessed, moved to aircraft stretcher, covered and secured with straps. In flight: Monitor SR (sinus rhythm), rate 84-78 B/P 153/97 - 138/96 ETCO2 44-39 SpO2 100% IV at KVO (keep vein open). The patient is given Versed (medication for sedation) 2 mg (milligrams) and Fentanyl (medication for sedation) 25 mcg (micrograms) IV with effect. Report called to (Hospital B) ER. ..." Review revealed the air transport departed the scene at 2320. Review revealed the air transport arrived to Hospital B at 2340 with arrival vital signs recorded as B/P 159/110, HR 78, SPO2 100%. Care was transferred to the ED at 2345.

Review of inpatient records from Hospital B for Patient #24 reveal vital signs on arrival on 08/15/2018 at 2345 in the DED at Hospital B were BP 130/93, HR 77, SPO2 100%. He had a GCS of 3. He received a chest x-ray which showed collapse of the upper lobe of the right lung, and an EKG which showed normal sinus rhythm. He was admitted to the ICU with suspected overdose and respiratory failure. Review of the discharge summary revealed, "he woke up several hours later and was agitated and subsequently extubated and weaned to RA [room air]." Review revealed he was discharged to home on 08/15/2018.


2. Ambulance Trip Report #25

Review of a ground ambulance trip report revealed Patient #25, a 35 year old female patient was found unresponsive in a vehicle in a private parking lot on 08/14/2018. Review revealed a male patient was also present. Review of the EMS trip report revealed Run Number 18-27422-01 which stated, "Chief complaint: Overdose opioid." Review revealed at 2228, "Arrived on scene to find single vehicle in dark parking lot. Vehicle is occupied times two. Male and female slumped over in front seats." Review revealed Patient #25 had constricted pupils and shallow respirations at 6 breaths per minute, with a GCS of 3. Review revealed at 2228 EMS requested another ambulance. Review revealed at 2230, an IV line was placed, and at 2223, 2mg Narcan was administered with little response. Review revealed at 2235, "Contacted [Hospital A DED] via handheld to inform of pending situation with two patients requiring high dose Narcan. Advised [Hospital A DED] does not have capability to treat patients long term, advised to fly if pt's require possible intensive care. Contacted dispatch to obtain two helicopters." Review revealed at 2237, 2mg Narcan was administered, and at 2245 Patient #25 spontaneously moved her feet, her respirations were slightly improved, and an additional 2mg of Narcan was given. The patient was loaded into Ambulance #2 at 2249. Vitals signs at the time of ground transport were BP 112/80, HR 62, SPO2 100%, RR 12, with a GCS of 3. At 2256, 2mg Narcan was administered. At 2259, patient was moving her feet and responding to painful stimuli. At 2302, Ambulance #2 arrived at a makeshift loading zone in Hospital A's parking lot. At 2304 and 2312, 2 mg Narcan was administered. Patient #25 began to vomit at 2315 and 8mg ondansetron [anti-nausea medication] was given. Review revealed at 2321, Helicopter #2 arrived and decided to intubate the patient with the ground EMS crew remaining on scene for support. The flight crew assumed care of Patient #25 and took off shortly en route to Hospital B.

Review of the air ambulance trip report for Patient #25 revealed the flight crew was dispatched at 2246 to Hospital A and arrived on scene at 2318. Review of the EMS patient assessment recorded at 2320 recorded a GCS (Glasgow Coma Scale) of 6 (range is 3-15 with 3 indicating coma). Review of vital signs at 2323 revealed B/P 105/73, Pulse 70, RR (respiratory rate) 9 SPO2 99%. Review revealed the air flight crew intubated the patient at 2335 due to a need to protect the patient's airway. Review revealed the air transport departed the landing zone at 2345. Review of the trip report revealed a GCS score of 3 at 2350. Review revealed the air transport arrived to Hospital B on 08/15/2018 at 0003 with transfer of care to Hospital B at 0010.

Medical Record Review #25 Hospital B

Review of inpatient medical records from Hospital B for Patient #25 revealed she arrived at the DED at Hospital B on 08/15/2018 at 0010 with the following vital signs: BP 102/76, HR 57, RR 20, SPO2 100. She received a chest x-ray which showed no acute infiltrates and an EKG which showed normal sinus rhythm. She was admitted to the ICU for unintentional polypharmaceutical overdose and respiratory failure. Review revealed she was extubated after less than 12 hours and transferred out of the ICU on 08/15/2018. Review revealed she was discharged to home on 08/16/2018.


