HospitalInspections.org

Based on review of the DED (Dedicated Emergency Department) EMTALA (Emergency Management Treatment and Labor Act) log for August 2021, policy and procedure review, ambulance run report review, paramedic incident report review, medical record review, and staff and physician interviews the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings included:

1. The hospital failed to ensure a medical screening examination (MSE) was provided within the capability of the hospital's Dedicated Emergency Department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for one (1) of 6 sampled DED patients that presented via EMS, (Patient #22).

2. The hospital failed to ensure that an adequate medical screening examination was provided for patients who presented to the hospital's Labor and Delivery for evaluation of non-labor complaints in 2 of 4 sampled patients, (Patient #18, Patient #21).

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

3. The hospital's Dedicated Emergency Department and physician failed to ensure an appropriate transfer by failing to ensure the receiving hospital had available space; and by failing to ensure the receiving hospital had agreed to accept transfer of a patient for one (1) of 4 sampled patients that were transferred with an EMC to other acute care hospitals, (Patient #22).

~ Cross refer to §489.24(e)(1)-(2) Appropriate Transfer, Tag A2409.

Based on review of hospital policy, ambulance trip report, dedicated emergency department (DED) EMTALA (Emergency Medical Treatment and Labor Act) log and staff interviews, the hospital failed to ensure that each individual presenting to the DED seeking care for an emergency medical condition was included on the central DED log for one (1) of 21 DED patients reviewed, (Patient #22).

The findings include:

Review of the policy and procedure titled "EMTALA Policy" last reviewed 10/2020 revealed "POLICY/PROCEDURE...

G. Emergency Medical Care Log.

1. A record of all individuals who present to (Hospital A) Health seeking emergency medical care will be maintained for persons presenting to the emergency department ...seeking emergency care ..."

Review of an ambulance trip report from (local) County EMS (emergency management services) confirmed that Patient #22 was taken to Hospital A's (receiving hospital) DED on 08/23/2021. Review of the trip report recorded the ambulance crew arrived at Hospital A (receiving hospital) on 08/23/2021 (time not identified). Review of the report revealed, "...Upon arrival at Hospital A's ED (just inside the ED foyer), the crew was informed by a nurse and Dr. [MD #1] that the patient would not be admitted to the hospital due to his potential need for dialysis...The physician provided ice packs to the febrile patient and again asked them to transport the patient to Hospital B. The crew complied with his orders, and the patient was transported rapidly to Hospital B where he was then released to ED nursing staff..." Review of the report revealed EMS arrived at Hospital B at 1749.

Review of Hospital A's DED log for August 2021 showed no documented evidence that Patient #22 presented for a medical screening examination (MSE).

Interview on 09/07/2021 at 1628 with MD #1 revealed Paramedic #1 called in report when he was in bound with Patient #22 and failed to inform staff that he was a dialysis patient. MD #1 stated he told the nurse to tell them to continue with the transport to Hospital A. MD #1 stated in the meantime, Patient #22's family showed up at the hospital and was upset that Patient #22 was being transported there and the family did not want him at Hospital A because they did not have dialysis services. MD #1 stated once he learned from the family that Patient #22 was a dialysis patient, he attempted to contact EMS to have them divert to Hospital B. MD #1 stated it was too late and EMS had already arrived at Hospital A. MD #1 stated EMS made it just inside one set of double doors that connect to the EMS bay before they were stopped by a nurse and himself. MD #1 stated he evaluated Patient #22 while he was lying on the stretcher and noted him to have an intact airway, bruising on his face from a previous fall, not alert, and unable to answer questions. MD #1 stated he discussed with Paramedic #1 that Hospital A did not have Dialysis capabilities and how difficult it had been to transfer patients recently, that he felt Patient #22 was stable enough for EMS to go ahead and transport to Hospital B. MD #1 stated Patient #22's vitals were stable for the most part and he was on supplemental oxygen. MD #1 stated "I know I was incapable to get a transfer" therefore he felt it was in Patient #22's best interest to be transported to Hospital B. Interview revealed Patient #22 was never registered while at the DED.

Interview on 09/08/2021 at 0939 with RN #1 revealed she was charge nurse the shift of Patient #22's incident. RN #1 stated EMS "encoded" (called their report in) and asked if they could transport in and proceeded to give report. RN #1 stated Paramedic #1 did not disclose Patient #22 was a dialysis patient. RN #1 stated she conferred with MD #1 and he agreed to have EMS transport Patient #22 to Hospital A. RN #1 stated Patient #22's family showed up at the hospital before EMS and was "upset" because they did not want him there because he was a dialysis patient. RN #1 stated at that point staff attempted to contact EMS to divert to Hospital B, but they had already arrived at Hospital A. RN #1 stated EMS brought Patient #22 into an area just outside the EMS bay, that had two sets of double doors entering the hospital; they were stopped in the area between the two sets of double doors. RN #1 stated MD #1 consulted with Paramedic #1 and they ended up transporting him to Hospital B. RN #1 stated she told MD #1 "this is an EMTALA violation." Interview revealed Patient #22 was never registered following arrival to the ED.

