HospitalInspections.org

Based on document review, observation and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The hospital failed to ensure that EMTALA signage was posted at the ambulance bay entrance where it would be visible to individuals arriving by ambulance. (See A-2402).

2. The hospital failed to ensure that they followed the process for arranging transportation, to prevent potential delay in the evaluation and treatment. (See A-2408).

3. The hospital failed to ensure that the Receiving Hospital (Hospital B) had the available space and agreed to accept the patient, and that the transfer was arranged with the appropriate transportation (See A-2409).

Based on document review, observation, and interview, it was determined that for 1 of 1 emergency department (ED), the hospital failed to ensure that EMTALA signage was posted at the ambulance bay entrance where it would be visible to invididuals arriving by ambulance.

Findings include:

1. The hospital's policy titled, "EMTALA (Cobra)(Transfers)" (effective 2018), was reviewed and required, " ...The hospital shall post signs in the areas designated, which specifies patient rights under EMTALA ..."

2. A tour of the Emergency Department (ED) was conducted on 04/21/2025 at approximately 2:00 PM. The required EMTALA signage was posted at the check-in desk in both English and Spanish; however, there was no signage posted from the ambulance bay entrance, which enters directly into the ED treatment area, bypassing the check-in desk.

3. An interview was conducted with ED Nurse (E#6) on 04/21/2025, at approximately 2:30 PM. E#6 stated that patients brought in by ambulance would generally be roomed right away and not brought to the waiting room unless they didn't have any beds. E#6 stated that there were no EMTALA signs posted by the ambulance bay entrance, in the rooms, or any where else besides at the check-in desk.

Based on document review and interview, it was determined that for 1 of 7 patients' (Pt. #1) clinical records reviewed requiring transfer to another hospital, Hospital A (Transferring Hospital) failed to ensure the process for arranging transportation was followed, to prevent potential delay in the evaluation and treatment of Pt. #1.

Findings include:

1. On 4/21/2025, the clinical record for Pt. #1 was reviewed. On 11/14 2024, Pt. #1 went to Hospital A's ED due to cough. The clinical record included:

- On 11/14/2024 at 1:15 PM, E #3's (ED RN/Registered Nurse) progress note indicated that Pt. #1 walked into Hospital A's ED due to cough for two days. Pt. #1's initial vital signs as follows: Blood Pressure 113/65 (low blood pressure is below 90/60, high blood pressure 130/80 and above); Pulse 89 (Normal 60-100); Respiration 24 (Normal 12-20); Temperature 98-degree Fahrenheit (Normal 97-99); Oxygen Saturation/Level 74% (Normal 92-100%) on Room Air. Oxygen 4 liters per minute via nasal cannula was administered to Pt. #1 causing Pt. #1's oxygen level to go up to 94%. E #3 rated Pt. #1's ESI (Emergency Severity Index) as 2 (Critical).

- On 11/14/2024 at 1:29 PM, MD #1's (ED Attending Physician) progress note indicated, "non-productive cough ... We did request records from (Hospital E) ... found that (Pt. #1) was diagnosed with a right-sided pneumonia (chest x-ray read by radiology as pneumonia versus atelectasis/lung collapse versus pulmonary edema/fluids in the lungs). (Pt. #1 had) a mild elevation of ... white (blood) count (indicator for infection) ... electrolyte panel (minerals) showed a creatinine (test for kidney function) in the 1.7 range (Normal 0.5-1.1) ... troponin (test to identify heart damage) of 0.55 (Normal 0.06 and below)and a BNP (B-type natriuretic peptide/test for heart failure) of 240 (Normal 100 and below) ...Final Impression: Pneumonia, elevated D-dimer (test to detect clot in the lungs), acute hypoxic respiratory failure (type of respiratory problem), acute kidney injury ... elevated troponin ..."

- On 11/14/2024 at 4:15 PM, MD #1 documented, " ... talked with (Name of Hospital A's Hospitalist) ...Based on the elevated d-dimer ... inability to do a CT scan (imaging test) or VQ scan (test to identify clot in the lungs) ... elevated troponin and (Pt. #1) requiring a large amount of oxygen, (Pt. #1) was not felt to be appropriate for admission (at Hospital A) ..."

- On 11/14/2024 at 5:00 PM, MD #1 documented, " ... contacted (Hospital F) for potential transfer... At 6:30 PM, (discussed Pt. #1 with name of physician at Hospital F) who (accepted Pt. #1's transfer) ..."

- On 11/14/2024 at 6:33 PM, E #4 (ED RN) documented that Pt. #1 received bed assignment (Room 437 at Hospital F). At 6:37 PM, E #4 documented, " (Private Ambulance A) has no available ambulances for 4 hours.