Interviews

Interview on 08/29/2018 at 0915 with EMT #1 revealed he remembers the events of 08/14/2018. Interview revealed when the truck arrived on the scene, the patient had "depressed respiratory status" and both patients needed more assistance. Interview revealed a second truck was called to provide assistance and one to one care. Interview revealed the male patient was intubated prior to leaving the scene. Interview revealed EMT #1 placed a radio call to Hospital A to report they were out of Narcan and they had two critical patients. Interview revealed the staff member called the Hospital DED to "give them a head's up that they were bringing the two patients so they could prepare'. Interview revealed when he placed the radio call to Hospital A, he "was told to check flight status," though he did not recall the exact wording used. Interview revealed he immediately called dispatch to request helicopter transport. Interview revealed, "After the initial call [to Hospital A], I don't remember calling them back at all- at that point they're no longer part of the equation." Further interview revealed, "We would have come [to Hospital A] if they had accepted them." Interview revealed the EMT could not remember a time when the hospital had been on diversion status, but he assumed the hospital would notify EMS directly if they were unable to accept patients. Interview revealed Hospital A was not on diversion on 08/14/2018.

Interview on 08/29/2018 at 1010 with RN #3 revealed he was the nurse who answered the radio call from EMS on the evening of 08/14/2018. Interview revealed that he assumed at the time of the call the EMS was en route; interview revealed, "I told them they might want to consider air [transport]." Interview revealed that RN #3 knew that there were no ICU beds available, which meant "we were not able to admit anything that might require an ICU bed, [but] patients that need emergency care could still come here." Interview revealed his understanding of the call was that the EMS crew was requesting the DED have Narcan available for their arrival, and that the general purpose of radio calls from EMS to the DED is to alert the facility that a patient is on the way. Interview revealed, "At no point did they ask to come here;" further interview revealed, "As a general rule, they don't call and ask if they can come to our hospital." Interview revealed RN #3 assumed that the patients might potentially meet "flight criteria," but could not say what specific criteria the patients would have met. Interview revealed he was not aware of whether the patients were intubated but assumed they would need intensive care. Interview revealed a typical nurse would not know what "flight criteria" meant to an EMT, and that RN #3 knew about flight criteria because of his previous EMT training. Interview revealed, "I've been a paramedic for over 18 years. If that were my scene, the more info I have, the more appropriate decision I could make. I didn't tell them they couldn't come." Interview with the nurse confirmed Hospital A's DED was not on diversion on 08/14/2018.

Interview on 08/29/2018 at 1050 with RN #4 revealed he was the Director of Emergency Services at Hospital A. Interview revealed that there is no policy for who can answer the radio or what they should say, but that the general purpose of the call is usually to alert the DED of an incoming patient. Interview revealed, "There is no expectation for an RN to provide any directive" to EMS over the radio, and that if the hospital is on diversion status, there is a telephone protocol to alert EMS and neighboring hospitals. Interview confirmed the hospital was not on diversion status on 08/14/2018 and the DED was no busier than usual. RN #4 could not recall a time over the past four years that the hospital was on diversion status. Interview revealed that in regards to RN #3 stating that EMS should consider whether the patients met flight criteria, "I don't know what that means ...I wouldn't expect him to say that." Interview revealed that nurses in the DED are made aware of what beds are available in the hospital but bed availability "should not impact a radio call." Interview revealed that ultimately there was no reason why EMS could not have brought the patients to Hospital A for treatment.

Interview on 08/29/2018 at 1144 with MD #5 revealed that he was the physician on duty in the DED on the evening of 08/14/2018. Interview revealed MD #5 overheard the radio call, but did not give any orders or directions, and "that was the last I heard about it." Interview revealed he assumed there would be another call from EMS to say they were en route, but no call ever came. Interview revealed MD #5 was not aware of anything that was happening in the hospital parking lot or helipad area, but heard a helicopter and assumed they were flying a patient. Interview revealed his impression was that EMS intended to bring the patients to Hospital A but their decision was influenced by the lack of critical care beds available. Interview revealed, "It was not my intent to divert those patients. It would have been better for them to be at our facility at least initially."

Interview on 08/29/2018 at 1130 with EMS Staff #6 revealed he was the EMS manager. Interview revealed the EMS ground transport was owned and operated by Hospital A, and the EMS staff were employees of Hospital A. Interview revealed EMS staff followed state protocols that had been approved by state and local Medical Directors for determining where to take patients in an emergency. Protocols and destination templates were submitted for review that directed the EMS crew when it would be appropriate to bypass Hospital A. Review of these protocols included "Post Resuscitation; Trauma/Burn; Pediatric; STEMI; Stroke; and Mass Causality". Interview revealed if the patient being transported didn't fall under one of the protocols identified, the patient would be brought to Hospital A. Interview revealed the patient would be brought to the closest appropriate facility. Interview revealed there was no reason not to bring these two patients to Hospital A. The staff member stated "They should have (brought them to Hospital A). I assume they didn't come here because they needed critical care and when (RN #3) said we had no beds, I think they made the decision to fly to (Hospital B). We can stabilize overdosed patients here. Having no ICU beds available here influenced their decision.

The facility failed to ensure that their policy and procedure were followed as evidenced by failing to provide an appropriate medical screening examination within the capabilities of the hospital's dedicated emergency department for Patient #24 and #25 on 8/14/2018 to include ancillary services routinely available ( Laboratory services, diagnostic testing, medication administration and the availability of on-call physicians). The policy states, "An individual MUST receive an MSE, within the capabilities of the hospital's DED, to determine whether or not an EMC exists."





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