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Based on review of medical records, Emergency Medical Services (EMS) report, video review, Medical Staff Bylaws, and Rules and Regulations, Observations, Emergency Department (ED) policies and procedures, and interviews, it was determined that the facility failed to enforce their policies and procedures for Patient #1 who presented to the facility's Emergency Department 9/15/2020 seeking emergency services.

FINDINGS:

Cross refer A2406 as it relates to the facility's failure to provide a medical screening examination for Patient #1 who presented to the facility's ED on 9/15/2020 seeking emergency treatment.

Cross refer A2407 as it relates to the facility's failure to provide stabilizing treatment for Patient #1 who presented to the facility's ED on 9/15/2020 seeking emergency treatment.

Cross refer A2409 as it relates to the facility's failure to provide an appropriate transfer for Patient #1 who presented to the facility's ED on 9/15/2020 seeking emergency treatment.

Based on a review of medical records, Emergency Medical Services report, video, hospital documents, Medical Staff Bylaws Rules and Regulations, observations, Emergency Department (ED) policies and procedures, and interviews, it was determined that the facility failed to provide an appropriate medical screening exam for Patient #1 who presented to the hospital seeking emergency services.

FINDINGS:

MEDICAL RECORD

A review of Patient # 1's Emergency Medical Services (EMS) ambulance trip report on 9/15/2020 revealed EMS was dispatched to the private residence of Patient #1 who was experiencing nausea and vomiting. Patient #1 provided a medical history that included diabetes (too much sugar in the blood), high blood pressure, and gastroparesis (a condition that prevents the stomach from properly emptying). Patient #1 reported that she had been discharged from the hospital (Hospital #1) the previous day after being admitted for 9 days. Patient #1 reported she had been told that she had a blockage in her small intestine, and if she continued to have nausea and vomiting to return to the hospital (Hospital #1). The report revealed Patient #1 wanted to return to the same hospital (Hospital #1) where she had been previously admitted. Patient # 1's initial assessment at 9:20 p.m. in the ambulance revealed a heart rate of 114 beats/minute (normal adult heart rate is 60-100), respirations were 18/minute (normal adult respirations 12-20), blood pressure 179/P (palpable only - normal adult blood pressure is 90-120/60-80), and blood glucose level of 249 (normal range of blood glucose for a person with diabetes is 80-130). A second assessment was done at 9:35 p.m. and revealed Patient # 1's heart rate -110, respirations-18, and blood pressure 190/108. The final EMS assessment was performed prior to arrival at the hospital and revealed Patient # 1's heart rate-114, respirations-18, blood pressure 185/108. EMS Paramedic HH's narrative report revealed Patient #1 stated she continued to have nausea and vomiting and needed to return to the hospital. Patient #1 was being transported back to the hospital (Hospital #1) of her choice. Patient #1 had to wait on the wall (waiting on a stretcher outside the treatment area of the Emergency Department) for a bed to become available. Patient #1 waited on a stretcher from 9:54 p.m. until 11:00 p.m. Patient #1 decided she did not want to wait any longer. Patient #1 decided she wanted to go to another hospital (Hospital #2) for treatment. Paramedic HH called his battalion chief and made him aware of the wait time. Battalion chief advised Paramedic HH if Patient #1 stated she wanted to go to another facility permission was granted for EMS to transport to another facility. Patient #1 was transported from Hospital #1 to Hospital #2.

A review of Hospital # 1's Emergency Department (ED) Medical Record of Patient #1 revealed an emergency encounter was created on 9/15/2020 at 9:56 p.m. Patient #1 arrived in the ED at 9:57 p.m. with a neighboring county's Emergency Medical Service (EMS) ambulance. Electronic documentation on 9/15/20 at 11:30 p.m. revealed the ambulance left with Patient #1 at 11:35 p.m. Electronic documentation on 9/16/2020 at 12:05 a.m. Documentation revealed Patient # 1's status as having left without being seen before triage (a quick assessment of a patient and determination of the urgency of the needs.)

VIDEO
A review of four (4) videos provided by the hospital revealed portions of the time Patient #1 was at the hospital.

The first video started at 9:58:14 p.m. and revealed a patient being placed on the wall (waiting on a stretcher outside the treatment area of the Emergency Department) by Emergency Medical Services (ambulance). Patient #1 was brought into the doors at 9:58:14 by ambulance attendants. Charge Nurse RN DD and Emergency Room Communications EMT CC were sitting at the registration desk when Patient #1 arrived. Patient #1 could be seen with her head bobbing up and down toward a vomit bag. The Emergency Medical Services (EMS) ambulance Paramedic, Emergency Medical Technician EMT HH, was seen providing registration information to Charge Nurse, Registered Nurse RN DD, and Emergency Room Communications EMT CC at 9:59:00 p.m. At 10:01:00 p.m. the video was cut off with Emergency Medical Services moving Patient #1 to the wall.

The second video provided started at 11:25:57 p.m. and revealed Paramedic HH coming out of the hallway where Patient #1 was waiting on the wall. EMT HH was seen talking to Charge Nurse RN DD and EMT CC. They had a conversation until 11:27:00 p.m. when EMT HH went back through the hall to the wall where Patient #1 was waiting. The video ended at 11:27:04 p.m.

The third video provided started at 11:29:50 p.m. EMT HH and another EMS attendant were observed bringing Patient #1 through the doors of the hallway where they had been waiting on the wall. Charge Nurse RN DD and EMT CC were sitting at the Emergency Room Communications desk observing Patient #1 being transported out of the hospital by EMS. As EMS walked through the doors, Charge Nurse RN DD and EMT CC remained seated and appeared to be talking to the EMS crew at 11:30:04 p.m. At 11:30:05, EMS had exited the doors. The video ended at 11:30:14 p.m.

The fourth and final video provided by the facility started at 11:30:12 p.m. and revealed EMS putting Patient #1 back on the ambulance and driving away from the hospital at 11:31:00 p.m. The video ended at 11:32:02 p.m.

A review of the Emergency Department Medical Record of Patient #1 from Hospital #2 revealed a nursing assessment was performed on 9/16/2020 at 1:13 a.m. Patient #1 was brought in via Emergency Medical Services on 9/15/2020 at 11:38 p.m. with active nausea and vomiting (N/V) since 9:00 p.m. the same date. Patient #1 had recently been admitted to Hospital #1 for a small bowel obstruction (a condition where material from the stomach is not able to pass through the bowel) and was discharged the previous day. The report revealed Patient #1 had requested to go to Hospital #1, but EMS brought her to Hospital #2 actively vomiting at triage. No triage level was defined. A Medical Screening Exam (MSE) was performed on 9/16/2020 at 1:33 a.m. The MSE's history of present illness revealed Patient #1 had a history of diabetes, slow emptying of the stomach, multiple abdominal surgeries, and partial bowel obstruction. Patient #1 had not had a bowel movement in 2 days and she was feeling worse. Diagnosis from the MSE was progression to complete bowel obstruction. The plan was to admit to the hospital.

MEDICAL STAFF BYLAWS, RULES AND REGULATIONS
A review of the Medical Staff Bylaws, approved by the board of trustees on 12/20/07, revealed the purpose of the Medical Staff is to serve as the primary means of accountability to the Board for appropriateness of the quality of the medical care, treatment, and services provided to patients. A review of the Medical Staff Rules and Regulations, approved by the Governing Body on 5/28/09, revealed any patient who requests examinations or treatment in the Emergency Department shall receive an appropriate medical screening exam within the capacity of the emergency department to determine whether an emergency exists. Physicians who have been granted clinical privileges are qualified to perform medical screening exams. Properly credentialed nurse practitioners, physician assistants, or other qualified clinical staff functioning under approved protocols and physician supervision may perform medical screening exams.