Interview on 09/08/2021 at 1222 with Paramedic #1 revealed he was first met by a nurse in the area between the two set of double doors leading into the ED at Hospital A. Paramedic #1 stated he was then informed Patient #22 was not allowed in the hospital. Paramedic #1 stated MD #1 proceeded to tell him Patient #22's family did not want him there due to him being a dialysis patient, the hospital being incapable of providing dialysis and the ED was "swamped and had no beds." Paramedic #1 stated MD #1 was concerned he would not be able to transfer Patient #22 due to increased difficulty transferring patients recently. Paramedic #1 stated MD #1 requested he transport Patient #22 to Hospital B, in which he did.

Based on policy and procedure review, ambulance run report review, medical record review, paramedic incident report review, and staff and physician interviews the hospital failed to ensure that an adequate medical screening examination was provided for a patient (Patient #22) who presented to the hospital's DED (Dedicated Emergency Department) for evaluation on 08/23/2021; The hospital failed to ensure that an adequate medical screening examination was provided for patients who presented to the hospital's Labor and Delivery for evaluation of non-labor complaints in two (2) of 4 sampled patients, ( Patient #18, Patient #21)

The findings included:

1. Review of the policy and procedure titled "EMTALA (Emergency Medical Treatment and Labor Act) Policy" last reviewed 10/2020 revealed "POLICY/PROCEDURE Any person who comes to (Hospital A) Health requesting assistance for a potential emergency medical condition or emergency services will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists ...IMPLEMENTATION ...D. Medical Screening Examinations: 1. A medical screening exam is required when an individual: a. Seeks care at the hospital Emergency Department ...b. Arrives anywhere on the hospital premises and stated that he or she may have an emergency ..."

Review of the EMS (emergency management services) run report dated 08/23/2021 at 1630 revealed Patient #22's family called EMS due to AMS (Altered Mental Status). Review of the run report revealed "The patient was found seated upright (and not in a tripod position but with his chin on his chest) inside his home. The patient was unresponsive to all stimuli and in obvious (yet mild) respiratory distress (as noted by his low SpO2 (Oxygen Saturation of the blood), his RR [respiratory rate], and his respiratory effort). The patient's family stated that the patient had recently been diagnosed with COVID-19 and had been suffering with S/S [signs and symptoms] of both COVID and pneumonia for roughly two weeks ...On exam, the patient was without diaphoresis but was mildly pale and mildly jaundice (yellowing of the skin). Radial pulse in the left upper extremity was present and strong, as were the femoral pulses. Carotid pulses and radial pulse in the right upper extremity were inaccessible due to orthopedic appliances in place due to fractures the patient recently sustained in a fall. The patient was incapable of speaking due to his state of unresponsiveness. He was without retractions but was quite tachypneic (increased respiratory rate). He also presented with mild ABD [abdominal] accessory muscle use. Auscultation of lung sounds revealed bibasilar rhonchi, and the lower lobes were diminished. Upper lobes were clear, however. Aside from mild lower extremity edema and the listed VS [vital signs], the secondary physical exam for this patient was otherwise unremarkable. Just prior to removing the patient from his home, the EMS crew explained to the patient's family their desire to transport the patient to the closest hospital (despite the family's wish to have him transported to [Hospital B]) due to his instability. The family was, at that time, without protest. The patient was taken to the ambulance, and vascular access was established via bilateral IO (Intraosseous - in the bone) sites in the lower extremities. The patient, at the time of IO bolus initiation, responded to the painful stimulus (but very briefly) with moaning and grimace only. Otherwise, the patient displayed no responses to any additional stimuli ...Furthermore, oxygen therapy via NRB (non-rebreather) produced an increase in the patient's SPo2 but no significant changes in his RR and respiratory effort. As the patient showed no observable improvements, the EMS crew continued to the closest hospital, despite the hospital's inability to provide emergency dialysis to this CKD [chronic kidney disease] patient. Upon arrival at Hospital A's ED (just inside the ED foyer), the crew was informed by a nurse and Dr. [MD #1] that the patient would not be admitted to the hospital due to his potential need for dialysis. The Paramedic voiced his concern for the patient's instability and need to be immediately stabilized before being transported to Hospital B. However, the physician explained that he felt that the patient was stable enough for the transport. The Paramedic voiced his concern about the IO flow problems, and the physician stated that he could place a central line but that doing so would only delay transport. The physician provided ice packs to the febrile patient and again asked them to transport the patient to Hospital B. The crew complied with his orders, and the patient was transported rapidly to Hospital B where he was then released to ED nursing staff with only a slight improvement in his body temperature and slightly more responsive to painful stimuli - - but without changes otherwise."

