Based on interviews, review of medical records, policy and procedures the hospital failed for 1 (#1) of 27 patients to ensure that an individual who presents to the Emergency Department with complaints of chest pain was provided an appropriate medical screening examination within the capability of the hospital's Emergency Department to determine that an emergency medical condition existed for 1 ( patient # 1) of 27 sampled patient review. The facility also failed to enter 1( patient # 1) of 27 sampled patients was entered into the hospital's Daily Log (central log). Additionally, the facility failed to ensure that on 12/13/2016 Patient #1 received stabilizing treatment and was appropriately transferred to another facility. Findings: REFERENCE to A-2406 Based on interviews, review of medical records, policy and procedures the hospital failed to provide a Stabilizing Treatment within the capability of the hospital for 1 (#1) of 27 patients presenting to the hospital's Emergency Department. REFERENCE to A-2407-Based on interviews, review of medical records, policy and procedures the hospital failed to provide a Stabilizing Treatment within the capability of the hospital for 1 (#1) of 27 patients presenting to the hospital's Emergency Department. REFERENCE to A-2409 Based on interviews, review of medical records, policy and procedures the hospital failed to appropriately transfer 1 (#1) of 27 patients by not ensuring, based on a Medical Screening Examination, that medical treatment was first provided that was within the capability and capacity of the hospital to minimize risks to the individual's health, failed to ensure the receiving hospital was contacted and agreed to accept the patient and has space and qualified personnel available to provide treatment and to provide the receiving hospital with records documenting the care and treatment provided to the patient.

Based on review of the facility's medical records, policy and procedures and the Emergency Department Central Log the facility failed to ensure that their and policy and procedure was followed regarding maintaining a central log for (#1) of 27 sampled patients. Findings: The hospitals Emergency Department Central Log titled ,"Daily Log" was reviewed. Review of the facility's "Daily Log" dated 12/13/2016 revealed that Patient #1 was not registered on the log when he/she (MDS) dated [DATE]. Review of the medical record for patient #1, (per the Risk Manager, was created 2 days ' post encounter), revealed an Admission Face Sheet with the admitted and time to be 12/15/2016 at 9:27 PM with diagnosis from EMS (Emergency Medical Services) stated Chest Pain. The record revealed that the patient was XFR(Transferred)to another Hospital. The discharge date /time was 12/15/2016 at 9:36 PM. Included with the Face Sheet were 2 documents, Emergency Department, Nursing Notes. The second form was titled Physician Documentation. Review of the nursing note dated 12/22/2016 at 5:34 PM revealed Addendum: On 12/13/2016 at approximately 9:15 PM, EMS( Emergency Medical Services) arrived into ED (Emergency Department) with a patient. This nurse was charting at the nurse ' s station when the EMS paramedic laid three EKG strips in front of nurse and asked where physician was located. This nurse advised the paramedic where the ED physician was down the hall by registration, paramedic left station and headed towards the location of physician. Moments later, paramedic and physician returned to nurse ' S station, discussion occurred between ED physician, the paramedics who had transported patient # 1, and the facility's paramedic, regarding nearest location of suitable hospital for EMS to take patient to for stated " STEMI( ST Segment Elevation Myocardial Infarction) alert " ( Possible . The paramedic advised the ED physician of " protocol " , The ED physician stated " I am not holding up patient care for protocol. " This nurse advised of need to get charge nurse, and went to retrieve the charge nurse form triage. This nurse explained to charge nurse that EMS brought what was said to be a STEMI alert into building and questions of protocol are being asked at the nurses by ED physician. The charge nurse advised she would be there in just a minute. This nurse returned to nurse ' s station to observe EMS and patient gone form building. Upon looking out ED doors, EMS lights on heading South on US 19. Review of the nursing note was written by staff I. Review of the second document revealed a Physician note dated 12/19/2016 at 9:09 PM, " Addendum: This note is being entered after the fact, since the patient never registered, due to the high level of volume and acuity in the ED at the time patient presented. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that Patient #1 was registered on the Daily Log on 12/13/2016 at first point of contact as stated in the policy. Review of the facility's Policy and Procedure, titled "Medical Screening and Treatment/Transfer Policy (EMTALA)" Revision date of 09/29/2016 revealed on page 8. Emergency Department Log, " Each hospital must maintain a central log to track the care provided to each individual who comes to the hospital seeking care for an emergency condition. " " The log entry must be made at the first point contact and must contain, the name of the patient, and the disposition of the patient as patient stabilized and transferred."