DOCUMENTS

A review of Emergency Department committee meeting minutes from 9/27/19 through 10/2/2020 revealed the committee met at least quarterly. Emergency Medical Treatment and Labor Act (EMTALA) education topics were discussed at each meeting. On 7/23/2020 EMTALA was discussed as follows:
'If an ambulance wants to leave and go somewhere else. AMA (Against Medical Advice) signed and if possible MSE (Medical Screening Exam) completed. Need signatures and express invitation to return. Document. Do not discuss if insurance will pay.'

POLICIES

A review of the facility's policy number 301-38 titled "EMTALA" issued 1/98, last reviewed 09/19 revealed that the purpose of the policy is to ensure that all patients have the opportunity to review their right to medical screening exam and stabilization treatment for an emergency medical condition. To ensure that any person coming to the emergency department who requests medical treatment and any person coming to the main building, including parking lots, drives, and sidewalks of the hospital campus, where the emergency department is located, who request emergency care or appears to have a medical emergency, receives an appropriate medical screening examination and stabilization treatment as required by Emergency Medical Treatment and Labor Act (EMTALA). All patients, including direct, admits and patients going directly to Labor and Delivery presenting to triage will be placed on triage log.

Medical Screening Exam:
Medical screening exam (MSE) means the process required to reach with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition does or does not exist. A non-discriminatory process (i.e. level of care will not be based on payment status, race, national, origin, etc.) will be used to reasonably determine whether an emergency medical condition exists. Such screening must be done within the facility's capability and available personnel, including on-call physicians. The medical screening examinations is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is stabilized or appropriately transferred. Evidence of evaluation must be documented in the medical record prior to discharge. The emergency room physician or nurse practitioner/physician assistance working in conjunction with the emergency room physician and or primary care physician may perform a medical screening exam. If an individual refuses a medical screening exam, the Registered Nurse (RN) or Medical Doctor (MD) will inform the patient of the risk and benefits involved in the refusal of the medical screening exam. If the patient refuses, he/she will be asked to sign out AMA (Against Medical Advice) and a synopsis of the education given to the patient and family will be documented in the electronic medical record by nurse or physician. A concerted effort will be made to get the patient or responsible family member's signature.

Policy:
A. The hospital Emergency Department provides a medical screening examination and stabilization treatment to any individual regardless of diagnosis, financial status, race, color, national origin, or handicap. Care will be rendered in the same manner and with the same care given to any other patient under similar circumstances, regardless of the patient's ability to pay.
B. Screening and Stabilization treatments, within the scope of this facility's ability, are provided to any individual with an emergency medical condition. No transfer to another facility or Physician's office will be accomplished until a medical screening exam and any necessary stabilization is performed.
C. The hospital's Emergency Department will not refuse to screen a patient or provide stabilization treatment to anyone that is enrolled in a managed care plan even if the plan may refuse to authorize treatment or to pay for such screening and treatment. The patient will also be informed that the hospital will provide a medical screening exam and stabilization treatment regardless of ability to pay.

A review of the facility's policy number 302-8 titled " Patients Who Leave Against Medical Advice (AMA) / Who Leave without Being Seen (LWBS)" effective 11/83, last reviewed 03/18 revealed that the purpose of the policy is to describe the procedure to be used when a patient decides to leave against medical advice (AMA) or when a patient leaves without being seen (LWBS), proving the Hospital has taken all reasonable steps to secure written, informed refusal of further examination or treatment and the individual has been informed of risk and benefits of refusing treatment and or examination.

Left Without Being Seen (LWBS):
Refers to those patients who are present to be seen in the ED, decide to leave before a medical screening examination.
A. If the patient informs the nurse at triage that he/she wishes to leave, the nurse should attempt to counsel the patient. If the patient still insists on leaving the provider will be notified and will counsel the patient and perform/ complete a medical screening examination. If a potential emergency medical conditions exist, the patient will be counseled and encouraged to stay and have the medical screening examination completed. If the patient still expresses a desire to leave, the risk of leaving without being seen will be documented in the notes and the patient will be asked to sign out AMA.
B. When a patient has been assigned a room and informs the nurse, he/she wishes to leave, the nurse should attempt to counsel the patient. If the patient has abnormal vital signs or mental status, the nurse attempt to ask the patient to wait and get the physician to see the patient expeditiously. The nurse needs to verbalize to the patient and the accompanying visitors the consequences of leaving and the potential of endangerment of leaving. This must be documented in the chart by the nurse. If the patient doesn't understand, the nurse shall inform the lead physician. The nurse will have the patient sign statement of the patient leaving against medical advice form 0157. If the patient refuses to sign, the nurse should document this in the nursing notes and have a witness cosign the refusal to sign. If the patient leaves before being seen without notifying the medical staff, the nurse/physician that discovers the patient has left should attempt to locate the patient. Three documented, interval attempts to locate the patient should be made. If attempts to locate have been unsuccessful, this is documented in the electronic medical record. This is classified as an elopement.

A review of the facility's policy number G-15, titled "Diversion Status" effective 04/2002, last reviewed 07/2020 revealed that the purpose of the policy is to establish guidelines and levels of authority when there is a need to temporarily divert ground or air ambulances carrying patients and patient transfers. There may be circumstances when the facility has reached full capacity due to an unusually high census and acuity. Under the most extreme situations, and after careful evaluation, a decision to temporarily divert patients will be implemented until the capacity to provide a safe level of care can be assured. At no time will a patient be refused a medical screening exam and treatment required by EMTALA if physically presented to the Hospital.

A review of the facility's policy number 301-03 titled "Emergency Services Triage System" effective 01/1981, last reviewed 05/2020 provides a standardized system whereby patients presenting to the Emergency Department (ED) are treated in order of priority based upon acuity utilizing the Emergency Severity Index Five-Level Triage System.

A. TRIAGE SYSTEM:

The major function of the Triage System is to direct patient flow to ensure that every patient receives appropriate care. Triage has the authority to ensure patient placement is done quickly and appropriately. All patients who present to the Emergency Department will be assessed by a Registered Nurse and will receive an appropriate medical screening by a Physician or Nurse Practitioner.

B. TRIAGE PROCESS:

a. An RN will triage all patients arriving at the ED to identify life-threatening conditions and prioritize according to acuity.
b. Any patient presenting to the ED is to be directed immediately to an empty available bed and triaged at the bedside.
c. Patient triage in the "triage room" should be avoided until all beds in the ED are full, as appropriate.
d. Every effort will be made to place patients presenting to the ED in treatment rooms.
e. Due to bed availability, patients having to wait in the waiting room may be unavoidable.

C. PROCEDURE: When a patient presents for treatment and there is no available bed/treatment room available, the Triage Nurse will
1. Complete the triage process for the patients, as described above. Patients triaged at Level 1 are never left in the waiting area and Level 2's are always given priority for a room.
2. Apologize to the patient for the lack of an available room.
3. Inform the patient of the approximate wait time anticipated if known.
4. Round on the patient every hour.
5. Keep the Charge Nurse informed of patients waiting.
6. Monitor for bed availability and escort patient to room as soon as available.
7. All patients in the waiting room area to be visually monitored by hospital personnel.

