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Based on record review, document review and staff interviews it was determined the hospital failed to follow the guidelines set forth in the Emergency Medical Treatment and Labor Act (EMTALA) in three (2) of twenty (20) medical records reviewed (Patients #1 and #20). This failure has the potential to delay potentially life saving treatment that could result in the potential worsening of the patient symptoms or possible death.

Findings include:

1. A review of the medical record for patient #1 reveals a forty-three (43) year old male that presented to the emergency room (ER) via ambulance on 10/25/19 at 7:35 p.m. The patient was triaged by the charge nurse. The patient complained of left-sided abdominal pain. The patient had a heart rate of one hundred nineteen (119) and a temperature of one hundred one point nine (101.9). The physician did a medical screening on the patient at 7:39 p.m. and tests were ordered. The patient was diagnosed sepsis and colitis with abscess. The patient was refused admission by the on-call surgeon and was in the process of being transferred when he decided to leave against medical advice (AMA).

2. A review of the hospital document entitled 'ED Medhost MD Document' dated 10/26/19 at 0041 (12:41 a.m.) states, "Patient meets sepsis criteria with tachycardia and originally tachycardia and fever. Patient's abdominal computed tomography (CT) with contrast shows that his colitis with abscess has gotten worse. Patient has been given Zosyn and Vancomycin in the emergency department. Patient's case has been discussed with on-call surgeon which has suggested transfer to tertiary center. I have made multiple contacts including Charleston, Huntington with Cabell Huntington, as well as St. Mary's and WVU Morgantown all of which have no beds available. I have made contact with Roanoke Memorial and await return phone call ... 1:10 a.m. Received phone call back from outlying facility which have accepted the patient as a emergency department to emergency department transfer. They will have surgery evaluate him in the emergency department at that time.'

3. An interview was conducted with ER provider #1 on 12/9/19 at approximately 1:15 p.m. While discussing the record for patient #1 he stated he remembered the patient was very sick. He stated, "I called the on-call surgeon and he said that the guy had signed out AMA on two (2) previous occasions and he didn't want to fool with him." He stated he had called multiple places in the state and the only place that had bed availability was out of state. He further stated he was not aware the patient had signed out AMA until now.

4. An interview was conducted with the Chairman of the ER on 12/9/19 at approximately 2:30 p.m. During the discussion about patient #1 he stated that he was not aware an issue had occurred with the on-call surgeon not accepting the patient. He stated he felt the ER physician did the right thing by trying to take care of the patient since the on-call physician refused to accept the patient.

5. A review of the administrator on-call documented for October 2019 reveals the Chief Executive Officer (CEO) was the administrator on call on October 25th and 26th.

6. An interview was conducted with the CEO on 12/10/19 at approximately 9:25 a.m. During the discussion about the transfer of patient #1 he stated, "If I had known about the incident I would have called and told him (on-call surgeon) he had to go see the patient." He further stated he felt the patient could have been cared for by the staff at the hospital.

7. A review of the on-call surgeon's privileges reveals he is able to perform colon surgery for benign or malignant disease and drainage of intra-abdominal abdominal and deep ischiorectal abscess.

8. A review of the hospital policy entitled 'Patient Transfers' effective 10/2017 states: "The transferring hospital must, within its capability, provide treatment to minimize the health of the individual or unborn child."

9. A discussion was held on 12/10/19 at approximately 7:15 a.m. with the charge nurse who was working the evening of 10/25/19. She stated the patient was loaded on the ambulance when he decided to leave. She didn't witness the patient signing out AMA, however; she was informed by Registered Nurse (RN) #1 that the patient didn't want to be transferred and had left before signing the AMA form. When questioned if the physician was notified, she stated, "I have no idea."

10. In an interview conducted with RN #1 on 12/10/19 at approximately 7:25 a.m. she stated the patient never refused to see the on-call surgeon or any physician at the hospital. She stated she thought she notified the physician about the patient leaving AMA but couldn't say for sure.

11. A review of the hospital document entitled 'Medical Staff By-Laws,' last reviewed by the Chief of Staff on 7/9/19, states: "If after discharge this patient presents to the Emergency Room within thirty (30) days of the discharge date and needs admitted, the patient will be admitted to the previous physician. The only exception to this is if the presenting patient previously signed out against medical advice, the physician to whom the patient was assigned is not responsible unless the physician is on assigned call."