Based on interviews, written statements review, review of medical records, policy and procedures review, Emergency Medical Services review, the hospital failed to ensure that an appropriate Medical Screening Examination was provided within the capability of the hospital's emergency department for 1 ( patient # 1) of 27 sampled patients presenting to the hospital's Emergency Department with complaint of chest pains. This failure presents a substantial probability to adversely affect all patient's health and safety. Findings: The EMS report dated 12/13/2016 for patient #1 was reviewed. The section of the report titled "Narrative" revealed in part, "Medic (#) responded to chest pain. Upon arrival found [AGE] year old ...sitting on bed awaiting our arrival. Pt appears in no acute distress. Pt. states the chest pain began about 2040 (8:40 PM) hours this evening. Pt. states pain is 5/10 non radiating substernal pressures. Staff states they contacted pt. physician who ordered 2-nitro and 1-clonidine PTA (Prior to arrival). Pt is conscious and alert. Pt is alert to person, time, place and event. Pt, has patent airway, is breathing without distress and no obvious external bleeding is noted. Physical assessment shows tenderness to substernal area upon palpitation and inspiration ...Pt. denies difficulty breathing, nausea or vomiting, diarrhea and abdominal pain ...Pt. assisted to EMS cot and secured with all seatbelts. Pt. Placed on CM (cardiac monitor) -sinus rhythm, 12 lead ecg -(electrocardiogram) non diagnostic for any st (ST-segment) changes, Administered oxygen as noted. Pt. loaded in unit without incident. Administered ASA (aspirin) as noted. Initiated iv (intravenous) as noted, bgl (blood glucose) as noted. Administered Nitro as noted with no relief. Pt's. vitals were obtained and monitored throughout transport. Administered additional Nitro as noted. Upon re-evaluation of EKG noted changes in 12 lead cg showing elevation in II, II and VAL (limb lead-positive electrode on the left arm). Upon arrival at RR (Seven Rivers Regional Medical Center) pt. unloaded and brought into ER, located ER (MD NAME) so he could evaluate the CG's and advise. ED (MD NAME) advised to immediately transfer pt. to (ACUTE CARE HOSPITAL NAME) for catch lab. We advised ED (MD NAME) that paperwork for transport must be completed due to METAL regulations, ED (MD NAME) responded with "I'm not worried about paperwork right now, I'm concerned with pt. care." Contacted Medic (#) who spoke with ED (MD's NAME)via telephone and advised him again we would do the transfer after paperwork was complete due to METAL, ED (PHYSICIAN"S NAME) advised to have crew immediately transfer pt. to (ACUTE CARE HOSPITAL NAME) for catch lab. Issues SEMI (ST elevated Myocardial Infarction - Heart Attack) alert. Pt loaded back into ems unit and transported to (ACUTE CARE HOSPITAL NAME). While en route initiated 2nd IV and administered fluid bolus as noted. Upon arrival at (ACUTE CARE HOSPITAL NAME) pt. placed in ER room with full report given to ER (emergency room ) nurse." Review of the medical record for patient #1, (per the Risk Manager, was created 2 days ' post encounter), revealed an Admission Face Sheet with the admitted and time to be 12/15/2016 at 9:27 PM (Patient #1 actually presented to the hospital ED on 12/13/2016) with diagnosis from EMS (Emergency Medical Services) stated Chest Pain. The record revealed that the patient was FRI(Transferred)to another Hospital. The discharge date /time was 12/15/2016 at 9:36 PM. Included with the Face Sheet were 2 documents, Emergency Department, Nursing Notes. The second form was titled Physician Documentation. Review of the nursing note dated 12/22/2016 at 5:34 PM revealed Addendum: On 12/13/2016 at approximately 9:15 PM, EMS( Emergency Medical Services) arrived into ED (Emergency Department) with a patient. This nurse was charting at the nurse ' S station when the EMS paramedic laid three EKG strips in front of nurse and asked where physician was located. This nurse advised the paramedic where the ED physician was down the hall by registration, paramedic left station and headed towards the location of physician. Moments later, paramedic and physician returned to nurse ' S station, discussion occurred between ED physician, the paramedics who had transported patient # 1, and the facility's paramedic, regarding nearest location of suitable hospital for EMS to take patient to for stated " SEMI( ST Segment Elevation Myocardial Infarction) alert " Possible . The paramedic advised the ED physician of " protocol " , The ED physician stated " I am not holding up patient care for protocol. " This nurse advised of need to get charge nurse, and went to