D. TRIAGE ASSESSMENT: Upon arrival, all patients (including patients arriving by EMS) will have a primary survey to include airway, breathing, circulation, and disability, and focus chief complaint.
1. Based on the triage category full assessments are completed within:
a. Category I: within one hour of arrival to the room
b. Category II: within one hour of arrival to the room
c. Category III: within two hours of arrival to the room
d. Category IV & V: Focused assessment at triage.

INTERVIEWS

An interview was conducted via telephone with Paramedic HH on 10/6/24 at 9:21 a.m. Paramedic HH said he remembers the call. Paramedic HH said they got a call for a lady, Patient #1, who was vomiting. Emergency Medical Services (EMS), took her on to Hospital #1 and waited a couple of hours. Paramedic HH explained that when they arrived at Hospital # 1, the emergency medical technician at the desk entered the patient into the log and parked them on the wall. He said that nobody assessed the patient while they waited for almost 2 hours. He further explained that when they asked if the patient would be assessed, the facility's staff said they could not give a specific time/availability. Paramedic HH said no one took vitals or looked at the patient. Paramedic HH stated that after lying on the stretcher for about 2 hours, she decided to leave for another facility. Paramedic HH said he called their supervisor and were told to take her to Hospital #2 if that is where she wanted to go. Paramedic HH said the staff at Hospital #1 asked if they were leaving, and EMS said, yes. EMS then left. EMS took Patient #1 to Hospital #2 and she was immediately sent to triage and EMS left the scene. Paramedic HH said other EMS crews have told him when they left with a patient, the patient has been asked to sign Against Medical Advice (AMA). Paramedic HH said the facility did not ask Patient #1 to sign an AMA form and they did not try to stop them from leaving.

An interview was conducted in the Patient Assistance Conference Room on the first floor of the facility on 10/6/2020 at 9:38 a.m. with the Assistant Nurse Manager of the Emergency Department (RN DD). RN DD stated that he recalled the incident concerning Patient #1 because it was bizarre that the ambulance just left. RN DD said 9/15/2020 was a busy shift and he thought the facility was on diversion when he got on shift. RN DD said the waiting room was full, beds were full, and they had other stretchers waiting for a bed to become available. RN DD said they were on Emergency Medical Services (EMS) diversion. He was not at ERC (Emergency Room Communications) where they take radio calls from EMS when Patient #1 first arrived. RN DD said he was out on the floor and when he came to the door, he saw EMS waiting and asked why EMS was waiting. The hospital staff at the command center, Emergency Medical Technician (EMT CC) told RN DD that Patient #1 was actively vomiting and hypertensive according to the EMS radio report. That is why Patient #1 was not placed in the general waiting room for triage. RN DD said patients would ordinarily go out to the waiting room to be triaged, but since Patient #1 was actively vomiting EMT CC did not place Patient #1 out to expose other people in the waiting room. RN DD went back to his charge nurse duties and later when he went back out to ERC, he saw EMS taking Patient #1 out the door. RN DD said he called out to EMS and told them they could not leave because it would be an Emergency Medical Treatment and Labor Act (EMTALA) violation. RN DD said EMS never looked back and just kept going. RN DD said he knew it was trouble when they heard EMS call report to Hospital # 2 after they left. They did not have a chance to ask her to sign an Against Medical Advice (AMA) form. Patient #1 never gave them a warning she wanted to leave and when EMS started to leave, they could not stop them. RN DD said no one asked Patient #1 to sign AMA because they did not have a chance. RN DD said he thought Patient #1 was on the wall about 1 hour and 30 minutes to 1 hour 40 minutes before leaving. RN DD said sometimes EMS may have to wait up to 6 hours. If there are no rooms, EMS will have to wait with the patient.

An interview was conducted in the Patient Assistance Conference Room of the facility on 10/6/2020 at 11:45 a.m. with Emergency Medical Technician (EMT) CC. EMT CC said he does remember the incident on 9/15/2020. EMT CC said he received a call-in on the radio from an out-of-county Emergency Medical Services (EMS) unit. He said the report was that a patient was coming in for nausea and vomiting and had just been released from this hospital the previous week. EMS gave vital signs and said the patient (Patient #1) wanted to return to the current hospital because she had been recently released from this hospital. EMT CC said he cannot remember everything. When Patient #1 arrived, EMT CC said he was putting another patient into the computer. EMT CC said he remembers Patient #1 looked pale. EMT CC said he always gives the charge nurse a call and let them know a patient was there waiting on the wall. He recalled that Patient #1 started vomiting as soon as she arrived. He held Patient #1 on the wall until a room was available. Patient #1 was waiting to go to a room straight from the EMS bay. EMT CC said he did not put Patient #1 in the waiting room for triage. EMT CC said he thought Patient #1 needed to get a bed as soon as possible. EMT CC said unfortunately, it was a long wait. EMT CC said he remembers Patient #1 waited for about an hour and a half. He said the Emergency Department (ED) had about 3 patients in holding at the wall (waiting on a stretcher on the wall). EMT CC said at the time, they were getting people held at the wall back to a bed within about 2 hours. There was one other patient ahead of Patient #1. EMT CC said he and Charge Nurse, RN DD decided this patient needed priority. EMS had the patient in the hallway for less than two hours and EMT CC said he saw EMS leaving with Patient #1 and called out to them that they could not leave like that. The charge nurse was already at the ERC desk and called out loudly to EMS that they could not leave, that it would be an Emergency Medical Treatment and Labor Act violation (if they left). EMT CC said EMT HH who was in charge of transporting Patient #1 mumbled and walked on out. EMT CC said no one came and asked how long a wait it would be, nor told them that Patient #1 wanted to go somewhere else. They just walked out of the hall where they were holding and left. EMT CC said he knew it was a problem when they heard the EMS crew calling report to the hospital across the block. EMT CC said nursing staff has all gone over EMTALA. He said he has not received formal training but has been advised of EMTALA as far as his position on the radio. EMT CC said the charge nurses are trained, and they train the staff.

An interview was conducted in the Patient Assistance Conference Room of the facility on 10/6/2020 at 2:45 p.m. with the Emergency Department Nurse Manager, (RN EE). She said EMTALA training is done online RN EE said whenever a patient comes in by Emergency Medical Services (EMS) ambulance they get checked in and the person at the desk looks for a room assignment. Once a room is available, the patient goes back to the room. When the patient goes to the back, the attendant at the Emergency Room Communications desk does an overhead page "EMS to Room" and everyone meets in the room to see the patient. Report would be given to the nurse and the doctor if available, then the nurse would triage the patient. The person sitting at the desk should make contact with the charge nurse and tell them EMS is on the way in and the charge nurse would start to look for a room to make available. The patient does not get triaged until they get to the back. RN EE said everyone in the administration was aware of this incident that occurred on 9/15/2020. RN EE said Patient #1 should have been seen and should not have left without signing an Against Medical Advice (AMA) form. She said the hospital has had a lot of problems with EMS and law enforcement not wanting to wait and taking patients out of the Emergency Department (ED).
RN EE said they were already aware that this was an Emergency Medical Treatment and Labor Act (EMTALA) violation even surveyors arrived. She said they were already making changes to try to prevent some of this from happening in the future. Emergency Department Nurse Manager, RN EE, confirmed that during their own investigation of the incident, the hospital found that ED staff had not done what they needed to do to get Patient #1 to sign out AMA, and that staff had not documented in the medical record.

