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Based on review of facility policy, review of Emergency Services 911 dispatch audio recordings, review of Emergency Medical Services (EMS) reports, review of the Emergency Department (ED) central log, medical record review, and interviews, the facility failed to provide a Medical Screening Exam (MSE) for 2 patients (Patient #39 and Patient #40) for 40 ED patients reviewed.

The findings include:

Refer to A-2406.

Based on review of facility policy, review of Emergency Services 911 dispatch audio recordings, review of Emergency Medical Services (EMS) reports, review of the Emergency Department (ED) central log, and interviews, the facility failed to ensure 2 patients (Patient #39 and Patient #40), who presented to the ED for medical treatment were listed on the ED Central Log of 40 patients sampled.

The findings include:

Review of Facility A's policy titled "Registration and EMTALA [Emergency Medical Treatment and Labor Act] Compliance" revised 6/2016 showed "...A brief registration with patient name and identifiers is entered into the computer to notify ED staff of a new patient...A report is available through [named medical record program] containing all patients that present to ED requesting care. The report includes patient name, chief complaint, and disposition along with other information...No registrations will be canceled once the patient has made known to the registration clerk their request for medical care even if the patient leaves at any point in time, including prior to triage..."

Review of the Facility A's policy titled "Plan for the Provision of Patient Care" revised 6/2016 showed "...Medical Imaging staff will be available 24 hours a day, 7 days a week..."

Review of a 911 Dispatch Operator audio recording dated 8/20/2020 at 5:40 AM revealed an ED nurse at Facility A (Jellico Medical Center ) calls 911 dispatch and stated "...Hey this is [named ED Nurse at Facility A] over here in the emergency room...We've got a woman here in a car and she's got her husband [actually was her son] here...she thinks he's paralyzed. This is not something new. He's usually in a wheelchair. We can't do any kind of imaging here. We told her...she's like where's the next closest hospital that they can do some kind of CT [computed tomography] scan. We explained to her that [Facility D] was...We told her what exit it was and she was gonna head that way. Then she wanted to know could they get an ambulance to take him over there. We can't do any kind of CT scan or x-ray...[911 Dispatch Operator then asked] Is she at the ER [emergency room] bay...[ED nurse then stated] She's in the car they're all in the car, her and him both are in the car. [911 Dispatch Operator then asked] Okay are they at the ER bay, are they at the doors, are they in the parking lot? [ED nurse then stated] they're at the ambulance bay...[911 Dispatch Operator then asked] Is he normally paralyzed...[ED nurse then stated] Yeah, yeah he's in a wheelchair and tonight something popped in his back and he's like now I can't move at all so he's laying flat, they've got the seats laid down so he's laying flat in the back of the car..."

Review of a 911 dispatch audio recording dated 8/20/2020 at 5:42 AM between dispatch and the EMS crew revealed the 911 dispatch operator] told the EMS crew to "...Please be in route to Jellico ER [Facility A]. Patient is gonna be in a vehicle in the ambulance bay. [Facility A ED staff] advised them [Patient #39 and his mother] they couldn't help them there so they're requesting transport to [Facility D]...A male subject that is paralyzed advised that something popped in his back and now he can't move the rest of his body...[EMS crew then stated]...[6:03 AM] We are responding...[6:09 AM]...We're on scene [Facility A]..."

Review of a 911 dispatch audio recording dated 8/20/2020 at 6:12 AM between dispatch and Patient #39's mother revealed the patient's mother stated "...My son's having seizures and he's throwing up so I need an emergency vehicle to bring him to the hospital...he threw up blood...I don't know what the address is but I pulled up into this parking lot thing and it says [named drug store]...I don't really know where I'm at...[911 dispatch operator then asked] Did you just go to the hospital with him...[Patient #39's mother then stated] I did but he started throwing up and we couldn't get him out so I was going to drive him to the hospital [Facility D]...but he started throwing up again and seizing on me...so I don't think it's safe for me to drive him if he's seizing..."

Review of an EMS report (run sheet) dated 8/20/2020 showed EMS was dispatched to Facility A's ED at 6:09 AM for a male patient (Patient #39) in a vehicle with back pain. Further review showed "...UPON ARRIVAL ED STAFF STATES PT [patient] PRESENTED TO ED C/O [complaint of] BACK PAIN/PARALYSIS LAYING IN THE BACK OF A VEHICLE REQUESTING A CT SCAN. STAFF STATES THEY DID NOT HAVE CT SERVICES AVAILABLE AND REQUESTED EMS TRANSPORT PT TO ALTERNATE ED..." Further review showed when EMS arrived, they were told Patient #39 and his mother had left the ED in search of another ED. EMS was still on scene at Facility A when they were dispatched to a nearby drug store parking lot (approximately 1 mile from Facility A) for the same patient. Upon arrival, Patient #39 was found lying on his back in the back of a vehicle conscious, alert and oriented. Patient #39's mother reported she called 911 after the patient had a seizure and vomited. The patient reported he began experiencing mid-back pain at approximately 5:00 AM and moved to the back seat to lay down and while moving, he experienced a sharp mid-back pain and had an immediate loss of movement and sensation in all extremities. EMS left Facility A and transported Patient #39 to Facility C.

