Memorial Health University Medical Center

Based on review of the Medical Emergency Team log, ED Central Log, Medical Staff Rules and Regulations, policies and procedures, tour, staff interviews, observations, credential files, and personnel files, it was determined that the facility failed to ensure that an approrpiate medicdal screening examination was provided for an individual after a prudent layperson observed and beleived that one visitor (Visitor #1) on hospital property was suffering from a possible emergency medical condition.

Findings were:

1. Cross refer to A-2406, as it relates to failure to provide an appropriate medical screening examination for Visitor #1.

Based on review of the Medical Emergency Team (MET) log, Emergency Department Central log, review of medical records, Medical Staff Bylaws Rules and Regulations, policies and procedures, credential and personnel files, staff interviews, and observations during a facility tour, it was determined that the facility failed to provide an appropriate medical screening examination that was within the capability of the hospital's emergency department to determine whether or not an emergency medical conditions existed, when a prudent layperson observed and beleived that a visitor (Visitor #1) on the facility's property suffering from a potential emergency medical condition.

Findings included:

1. Medical Emergency Team (MET) Log and Emergency Department (ED) Central Log

A review of the Medical Emergency Team (MET) Log revealed that on 4/29/19 at 3:25 p.m., the MET was activated for a visitor (name unknown) in the hospital snack bar with symptoms of weakness and being pale. The log revealed that the visitor refused treatment in the Emergency Department (ED).

Further review of the MET Log dated 1/1/19 through 5/31/19 revealed the following:

In January 2019, MET was activated a total of 224 times. Of these, nine (9) incidents involved non-patients in public areas. Of these nine (9), three (3) refused treatment in the ED.

In February 2019, MET was activated a total of 211 times. Of these, five (5) incidents involved non-patients in public areas. Of these five (5), one (1) did not include an outcome.

In March 2019, MET was activated a total of 195 times. Of these, three (3) incidents involved non-patients in public areas. Of these three (3), one (1) refused treatment in the ED.

In April 2019, MET was activated a total of 218 times. Of these, thirteen (13) incidents involved non- patients in public areas. Of these thirteen (13), three (3) refused treatment in the ED.

In May 2019, MET was activated a total of 266 times. Of these, three (3) incidents involved non-patients in public areas who were taken to the ED

The ED Central log dated 1/1/19 through 6/15/19 was reviewed.

2. Interviews

An interview with Security Officer (Security) DD took place in an administrative conference room on 6/18/19 at 10:15 a.m. Security DD recalled that he responded to a request for assistance with a visitor in the concession area who was not feeling well. Security DD observed Visitor #1 to be pale and sweaty and complained of nausea and abdominal pain. Visitor #1 explained that she was visiting a friend who was having surgery after a motor vehicle accident. Security DD called for assistance from the Medical Emergency Team (MET) and RN BB responded. Security DD recalled that RN BB told Visitor #1 that he could take her to the ED but that she would have to pay. Security DD recalled that RN BB reiterated this statement several times. Security DD and RN BB escorted Visitor #1 via wheelchair to the surgical waiting area to find her (Visitor #1) husband. Visitor #1 was assisted to the bathroom by her husband where they remained for 10 to 15 minutes. Security DD recalled that Visitor #1 required assistance with ambulation. Security DD stated that RN BB reiterated to Visitor #1's husband that he (RN BB) could take Visitor #1 to the ED but there would be a charge for the visit. Visitor #1 and her husband declined the ED at which point RN BB informed Security DD that he had other matters to take care and requested that Security DD escort Visitor #1 to their vehicle. Security DD recalled that Visitor #1 and her husband had limited English proficiency. Visitor #1 did not tell Security DD that money was a factor in her decision not to go to the ED.

A phone interview with RN BB took place on 6/17/19 at 7:00 p.m. RN BB explained that he was a Registered Nurse (RN) and had been working on the Critical Care unit for several years. RN BB recalled that on 4/29/19 he was assigned to be the MET RN and responded to a request for assistance in the concession area. Upon arrival to the concession area, RN BB observed Visitor #1 leaning against a counter. Visitor #1 was alert, oriented, and pale in color. Visitor #1 explained that she was visiting a friend who was having surgery. Visitor #1 advised RN BB that her husband was in the surgical waiting area. RN BB stated that Security DD retrieved a wheelchair for Visitor #1 and she was assisted into the wheelchair. RN BB asked Visitor #1 if she wanted to go to the ED or go to find her husband. RN BB recalled that at some point in the dialogue, he told Visitor #1 that there may be a charge for going to the ED. RN BB further explained that MET RN's were instructed, over ten years ago, to disclose that there may be a charge incurred to any non-patient in public spaces who requested to go to the ED. RN BB recalled that Visitor #1 requested to go find her husband and was taken to the surgical waiting area. At some point during the dialogue, RN BB asked Visitor #1 if she had been out of the country recently, which she replied 'no'. RN BB explained that questions about foreign travel are routine in the ED and admission process. Once in the surgical waiting room, Visitor #1 stated that she needed to have a bowel movement and was assisted by her husband to the bathroom. RN BB asked Security DD to remain present in case assistance was required. After Visitor #1 was done in the bathroom, RN BB again asked her if she wished to go to the ED. RN BB stated that Visitor #1 and her husband were emphatic that they did not wish to go to the ED. RN BB asked the Security DD to escort Visitor #1 and her husband to their vehicle. RN BB recalled that he was assigned to care for Visitor #1's friend the next day in the critical care unit and spoke with Visitor #1. RN BB recalled that Visitor #1 hugged and thanked him for his assistance the previous day. RN BB stated that as a result of this incident, all MET nurses were reminded of the applicability of EMTALA with visitors. RN BB stated that at the time of this incident, he had recently completed the facility's mandatory annual competencies which included EMTALA. The facility failed to ensure that an appropriate medical screening examination was provided on for visitor #1, after a suggestion was made by a hospital staff member that visitor #1 could go to the ED, but would have to pay. As this suggestion resulted in Visitor #1 refusing to go to the ED for a medical screening examination.

An interview with MET Director (Director) AA took place on 6/17/19 at 2:00 p.m. in an administrative conference room. MET Director AA explained that in addition to MET, she was the Director of the Trauma Intensive Care Unit (ICU), Neurology ICU, and PICC Team. Staff assigned to MET included a Critical Care RN, a Critical Care Registered Respiratory Therapist (RRT), and a Critical Care Internal Medicine Resident. RN's assigned to be the MET RN for the shift were Critical Care RN's but did not have a patient assignment while assigned to MET. Hospital staff activated MET for clinical concerns about patients and non-patients. The MET responds to all areas on the hospital premises as well as all Code Blue (code announced when a patient or non-patient goes into cardiac or respiratory arrest). Director AA explained that one of the requirements to be a MET RN was to have an advanced certification such Critical Care Certification or be currently enrolled in a certification class.

Director AA recalled that on 4/29/19, RN BB was assigned to be the MET RN. Director AA observed RN BB in the hospital vending area attending to Visitor #1, who had complained of faintness. Director AA explained that she did not actively assist RN BB but did remain and observe in case RN BB required additional assistance. Director AA recalled that Security DD and another ancillary staff member were also present. Director AA recalled that RN BB assisted Visitor #1 into a wheelchair and asked if she wanted to go to the Emergency Department. Director AA could not hear Visitor #1's response. RN BB told Visitor #1 that there may be a charge for the ED. Director AA explained that it had been the practice of MET to inform non-patient's that a charge for the ED visit was possible. Visitor #1 requested to find her husband who was in the vicinity of the surgical waiting area. Director AA recalled that RN BB took Visitor #1 to the surgical waiting area accompanied by Security DD. RN BB later informed Director AA of the events that took place in the surgical waiting area. Once in the surgical lobby, Visitor #1 requested to go to the bathroom and her husband assisted her in the bathroom. Visitor #1's husband informed RN BB that she (Visitor #1) had ongoing gastrointestinal problems that caused her to frequent the bathroom. RN BB requested Security DD remain close by in the event assistance was needed. RN BB assisted Visitor #1 back into the wheelchair and asked her if she had been out of the country recently. RN BB again asked Visitor #1 if she wanted to go to the ED and she declined. RN BB informed Director AA that he spoke with Visitor #1 and her husband the next day as he was the RN assigned to care for Visitor #1's friend/family. Visitor #1 told RN BB that she felt better and thanked him for his assistance.

Director AA explained that after the incident was brought to her attention, she met one on one with all MET nurses and reviewed EMTALA regulations. All MET RN's were required to complete a computer-based learning module on EMTALA and sign an attestation. Director AA explained that all staff members were required to complete annual computerized learning that included a review of EMTALA obligations.

During the exit conference on 6/18/19 at 3:00 p.m. in an administrative conference room Chief Medical Officer (CMO) FF stated that until this incident, he had been unaware of a practice of informing non-patients that there may be a cost associated with a visit to the ED.

3. Policies and Procedures

Review of the facility's policy number LL.EM.2 titled ' EMTALA - Medical Screening Examination and Stabilization Policy', last reviewed 2/18 revealed in part: The purpose of the policy was to establish guidelines to provide appropriate medical screening examinations (MSE) and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA, 42 U.S.C. º 1395dd, and all Federal regulations and interpretive guidelines promulgated thereunder..

Further review of the policy revealed that an EMTALA obligation was triggered when an individual came to a dedicated emergency department (DED) and:

1. the individual or a representative acting on the individual's behalf requested an examination or treatment for a medical condition; or

2. a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needed an examination or treatment of a medical condition.