12. An interview was conducted with the Director of Risk Management and Patient Safety on 12/11/19 at approximately 2:15 p.m. He stated he felt like patient #1 could have been cared for at the hospital.

13. A review of the medical record for patient #20 reveals a thirty (30) year old male that presented to the ER by private vehicle on 11/20/19 at 2:05 a.m. with complaints of homicidal and suicidal ideations. The patient was triaged at 2:09 a.m. Medical screening exam was begun by the physician at 2:20 a.m. The patient was given a high-level suicide risk score. He was placed with a sitter monitoring one on one (1:1). The hospital has no psychiatric service so the patient was to be transferred to another hospital with psychiatric services. When the ambulance arrived to transport the patient, he refused to be transported. The patient was allowed to sign out AMA with no change in condition noted in the record. The patient left the property with no notification to the police.

14. A review of the hospital policy entitled 'Suicide Risk and Assessment Precautions,' effective date 6/2019, states: "All attempts must be made by the staff to explain to the patient the necessity of further medical assessment by a physician. Staff may notify the local police department as to the patient's whereabouts ..."

15. In an interview with the CNO on 12/10/19 at approximately 4:05 p.m. it was her expectation that nursing staff would notify the police if a suicidal/homicidal patient left AMA.

16. A review of the hospital document entitled 'Learning Detail 2019 EMTALA' reveals all ER staff have completed the EMTALA training for the year.

17. A review of the hospital documents entitled 'EMTALA Challenges: Emergency Medical Treatment and Active Labor Act Challenges for Clinicians' reveals twenty-two (22) of twenty-nine (29) ER providers (Provider #1-#22) do not have current EMTALA training.

18. In an interview with the Director of Risk Management and Patient Safety on 12/11/19 at approximately 2:15 p.m. he concurred it was the expectation of all hospital personnel to have yearly EMTALA training. He concurred with the findings of patients #1 and #20.

Based on record review, document review and staff interviews it was determined the hospital failed to ensure the on-call surgeon provided services to the best of his capabilities in one (1) out of twenty (20) records reviewed (Patient # 1). This failure has the potential to possibly delay life-saving treatment to the patient seeking the services of this hospital for an emergency medical condition.

Findings include:

1. A review of the medical record for patient #1 reveals a forty-three (43) year old male that presented to the emergency room (ER) via ambulance on 10/25/19 at 7:35 p.m. The patient was triaged by the charge nurse. The patient complained of left-sided abdominal pain. The patient had a heart rate of one hundred nineteen (119) and a temperature of one hundred one point nine (101.9). The physician did a medical screening on the patient at 7:39 p.m. and tests were ordered. The patient was diagnosed sepsis and colitis with abscess. The patient was refused admission by the on-call surgeon and was in the process of being transferred when he decided to leave against medical advice (AMA).

2. A review of the hospital document entitled 'ED Medhost MD Document' dated 10/26/19 at 0041 (12:41 a.m.) states: "Patient meets sepsis criteria with tachycardia and originally tachycardia and fever. Patient's abdominal CT (computed tomography) with contrast show that his colitis with abscess has gotten worse. Patient has been given Zosyn and Vancomycin in the emergency department. Patient's case has been discussed with on-call surgeon which has suggested transfer to tertiary center. I have made multiple contacts including Charleston, Huntington with Cabell Huntington, as well as St. Mary's and WVU Morgantown, all of which have no beds available. I have made contact with Roanoke Memorial and await return phone call ... 1:10 a.m. Received phone call back from outlying facility which have accepted the patient as a emergency department to emergency department transfer. They will have surgery evaluate him in the emergency department at that time."

3. An interview was conducted with ER provider #1 on 12/9/19 at approximately 1:15 p.m. While discussing the record for patient #1 he stated he remembered the patient was very sick. He stated, "I called the on-call surgeon and he said that the guy had signed out AMA on two (2) previous occasions and he didn't want to fool with him." He stated he had called multiple places in the state and the only place that had bed availability was out of state. He further stated he was not aware the patient had signed out AMA until now.

