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On the days of the EMTALA investigation survey based on observations, interviews, review of hospital policy and procedures, and hospital emergency room audio transmission, the hospital failed to provide a medical screening examination for a patient transported via emergency medical services to its emergency department for 1 of 1 patients. (Patient 21)


The findings are:

Cross Reference to A 2406: The hospital failed to provide a medical screening examination to determine the existence of an emergency medical condition for 1 of 1 patients transported via Emergency Medical Services (EMS) to the hospital's emergency department.

The hospital submitted the following action plan:

1. Since the summer of 2013, the CEO (Chief Executive Officer) and Medical Staff Leadership have been actively recruiting gastroenterologists to practice at the Hospital. Two gastroenterologists will be at the hospital by July 1, 2014 and one of whom will begin practice at the Hospital on April 1, 2014 and who will begin taking call after an appropriate orientation to the hospital, which includes a review of EMTALA requirements as they pertain to on - call physicians.

2. On March 20, 2014, the CEO, Chief Nursing Officer (CNO), Chief Quality Officer (CQQ), ED Medical Director and ED Director spoke with the President of the ED physician group with which the hospital contracts for ED services, to discuss Mary Black Memorial Hospital hospital's EMTALA policy and procedures, including the handling of requests from ambulances and patients who arrive to the hospital by ambulance.

3. On March 20, 2014, ED Director, contacted the ED nurse who participated in the call with EMS to discuss the incident, our EMTALA policy and the duty of the staff to report any patient safety concerns to the Charge Nurse or escalate concerns utilizing the chain of command.

4. On March 20, 2014, the ED Medical Director reeducated the ED physician on call regarding EMTALA requirements and related physician duties and responsibilities, including responsibilities concerning patients who arrive in ambulances.

5. On March 26, 2014, the CNO, CEO, and ED Director met with the ED Charge nurses to reeducate on EMTALA, Chain of Command and the procedure for reporting patient safety concerns.

6. By March 31, 2014, CNO met with the Nursing Supervisors to reeducate on EMTALA, Chain of Command, and the procedure for reporting patient safety concerns.

7. On April 3, 2014, the Medical Staff Performance Improvement Committee met to review the occurrence and subsequent actions taken by the hospital.

8. A Quality Assurance Process Improvement team convened on April 4, 2014, to review handling of all Ambulance calls to assure compliance with the hospital's policy and procedures and that responses are appropriate.

9. On March 26, 2014, EMTALA compliance was added as a permanent agenda item to all ED staff meetings to assure ongoing compliance.

On the days of the EMTALA complaint investigation based on review of the hospital policy and procedures, review of hospital audio transmission, interview, and review of the "Patient Care Report", the hospital failed to provide a medical screening examination and treatment for a patient transported via Emergency Medical Services (EMS) at the patient's request to the hospital's emergency department for 1 of 1 patient who presented to the hospital's emergency department via ambulance transport seeking care. (Patient 21)


The findings are:


Hospital policy, titled, "EMTALA Policy", LD .0021, effective 02/09/2007, reads, "....To provide a Medical Screening Examination (and Treatment as required) to an individual brought in by ambulance, regardless of ownership, if the ambulance is on Hospital Property, for purposes of examination or treatment at the Hospital's Dedicated Emergency Department...5. If it determined that the individual has an Emergency Medical Condition, to provide the individual with further medical examination and treatment as required to stabilize the Emergency Medical Condition within the Capability of the Hospital unless an appropriate transfer to another medical facility is necessary because the Hospital lacks either the Capacity or Capability to Stabilize the individual's condition. Definition 1: Campus of the Hospital or Hospital Property-The physical area immediately adjacent to the Hospital's main buildings, and other areas and structures that are located within 250 yards of the main building that provide care for Hospital patients....Definition 13: Comes to the Emergency Department: is on Hospital Property in a ground or air ambulance not owned by the hospital for presentation for examination and treatment for a medical condition a Hospital's Dedicated Emergency Department.

On 04/02/14 at 3:00 p.m., review of emergency medical services(EMS) crew audio transmission dated March 18, 2014 to MBMH (acute care hospital) submitted by the Director, Emergency Department cell phone revealed a female voice transmitting a call to MBMH that the EMS transport crew was transporting a patient with a complaint of vomiting blood since 11:00 p.m. who had received a stent placement in right kidney earlier today. The audio revealed a return call from MBMH requesting the name of hospital where the patient had the surgery performed. The name of the hospital was stated by the EMS crew. Then, MBMH instructed the EMS crew to transport the patient to Hospital B(another acute care hospital within five (5) miles) because MBMH had no gastrointestinal services. The EMS crew returned a call to MBMH and stated that the patient requested transport to MBMH, and "we are pulling up". MBMH returned a call to the EMS crew to transport the patient to Hospital B. The audio transmission ended. On 04/02/14 at 3:15 p.m., the Director revealed that the term "pulling up" means "they are close".

On 4/3/14 at 10:00 a.m., a review of ambulance patient care run report for Patient 21 revealed, "Pt (patient) A O x 4 (alert and oriented), jaundice in color, warm, dry. Pt states has been vomiting since outpatient procedure this am(morning) from Hospital B (an acute hospital). Pt states had a stent placed in R (right) kidney from obstruction. Daughter states blood became present in vomit about 23:00 (11:00 p.m.). Pt denies SOB (shortness of breath), denies diarrhea, denies fever. No vomiting present w (with) EMS (Emergency Medical Services)....Transferred pt (patient) to main stretcher. Per pt xport (transport) to MBMH (acute care hospital), per MBMH divert to patient to Hospital B....".

