The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

DAVIS REGIONAL MEDICAL CENTER 218 OLD MOCKSBVILLE RD PO BOX 1823 STATESVILLE, NC 28687 Feb. 6, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
The hospital's Dedicated Emergency Department (DED) qualified medical professional failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 22 sampled DED patients (#10).

~ Cross refer to 489.24(r) and 489.24(c) Medical Screening Examination - Tag A 2406.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, medical record reviews, internal investigation review, Video surveillance review, review of e-mails, Self-report action plan review, review of staff meetings, written statement review, Eloped summary reports, Diversion Hour forms, staff interviews and physician interviews the hospital's Dedicated Emergency Department (DED) qualified medical professional failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 22 sampled DED patients (#10).

The findings include:

Review on 02/06/2019 of a policy titled "EMERGENCY MEDICAL TREATMENT AND PATIENT TRANSFER" last revised 09/2013 revealed "Medical Screening Examination is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor. Such screening must be done within the Hospital's Capacity and Capability and available personnel, including on-call physicians. The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either Stabilized or Appropriately Transferred ...1. Medical Screening. When an individual comes to the Emergency Department of the Hospital, or to any location on the Hospital's campus ...and a request is made on the individual's behalf for a medical examination or treatment an appropriate Medical Screening Examination, within the Capabilities of the department ...shall be provided to determine whether an Emergency Medical Condition exists ..."

Video review on 02/05/2019 at 1510 of the ambulance entrance at Hospital A's DED revealed the video was dated on 12/17/2018, time stamped 2244 and 10 seconds, and showed a local police officer with a patient entering the ambulance entrance. Further review of the video time stamped at 2244 and 44 seconds revealed the same local police officer with the same patient (#10) exiting the ambulance entrance. Video review did not reveal what happened during that 34 seconds

DED record review, on 02/05/2019, revealed Patient #10 arrived on 12/18/2018 at 1127 with law enforcement. Review of the nursing notes revealed " ...Presenting Complaint: pt (patient) was brought in by law enforcement as BH (behavioral health) patient. Secretary states that she was very busy and just looked up and said did you know that we were on diversion. Looked back at her paperwork and the officer walked out ..." Review of the "Disposition Summary" revealed " ...Patient left the facility before triage: Not evaluated by a Provider ...Patient left due to Unknown reason ..."

Interview on 02/05/2019 at 1340 with NM #1 (Nurse Manager) revealed CNA #1 (certified nursing assistant) told her about the incident on the morning of 12/18/2018 before CNA #1 left, CNA #1 worked 7pm 12/17/2018 to 7am on 12/18/2018. Interview revealed NM #1 entered Patient #10 in the log as "John Doe." Interview revealed NM #1 was not able to back time the log and enter Patient #10 when he had actually arrived on 12/17/2018. Interview revealed NM #1 notified the CQO (Chief Quality Officer) and an investigation was started.

Review on 02/05/2019 of a hospital form titled "Diversion Hours [DATE]-January 2019" revealed Hospital A's DED was on psychiatric diversion on 12/17/2018 from 2122-0122.

Review on 02/05/2019 of the hospital's internal investigation revealed three staff statements were collected about Patient #10's arrival to the DED on 12/17/2018. Review on 02/06/2019 of CNA #1's employee statement dated 12/17/2018 revealed "We were on psychiatric diversion, a patient in room 19 came out of his room and sat on the floor in the hallway near room 20. I told him he couldn't sit there, he had to go to his room and he could put his chair in his doorway if he wanted to. He returned to this room and slammed his door. A while later he threw his bedside table, chair and glasses at the door and glass window of the room. I called (local police) to come help calm the patient. About 5 or 6 police officers showed up and while they were talking to the patient I cleared all the furniture out of his room. (Police Officer #2) and his supervisor were among the officers that came. When they got the patient calmed down all of them came near my desk and I told them we were on psychiatric diversion. They all said thank you for telling us because dispatch never notifies us. About one hour later (Police Officer #2) came back with a patient in handcuffs. I said 'you know we are on psychiatry diversion right.' He said oh and turned around and left and was gone before I had a chance to register the patient ..." Review on 02/06/2019 of Security Officer #4's employee statement dated 12/19/2018 revealed "I (Security Officer #4) was sitting beside (CNA #1) when (Police Officer #2) came in with a psych patient. (CNA #1) said to (Police Officer #2) 'we are on psych diversion!' (Police Officer #2) looked at (CNA #1) like ...Oh Okay! Then proceeded to turn around and walk out the ED with the psych patient!!! Prior to this, (CNA #1) had called and told every place that 'we are on psych Diversion!!' This took place 12/17/2018 ...night shift ..." Review on 02/06/2019 of CNA #2's employee statement no date written revealed "On Monday, December 17, 2018 at approximately 10:45pm, I was working at (Hospital B's DED). A (Police Officer #2) brought in a patient who was a possible IVC (Involuntary Commitment). During that time when the patient was being Triaged, the officer was laughing with the clerk. The officer stated that he had initially taken this patient to (Hospital A's DED), even though he knew that (Hospital A) was on diversion. He stated he took the patient there first to get a reaction from the 'girls.' After leaving (Hospital A's DED), he brought this patient to (Hospital B's DED)."

