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Based on interview and record review, Facility A failed to implement and maintain it's Emergency Medical Treatment and Active Labor Act (EMTALA), policy and procedures (P&Ps), by not ensuring the following:

1. One of 32 sampled patients (Patient 16), presented to Facility A by ambulance, seeking emergency medical care after sustaining a sexual assault who was not logged or registered to the centralized log of the Emergency Department (ED). (Refer to Tag A- 2405)

2. One of 32 sampled patients (Patient 16), present to the ED, by ambulance, with an emergency medical condition and were not provided a timely triage or Medical Screening Exam (MSE). (Refer to Tag A-2406)

3. One of 32 sampled patients (Patient 16), presented to the ED by ambulance with an emergency medical condition, was not stabilized or transferred appropriately to Facility B. (Refer to Tag A-2409)

These failures resulted in one of 32 sampled patients being transferred from Facility A to Facility B without being logged into the ED, or provided MSE and stabilizing treatment for an emergency medical condition, which delayed treatment and potentially jeopardized Patient 16's health.

Based on interview and record review, Facility A failed to maintain a centralized log ( a log that records every individual who presents to hospital for an emergency) for the Emergency Department (ED) per it's Emergency Medical Treatment and Active Labor Act (EMTALA) policy and procedure (P&P) for one of 32 sampled patients (Patient 16) when, Patient 16 presented to Facility A, by ambulance, seeking emergency medical care and evaluation after sustaining a sexual assault, and was told to go to Facility B without logging in the Facility A's ED central log.

This failure resulted in Facility A not fulfilling their EMTALA obligation as required by Medicare and an incomplete centralized log which did not record Facility A's actions and refusal to evaluate Patient 16.

Findings:

An unannounced visit was conducted on April 30, 2025, through May 1, 2025, to investigate a possible EMTALA violation.

There was no documented evidence to indicate Patient 16 was registered on Facility A's Emergency Department (ED) log, nor was there documentation indicating Patient 16 received a medical screening examination to rule out if an emergency medical condition existed or that the patient was medically stabilized.

During a concurrent interview and Facility A's surveillance video review, on April 30, 2025, at 2: 58 PM, with the Security Manager (SM) and the Director of the Emergency Department (DED), surveillance video of ambulance bay (parking for emergency vehicles delivering patients to the ED) dated April 22, 2025, from 1:50 AM - 1:54 AM, was reviewed. The surveillance video indicated the following:

At 1:51 AM, an ambulance arrived at the ED and backed into the ambulance bay.

At 1:52 AM, Registered Nurse 1 (RN 1) is seen walking from the ED entrance to the ambulance to speak with the ambulance crew.

At 1:53 AM, RN1 returned to the ED entrance and the ambulance drove away.

SM and the DED both stated and confirmed, an ambulance arrived at Facility A's property and left after speaking with RN 1 and no patient was transported from the ambulance into the ED prior to the ambulance leaving the property.

During a telephone interview, on April 30, 2025, at 3:07 PM, with RN 1, RN 1 stated, she received a call from Facility C's base station and was notified an ambulance was to arrive with a victim of an alleged sexual abuse. RN 1 stated, after she received the information from Facility C, she spoke with the Nursing Supervisor (NS) and was advised to contact Facility C and have the ambulance rerouted to Facility B because they were SART (Sexual Assault Response Team - a team of health care professionals specialized to treat patients who have suffered sexual abuse and can collect evidence of the crime) certified. RN 1 stated, she contacted Facility C and requested the ambulance to be rerouted. RN 1 stated, the ambulance arrived at Facility A's ambulance bay and she went to the ambulance and told them they had been rerouted to Facility B and watched them leave. RN 1 further stated the ambulance was on Facility A's property and that Facility A should have accepted the patient and provided medical clearance. RN 1 stated the patient was not logged to the ED's centralized log.