Review of Facility A's ED central log dated 8/20/2020 showed Patient #39 was not listed on the log.

During a telephone interview on 11/4/2020 at 4:15 PM, Paramedic #1 stated he received a 911 dispatch call to transport Patient #39 from Facility A's ambulance bay to another facility. He stated he had spoken with Facility A's ED nursing staff via phone and told them he wasn't comfortable transporting a patient who had not been triaged or met EMTALA requirements. Paramedic #1 stated Patient #39 was not in the ambulance bay when EMS arrived at Facility A, but while he was still on scene at Facility A, he received a 911 dispatch call to respond to a nearby drug store parking lot for the same patient. When EMS arrived in the parking lot, Patient #39 was found lying in the back seat of a car, unable to move his extremities, and had vomited. Patient #39 was then transported to Facility C by EMS.

During a telephone interview on 11/5/2020 at 2:30 PM, Registered Nurse (RN) #1 at Facility A stated she went out to the ambulance bay to assist Patient #39 out of a private vehicle. RN #1 stated the patient was unable to move his lower extremities and was requesting the facility do a CT scan. Before attempting to remove the patient from the vehicle, RN #1 informed the patient and his mother that the facility was unable to provide a CT scan. The patient's mother then asked RN #1 to call an ambulance, but the patient left with his mother prior to arrival of EMS.

During a telephone interview on 11/5/2020 at 3:20 PM, RN #2 at Facility A stated Patient #39 arrived at the ED in a private vehicle and was parked in the ambulance bay. RN #2 stated the patient was paralyzed, was lying in the back seat of the car, and requested the facility do a CT scan. The patient's mother was informed the facility was unable to do a CT scan, so they left the Facility A's ED to go to another hospital.

During a review on 11/5/2020 at 3:40 PM, Facility A's ED Nurse Manager confirmed Patient #39 was not listed on the ED central log.

Review of 911 dispatch audio recording dated 8/25/2020 at 1:55 AM between dispatch and a nurse at a long-term care (LTC) facility showed "... [911 dispatch operator] Campbell County 911...[Nurse then stated] This is [named Nurse] at [named LTC facility]. I have a resident [Patient #40] who has...pulled her PEG [percutaneous endoscopic gastrostomy (feeding)] tube out and she's got tube feedings to her abdominal cavity and needs to go to the hospital...she only pulled it partially out and the tube feeding is going into her abdominal cavity..."

Review of a 911 dispatch audio recording dated 8/25/2020 at 1:56 PM between 911 dispatch operator and EMS crew showed "...[911 dispatch operator stated] I have a call at [named LTC facility] about a female...she partially pulled out her PEG tube. Food is going into her abdominal cavity..." Continued review showed EMS advised dispatch they arrived at the LTC facility at 2:10 AM and they would be transporting Patient #40 to Facility A. EMS called the 911 dispatch operator back at 2:26 AM and stated "...They [Facility A] can't x-ray...so can you put us in route to [Facility D] instead...That's where we're headed..." EMS arrived at Facility D at 2:59 AM.

Review of an EMS record (run sheet) dated 8/25/2020 at 2:11 AM showed Patient #40 was transported to Facility A from a LTC facility (located next door to Facility A) for a PEG tube replacement and upon arrival to the ED at Facility A, EMS was met outside at the ambulance bay by nursing staff and "...TOLD WE WOULD HAVE TO TAKE PT [patient] TO ANOTHER ER DUE TO THEY HAVE NO IMAGING [radiology]..." Patient #40 was transported to Facility D.

Review of Facility A's ED central log dated 8/25/2020 showed Patient #40 was not listed on the log.

During a telephone interview on 11/4/2020 at 4:45 PM, Paramedic #2 stated EMS transported Patient #40 to Facility A because her PEG tube came out and it needed to be replaced. The paramedic stated ED staff came out to the ambulance bay and said they could not see the patient because x-ray was not available. The patient was then transported to Facility D.

During an interview on 11/5/2020 at 3:40 PM, the ED Nurse Manager confirmed Patient #40 was not listed on the ED central log.

Based on review of facility policy, review of Emergency Services 911 dispatch audio recordings, review of Emergency Medical Services (EMS) reports, review of Emergency Department (ED) medical records, and interviews, the facility failed to ensure that patients who presented to the ED were provided an appropriate medical screening examination within the capability of the hospital's emergency department to include ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition (EMC) exist for 2 (Patient #39 and Patient #40) of 40 ED patients sampled.