Such obligation was further extended to those individuals who presented elsewhere on hospital property requesting examination or treatment for an emergency medical condition (EMC). Further, if a prudent layperson observer would believe that the individual was experiencing an EMC, then an appropriate MSE, within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of on-call physicians), would be performed. The MSE must be completed by an individual (i) qualified to perform such an examination to determine whether an EMC exists, or (ii) with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. If an EMC was determined to exist, the individual was provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilization treatment was applied in a non-discriminatory manner (e.g., no different level of care because of age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state or local law).

The policy revealed that an MSE was required when an individual arrived on the hospital property, either in the DED or property other than the DED, did not request for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment.

The policy revealed the following regarding the extent of the MSE:

a. The hospital must perform an MSE to determine if an EMC existed. It was not appropriate to merely log in or triage an individual with a medical condition and not provide an MSE. Triage was not equivalent to an MSE. Triage entailed the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual was screened by a physician or other QMP.

b. An MSE was the process required to reach, with reasonable clinical confidence, the point at which it was determined whether the individual had an EMC or not. An MSE was not an isolated event. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital.

c. The individual was continuously monitored according to the individual's needs until it was determined whether or not the individual had an EMC, and if he or she did, until he or she was stabilized or appropriately admitted or transferred. The medical record reflected the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer.

d. The extent of the necessary examination to determine whether an EMC existed was generally within the judgment and discretion of the physician or other QMP that performed the examination function according to algorithms or protocols established and approved by the medical staff and governing board.

e. The MSE varied based on the individual's signs and symptoms:

The hospital was required to provide an MSE and necessary stabilizing treatment to any individual regardless of age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state or local law.

Further review of the policy revealed that only the following individuals performed an MSE:

1. A qualified physician with appropriate privileges;

2. Other qualified licensed independent practitioner (LIP) with appropriate competencies and privileges; or

3. A qualified staff member who:

a. was qualified to conduct such an examination through appropriate privileging and demonstrated competencies;

b. was functioning within the scope of his or her license and in compliance with state law and applicable practice acts (e.g., Medical or Nurse Practice Acts);

c. was performing the screening examination based on medical staff approved guidelines, protocols or algorithms;

d. was approved by the facility's governing board as set forth in a document such as the hospital bylaws or medical staff rules and regulations, which document has been approved by the facility's governing body and medical staff. It was not acceptable for the facility to allow informal personnel appointments that could change frequently.

QMPs performed an MSE if licensed and certified, approved by the hospital's governing board through the hospital's by-laws, and only if the scope of the EMC is within the individual's scope of practice. The designation of QMP was set forth in a document approved by the governing body of the hospital. Each individual QMP approved to provide an MSE under EMTALA was appropriately credentialed and met the requirements for annual evaluations set forth in the protocol agreements with physicians and the State's medical practice act, nurse practice act or other similar practice acts established to govern health care practitioners. Only appropriately credentialed APRNs, PAs and physicians performed MSEs in the DED.

An MSE, stabilizing treatment, or appropriate transfer was not delayed in order to inquire about the individual's method of payment or insurance status or conditioned on an individual's completion of a financial responsibility form, an advance beneficiary notification form, or payment of a co-payment for any services rendered. The facility followed reasonable registration processes for individuals for whom examination or treatment was required. Reasonable registration processes could include asking whether the individual was insured, and if so, what that insurance was, if these procedures did not delay screening or treatment or unduly discourage individuals from remaining for further evaluation. The hospital could seek non-payment information from the individual's health plan about the individual, such as medical history. Requests for payment of copays, deductibles or a deposit for the encounter were not to be made until after completion of an MSE and the provision of any necessary stabilization treatment.

The performance of the MSE and the provision of stabilizing treatment was NOT conditioned on an individual's completion of a financial responsibility form, an advance beneficiary notification form, or payment of a co-payment for any services rendered.

Continued review of the policy revealed that individuals who inquired about financial responsibility for emergency care were provided a response by a staff member who had been well trained to provide information regarding potential financial liability. The staff member providing information on potential financial liability should clearly inform the individual that the hospital will provide an MSE and any necessary stabilizing treatment, regardless of his or her ability to pay. Individuals who believe that they have an EMC should be encouraged to remain for the MSE.

If an individual refused to consent to examination or treatment and indicated his or her intention to leave prior to triage or prior to receiving an MSE or if the individual withdrew the initial request for an MSE, facility personnel must request that the individual sign the Waiver of Right to Medical Screening Examination Form that was part of the Sign-In Sheet or document on the Sign-In Sheet the individual's refusal to sign the Waiver of Right to Medical Screening Examination Form. If an individual refused to sign a consent form, the physician or nurse must document that the individual had been informed of the risks and benefits of the examination and/or treatment but refused to sign the form.

Further review of the policy revealed that if an individual left the facility without notifying facility personnel, this must be documented upon discovery. The documentation reflected that the individual had been at the facility and the time the individual was discovered to have left the premises. Triage notes and additional records must be retained. If the individual left prior to transfer or prior to an MSE, the information was documented on the individual's medical record. If an individual had not completed a Sign-In Sheet, an ED staff member completed a sheet and if the individual's name was not known, a description of the individual leaving was entered on the form. All individuals who presented for evaluation or treatment were entered on the Central Log.

Review of the Medical Staff Rules and Regulations, last revised 4/19/19, Section 6 titled, 'Medical Screening Examination' revealed that any individual who presented to the ED and requested examination or treatment was provided with a medical screening examination (MSE). The purpose of the MSE was to determine if the individual was having an emergency condition. An MSE was performed by a physician or resident physician. In the case of a pregnant woman, the MSE could be performed by a Labor and Delivery Registered Nurse in consultation with a physician with appropriate clinical privileges.

The following additional policies were reviewed: ED Triage, ED Evaluation and Treatment of the Pregnant Patient, EMTALA Central Log, EMTALA Provision of On-Call Coverage, EMTALA Signage, EMTALA Transfer, EMTALA Medical Screening Examination, Patient Grievance and Complaint Management.

4. Sample Emergency Department Medical Record Review

A review of twenty (20) ED patient medical records (Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, Patient #19, Patient #20, Patient #21) that included twelve (12) (Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #19) patients that were escorted to the ED by a MET member, did not reveal any EMTALA violation concerns.

5. Personnel and Credential File Review

Review of three (3) staff files (Director AA, RN BB, Director EE) revealed that each file contained all required documentation that included EMTALA training. Review of one (1) credential file (ED Medical Director CC) revealed that all required documentation was present including EMTALA training.

6. Meeting Minutes

Review of the Quality and Safety Committee meeting minutes for July 2018 through May 2019 revealed that Quality and Patient Safety were standing agenda items. Meeting minutes dated 11/7/18 revealed that EMTALA Annual Quality Performance was presented that included a discussion of EMTALA cases elsewhere and recommendations moving forward.

7. Observation

A tour of the ED was conducted on 6/17/19 at 3:00 p.m. accompanied by ED Director EE and ED Quality Improvement Manager. During the tour it was observed that the main ED entrance had appropriate EMTALA signage in both, English and Spanish. Two uniformed security guards were stationed at the entrance. All persons were screened with a metal detector prior to entry into the waiting area. Upon entry to the ED lobby, patients were entered into the electronic ED central log. The triage area had of three (3) rooms staffed by RN's at all times. A mid-level provider such as a Nurse Practitioner was in the triage area daily from approximately 8:00 a.m. until 12:00 a.m. depending on the volume of patients. The mid-level provider performed the MSE in the triage area and assigned a treatment area based on the screening exam. It was stated that registration was not completed until the patient had received an MSE and patients were never told that payment was expected. It was stated that a list of specialty on-call physicians was electronic and could be accessed by any staff member.

Based on review of medical records, staff interviews, Medical Staff Rules and Regulations, review policies and procedures review, review of facility Quality and Patient safety Committee, review of video surveillance, credential file and personal files, it was determined that the facility failed to provide an appropriate medical screening examination to an individual who presented to the hospital's emergency department (property) requesting an examination or treatment of a medical condition for 1 (Patient #21) sampled patient.

Refer to findings in Tag 2406.

Based on review of medical records, staff interviews, Medical Staff Rules and Regulations, review policies and procedures review, review of facility Quality and Patient safety Committee, review of video surveillance, credential file, and personal files review, it was determined the facility failed to an appropriate medical screening examination to an individual who presented to the hospital's emergency department (property) requesting an examination or treatment of a medical condition for 1 (#21) sampled patients.

The findings were:

1. Surveillance Video

A review of the facility's 12/19/18 surveillance video on 1/24/19 at 1:30 pm in the Chief of Security's office revealed the following:

2:50 p.m. - a white transport van parked near the emergency room s (ER) entrance. Transporter AA walked into ER heading in direction of the bathroom.

2:54 p.m.- Transporter AA walking towards ER entrance from direction of the bathroom. Transporter AA interacted with occupant in a white car. (No audio available)

2:55 p.m.- Transporter AA re-enters ER, stands in one place and appears to be looking around moving his head from side to side. Transporter AA exits the ER and interacts again with the occupant in the white car.

2:56 p.m. Transport AA enters white transport van and begins driving off. Occupant in white car also begins to drive off.

2. Grievance and Complaint Log

Review of the facility's Grievance and Complaint log from 08/2018 - 1/24/19, revealed that Patient #21 had called the facility's complaint department on 12/19/18 reporting that she had sustained an injured ankle on her job and had driven herself to the facility's emergency room . (ER). The log further revealed that Patient #21 had asked a facility employee (Transporter AA) for a wheelchair. The facility employee (Transporter AA) had entered the ER to search for a wheelchair but returned and informed Patient #21 that there were no wheelchairs.

Patient #21 then drove to another facility. The Grievance and Complaint log also revealed that an Issue ID identifier was assigned to the complaint and an email sent to the facility's leadership including the Chief Nursing Officer.

