HospitalInspections.org

Based on Emergency Department (ED) record review for Hospital #1, Emergency physician report, physician interviews, Medical Director interviews, Administrator interview, ED staff interviews, Emergency Medical Services (EMS) personnel report, EMS interviews, EMS handwritten statement review, family interview, and Hospital #2 medical record review, the hospital failed to comply with 489.20 by failing to provide a Medical Screening Exam (MSE) and Stabilizing Treatment, failing to ensure no Delay in Examination/Treatment and failing to ensure an Appropriate Transfer within its capacity that minimized the health risks of Patient #20, one (1) of 31 ED patients reviewed.


Findings Include:



On 5/20/16 the State Office received a complaint which stated:
"My name is... and I am the Investigator for the Bureau of EMS. I have a case that I am investigating and... my director had asked me to contact you for guidance. One of our licensed services (Hospital #1) EMS has a call of a fall at their courthourse. The patient presented with a possible hip fracture and the crew attempted to take the patient out of their county to an appropriate trauma facility. The patient also had cardiac history so they chose (Hospital #2). The patient adamantly refused and wanted to be taken to (Hospital #1). After numerous attempts the crew transported to (Hospital #1). Upon arriving at (Hospital #1) and wheeling the patient inside the doctor met the crew and talked with the patient. From that point forward we have different reports. The medic alleges that the doctor refused to see the patient and ordered them to take the patient to (Hospital #2). The ER Staff, and other witnesses state the doctor offered to treat the patient but advised that they would not be able to provide orthopedic care if a fracture was found and would then need to be transported out. The patient then agreed to be transported and was taken by ambulance to (Hospital #2). Our question for you would be is the physician talking with the patient who presented with an outward rotation of a lower extremity and then EMS taking the patient to another facility ok or was this an EMTALA violation? Can you provide any guidance with this from the facilities side. I have included statements from both the ER (Emergency Room) Nurse and MD (Medical Doctor)."


An unannounced visit was made to Hospital #1 on 5/24/16 at 10:30 a.m. An Entrance Conference was held at 10:45 a.m. with Chief Executive Officer (CEO), Emergency Medical Services (EMS) Supervisor, Quality/ Clinical Development Coordinator, and Chief Nursing Officer (CNO) in attendance. The reason for the visit was explained and the complaint summarized. Paperwork to be completed by the hospital during the survey was given to the CEO. Information concerning the policies/procedures to be reviewed, patient lists needed and other materials was given to the CNO.


An ED tour was conducted with the CEO on 4/25/16 at 4:25 p.m. There was appropriate EMTALA signage in all required areas. Observation revealed 11 ED beds in the unit.

ED RECORD REVIEWS

Hospital #1
There was no documented evidence of an ED medical record for Patient #20.

Hospital #2
Review of Hospital #2's ED record revealed that Patient #20 arrived at the ED by ambulance on 7/28/15 at 11:52 a.m. The Triage Sign-in Sheet documented that the EMS activated a BRAVO at 11:38 a.m., prior to arrival due to EMS thinking he was on blood thinners. During the ambulance transfer the notes revealed the patient's blood pressure was 148/73 at 11:40 a.m. Review of the hospital's Triage notes revealed the patient was triaged at 11:55 a.m. as a Level 3 with a chief complaint: Fall from a height while walking, onto a concrete surface. Xrays revealed four views of the right femur which showed a Right Intertrochanteric Hip Fracture. His right shoulder was x-rayed due to complaints of pain. These xrays were unremarkable. He received a MSE and was admitted to the hospital at 2:36 p.m. Admission diagnoses included right hip fracture, acute blood loss anemia, acute urinary tract infection and acute kidney injury. During hospitalization, he was also found to have thrombocytopenia, sepsis, symptomatic bradycardia and chronic colon cancer. A cardiologist was consulted. Review of surgical physician's notes revealed the patient tolerated a 7/29/15 surgery well with no complications. Post-op on 7/31/15, the doctor ordered two (2) units of packed red blood cells due to a decreasing hematocrit. The patient was discharged from Hospital #2 on 8/3/15 and taken by a transport service to Hospital #1's Swing Bed Unit.