The hospital failed to provide a medical screening exam to Patient #1 and failed to follow their EMTALA policies.

Based on review of medical records, Emergency Medical Services report, video, hospital documents, Medical Staff Bylaws Rules and Regulations, observations, Emergency Department (ED) policies and procedures, and interviews, it was determined that the facility failed to provide necessary stabilizing treatment for Patient #1 who presented to the facility's the Emergency Department 9/15/2020 seeking emergency services.

FINDINGS:

MEDICAL RECORD

A review of Patient # 1's Emergency Medical Services (EMS) ambulance trip report on 9/15/2020 revealed EMS was dispatched to the private residence of Patient #1 who was experiencing nausea and vomiting. Patient #1 provided a medical history that included diabetes (too much sugar in the blood), high blood pressure, and gastroparesis (a condition that prevents the stomach from properly emptying). Patient #1 reported that she had been discharged from the hospital (Hospital #1) the previous day after being admitted for 9 days. Patient #1 reported she had been told that she had a blockage in her small intestine, and if she continued to have nausea and vomiting to return to the hospital (Hospital #1). The report revealed Patient #1 wanted to return to the same hospital (Hospital #1) where she had been previously admitted. Patient # 1's initial assessment at 9:20 p.m. in the ambulance revealed a heart rate of 114 beats/minute (normal adult heart rate is 60-100), respirations were 18/minute (normal adult respirations 12-20), blood pressure 179/P (palpable only - normal adult blood pressure is 90-120/60-80), and blood glucose level of 249 (normal range of blood glucose for a person with diabetes is 80-130). A second assessment was done at 9:35 p.m. and revealed Patient # 1's heart rate -110, respirations-18, and blood pressure 190/108. The final EMS assessment was performed prior to arrival at the hospital (Hospital #1) and revealed Patient # 1's heart rate-114, respirations-18, blood pressure 185/108. Patient #1 remained alert and oriented throughout the transport. EMS Paramedic HH's narrative report revealed Patient #1 stated she continued to have nausea and vomiting and needed to return to the hospital. Patient #1 was being transported back to the hospital (Hospital #1) of her choice. Paramedic HH's narrative revealed when Patient # 1's blood glucose was 249, Patient #1 said her blood sugar normally runs around 200. The narrative continued and revealed Patient #1 did have some elevated blood pressure readings and she had taken her blood pressure medications that morning as prescribed. Patient #1 had to wait on the wall (waiting on a stretcher outside the treatment area of the Emergency Department) for a bed to become available. Patient #1 waited on a stretcher from 9:54 p.m. until 11:00 p.m. Patient #1 decided she did not want to wait any longer. Patient #1 decided she wanted to go to another hospital (Hospital #2) for treatment. Paramedic HH called his battalion chief and made him aware of the wait time. Battalion chief advised Paramedic HH if Patient #1 stated she wanted to go to another facility permission was granted for EMS to transport to another facility. Patient #1 was transported from Hospital #1 to Hospital #2.

A review of Hospital # 1's Emergency Department (ED) Medical Record of Patient #1 revealed an emergency encounter was created on 9/15/2020 at 9:56 p.m. Patient #1 arrived in the ED at 9:57 p.m. with a neighboring county's Emergency Medical Service (EMS) ambulance. Electronic documentation on 9/15/20 at 11:30 p.m. revealed the ambulance left with Patient #1 at 11:35 p.m. Electronic documentation on 9/16/2020 at 12:05 a.m. Documentation revealed Patient # 1's status as having left without being seen before triage (a quick assessment of a patient and determination of the urgency of the needs.)

VIDEO

A review of 4 videos provided by the hospital revealed portions of the time Patient #1 was at the hospital.

The first video started at 9:58:14 p.m. and revealed a patient being placed on the wall (waiting on a stretcher outside the treatment area of the Emergency Department) by Emergency Medical Services (ambulance). Patient #1 was brought into the doors at 9:58:14 by ambulance attendants. Charge Nurse RN DD and Emergency Room Communications EMT CC were sitting at the registration desk when Patient #1 arrived. Patient #1 could be seen with her head bobbing up and down toward a vomit bag. The Emergency Medical Services (EMS) ambulance Paramedic, Emergency Medical Technician EMT HH, was seen providing registration information to Charge Nurse, Registered Nurse RN DD, and Emergency Room Communications EMT CC at 9:59:00 p.m. At 10:01:00 p.m. the video was cut off with Emergency Medical Services moving Patient #1 to the wall.

The second video provided started at 11:25:57 p.m. and revealed Paramedic HH coming out of the hallway where Patient #1 was waiting on the wall. EMT HH was seen talking to Charge Nurse RN DD and EMT CC. They had a conversation until 11:27:00 p.m. when EMT HH went back through the hall to the wall where Patient #1 was waiting. The video ended at 11:27:04 p.m.

The third video provided started at 11:29:50 p.m. EMT HH and another EMS attendant were observed bringing Patient #1 through the doors of the hallway where they had been waiting on the wall.
Charge Nurse RN DD and EMT CC were sitting at the Emergency Room Communications desk observing Patient #1 being transported out of the hospital by EMS. As EMS walked through the doors, Charge Nurse RN DD and EMT CC remained seated and appeared to be talking to the EMS crew at 11:30:04 p.m. At 11:30:05, EMS had exited the doors. The video ended at 11:30:14 p.m.

The fourth and final video provided by the facility started at 11:30:12 p.m. and revealed EMS putting Patient #1 back on the ambulance and driving away from the hospital at 11:31:00 p.m. The video ended at 11:32:02 p.m.

A review of the Emergency Department Medical Record of Patient #1 from Hospital #2 revealed a nursing assessment was performed on 9/16/2020 at 1:13 a.m. Patient #1 was brought in via Emergency Medical Services (EMS) (ambulance) on 9/15/2020 at 11:38 p.m. with active nausea and vomiting (N/V) since 9:00 p.m. the same date. Patient #1 had recently been admitted to Hospital #1 for a small bowel obstruction (a condition where material from the stomach is not able to pass through the bowel) and was discharged the previous day. The report revealed Patient #1 had requested to go to Hospital #1, but EMS brought her to Hospital #2 actively vomiting at triage. No triage level was defined. A Medical Screening Exam (MSE) was performed on 9/16/2020 at 1:33 a.m. The MSE's history of present illness revealed Patient #1 had a history of diabetes, slow emptying of the stomach, multiple abdominal surgeries, and partial bowel obstruction. Patient #1 had not had a bowel movement in 2 days and she was feeling worse. Diagnosis from the MSE was progression to complete bowel obstruction. The plan was to admit to the Hospital #2.

MEDICAL STAFF BYLAWS, RULES AND REGULATIONS

A review of the Medical Staff Bylaws, approved by the board of trustees on 12/20/07, revealed the purpose of the Medical Staff is to serve as the primary means of accountability to the Board for appropriateness of the quality of the medical care, treatment, and services provided to patients. A review of the Medical Staff Rules and Regulations, approved by the Governing Body on 5/28/09, revealed any patient who requests examinations or treatment in the Emergency Department shall receive an appropriate medical screening exam within the capacity of the emergency department to determine whether an emergency exists. Physicians who have been granted clinical privileges are qualified to perform medical screening exams. Properly credentialed nurse practitioners, physician assistants, or other qualified clinical staff functioning under approved protocols and physician supervision may perform medical screening exams.