3. Staff Interviews

An attempt on 1/24/19 at 1:45 pm, to contact Transporter AA via a listed telephone number located in his personnel record failed.

a. During an interview with the Director of Accreditation (DA) in the Medical Staff President's office on 1/23/19 at 1:30 p.m., The DA stated the Patient #21 arrived at the Emergency Department entrance, and there was also one of the facility's transport staff member (Transporter AA) waiting in his van. The DA stated transport staff normally would not be present at the ED entrance. The DA further stated, that the transport team member Transporter AA, was an employee of the facility and not a contractor. The DA stated that Patient #21 needed a wheelchair and that AA went into the Emergency Department to search for a wheelchair but was not able to find a wheelchair for Patient #21. The DA stated Patient #21 left the campus, and that Transporter AA did not inform any Emergency Department staff of the incident. The DA stated Transporter AA retired in December 2018 and is no longer an employee at the facility.

b. An interview with the Chief Medical Officer (CMO) on 1/24/2019 at 9:46 a.m., in the Medical Staff President conference room revealed that the CMO has been employed at the facility since 1989 and has been in the role of CMO since 2004. He stated that he first became aware of the circumstances involving Patient #21 from the compliance personnel after Patient #21 called and logged a complaint. The CMO then notified the facility ' s Risk Manager/Attorney who the CMO asked to assist the compliance department in its investigation. The CMO further stated per his understanding, Patient #21 made initial contact with a non-emergency transport driver in the facility ' s parking lot and requested a wheelchair. Per the CMO, it was not clear if Patient #21 was requesting a wheelchair for herself or another person and that the facility was not able to confirm if Patient #21 was treated at another medical facility. The CMO stated that video surveillance was utilized in identifying the involved facility employee. The CMO stated that any occurrences involving Emergency Medical Treatment and Labor Act (EMTALA) are typically tracked, including all Left Without Been Seen and Against Medical Advice patients from the Emergency Department (ED). The CMO added that regarding physicians with approved privileges for employment at the facility, a Memorandum of Understanding (MAU) is signed after viewing an on-line EMTALA power point and that EMTALA training is included in all new hire personnel on-boarding period. The CMO stated that it is the facility ' s intention that everyone in the facility ' s system, has EMTALA awareness.

c. During an interview with the Associate Director in Training of the ED/Director of Transport EE on 1/24/19 at 10:10 a.m., stated he worked on the day of the incident, but he was not present during the time of the location of the incident and was first informed of the incident by his superior. Associate Director in Training of the ED/Director of Transport EE further stated, wheelchairs were normally located at the front entrance and at different alcoves/storage areas in the ED. During a second interview with Associate Director in Training of the ED/Director of Transport EE at 11:45 a.m., he stated there were approximately 70 wheelchairs for the entire hospital. Associate Director in Training of the ED/Director of Transport EE stated he met Transporter AA for the first time at the Transporter AA's retirement gathering at the hospital. Associate Director in Training of the ED/Director of Transport EE stated he spoke with the Transport Team Manager to inquire if staff had EMTALA training. Associate Director in Training of the ED/Director of Transport EE stated, based on his assessment the majority of the Transport team needed an EMTALA refresher training. Associate Director in Training of the ED/Director of Transport EE stated training for the Transport team took place after the incident during the month of December 2018.

d. During an interview with RN FF in the Emergency Department (ED) on 1/24/19 at 10:10 a.m., RN FF stated she did not work the day of the incident on 12/19/18. RN FF further stated, she was approached and responded to patient needs over her eight years as an ED nurse at the facility by non-clinical personnel of patients, persons whom needed medical care. RN FF was able to describe the hospital's EMTALA policy and she stated her last EMTALA training was within the last calendar year.

e. During an interview with Security Officer GG at the front entrance of the Emergency Department (ED) on 1/24/19 at 10:50 a.m., Security Officer GG stated he has assisted persons who presented to the Emergency Department (ED) outside and inside entrance of the ED. Security Officer GG further stated, for those who needed medical assistance he would notify a nurse to facilitate care. Security GG was able to satisfactory describe EMTALA and his role with the requirement and stated that he has received EMTALA training.

f. An interview with Transporter BB on 1/24/2019 at 11:50 a.m., in the Medical Staff President conference room revealed that he has been employed at the facility for four and a half years. He described the Emergency Medical Treatment and labor Act (EMTALA) as not refusing anyone whose seeking treatment or to a pregnant woman who's in active labor. Transporter BB states that in the event a person approaches him for assistance anywhere on the facility's property, security notification is done. Transporter BB added that he does not drive the transport vehicle but at times, assist when two persons are needed to assist a patient. Transporter BB stated that wheelchairs are stored in the department and utilized once an assignment is given. Transporter BB added that the Transport department currently houses 12-15 wheelchairs with a recent receipt of 10-12 new wheelchairs.

g. During an interview with Security Officer HH in the Medical Staff President's office on 1/24/19 at 11:55 a.m., she stated that she could not remember if she worked on the day of the incident on 12/19/18. Security officer HH further stated that she worked different areas of the hospital but was not at the front entrance of the Emergency Department (ED) often. Security Officer HH stated when she is approached by people who need medical help, she assists where she is capable, or she notifies clinical staff members to facilitate care. Security Officer HH satisfactorily described EMTALA and her role with the requirement and stated she last received EMTALA training October 2018.

h. An interview with Housekeeper KK on 1/24/2019 at 1:37 pm., in the Medical Staff President conference room revealed that she has been employed at the facility for three years. Housekeeper KK described viewing a video about EMTALA during her facility orientation. She stated that her understanding of the Emergency Medical Treatment and labor Act (EMTALA), is to provide assistance to the patient when they are in need and that situations frequently arises, where she renders assistance to anyone who needs it. Housekeeper KK described a recent occurrence, where a passenger upon disembarking from the bus, at the bus stop in front of the facility, immediately requested her assistance. Housekeeper KK then notified security who brought a wheelchair and took the passenger to the emergency department.

i. During a phone interview with Security Officer JJ on 1/24/18 at 1:45 p.m., he stated he worked on the day of the incident 12/19/18. Security Officer JJ stated he was at the front entrance of the Emergency Department (ED) speaking with another staff member (unnamed). Security Officer JJ further stated on the day and time of the incident, he observed Transporter AA entering the ED front entrance searching for something at the front entrance and behind the security desk. Security Officer JJ stated AA did not say one word to him and the other staff member, and that Transporter AA did not stay long and proceeded to go out of the ED front entrance. Security Officer JJ satisfactorily described EMTALA and his role regarding the requirement.

4. Medical Staff Rules and Regulations

Rules and Regulations, dated 12/11/18 revealed that the purpose of Emergency admissions was to identify those patients most in need of emergency care, patients who present to the Medical Center seeking emergency care may be triaged by an Emergency Department Nurse before being examined by a physician or other Practitioner authorized to perform a screening examination. Further policy review revealed that any individual who comes to the Medical Center Emergency department requesting examination or treatment shall be provided with an appropriate medical screening examination (MSE). The purpose of the MSE is to determine if the individual is experiencing an emergency condition.

5. Review of facility Policy and Procedures included but were not limited to the following:

a. EMTALA-Signage Policy, dated 2/18 revealed documentation that all of the facility's emergency departments and any other place likely noticed by all individuals entering the emergency department and those individuals waiting for examination and treatment in areas of the hospital other than the traditional emergency department such as the entrance area, admitting areas, waiting rooms, and treatment areas located on hospital property must post conspicuously, appropriate signage notifying individuals of their right to an MSE (medical screening examination) and stabilization or treatment for an EMC (emergency medical condition) and required services for women in labor as specified under EMTALA as well as information indicating whether or not the hospital participates in the Medicaid program. The policy further revealed documentation, all hospitals must post signage that, at a minimum, meets the following requirements: - signage must be conspicuously posted in any place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than the traditional emergency department (e.g., entrance, admitting area, waiting room, labor and delivery, and other treatment areas located on hospital property): - signage must be readable from anywhere in the area - wording on signage must be clear and in simple terms in a language(s) that is (are) understandable by the population the hospital serves. The contents of the signage must: - indicate whether or not the hospital participates in a Medicaid program approved under a State plan under Title XIX; - specify the rights of individuals with EMCs to receive an MSE and necessary stabilization and treatment for any EMC regardless of the ability to pay; and - specify the rights of women in labor who come to the emergency department for health care services.

The signage content must include the following language:

IT ' S THE LAW!

If you have a medical emergency or are in labor, even if you cannot pay or do not have medical insurance or you are not entitled to Medicare or Medicaid, you have the right to receive, within the capabilities of this hospital ' s staff and facilities: An appropriate medical screening examination; necessary stabilizing treatment (including treatment for an unborn child); and if necessary, an appropriate transfer to another facility. This hospital (does/does not) participate in the Medicaid program.

b. Triage dated 1/2016 revealed that it's the facility's emergency department policy to categorize individuals seeking treatments into five priority levels to determine the appropriate order for care to be provided. Continued policy review revealed definition of terms as follows: Emergency severity index (ESI) - a five level triage system that facilitates the prioritization of patients based on the urgency of the patient's condition and how many resources each patient will utilize.

Triage- a process where a rapid, systematic collection of data relevant to each patient's chief complaint, age, cognitive level and social situation is conducted to obtain sufficient information to determine patient acuity and any immediate physical or psychological need. The process includes sorting and prioritizing patients for the most efficient and appropriate treatment area.

Priority level 1 (Critical)- The patient requires immediate life-saving interventions.

Priority level 2 (Emergent)- The patient is at high risk for rapid deterioration or presents with symptoms suggestive of a condition requiring time-sensitive evaluation and treatment.

Priority level 3 (Urgent)- The patient does not fit the criteria for level 1 or 2. Patient is predicted to require two or more resources based on the ESI resource list. The patient may require an in-depth evaluation but are felt to be stable in the short term.