DOCUMENT REVIEW

Review of Hospital #1's ED Log for the date 7/28/15 revealed no documented evidence that Patient #20 was seen in their ED.

WRITTEN STATEMENT REVIEWS

Review of (Hospital #1's) handwritten Ambulance Service Patient Care Report revealed that a call was received on 7/28/15 at 10:44 a.m. for regarding a patient's fall. An ambulance was on the scene at 10:47 a.m. and reached Hospital #1 at 11:48 a.m. EMS handwritten narrative stated, "Unit 3 responded to ...County Court House for a cc of right hip pain. Pt (Patient) states he fell on his right side. Pt denies any LOC (loss of consciousness). Pt is AOX4 (alert and oriented times 4). Pt right leg is shorter than left leg and turned out. Pt was informed he need to (go to)(Hospital #2) or (another area hospital). Pt refused 3X (three times). Pt denied all back or neck pain." His pain level was documented at 11:00 a.m. as 3 (on a scale of 1 to 10) and a 7 at 11:15 a.m. The patient had a prior cardiac history and was placed on a cardiac monitor and given oxygen. The pt was given Zofran 8 milligrams (mg) intravenous (IV) at 11:05 a.m., and Demerol 25mg IV at 11:15 a.m. and again at 11:30 a.m.

EMS Additional Narrative stated, "Came to (Hospital #1) ER with pt. ED Physician #1 refused to treat pt and told me to take the pt somewhere else, she isn't going to see pt. Pt transport. While in route pt pain became worse. Pt was given 50 of Demerol 25 at 11:15 (a.m.) and 25 at 11:30 (a.m.). Pt was administered 8 (mg) of Zofran, 1000 ml (milliliter) NS (Normal Saline) at 11:01 (a.m.) and 1000 ml at 11:30 (a.m.). Pt stated pain is now a 3. Bravo was called into (Hospital #2) at 11:34 (a.m.). Pt was taken into (Hospital #2). Report was given to RN (Registered Nurse) and care was handed over. No further pt contact."


Review of a "Prehospital Care Report" form (written by Paramedic #1) revealed:
"Incident Date: 07/28/2105 - Primary Impression: Traumatic Injury - Secondary Impression: Pain - Narrative / Summary of Events: ALS 3 responded to a cc of a fall at the (county) Court House AOS to find a 96YOWM (year old white male) sitting in a chair outside. Pt stated he fell on his right hip. Pt is AOX4 and Pt denies and (any) LOS. Pt has obvious right hip fracture. Pt has refused X3 to be transported anywhere but (Hospital #1). Pt denies any back or neck pain. Pt was loaded into the unit w/o (without) incident. Pt was brought to (Hospital #1) because he refused to go to (Hospital #2) or (another area hospital). Pt was brought into the ER and (Physician #1) and (RN #1) met me at the nurses station and (Physician #1) refused to treat or see the pt. See (She) told me 'See (she) will not see this pt and give him two ER (Emergency Room) bills and for me to take the pt somewhere else.' (Physician #1) told the pt he can't be seen here and needs to go somewhere else. Pt then agreed. I loaded the pt back up per doctors orders and took the pt to (Hospital #2). Pt wouldn't go to (Hospital #2) because he lives in (name of town) and always came here. But pt did finally agree to after (Physician #1) refused to treat the pt in the ER here at (Hospital #1). The reason I didn't take the pt strait (straight) to (Hospital #2) is because the pt was AOX4 (alert and oriented X4) and it would have been against the law to go against the pts wishes and just taken him anywhere I saw fit even though I knew he needed to a higher level of care. Pt was loaded back up and taken strait (straight) to (Hospital #2). A BRAVO alert was called into (Hospital #2) at 1134 (11:34 a.m.) and pt was given 50mg of Demerol and 8mg of Zofran, 2000ml of NS while in route. Pt was taken to ER 4 at (Hospital #2) and report was given to ER nurse at bedside."