Review revealed Patient #22 presented to Hospital B DED on 08/23/2021 at 1755 with an arrival complaint of "unresponsive." Patient #22's initial vital signs at 1800 were as follows: Blood Pressure-140/90; Respiratory Rate-30; Heart Rate-120; Sp02-93% on a non-rebreather; Temperature-102.2 F; and GCS (Glasgow Coma Scale)-5. Review of the ED provider note dated 08/23/2021 at 1811 revealed "HPI (history of present illness) (Patient #22) is a 63 y.o. male ...presents to the emergency department with 5 hours of apparently being unresponsive at home...has end-stage renal disease on dialysis. EMS arrived on scene to find the patient minimally responsive and took him to the Hospital A emergency department. EMS tell me that the emergency department doctor met them at the EMS doors and advised that they continue onto the Hospital B emergency department. At that time EMS had IO lines in both tibia and patient was being managed on a nonrebreather. No specific intervention was performed at the emergency department and they redirected to Hospital B ...06:51 PM ...The decision was made to intubate the patient for airway protection as well as hypoxic respiratory failure. We will also establish IV access with central line ...Final diagnoses: Acute respiratory failure with hypoxia." Review of the admission H&P (history and physical) dated 08/23/2021 at 2106 revealed "Patient is a 63-year-old male brought to the emergency room found to be in respiratory failure and obtunded (unresponsive) requiring intubation. He is Covid positive ...Patient has end-stage renal disease on dialysis ...He arrived in the emergency room acute hypercapnic hypoxemic (elevated carbon dioxide; decreased oxygen in the blood) respiratory failure requiring emergent intubation ..." Review of the Discharge summary dated 08/28/2021 at 2254 revealed "(Patient #22) is a 63 y.o. year old male with ESRD (End Stage Renal Disease) ...arrived on 8/23/21 obtunded and hypoxemic requiring intubation on arrival to the ED...He was intubated and admitted to the critical care team for acute hypoxemic respiratory failure secondary to presumed covid/aspiration pneumonia. He developed septic shock requiring vasopressor support and required CRRT [continuous renal replacement therapy - continuous dialysis] for his renal failure... Despite critical care management, his condition continued to deteriorate ...On 8/28/21 at 20:25, patient expired."

Review of Paramedic #1's incident report dated 08/23/2021 revealed "The patient in the above incident (CAD# 21E016204) was an elderly male who presented with S/S of acute sepsis secondary to COVID-19. He was unresponsive, hypoxic (as noted by skin color and low SpO2), tachypneic (with shallow respirations), febrile (with a rectal temperature of 102.9 degrees Fahrenheit), and tachycardic. This patient was obviously unstable, and immediately the lead Paramedic realized that he was facing difficult circumstances in that the patient may have potential airway problems and seizures (or other neuromotor complications) related to the aforementioned conditions. An additional issue was vascular access due to the patient having a dialysis site on his left upper extremity, an orthopedic cast on his right upper extremity, and a cervical collar in place (for recent spinal trauma), which would disallow external jugular catheterization. Just prior to this unstable patient being moved to the ambulance, the Paramedic informed the patient's family (after they told him that they wanted their loved one transported to Hospital B) that he would be transporting the patient to the closest hospital [Hospital A] due to his instability ...Rapid transport was then initiated to (Hospital A) Health, the closest hospital. The Paramedic believed that the patient, despite his renal history, needed to be stabilized at the closest facility and could be transported to (Hospital B) after being stabilized in (Hospital A). Upon arrival at (Hospital A) Health, just inside the emergency department, the EMS crew was approached by a nurse and a physician, who both stated that the patient could not be admitted due to the family's desire to not have the patient at their hospital due to his renal history. They explained that they had spoken with the family even before the ambulance had arrived at their hospital, adding that (Hospital A) Health did not have the capabilities to perform dialysis. The physician then ordered the crew to load the patient back onto the ambulance. The Paramedic explained his position to the physician, but the physician then adamantly (but politely) declined to accept the patient. He stated that he understood the Paramedic's position but stated that, although the patient was unstable, he felt that the patient would survive the trip to (Hospital B) due to his faith in the Paramedic's competency, the patient's BP being not yet hypotensive, the patient's heart rate not being grossly tachycardic in his opinion, and the patient still having a patent airway. He did voice concern about the IO infusions but stated that he would place a central line if the Paramedic felt uncomfortable with what was in place. However, the physician stated that the placement of a central line would only delay transport. The nurse then informed the physician that he was about to commit an EMTALA violation. He then informed her that he was aware of this but claimed that he would take full responsibility for his decision and address the EMTALA issue later. He then asked the EMS crew to leave (Hospital A) Health to transport the patient to (Hospital B). At (Hospital B) the Paramedic was politely asked by a physician why this patient was not transported to the closest hospital. After his question was answered, the physician stated that he would be in touch with (Hospital A). He also asked for contact information for the patient's family in order for him to discuss DNR and advanced directives for this patient, adding that the patient would most likely need RSI (rapid sequence intubation) soon ..."

