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Based on interview and record review, the facility failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) as evidenced by:

1. The facility failed to provide a medical screening exam (MSE) for one of 22 patients (Patient 3). (Refer to C 2406)

2. The facility failed to ensure the Emergency Department (ED) log included the names of all patients who presented for treatment. (Refer to C 2405)

Based on interview and record review, the facility failed to maintain a central log in which each patient presenting for emergency care was listed. The emergency department (ED) log failed to include the name for one of 22 patients (Patient 3). This had the potential to result in the facility's inability to accurately track the care given to each patient.

Findings:

The facility's Emergency Medical Treatment and Active Labor Act (EMTALA) policy, dated 7/2019, was reviewed. It indicated, "Each dedicated emergency department of the hospital will maintain a central log recording the names of individuals who come to the emergency department. The central log will record the name of each person who presents for emergency services and whether the person refused treatment, was refused treatment by the hospital or whether the individual was transferred, admitted and treated, stabilized and transferred or discharged. The policy defined a central log as "a log maintained by the hospital on each individual who comes to its dedicated emergency department or any location on the hospital property seeking emergency assistance and the disposition of each individual." The policy defined hospital property to mean "the entire campus of the hospital, including areas and structures that are located within 250 yards of the main buildings and any other areas determined on an individual basis by the CMS (Centers for Medicare/Medicaid Services) regional office, to be part of the main campus. District property includes the parking lots, sidewalks and driveways on the main campus."

On 12/23/19 at 2 pm, the California Department of Public Health (CDPH) received a complaint from an anonymous individual (complainant). The complainant indicated a patient was brought in by ambulance to the ED on 9/13/19 around 3 to 4 pm, and the ED physician refused to evaluate the patient because he had previously been seen 12 to 16 hours before in the ED.

A review of the ambulance log indicated a run report for Patient 3 on 9/13/19 at 2:26 pm.

A review of the ED log, provided by the ED Director, included Patient 3's name on 9/13/19 at 12:14 am and discharge at 6:16 am. Patient 3's name did not appear on the ED log for the ambulance report at 2:26 pm.

The ambulance radio's audio report for 9/13/19, was reviewed in the presence of ambulance staff (AMBS) 1 and ambulance director (AMBD) on 1/29/20 starting at 9:25 am. The ambulance staff could be heard stating, at 2:40 pm, we are literally coming up to the back door.

During an interview on 1/29/20 at 9:40 am, Registered Nurse (RN) 1 said she thought the ambulance was met by the physician outside the ED. She confirmed Patient 3's name was not in the ED log and explained that the patient did not come into the ED, otherwise she would have written his name in the ED log.

Based on interview and record review, the facility failed to ensure a medical screening exam (MSE) was performed for one of 22 patients (Patient 3). Patient 3 came to the hospital (Hospital A) by ambulance and was not provided a MSE prior to transfer to another facility (Hospital B). Patient 3 requested to be taken to Hospital B. This had the potential to result in a serious decline in Patient 3's condition prior to arrival at Hospital B.

Findings:

The facility's Emergency Medical Treatment and Active Labor Act (EMTALA) policy, dated 7/2019, was reviewed. It indicated, "A MSE will be offered to any individual who comes to the emergency department. The MSE must be provided within the capability of the dedicated ED, including ancillary services routinely available to the dedicated ED. The MSE must be the same appropriate examination that the hospital would perform on any individual with similar signs and symptoms, regardless of the individual's ability to pay for medical care." The policy defined, "Comes to the ED means an individual who 1. Presents at the hospital's dedicated emergency department and requests or has a request made on his/her behalf for examination and treatment for a medical condition, or a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition. 2. Presents on hospital property other than a dedicated emergency department, and requests or has a request made on his/her behalf for exam and treatment for what may be an emergency medical condition, or a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs emergency examination or treatment. . . . " The policy defined hospital property to mean "the entire campus of the hospital, including areas and structures that are located within 250 yards of the main buildings and any other areas determined on an individual basis by the CMS (Centers for Medicare/Medicaid Services) regional office, to be part of the main campus. District property includes the parking lots, sidewalks and driveways on the main campus."

On 12/23/19 at 2 pm, the California Department of Public Health (CDPH) received a complaint from an anonymous individual (complainant). The complainant indicated a patient was brought in by ambulance to the ED, on 9/13/19 around 3 to 4 pm, and the ED physician refused to evaluate the patient because he had previously been seen, 12 to 16 hours prior, in the ED.

A review of the ambulance log indicated a run report for Patient 3, on 9/13/19 at 2:26 pm.