Review of a statement of the events of 7/28/15 concerning Patient #20, as written and signed by Physician #1 on 7/28/15 and submitted by Hospital #1, revealed:
"This morning I overheard (Nurse #1) speaking to (Paramedic #1) about an obvious hip rotation. The wife was waiting for him and she verbalized his cardiac comorbidity which included a pacemaker. I explained to her that (Hospital #2) would be a better option for his care as he would need cardiac clearance as well as orthopedics, services not available at this facility. It was during this time that the patient was rolled into the facility. I met him in the hall on the stretcher. There was an obvious deformity. I discussed with the patient that I believed he should be seen at (Hospital #2) simply because there would be a cardiologist and orthopedist who could care for him. I asked him if he would feel comfortable going there. He did not refuse treatment at (Hospital #2). I did not refuse to see the patient. I simply explained to him that I could not provide the services he required. He verbalized understanding that my intention was for his benefit."


Review of a 5/9/16 statement written and signed by EMT #2 regarding the 7/28/15 incident revealed:
"I, (EMT #2) and (Paramedic #1) were called to the courthouse for a fall of an elderly gentleman. Upon arrival we found an elderly male complaining of leg pain. We took the stretcher off the truck and assisted the male onto the stretcher and into the ambulance. We noticed that one leg was shorter than the other and got baseline vitals and a short medical history of the patient. We told the patient we believed he needed to go to (Hospital #2) because of the extent of his injury. The patient stated he wanted to go to (Hospital #1) because it was closer to home. We told patient two to three times he needed to go to (Hospital #2). We started to (Hospital #1) and (Paramedic #1) communicated with (Hospital #1) by phone. I do not know what was said between (Paramedic #1) and the E.R. Upon arrival at the E.R. we met (Physician #1) and (RN #1) in the hall. (Physician #1) talked with (Paramedic #1) and told him the patient needed to go to another facility that he should have been carried to start with. Told Dr. that we had tried three times to get patient to go to (Hospital #2) and he had refused and wanted to come to (Hospital #1). Dr. talked with patient further about his injuries and was told treatment could be started there but would then have to be transferred to another facility. The patient then said he would go to (Hospital #2). Upon turning to stretcher and starting out the door (Paramedic #1) then turned to me and said, "Call Air Evac." My response was, "Why are we calling Air Evac when we are only 36 miles away?" His response was "Because I told you to." I refused to call Air Evac and his response to me was I needed to learn to do my damn job and follow orders. As exiting the back door we ran into (EMT #1). (Paramedic #1) told (EMT #1) to call Air Evac. (EMT #1) had no idea what was going on and ask, "What am I calling them for?" At this point (Paramedic #1) began to talk very ugly to us. Patient's family was standing outside of E.R. and I ask were we not taking the patient and (Paramedic #1) told me to take my ass and the truck to the Heli Pad. I pulled truck to Heli Pad and stayed in cab because I did not want any more confrontation with (Paramedic #1). I looked up and saw (EMS Supervisor) coming toward the ambulance. She got in the ambulance and ask (Paramedic #1) what he had and what the extent of the injuries to the patient were. After they talked (EMS Supervisor) asked (Paramedic #1) to please take the patient to (Hospital #2). We carried patient to (Hospital #2) and turned over care."