Interview on 09/07/2021 with the Vice President of Nursing (VPN #1) revealed the hospital had recently implemented a process called "field triage." VPN #1 explained field triaging came about during the recent surge of COVID patients and the need for the ED to hold admissions due to bed unavailability. VPN #1 explained field triaging was when EMS was in bound to the facility and called their report in over the radio, EMS provided a detailed patient report and if the hospital was on field triage at that time, the nurse would consult with the MD and the MD made the decision on whether EMS could proceed onto the ED or needed to transport to another hospital. VPN #1 stated if a patient presented to the ED by car, they would not turn them away, they would provide treatment for them. VPN #1 stated if EMS stated they "needed to come here," we would let them come. VPN #1 stated there were times when the ED was holding admission to the inpatient units or patients needing transfers, therefore limiting the number of rooms to place incoming ED patients. VPN #1 stated when staff considered field triaging, there were a series of questions that had to be answered collaboratively between the ED MD on duty, charge nurse on duty, and the house supervisor on duty. VPN #1 stated determining factors such as how many admissions and transfers were waiting in the ED, the acuity of the patients, staffing, number of patients waiting to be seen, and number of available ED beds all played a role in the decision to implement field triaging. Interview revealed on 08/23/2021 (the day Patient #22 presented to the ED) the ED was on field triage.

Interview on 09/07/2021 at 1628 with MD #1 revealed field triaging was put into place recently when the hospital was "overwhelmed" and transfers becoming increasingly difficult due to limited beds in the state. MD #1 stated the theory behind field triaging was when EMS called in with a patient that the MD felt was going to need a higher level of service the hospital could not provide such as dialysis, they would divert EMS to the next closest facility that had that capability. Interview revealed on 08/23/2021 (the day Patient #22 presented to the ED) the ED was on field triage. MD #1 stated Paramedic #1 called in report when he was in bound with Patient #22 and failed to inform staff that he was a dialysis patient. MD #1 stated he told the nurse to tell them to continue with the transport to Hospital A. MD #1 stated in the meantime, Patient #22's family showed up at the hospital and was upset that Patient #22 was being transported there and the family did not want him at Hospital A because they did not have dialysis services. MD #1 stated once he learned from the family that Patient #22 was a dialysis patient, he attempted to contact EMS to have them divert to Hospital B. MD #1 stated it was too late and EMS had already arrived at Hospital A. MD #1 stated EMS made it just inside one set of double doors that connect to the EMS bay before they were stopped by a nurse and himself. MD #1 stated he evaluated Patient #22 while he was lying on the stretcher and noted him to have an intact airway, bruising on his face from a previous fall, not alert, and unable to answer questions. MD #1 stated he discussed with Paramedic #1 that Hospital A did not have Dialysis capabilities and how difficult it had been to transfer patients recently, that he felt Patient #22 was stable enough for EMS to go ahead and transport to Hospital B. MD #1 stated Patient #22's vitals were stable for the most part and he was on supplemental oxygen. MD #1 stated "I know I was incapable to get a transfer" therefore he felt it was in Patient #22's best interest to be transported to Hospital B.