The findings include:

Review of Facility A's policy titled "Registration and EMTALA [Emergency Medical Treatment and Labor Act] Compliance" revised 6/2016 showed "...It is the policy of [Facility A] for all patients to be medically screened for severity of illness by a qualified and competent nurse and physician..."

Review of Facility A's policy titled "Emergency Department Triage" revised 6/2016 showed "...All patients ... shall be evaluated by a Triage Nurse to determine the nature of their presenting complaints, their condition, and their priority for receiving a medical screening exam, and shall be designated a triage priority ..."

Review of the Facility A's policy titled "Plan for the Provision of Patient Care" revised 6/2016 showed "...Medical Imaging staff will be available 24 hours a day, 7 days a week..."

Review of a 911 dispatch audio recording dated 8/20/2020 at 5:40 AM revealed an ED nurse at Facility A called 911 dispatch and stated "...Hey this is [named ED Nurse at Facility A] over here in the emergency room...We've got a woman here in a car and she's got her husband [actually was her son] here...she thinks he's paralyzed. This is not something new. He's usually in a wheelchair. We can't do any kind of imaging here. We told her...she's like where's the next closest hospital that they can do some kind of CT [computed tomography] scan. We explained to her that [Facility D] was...We told her what exit it was and she was gonna head that way. Then she wanted to know could they get an ambulance to take him over there. We can't do any kind of CT scan or x-ray...[911 Dispatch Operator then asked] Is she at the ER [emergency room] bay...[ED nurse then stated] She's in the car they're all in the car, her and him both are in the car. [911 Dispatch Operator then asked] Okay are they at the ER bay, are they at the doors, are they in the parking lot? [ED nurse then stated] they're at the ambulance bay...[911 Dispatch Operator then asked] Is he normally paralyzed...[ED nurse then stated] Yeah, yeah he's in a wheelchair and tonight something popped in his back and he's like now I can't move at all so he's laying flat, they've got the seats laid down so he's laying flat in the back of the car..."

Review of a 911 dispatch audio recording dated 8/20/2020 at 5:42 AM between dispatch and the EMS crew revealed the 911 dispatch operator told the EMS crew to "...Please be in route to Jellico ER [Facility A]. Patient is gonna be in a vehicle in the ambulance bay. [Facility A ED staff] advised them [Patient #39 and his mother] they couldn't help them there so they're requesting transport to [Facility D]...A male subject that is paralyzed advised that something popped in his back and now he can't move the rest of his body...[EMS crew then stated]...[6:03 AM] We are responding...[6:09 AM]...We're on scene [Facility A]..."

Review of a 911 dispatch audio recording dated 8/20/2020 at 6:12 AM between dispatch and Patient #39's mother revealed the patient's mother stated "...My son's having seizures and he's throwing up so I need an emergency vehicle to bring him to the hospital...he threw up blood...I don't know what the address is but I pulled up into this parking lot thing and it says [named drug store]...I don't really know where I'm at... [911 dispatch operator then asked] Did you just go to the hospital with him...[Patient #39's mother then stated] I did but he started throwing up and we couldn't get him out so I was going to drive him to the hospital [Facility D]...but he started throwing up again and seizing on me...so I don't think it's safe for me to drive him if he's seizing..."

Review of an EMS report (run sheet) dated 8/20/2020 showed EMS was dispatched to Facility A's ED at 6:09 AM for a male patient (Patient #39) in a vehicle with back pain. Further review showed "...UPON ARRIVAL ED STAFF STATES PT [patient] PRESENTED TO ED C/O [complaint of] BACK PAIN/PARALYSIS LAYING IN THE BACK OF A VEHICLE REQUESTING A CT SCAN. STAFF STATES THEY DID NOT HAVE CT SERVICES AVAILABLE AND REQUESTED EMS TRANSPORT PT TO ALTERNATE ED..." Further review showed when EMS arrived, they were told Patient #39 and his mother had left the ED in search of another ED. EMS was still on scene at Facility A when they were dispatched to a nearby drug store parking lot (approximately 1 mile from Facility A) for the same patient. Upon arrival, Patient #39 was found lying on his back in the back of a vehicle conscious, alert and oriented. Patient #39's mother reported she called 911 after the patient had a seizure and vomited. The patient reported he began experiencing mid-back pain at approximately 5:00 AM and moved to the back seat to lay down and while moving, he experienced a sharp mid-back pain and had an immediate loss of movement and sensation in all extremities. EMS left Facility A and transported Patient #39 to Facility C.

Review of Facility A's ED medical records dated 8/20/2020 revealed there was no medical record for Patient #39.