Priority level 4 (Non-urgent)- The patient does not fit the criteria for level 1, 2, or 3. This patient will require only one resource based on the ESI resource list and are considered stable.

Priority level 5 (Minor)- The patient does not fit the criteria for level 1, 2, 3, or 4 and will require no resources based on the ESI resource list. A Registered Nurse who has maintained annual training and updates will perform the initial triage. The registered nurse that is assigned to triage location is required to have a minimum of one year of emergency nursing experience.

c. EMTALA - Medical Screening Examination and Stabilization , dated 2/2018 revealed its purpose is to reflect guidance under the Emergency Medical Treatment and Labor Act (EMTALA). An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and 1) the individual or a representative acting on the individual ' s behalf requests an examination or treatment for a medical condition or 2) a prudent layperson observer would conclude from the individual ' s appearance or behavior that the individual needs an examination or treatment of a medical condition. Continued policy review revealed that such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition (EMC). Further, if a prudent layperson observer would believe that the individual is experiencing an EMC, then an appropriate MSE, within the capabilities of the hospital ' s DED (including ancillary services routinely available and the availability of on-call physicians). The MSE must be completed by an individual (i) qualified to perform such examination to determine whether an EMC exists, or (ii) with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilization treatment shall be applied in a non-discriminatory manner (e.g., no different level of care because of age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identification or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state or local law.

d. EMTALA-Central Log Policy, dated 2/18 revealed documentation that the hospital would 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 would 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 policy further revealed documentation, the Central Log include patient logs from the traditional ED (Emergency Department) and either by direct, or indirect reference, patient logs from any other areas of the hospital where an individual may present for emergency services or receive a medical screening examination, such as Labor and Delivery. The policy revealed documentation that the Central Log must contain at a minimum, the name of the individual and whether the individual: - refused treatment, -was refused treatment, -was transferred, -was admitted and treated, -was stabilized and transferred, -was discharged , or -expired. The policy revealed documentation duplicate accounts created for the same patient who visited the hospital on more than one occasion would be consolidated so that only one medical record number per patient existed; and the Central Log would be retained for a minimum of five years from the date of disposition of the individual.

e. EMTALA -Provision of On-Call Coverage Policy, dated 2/18 revealed documentation that the facility must maintain a list of physicians on its medical staff who have privileges at the hospital or, if it participated in a community call plan, a list of all physicians who participate in such plan. The policy further revealed, physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with EMCs who are receiving services in accordance with the resources available to the hospital. The hospital ensured privileged physicians were aware of their legal obligations as reflected in the policy and the Medical Staff Bylaws and would take all necessary steps to ensure that physicians perform their obligations as set forth herein and in each document. The policy revealed documentation that the facility ' s governing board required that the medical staff be responsible for developing an on-call rotation schedule that included the name and direct telephone number or direct pager of each physician who required to fulfill on-call duties. Practice group names and general office numbers were not acceptable for contacting the on-call physician. Individual physician names with accurate contact information, including the direct telephone number or direct pager where the physician can be reached, are to be put on the on-call list. The hospital must be able to contact the on-call physician with the number provided on the list. If the on-call physician decides to list an answering service number as the preferred method of contact, his/her mobile phone number must be provided to the hospital as a backup number to reach the on-call physician. The backup number will be used by hospital and Transfer Center personnel when the On-Call Physician does not respond to calls in a timely manner. Each physician was responsible for updating his or her contact information as necessary and each hospital shall provide a copy of the daily on-call schedule to the Transfer Center. The on-call schedule may be by specialty or sub-specialty (e.g., general surgery, orthopedic surgery, hand surgery, plastic surgery), as determined by the hospital and implemented by the relevant department chairpersons. The Medical Executive Committee (MEC ) shall review the on-call schedule and make recommendations to the CEO when formal changes are to be made or when legal and/or operational issues arise. The policy further revealed documentation that the hospital would keep local Emergency Medical Services advised of the times during which certain specialties are unavailable. The policy revealed documentation that the hospital must keep a record of all physicians on-call and on-call schedules for at least five years. On more than one occasion would be consolidated so that only one medical record number per patient existed; and the Central Log would be retained for a minimum of five years from the date of disposition of the individual.

f. EMTALA-Transfer Policy, dated 2/18 revealed documentation that any transfer of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual ' s behalf or by a physician order with the appropriate physician certification as required under EMTALA. EMTALA obligations regarding the appropriate transfer of an individual determined to have an EMC apply to any emergency department (ED) or dedicated emergency department (DED ) of a hospital whether located on or off the hospital campus and all other departments of the hospital located on hospital property. The policy further revealed documentation, that a hospital with specialized capabilities or facilities (including, but not limited to burn units, shock-trauma units, neonatal intensive care units, dedicated behavioral health units, or regional referral centers in rural areas) shall accept from a transferring hospital an appropriate transfer of an individual with an EMC who requires specialized capabilities if the receiving hospital has the capacity to treat the individual. The transferring hospital must be within the boundaries of the United States. The transfer of an individual shall not consider age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state or local law, except to the extent that pre-existing medical condition or physical or mental handicap is significant to the provision of appropriate medical care to the individual. The policy revealed documentation that the CEO must designate in writing an administrative designee by title responsible for accepting transfers in conjunction with a receiving physician. The CEO administrative designee, in conjunction with the receiving physician, e.g., ED physician, has authority to accept the transfer if the hospital has the capability and capacity to treat the individual. The policy further revealed processes in place for patients that who have not been stabilized, patients not stabilized that require a higher level of care, patients moved to diagnostic facilities, patients moved to off campus hospital based affiliates to non-affiliated hospital, pre-existing transfer agreements, transfers for high risk deliveries, diversion/exceeded capacity, lateral transfers, women in labor, and patients placed on observation status.

6. Quality and Patient Safety Meeting

A review of the facility's Quality and Patient Safety Committee Agenda dated 11/6/18 revealed documentation the facility discussed EMTALA Compliance Quality, a PowerPoint of EMTALA requirements.

7. Credentialing File

A review of one (1) credential file (Medical Director of emergency room LL) revealed current state licensure, delineation of privileges and evidence of EMTALA training within the past year.

8. Personnel Files

A review of five (5) personnel files (Transporter AA, Transporter BB, Nurse Manager of emergency room FF, Security Officer JJ and Housekeeper KK) revealed current state licensure (where applicable), facility required orientation, competency testing and EMTALA training.

The facility failed to ensure that their policies and procedures and Medical Staff Bylaws were followed as evidenced by failing to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for Patient #21, who presented to the hospital's emergency department (property) requesting an examination and/or treatment for an ankle injury on 12/19/2018.

Based on review of the Central Log, medical records, policies and procedures, hospital B's medical record, Daily Transfer Log, Diversion Tracking Log, Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Rules and Regulations, Professional Services Agreement, ED staffing, Pod D census, Performance Corrective Counseling data, observations, personnel and credential files, and staff interviews, it was determined that the facility failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's Emergency Department (ED), including ancillary services routinely available to the ED to determine whether or not an emergency medical condition existed for one (1) individual (patient #2) of twenty (20) sampled patients when the patient presented to the ED via Emergency Medical Services (EMS) on 04/17/16.

Findings:

1. Cross refer to A2406 as it relates to failure to provide an appropriate Medical Screening Exam (MSE) for patient #2 on 04/17/2016.

2. Cross refer to A2407 as it relates to failure to provide appropriate stabilizing treatment for patient #2 on 04/17/2016.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the Central Log, medical records, policies and procedures, hospital B's medical record, Daily Transfer Log, Diversion Tracking Log, Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Rules and Regulations, Professional Services Agreement, ED 00, Pod D census, Performance Corrective Counseling data, observations, personnel files, credential files, and facility's corrective actions, and staff interviews, it was determined that the facility failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's Emergency Department (ED), including ancillary services routinely available to the ED to determine whether or not an emergency medical condition existed for one (1) individual (patient #2) of twenty (20) sampled patients when the patient presented to the ED via Emergency Medical Services (EMS) on 04/17/16.

Findings:

Review of the ED Central Log and patient #2's record revealed that the patient was brought to the ED on 04/17/16 at 5:47 a.m. by EMS. The EMS report revealed that the ambulance attendants responded to a [AGE]-year-old patient who was complaining of suicidal ideations (thoughts of committing suicide). The report revealed the ambulance attendants arrived on the scene and found the patient out with a police officer. The report further revealed that the patient was having thoughts of harming himself/herself and that the patient had superficial cuts on his/her wrist. The report noted that the patient had a history of psychological behavior and manic (state of extreme periods of euphoria) and depressive (periods of extreme emotional lows) behavior. In addition, the report revealed the patient wanted to be taken to the hospital. The report revealed the patient was received by Memorial Health University Medical Center's (MHUMC) Registered Nurse (RN) #2 and that the nurse signed that he/she had received the written EMS report.

Further review of the patient's medical record revealed that the patient arrived in the ED on 04/17/16 at 5:47 a.m. by ambulance, escorted by police. Documentation revealed that the patient's chief complaint was anxiety and that the patient was triaged (assessment by a nurse to determine the priority in which patients will be seen by the provider) as a non-urgent patient.

Review of the facility's policy entitled Triage, policy number ED136, last revised 01/2016, effective 06/2016, revealed that the facility utilized Emergency Severity Index (ESI) five (5) level triage system. The ESI system defined the five (5) levels as follows:

--level 1 immediate life-saving (the facility's computer system revealed these patients were critical);

--level 2 high risk for rapid deterioration (the facility's computer system revealed these patients were emergent);

--level 3 required two (2) or more resources (the facility's computer system revealed these patients were urgent);

--level 4 required only one (1) resource (the facility's computer system revealed these patients were non-urgent); and

--level 5 required no resources (the facility's computer system revealed these patients were minor).