On 4/2/14 at 2:20 p.m., the hospital's Chief Quality Officer reported, "We (Mary Black Memorial Hospital) lost our three (3) Gastroenterologists since July 1, 2013. If a patient with a gastroenterology complaint presents to our emergency department, the emergency department consults with a general surgeon on call. Either the patient is admitted, discharged after treatment, or transferred to a hospital with Gastroenterology specialists.

On 4/3/14 from 10:00 a.m. to 10:15 a.m., Paramedic 1 verified that he/she was on duty on March 18, 2014 and revealed the emergency medical services transport unit was dispatched to an assisted living facility for a patient who was vomiting. Paramedic 1 stated the patient's daughter and the assisted living staff reported the patient had a stent placed in the patient's left kidney earlier in the week at hospital B. Paramedic 1 reported, "The patient's skin color and vitals were stable. The patient's daughter stated for the patient to go to Hospital B, but the patient stated, "no, go to MBMH". Paramedic 1 stated, "My partner called a few times before contacting someone at MBMH. After contacting MBMH staff and relaying the report, the nurse at MBMH who received the EMS transport crew's report asked the EMS transport crew where the patient had the procedure. Paramedic 1 stated, "I'm driving slowly so they can finish report when the nurse states for us to divert the patient to Hospital B." My partner states, "the patient is adamant about coming here". The patient states "no" to a diversion to Hospital B. Paramedic 1 reported that information at this time, and the ambulance is about to be under the canopy of MBMH's emergency room. Paramedic 1 stated, "We were probably less than 75 feet from being under the canopy." Paramedic 1 reported, "So when the nurse said to divert, I stopped, talked to daughter who was already out of the car, told her what was going on, and she spoke to the patient, and we left....". When asked how long the ambulance was on the property of MBMH, Paramedic 1 stated, "about 5-6 minutes".

On 04/03/14 at 10:20 a.m., Paramedic 2 verified that he/she was on duty on March 18, 2014 and stated that he/she recalled the incident on March 18, 2014 that started with a call to the patient's residence because the patient was vomiting blood. Paramedic 2 reported that the patient's daughter reported the patient had a stent placed in a kidney at Hospital B, and then had started vomiting blood around 11:00 p.m.. Paramedic 2 reported the patient requested transport to MBMH. Paramedic 2 stated the patient was loaded into the ambulance and a call was placed to MBMH to give the patient's complaint and history of recent surgery. Paramedic 2 stated that MBMH answered the call and requested the location of the hospital that had performed the patient's surgery. Paramedic 2 stated that after the requested information was relayed to MBMH, EMS was instructed by MBMH staff to transport the patient to Hospital B because MBMH did not have gastrointestinal services. Paramedic 2 stated that he/she returned a call to MBMH informing MBMH staff that the patient requested transport to MBMH. By this time, Paramedic 2 stated that the ambulance was already on MBMH's property, but MBMH called and gave instructions to transport the patient to Hospital B. Paramedic 2 stated that by the end of the radio call, the ambulance had pulled under the hospital's canopy to circle around and go to Hospital B.

On 04/03/14 at 2:25 p.m., MBMH Emergency Department (ED) Physician 4 stated he/she was on duty on March 18, 2014 when the incident occurred. ED Physician 4 stated the incident involved a call from the EMS transport crew with a patient with a complaint of vomiting blood who had surgery on the kidney the day before. ED Physician 4 stated that he/she inquired about the location of where the surgery was performed, and then gave instructions for the EMS crew to transport the patient to Hospital B because we (MBMH) did not have gastrointestinal services. The EMS crew returned a second call stating that the patient wanted to be seen at MBMH. ED Physician 4 stated that he/she gave instructions for the EMS crew to transport the patient to Hospital B. ED Physician 4 stated, "I think by the second call they (EMS) were already on the property.

On 4/3/14 from 5:00 p.m. to 5:05 p.m., the Chief Quality Officer reported that EMS notified them (MBMH) on the morning after the incident stating that they(EMS) just wanted to make them(MBMH) aware of the incident. The Chief Quality Officer reported that an investigation of the incident was initiated.


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On 4/3/14 from 10:42 a.m. to 11:00 a.m., during an interview with Emergency Department Registered Nurse (RN) 1, RN 1 verified that he/she was on duty in the emergency department on March 18 when the incident occurred. RN 1 revealed, "around 2:00 am, EMS (emergency medical services) called, and I answered the radio. EMS gave a brief history about the patient, outpatient surgery day before, vitals signs, age of patient, and what had transpired earlier. The chief complaint was expression of blood and nausea and vomiting. The physician, (Emergency Room Physician 4) had me ask the EMS crew where the surgery was, and they(EMS crew) stated the patient had it at Hospital B. Then, the physician advised me to have them take patient back to Hospital B for continuity of care. They (EMS crew) stated that they were pulling in. I took that to be off the streets. So I didn't go to see if they were outside or not. Radio transmission ended. The ambulance pulled through the bay very slowly and turned their lights on and left....". RN 1 reported that if a patient presents to the emergency department with a condition that the emergency room or general surgeon can't handle, the patient is transferred to another hospital. RN 1 reported that he/she was not really familiar with the hospital's EMTALA policies, but that he/she had a conversation with the Chief Nursing Officer and is scheduled for EMTALA training. RN 1 stated that he/she had worked at MBMH 's emergency department approximately four (4) months. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to provide a medical screening examination to Patient #21 brought in by ambulance on March 18, 2014 and was on hospital property (verified by interview by RN 1) for purposes of examination or treatment at the Hospital's dedicated Emergency Department.