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Based on surveillance video review, Policy and Procedure review, Physician On-call Schedule review, EMS(Emergency Medical Services) Patient care Report, and interview, it was determined the facility failed to ensure that an individual who comes to the hospital's emergency department receive an appropriate medical screening examination within the capability of the hospital's emergency department which includes ancillary services routinely available to the emergency department, when a request was made on the behalf of an individual for examination or treatment for 1 (#1) of 20 sampled who presented to the hospital's property via ambulance and intubated. The request was made on Patient #1's behalf by the EMS personnel to take the patient to the closet hospital emergency department (Hospital C) because Hospital A did not have a Gastrointestinal physician specialist on call to provide further evaluation and treatment for an identified EMC.
Refer to findings in Tag A-2406.

Based on review of medical record, video surveillance review, policy and procedure review, physician on -call schedule review, and staff interview, it was determined the facility failed to ensure the provision of emergency services within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize an identified EMC for 1 of 20 sampled patients. Patient #1, presented to the ED intubated and in unstable condition.
Refer to findings in Tag A-2407.

Based on video surveillance review, Emergency Department (ED) central logs review, radio communication log review, policy review, and staff interview, it was determined the facility failed to ensure the ED central log included all individuals who presented to the emergency department seeking treatment. This failure affected 1 of 20 sampled patients, Patient #1.

The findings included:

Review of the facility policy, titled, Emergency Treatment and Labor Act, reviewed 02/2024, documented, in part,
"Central Log:
The Hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE.

Review of the surveillance video conducted on 02/29/24 at approximately 11:00 AM, while accompanied by the Director of Patient Safety, revealed that on 12/29/23 at 3:31 AM, two paramedics entered the Emergency Department (ED) through the ambulance entrance. Patient #1 was on a stretcher and was intubated. They proceeded to the nurses' station in the ED, and one of the paramedics with paperwork on hand, placed the paperwork on the counter and interacted with one of the nurses, who was on the phone. There were two other nurses at the nurses' station and a physician was standing outside the station during the interaction. The paramedics then left the facility with Patient #1 at 3:32 AM.

Review of the facility's radio communication log, dated 12/29/23, documented the medical transportation company called Hospital C to report the incoming patient (Patient #1). Patient #1 was with a gastrointestinal (GI) bleed.

Review of the ED central logs also failed to provide evidence that patient #1 was registered into the system on 12/29/23 when he arrived via medical transportation company seeking medical care.

Interview with the Director of Patient Safety conducted on 02/29/24 at approximately 11:00 AM confirmed Patient #1 was not listed on the ED central log.


An interview was conducted with the ED Physician on 03/01/24 at 10:00 AM revealed he recalls the interaction with Facility A. He stated that he did not know why the patient was brought into the ED and was not registered.

Based on surveillance video review, Policy and Procedure review, Physician On-call Schedule review, EMS(Emergency Medical Services) Patient care Report, and interview, it was determined the facility failed to ensure that an individual who comes to the hospital's emergency department receive an appropriate medical screening examination within the capability of the hospital's emergency department which includes ancillary services routinely available to the emergency department, when a request was made on the behalf of an individual for examination or treatment for 1 (#1) of 20 sampled who presented to the hospital's property via ambulance and intubated. The request was made on Patient #1's behalf by the EMS personnel to take the patient to the closet hospital emergency department (Hospital C) because Hospital A did not have a Gastrointestinal physician specialist on call to provide further evaluation and treatment for an identified EMC.


The findings included:

Review of the facility policy, titled, Emergency Treatment and Labor Act, reviewed 02/2024, revealed in part, "B. Medical Screening Examination
1. The Hospital shall provide a medical screening examination to any individual who comes to the Emergency Department ... 2. The medical screening examination is the examination of the patient by the Qualified Medical Person required to determine within reasonable clinical confidence whether an emergency medical condition does or does not exist. The examination should be tailored to the patient's complaint, and depending on the presenting symptoms, the medical screening examination may represent a spectrum ranging from a simple process involving only a brief history and physical examination, to a complex process that also involves performing ancillary studies and procedures.
3. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred.
The medical screening examination, and ongoing patient assessment, must be documented in the medical record."