4. An interview was conducted with the Chairman of the ER on 12/9/19 at approximately 2:30 p.m. During the discussion about patient #1 he stated that he was not aware an issue had occurred with the on-call surgeon not accepting the patient. He stated he felt the ER physician did the right thing by trying to take care of the patient since the on-call physician refused to accept the patient.

5. A review of the administrator on-call documented for October 2019 reveals the Chief Executive Officer (CEO) was the administrator on call on October 25th and 26th.

6. An interview was conducted with the CEO on 12/10/19 at approximately 9:25 a.m. During the discussion about the transfer of patient #1 he stated, "If I had known about the incident I would have called and told him (on-call surgeon) he had to go see the patient." He further stated he felt the patient could have been cared for by the staff at the hospital.

7. A review of the on-call surgeon's privileges reveals he is able to perform colon surgery for benign or malignant disease and drainage of intra-abdominal abdominal and deep ischiorectal abscess.

8. A review of the hospital policy entitled 'Patient Transfers' effective 10/2017 states: "The transferring hospital must, within its capability, provide treatment to minimize the health of the individual or unborn child."

9. A discussion was held on 12/10/19 at approximately 7:15 a.m. with the charge nurse who was working the evening of 10/25/19. She stated the patient was loaded on the ambulance when he decided to leave. She didn't witness the patient signing out AMA, however; she was informed by RN #1 that the patient didn't want to be transferred and had left before signing the AMA form. When questioned if the physician was notified, she stated, "I have no idea."

10. In an interview conducted with RN #1 on 12/10/19 at approximately 7:25 a.m. she stated the patient never refused to see the on-call surgeon or any physician at the hospital. She stated she thought she notified the physician about the patient leaving AMA but couldn't say for sure.

11. A review of the hospital document entitled 'Medical Staff By-Laws,' last reviewed by the Chief of Staff on 7/9/19, states: "If after discharge this patient presents to the Emergency Room within thirty (30) days of the discharge date and needs admitted, the patient will be admitted to the previous physician. The only exception to this is if the presenting patient previously signed out against medical advice, the physician to whom the patient was assigned is not responsible unless the physician is on assigned call."

12. An interview was conducted with the Director of Risk Management and Patient Safety on 12/11/19 at approximately 2:15 p.m. He stated he felt like patient #1 could have been cared for at the hospital.

Based on record review, document review and staff interviews it was determined the hospital failed to follow its own policies to ensure patients were provided care to the best of their ability in three (2) of twenty (20) records reviewed (patients #1 and #20). This failure has the potential to delay potentially life-saving care to the patient seeking the services of this hospital for a possible emergency condition.

Findings include:

1. A review of the medical record for patient #1 reveals a forty-three (43) year old male that presented to the emergency room (ER) via ambulance on 10/25/19 at 7:35 p.m. The patient was triaged by the charge nurse. The patient complained of left-sided abdominal pain. The patient had a heart rate of one hundred nineteen (119) and a temperature of one hundred one point nine (101.9). The physician did a medical screening on the patient at 7:39 p.m. and tests were ordered. The patient was diagnosed sepsis and colitis with abscess. The patient was refused admission by the on-call surgeon and was in the process of being transferred when he decided to leave against medical advice (AMA).

2. A review of the hospital document entitled 'ED Medhost MD Document' dated 10/26/19 at 0041 (12:41 a.m.) states: "Patient meets sepsis criteria with tachycardia and originally tachycardia and fever. Patient's abdominal CT (computed tomography) with contrast show that his colitis with abscess has gotten worse. Patient has been given Zosyn and Vancomycin in the emergency department. Patient's case has been discussed with on-call surgeon which has suggested transfer to tertiary center. I have made multiple contacts including Charleston, Huntington with Cabell Huntington, as well as St. Mary's and WVU Morgantown, all of which have no beds available. I have made contact with Roanoke Memorial and await return phone call ... 1:10 a.m. Received phone call back from outlying facility which have accepted the patient as a emergency department to emergency department transfer. They will have surgery evaluate him in the emergency department at that time."

3. An interview was conducted with ER provider #1 on 12/9/19 at approximately 1:15 p.m. While discussing the record for patient #1 he stated he remembered the patient was very sick. He stated, "I called the on-call surgeon and he said that the guy had signed out AMA on two (2) previous occasions and he didn't want to fool with him." He stated he had called multiple places in the state and the only place that had bed availability was out of state. He further stated he was not aware the patient had signed out AMA until now.