Review of an undated, written and signed statement from RN #1 regarding the 7/28/15 incident with Patient #20 revealed: "At approximately 11:40 a.m. (Paramedic #1) gave report over cell phone with Bravo pt with obvious hip rotation. Reported vs (vital signs) are normal but pt insisted to come here at (Hospital #1). Wife was in the ER waiting on patient. (Physician #1) was speaking with wife about previous hx (history) and medications. Wife reported he had some heart conditions c (with) a pacemaker. Wife was wondering if he would go somewhere else. (Physician #1) gave her the options d/t (due to) heart condition and other comorbidities, also the obvious hip deformity. Wife would pick for (Hospital #2) or (another area hospital) for orthopedic surgeon and to clear for the cardiologist. Patient came through door per EMS stretcher. I noted obvious hip rotation c shortening on R (right) leg. (Physician #1) met him in the hallway with myself. (Physician #1) spoke to him if needed transport, pt agreed with wife to go to (Hospital #2) or (another area hospital). (Physician #1) expressed her belief that his hip was fx (fractured) and needed higher level of care due to comorbidities. Paramedic (#1) asked (Physician #1) if she was refusing to treat this patient. (Physician #1) denied this and wanted to make sure what he needed for treatment. (Paramedic #1) at the HOB (head of bed) stretcher he reported, "He refused to go anywhere else but here." Pt asked (Physician #1) if he needed to go for treatment. She did believe he needed treatment, pt agreed to go to (Hospital #2). (Paramedic #1) said, "Well I can just call the Air Evac." Sometime during speaking with pt he would like to go to (Hospital #2) now instead of the wait. (Paramedic #1) insisted that pt did refuse transfer elsewhere but here. With obvious hip fx c comorbidities needed quickly treatment, if he knew this, he should have called the Air Evac on scene instead of bringing obvious fx to a facility without orthopedics or cardiologists."



INTERVIEWS


On 5/24/16 at 3:45 p.m. an interview has held with Ambulance Service EMT #1. He stated, "I was not on call with (Paramedic #1) but heard first-hand what happened in the emergency department. (Paramedic #1) came through the door and stated that the doctor couldn't take care of him (the patient) here. The patient was adamant about coming here. (Paramedic #1) was very loud. I saw the doctor patting the patient on the hand and telling him he would have to go elsewhere. The Paramedic asked me to call a helicopter. I told him no. Afterward, the Paramedic asked partner (EMT #2) to call a helicopter and he wouldn't either. There was supposedly a helicopter called. It was thought to be (Paramedic #1) who called them. ...EMS Supervisor showed up and told (Paramedic #1) to take the patient by ground. The Paramedic was upset. Later said he was upset at the patient for wanting to come to this ED. (Paramedic #1) is good-hearted and means well, but has a short fuse. I also believe he was upset because the staff here was not listening to him. In other jobs he has been the boss and doesn't like to be told what to do."


On 5/25/16 at 10:30 a.m. an interview was held with Hospital #1's Chief Executive Officer (CEO) regarding the 7/28/15 incident involving Patient #20. He stated that Physician #1 was a very kind and capable doctor. He said he thought that she was just caught off-guard when Patient #20 came to this ED instead of to Hospital #2. He stated, "Also, she had to be somewhat upset when the paramedic brought this patient to our emergency department with these injuries and the paramedic began to talk loudly and inappropriately with the staff." The CEO offered no further information regarding no MSE, no stabilizing treatment, a delay in treatment and no transfer form being completed for Patient #20 on 7/28/15.


During an interview on 5/25/16 at 11:35 a.m. RN #1 stated, "The report was to have been over the radio from the ambulance. On this patient it came in by phone. Nobody could calm him (Paramedic #1) down that morning when the ambulance came in. He was manic. (Physician #1) asked the patient if he was in pain. The patient stated 'No'. The leg issue was obvious - rotated and looked shorter than the other one. (Physician #1) stated that the patient would need to be transferred due to his injury. The Paramedic cussed (Physician #1) in the hallway and took the patient out of the ER by stretcher. He also cussed the personnel (EMTs) while going out for not calling a helicopter. Paramedic #1 said, "This is bullshit" as he was taking the patient out of the ER. The patient heard all this. The patient was being rolled down to Room 2A (by ED staff). There are no vital signs taken because he never got in the bed. The ED staff was shocked and wondered what he (Paramedic #1) was doing. He was in a manic state. There was no time to complete a Transfer Form/MSE. (Paramedic #1) had acted like this before in front of a patient. We have tangled up before over things. (Physician #1) and I were expecting the patient to be placed in Room 2A. The stretcher was never brought to the bed. (Paramedic #1) left with the patient before being placed in the bed for vital signs. There was no chance to do the transfer form." The RN was asked about security and whether or not they were called on the day of the incident. She stated, "There used to be a security company, but I think EMS personnel were to function as security at the time of the incident."