- On 11/14/2024, E #4's succeeding documentation as follows: At 6:38 PM, "Spoke to (Private Ambulance B), they are able to transport (Pt. #1) if (Pt. #1) is able to pay $500 downpayment. Will call back after talking to (Pt. #1) ..." At 6:56 PM, "(Pt. #1) has the downpayment. $400 cash with $100 (credit card). Per (Private Ambulance B), that is acceptable and will be here in 60-70 minutes. ETA (Expected Time of Arrival) 8 PM ... report given to (Name of staff at Hospital F) ... "

- The transfer records indicated that Pt. #1's mode of transfer was affected through Private Ambulance B with ALS/advance life support capabilities. Reasons included: Pt. #1 requiring higher level of care, intravenous heparin drip/blood thinner, oxygen device, and cardiac monitoring. Pt. #1's medical diagnoses included NSTEMI (Non-ST elevated myocardial infarction/type of heart attack), ARF (Acute Renal Failure), and elevated D-dimer.

- The clinical record did not indicate that Hospital A's ambulance crew was requested to transfer Pt. #1 to Hospital F.

2. On 4/22/2025, the clinical record for Pt. #1 at Hospital F was reviewed. The clinical record indicated that Pt. #1 was admitted at Hospital F on 11/14/2024 at 9:32 PM (2 hours and 59 minutes when Hospital A received bed from Hospital F).

3. On 4/22/2025, the hospital's document titled, "EMTALA (Cobra)(Transfers)" (reviewed by the Hospital on 3/2024) indicated, " ... Procedure: A patient coming to the Emergency Department (ED) seeking emergency care shall receive an appropriate medical screening exam (MSE) to determine whether an emergency medical condition exists. Treatment shall not be delayed regardless of ability to pay ..."

4. On 4/22/2025, the hospital's document titled, "(Name of Hospital A) Summary of Services" (undated) indicated, " ... Emergency Services ... (Hospital A) owns and operates its own ambulance services within (Hospital A's) District. (Hospital A's) Ambulance Services is staffed 24/7 and consists of 911 response, emergency, and non-emergency transfer ..."

5. On 4/22/2025, the hospital's document titled, "Transfer of a Patient" (reviewed by the Hospital on 8/2022) indicated, " ... To ensure the safe and timely transfer of patients to a higher level of care for further diagnostic evaluation or treatment ... 3. Arranging Transportation. Nursing contacts (Hospital A's) ambulance crew to request paging for a second crew if needed. If (Hospital A's ambulance) is unavailable, begin contacting alternate ambulance services ... Notify selected transport service directly (nursing or designee may delegate to EMS if appropriate) ..."

6. On 4/22/2025 at approximately 9:45 AM, a telephone interview was conducted with MD #1 (ED Attending Physician). MD #1 stated that Pt. #1 had an emergency medical condition and needed a higher level of care for further evaluation and treatment.

7. On 4/22/2025 at approximately 10:37 AM, an interview was conducted with E #5 (EMS Director/Ambulance Service). E #5 stated, "We are an ALS provider meaning we have a paramedic on board at all times. We transfer patients when we have staff. When the hospital has a transfer, the ED staff would contact us, and we would page our crew to come in. We do not transfer to (Hospital E/OSH). It takes us out of our service area." When asked for documentation, E #5 was unable to provide proof that Hospital A does not transfer patients to Hospital E.

8. On 4/22/2025 at approximately 11:40 AM, a telephone interview was conducted with MD #4 (ED Medical Director), MD #4 stated that it is not appropriate to ask payment from patients while evaluation and treatment are being conducted, including patients needing higher level of care.

9. On 4/22/2025 at approximately 3:00 PM, a telephone interview was conducted with E #4 (ED RN). E #4 stated, "Regarding transferring of patients to another hospital, it depends on their clinical status. If non-critical, we will call private ambulances. If the ambulance would require payment, we will ask the patient." E #4 was not sure if it was appropriate to ask a patient for payment before providing the ambulance service in order for a patient to receive further evaluation and treatment at another hospital.

10. On 4/22/2025 at approximately 3:29 PM, findings were discussed with E #2 (Chief Nursing Officer). E #2 stated, "The patient should not be asked to pay. If that happens, the ED staff is expected to tell me or the CEO."

Based on document review and interview, it was determined that for 1 of 7 transferred patient (Pt. #2) records reviewed, the Transferring Hospital (Hospital A) failed to ensure that the Receiving Hospital (Hospital B) had the available space and agreed to accept the patient, and that the transfer was arranged with the appropriate transportation.