4. An interview was conducted with the Chairman of the ER on 12/9/19 at approximately 2:30 p.m. During the discussion about patient #1 he stated that he was not aware an issue had occurred with the on-call surgeon not accepting the patient. He stated he felt the ER physician did the right thing by trying to take care of the patient since the on-call physician refused to accept the patient.

5. A review of the administrator on-call documented for October 2019 reveals the Chief Executive Officer (CEO) was the administrator on call on October 25th and 26th.

6. An interview was conducted with the CEO on 12/10/19 at approximately 9:25 a.m. During the discussion about the transfer of patient #1 he stated, "If I had known about the incident I would have called and told him (on-call surgeon) he had to go see the patient." He further stated he felt the patient could have been cared for by the staff at the hospital.

7. A review of the on-call surgeon's privileges reveals he is able to perform colon surgery for benign or malignant disease and drainage of intra-abdominal abdominal and deep ischiorectal abscess.

8. A review of the hospital policy entitled 'Patient Transfers' effective 10/2017 states: "The transferring hospital must, within its capability, provide treatment to minimize the health of the individual or unborn child."

9. A discussion was held on 12/10/19 at approximately 7:15 a.m. with the charge nurse who was working the evening of 10/25/19. She stated the patient was loaded on the ambulance when he decided to leave. She didn't witness the patient signing out AMA, however; she was informed by RN #1 that the patient didn't want to be transferred and had left before signing the AMA form. When questioned if the physician was notified, she stated, "I have no idea."

10. In an interview conducted with RN #1 on 12/10/19 at approximately 7:25 a.m. she stated the patient never refused to see the on-call surgeon or any physician at the hospital. She stated she thought she notified the physician about the patient leaving AMA but couldn't say for sure.

11. A review of the hospital document entitled 'Medical Staff By-Laws,' last reviewed by the Chief of Staff on 7/9/19, states: "If after discharge this patient presents to the Emergency Room within thirty (3) days of the discharge date and needs admitted, the patient will be admitted to the previous physician. The only exception to this is if the presenting patient previously signed out against medical advice, the physician to whom the patient was assigned is not responsible unless the physician is on assigned call."

12. An interview was conducted with the Director of Risk Management and Patient Safety on 12/11/19 at approximately 2:15 p.m. He stated he felt like patient #1 could have been cared for at the hospital.

13. A review of the medical record review for patient #20 reveals a thirty (30) year old male that presented to the ER by private vehicle on 11/20/19 at 2:05 a.m. with complaints of homicidal and suicidal ideations. The patient was triaged at 2:09 a.m. Medical screening exam was begun by the physician at 2:20 a.m. The patient was given a high-level suicide risk score. He was placed with a sitter monitoring one on one (1:1). The hospital has no psychiatric service so the patient was to be transferred to another hospital with psychiatric services. When the ambulance arrived to transport the patient, he refused to be transported. The patient was allowed to sign out AMA with no change in condition noted in the record. The patient left the property with no notification to the police.

14. A review of the hospital policy entitled 'Suicide Risk and Assessment Precautions' effective date 6/2019, states: "All attempts must be made by the staff to explain to the patient the necessity of further medical assessment by a physician. Staff may notify the local police department as to the patient's whereabouts ..."

15. In an interview with the CNO on 12/10/19 at approximately 4:05 p.m. it was her expectation that nursing staff would notify the police if a suicidal/homicidal patient left AMA.

16. A review of the hospital document entitled 'Learning Detail 2019 EMTALA' reveals all ER staff have completed the EMTALA training for the year.

17. A review of the hospital documents entitled 'EMTALA Challenges: Emergency Medical Treatment and Active Labor Act Challenges for Clinicians' reveals twenty-two (22) of twenty-nine (29) ER providers (Provider #1-#22) do not have current EMTALA training.

18. In an interview with the Director of Risk Management and Patient Safety on 12/11/19 at approximately 2:15 p.m. he concurred it was the expectation of all hospital personnel to have yearly EMTALA training. He concurred with the findings of patients #1 and #20.