During a concurrent interview and record review of Patient 16's [Name of Ambulance Services] "Electronic Patient Care Record" ("ePCR"- a record of care provided to a patient by the ambulance personnel during transport to the hospital), on April 30, 2025, at 3:42 PM, with the Paramedic (EMT-P), the "ePCR" dated April 22, 2025 indicated, Facility C's base station was contacted on April 22, 2025 at 1:24 AM for destination orders. The "ePCR" indicated, "[Facility C] Base Hospital was contacted for destination orders and advised that the pt [patient] would need a SART certified hospital. [Facility C] advised that the pt should go to a local facility first and be medically cleared ...While in route ... [the ambulance] was originally transporting to [Facility A] and ...when on [Facility A] property a nurse from the facilities ED advised to direct to [Facility B] for reasons unknown to the [ambulance] crew ...". EMT-P stated, upon arrival to Facility A, a nurse met the ambulance in the ambulance bay and told them that they had been rerouted to Facility B and they should have been contacted by Facility C and to continue on with the patient to Facility B. EMT-P stated, he did receive a notification from his dispatch for updated destination to Facility B, but that he did not receive that update from dispatch until after the ambulance had already arrived to Facility A.

During a concurrent interview and record review, on May 1, 2025, at 11:22 AM, with the DED, the facility's policy and procedure (P&P) titled, "EMTALA - Central Log Policy" dated June 2023, was reviewed. The P&P indicated, " ...The hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination (MSE) could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged ...". The DED stated, once a patient is on the hospital property, they cannot be rerouted to another facility. The DED stated, Patient 16 arrived at the hospital property by ambulance and should have been logged to the emergency department, medically screened by the doctor and then transferred appropriately for SART services.

Based on interview and record review, the facility failed to ensure it's policy and procedures (P&P's) pertaining to the Emergency Medical Treatment and Labor Act (EMTALA) were implemented to provide an appropriate medical screening examination (MSE - a medical examination by a qualified provider to determine if an emergency medical condition (EMC) exists) within the capability of the hospital's Emergency Department (ED) for one of 32 sampled patients (Patient 16) when, Patient 16 was transported to Facility A's Emergency Department (ED) by an ambulance for an EMC, and was not provided a triage (the process of sorting patients into groups based on their need for care), or provided an MSE prior to Patient 16 redirected to Facility B.

This failure resulted in Patients 16 not being provided an appropriate triage to address the severity or MSE to address an existing emergency medical condition and had the potential to severely impact the health and welfare of Patient 16 and other patients entered into Facility A.

Findings:

An unannounced visit was conducted on April 30, 2025, through May 1, 2025, to investigate a possible EMTALA violation.

There was no documented evidence to indicate Patient 16 was registered on Facility A's Emergency Department (ED) log, nor was there documentation indicating Patient 16 received a medical screening examination to rule out if an emergency medical condition existed or that the patient was medically stabilized.

During a concurrent interview and Facility A's surveillance video review, on April 30, 2025, at 2: 58 PM, with the Security Manager (SM) and the Director of the Emergency Department (DED), surveillance video of ambulance bay (parking for emergency vehicles delivering patients to the ED) dated April 22, 2025, from 1:50 AM - 1:54 AM, was reviewed. The surveillance video indicated the following:

At 1:51 AM, an ambulance arrived at the ED and backed into the ambulance bay.

At 1:52 AM, Registered Nurse 1 (RN 1) is seen walking from the ED entrance to the ambulance to speak with the ambulance crew.

At 1:53 AM, RN1 returned to the ED entrance and the ambulance drove away.

SM and the DED both stated and confirmed, an ambulance arrived at Facility A's property and left after speaking with RN 1 and no patient was transported from the ambulance into the ED prior to the ambulance leaving the property.

During a telephone interview, on April 30, 2025, at 3:07 PM, with RN 1, RN 1 stated, she received a call from Facility C's base station and was notified an ambulance was to arrive with a victim of an alleged sexual abuse. RN 1 stated, after she received the information from Facility C, she spoke with the Nursing Supervisor (NS) and was advised to contact Facility C and have the ambulance rerouted to Facility B because they were SART (Sexual Assault Response Team - a team of health care professionals specialized to treat patients who have suffered sexual abuse and can collect evidence of the crime) certified. RN 1 stated, she contacted Facility C and requested the ambulance to be rerouted. RN 1 stated, despite her attempt to reroute the ambulance prior to arrival at Facility A's property, the ambulance arrived at Facility A's ambulance bay. RN 1 stated, she spoke with the ambulance crew and notified them they had been rerouted and to continue on to Facility B and watched them leave. RN 1 further stated the ambulance was on Facility A's property and that Facility A should have accepted the patient and provided medical clearance.