Review of the facility video surveillance conducted on 02/29/24 at approximately 11:00 AM revealed Patient #1 was brought into the Emergency Department (ED) on a stretcher by two paramedics on 12/29/23 at 3:31 AM. The two (2) paramedics with a stretcher and patient came in through the ambulance entrance. Patient #1 was on a stretcher and was intubated. They proceeded to the nurses' station. One of the paramedics, with paperwork in hand, placed the paperwork on the counter and interacted with one of the nurses at the nurses' station, who was on the phone. There were two other nurses at the station and a physician standing outside the nurses' station during the interaction. The paramedics then left the facility with Patient #1 at 3:32 AM.


Review of the Medical Transportation notes dated 12/29/23 documented as follows:
"Upon arrival to Facility A, spoke to Registered Nurse, patient was admitted for diagnosis of Gastrointestinal Bleed. Patient is to be transported to Facility B.
Patient received three liters of normal saline and one unit of blood.
At approximately 1:30 AM, patient was found responding to painful stimuli, hypotensive (Low Blood Pressure), blood pressure 72/27(normal BP 120/80). Patient is breathing approximately 10 (normal is 14-20)beats per minute.
Notified nurse and staff that patient is unstable for transport and needs to be intubated(insertion of a tube into the trachea for ventilation) and ventilated (use of a machine to support or replace the breathing of a person that is critically ill). Due to patent's condition, patient will be transported to [Facility C], which is closer.
Awaited patient to be intubated and placed on Dopamine (in critical care medication that manages low blood pressure) drip. Patient has an nasogastric tube filled with blood. Patient has normal sinus rhythm and pulse is weak. Loaded patient into unit [ambulance] and transported to [Hospital C] with no incident. Alerted hospital of estimated time of arrival.
Brought patient into ED and Registered Nurse states patient is not accepted at this time and GI services are not available. Loaded patient into unit [ambulance] and transported to [Hospital] B without incident. Patient is unstable and cardiac alert... [At Hospital B].....Patient placed on hospital ventilator and notified nurse that Hospital C did not accept the patient."

Patient #1 left Hospital C at 3:32 AM and arrived at Hospital B at 4:00 AM.


Review of the On-Call schedule revealed the facility had coverage for all services delineated on the hospital license. Further review revealed that on 12/29/23, Hospital C had GI and cardiology on-call coverage


Further record review of Patient #1 for Hospital B indicated that on 12/29/23 at 4:07 AM, Patient #1 had pulseless electrical activity requiring resuscitation efforts. Patient #1 was admitted to the Intensive Care Unit of Hospital B.





Interview was conducted with the Transportation Company's Paramedic on 02/20/24 at 1:47 PM (Interview obtained during previous review at Hospital A) revealed when he arrived at Hospital A, he decided the patient was unstable and should go to Hospital C, as they were closer. He transferred the patient to the stretcher, was told Hospital C was 'on hold' (patient had not been accepted) but he proceeded to take the patient to Hospital C. Enroute, he called Hospital C to advise them of the patient, and they responded, 'ok, we'll see you when you get here'. When he arrived, the nurse and doctor told him they did not have GI on-call. He stated he was at Hospital C less than five minutes and was told to take the patient to Hospital B and he did so.


Interview with Staff A, Registered Nurse, conducted on 03/01/24 at 8:28 AM, revealed his recollection of the event on 12/29/23. The nurse stated he was working triage, a request to accept a transfer from Facility A was called and they did not have intensive care beds available. The ED physician decided not to accept the patient. In the early morning, he happened to go to the nurses' station and saw the medical transport company with two attendants coming in with a patient. The charge nurse asked them why are you here and said, 'We did not accept the patient and did not get a report on the patient'. The paramedic stated it was his discretion, based on the patient's condition and this facility (Hospital C) was closer, but he never said it was a medical emergency.