Medical record review of an ED Provider Note showed Patient #39 presented to Facility C by ambulance on 8/20/2020. The patient received a MSE. Diagnostic tests were done, including laboratory tests, a chest x-ray, and a CT scan of the lumbar spine, thoracic spine, cervical spine, and head, with no acute findings. Patient #39 was transferred via helicopter to Facility B for a higher level of care with a diagnosis of Acute Flaccid Quadriplegia.

During a telephone interview on 11/4/2020 at 4:15 PM, Paramedic #1 stated he received a 911 dispatch call to transport Patient #39 from Facility A's ambulance bay to another facility. He stated he had spoken with Facility A's ED nursing staff via phone and told them he wasn't comfortable transporting a patient who had not been triaged or met EMTALA requirements. Paramedic #1 stated Patient #39 was not in the ambulance bay when EMS arrived at Facility A, but while he was still on scene at Facility A, he received a 911 dispatch call to respond to a nearby drug store parking lot for the same patient. When EMS arrived in the parking lot, Patient #39 was found lying in the back seat of a car, unable to move his extremities, and had vomited. Patient #39 was then transported to Facility C by EMS.

During a telephone interview on 11/5/2020 at 2:30 PM, Registered Nurse (RN) #1 at Facility A stated she went out to the ambulance bay to assist Patient #39 out of a private vehicle. RN #1 stated the patient was unable to move his lower extremities and was requesting the facility do a CT scan. Before attempting to remove the patient from the vehicle, RN #1 informed the patient and his mother that the facility was unable to provide a CT scan. The patient's mother then asked RN #1 to call an ambulance, but the patient left with his mother to go to another ED before EMS arrived.

During a telephone interview on 11/5/2020 at 3:20 PM, RN #2 at Facility A stated Patient #39 arrived at the ED in a private vehicle and was parked in the ambulance bay. RN #2 stated the patient was paralyzed, was lying in the back seat of the car, and requested the facility do a CT scan. The patient's mother was informed the facility was unable to do a CT scan, so they left the Facility A's ED to go to another hospital.

During an interview on 11/5/2020 at 3:40 PM, the ED Nurse Manager confirmed Patient #39 was not triaged and did not receive a MSE.

Review of 911 dispatch audio recording dated 8/25/2020 at 1:55 AM between dispatch and a nurse at a long-term care (LTC) facility showed "... [911 dispatch operator] Campbell County 911...[Nurse then stated] This is [named Nurse] at [named LTC facility]. I have a resident [Patient #40] who has...pulled her PEG [percutaneous endoscopic gastrostomy (feeding)] tube out and she's got tube feedings to her abdominal cavity and needs to go to the hospital...she only pulled it partially out and the tube feeding is going into her abdominal cavity..."

Review of a 911 dispatch audio recording dated 8/25/2020 at 1:56 PM between 911 dispatch operator and EMS crew showed "...[911 dispatch operator stated] I have a call at [named LTC facility] about a female...she partially pulled out her PEG tube. Food is going into her abdominal cavity..." Continued review showed EMS advised dispatch they arrived at the LTC facility at 2:10 AM and they would be transporting Patient #40 to Facility A. EMS called the 911 dispatch operator back at 2:26 AM and stated "...They [Facility A] can't x-ray...so can you put us in route to [Facility D] instead...That's where we're headed..." EMS arrived at Facility D at 2:59 AM.

Review of an EMS record (run sheet) dated 8/25/2020 at 2:11 AM showed Patient #40 was transported to Facility A from a LTC facility (located next door to Facility A) for a PEG tube replacement and upon arrival to the ED at Facility A, EMS was met outside at the ambulance bay by nursing staff and "...TOLD WE WOULD HAVE TO TAKE PT [patient] TO ANOTHER ER DUE TO THEY HAVE NO IMAGING [radiology]..." Patient #40 was transported to Facility D.

Review of Facility A's ED medical records dated 8/25/2020 revealed there was no medical record for Patient #40.

Medical record review of an ED Physician's Documentation at Facility D showed Patient #40 arrived by ambulance to the ED on 8/25/2020 at 3:20 AM due to a PEG tube that was pulled out. The PEG tube was replaced, placement was verified by x-ray, and the patient was transported back to the LTC facility on 8/25/2020 at 4:24 AM.

During a telephone interview on 11/4/2020 at 4:45 PM, Paramedic #2 stated EMS transported Patient #40 to Facility A because her PEG tube came out and it needed to be replaced. The paramedic stated ED staff came out to the ambulance bay and said they could not see the patient because x-ray was not available. The patient was then transported to Facility D.

During an interview on 11/5/2020 at 3:40 PM, the ED Nurse Manager confirmed Patient #40 was not triaged and did not receive a MSE.