During a concurrent interview and record review of Patient 16's [Name of Ambulance Services] "Electronic Patient Care Record" ("ePCR"- a record of care provided to a patient by the ambulance personnel during transport to the hospital), on April 30, 2025, at 3:42 PM, with the Paramedic (EMT-P), the "ePCR" dated April 22, 2025 indicated, Facility C's base station was contacted on April 22, 2025 at 1:24 AM for destination orders. The "ePCR" indicated, "[Name of Facility C] Base Hospital was contacted for destination orders and advised that the [patient] would need a SART certified hospital. Facility C advised that the pt [patient] should go to a local facility first and be medically cleared ...While in route ... [the ambulance] was originally transporting to [ Name of Facility A] and ...when on Facility A's property a nurse from the facilities ED advised to direct to [Name of Facility B] for reasons unknown to the [ambulance] crew ...". EMT-P stated, upon arrival to Facility A, a nurse met the ambulance in the ambulance bay and told them that they had been rerouted to Facility B and they should have been contacted by Facility C and to continue on with the patient to Facility B. EMT-P stated, he did receive a notification from his dispatch for updated destination to Facility B, but that he did not receive that update from dispatch until after the ambulance had already arrived to Facility A.

During a concurrent interview and record review, on May 1, 2025, at 11:30 AM, with the DED, the facility's policy and procedure (P&P) titled, "EMTALA - Definitions & General Requirements" dated June 2023, was reviewed. The P&P indicated, " ...Policy: The hospital with an emergency department must provide to any individual ...who "comes to the emergency department" an appropriate Medical Screening Exam (MSE) within the capability of the hospital's emergency department ...to determine whether or not an emergency medical condition (EMC) exists ...The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department, when a an individual's requests emergency medical care on hospital property, other than in a DED, or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made ...". The DED stated, once an individual is on our property, or within 250 feet of our property and either request or need to be evaluated by a medical provider, the ED cannot refuse that person. The DED stated, it does not matter if the individual walks onto the hospital property or arrives via ambulance, once that person is on hospital property, they need to be logged and an MSE needs to be provided.

Based on interview and record review, the facility failed to ensure it's policies and procedures were followed pertaining to the Emergency Medical Treatment and Labor Act (EMTALA) were implemented and medical treatment was provided prior to transfer for one of 32 sampled patients (Pateint 16) when, Patient 16 was transported to Facility A's Emergency Department (ED) by an ambulance for an emergency medical condition (EMC) and did not receive medical treatment within the capabilities of the ED before being directed to go to Facility B by nursing staff.

This failure resulted in Patient 16's transferred from Facility A's property to Facility B without receiving medical treatment that was within Facility A's capacity, delaying treatment and had the potential risk to jeopardize Patient 16's health and safety.

Findings:

An unannounced visit was conducted on April 30, 2025, through May 1, 2025, to investigate a possible EMTALA violation.

There was no documented evidence to indicate Patient 16 was registered on Facility A's Emergency Department (ED) log, nor was there documentation indicating Patient 16 received a medical screening examination to rule out if an emergency medical condition existed or that the patient was medically stabilized.

During a concurrent interview and Facility A's surveillance video review, on April 30, 2025, at 2: 58 PM, with the Security Manager (SM) and the Director of the Emergency Department (DED), surveillance video of ambulance bay (parking for emergency vehicles delivering patients to the ED) dated April 22, 2025, from 1:50 AM - 1:54 AM, was reviewed. The surveillance video indicated the following:

At 1:51 AM, an ambulance arrived at the ED and backed into the ambulance bay.

At 1:52 AM, Registered Nurse 1 (RN 1) is seen walking from the ED entrance to the ambulance to speak with the ambulance crew.

At 1:53 AM, RN1 returned to the ED entrance and the ambulance drove away.

SM and the DED both stated and confirmed, an ambulance arrived at Facility A's property and left after speaking with RN 1 and no patient was transported from the ambulance into the ED prior to the ambulance leaving the property.