The Job Aid attached to this policy noted that an example of level 2 patients included those with suicidal or homicidal ideations.

Review of the facility's policy entitled Evaluation and Admission of Psychiatric Patients, policy #ED133, last revised 01/2016, effective 06/2016, revealed that the policy was to ensure quality mental health care for the patient with psychiatric and addictive disorders. This policy required patients to be provided with an appropriate evaluation to determine the need for admission to a psychiatric facility. This policy defined Pod D as the area designated in the ED for mental health patients. The policy was that patients were to be triaged per policy number #ED136 (the above policy) and noted that suicidal or homicidal patients were to be triaged as level 2 patients. This policy required patients in Pod D to be placed on elopement precautions.

Patient #2's medical record revealed that the Consent for Medical Treatment was signed on 04/17/16 by patient #2; there was no time noted on the form. The patient's documented past medical history included chronic back pain, chronic left shoulder pain, alcohol abuse, and opiate (narcotics such as heroin, methadone, codeine, and morphine) addiction. Documentation revealed that the patient was placed in room D03/A on 04/17/16 at 6:03 a.m. At 6:09 a.m., RN #2 noted that after being brought to the facility by a local police department officer, the patient changed his/her mind about wanting to be seen. The nurse noted that the patient ran through the nurses' station and out the door ( the door that exits the nurses' station into the ambulance bay hallway). The nurse noted that the police officer brought the patient back into the ED and reported that the patient was not a '1013' (Georgia's law that allows a patient to be held involuntarily when they are a threat to self or others) and that the patient had presented to the ED willingly to be evaluated. The RN further noted that the patient adamantly requested to leave, stating that he/she did not want or need to be seen and that coming to the ED had been the wrong answer. Nurses' notes revealed that the RN completed the Columbia-Suicide Severity Rating Scale at 6:08 a.m. The nurse noted that the patient denied wishing he/she were dead or having any thoughts of killing himself/herself for the past month. In addition, the nurse noted that the patient denied ever trying to end his/her life. Further documentation revealed that the patient left without being seen (LWBS) and was discharged home in stable condition on 04/17/16 at 6:15 a.m. There was no documented evidence that the ED physician had been informed of the patient's decision to leave or that the Patient Leaving the ED form #9611 had been completed.

Review of the nearby hospital's (hospital B) medical record for patient #2 revealed that the patient was admitted to their ED on 04/17/16 at 6:37 a.m. Documentation revealed that the patient's vital signs (temperature, pulse, respirations, blood pressure, and oxygen saturation) were within normal limits, and the patient was triaged as a non-urgent patient. Nurses' notes indicated that the patient was placed on suicide precautions. The patient was evaluated at 7:33 a.m. by a physician who noted that the patient was depressed, had suicidal thoughts and attempts, and that the patient had injuries to both wrists. The physician further noted that the patient had no previous suicide attempts. Orders included but were not limited to the following: blood work, urine drug screen, Ativan (used to treat anxiety) 1 milligram (mg) by mouth was order and administered four(4) times, Geodon (used to treat psychotic disorders) 20 mg intramuscularly was ordered and administered twice. Nurses' notes revealed that the patient received the Ativan as ordered on [DATE] at 8:21 a.m., 9:14 a.m., 11:30 p.m., and on 04/18/16 at 8:49 p.m. Nurses' notes revealed that the patient received the Geodon as ordered on [DATE] at 10:43 a.m. and on 04/18/16 at 8:53 p.m. Review of the lab results revealed that the patient tested positive for cocaine use. The psychiatric counselor's notes indicated that the patient did not want inpatient psychiatric treatment, that the patient was manipulative, and that the patient was at extreme risks for self-harm. The physician signed the 1013 form and began trying to transfer the patient to a psychiatric facility. The physician noted that there was difficulty finding an accepting facility that had an available bed. The physician's clinical impressions of the patient were: suicidal attempt, cocaine use, and superficial self-injuries to both wrists. On 04//19/16 at 2:11 a.m., the transfer form revealed the patient was accepted to a psychiatric facility by an accepting physician. Documentation revealed that the police transported the patient to the accepting psychiatric facility.

Review of the facility's policy entitled Patient Care Routine Guidelines, policy #ED139, last revised 01/2016, effective 06/2016, revealed that a withdrawal for medical request form was required to be completed if a patient was signing out Against Medical Advice (AMA) or had eloped and referenced Refer to Leaving Hospital Before Discharge, policy #PC-5026. This policy also required that patients leaving without being seen, either before or after triage were to be informed of the risks of leaving and the Patient Leaving the ED form #9611 was to be completed and signed by the patient. The staff were required to document the disposition as LWBS and to discharge the patient from EPIC (the facility's electronic medical record system). This policy referred to policy #PC5026 Leaving Hospital Before Discharge.

Review of the facility's policy entitled Leaving Hospital Before Discharge, policy #PC-5026, last revised 08/2015, effective 10/2015, revealed that the policy was to ensure that patients received counseling and that there be documentation recorded when patients leave against medical advice (AMA). This policy defined Withdrawal of Request for Medical Care (LWBS) as those patients who leave the hospital before having an MSE. This policy required the following:

1. If a patient expresses a desire to leave the hospital prior to the discharge by a physician, explain the consequences of such act, (e.g., if the patient chooses to leave the hospital without a physician-ordered discharge, the patient is doing so at his/her own risk.)

2. Notify the patient's primary physician of the patient's desire to leave the hospital.

3. If the patient is not medically stable, explain the risks to the patient either in person or by phone.

4. If there is a question as to the decision-making capacity of the patient or guardian of a minor child, contact a case manager or psychiatric assessment team member, and nurse manager as soon as possible.

5. If the patient verbalizes understanding of the medical risks of leaving AMA and has Decision Making Capacity, complete the Patient Leaving the Hospital form #9634 and ask the patient to sign it. If the patient refuses to sign the form, document the risks discussed and that the patient refused to sign the form. Get a second team member to witness.

6. Document the patient's stated reason for wanting to leave AMA, who counseled the patient, what counseling was given to the patient, the time the patient left, and the patient's medical condition at discharge.

Review of facility policy entitled Emergency Medical Screening, Stabilization, Treatment & Transfer, policy #PC1019, last revised 10/2015, effective 04/2016, revealed it was the facility's policy that any individual who comes to the ED or Labor and Delivery requesting examination or treatment shall be provided with an appropriate medical screening examination without regard to diagnosis, financial status, race, color, national origin, or handicap. This policy noted that the examination was to be conducted by qualified personnel in accordance with the facility's Medical Staff Bylaws, and Rules and Regulations. This policy required the following steps if a patient withdrew his/her request for examination or treatment:

--explain that further medical examination and treatment might be required to identify and stabilize the emergency medical condition;

--inform the individual of the benefits of the examination and treatment and the risks of not receiving the examination and treatment; and

--ask the individual to sign the Patient Leaving the ED form #9611. If the individual refused to sign the form the staff was to document the discussion with the individual.

Review of the Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Rules and Regulations, signed by the Medical Staff President on 07/28/16, and pending approval by the Chair of the Board of Directors. Article II, Section 6. Medical Screening Examination required:

A. Any individual who comes to the Medical Center ED requesting examination or treatment shall be provided with an appropriate MSE. The purpose of the MSE is to determine if the individual is experiencing an emergency condition.

B. An MSE may be performed by a physician or resident physician. In the case of a pregnant woman, the MSE may also be conducted by a Labor & Delivery RN in consultation with a physician with appropriate clinical privileges.

Review of the Professional Services Agreement for the Emergency Physicians made and entered into on 12/31/2014 to be effective 01/01/14, revealed physicians on duty in the ED shall be responsible for examining and/or treating all persons who present themselves for care and/or treatment at the ED and providing, or causing to be provided, to such persons, medical treatment which may be necessary, in accordance with sound medical practice. In addition, revealed the Group (contracted physicians) agreed that all emergency medical services provided pursuant to the agreement shall be performed in compliance with all applicable standards set forth by law or ordinance or established by the rules and regulations of any federal, state or local agency,department, commission, association or other pertinent governing, accrediting, or advisory body, including the Joint Commission (Joint Commission), having authority to set standards for health care facilities, including compliance with the COBRA (consolidated omnibus budget reconciliation act) / EMTALA (Emergency Medical Treatment and Labor Act) laws, rules, and regulations.

On 08/29/16 at 11:45 a.m. in the ED Education Room, patient #2 listed place of employment was called and the operator reported that the business did not have an employee by patient #2's listed first or last name.

On 08/29/16 at 11:50 a.m. and 11:55 a.m. in the ED Education Room, two (2) attempts were made to reach patient #2 at the patient's listed home telephone number. During both calls, a voicemail with return call information was left for the patient.

On 08/29/16 at 12:40 p.m. in the ED Education Room, a call was made to the police department (PD) where officer #6 was employed at the time of the incident. Per the PD, the officer was no longer with that department but they did provide information as to where officer #6 was now working.

On 08/29/16 at 1:10 p.m. in the ED Education Room, an attempt was made to reach patient #2 by telephone. A voicemail with return call information was left for the patient.

