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Based on review of ambulance reports, the facility's central log, medical records, Medical Staff Rules and Regulations, policies and procedures and interviews, it was determined the facility failed to ensure that two of 20 sampled patients (P#1 and P#12) received appropriate medical screening examinations when P#1 was transported to the Emergency Department (ED) on 9/15/21 via emergency medical services (EMS) for abdominal pain and when P#12 was escorted to the ED on 7/27/21 by law enforcement for a mental health evaluation.

Findings were:

Cross refer C-2406, as it relates to the facility's failure to provide P#1 and P#12 with an appropriate medical screening examination.

Based on a review of the facility's Emergency Department (ED) Log, ED Census Monthly Report, ambulance report, policies, and procedures, staff training records, and interviews with staff, it was determined that the facility failed to enter one of 20 patients sampled (P#1) into the facility's (ED) central log when P#1 arrived via EMS on 9/15/21 for complaints of abdominal pain.

Findings included:

A review of the facility's ED Log for September 2021 failed to reveal an entry for P#1.

A review of the facility's ED Census Monthly Report for April 2021 through September 2021 failed to reveal an entry for P#1.

A review of the Emergency Medical Service (EMS) #1 ambulance report dated 9/15/21 revealed that EMS #1 was dispatched to P#1's residence through a 911 call. EMS #1 arrived at Facility #1 at 9:19 p.m. The ambulance report documented that Registered Nurse (RN) DD was outside the ED when EMS #1 arrived. RN DD stated that EMS #2 was enroute to transport P#1 to Facility #2. EMS #1 staff asked RN DD to sign P#1's transfer paperwork and RN DD refused and stated that she would not register P#1. EMS #1 asked EMS #2 to sign P#1's transfer paperwork. P#1 was transferred from the EMS #1 stretcher to the EMS #2 stretcher and EMS #2 took over P#1 care.

A review of the facility's policy and procedure number ED-P012 titled 'Sign-in Registration Procedure and Chart Flow', last reviewed 11/2/20 revealed that all patients were processed in the same manner according to the acuity of their illness/injury. Charts were generated on all patients that presented to the ED requesting treatment for their illness and/or injury.

1. The patient presented and signs in the admissions desk.
2. The information on the sign in sheet included: sign in time, name, age, social security number, and complaint.
3. The sign in sheet was brought to the ED by admissions and placed in the box on the wall.
4. The nurse called the patient back to the treatment area for triage and treatment, as room allows. If all treatment rooms were occupied the patient could be triaged and then asked to sit in the waiting area until a room became available.
5. The registration officer completed the consent to treat and had the patient sign.

A review of the facility's policy number, ED-P017, "Transfer of Patient to Another Facility," effective 11/1/17, revealed that the hospital, whether transferring or receiving patients, had to document the following:

a. A central log

During a telephone interview with Paramedic CC on 10/05/21 at 10:35 a.m., Paramedic CC stated that RN DD refused to allow P#1 to enter the ED when they presented with P#1 on 9/15/21. Paramedic CC stated that EMS#2 arrived, and P#1 was moved from EMS#1's ambulance into EMS#2's ambulance via stretcher while in the parking lot. Per Paramedic CC, P#1 was never assessed or treated by any staff at Facility#1. P#1 was transported to Facility#2 by EMS#2.

During an interview with RN DD on 10/6/21 at 9:00 a.m. in the conference room, RN DD stated that patients were signed into the ED log after they enter the building. RN DD stated that she did not assess P#1 while she (P#1) was on the hospital property.

During an interview with Administrator AA on 10/6/21 at 12:47 p.m. in the conference room, Administrator AA acknowledged that P#1 had not been entered into the patient ED log per EMTALA regulations.

A review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) training revealed that all patients that present to facility property would be logged into the facility registration system and include patient name, complaint, disposition, and name of the treating MD.

A medical record was obtained for P#1 at Facility #2. P#1's medical record documented that P#1 was admitted to Facility #2 on 9/15/21 at 6:28 p.m. via ambulance for shortness of breath .

Based on a review of the emergency medical service (EMS) reports, policies and procedures, Medical Staff Rules and Regulations, staff training records, and interviews, it was determined that the facility failed to provide two of 20 (P#1 and P#12) sampled patients with an appropriate medical screening exam within the capability and capacity of the hospital's emergency department. Specifically, P#1 was transported by EMS to the facility's Emergency Department (ED) on 9/15/21 with a chief complaint of abdominal pain. Upon arrival, the facility staff insisted that the patient be transferred to another facility for treatment without receiving an appropriate medical screening exam. P#12 presented to the facility ED on 7/27/21 with local law enforcement for a mental health evaluation. Law enforcement informed the facility of the intent to transport the patient to another facility. The facility failed to ensure that P#12 received an appropriate medical screening exam prior to P#12 leaving the facility ED.