During an interview on 5/25/16 at 12:05 p.m. about the 7/28/15 incident regarding Patient #20, EMT #2 stated, "I have known (Paramedic #1) for a long time. We worked together at another job. He did the same thing at (crisis center name) and they let him go from there. His part-time position there was tech. He was only there three (3) to four (4) months. The staff was more afraid of him than the patients. On the date of this incident (7/28/15) he was in a rage. (EMS Supervisor), over EMS, came out to the helicopter pad and talked with (Paramedic #1). After this, he calmed down and apologized for his behavior. He had pretty much been in a rage all day. (Paramedic #1) has been a basic EMT for about 14 years, then went thru the Academy and the EMT-Paramedic school. I told (Paramedic #1) this behavior was going to have to stop. Then he threatened me. He stated he was not going to rest until he got (EMS Supervisor) fired."


On 5/27/16 at 5:00 p.m. a telephone interview was held with Physician #3, the ED Medical Director at Hospital #1 when the incident occurred. Physician #3 was asked whether he could provide any information concerning the 7/28/15 incident when the 96 year old male patient was brought to the ED by ambulance and the physician on duty, (Physician #1), did not perform a MSE, no stabilizing treatment, and did not complete a Transfer Form. Physician #3 stated, "I have a lot of respect for (Physician #1) and I can tell you many things about the Paramedic and they are all bad. He was very disrespectful to female employees, both doctors and nurses. He did this a lot. "If somebody needs help and we have the services to admit the patient, they are to be brought here and sometimes stabilized and transferred." Physician #3 offered no further information regarding no MSE, stabilizing treatment or transfer form being completed for Patient #20.



On 5/31/16 at 8:30 a.m. Physician #1 returned a 5/26/16 telephone call made requesting an interview. When she was asked to tell what occurred at Hospital #1 regarding a patient by the name of (Patient #20) on the day of 7/28/15, she stated, "The patient, an elderly male, was brought in by ambulance. He should have been taken to a hospital with an orthopedic physician/surgeon. The paramedic made call to the emergency department over the telephone instead of the radio, by policy. He gave only that the patient fell and his vital signs. He stated that the patient insisted on coming to that hospital. The patient was brought by stretcher into the ED. I saw him and observed his injury briefly and determined he needed an orthopedic specialist. The patient was told that he needed to go to (Hospital #2) and he agreed to go. He was asked about pain and stated no pain. They were preparing to take the patient into a room for further MSE, vital signs by a nurse, etc, when the paramedic took the patient back to the ambulance. He wanted to send the patient to (Hospital #2) by helicopter. He was previously outside making a scene. This was the only time we had a conflict. I do not remember the patient's wife. This was not our normal procedure at all." Physician #1 offered no further information regarding no MSE, stabilizing treatment or transfer form being completed for Patient #20.



On 5/31/16 at 3:45 p.m. a telephone interview was held with RN #2, the first nurse to see and admit Patient #20 to the ED at Hospital #2. RN #2 was asked if he remembered the elderly male patient who had a fractured hip brought to their ED by EMS on 7/28/15. He said that they see 3,000 to 3,500 patients per month and it would be hard to remember that far back. RN #2 did state that it was not uncommon for (Hospital #1), for EMS to bring straight over without being evaluated. We service eight (8) counties. It's hard to remember." The RN could offer no further information.