During a telephone interview with RN #2 on 08/29/16 at 1:35 p.m. in the ED Education Room, the RN indicated he/she was working on 04/17/16 when the patient presented to the ED via EMS and escorted by a police officer (#6). The RN explained that after the patient (#2) was triaged the patient was assigned to room D03A in Pod D. The nurse explained that Pod D is a five-bed, locked and monitored area of the ED, designated for patients presenting with psychiatric related complaints. The RN stated that the patient was screened for suicidal ideations and that the patient had denied any suicidal thoughts. The RN continued by stating a few minutes after the patient arrived, the patient indicated he/she had changed his/her mind about being treated and expressed that he/she wanted to leave. The RN stated the patient then ran through the nurse ' s station and exited through the door leading out of the nurse ' s station to the ambulance bay hallway. The RN indicated that he/she did not see the patient exit the building, but had assumed the patient ran outside. The RN stated the police officer (#6) that had accompanied the patient to the ED brought the patient back into the ED. The RN indicated that he/she asked the officer (#6) if the patient was a 1013 and was told by the officer (#6) that the patient was not. The RN stated that since the patient was not a '1013', the patient was able to leave at any time. When asked if the nurse had assessed or noticed any marks on the patient ' s wrists, the RN stated he/she did notice some scratches but that the patient had denied any self-harm. When asked what the RN would have done if the patient had indicated any suicidal ideations and requested to leave the facility, the RN stated he/she would have notified the physician to see if a '1013' were necessary. The RN added that a patient could not be made a '1013' if the patient was not displaying any signs or symptoms of possible harm to themselves or others. The RN stated the patient then LWBS. When asked how the staff was required to handle a patient that wanted to leave AMA or LWBS, the nurse explained that the facility's Leaving the Hospital form was to be completed. The RN went on to explain that when a patient refused to sign the form the nurse and a second witness was to sign the form and indicate on the form and in the medical record that the patient refused to sign. When asked why the form was not filled out, the RN indicated he/she did not know. The RN stated when he/she reported for work the next day, he/she was told by other staff members that the security officer had taken the patient to the McDonald ' s up the street. The RN stated he/she had no idea why the security officer would have done that as the facility has non-emergent transport available for patients. The RN added that the security officer did not have the authority to transport the patient anywhere.

Review of the ED staffing for 04/17/16 during the hours that the patient presented to the ED revealed there was one (1) Registered Nurse and one (1) Psych Technician assigned to Pod D from 04/16/16 at 7:00 p.m. until 04/17/16 at 7:00 a.m. The Pod D census from 4:00 a.m. until 8:00 a.m. was one (1) patient.

On 08/29/16 at 3:00 p.m. in the ED Education Room, the Clinical Compliance Officer (CCO) informed the surveyors that the EMS had refused their request to interview the ambulance attendants who had brought the patient into the ED on 04/17/16 and that the surveyors would have to go through the EMS legal department in order to interview the ambulance attendants. The surveyors requested that the facility try going through the EMS legal department to see if an interview could be conducted with the ambulance attendants.

On 08/29/16 at 3:40 p.m. in the ED Education Room, an attempt to reach the police officer (#6) by telephone at his/her current employer was made. A voicemail with the return call information was left for the on-call sergeant at the department, but the on-call sergeant and/or officer #6 never returned the call.

On 08/29/16 at 4:10 p.m. in the ED Education Room, an attempt was made to reach the patient (#2) by telephone. A voicemail with return call information was left for the patient. Patient #2 never returned any of the calls made by the surveyors.

During an interview #8 with the Chief of Security (COS) on 08/29/16 at 4:45 p.m. in the ED Education Room, the COS confirmed that on 04/18/16 that he/she was notified by the Security Services Manager at a nearby hospital of a possible EMTALA violation. The COS explained that he/she was informed of the event and was also shown a video by the nearby hospital's Security Services Manager which depicted the Memorial security guard (#5) dropping the patient (#2) off at a local fast food restaurant ' s parking lot, which was directly adjacent to the nearby hospital ' s ED. The COS explained that the Security Officer (#5) was questioned and that the Security Officer had initially denied the allegation. The COS provided a copy of the Performance Corrective Counseling and his/her notes.

The COS notes revealed that he/she had received the call from the nearby hospital's Security Services Manager regarding the possible EMTALA violation on 04/18/16 at approximately 9:00 a.m. The COS noted that he/she was informed that a Memorial Security Officer (#5) had dropped a patient off at a local fast food restaurant that was adjacent to the other hospital's ED and that the other hospital's video showed that the patient had then walked into the other hospital's ED. The COS's notes indicated he/she spoke with the security officer who had confirmed that he/she was familiar with the patient and that he/she and the patient had developed a rapport during the patient ' s previous visits to the facility. The COS noted that the security officer denied that he/she transported the patient on 04/17/16. The COS continued by stating that when the security officer was confronted with the video evidence, the officer acknowledged that he/she had transported the patient to the restaurant parking lot. The COS noted that the officer explained that the patient had presented to the facility ' s ED after cutting his/her wrists, that the patient had become upset during the ED visit, and that the officer was concerned for the patient and had asked the patient if he/she wanted to go to another facility for treatment, and that the patient had stated he/she did want to go to another nearby hospital, so the security officer transported the patient to the local restaurant's parking lot in the hospital's security vehicle.

Review of the facility's policy entitled Patrol Vehicles, policy #SEC2017, effective date 09/01/14, revealed that disciplinary action was required for use of the vehicle off hospital property or for unauthorized personal use.

Review of the Performance Corrective Counseling dated 04/26/16 revealed the Security Officer (#5) had been counseled regarding the event, had denied the event, and had been terminated due to failure to follow facility policy.

Observation of Pod D in the ED on 08/30/16 at 10:10 a.m. revealed the Pod was located on the right side after entering through the ambulance bay, the Pod was accessible through two (2) doors. One (1) door was a single door leading to the Pod D nurse ' s station. The door was noted to be locked from the outside (hallway) and required an employee identification badge for entry. The second door was a double-door, which led directly into the Pod and could only be accessed by electronic entry initiated by the nursing staff working on Pod D. Inside the nurse ' s station was a Dutch door (a door that was divided horizontally in such a fashion that the bottom half may remain shut/locked while the top half remained open, if desired) which was noted to be open at the top. The bottom half of the door was locked and could not be opened from the patient ' s side without reaching over the door to unlock it from the inside. A small window, approximately six (6) inches wide by thirty-six (36) inches in length, was noted on the top portion of the door. Two (2) security guards, one (1) nurse (#9), and one (1) psychiatric technician were observed in the Pod D nurse ' s station at the time of the observation.

During an interview with the Pod D RN (#9) on 08/30/15 at 10:15 a.m. in Pod D nurses' station, the RN stated that the top portion of the Dutch door in the nurses' station was normally kept open unless security was in, or near, the nurses' station. The RN stated that if security was not present, the door remained closed. The RN indicated that when patients are brought in via EMS, an electronic report is generated that includes the EMS assessment. The RN stated that the report would then be signed by the receiving nurse. The RN explained that it was possible for the receiving RN to read the electronic report, but that EMS gave a verbal report of the patient when the receiving nurse assumed the patient's care. The RN continued by stating that if a patient told EMS that they were suicidal, but the patient denied suicidal ideations during the psych screening, further questions were asked to assess the patient ' s mental status. The RN stated that if a patient were requesting to leave and had verbalized, or displayed any signs or symptoms of suicidal ideations, he/she would notify the ED physician immediately so that the patient could be assessed for a possible 1013. The RN explained that the physicians were historically prompt in assessing patients presenting with psych complaints who were threatening to leave without being seen. The RN indicated it was the determination of the MD whether or not a patient was to be made a '1013' after being assessed for stability. The RN explained that if a patient wanted to leave without being seen or AMA but refused to sign the form, the RN indicated the patient form was to be signed by two (2) nurses and the medical record noted.

On 08/30/16 at 2:20 p.m. in the Medical Staff President Room, an attempt was made to reach the patient by telephone. A voicemail with return call information was left for the patient.

During a telephone interview with the Psych Tech (PT) (#3) on 08/30/16 at 8:03 p.m. at the Holiday Inn Hotel, the PT stated he/she was working the morning of 04/17/16 when the patient (#2) came into the facility via EMS and accompanied by a local on-duty police officer (#6.) The PT stated that EMS reported that the patient was consuming alcohol and using drugs while at a friend ' s home. The PT continued by stating that EMS explained that the patient was involved in an argument with his/her friends and the police were called. After arriving, the police found the patient in the woods. EMS stated that the patient stated to the police that he/she wanted to go to the hospital to talk to someone about his/her problems. The PT stated that he/she heard the police officer as he/she told the RN (#2) that the patient did have some superficial scratches on his/her wrist area. The officer added that the patient had been running in the woods and that the scratches did not appear to be fresh wounds. The PT stated that shortly after arrival, the patient verbalized that he/she wanted to leave and asked the officer if he/she could leave. The PT explained that the RN asked the officer if the patient was a '1013' to which the officer stated no. The PT then ran out of the room and through the nurse ' s station. The PT stated that the officer brought the patient back into the ED. The PT indicated the officer was again asked if the patient was a '1013'. The officer stated the patient was free to leave at any time. The PT stated the MD was asked to see the patient at that time. The PT explained that the MD spoke to the patient at the bedside and asked the patient if he/she was feeling suicidal or homicidal. The patient indicated at that time that he/she was not. When asked which MD saw the patient, the PT stated he/she could not remember. The PT stated that the MD told the RN that they were not going to hold the patient, and the patient was free to leave. The PT stated the patient then left the ED. When asked if the top portion of the door at the nurse ' s station was usually left open, the PT indicated that the top of the door was only left open if one patient was in the back at one time. The PT stated that if there is only one staff member in the Pod D area, the door is always kept closed and locked. The PT added that staff has asked the management to change the door as they feel unsafe with the Dutch door.

Review of four (4) personnel files #s 1, 2, 3, and 5, revealed all four (4) staff members attended EMTALA training between 05/27/15 and 08/26/15.

Review of two (2) credential files #s 4 and 7, revealed both physicians had completed EMTALA training between 02/17/15 and 08/14/15.

Based on review of medical records and policies and procedures it was determined that the facility failed to provide further medical examination and treatment as required to stabilize the emergency psychiatric condition that was within the capabilities of the staff and facilities available at the hospital for one (1) individual (#2) of twenty (20) sampled patients.