Interview on 09/08/2021 at 0939 with RN #1 revealed she was charge nurse the shift of Patient #22's incident. RN #1 stated EMS "encoded" (called their report in) and asked if they could transport in and proceeded to give report. RN #1 stated Paramedic #1 did not disclose Patient #22 was a dialysis patient. RN #1 stated she conferred with MD #1 and he agreed to have EMS transport Patient #22 to Hospital A. RN #1 stated Patient #22's family showed up at the hospital before EMS and was "upset" because they did not want him there because he was a dialysis patient. RN #1 stated at that point staff attempted to contact EMS to divert to Hospital B, but they had already arrived at Hospital A. RN #1 stated EMS brought Patient #22 into an area just outside the EMS bay, that had two sets of double doors entering the hospital; they were stopped in the area between the two sets of double doors. RN #1 stated MD #1 consulted with Paramedic #1 and they ended up transporting him to Hospital B. RN #1 stated she told MD #1 "this is an EMTALA violation."

Interview on 09/08/2021 at 1222 with Paramedic #1 revealed Patient #22's family did not want him transported to Hospital A due to his renal history. Paramedic #1 explained to the family his concerned that Patient #22 was unstable and needed transporting to the closest facility. Paramedic #1 stated during his encode to the hospital he did not disclose he was a dialysis patient. Paramedic #1 stated he was first met by a nurse in the area between the two set of double doors leading into the ED. Paramedic #1 stated he was then informed Patient #22 was not allowed in the hospital. Paramedic #1 stated MD #1 proceeded to tell him Patient #22's family did not want him there due to him being a dialysis patient, the hospital being incapable of providing dialysis and the ED was "swamped and had no beds." Paramedic #1 stated MD #1 was concerned he would not be able to transfer Patient #22 due to increased difficulty transferring patients recently. Paramedic expressed his concerns to MD #1 of Patient #22's instability supported by his abnormal vital signs, tachycardia, tachypnea, febrile, altered mental status and lack of vascular access. Paramedic #1 stated MD #1 was not "really concerned" about his SP02 because it was stable with supplemental oxygen. Paramedic #1 stated MD #1 told him "you know your stuff; I have confidence you'll get him there alive." Paramedic #1 stated MD #1 stated Patient #22 was not "unstable enough" to be transported. Paramedic #1 stated the transport to Hospital B was uneventful.

2. Additional Findings (Patient #18):

Review of the Rules and Regulations last revised 03/09/2021 revealed "10.2. Medical Screening Examinations: Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified medical personnel who can perform medical screening examinations within applicable Hospital policies and procedures are defined as ...(b) Labor and Delivery: (1) members of the Medical Staff with OB/GYN privileges ... (3) Registered Nurses who have achieved competency, in accordance with Labor and Delivery Policies and Procedures ..."

Review of the policy and procedure titled "Medical Staff Coverage for Unassigned Obstetric Patients" effective 07/27/2020 revealed " ...B. All obstetrical patients that are admitted in a LD (Labor and Delivery) outpatient status must receive a medical screening exam by an obstetrician or qualified Maternity Service RN ..."

Review of the policy and procedure titled "EMTALA Policy" last reviewed 10/2020 revealed "POLICY/PROCEDURE Any person who comes to (Hospital A) Health requesting assistance for a potential emergency medical condition or emergency services will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists ...IMPLEMENTATION ...D. Medical Screening Examinations: 1. A medical screening exam is required when an individual: a. Seeks care at the hospital Emergency Department or Maternity Services Unit. 3. The medical screening examinations will be conducted only by individuals determined qualified by Hospital Bylaws or Rules and Regulations ( ...or qualified registered nurse) ..."

Closed medical record review on 09/07/2021 revealed Patient #18 presented to L&D on 05/27/2021 at 1636 with complaints of "High BP (blood pressure) and labs." Review revealed Patient #18's MSE was initiated at 1636 by RN #3. Review of RN #3's note dated 05/27/2021 at 1650 revealed "Received this G3P2 (gravida-number of pregnancies; para-number of births) to treatment room from office for elevated BP, patient denies contractions, bleeding or LOF (loss of fluids) ...patient denies HA (headache) or visual changes." Patient #18's Blood Pressure at 1652 was 147/88 and 149/91 at 1708. Review RN #3's note at 1720 revealed "MD #2 updated on patient arrival/status." Review revealed orders for "External Fetal Monitoring Routine, Fetal Heart Tones, Fundal Height On Arrival ...Urine Dipstick ...MASU (maternity services unit) Referred Outpatient to Services of Routine" were ordered at 1722 and at 1733 a CBC (complete blood count) and complete metabolic panel was ordered. Review of RN #3's note at 1850 revealed "MD #2 updated on BP/labs, orders received." Review of RN #3's note at 1900 revealed "discharge and follow up instructions provided to patient, patient verbalized understanding." Review revealed Patient #18 was discharged on 05/27/2021 at 1903 with a diagnosis of elevated BP in pregnancy. Review revealed Patient #18 was not seen by an Obstetrician.