On 5/31/16 at 5:30 p.m. a telephone interview was held with the wife of Patient #20. She was asked if they could give a summary of their experience at Hospital #1 following (Patient #20's) fall at the courthouse on 7/28/15. She said she could speak for herself because her husband fell on 8/9/15 and died on 8/14/15 of pneumonia in (another area hospital). Regarding the 7/28/15 incident she stated, "He was only there for a short time. They took him in the ambulance around to the door. He never was taken out of the ambulance." The patient's wife was asked if Patient #20 had insisted on going to Hospital #1) ED. She stated, "They took him there. I don't think he requested it." When asked if anyone was rude to them there, she stated "No". She did not know whether the doctor said she would not see him or told the ambulance crew to take him on to (Hospital #2).


On 6/7/15 at 10:15 a.m. a telephone interview with Hospital #1's Quality/Clinical Development Coordinator revealed that Hospital #1 has two (2) EMTALA programs each year. "We have a Super Bowl each January where employees have a month to complete the power point program with a test at the end. This is from each January 25th to February 25th. The second EMTALA program for employees is given live by the Chief Nursing Officer. " Review of information faxed that day revealed sign-in sheets for EMTALA program dated 5/15/16 at 1:00 p.m. with EMS, 5/19/16 at 5:00 p.m. with Business Office, 5/31/16 at 3:00 p.m. and 7:30 p.m., and on 6/1/16 at 10:00 a.m., 1:00 p.m., 5:00 p.m. and 7:30 p.m.



POLICIES AND PROCEDURES


Review of the facility's "Emergency Room - Objectives" policy (reviewed 08/2012; 6/2015) revealed: "1. Services provided for emergencies shall be of high quality and rendered in an effective manner. 2. To render immediate attention to those patients who come or are brought to the emergency service... 7. To maintain an environment conducive to providing quality of care for all patients... 9. To promote good public relations with patients, their families and anyone coming to the emergency department."


Review of the facility's "Emergency Department Triage" policy (reviewed 08/2012; 06/2015) revealed: "Policy: Patients presenting to the Emergency Department are triaged as soon as possible after arrival to the Emergency Department. Objectives of Triage: The goals of triage are the identification of patients needing immediate care and the determination of the appropriate treatment area for each patient... Primary Functions:... Provides preliminary assessment of patients... Obtasins and documents medical history. Documents pertinent information on triage record..."


Review of the facility's "Emergency Room - Documentation of Triage" policy (reviewed 08/2012; 06/2015) revealed: "The triage personnel documents the following information on the triage record or on an appropriate portion of the medical record. Date. Time of arrival. Name of patient... Complete set of vital signs. Chief complaint. Assessment... Mode of arrival. Triage classification... Any intervention begun or completed prior to arrival at ED... Disposition of patient. Pertinent medical history... The triage nurse documents any intervention under the Treatments section of the triage record..."


Review of the facility's "Emergency Room Records" policy (reviewed 08/2012; 06/2015) revealed:
"Policy: Records will be kept for each patient who is treated in the ER. Promptly filled out and accurate records will be maintained as to the proper identification and treatment given to patients in the ER. Procedure: 1. A visit number will be assigned in the EMR for all patients. 2. The ER record will be completed at the triage area by the patient or family member with the patient... 4. Nursing personnel are responsible for documenting all nursing treatment rendered and for stating the patient's progress. 5. Time of discharge for the ER should be stated. 6. All numbered emergency records will be logged in the ER log in the computer."


Review of the facility's "Emergency Room Philosophy, Responsibilities, Functions, Objectives" policy (reviewed 08/2012; 06/2015) revealed: "... A. Responsibilities in the area are to: ... 3. Provide for the keeping of complete and accurate medical records on each patient... B. Functions of the Emergency services are to give: 1. Adequate appraisal and initial treatment or advice to any person who considers himself acutely ill or injured and presents himself at the Emergency area... C. Objectives of the Emergency Services area are: 1. Provide care for persons who have been injured or have been taken suddenly ill..."