Cross refer to A2406 as it relates to failure to provide an appropriate Medical Screening Examination (MSE) for patient #2 who presented with an emergency medical condition on 04/17/16

.Findings:

The facility's policy entitled Emergency Medical Screening, Stabilization, Treatment & Transfer, policy #PC1019, last revised 10/2015, effective 04/2016 was reviewed. This policy noted that an individual was considered to be stabilized when the treating physician has determined, with reasonable clinical confidence, that the individual's emergency medical condition has been resolved although the underlying medical condition may persist. The policy also revealed that an individual was considered stable for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be

performed as an outpatient, or later as an inpatient, provided the individual has been given a plan for appropriate follow-up care with discharge instructions. For the purpose of discharging an individual with psychiatric condition(s), the individual is considered to be stable for discharge when he/she is no longer considered to be a threat to self or to others. The hospital, within reason, shall assist or provide necessary information to discharged individuals to secure the necessary follow-up care to prevent relapse or worsening of the medical condition upon release from the hospital.

The facility failed to ensure that stabilizing treatment was provided for Patient #2 who presented to the ED with complaints of suicidal ideations on 4/17/2016.

Based on observation and staff interview, and review of facility policies, the facility failed to provide a safe environment for the patients housed in their behavioral health facility.

Findings include:

Observation during a tour of the Behavioral Health Unit with the Executive Director of Med/Surg and Behavioral Health and the Assistant Nurse Manager on 8/13/2015 at 10:00 AM revealed:

+ The women's common shower on the B hall was found to have a shower curtain hanging on a rod, which did not break away with vigorous pulling by the surveyor and the Executive Director of Med/Surg and Behavioral Health.

+ The dining room was found to have 23 medium weight, wood framed chairs which could be easily lifted, and potentially used to harm patients or staff

The Executive Director of Med/Surg and Behavioral Health acknowledged the above findings on 8/13/2015 at 10:20 AM.

Review of facility policy number 12.004, General Safety, origination date August 2007, effective date May 2013, revealed that the hospital's policy is to provide a safe and healthy environment for patients, staff, volunteers and visitors.

Review of the facility's Privacy Practices, Patient Right for Georgia's Mental Health Hospital, revealed that patients are entitled to a safe and humane place to live while they are in the hospital

Based on observation, review of facility policies, and review of the Behavioral Health Center's nursing department staffing for a two (2) week period, the facility failed to have sufficient nursing staff to adequately care for the patients housed in the behavioral health facility.

Findings include:

Observation during a tour of the Behavioral Health Unit with the Executive Director of Med/Surg and Behavioral Health and the Assistant Nurse Manager on 8/13/2015 at 10:00 AM revealed :

The Behavioral Health Unit is in the shape of an H, with the nurse's station connecting hall A and hall B. A ceiling mounted video camera was noted at the far end of each hall. Patient room doors were found locked.

The Treatment Mall contained two (2) rooms for group therapy. One group therapy session was being conducted, which contained twelve (12) patients, one (1) psychotherapist, and two (2) mental health technicians. One (1) patient was noted to be in a treatment team conference with staff members. One (1) security guard was standing in the open area between the therapy rooms. The security guard was not armed with a weapon, spray, or handcuffs

Review of facility policy number HR-1030, Nursing Staffing/Scheduling, origination date 5/10/95, effective date 11/2012, revealed that the hospital's policy is to provide an appropriate number of caregivers to meet patient needs and fulfill the mission of the hospital.

Review of the Behavioral Health Center's nursing department staffing for a two (2) week period (7/19-8/1/2015) revealed that staff worked twelve(12) hour shifts, and were understaffed (according to their staffing matrix, and including all 1:1 patients) on fourteen (14) of twenty eight (28) shifts (7/19, 7/23, 7/24, 7/25, 7/26, 7/29, 7/30, 7/31, and 8/1/2015)

Based on review of medical records, Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Bylaws, Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Rules and Regulations, Medical Staff Bylaws, Policies, and Rules and Regulations: Credentials Policy, policies and procedures, Physician Central Access Information Sheet, Transfer Center recordings, Medical Staff Roster, ED physicians' schedule, on-call schedules, staff interviews, personnel files, credential files, Corporate Ethics and Compliance Office, it was determined that the facility lacked an effective system to ensure that individuals from a referring hospital were accepted as an appropriate transfer who required the specialized capabilities or facilities if the receiving hospital had the capacity to treat the individual. This affected 1 of 20 sampled patients (#1). Refer to findings in tag A-2411.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Bylaws, Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Rules and Regulations, Medical Staff Bylaws, Policies, and Rules and Regulations: Credentials Policy, policies and procedures, Physician Central Access Information Sheet, Transfer Center recordings, Medical Staff Roster, ED physicians' schedule, on-call schedules, staff interviews, personnel files, credential files, Corporate Ethics and Compliance Office, it was determined that the facility lacked an effective system to ensure that individuals from a referring hospital were accepted as an appropriate transfer who required the specialized capabilities or facilities if the receiving hospital had the capacity to treat the individual. This affected 1 of 20 sampled patients (#1).

Findings were:

Review of the Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Bylaws, dated 02/22/11, revealed in Article 2.A.3.a, that active staff were responsible for emergency call.

Review of the Medical Staff Bylaws, Policies, and Rules and Regulations: Medical Staff Rules and Regulations, dated 02/22/11, revealed in Article 1 Section 1.a, that patients were to be admitted to the facility on on ly by order of a Medical Staff appointee who had been granted admitting privileges.

Review of the Medical Staff Bylaws, Policies, and Rules and Regulations: Credentials Policy, dated 02/22/11, Article 3 B.1.b., required the Medical Staff to abide by all Bylaws, policies (including but not limited to, the Medical Staff Code of Conduct, Physician Health Policy, and the Quality Policy and Procedure Manual which included Behavioral Expectations), and Rules and Regulations of the Hospital and Medical Staff in force during the time the individual was reappointed.

Review of the facility's policy entitled Transfer Center, policy number N046.00, last revised 11/30/11, revealed outlying physicians were to be connected with a physician from the facility. All Transfer Center calls were to be screened by the operator to determine if the request was and ED to ED transfer or a physician to physician inpatient admission request. For outlying ED patients, the operator was to connect the caller with the requested specialist on-call or the facility's ED physician. The operator was to connect all calls for ED patients with the facility's ED physician after 10 minutes if the specialist had not responded. The policy required, Any request for transfer of a patient in an ED that was not accepted by a specialty physician to be immediately connected with the facility's ED physician. The ED physician was then to follow EMTALA (Emergency Medical Treatment and Labor Act) guidelines to determine whether the patient required transfer. In addition, the policy required the operator to stay on the line and record the call, facilitate transportation if needed, and assist the physician with access to bed control and Access nurses, or Nursing Supervisor to secure an appropriate bed. Furthermore, the policy revealed that when there was a conflict about acceptance the administrator on-call or the Chief Medical Officer was to be contacted.

Patient #1's medical record from the transferring hospital was reviewed. The medical record indicated that on 4/06/2012 patient #1 presented to the emergency room with Chief Complaint, Pt told to come to ER (emergency room ) by md (medical doctor) for evaluation of upper lung mass. Further review revealed that the patient's vital signs were Temperature: 97.9, pulse: 89; and Blood Pressure: 149/87. Review of the ED Physician Note dated 04/06/2012 indicated that patient #1 an [AGE] year old presented to the emergency room with weakness, decreased activity , no chest pain and no fever. The section titled Physical examination, specified in part, ...Musculoskeletal: Generalized weakness...Chest X-Ray: Interpretation by Emergency Physician large left sided mass. Radiology results: Discussed with radiologist, Aortic aneurysm leaking,. Impression and Plan; Diagnosis: Leaking thoracic aortic aneurysm... Notes Dr. (cardio thoracic surgeon on call at MHUMC/credential file #1) refused patient... at 5:20 PM. You never send me patients. A review of the Patient Transfer Form dated 04/06/2012 at 5:20 P.M. that patient #1 was transferred via air ambulance to another acute care hospital, Condition on transfer Critical.

Review of Memorial Health University Medical Center (MHUMC) form titled the Physician Central Access Information Sheet dated 04/06/12, indicated that MHUMC received a call at 5:08 p.m. from the transferring facility's Emergency Department (ED) physician. The form noted that the transferring ED physician was requesting a cardio-thoracic surgeon. Documentation revealed the physician on-call for that service was physician / credential file #1. The form revealed the ED physician was attempting to transfer a patient (#1) who had a leaking aortic aneurysm (swelling of the vessel). The form noted that initially the facility's ED physician /credential file #2 had agreed to accept the patient. In addition, the form noted that the cardio-thoracic surgeon refused to accept the patient after speaking with the transferring ED physician and instructed the Transfer Center to notify the facility's ED physicians not to accept the patient. The facility refused to accept from a referring hospital patient #1 on 4/6/2012, who required the hospital's specialized capability and capacity to treat this patient.

Review of the Transfer Center's recordings at 12:35 p.m. on 04/18/12 in the Clinical Compliance Officer's (COO) office revealed the following conversations between the transferring ED physician, receiving facility's ED physician, on-call cardio-thoracic surgeon, and the Transfer Center operator. These recordings were dated 04/06/12.

Recording number 1 was recorded at 5:09 p.m. In this recording, the transferring ED physician told the Transfer Center operator that he wanted to transfer a patient that had a leaking thoracic aorta aneurysm. The physician gave his name, the transferring facility's name, his telephone number, the patient's name and date of birth, and confirmed that the patient was in the ED at the time of the call.

Recording number 2 was recorded at 5:10 p.m. The Transfer Center operator confirmed that the transferring ED physician wanted to speak with a cardio-thoracic surgeon.