DOCUMENTS

A review of Emergency Department committee meeting minutes from 9/27/19 through 10/2/2020 revealed the committee met at least quarterly. Emergency Medical Treatment and Labor Act (EMTALA) education topics were discussed at each meeting. On 7/23/2020 EMTALA was discussed as follows: 'If an ambulance wants to leave and go somewhere else. AMA signed and if possible MSE completed. Need signatures and express invitation to return. Document. Do not discuss if insurance will pay.'

POLICIES

A review of the facility's policy number 301-38 titled "EMTALA" issued 1/98, last reviewed 09/19 revealed that the purpose of the policy is to ensure that all patients have the opportunity to review their right to medical screening exam and stabilization treatment for an emergency medical condition. To ensure that any person coming to the emergency department who requests medical treatment and any person coming to the main building, including parking lots, drives, and sidewalks of the hospital campus, where the emergency department is located, who request emergency care or appears to have a medical emergency, receives an appropriate medical screening examination and stabilization treatment as required by Emergency Medical Treatment and Labor Act (EMTALA). All patients, including direct, admits and patients going directly to Labor and Delivery presenting to triage will be placed on triage log.

Medical Screening Exam:

Medical screening exam (MSE) means the process required to reach with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition does or does not exist. The medical screening examinations is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is stabilized or appropriately transferred.

Stabilize or Stabilized:

With respect to an emergency medical condition, that the individual is provided such medical treatment as necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the facility; or with respect to a pregnant woman, who is having contractions and who cannot be transferred before delivery without a threat to the health or safety of the woman or her unborn child, that the woman has delivered the child and the placenta.

Stable for Discharge:

A patient is considered stable for discharge when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care including diagnostic workup and/ or treatment could reasonably be performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow up with the discharge instructions.

Policy:

A. The hospital Emergency Department provides a medical screening examination and stabilization treatment to any individual regardless of diagnosis, financial status, race, color, national origin, or handicap. Care will be rendered in the same manner and with the same care given to any other patient under similar circumstances, regardless of the patient's ability to pay.
B. Screening and Stabilization treatments, within the scope of this facility's ability, are provided to any individual with an emergency medical condition. No transfer to another facility or Physician's office will be accomplished until a medical screening exam and any necessary stabilization is performed.
C. The hospital's Emergency Department will not refuse to screen a patient or provide stabilization treatment to anyone that is enrolled in a managed care plan even if the plan may refuse to authorize treatment or to pay for such screening and treatment. The patient will also be informed that the hospital will provide a medical screening exam and stabilization treatment regardless of ability to pay.

Stabilization:
A patient is stabilized if the treating physician attending to the patient in the emergency department has determined within reasonable clinical confidence that the emergency medical condition has resolved. For the patient whose emergency medical condition has not been resolved, the determination whether he/ she is medically stable may occur in one of the following two circumstances: Stable for transfer and Stable for discharge.

A review of the facility's policy number 302-8 titled " Patients Who Leave Against Medical Advice (AMA) / Who Leave without Being Seen (LWBS)" effective 11/83, last reviewed 03/18 revealed that the purpose of the policy is to describe the procedure to be used when a patient decides to leave against medical advice (AMA) or when a patient leaves without being seen (LWBS), proving the Hospital has taken all reasonable steps to secure written, informed refusal of further examination or treatment and the individual has been informed of risk and benefits of refusing treatment and or examination.

Left Without Being Seen (LWBS):
Refers to those patients who are present to be seen in the ED, decide to leave before a medical screening examination.
A. If the patient informs the nurse at triage that he/she wishes to leave, the nurse should attempt to counsel the patient. If the patient still insists on leaving the provider will be notified and will counsel the patient and perform/ complete a medical screening examination. If a potential emergency medical conditions exist, the patient will be counseled and encouraged to stay and have the medical screening examination completed. If the patient still expresses a desire to leave, the risk of leaving without being seen will be documented in the notes and the patient will be asked to sign out AMA.
B. When a patient has been assigned a room and informs the nurse, he/she wishes to leave, the nurse should attempt to counsel the patient. If the patient has abnormal vital signs or mental status, the nurse attempt to ask the patient to wait and get the physician to see the patient expeditiously. The nurse needs to verbalize to the patient and the accompanying visitors the consequences of leaving and the potential of endangerment of leaving. This must be documented in the chart by the nurse. If the patient doesn't understand, the nurse shall inform the lead physician. The nurse will have the patient sign statement of the patient leaving against medical advice form 0157. If the patient refuses to sign, the nurse should document this in the nursing notes and have a witness cosign the refusal to sign. If the patient leaves before being seen without notifying the medical staff, the nurse/physician that discovers the patient has left should attempt to locate the patient. Three documented, interval attempts to locate the patient should be made. If attempts to locate have been unsuccessful, this is documented in the electronic medical record. This is classified as an elopement.

A review of the facility's policy number 301-03 titled, "Emergency Services Triage System" effective 01/1981, last reviewed 05/2020 documents:

A. TRIAGE SYSTEM:

The major function of the Triage System is to direct patient flow to ensure that every patient receives appropriate care. Triage has the authority to ensure patient placement is done quickly and appropriately. All patients who present to the Emergency Department will be assessed by a Registered Nurse and will receive an appropriate medical screening by a Physician or Nurse Practitioner.

D. TRIAGE ASSESSMENT: Upon arrival, all patients (including patients arriving by EMS) will have a primary survey to include airway, breathing, circulation, and disability, and focus chief complaint.
1. Based on the triage category full assessments are completed within:
a. Category I: within one hour of arrival to the room
b. Category II: within one hour of arrival to the room
c. Category III: within two hours of arrival to the room
d. Category IV & V: Focused assessment at triage.

INTERVIEWS

An interview was conducted via telephone with Paramedic HH on 10/6/24 at 9:21 a.m. Paramedic HH said he remembers the call. Paramedic HH said they got a call for a lady, Patient #1, who was vomiting. Emergency Medical Services (EMS), took her on to Hospital #1 and waited a couple of hours. Paramedic HH explained that when they arrived at Hospital # 1, the emergency medical technician at the desk entered the patient into the log and parked them on the wall. He said that nobody assessed the patient while they waited for almost 2 hours. He further explained that when they asked if the patient would be assessed, the facility's staff said they could not give a specific time/availability. Paramedic HH said no one took vitals or looked at the patient. Paramedic HH stated after lying on the stretcher for about 2 hours, she decided to leave for another facility. Paramedic HH said he called their supervisor and were told to take her to Hospital #2 if that is where she wanted to go. Paramedic HH said the staff at Hospital #1 asked if they were leaving, and EMS said, yes. EMS then left. EMS took Patient #1 to Hospital #2 and she was immediately sent to triage and EMS left the scene. Paramedic HH said other EMS crews have told him when they left with a patient, the patient has been asked to sign Against Medical Advice (AMA). Paramedic HH said the facility did not ask Patient #1 to sign an AMA form and they did not try to stop them from leaving.