retrieve the charge nurse form triage. This nurse explained to charge nurse that EMS brought what was said to be a SEMI alert into building and questions of protocol are being asked at the nurses by ED physician. The charge nurse advised she would be there in just a minute. This nurse returned to nurse ' S station to observe EMS and patient gone form building. Upon looking out ED doors, EMS lights on heading South on US 19. Review of the nursing note was written by staff I. Review of the second document revealed a Physician note dated 12/19/2016 (Six (6) days status/Post Patient #1's presentation to RR) at 9:09 PM, " Addendum: This note is being entered after the fact, since the patient never registered, due to the high level of volume and acuity in the ED at the time patient presented. I was asked by a paramedic to review an EKG( Electrocardiogram)for a patient with chest pain while I was at the computer in a back office of the ED. The EKG showed an acute inferior MI (SEMI). I asked the paramedic to take me where the patient is. The paramedic brought me to the patient at the door of the ED still on the EMS stretcher. I evaluated the patient and confirmed that he was having chest pain and appeared stable, without evidence of vomiting. I informed EMS and the ED staff that we needed to transfer the patient to a facility that had access to a heart categorization lab as soon as possible, since the one at this facility was closed at the time. They told me that the closest hospital with an open CATHY lab was at another facility. I spoke to the EMS supervisor on speaker phone and explained that the patient needed a higher level of care of a services that was not available at this facility and that the patient # 1 needed to transferred as soon as possible. I asked he to expedite the transfer. I told him that in the interest of patient safety, that we should focus on getting him to the CATHY lab immediately. The paramedic supervisor agreed to help and the patient was transferred without delay. 2. Review of a statement written on 12/14/2016 by staff DJ the emergency room Tech/Paramedic revealed: A patient as brought into the ED via ambulance the night of December 13, 2016 for chest pain. Upon arrival to ED, the paramedic noted that patient's EEC( Electrocardiogram) showed a SEMI. The paramedic showed the EEC to to staff I, to which I stated that EEC should be shown to the ED Doctor. Upon showing the doctor the EEC, both the paramedic and the doctor came back around to the pt's side. The doctor then came over to the nursing station to tell us that he was a SEMI and needed a CATHY lab. The doctor asked myself, if our CATHY lab was open right now an if not, where was the closest one. I told the doctor that our CATHY lab was not open right now and the closest facility with a CATHY lab would be another facility. The doctor stated that patient # 1 needed be sent there. I told him doctor that he cannot just send them away that he needs to at the very least register and see the patient, and call the receiving facility. The doctor then said that we do not need to waste time that the patient needed a CATHY lab. To which someone said, you cannot do that, that is a METAL( Emergency Treatment and Active Labor Act) violation. The doctor replied stating that it was not an METAL violation, that it was a necessity for the care of the patient. The ambulance crew needed to call their supervisor, to which they did. At that time, I( Staff I) had turned to get transfer paperwork and someone went to get the charge nurse who was triaging a new patient. By the I had looked up, the patient was gone. Review of the facility ' S Policy and Procedure, titled " Medical Screening and Treatment/Transfer Policy (METAL " , Original Effective date of 08/1989 and Revision date of 09/29/2016 revealed on page 2 under Screening Examination " Upon presentation of an individual in accordance with policy, the individual will be taken to an appropriate DEAD( Dedicated Emergency Department) examination site for an appropriate medical screening examination. Consent for treatment will be obtained. Medical screening examination procedure will be initiated by an individual authorized by the Hospital Governing Board, and a patient chart will be prepared. The facility failed to ensure that an appropriate medical screening screening examination was documented in the medical record format when Patient #1 initially presented to the facility's ED on 12/13/2016. The facility also failed to ensure that on 12/13/2016 their policy and procedure was followed as evidenced by failing to ensure that patient #1 was taken to the appropriate DEAD examination site for an appropriate medical screening examination.