A review of the ED log, provided by the ED Director, included Patient 3's name on 9/13/19 at 12:14 am and discharge at 6:16 am. Patient 3's name did not appear on the ED log for the ambulance report at 2:26 pm.

A review of Patient 3's ED first visit on 9/13/19 indicated he presented with a complaint of shortness of breath and intoxication at 12:14 am. A MSE was performed at 12:15 am. Patient 3 was treated and remained in the ED until discharged at 6:16 am. Prior to discharge, it was recommended to Patient 3 that he be transferred to Hospital B because more definitive care could be provided there, however Patient 3 refused this recommendation. Patient 3 was provided with a prescription for medication and discharged.

There was no ED record for Patient 3's second visit to the ED on 9/13/19, but there was an ambulance run report. A review of the ambulance report indicated the call was received from Patient 3 at 2:26 pm. The ambulance crew assessed Patient 3 at 2:32 pm, departed the scene at 2:39 pm and arrived at their destination at 3:51 pm. The narrative portion of the report indicated the ED physician (MD 1) was notified and the ambulance staff were told to take Patient 3 to Hospital B because he needed care that could not be provided at Hospital A. There was nothing in the run report to indicate, whether or not, the ambulance was on hospital property prior to transporting Patient 3 to Hospital B. Two ambulance staff were on duty during the ambulance run, AMBS 2 and AMBS 3.

The ambulance radio's audio report for 9/13/19, was reviewed in the presence of ambulance staff (AMBS) 1 and ambulance director (AMBD) on 1/29/20 starting at 9:25 am. Registered Nurse (RN) 1 answered the radio call inside the hospital. At 2:26 pm, Patient 3 can be heard saying he needed to be taken to Hospital B, a hospital who could help him. AMBS 1 said the ambulance was on scene at 2:30 pm and left the scene at 2:39 pm. At 2:40 pm, the ambulance staff could be heard stating, we are literally coming up to the back door, can I give you a face to face report? MD 1 could be heard saying, Ok. The ambulance staff then said, this is a 51 year old with a chief complaint of shortness of breath. This was the end of the audio recording.

During an interview on 1/29/20 at 9:40 am, RN 1 said she thought the ambulance was met outside by the physician. She confirmed Patient 3 did not come into the ED, otherwise she would have written his name in the ED log.

During an interview on 1/28/20 at 4:35 pm, AMBS 3, said she was unable to recall this patient but the only reason they would have transported Patient 3 to Hospital B would have been pursuant to the ED physician's order. AMBS 3 said she was unable to recall anything about this ambulance run.

During interviews on 1/28/20 at 1:25 pm and 1/29/20 at 2:30 pm, AMBS 2 said Patient 3 told them he had just been treated at Hospital A and was told he needed to go to another facility that could provide more treatment which could not be provided at Hospital A. She recalled Patient 3 saying he didn't want to go to Hospital A but wanted to go to Hospital B. She said this should have been charted in the record. AMBS 2 said MD 1 may have come out to the ambulance and said we can't help Patient 3 here (Hospital A) so take him to Hospital B.

During an interview on 1/29/20 at 1:10 pm, MD 1 said he recalled treating Patient 3 earlier on the day on 9/13/19 and recommending Patient 3 go to Hospital B but he didn't want to go. MD 1 said he thought he talked to the ambulance crew later that day and told them to take Patient 3 to Hospital B on the phone. He said Patient 3 did not want to come to this hospital (Hospital A) and be seen here again but instead wanted to go to Hospital B. He said Patient 3 did not come inside the ED but he also did not recall going outside to see Patient 3.

During an interview on 1/30/20 at 8:15 am, AMBD said they had no protocol for a face to face report between ambulance crew and the ED physician. She explained that this hardly ever happens but if they don't have time to give report over the phone, as soon as they get to the ED door they will give a verbal report to the physician. AMBD said a verbal to verbal report with the substance of the conversation, should be charted in the patient's record. She said if a patient requests to go to another facility and if the patient's condition allows and they have another ambulance to cover the hospital they will try to accommodate the request. AMBD said if a patient requested to go to another facility or if he refused to come to this hospital (Hospital A), it should be charted in the record.

The Ambulance Patient Destination Policy, last revised 7/26/12, was reviewed. It indicated, "when a person or his legally authorized representative requests emergency transportation to a Receiving Facility other than the most accessible acute care hospital, the request should be honored when the Base Hospital determines the condition of the patient permits such transport; except when the provider agency determines that such transport would unreasonably remove the transport unit from the area."