Interview on 09/08/2021 at 1015 with RN #3 revealed she did not recall Patient #18. RN #3 stated the RNs completed the MSE which included checking fetal heart tones, vital signs, enter chief complaint into the computer system, and dip the patient's urine. RN #3 stated the RNs then called the on-call OB MD and verbally updated them on the MSE findings and received MD orders following report. RN #3 stated after all lab and test were resulted, the nurse would call the MD back and update on findings. RN #3 stated the MDs "don't always come to see the patient, we do a verbal consultation." RN #3 stated if the RN requested the MD to come in and see the patient, the MD would come in. Interview revealed it was "based on their (MDs) discretion" whether they came in to evaluate the patient or not.

Interview on 09/08/2021 at 1210 with MD #2 revealed the RNs completed the MSE. MD #2 stated if a patient was being admitted, transferred, or at the request of the RN; the provider would come in and physically see the patient. MD #2 stated the RNs were "evaluating patients for labor." MD #2 stated the providers were involved in the patients care remotely. Interview revealed for non-labor complaints such as abdominal pain, the provider would give orders for labs, urine, vital signs, and fetal heart monitoring to name a few. MD #2 stated then the RN updated the provider on the result and in conjunction with the MD remotely, a disposition decision would be made.


3. (Patient #21):

Closed medical record review on 09/07/2021 revealed Patient #21 presented to L&D on 08/02/2021 at 0721 with complaints of "blood in urine, abdominal and back pain." Review revealed Patient #21's MSE was initiated at 0721 by RN #2. Review of RN #2's note dated 08/02/2021 at 0727 revealed "Received this G2P1 to the tx (treatment room) with c/o (complaints of) back pain for 2 days and abd pain began this morning. Reports when she went to the bathroom this morning she was 'peeing blood.' Denies urinary frequency or burning. Denies contraction, leaking of fluid, or vaginal bleeding. Pt (patient) to services of MD #2." Review of OB RN #2's note at 0752 revealed "MD #2 notified of pts arrival and mse findings, orders received." Review revealed orders for "External Fetal Monitoring Routine, Fetal Heart Tones, Fundal Height On Arrival ...Urine Dipstick ...MASU (maternity services unit) Referred Outpatient to Services of Routine ...Urinalysis ..." were placed at 0809. Review of RN #2's note at 0949 revealed "Discharge and follow up instructions provided, pt verbalized understanding of all instructions." Review revealed Patient #21 was discharged home on 08/02/2021 at 0951 with a diagnosis of "22 weeks gestation of pregnancy (acute) Abdominal pain affecting pregnancy (Acute)." Review revealed Patient #21 was not seen by an Obstetrician.

Interview on 09/08/2021 at 1001 with RN #2 revealed the RNs had "preset" MSE questions that "walks you through" the process. RN #2 stated once she was done with the MSE, she would call and update the on-call MD of the patient's arrival and findings and obtain orders. RN #2 stated once orders were completed, she would notify the MD of the results and the MD "makes the decision whether to discharge, admit, or needed further evaluation." RN #2 stated the MD did not always come in and physically see the patient. RN #2 stated the MD would come in and assess the patient at the RNs request. Interview revealed MD #2 did not come in and see Patient #21, she was evaluated via verbal consult.

Interview on 09/08/2021 at 1210 with MD #2 revealed the RNs completed the MSE. MD #2 stated if a patient was being admitted, transferred, or at the request of the RN; the provider would come in and physically see the patient. MD #2 stated the RNs were "evaluating patients for labor." MD #2 stated the providers were involved in the patients care remotely. Interview revealed for non-labor complaints such as abdominal pain, the provider would give orders for labs, urine, vital signs, and fetal heart monitoring to name a few. MD #2 stated then the RN updated the provider on the result and in conjunction with the MD remotely, a disposition decision would be made.

Based on hospital policy review, medical record reviews, emergency management services run report, paramedic incident report, physician and staff interviews the hospital's Dedicated Emergency Department (DED) physician failed to ensure an appropriate transfer by failing to ensure the receiving hospital had available space; and by failing to ensure the receiving hospital had agreed to accept transfer of the individual for one (1) of 4 sampled patients that were transferred with an EMC (Emergency Medical Conditions) to other acute care hospitals, (Patient #22)

The findings included:

Review of the policy and procedure titled "EMTALA (Emergency Medical Treatment and Labor Act) Policy" last reviewed 10/2020 revealed "POLICY/PROCEDURE Any person who comes to (Hospital A) Health requesting assistance for a potential emergency medical condition or emergency services will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists ...IMPLEMENTATION ...D. Medical Screening Examinations: 1. A medical screening exam is required when an individual: a. Seeks care at the hospital Emergency Department ...b. Arrives anywhere on the hospital premises and stated that he or she may have an emergency ...E. Stabilizing Treatment For Emergency Medical Conditions: 1. If the examining qualified medical personnel determines that a person has an emergency medical condition, the following shall occur: a. Further medical examination and such treatment as may be required to stabilize the patient's medical condition within the capabilities of the Hospital through the Emergency Department ...5. Before transfer can occur, arrangements must be made with a physician at the receiving facility to accept the patient in transfer ..."