An interview was conducted in the Patient Assistance Conference Room on the first floor of the facility on 10/6/2020 at 9:38 a.m. with the Assistant Nurse Manager of the Emergency Department (RN DD). RN DD stated that he recalled the incident concerning Patient #1 because it was bizarre that the ambulance just left. RN DD said 9/15/2020 was a busy shift and he thought the facility was on diversion when he got on shift. RN DD said the waiting room was full, beds were full, and they had other stretchers waiting for a bed to become available. RN DD said they were on Emergency Medical Services (EMS) diversion. He was not at ERC (Emergency Room Communications) where they take radio calls from EMS when Patient #1 first arrived. RN DD said he was out on the floor and when he came to the door, he saw EMS waiting and asked why EMS was waiting. The hospital staff at the command center, Emergency Medical Technician (EMT CC) told RN DD that Patient #1 was actively vomiting and hypertensive according to the EMS radio report. That is why Patient #1 was not placed in the general waiting room for triage. RN DD said patients would ordinarily go out to the waiting room to be triaged, but since Patient #1 was actively vomiting EMT CC did not place Patient #1 out to expose other people in the waiting room. RN DD went back to his charge nurse duties and later when he went back out to ERC, he saw EMS taking Patient #1 out the door. RN DD said he called out to EMS and told them they could not leave because it would be an Emergency Medical Treatment and Labor Act (EMTALA) violation. RN DD said EMS never looked back and just kept going. RN DD said he knew it was trouble when they heard EMS call report to Hospital # 2 after they left. They did not have a chance to ask her to sign an Against Medical Advice (AMA) form. Patient #1 never gave them a warning she wanted to leave and when EMS started to leave, they could not stop them. RN DD said no one asked Patient #1 to sign AMA because they did not have a chance. If rooms are available when EMS comes, the patient is taken back to a room and triaged in a room. They may be sent out to the waiting area after triage but according to the triage level, they may stay in the triage room. RN DD said he thought Patient #1 was on the wall about 1 hour and 30 minutes to 1 hour 40 minutes before leaving. RN DD said sometimes EMS may have to wait up to 6 hours. If there are no rooms, EMS will have to wait with the patient.

An interview was conducted in the Patient Assistance Conference Room of the facility on 10/6/2020 at 11:45 a.m. with Emergency Medical Technician (EMT) CC. EMT CC said he does remember the incident on 9/15/2020. EMT CC said he received a call-in on the radio from an out-of-county Emergency Medical Services (EMS) unit. He said the report was that a patient was coming in for nausea and vomiting and had just been released from this hospital the previous week. EMS gave vital signs and said the patient (Patient #1) wanted to return to the current hospital because she had been recently released from this hospital. EMT CC said he cannot remember everything. When Patient #1 arrived, EMT CC said he was putting another patient into the computer. EMT CC said he remembers Patient #1 looked pale. EMT CC said he always gives the charge nurse a call and let them know a patient was there waiting on the wall. He recalled that Patient #1 started vomiting as soon as she arrived. He held Patient #1 on the wall until a room was available. Patient #1 was waiting to go to a room straight from the EMS bay. EMT CC said he did not put Patient #1 in the waiting room for triage. EMT CC said he thought Patient #1 needed to get a bed as soon as possible. EMT CC said unfortunately, it was a long wait. EMT CC said he remembers Patient #1 waited for about an hour and a half. He said the Emergency Department (ED) had about 3 patients in holding at the wall (waiting on a stretcher on the wall). EMT CC said at the time, they were getting people held at the wall back to a bed within about 2 hours. There was one other patient ahead of Patient #1. EMT CC said he and Charge Nurse, RN DD decided this patient needed priority. EMS had the patient in the hallway for less than two hours and EMT CC said he saw EMS leaving with Patient #1 and called out to them that they could not leave like that. The charge nurse was already at the ERC desk and called out loudly to EMS that they could not leave, that it would be an Emergency Medical Treatment and Labor Act violation (if they left). EMT CC said EMT HH who was in charge of transporting Patient #1 mumbled and walked on out. EMT CC said no one came and asked how long a wait it would be, nor told them that Patient #1 wanted to go somewhere else. They just walked out of the hall where they were holding and left. EMT CC said he knew it was a problem when they heard the EMS crew calling report to the hospital across the block. EMT CC said nursing staff has all gone over EMTALA. He said he has not received formal training but has been advised of EMTALA as far as his position on the radio. EMT CC said the charge nurses are trained, and they train the staff.

An interview was conducted in the Patient Assistance Conference Room of the facility on 10/6/2020 at 2:45 p.m. with the Emergency Department Nurse Manager, (RN EE). She said EMTALA training is done online RN EE said whenever a patient comes in by Emergency Medical Services (EMS) ambulance they get checked in and the person at the desk looks for a room assignment. Once a room is available, the patient goes back to the room. When the patient goes to the back, the attendant at the Emergency Room Communications desk does an overhead page "EMS to Room" and everyone meets in the room to see the patient. Report would be given to the nurse and the doctor if available, then the nurse would triage the patient. The person sitting at the desk should make contact with the charge nurse and tell them EMS is on the way in and the charge nurse would start to look for a room to make available. The patient does not get triaged until they get to the back. RN EE said everyone in the administration was aware of this incident that occurred on 9/15/2020. RN EE said Patient #1 should have been seen and should not have left without signing an Against Medical Advice (AMA) form. She said the hospital has had a lot of problems with EMS and law enforcement not wanting to wait and taking patients out of the Emergency Department (ED). RN EE said they were already aware that this was an Emergency Medical Treatment and Labor Act (EMTALA) violation even surveyors arrived. She said they were already making changes to try to prevent some of this from happening in the future. Emergency Department Nurse Manager, RN EE, confirmed that during their own investigation of the incident, the hospital found that ED staff had not done what they needed to do to get Patient #1 to sign out AMA, and that staff had not documented in the medical record.

The hospital failed to provide stabilizing treatment to Patient #1 and follow their policies.

Based on review of medical records, Emergency Medical Services report, video, Emergency Department policies and procedures, and interviews, it was determined that the facility failed to provide an appropriate transfer for Patient #1 who presented to the facility's the Emergency Department 9/15/2020 seeking emergency services


FINDINGS:

MEDICAL RECORD
A review of Patient # 1's Emergency Medical Services (EMS) ambulance trip report on 9/15/2020 revealed EMS was dispatched to the private residence of Patient #1 who was experiencing nausea and vomiting. Patient #1 provided a medical history that included diabetes (too much sugar in the blood), high blood pressure, and gastroparesis (a condition that prevents the stomach from properly emptying). Patient #1 reported that she had been discharged from the hospital (Hospital #1) the previous day after being admitted for 9 days. Patient #1 reported she had been told that she had a blockage in her small intestine, and if she continued to have nausea and vomiting to return to the hospital (Hospital #1). The report revealed Patient #1 wanted to return to the same hospital (Hospital #1) where she had been previously admitted. Patient #1 had to wait on the wall (waiting on a stretcher outside the treatment area of the Emergency Department) for a bed to become available. Patient #1 waited on a stretcher from 9:54 p.m. until 11:00 p.m. Patient #1 decided she did not want to wait any longer. Patient #1 decided she wanted to go to another hospital (Hospital #2) for treatment. Paramedic HH called his battalion chief and made him aware of the wait time. Battalion chief advised Paramedic HH if Patient #1 stated she wanted to go to another facility permission was granted for EMS to transport to another facility. Patient #1 was transported from Hospital #1 to Hospital #2.

A review of Hospital # 1's Emergency Department (ED) Medical Record of Patient #1 revealed an emergency encounter was created on 9/15/2020 at 9:56 p.m. Patient #1 arrived in the ED at 9:57 p.m. with a neighboring county's Emergency Medical Service (EMS) ambulance. Electronic documentation on 9/15/20 at 11:30 p.m. revealed the ambulance left with Patient #1 at 11:35 p.m. Electronic documentation on 9/16/2020 at 12:05 a.m. Documentation revealed Patient # 1's status as having left without being seen before triage (a quick assessment of a patient and determination of the urgency of the needs.)