During a telephone interview, on April 30, 2025, at 3:07 PM, with RN 1, RN 1 stated, she received a call from Facility C's base station and was notified an ambulance was to arrive with a victim of an alleged sexual abuse. RN 1 stated, after she received the information from Facility C, she spoke with the Nursing Supervisor (NS) and was advised to contact Facility C and have the ambulance rerouted to Facility B because they were SART (Sexual Assault Response Team - a team of health care professionals specialized to treat patients who have suffered sexual abuse and can collect evidence of the crime) certified. RN 1 stated, she contacted Facility C and requested the ambulance to be rerouted. RN 1 stated, despite her attempt to reroute the ambulance prior to arrival at Facility A's property, the ambulance arrived at Facility A's ambulance bay. RN 1 stated, she spoke with the ambulance crew and notified them they had been rerouted and to continue on to Facility B and watched them leave. RN 1 further stated the ambulance was on Facility A's property and that Facility A should have accepted the patient and provided medical clearance.

During a concurrent interview and record review of Patient 16's [Name of Ambulance Services] "Electronic Patient Care Record" ("ePCR"- a record of care provided to a patient by the ambulance personnel during transport to the hospital), on April 30, 2025, at 3:42 PM, with the Paramedic (EMT-P), the "ePCR" dated April 22, 2025 indicated, Facility C's base station was contacted on April 22, 2025 at 1:24 AM for destination orders. The "ePCR" indicated, "[Name of Facility C] Base Hospital was contacted for destination orders and advised that the pt [patient] would need a SART certified hospital. Facility C advised that the pt should go to a local facility first and be medically cleared ...While in route ... [the ambulance] was originally transporting to [ Name of Facility A] and ...when on Facility A's property a nurse from the facilities ED advised to direct to [Name of Facility B] for reasons unknown to the [ambulance] crew ...". EMT-P stated, upon arrival to Facility A, a nurse met the ambulance in the ambulance bay and told them that they had been rerouted to Facility B and they should have been contacted by Facility C and to continue on with the patient to Facility B. EMT-P stated, he did receive a notification from his dispatch for updated destination to Facility B, but that he did not receive that update from dispatch until after the ambulance had already arrived to Facility A.

During a telephone interview on May 1, 2025, at 9:00 AM, with Nursing Supervisor 1 (NS 1), NS 1 stated, she was contacted by Registered Nurse 1 (RN 1) in the early morning hours of April 22, 2025, for guidance regarding transport of a patient who was the victim of a sexual assault. NS 1 stated, she was concerned about this patient being transported to Facility A, because Facility A did not have a SART program. NS 1 stated, she had read in the newspaper that Facility B had an active SART program and recommended RN 1 call Facility C to reroute the ambulance to Facility B. NS 1 further stated, she did not receive formal correspondence from Facility A or Facility B that Facility B had an active SART program.

During an interview on May 1, 2025, at 9:43 AM, with the Medical Doctor 1 (MD 1), MD 1 stated, once an ambulance is on hospital property, the facility cannot reroute the patient. MD 1 stated that a patient is the responsibility of the ED to ensure all EMTALA obligations are met by providing an MSE, providing stabilizing care for an emergency medical condition and must be transferred appropriately to an accepting hospital with an accepting provider.

During a concurrent interview and record review, on May 1, 2025, at 11:22 AM, with the DED, the facility's policy and procedure (P&P) titled, "Transfer of Patient to Another Facility" dated October 2023, was reviewed. The P&P indicated, "Purpose: Establish guidelines based on EMTALA standards to ensure that adequate care is given to each patient. If unable to continue with care, offer specialty care or higher level of care, patient is to be transferred to an appropriate facility ...all patients will be evaluated by the Emergency Department physician regardless of condition, race, religious preference or ability to pay. B. If the physician determines, through hospital policy, that the patient should be transferred to another facility for further care, EMTALA standards must be followed ...". The DED stated, Patient 16 should have been evaluated by the ED provider to stabilize Patient 16's EMC and an appropriate transfer to Facility B should have been completed. The DED stated the EMTALA obligation to Patient 16 was not fulfilled and the facility's P&P was not followed.

During a review of the facility P&P titled "EMTALA- Transfer Policy" dated June 2023, the P&P indicated, " ...Any transfer of an individual with an EMC must be initiated either by written request for transfer from the individual or the legally responsible person acting on the individual's behalf or by a physician ...EMTALA obligations regarding the appropriate transfer of an individual determined to have an EMC apply to any Emergency Department (ED) ...of a hospital whether located on or off the hospital campus and all other departments of the hospital located on hospital property ...".

During a review of the facility P&P titled, "EMTALA - Definitions & General Requirements", dated June 2023, the P&P indicated, " ...Appropriate transfer occurs when: (i) the transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health ...".