Findings included:

A review of the Emergency Medical Service (EMS) #1 ambulance report dated 9/15/21 revealed that EMS #1 was dispatched to P#1's residence through a 911 call. EMS #1 arrived at Facility #1 at 9:19 p.m. The ambulance report documented that Registered Nurse (RN) DD was outside the ED when EMS #1 arrived. RN DD stated that EMS #2 was enroute to transport P#1 to Facility #2. EMS #1 staff asked RN DD to sign P#1's transfer paperwork and RN DD refused and stated that she would not register P#1. EMS #1 asked EMS #2 to sign P#1's transfer paperwork. P#1 was transferred from the EMS #1 stretcher to the EMS #2 stretcher and EMS #2 took over P#1 care.

A review of the facility's policy number, ED-009, "Medical Screening Exam," effective 11/1/17, revealed that all patients that presented to the Emergency Department (ED) would be triaged and receive a medical screening exam (MSE) by the ED Physician, Physician Assistant (PA), or Nurse Practitioner (NP) that was on duty. Upon presenting to the ED, the patient would be triaged by an ED nurse on duty and assigned a triage category according to the triage criteria. Patients who elected not to be treated at the facility would be provided information concerning alternate community resources for the appropriate level of care.

A review of the facility's policy number, ED-P017, "Transfer of Patient to Another Facility," effective 11/1/17, noted that any individual who presents to the ED seeking an examination or medical treatment would be provided an Medical Screening Exam (MSE) by qualified medical personnel to determine if an emergency medical condition (EMC) exist. If it were determined that an individual had an EMC, the hospital would provide the individual with further medical examination and treatment to stabilize the medical condition within the hospital's capability or arrange transfer of the individual to another medical facility. Any patient transferred to another health care facility would be stabilized prior to transport, and written consent would be received prior to the transfer.

A review of the facility's Medical Staff Rules and Regulations, no date, revealed:

B. Emergency Services
1. Responsibility
(a) Appointees of the staff accept responsibility for emergency service care in accordance with emergency service policies and procedures.
(b) The Chief of Emergency Services or the emergency service committee had overall responsibility for emergency care.
8. An appropriate emergency service medical record was kept for every patient receiving emergency service. The record included:
(I) adequate patient identification
(ii) information on the time of arrival and by whom the patient was transported
(iii) pertinent history including details on first aid or emergency care given prior to arrival

12. Patients with conditions whose definitive care was beyond the capabilities of the hospital were referred to the appropriate facility, when in the judgement of the attending practitioner the patient's condition permitted such a transfer. The procedures for patient transfer to other facilities were followed.

14. Qualified Medical Persons or Personnel (QMP): in addition to a physician, QMP may perform medical screening examinations. Individuals in the following professional categories who have demonstrated competencies in the performance of medical screening examinations and who were functioning within the scope of his/her license and policies of the facility, had been approved by the MEC and Governing Board as QMP: Physician Assistants and Advanced Registered Nurse Practitioners.

A review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) training revealed that individuals presenting to the facility's property (main campus and facility-owned buildings within 250 yards of the facility) would receive emergency care. A further review revealed that facility property included driveways, parking lots, and ambulances owned and operated by the facility. A Medical Screening Exam (MSE) would be provided without delay by an Medical Doctor (MD). Any refusals for examination or treatment would require the patient to be informed of the risks and benefits of transfer. An informed refusal form would be completed and placed in the patient's medical record, along with documented facts and circumstances of refusal to sign.

An interview with the Director of Emergency Medical Services (Director) #1 BB took place via telephone on 10/5/21 at 9:45 a.m. Director BB explained that when Emergency Medical Services (EMS) #1 arrived at Facility #1 with P#1, RN DD came out to the ambulance bay and 'wagged her finger' at EMS #1 staff and told them not to bring that patient in the ED. Director BB stated that Facility #1's staff refused to sign EMS #1's paperwork. Facility #1's staff did not assess P#1. Facility #1 called EMS #2 and had them transport P#1 to Facility #2.

During an interview with Paramedic II on 10/5/21 at 10:02 a.m., in the conference room, Paramedic II recalled that RN DD called Emergency Medical Services (EMS) #2 office on 9/15/21 and requested transport for P#1 to Facility #2. RN DD explained to Paramedic II that EMS #1 was en route to Facility #1. Paramedic II recalled that EMS #1 was backed up to Facility #1's ED doors with the ambulance's back doors open. Paramedic CC told Paramedic II that Facility #1 would not allow them to offload P#1. Paramedic II recalled that neither P#1 nor her family refused treatment from Facility#1. RN DD never requested that P#1 receive an Medical Screening Exam from Facility #1.