Interview with the ED Physician conducted on 03/01/24 at 10:00 AM revealed he recalls the interaction with Facility A. They were trying to transfer Patient #1, who had a Gastrointestinal (GI) Bleed, and the patient needed an intensive level of care. The physician stated, as he recalls, there were no intensive care beds available and no GI doctor on-call. The physician told Facility A they could not take the transfer. He stated then the EMS (paramedic) brought in a patient, not sure for what, and they were speaking to the nurse, he assumed that they had made a mistake by bringing the patient here, and they were directed to go to Facility B. The physician stated he was not aware that the patient they were trying to transfer from Facility A was Patient #1. He had learned that after the patient left the ED. The physician was asked if Patient #1 received appropriate care and he stated if the patient was unstable or had a change in condition, and needed to be seen then they would have proceeded like with any other patient. He stated he was not aware of why the patient was brought in and the patient therefore was not seen.

There was no documented evidence that a medical screening examination (MSE) was provided in the ED for Patient #1. The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to provide an MSE tailored to the patient's presenting patient's complaint and depending on the presenting signs and symptoms for patient #1 on 12/29/2023, who had an identified emergency medical condition.

Based on review of medical record, video surveillance review, policy and procedure review, physician on -call schedule review, and staff interview, it was determined the facility failed to ensure the provision of emergency services within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize an identified EMC for 1 of 20 sampled patients. Patient #1, presented to the ED intubated and in unstable condition.

The findings included:

Review of the facility policy, titled, Emergency Treatment and Labor Act, reviewed 02/2024, for any patient who present to the ED, documented, in part:
"If an individual "comes to the Emergency Department" as defined above:
B. The Hospital will either:
1. Provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition, or
2. Arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below, while providing stabilizing treatment according to the hospital's capability."

Review of the facility video surveillance conducted on 02/29/24 at approximately 11:00 AM, while accompanied by the Director of Patient Safety, revealed Patient #1 was brought into the Emergency Department (ED) on a stretcher by two paramedics on 12/29/23 at 3:31 AM. The two (2) paramedics with a stretcher and patient came in through the ambulance entrance. Patient #1 was on a stretcher and was intubated. They proceeded to the nurses' station. One of the paramedics, with paperwork in hand, placed the paperwork on the counter and interacted with one of the nurses at the nurses' station, who was on the phone. There were two other nurses at the station and a physician standing outside the nurses' station during the interaction. The paramedics then left the facility with Patient #1 at 3:32 AM. Video surveillance review verified Patient #1 did not receive stabilizing treatment as required or further assessment to monitor changes in condition. The patient was in the ED for approximately one (1) minute.


Review of the On-Call schedule revealed the facility had coverage for all services delineated on the hospital license. Further review revealed that on 12/29/23, Hospital C had GI and cardiology on-call coverage. There was no evidence or documentation that a GI on-call specialist was notified of Patient #1 who presented from Hospital A with a GI Bleed requiring Intensive Care services.


Interview with Staff A, Registered Nurse, conducted on 03/01/24 at 8:28 AM, revealed his recollection of the event on 12/29/23. The nurse was asked if anyone asked the paramedics to explain why they brought the patient in, was there a change in condition, or was the patient stable, and he replied, 'no'.

Interview with the ED Physician, conducted on 03/01/24 at 10:00 AM, revealed he was not aware if the patient was unstable, had a change in condition. He said, if so, they would have proceeded like with any other patient, but he was not aware of why the patient was here.

Interview with Staff B, Registered Nurse, conducted on 03/01/24 at 11:00 AM, revealed her recollection of Patient #1. Facility A had contacted the facility earlier for the patient to be transferred to them, he had a GI bleed and needed ICU (Intensive Care Unit) placement. Staff B stated there was no capacity, so the patient was not accepted. The nurse recalls the paramedics speaking to the charge nurse and they were told the patient was to go to Facility B. The nurse stated no one had evaluated the patient, but he was sedated and intubated. The nurse confirmed that no one asked the paramedic if the patient had a change in condition or the reason why he chose a convenient closer location.

There was no documented evidence that the patient was provided further evaluation or treatment, and stabilization as required. There was no documented evidence that a GI on-call specialist was called for Patient #1 to provide further evaluation and treatment for his identified emergency medical condition. The facility failed to ensure that stabilizing treatment was provided as required for patient #1 on 12/29/2023 when he presented to the hospital's emergency department.