Review of the facility's "Provisions of Patient Care - Emergency Room" policy (reviewed 08/2012; 06/2015) revealed: "... THe ER team provides immediate assessment and prioritization of immediate needs according to the triage policy... Some services, which are not provided, are... orthopedic,... and cardiology except on an emergency basis. After emergency measures have been initiated and the patient stabilized, within the capabilities of the ER Department, the patient may be admitted to a unit within the hospital, transfered to another institution..."


Review of the facility's "Scope of Care - Emergency Room" policy (reviewed 08/12; 12/12; 06/2015) revealed: "As Level IV Trauma Center...department is responsible for the immediate treatment of medical and surgical emergency... After stabilization,... cardiac,... orthopedics, and some surgical patients are often transferred to other facilities via ambulance..."


Review of the facility's "Emergency Room ...Evaluation And Transfer Of Patients With Emergency Medical Conditions..." Policy # ER.0151 (reviewed 08/2012; 06/2015) revealed: "Purpose: To establish a method for the screening and, if indicated, transfer of hospital inpatients who have unstable emergency medical conditions better elsewhere... To comply with local, state and federal laws. Terms:... E. Emergency Department Log 1. A log will be maintained to record each individual who comes to the emergency department.... Policy: I. Medical Screening - Persons requesting examination or treatment for medical/psychiatric conditions are provided appropriate medical screening examinations... Initial medical screening and treatment includes the use of necessary ancillary services..."


Review of the facility's "Emergency Room ...Evaluation And Transfer Of Patients With Emergency Medical Conditions..." Policy # ER.0152 (reviewed 08/2012; 06/2015) revealed: ...Procedure: 1. Initiates ED log with patient name, date, time of arrival...presenting complaint... Triage Personnel 2. Performs triage evaluation and provides further evaluation and stabilizing treatment as appropriate... 3. Registers patient and generates a medical record... ER Physician... 4. a. Performs medical screening evaluation and stabilizing treatment. b. Explains need for further treatment,...and if indicated, need for transfer, and risk and benefits of transfer. c. If stable... completes Authorization for Transfer..., including haveing the patient/authorized representative sign in the appropriate spaces... If patient is to be transferred... because the anticipated benefits exceed the risks, (1) provides stabilizing treatment according to available resources. (2) has received agreement of the receiving facility and receiving physician to accept transfer and provide appropriate medical treatment..."


Review of the facility's "Emergency Physician Patient Care Responsibility" policy (reviewed 08/2012; 06/2015) revealed: "...I. Orthopedic Patients - The emergency department physician will be responsible for diagnosing fractures and immobilizing them appropriately. Other treatment for pain and supportive measures should also be initiated... Transfer of patient for further care should be done after consultation with the appropriate back-up physician... VI. Patient Transfers To Other Facilities - A complete and comprehensive transfer note should accompany any patient transferred to another facility... Always contact the facility to which you are transferring the patient to apprise them of the patient's status and complete the Cobra (Transfer) form... VIII. Patient Records - The emergency department physician will legibly complete the entire physician's portion of the patient's chart on each and every patient her attends..."


Review of the facility's "Transfer Guidelines for Adult and Pediatric Trauma Patients" policy (reviewed 08/2012; 06/2015) revealed: "Objective:... each case should be evaluatedby the Emergency Room Physician to determine appropriate treatment. Procedure: ... B. Transfer of patient shall be in accordance with State and Federal Law... D. The hospital shall have the responsibility for obtaining the consent for transfer from the patient...E. The attending nurse will call report to the nurse at the accepting hospital. F. A copy of medical record... shall be sent with the patient or faxed after transport initiated to prevent delay in treatment. G.... the patient shall be stabilized..."