VIDEO
A review of four (4) videos provided by the hospital revealed portions of the time Patient #1 was at the hospital.

The first video started at 9:58:14 p.m. and revealed a patient being placed on the wall (waiting on a stretcher outside the treatment area of the Emergency Department) by Emergency Medical Services (ambulance). Patient #1 was brought into the doors at 9:58:14 by ambulance attendants. Charge Nurse RN DD and Emergency Room Communications EMT CC were sitting at the registration desk when Patient #1 arrived. Patient #1 could be seen with her head bobbing up and down toward a vomit bag. The Emergency Medical Services (EMS) ambulance Paramedic, Emergency Medical Technician EMT HH, was seen providing registration information to Charge Nurse, Registered Nurse RN DD, and Emergency Room Communications EMT CC at 9:59:00 p.m. At 10:01:00 p.m. the video was cut off with Emergency Medical Services moving Patient #1 to the wall.

The second video provided started at 11:25:57 p.m. and revealed Paramedic HH coming out of the hallway where Patient #1 was waiting on the wall. EMT HH was seen talking to Charge Nurse RN DD and EMT CC. They had a conversation until 11:27:00 p.m. when EMT HH went back through the hall to the wall where Patient #1 was waiting. The video ended at 11:27:04 p.m.

The third video provided started at 11:29:50 p.m. EMT HH and another EMS attendant were observed bringing Patient #1 through the doors of the hallway where they had been waiting on the wall.
Charge Nurse RN DD and EMT CC were sitting at the Emergency Room Communications desk observing Patient #1 being transported out of the hospital by EMS. As EMS walked through the doors, Charge Nurse RN DD and EMT CC remained seated and appeared to be talking to the EMS crew at 11:30:04 p.m. At 11:30:05, EMS had exited the doors. The video ended at 11:30:14 p.m.
The fourth and final video provided by the facility started at 11:30:12 p.m. and revealed EMS putting Patient #1 back on the ambulance and driving away from the hospital at 11:31:00 p.m. The video ended at 11:32:02 p.m.

A review of the Emergency Department Medical Record of Patient #1 from Hospital #2 revealed a nursing assessment was performed on 9/16/2020 at 1:13 a.m. Patient #1 was brought in via Emergency Medical Services (EMS) (ambulance) on 9/15/2020 at 11:38 p.m. with active nausea and vomiting (N/V) since 9:00 p.m. the same date. Patient #1 had recently been admitted to Hospital #1 for a small bowel obstruction (a condition where material from the stomach is not able to pass through the bowel) and was discharged the previous day. The report revealed Patient #1 had requested to go to Hospital #1, but EMS brought her to Hospital #2 actively vomiting at triage. No triage level was defined. A Medical Screening Exam (MSE) was performed on 9/16/2020 at 1:33 a.m. The MSE's history of present illness revealed Patient #1 had a history of diabetes, slow emptying of the stomach, multiple abdominal surgeries, and partial bowel obstruction. Patient #1 had not had a bowel movement in 2 days and she was feeling worse. Diagnosis from the MSE was progression to complete bowel obstruction. The plan was to admit to the hospital.

POLICIES

A review of the facility's policy number 301-38 titled, "EMTALA" issued 1/98, last reviewed 09/19 documented:

Stable for transfer:
A patient is stable for transfer from one facility to another when the treating physician has determined within reasonable clinical confidence, that the patient is expected to leave and be received at the next facility, with no material deterioration in his/her medical condition; and the treating physician reasonably believes the receiving facility has the capability to manage the patient's medical condition and reasonably foreseeable complication of that condition.

Policy:
B. Screening and Stabilization treatments, within the scope of this facility's ability, are provided to any individual with an emergency medical condition. No transfer to another facility or Physician's office will be accomplished until a medical screening exam and any necessary stabilization is performed.

Stabilization:
A patient is stabilized if the treating physician attending to the patient in the emergency department has determined within reasonable clinical confidence that the emergency medical condition has resolved. For the patient whose emergency medical condition has not been resolved, the determination whether he/ she is medically stable may occur in one of the following two circumstances: Stable for transfer and Stable for discharge.
Transfer:
A stabilized patient may be transferred upon request or in accordance with pre-arranged transfer/treatment plans upon the following conditions:
1. The individual agrees to the transfer.
2. Documentation must show that a medical screening exam and necessary stabilization procedures have been performed
3. If the patient demands the transfer, the demand must be in writing and must indicate the reason(s) for the request as well as indicate that the patient is aware of the risk and benefits of the transfer. A patient whose emergency medical condition has not been stabilized may be transferred to another facility if:
a. The patient and/or responsible family member, after being informed of the risk and benefits and the hospital's obligation to provide stabilization treatment, demand a transfer. If the patient demands the transfer, the demand must be in writing and must indicate the reason(s) for the request as well as indicate the patient is aware of the risks and benefits of the transfer.
b. The hospital does not have the capability to stabilize the emergency medical condition and another facility has that capability and the physician certifies that the benefit of the transfer to another facility outweighs the risk to the individual.
Appropriate transfer occurs when:
a. The transferring hospital provides medical treatment within its capacity that minimizes the risk to the individual's health and in the case of a woman in labor, the health of an unborn child.
b. The receiving facility has the available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer to the individual and to provide appropriate medical treatment.
c. The transferring hospital sends to the receiving hospital all medical records (or copies thereof) related to the emergency medical condition for which the individual has presented, available at the time of transfer, including records related to the individual's emergency medical condition.
d. The transfer is effected through qualified personnel, transportation, and equipment as required, including the use of necessary and medically appropriate life support measures during the transfer.


A review of the facility's policy number 302-8 titled " Patients Who Leave Against Medical Advice (AMA) / Who Leave without Being Seen (LWBS)" effective 11/83, last reviewed 03/18 revealed that the purpose of the policy is to describe the procedure to be used when a patient decides to leave against medical advice (AMA) or when a patient leaves without being seen (LWBS), proving the Hospital has taken all reasonable steps to secure written, informed refusal of further examination or treatment and the individual has been informed of risk and benefits of refusing treatment and or examination.

Left Without Being Seen (LWBS):
Refers to those patients who are present to be seen in the ED, decide to leave before a medical screening examination.
A. If the patient informs the nurse at triage that he/she wishes to leave, the nurse should attempt to counsel the patient. If the patient still insists on leaving the provider will be notified and will counsel the patient and perform/ complete a medical screening examination. If a potential emergency medical conditions exist, the patient will be counseled and encouraged to stay and have the medical screening examination completed. If the patient still expresses a desire to leave, the risk of leaving without being seen will be documented in the notes and the patient will be asked to sign out AMA.
B. When a patient has been assigned a room and informs the nurse, he/she wishes to leave, the nurse should attempt to counsel the patient. If the patient has abnormal vital signs or mental status, the nurse attempt to ask the patient to wait and get the physician to see the patient expeditiously. The nurse needs to verbalize to the patient and the accompanying visitors the consequences of leaving and the potential of endangerment of leaving. This must be documented in the chart by the nurse. If the patient doesn't understand, the nurse shall inform the lead physician. The nurse will have the patient sign statement of the patient leaving against medical advice form 0157. If the patient refuses to sign, the nurse should document this in the nursing notes and have a witness cosign the refusal to sign. If the patient leaves before being seen without notifying the medical staff, the nurse/physician that discovers the patient has left should attempt to locate the patient. Three documented, interval attempts to locate the patient should be made. If attempts to locate have been unsuccessful, this is documented in the electronic medical record. This is classified as an elopement.