Review of the EMS (emergency management services) run report dated 08/23/2021 at 1630 revealed Patient #22's family called EMS due to AMS (Altered Mental Status). Review of the run report revealed "The patient was found seated upright (and not in a tripod position but with his chin on his chest) inside his home. The patient was unresponsive to all stimuli and in obvious (yet mild) respiratory distress (as noted by his low SpO2 (Oxygen Saturation of the blood), his RR [respiratory rate], and his respiratory effort)...the EMS crew continued to the closest hospital, despite the hospital's inability to provide emergency dialysis to this CKD [chronic kidney disease] patient. Upon arrival at Hospital A's ED (just inside the ED foyer), the crew was informed by a nurse and Dr. [MD #1] that the patient would not be admitted to the hospital due to his potential need for dialysis. The Paramedic voiced his concern for the patient's instability and need to be immediately stabilized before being transported to Hospital B. However, the physician explained that he felt that the patient was stable enough for the transport. The Paramedic voiced his concern about the IO flow problems, and the physician stated that he could place a central line but that doing so would only delay transport. The physician provided ice packs to the febrile patient and again asked them to transport the patient to Hospital B. The crew complied with his orders, and the patient was transported rapidly to Hospital B where he was then released to ED nursing staff..."

Review revealed Patient #22 presented to Hospital B DED on 08/23/2021 at 1755 with an arrival complaint of "unresponsive." Patient #22's initial vital signs at 1800 were as follows: Blood Pressure-140/90; Respiratory Rate-30; Heart Rate-120; Sp02-93% on a non-rebreather; Temperature-102.2 F; and GCS (Glasgow Coma Scale)-5. Review revealed Patient #22 was admitted on 08/23/2021. Review of the Discharge summary dated 08/28/2021 at 2254 revealed "Patient #22 is a 63 y.o. year old male with ESRD (End Stage Renal Disease) ...arrived on 8/23/21 obtunded and hypoxemic requiring intubation on arrival to the ED. Per family, patient was chronically sick at baseline and was found unresponsive. EMS arrived and found patient febrile and profoundly hypoxemic to 66%. CXR [chest x-ray] with bibasilar opacities. Covid test was positive on admission. He was intubated and admitted to the critical care team for acute hypoxemic respiratory failure secondary to presumed covid/aspiration pneumonia. He developed septic shock requiring vasopressor support and required CRRT [continuous renal replacement therapy - continuous dialysis] for his renal failure. He was treated with broad spectrum antibiotics, steroids and remdesivir (medication used to treat COVID). He was also anticoagulated for possible pulmonary embolism (blood clot in the lungs). Despite critical care management, his condition continued to deteriorate ...On 8/28/21 at 20:25, patient expired."

Review of Paramedic #1's incident report dated 08/23/2021 revealed "The patient in the above incident (CAD# 21E016204) was an elderly male who presented with S/S of acute sepsis secondary to COVID-19. He was unresponsive, hypoxic (as noted by skin color and low SpO2), tachypneic (with shallow respirations), febrile (with a rectal temperature of 102.9 degrees Fahrenheit), and tachycardic. This patient was obviously unstable...Upon arrival at (Hospital A) Health, just inside the emergency department, the EMS crew was approached by a nurse and a physician, who both stated that the patient could not be admitted due to the family's desire to not have the patient at their hospital due to his renal history. They explained that they had spoken with the family even before the ambulance had arrived at their hospital, adding that (Hospital A) Health did not have the capabilities to perform dialysis. The physician then ordered the crew to load the patient back onto the ambulance. The Paramedic explained his position to the physician, but the physician then adamantly (but politely) declined to accept the patient. He stated that he understood the Paramedic's position but stated that, although the patient was unstable, he felt that the patient would survive the trip to (Hospital B) due to his faith in the Paramedic's competency, the patient's BP being not yet hypotensive, the patient's heart rate not being grossly tachycardic in his opinion, and the patient still having a patent airway. He did voice concern about the IO infusions but stated that he would place a central line if the Paramedic felt uncomfortable with what was in place. However, the physician stated that the placement of a central line would only delay transport. The nurse then informed the physician that he was about to commit an EMTALA violation. He then informed her that he was aware of this but claimed that he would take full responsibility for his decision and address the EMTALA issue later. He then asked the EMS crew to leave (Hospital A) Health to transport the patient to (Hospital B)..."