Based on interviews, review of medical records, policy and procedures the hospital failed to provide a Stabilizing Treatment within the capability of the hospital for 1 (#1) of 27 patients presenting to the hospital's Emergency Department. Findings: Review of the nursing note dated 12/22/2016 at 5:34 PM revealed Addendum: On 12/13/2016 at approximately 9:15 PM, EMS( Emergency Medical Services) arrived into ED (Emergency Department) with a patient. This nurse was charting at the nurse ' s station when the EMS paramedic laid three EKG strips in front of nurse and asked where physician was located. This nurse advised the paramedic where the ED physician was down the hall by registration, paramedic left station and headed towards the location of physician. Moments later, paramedic and physician returned to nurse ' S station, discussion occurred between ED physician, the paramedics who had transported patient # 1, and the facility's paramedic, regarding nearest location of suitable hospital for EMS to take patient to for stated " STEMI( ST Segment Elevation Myocardial Infarction) alert " ( Possible . The paramedic advised the ED physician of " protocol " , The ED physician stated " I am not holding up patient care for protocol. " This nurse advised of need to get charge nurse, and went to retrieve the charge nurse form triage. This nurse explained to charge nurse that EMS brought what was said to be a STEMI alert into building and questions of protocol are being asked at the nurses by ED physician. The charge nurse advised she would be there in just a minute. This nurse returned to nurse ' s station to observe EMS and patient gone form building. Upon looking out ED doors, EMS lights on heading South on US 19. Review of the nursing note was written by staff I. Review of the second document revealed a Physician note dated 12/19/2016 at 9:09 PM, " Addendum: This note is being entered after the fact, since the patient never registered, due to the high level of volume and acuity in the ED at the time patient presented. I( ED Physician) was asked by a paramedic to review an EKG( Electrocardiogram)for a patient with chest pain while I was at the computer in a back office of the ED. The EKG showed an acute inferior MI (STEMI). I asked the paramedic to take me where the patient is. The paramedic brought me to the patient at the door of the ED still on the EMS stretcher. I evaluated the patient and confirmed that he was having chest pain and appeared stable, without evidence of vomiting. I informed EMS and the ED staff that we needed to transfer the patient to a facility that had access to a heart catheterization lab as soon as possible, since the one at this facility was closed at the time. They told me that the closest hospital with an open CATH lab was at another facility. I spoke to the EMS supervisor on speaker phone and explained that the patient needed a higher level of care of a services that was not available at this facility and that the patient # 1 needed to transferred as soon as possible. I asked he to expedite the transfer. I told him that in the interest of patient safety, that we should focus on getting him to the CATH lab immediately. The paramedic supervisor agreed to help and the patient was transferred without delay. Review of a statement written on 12/14/2016 by staff J the emergency room Tech/Paramedic revealed: A patient as brought into the ED via ambulance the night of December 13, 2016 for chest pain. Upon arrival to ED, the paramedic noted that patient's ECG showed a STEMI. The paramedic showed the ECG to to staff I, to which I stated that ECG should be shown to the ER Doctor. Upon showing the doctor the ECG, both the paramedic and the doctor came back around to the pt's side. The doctor then came over to the nursing station to tell us that he was a STEMI and needed a CATH lab. The doctor asked myself, if our CATH lab was open right now an if not, where was the closest one. I told the doctor that our CATH lab was not open right now and the closest facility with a CATH lab would be another facility. The doctor stated that patient # 1 needed be sent there. I told him doctor that he cannot just send them away that he needs to at the very least register and see the patient, and call the receiving facility. The doctor then said that we do not need to waste time that the patient needed a CATH lab. To which someone said, you cannot do that, that is a EMTALA violation. The doctor replied stating that it was not an EMTALA violation, that it was a necessity for the care of the patient. The ambulance crew needed to call their supervisor, to which they did. At that time, I had turned to get transfer paperwork and someone went to get the charge nurse who was triaging a new patient. By the I had looked up, the patient was gone. Review of the policy and procedure titled" Medical Screening and Treatment/Transfer Policy( EMTALA)." revision date of 09/29/2016 states that " to stabilize" means with respect to an emergency medical condition, to provide such medical treatment of the condition necessary to assure within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during transfer of the individual from a facility or that, with respect to a condition described in paragraph (2). Placing the health of the individual in serious jeopardy , serious impairment of bodily functions or serious dysfunction of any body organ. The hospital failed to ensure that stabilizing treatment was provided prior to patient #1 leaving the ED on 12/13/2016.