Recording number 3 was recorded at 5:11 p.m. The operator informed the transferring ED physician that physician / credential file #1 was on-call for that specialty and that the Transfer Center would page the surgeon and call the ED physician back. The transferring ED physician then asked to speak with the facility's ED physician.

Recording number 4 was recorded at 5:12 p.m. The operator informed the facility's ED staff member that the transferring ED physician wanted to speak with one of the facility's ED physicians. Physician / credential file number 2 informed the operator that he/she was busy evaluating a patient and the operator stated the transferring ED physician had hung up.

Recording number 4 was recorded at 5:18 p.m. The Transfer Center operator informed the transferring ED physician that the cardio-thoracic surgeon had not called back and connected the ED physician with the facility's ED physicians. The transferring ED physician informed the facility's ED physician that he/she wanted to transfer a patient who had a leaking aortic aneurysm. The facility's ED physician replied he/she could not accept the patient without a cardio-thoracic surgeon. The transferring ED physician states the transferring facility's name, the patient's age, and reported that the patient had no chest or back pain. The transferring physician told the facility's ED physician that a CT (computerized tomography - specialized x-ray) confirmed that the patient had a leaking [DIAGNOSES REDACTED] aneurysm. The transferring ED physician stated the patient's blood pressure was 150/87 and that he/she was going to start an Esmolol drip to bring the patient's blood pressure down. In addition, the transferring ED physician stated the patient was actually pretty stable. The facility's ED physician stated that it would be inappropriate for him/her to accept the patient without an accepting cardio-thoracic surgeon and added he/she would try and contact the cardio-thoracic surgeon and asked the transferring facility to send a copy of the CT disc with the patient.

Recording number 6 was recorded at 5:25 p.m. The cardio-thoracic surgeon called the Transfer Center and was connected with the transferring ED physician. The transferring ED physician told the surgeon his/her name and the transferring facility's name. The transferring physician informed the surgeon that the CT revealed the patient had a leaking thoracic aortic aneurysm at the top of the [DIAGNOSES REDACTED], that the patient's blood pressure was 150/87, and that the patient had no chest or back pain. The surgeon asked who had read the CT? The transferring ED physician replied one of our radiologists and informed the surgeon that he/she had seen the CT and that it looked pretty scary. The surgeon asked if it was ascending or descending and the transferring ED physician replied let me look. The surgeon asked again which Radiologist read the CT and was informed that the transferring ED physician did not know. The surgeon asked whether the ED physician was calling from Statesboro or Brunswick and when the transferring ED physician replied Brunswick, the surgeon stated from Brunswick, you can ship him south brother, send him right on down to Jacksonville. The transferring physician then asked You don't want him, that's what you're telling me? The surgeon replied, that's what I'm telling you, ya'll send everything south. The transferring ED physician stated that was BS (curse word) and told the surgeon that the transferring facility sent everything to the receiving facility. The surgeon replied I don't get crap from ya'll. The ED physician stated he/she sent trauma patients to the facility. The surgeon replied trauma may come but I'm not a facility employee and I can tell you cardiac and all that stuff goes to Jacksonville. The ED physician asked, so you aren't accepting this patient? To which the surgeon replied, you got it, yep you can send him south. Yep, call the cardiac surgeons in Jacksonville where all the other stuff goes. You may send trauma up here but cardiac does not come up here. We don't get any of it none of the elective stuff, zero. So he can go south.

Recording number 7 was recorded at 5:28 p.m. The Transfer Center operator informed the surgeon that the transferring ED physician had hung up. The surgeon stated I'm not accepting when we don't get any of their cardiac business at all, it's just not fair. They send us someone with major problems and we get none of their elective work, it's not fair. I'm not gonna do it anymore. I'm happy to help anyone who helps us on a regular basis. On Friday afternoon when it's convenient and they don't want to mess with a Jacksonville referral. I'm not doing it. Make sure the ED physicians know not to accept this patient. The Transfer Center operator replied she would call the ED and inform them not to accept the patient. The surgeon stated the patient needed to go to Jacksonville where Brunswick sent all their cardiac work and that he/she was not available to take the patient.

Recording number 8 was recorded at 5:30 p.m. The Transfer Center called the ED and informed the ED physician / credential file #2 that the cardio-thoracic surgeon on-call had refused to accept the patient and that the surgeon had wanted the ED informed that they were not to accept the patient.

Review of facility policy entitled Physician On-Call, policy number MS 1011, effective date 05/2010, revealed the facility was to maintain an on-call schedule of physicians who were required to fulfill on-call duties. On-call was defined as qualified active medical staff member with clinical privileges who shall be responsible for rendering care to unassigned patient. This policy required the chairperson of each department to be responsible for developing an on-call rotation schedule. The on-call physician was required to: a.) be immediately available at least by telephone, b.) respond in person to emergencies within 30 minutes and non-emergencies within 60 minutes when requested to respond by the ED physician.

Review of the current Medical Staff Roster revealed all four (4) physician's whose credential files were reviewed were active Medical Staff members.

Review of the ED physician's schedule revealed physician / credential file #2 was working in the ED on 04/06/12 from 3:00 p.m. until 1:00 a.m.

During an interview (#1) on 04/18/12 at 1:30 p.m. in the Conference Room, the Customer Service Representative (Transfer Center Operator - TCO) confirmed the recorded events of 04/06/12 related to patient #1. The interviewee explained that the facility's policy was to contact the ED physician if a specialist refused a patient, and try to get the patient accepted. The operator added that if the ED physician had accepted the patient he/she would have had to call the on-call cardio-thoracic surgeon. The operator added there had never been a situation like this one before. He/she explained that on-call physicians did not normally refuse to accept patients. The operator stated the specialist would refuse a patient after speaking with a transferring ED physician and the two physicians determined that the patient did not need the specialist's services. The operator explained that in the event a physician refused a transfer the Transfer Center staff were to notify their supervisor and that he/she had tried to call the supervisor once during his/her shift and once when he/she got home. The operator stated he/she had been unable to reach the supervisor that evening. The TCO added that he/she had had EMTALA training about four (4) years ago.

During an interview (#2) on 04/18/12 at 1:45 p.m. in the Conference Room, the Customer Service Coordinator (CSC) confirmed that the above operator had not gotten in touch with him/her. The CSC explained that he/she had gone home sick that day. The CSC stated he/she had taken some medicine that had put him/her to sleep. He/she added that for all refused transfers the operators were to call him/her whether he/she was on-call or not. The CSC went on to explain that he/she tried to call the operator at home at 9:00 p.m. and had not gotten an answer. The CSC explained that had he/she spoken with the operator he/she would have suggested the operator contact the Administrator on-call. He/she added that the staff knew the protocol was to call the Administrator on-call.

During an interview (#3) on 04/18/12 at 2:00 p.m. in the Conference Room, the Manager of the Transfer Center (MOTC) stated that if the on-call physician refused to accept the patient the operators were to call the ED physician and get the patient accepted. He/she stated the operator had called the CSC but had not called him/her that evening. The MOTC added that the operator should have called the Administrator on-call. The MOTC went on to say he/she had been the MOTC for three (3) years and did not remember a situation like this occurring before. There was no documented evidence on patient #1's Physician Central Access Information Sheet to indicate that Administrator on-call or the Chief Medical officer was called since there was a conflict about the acceptance of patient #1. The facility failed to ensure that their Transfer Center policy was followed as it related to the acceptance of patients from transferring hospitals.

During an interview (#4) on 04/18/12 at 3:10 p.m. in the COO's office, the cardio-thoracic surgeon / credential file #1 stated he/she recalled the telephone call with the transferring physician on 04/06/12. The surgeon went on to say he/she agreed with what was said on the recording. The physician explained that the patient had not been in any pain, was stable, had a CT that showed a leaking aortic aneurysm, and was being put on medication to lower the patient's blood pressure. The physician stated he/she had questioned who had read the CT. In addition, the physician stated he/she had never seen a patient with a leaking aneurysm who was not having pain. The surgeon stated the transferring facility sent all their cardiac patients to Florida and that he/she had told the transferring physician, why don't you send the patient to Jacksonville. The physician stated Jacksonville was closer to the transferring facility and that if the patient needed to be seen immediately the transferring facility had a relationship with the Jacksonville facility which was closer. Review of the Vascular and Cardiac on-call schedule revealed and verified physician / credential file #1 was on-call on 04/06/12. The facility failed to ensure an appropriate transfer was accepted for an individual (Patient #1) who required the specialized capabilities of the cardiothoracic surgeon on 04/06/2012.

During an interview (#5) on 04/19/12 at 9:50 a.m. in the Conference Room, the Medical Director of the ED/President of the Medical Staff explained that if the specialist refused the patient the policy was to call the ED physician for acceptance. The physician stated the ED physician could then call the on-call specialist. The physician stated that when the Transfer Center received a transfer request and the facility could provide the service and had a bed the transfer should be accepted. The physician added that even if the request came from California the transfer should be accepted in order to comply with EMTALA regulations.

Review of five (5) of five (5) personnel files revealed the two (2) Transfer Center staff members (#'s 1 and 2) had no documented evidence of EMTALA training. Employee files #s 3, 4, and 5 (nurses) revealed the nurses received EMTALA training between 12/09 and 08/11.

Review of four (4) of four (4) credential files revealed all four (4) physicians had signed the Code of Business Practice Certificate of Receipt between 04/12/11 and 02/01/12. By signing this form, the physicians attested that they would abide by the Medical Staff Bylaws and Medical Staff Rules and Regulations, and had received and reviewed the EMTALA information provided which consisted of written material and a CD - ROM (compact disc read only memory). Review of the Corporate Ethics and Compliance Office, revised 02/2011, revealed the EMTALA information was to be reviewed and signed by Medical Staff members at their appointment and reappointment.