INTERVIEWS

An interview was conducted via telephone with Paramedic HH on 10/6/24 at 9:21 a.m. Paramedic HH said he remembers the call. Paramedic HH said they got a call for a lady, Patient #1, who was vomiting. Emergency Medical Services (EMS), took her on to Hospital #1 and waited a couple of hours. Paramedic HH explained that when they arrived at Hospital # 1, the emergency medical technician at the desk entered the patient into the log and parked them on the wall. He said that nobody assessed the patient while they waited for almost 2 hours. He further explained that when they asked if the patient would be assessed, the facility's staff said they could not give a specific time/availability. Paramedic HH said no one took vitals or looked at the patient. Paramedic HH stated that the patient was stable during the incident and that after lying on the stretcher for about 2 hours, she decided to leave for another facility. Paramedic HH said he called their supervisor and were told to take her to Hospital #2 if that is where she wanted to go. Paramedic HH said the staff at Hospital #1 asked if they were leaving, and EMS said, yes. EMS then left. EMS took Patient #1 to Hospital #2 and she was immediately sent to triage and EMS left the scene.

An interview was conducted in the Patient Assistance Conference Room on the first floor of the facility on 10/6/2020 at 9:38 a.m. with the Assistant Nurse Manager of the Emergency Department (RN DD). RN DD stated that he recalled the incident concerning Patient #1 because it was bizarre that the ambulance just left. RN DD said 9/15/2020 was a busy shift and he thought the facility was on diversion when he got on shift. RN DD said the waiting room was full, beds were full, and they had other stretchers waiting for a bed to become available. RN DD said they were on Emergency Medical Services (EMS) diversion. He was not at ERC (Emergency Room Communications) where they take radio calls from EMS when Patient #1 first arrived. RN DD said he was out on the floor and when he came to the door, he saw EMS waiting and asked why EMS was waiting. The hospital staff at the command center, Emergency Medical Technician (EMT CC) told RN DD that Patient #1 was actively vomiting and hypertensive according to the EMS radio report. That is why Patient #1 was not placed in the general waiting room for triage. RN DD said patients would ordinarily go out to the waiting room to be triaged, but since Patient #1 was actively vomiting EMT CC did not place Patient #1 out to expose other people in the waiting room. RN DD went back to his charge nurse duties and later when he went back out to ERC, he saw EMS taking Patient #1 out the door. RN DD said he called out to EMS and told them they could not leave because it would be an Emergency Medical Treatment and Labor Act (EMTALA) violation. RN DD said EMS never looked back and just kept going. RN DD said he knew it was trouble when they heard EMS call report to Hospital # 2 after they left. They did not have a chance to ask her to sign an Against Medical Advice (AMA) form. Patient #1 never gave them a warning she wanted to leave and when EMS started to leave, they could not stop them. RN DD said no one asked Patient #1 to sign AMA because they did not have a chance. If rooms are available when EMS comes, the patient is taken back to a room and triaged in a room. They may be sent out to the waiting area after triage but according to the triage level, they may stay in the triage room. RN DD said he thought Patient #1 was on the wall about 1 hour and thirty minutes to 1 hour 40 minutes before leaving. RN DD said sometimes EMS may have to wait up to 6 hours. If there are no rooms, EMS will have to wait with the patient.

An interview was conducted in the Patient Assistance Conference Room of the facility on 10/6/2020 at 11:45 a.m. with Emergency Medical Technician (EMT) CC. EMT CC said he does remember the incident on 9/15/2020. EMT CC said he received a call-in on the radio from an out-of-county Emergency Medical Services (EMS) unit. He said the report was that a patient was coming in for nausea and vomiting and had just been released from this hospital the previous week. EMS gave vital signs and said the patient (Patient #1) wanted to return to the current hospital because she had been recently released from this hospital. EMT CC said he cannot remember everything. When Patient #1 arrived, EMT CC said he was putting another patient into the computer. EMT CC said he remembers Patient #1 looked pale. EMT CC said he always gives the charge nurse a call and let them know a patient was there waiting on the wall. He recalled that Patient #1 started vomiting as soon as she arrived. He held Patient #1 on the wall until a room was available. Patient #1 was waiting to go to a room straight from the EMS bay. EMT CC said he did not put Patient #1 in the waiting room for triage. EMT CC said he thought Patient #1 needed to get a bed as soon as possible. EMT CC said unfortunately, it was a long wait. EMT CC said he remembers Patient #1 waited for about an hour and a half. He said the Emergency Department (ED) had about 3 patients in holding at the wall (waiting on a stretcher on the wall). EMT CC said at the time, they were getting people held at the wall back to a bed within about 2 hours. There was one other patient ahead of Patient #1. EMT CC said he and Charge Nurse, RN DD decided this patient needed priority. EMS had the patient in the hallway for less than two hours and EMT CC said he saw EMS leaving with Patient #1 and called out to them that they could not leave like that. The charge nurse was already at the ERC desk and called out loudly to EMS that they could not leave, that it would be an Emergency Medical Treatment and Labor Act violation (if they left). EMT CC said EMT HH who was in charge of transporting Patient #1 mumbled and walked on out. EMT CC said no one came and asked how long a wait it would be, nor told them that Patient #1 wanted to go somewhere else. They just walked out of the hall where they were holding and left. EMT CC said he knew it was a problem when they heard the EMS crew calling report to the hospital across the block. EMT CC said nursing staff has all gone over EMTALA. He said he has not received formal training but has been advised of EMTALA as far as his position on the radio. EMT CC said the charge nurses are trained, and they train the staff.

An interview was conducted in the Patient Assistance Conference Room of the facility on 10/6/2020 at 2:45 p.m. with the Emergency Department Nurse Manager, (RN EE). She said EMTALA training is done online RN EE said whenever a patient comes in by Emergency Medical Services (EMS) ambulance they get checked in and the person at the desk looks for a room assignment. Once a room is available, the patient goes back to the room. When the patient goes to the back, the attendant at the Emergency Room Communications desk does an overhead page "EMS to Room" and everyone meets in the room to see the patient. Report would be given to the nurse and the doctor if available, then the nurse would triage the patient. The person sitting at the desk should make contact with the charge nurse and tell them EMS is on the way in and the charge nurse would start to look for a room to make available. The patient does not get triaged until they get to the back. RN EE said everyone in the administration was aware of this incident that occurred on 9/15/2020. RN EE said Patient #1 should have been seen and should not have left without signing an Against Medical Advice (AMA) form. She said the hospital has had a lot of problems with EMS and law enforcement not wanting to wait and taking patients out of the Emergency Department (ED).
RN EE said they were already aware that this was an Emergency Medical Treatment and Labor Act (EMTALA) violation even surveyors arrived. She said they were already making changes to try to prevent some of this from happening in the future. Emergency Department Nurse Manager, RN EE, confirmed that during their own investigation of the incident, the hospital found that ED staff had not done what they needed to do to get Patient #1 to sign out AMA, and that staff had not documented in the medical record. RN EE said insurance information is not gathered until after the patient is in the back. She said they get that when they register the patient and get consent forms signed.

Hospital #1 failed to arrange for an appropriate transfer of Patient #1 per their policies and EMTALA requirements.