Findings include:

1. The Transferring Hospital's policy titled, "EMTALA (Cobra)(Transfers)" (effective 2018), was reviewed and required, " ...If a patient is found to have an emergency medical condition or is in active labor, the hospital shall provide: A. Staff and facilities needed to stabilize the medical condition or manage the active labor OR B. Transfer of the patient to another facility ... A transfer may be arranged providing the following conditions are met: 1. The receiving facility has: a. available space and qualified personnel for the treatment of the individual; b. agree to accept the patient; c. the transferring hospital sends to the receiving facility all medical records or copies related to the emergency condition; and d. the transfer is effected through qualified personnel and transportation ..."

2. The Transfering Hospital's (Hospital A) clinical record of Pt. #2's Emergency Department (ED) visit on 12/16/2024 was reviewed on 04/21/2025. Pt. #2 presented to the ED on 12/16/2024 at 5:34 AM with a chief complaint of recheck/abnormal lab. The record included the following:

The Medical Screening Examination/MSE completed by ED Physician (MD#2) on 12/16/2024 at 9:04 PM included " ...patient presented with shortness of breath ongoing and progressive for approximately 4 weeks. [Pt. #2] was seen at an outpatient clinic today for these symptoms and underwent some testing including a CBC [complete blood count]. [Pt. #2] was called with the results of the CBC and told to go to the ED for evaluation. Patient reports that [Pt. #2] feels short of breath today which is not significantly different from past week but has slowly and progressively increased over the course of the past month. Most noticeable with exertion and gets tired walking a short distance from car parking lot to the clinic. Denies chest pain with dyspnea [difficulty breathing]. Dyspnea improves somewhat with rest but does not resolve completely. [Pt. #2] also endorses lower extremity swelling but feels this is a chronic problem and that [Pt. #2] self discontinued Lasix [a diuretic] many months ago which was due to frequent urination and preceded this more recent dyspnea. [Pt. #2] also has experienced some night sweats over the past weeks ... Patient Disposition: Xfer [Transfer] Acute Care Hospital ... Condition: Serious ..."

Hematology Labs, dated 12/16/2024 at 9:05 PM, included the following:

- White Blood Count/WBC [normal range 3.90-13]: 186.05 [High]
- Hemoglobin/Hgb [normal range: 11-18]: 6.2 [Low]
- Platelet Count [normal range 150-450]: 67 [Low]

MD#2's Progress Notes included the following:

- Re-evaluation #1 at 9:47 PM: "breathing comfortably on 2L NC [2 Liters per min oxygen via nasal cannula]."
- Re-evaluation #3 at 10:53 PM: "Discussed with [Receiving Hospital] transfer center, awaiting call back from heme onc [hematology / oncology]. Discussed with heme onc and hospitalist; would accept to general medicine floor but no availability now and wound not accept to ICU [intensive care unit]."

MD#2's Medical Decision Making Narrative, signed 12/17/2024 at 5:51 AM, included "...Given the severity of these blood count derangements and acute nature, there is potential for development of severe potential life threatening cardiac, vascular, neurologic, infectious sequelae [a pathological condition resulting from disease]; the patient may also be a candidate for emergent interventions including [but] not limited to plasmaphoresis [procedure that separates plasma from blood cells and replaces it with another solution or returns it to the body]/leukophoresis [procedure healthcare providers use to remove white blood cells from the blood]. For these reasons, emergent transfer was promptly pursued for heme onc specialist consultation and admission to an ICU for close monitoring. Patient has acute on subacute dyspnea and was newly hypoxic in the ED requiring supplemental oxygen (2L NC) to maintain acceptable sats [saturations between 95%-100%] even at rest. [Pt. #2] does not have evidence of an acute associated cardiopulmonary, metabolic, or infectious source to explain [Pt. #2's] dyspnea and new O2 [oxygen] requirements. However, [Pt. #2] is at high risk for developing any of these complications... Patient is pending transfer at this time ..."

The ED Nursing Note, dated 12/17/2024 at 8:46 AM included "[Receiving Hospital] called, they wanted an update on patient's condition, they do not have room at this time. They will call when they do. If patient goes to other hospital they have asked us to call [them back]."

Vitals Sign records on 12/17/2024 at 8:48 AM indicated that Pt. #2 was still receiving oxygen delivery at 2 L/min; however, there was no assessment of the oxygen saturation at this time.

Discharge Instructions (written by ED Physician MD#3 per interview) were received by Pt. #2 on 12/17/2024 at 9:18 AM and included, " ...You were seen today for: Hyperleukocytosis [high WBC], Anemia [low hemoglobin], Thrombocytopenia [low platelets], Acute hypoxemic [low oxygen] respiratory failure ... Additional Instructions: Go directly to [Receiving Hospital] emergency department. Hand them your paperwork and image disc. Call 911 immediately for any concerns. Please show emergency department triage nurse the following statement: Patient with new onset leukocytosis, thrombocytopenia and anemia. Patient was to be admitted to [Receiving Hospital] but there were no beds. Patient drove via private car. Patient needs heme [hematology] onc [oncology] consult and plasmapheresis ...."