Review of the facility's "...Emergency Room Transfers" policy (reviewed 06/2015) revealed: "Purpose: To establish guidelines regarding the transfer of the... ER patient. To ensure the patient receives adequate care and is transferred to the appropriate facility. Policy: Emergency Room Transfers: 1. Transfers from the Emergency Room will be facilitated by the ERP (Emergency Room Physician)... 4. The patient must be medically stabilized to the best capability of this facility. 5. The patient or representative must agree to the transfer, and acceptance to the receiving facility must be made physician to physician with documentation of the receiving facility's physician's name.... 7. Patients will be transferred according to EMTALA Guidelines...8. Transfer papers will accompany patient or be faxed... This includes...EMTALA form...Documentation of report, condition and vital signs prior to transfer. 9. A nurse to nurse report should be given to the receiving facility prior to transport...


Review of the facility's "Medical Staff Bylaws" (revised 6/30/15) revealed:
"Section 8. Responsibilities of each Member. A. Each staff member must provide appropriate, timely and continuous care of his/her patients. He/she is not responsible for the actions of other staff members, allied health professionals ...or health system employees."


Review of the facility's "Security Plan" policy (reviewed 7/17/2015) revealed: "Purpose: To ensure that this facility meets all the Security needs of patients, visitors, and employees. This Security Plan is inclusive of all buildings... Policy: The Ambulance Service staff is responsible for security duties..."



CONCLUSION:
The complaint regarding Patient #20 was substantiated as a Past Non-Compliance and EMTALA violations were cited for the facility's failure to ensure this patient received a Medical Screening Exam from a physician during the time he was in their facility, failure to ensure the patient received stabilizing treatment, failure to ensure the patient received no delay in treatment and failure to ensure the patient received an appropriate transfer from their facility to another hosp

Based on Emergency Department (ED) record review for Hospital #1, Emergency physician report, physician interviews, Medical Director interviews, Administrator interview, ED staff interviews, Emergency Medical Services (EMS) personnel report, EMS interviews, EMS handwritten statement review, family interview, and Hospital #2 medical record review, the hospital failed to provide Patient #20, one (1) of 30 patients reviewed, with an appropriate Medical Screening Examination (MSE) within the capability of the hospital ' s emergency department.


Findings Include:


Cross Refer to A2400 for the hospital's failure to provide Patient #20 with an appropriate MSE within the capability of the hospital's ED.

Based on Emergency Department (ED) record review for Hospital #1, Emergency physician report, physician interviews, Medical Director interviews, Administrator interview, ED staff interviews, Emergency Medical Services (EMS) personnel report, EMS interviews, EMS handwritten statement review, family interview, and Hospital #2 medical record review, the hospital failed to provide Stabilizing Treatment within its capacity that minimized the health risks of Patient #20, one (1) of 31 ED patients reviewed.


Findings Include:


Cross Refer to A2400 for the facility's failure to ensure the provision of stabilizing treatment for Patient #20.

Based on Emergency Department (ED) record review for Hospital #1, Emergency physician report, physician interviews, Medical Director interviews, Administrator interview, ED staff interviews, Emergency Medical Services (EMS) personnel report, EMS interviews, EMS handwritten statement review, family interview, and Hospital #2 medical record review, the hospital did not prevent a delay in treatment for Patient #20, one (1) of 31 patients reviewed.

Findings Include:


Cross Refer to A2400 for the facility's failure to ensure Patient #20 did not receive a delay in treatment.

Based on Emergency Department (ED) record review for Hospital #1, Emergency physician report, physician interviews, Medical Director interviews, Administrator interview, ED staff interviews, Emergency Medical Services (EMS) personnel report, EMS interviews, EMS handwritten statement review, family interview, and Hospital #2 medical record review, the hospital failed to provide an appropriate Transfer for Patient #20, one (1) of 31 ED patients reviewed.


Findings Include:


Cross Refer to A2400 for the facility's failure to ensure the provision of an appropriate transfer for Patient #20.