During a telephone interview with Paramedic CC on 10/05/21 at 10:35 a.m. in the conference room, Paramedic CC remembered the event with P#1. When Emergency Medical Services (EMS) #1 arrived at Facility #1, RN DD came out and told her not to unload P#1. RN DD stated that EMS #2 would take P#1 to Facility #2 for treatment. Paramedic CC told RN DD that P#1 was stable, but RN DD refused to allow P#1 to enter the ED. Paramedic CC stated that EMS #2 arrived, and P#1 was moved from EMS #1's ambulance into EMS #2's ambulance via stretcher while in the parking lot. Per Paramedic CC, P#1 was never assessed or treated by any staff at Facility#1. P#1 was transported to Facility #2 by EMS #2.

During an interview with the Physician Assistant (PA) EE on 10/5/21 at 3:10 p.m. in the conference room, she stated that she recalled P#1. PA EE said that RN DD went outside to speak with EMS #1. PA EE stated that she never told Emergency Medical Services (EMS) #1 that they were not permitted to bring P#1 to the ED, and RN DD had not been instructed to tell EMS #1 not to unload P#1. PA EE stated that her understanding of EMTALA is that if a patient presented to the ED, they required an MSE. PA EE acknowledged that P#1 should have had an MSE as they were on the facility's property and had not refused treatment.

During an interview with Registered Nurse (RN) DD on 10/6/21 at 9:00 a.m. in the conference room, she recalled speaking with Emergency Medical Services (EMS) #1 staff when they arrived at Facility #1 with P#1 on 9/15/21. EMS #1 informed her that they (EMS #1) could not transport patients to Facility #2. RN DD notified EMS #2 that P#1 needed to be transported to Facility #2. RN DD stated that she did not assess P#1 while EMS #1 was onsite. PA EE was aware that P#1 was onsite. RN DD said that Facility #1 was not an appropriate facility because P#1's family requested to see a cardiologist.

During a follow-up interview with Administrator AA on 10/6/21 at 12:47 p.m. in the conference room, Administrator AA explained that her understanding of EMTALA is that if a patient presents within 250 yards of the facility, including sidewalks, and parking lots, the patient should receive an MSE. She added that all ED patients required stabilization before transfer to another facility. Administrator AA acknowledged that P#1 and P#12 should have received an MSE.

A review of Patient (P) #12's medical record revealed that P#12 presented to the facility's Emergency Department (ED) on 7/27/21 at 10:38 p.m. P#12 was brought in by local law enforcement. A further review revealed that at 10:48 p.m., the officer verbalized to RN GG that because all ED rooms were full and, additional patients were waiting for treatment, he decided to take P#12 directly to jail. Per RN GG's nurse's note, the officer planned to notify Mobile Crisis and have P#12 evaluated by them. P#12 was escorted from the facility's ED lobby by the officer. P#12 left without receiving a Medical Screening Exam (MSE) or treatment.

During an interview with Physician Assistant (PA) EE on 10/5/21 at 3:30 p.m. in the conference room, PA EE stated that she vaguely remembered hearing about P#12 after he had left the ED. She worked on 7/27/21, and she heard that local law enforcement planned to take P#12 to a local mental health facility for evaluation. PA EE stated that she would not always hear about patients that had presented to the ED and left with law enforcement. PA EE acknowledged that P#12 should have had an MSE before leaving the ED.

During an interview with Administrator AA on 10/6/21 at 1:02 p.m., in the facility conference room, Administrator AA revealed that all employees received annual EMTALA training. She added that all Emergency Department registration staff received EMTALA training. Administrator AA acknowledged that P#12 did not receive an Medical Screening Examination or stabilizing treatment.

During a telephone interview on 10/6/21 at 6:37 p.m., RN GG recalled that P#12 was brought to the Emergency Department (ED) by the Sheriff. RN GG explained that the Sheriff walked through the ED to see if there were any beds available. When the Sheriff realized the ED was at capacity, he told RN GG that he was taking P#12 to another facility. RN GG stated that she never told the Sheriff that P#12 required an Medical Screening Exam (MSE) before taking P#12 to another facility. RN GG said she never saw P#12 or took any of P#12's vital signs. RN GG stated that her understanding of EMTALA was that all patient information as confidential. P#12 left the facility without an MSE.