Review of the "Action Plan: EMTALA Self Report 12/20/2018" revealed 4 issues/actions were listed with a person responsible and completion date listed. Review of the first issue and action revealed " ...Issue Officer presented via ambulance entrance to ED desk. Action We are reviewing out intake procedures to identify any areas for improvement or clarification, and, if indicated, to revise provisions in the corresponding policies to line up with any changes in procedure ...Completion date 02/06/2018." Review of the second issue and action revealed "Issue Staff reminded officer (Hospital A) was on BH diversion. Action We have counseled the ED secretary about the inappropriateness of discussing diversion with anyone who presents to the hospital ...Completion date 12/20/2018." Review of the third issue and action revealed "Communication to law enforcement regarding diversion status. Action EMTALA refresher training to ED staff with a focus on the intake and registration process, particularly with regard to patient arrival when the hospital is on diversion. Education started 12/20/2018. Completion date 02/05/2018." Review of the fourth issue and action revealed "LWOT (left without treatment) process and follow-up. Action We are enhancing our tool for monitoring instances when patients leave before they are seen to focus on communication issues. All patients that LWOT will have reason documented and follow up phone call. Reasons will be trended to look for barriers to quick and efficient treatment. The Director of the ED will report aggregated results of this review for the next three months to the MEC, (Medical Executive Committee) the Quality Improvement Council, and the governing board. If any other issues come up during that three-month period, the Director of the ED will continue with 100% monitoring and reporting for an additional three months. Completion date 04/01/2019."

Review on 02/05/2019 of a Staff Meeting in the DED for staff dated 12/18/2018 revealed " ...9. DIVERSION: I want everyone in the department to know that when we are on diversion for BH patients, it is a hope that everyone takes this in to consideration and does not continue to bring patients to us. However should there be a patient brought into this ED, you will check them in as you would any other patient and never bring up the term diversion to the person or persons bringing them. Once they enter the building or step foot on the property, we need to check them in to be see. The same goes for the radio. I do not want there to be any confusion that we are not taking the patient in to this ED. There are policies and procedures in place to direct how we handle the situation when the ED is at max capacity with BH patients." Further review revealed a PowerPoint titled "EMTALA Essentials" which included a slide that stated "What does this mean for you? Patient presentation via EMS or escorted by law enforcement: NEVER tell EMS or law enforcement we are on diversion. If patient has presented on our grounds they require a MSE just like any other patient ..." Review revealed the "EMTALA Central Log Policy" was attached with a note that stated "When a patient comes onto the property and decides to leave. Document and Register as John Doe in (EMR) put as much info as you know."

Interview on 02/05/2019 at 1545 with NM #1 revealed after the 12/17/2018 event she had a staff meeting on 12/18/2018 where she discussed not to tell law enforcement about diversion if they have presented with a patient. In addition, she explained to put the patient in the system even if they left without treatment. Interview revealed all DED staff had attested they had received the training by 02/05/2019, except for 4 staff members and the 4 staff that had not, were PRN (worked as needed) or on FMLA (Family Medical Leave Act) and would not be able to work until they had completed the attestation and training.

Review on 02/05/2019 of an email dated 12/21/2018 from the Director of Medical Staff Services to DED medical staff revealed "Due to a recent event in the emergency room , leadership is requesting staff to please review as a refresher our EMTALA polices/procedures. By using the voting button, you acknowledge that you have read the following information and understand that it is your responsibility to implement and abide by these policies." Review revealed the email attached Hospital A's DED polices and a PowerPoint titled "EMTALA Essentials." Review of the PowerPoint revealed a slide that said "What does this mean for you? Patient presentation via EMS or escorted by law enforcement: NEVER tell EMS or law enforcement we are on diversion. If patient has presented on our grounds they require a MSE just like any other patient ..." Review revealed 100% of DED medical staff had attested to the education by 02/05/2018.

Review on 02/06/2019 of the "Eloped Summary" revealed a monthly summary which listed how many patients were: LWOT, LWBS, and AMA. Attached to each monthly summary was a list of the patients who LWOT, LWBS, and AMA for that month and the reason. Review revealed the months listed were October 2018 through January 2019.

Interview on 02/05/2019 at 1506 with the CQO (Chief Quality Officer) revealed after the event 12/17/2018 NM #1 and the CQO started a monthly audit of patients who LWOT. Interview revealed for each LWOT patient NM #1 and the CQO looked at the reason the patient left in the disposition and a follow up phone call was placed by NM #1 to the patient asking why they left, if they have been seen anywhere else or seen by a physician. Interview revealed this was to track if there were any trends in why patients were leaving. Interview revealed when they started looking at LWOT patients they wanted to do a look back so they started in October 2018 and will continue until April 2019. Interview revealed there had not been any trends so far. Interview revealed the CQO and administration had also looked at the facility's intake procedures and policies and no changes had been made.