Based on interviews, review of medical records, transfer log, policy and procedures the hospital failed to appropriately transfer 1 (#1) of 27 patients by not ensuring, based on a Medical Screening Examination, that medical treatment was first provided to minimize risks to the individual's health, failed to ensure the receiving hospital was contacted and agreed to accept the patient and has space and qualified personnel available to provide treatment and to provide the receiving hospital with records documenting the care and treatment provided to the patient. Findings: Review of the medical record for patient #1, (per the Risk Manager, was created 2 days ' post encounter), revealed an Admission Face Sheet with the admitted and time to be 12/15/2016 at 9:27 PM with diagnosis from EMS (Emergency Medical Services) that stated Chest Pain. The record revealed that the patient was XFR(Transferred)to another Hospital. The discharge date /time was 12/15/2016 at 9:36 PM PM. Included with the Face Sheet were 2 documents, Emergency Department, Nursing Notes. The second form was titled,Physician Documentation. Review of the nursing note dated 12/22/2016 at 5:34 PM revealed Addendum: On 12/13/2016 at approximately 9:15 PM, EMS( Emergency Medical Services) arrived into ED (Emergency Department) with a patient. This nurse was charting at the nurse ' s station when the EMS paramedic laid three EKG strips in front of nurse and asked where physician was located. This nurse advised the paramedic where the ED physician was down the hall by registration, paramedic left station and headed towards the location of physician. Moments later, paramedic and physician returned to nurse ' S station, discussion occurred between ED physician, the paramedics who had transported patient # 1, and the facility's paramedic, regarding nearest location of suitable hospital for EMS to take patient to for stated " STEMI( ST Segment Elevation Myocardial Infarction) alert " ( Possible . The paramedic advised the ED physician of " protocol " , The ED physician stated " I am not holding up patient care for protocol. " This nurse advised of need to get charge nurse, and went to retrieve the charge nurse form triage. This nurse explained to charge nurse that EMS brought what was said to be a STEMI alert into building and questions of protocol are being asked at the nurses by ED physician. The charge nurse advised she would be there in just a minute. This nurse returned to nurse ' s station to observe EMS and patient gone form building. Upon looking out ED doors, EMS lights on heading South on US 19. Review of the nursing note was written by staff I. Review of the second document revealed a Physician note dated 12/19/2016 at 9:09 PM, " Addendum: This note is being entered after the fact, since the patient never registered, due to the high level of volume and acuity in the ED at the time patient presented. I was asked by a paramedic to review an EKG( Electrocardiogram)for a patient with chest pain while I was at the computer in a back office of the ED. The EKG showed an acute inferior MI (STEMI). I asked the paramedic to take me where the patient is. The paramedic brought me to the patient at the door of the ED still on the EMS stretcher. I evaluated the patient and confirmed that he was having chest pain and appeared stable, without evidence of vomiting. I informed EMS and the ED staff that we needed to transfer the patient to a facility that had access to a heart categorization lab as soon as possible, since the one at this facility was closed at the time. They told me that the closest hospital with an open CATH lab was at another facility. I spoke to the EMS supervisor on speaker phone and explained that the patient needed a higher level of care of a services that was not available at this facility and that the patient # 1 needed to transferred as soon as possible. I asked he to expedite the transfer. I told him that in the interest of patient safety, that we should focus on getting him to the CATH lab immediately. The paramedic supervisor agreed to help and the patient was transferred without delay. Review of the Transfer Log for this facility revealed that patient #1 was list on 12/15/2016 as presenting to the Emergency Department at 9:27 PM, and Departed at 9:36 PM with a transfer destination to the receiving facility. The chief complaint of chest pain. Review of the emergency room Transfer Log revealed that for 12/15/2016 revealed that Patient #1 was listed as being transferred to receiving hospital with the chief complaint of chest pain. During an interview on 12/27/2016 at 9:30 AM, the Risk Manager revealed that the entry was a late entry for self-reported EMTALA violation Review of the Policy and Procedure titled, " Medical Screening and treatment/Transfer policy( EMTALA) page 3 Documentation Requirements: General Policy and Procedures, " The hospital shall thoroughly document all events associated with the provision of emergency medical services in accordance with this policy and procedure in the medical record, patient logs, Emergency Department forms and as otherwise appropriate. " Transfer" means the movement, including the discharge, of an individual outside the hospital's facility's at the direction of any person employed by ( or affiliated or associated, directly or indirectly, with) the hospital, but does not include such movement of an individual who is declared dead or leaves the the facility without permission). " Appropriate Transfer" includes bed availability, service capability to meet the patient's needs, scope of practice of physicians on duty and on call, availability of needed resources and administration or house supervisor approval. Review of the medical record from the receiving facility, that patient #1 was transported to receiving hospital from this facility did not reveal that the they were informed of the patient ' s transfer or received any information that was sent with the patient. The medical record did not reveal that the ED physician from transferring hospital or any other staff called the receiving facility. Review of the medical record for transferring facility revealed a Nursing Progress Note dated 12/15/2016 at 2:26 PM; " I faxed a request for any medical records for this patient to transferring hospital, Medical Records Department for 12/13/2016. A staff person from Medical Records called me back and stated that she had no records for this patient and the patient had not been registered there on that date. The last admission she had for patient # 1 was in 2014." .