Interview on 09/07/2021 at 1628 with MD #1 revealed field triaging was put into place recently when the hospital was "overwhelmed" and transfers becoming increasingly difficult due to limited beds in the state. MD #1 stated the theory behind field triaging was when EMS called in with a patient that the MD felt was going to need a higher level of service the hospital could not provide such as dialysis, they would divert EMS to the next closest facility that had that capability. Interview revealed on 08/23/2021 (the day Patient #22 presented to the ED) the ED was on field triage. MD #1 stated Paramedic #1 called in report when he was in bound with Patient #22 and failed to inform staff that he was a dialysis patient. MD #1 stated he told the nurse to tell them to continue with the transport to Hospital A. MD #1 stated in the meantime, Patient #22's family showed up at the hospital and was upset that Patient #22 was being transported there and the family did not want him at Hospital A because they did not have dialysis services. MD #1 stated once he learned from the family that Patient #22 was a dialysis patient, he attempted to contact EMS to have them divert to Hospital B. MD #1 stated it was too late and EMS had already arrived at Hospital A. MD #1 stated EMS made it just inside one set of double doors that connect to the EMS bay before they were stopped by a nurse and himself. MD #1 stated he evaluated Patient #22 while he was lying on the stretcher and noted him to have an intact airway, bruising on his face from a previous fall, not alert, and unable to answer questions. MD #1 stated he discussed with Paramedic #1 that Hospital A did not have Dialysis capabilities and how difficult it had been to transfer patients recently, that he felt Patient #22 was stable enough for EMS to go ahead and transport to Hospital B. MD #1 stated Patient #22's vitals were stable for the most part and he was on supplemental oxygen. MD #1 stated "I know I was incapable to get a transfer" therefore he felt it was in Patient #22's best interest to be transported to Hospital B. Interview revealed MD #1 did not follow the EMTALA policy and consult with a physician at Hospital B prior to transport and ensure Hospital B had available space and would accept Patient #22.

Interview on 09/08/2021 at 0939 with RN #1 revealed she was charge nurse the shift of Patient #22's incident. RN #1 stated EMS "encoded" (called their report in) and asked if they could transport in and proceeded to give report. RN #1 stated Paramedic #1 did not disclose Patient #22 was a dialysis patient. RN #1 stated she conferred with MD #1 and he agreed to have EMS transport Patient #22 to Hospital A. RN #1 stated Patient #22's family showed up at the hospital before EMS and was "upset" because they did not want him there because he was a dialysis patient. RN #1 stated at that point staff attempted to contact EMS to divert to Hospital B, but they had already arrived at Hospital A. RN #1 stated EMS brought Patient #22 into an area just outside the EMS bay, that had two sets of double doors entering the hospital; they were stopped in the area between the two sets of double doors. RN #1 stated MD #1 consulted with Paramedic #1 and they ended up transporting him to Hospital B. RN #1 stated she told MD #1 "this is an EMTALA violation."

Interview on 09/08/2021 at 1222 with Paramedic #1 revealed Patient #22's family did not want him transported to Hospital A due to his renal history. Paramedic #1 explained to the family his concerned that Patient #22 was unstable and needed transporting to the closest facility. Paramedic #1 stated during his encode to the hospital he did not disclose he was a dialysis patient. Paramedic #1 stated he was first met by a nurse in the area between the two set of double doors leading into the ED. Paramedic #1 stated he was then informed Patient #22 was not allowed in the hospital. Paramedic #1 stated MD #1 proceeded to tell him Patient #22's family did not want him there due to him being a dialysis patient, the hospital being incapable of providing dialysis and the ED was "swamped and had no beds." Paramedic #1 stated MD #1 was concerned he would not be able to transfer Patient #22 due to increased difficulty transferring patients recently. Paramedic expressed his concerns to MD #1 of Patient #22's instability supported by his abnormal vital signs, tachycardia, tachypnea, febrile, altered mental status and lack of vascular access. Paramedic #1 stated MD #1 was not "really concerned" about his SP02 because it was stable with supplemental oxygen. Paramedic #1 stated MD #1 told him "you know your stuff; I have confidence you'll get him there alive." Paramedic #1 stated MD #1 stated Patient #22 was not "unstable enough" to be transported.