Interview on 02/06/2019 at 1425 with Hospital A's CEO (Chief Executive Officer) revealed he was unsure of the date, but was contacted by Hospital B's COO (Chief Operating Officer) in December after the incident on 12/17/2018. Interview revealed Hospital B's COO explained to Hospital A's CEO what happened and their concern. Interview revealed Hospital A's CEO spoke to the DED staff and Quality Management to investigate the incident. Interview revealed from what he was told Hospital A's DED staff were in no way refusing treatment to a patient. Interview revealed Hospital A's CEO called Hospital B's COO and explained he would talk with his administrative staff and was grateful for the phone call. Interview revealed Hospital B's COO called the next day and explained they planned to report Hospital A to CMS for an EMTALA violation. Interview revealed Hospital A's CEO filed a self-report with CMS and education was done with DED staff to not discuss if the ER was on diversion, that if a patient was on the property they needed to be taken care of.

Review on 02/06/2019 at 1400 of an email sent from Hospital B's COO to Hospital A's CEO dated 12/21/2018 at 1056 revealed "(Hospital A CEO), here is the document that we provided the state. As you will read, I believe it is thoroughly consistent with our conversations (Hospital B's COO) ..." Review of the document revealed "Suspected EMTALA event report to CMS ...Narrative/specifics of concerns-(Patient #10) brought to (Hospital B's DED) at 11:02 pm 12/17/18 with IVC Custody order. Officer in attendance ...reported that he originally took patient to (Hospital A's DED) and CNA #1 at Triage verbally stated "No, We are on diversion" when (Police Officer #2) presented patient and IVC custody order. (Police Officer #2) turned around, left (Hospital A's DED) and brought patient to (Hospital B's DED) ..."

Interview on 02/06/2019 at 1405 with Police Officer #2 revealed he took Patient #10, an IVC patient to Hospital A's DED on 12/17/2018. Interview revealed he did not know that Hospital A was on psychiatric diversion. Interview revealed when he walked up to the desk with Patient #10 the staff member at the desk (CNA #1) stated that the hospital was on psychiatric diversion. Interview revealed Police Officer #2 turned around, left, and took Patient #10 to Hospital B's DED. Police Officer #2 stated the way CNA #1 stated Hospital A was on diversion made it seem like they could not take Patient #10. Interview revealed Police Officer #2 never had this happened before and had no issues since 12/17/2018.

Interview on 02/05/2019 at 1440 with the CQO revealed Security Officer #4 no longer worked at Hospital A and was not available for interview.

Interview on 02/06/2019 at 1348 with MD #3 revealed he was the DED physician on 12/17/2018 night shift when Patient #10 presented to the DED. Interview revealed no staff members told MD #3 about Patient #10. Interview revealed a "few" days later he was told that when the hospital was on diversion, CNA #1 told law enforcement they were on diversion and the officer left with the patient. Interview revealed there was EMTALA training afterward. Interview revealed it was not the hospital's intention to not treat a patient or have them walk-out.

Interview on 02/06/2019 at 0825 with CNA #1 revealed she was working as a CNA/unit secretary on 12/17/2018. Interview revealed prior to Patient #10 arriving there was a violent patient (Patient #21) and she had to call the local police to help get the patient under control. Interview revealed Police Officer #2 was one of the officers who helped get Patient #21 under control. Interview revealed after Patient #21 was under control, she told the police officers that the hospital was on psychiatric diversion. Interview revealed about 30 minutes to 1 hour later Police Officer #2 came in with Patient #10. Interview revealed CNA #1 stated to Police Officer #2 "you know were on psych diversion." Interview revealed Police Officer #2 turned around and left. Interview revealed Police Officer #2 did not give CNA #1 a chance to register Patient #10. Interview revealed CNA #1 did not mean that she was refusing to take Patient #10 when she told Police Officer #2 the hospital was on psychiatric diversion. Interview revealed CNA #1 told NM #1 about the incident the next morning. Interview revealed there were staff meetings afterward about EMTALA education. Interview revealed this had never happened before. Interview revealed if it did happen again CNA #1 would register the patient accept the patient and then tell law enforcement that the hospital was on psychiatric diversion.

Interview on 02/06/2019 at 0815 with CNA #2 revealed she worked at both Hospital A and Hospital B's DED. Interview revealed she was working at Hospital B's DED on the night of 12/17/2018. Interview revealed Police Officer #2 arrived to Hospital B's DED with Patient #10 and stated it was an IVC. Interview revealed she got vital signs on Patient #10. Interview revealed she heard Police Officer #2 laughing with the clerk at Hospital B's DED about Hospital A being on diversion and how Police Officer #2 brought Patient #10 to Hospital A to give them a hard time. Interview revealed on 12/18/2018 she worked at Hospital A's DED and told NM #1 about what she heard at Hospital B. Interview revealed she had training at Hospital A about EMTALA and a staff meeting that talked about what to do when on diversion. Interview revealed CNA #2 had not had a situation like that before.

NC 662