3. The Receiving Hospital's (Hospital B) clinical record of Pt. #2's ED visit on 12/17/2024 was reviewed on 04/24/2025. Pt. #2 presented to the ED on 12/17/2024 at 11:16 AM with a chief complaint of blood issues. The record included the following:

Triage was completed on 12/17/2024 at 11:27 AM and included "Vitals signs: Temp 98.1; Pulse 93; Resp 22; BP 119/70; SpO2 93%; Oxygen status: N/A [not applicable]... Sent here from OSH [outside hospital] for oncology consult following WBC results 186 & hgb 6.2, platelets 67. Reports went to OSH for feeling unwell, night sweats, & fatigue. No blood products given at OSH ... Patient acuity: 2 [Emergent - on a scale of 1-5 where 1 is the most acute/critical and 5 is non-urgent] ..."

The Medical Screening Exam, dated 12/17/2024 at 12:33 PM, included "...Patient was seen at an outside facility at which time [Pt. #2's] labs were abnormal for a leukocytosis of 180, hemoglobin of 6.2 and platelets of 67... Per chart review, outside facility contacted [Receiving Hospital] oncology who stated that patient would require admission but did not need to be emergently transferred. Patient told by outside facility to leave the emergency department and drive here for admission as there was not beds available for direct admission ... Laboratory workup here concerning for tumor lysis syndrome ... Malignant hematology evaluated patient in the emergency department and recommended admission to their service ... Recommended 125 cc [milliliters] of Lactated Ringer's continuous infusion. Did discuss the large-volume patient will receive as [Pt. #2] is also going to receive 2 units of packed red blood cells. Ordered home Lasix as patient has not yet taken it today ... Bed request placed to malignant hematology ..."

Hematology Labs, dated 12/17//2024 at 1:02 PM included WBC 195.4 [high]; Hgb: 5.9 [low]; and Platelets 69 [low].

The History & Physical, dated 12/17/2024 at 3:00 PM, included "[Pt. #2] presented with leukocytosis, anemia and thrombocytopenia suggestive of undiagnosed malignancy ... Admit to malignant hematology when bed available... Per patient and chart review, ...[Pt. #2] was called by [primary care provider] when labs result[ed] ... This provider then recommended patient present to local ED. There [Hospital A] [Pt. #2] received CTA [computed tomography angiogram - imaging of blood vessels] that reportedly demonstrates bulky lymphadenopathy [abnormal enlargement of the lymph nodes]; imaging unavailable at time of note (doesn't load) ... [Receiving Hospital] was contacted for transfer 12/16-12/17 overnight; given patient's hemodynamic stability and hospital at critical capacity. Patient was subsequently placed on the transfer list, though was then told by outside facility to discharge from the emergency department and drive to [Hospital B] and present to the ED here ..."

The ED timeline on 12/17/2024 indicated that Pt. #2 received 2 units of packed red blood cells as order while in the ED. The record also indicated that a bed was assigned at 6:25 PM, the bed was ready at 7:53 PM, and Pt. #2 was transferred to the inpatient malignant hematology unit at 8:43 PM.

4. A telephone interview was conducted with the ED Physician/ED Medical Director (MD#3) on 04/22/2025, at approximately 11:40 AM. MD#3 stated that when MD#3 took over care of Pt. #2, they were waiting for a bed. MD#3 stated that that morning, the patient voiced not wanting to wait anymore and MD#3 called the transfer center and stated that they were not likely to have a bed anytime soon. MD#3 then had a discussion with the patient, who asked "why can't we just drive there?" MD#3 stated that the patient called the son to come and didn't want to stay. MD#3 stated that they couldn't hold the patient and the patient was stable enough and the son was comfortable driving the patient to [Receiving Hospital]. MD#3 stated that during the day, Pt. #2 had been off oxygen and vital signs were stable. MD#3 stated that since the patient/son insisted on leaving, MD#3 instructed them to go directly to [Receiving Hospital's] ED and present the paperwork to them. MD#3 stated that MD#3 didn't realize that MD#3 did not document any notes on MD#3's evaluations, interactions, and conversations with Pt. #2 and stated that MD#3 should have. MD#3 stated that MD#3 recalled that Pt. #2 was speaking full sentences, was ambulatory, and off oxygen when Pt. #2 was discharged; however, noted that it wasn't documented.