1. Based on review of medical records, ambulance trip reports, Emergency On-schedules Medical Staff Rules and Regulations, Emergency Provider Agreement, Physician Credentialing Files, Policies and Procedures, observational tours, Operating Room Logs, House Supervisor's Report and staff interviews, it was determined that the facility failed to provide an appropriate Medical Screening Examination within the capability of the hospital emergency room , on- call Orthopedic physician, that was routinely available to the emergency department, to determine whether or not an emergency medical condition existed for two (2) of 24 sampled medical records patients for patient #'s 2 and 21 presented to the Emergency Department respectively with gunshot wounds. Refer to findings in Tag A-2406. 2. Based on review of medical records, policies and procedures and on-call schedules , and interviews, it was determined the hospital failed to provide stabilizing treatment within the capabilities of the staff and facilities available at the hospital for further evaluation and treatment as required to stabilize 2 (#2 & #21) of 24 sampled patients who presented to the hospital with gunshot wounds to the foot. Refer to findings in tag 2407.

Based on an observational tour, review of medical records, policies and procedures and on-call schedules, and interview, it was determined the hospital failed to provide stabilizing treatment within the capabilities of the staff and facilities available at the hospital for further evaluation and treatment as required to stabilize 2 (#2 & #21) of 24 sampled patients who presented to the hospital with gunshot wounds to the foot. Policy and Procedures The facility's policy titled "EMERGENCY MEDICAL TREATMENT AND LABOR ACT-EMTALA', policy number AMC-RI.280, last reviewed/revised 05/17, effective 02/14/01, revealed the purpose was to set forth policies and procedures for Hospital ' s use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA) was reviewed. The policy revealed in part, Definitions: A. " Capacity " encompasses such things as numbers and availability of qualified staff, beds and equipment, as well as the Hospital ' s past practices of accommodating patients in excess of its occupancy limits. B. "Capability " defined as the staff, equipment and specialty or specialist services available to care for a patient with an EMC ... "IV. POLICY: B. The Hospital will: (a) provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to " stabilize " the emergency medical condition, or (b) arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below. C. It is the policy of the Hospital to maintain a list of physicians from its medical staff who are on-call for duty after the medical screening examination to provide further medical examination and treatment as necessary to stabilize individuals who have been found to have an EMC ... E. Individuals Who Have An EMC, if after a MSE, it is determined that an individual has an EMC, the Hospital shall: 1. Within the capability and capacity of the staff and facilities available at the Hospital (including coverage available through the Hospital's on-call roster), provide treatment necessary to stabilize the individual, at which time the individual may be discharged ; or 2. Admit the individual to the Hospital in order to stabilize the individual; or 3. If stabilization of the individual is beyond the capabilities or capacity of the Hospital, arrange for appropriate transfer of the individual to another medical facility in accordance with this policy. Medical Record for Patient #2. Review of the patient's medical record (#2) revealed the patient presented to the facility's South Campus as a walk-in patient on 10/15/16 at 4:51 a.m. with complaints of a self-inflicted gunshot wound to the right foot. The triage (assessment by a nurse to determine the priority in which patients will be seen based on their presenting signs and symptoms) nurse noted that the patient was an ESI level 1 (Emergency Severity Index level of 1- patients that require life, limb, or organ saving interventions) and the patient was immediately placed in a room. The triage nurse also noted that the patient ambulated with assistance and had received no care of the wound prior to arrival. In addition, the triage nurse noted that the patient was allergic to shrimp, was on no home medications, and that the patient denied loss of consciousness at the time of the injury. Nurses' and the ED physician's notes revealed the following: --4:51 a.m., ED physician #9 ordered an x-ray of the right foot - results revealed four (4) of the bones in the top of the right foot were broken into multiple pieces and that there were numerous metallic foreign bodies in the surrounding area and generalized soft tissue swelling. --4:51 a.m., ED physician #9 ordered Tetanus - [DIAGNOSES REDACTED] - Pertussis Toxoid 0.5 milliliter intramuscular injection, administered at 5:05 a.m. to the right upper arm. --4:53 a.m., ED physician #9 ordered an intravenous (IV) lines, at 5:08 a.m., the nurse noted that a 20 gauge (size of IV catheter) IV was inserted into the patient's right inner elbow area, and at 5:11 a.m., the nurse noted that a 16 gauge IV was placed in the patient's left upper arm. --4:54 a.m., ED physician #9 ordered Ancef (antibiotic) 2 grams intravenously, administered at 5:07 a.m. --5:01 a.m., ED physician #9 ordered Morphine (medication used to treat pain) 4 milligrams administer intravenously, Zofran ( medication used to prevent nausea and vomiting) 4 milligrams administer intravenously, Normal saline 0.9% administer intravenously, the nurse noted that these were administered at 5:10 a.m. ED physician #9 noted that the patient had been medically screened. --5:06 a.m., the nurse noted that the patient's Glasgow Coma Scale score (assessment of eye movement, verbal response, and motor (movement) response) was 15 (normal 15) and trauma score was 12 (a score of 3-10 needs immediate care, 11 needs urgent care, and a 12 the care can be delayed). --5:10 a.m., the nurse documented the patient's vital signs (VS) as: temperature (T) 98.0 (normal 97.8-99.1), pulse (P) 87 (normal 60-100), respirations (R) 20 (normal 12-18), blood pressure (BP) 146/97 (normal 90/60-120/80), pulse oxygenation (PO - amount of oxygen in the blood) 98% (normal 95-100%) on two (2) liters of oxygen by nasal cannula, and right foot pain level was 10 on a scale of one (1) to 10 with one (1) being mild pain and 10 being severe pain. --5:29 a.m., financial registration completed. --5:39 a.m., the nurse documented the patient's VS as: P 65, R 18, BP 137/89, PO 100% on two (2) liters of oxygen by nasal cannula. --5:44 a.m., Final x-ray of Right foot completed. "Findings: There are comminuted fractures of the medial cuneiform tarsal bone and the first, second and third metatarsal bones. There are numerous foreign body densities surrounding the metatarsal bones. There is generalized soft tissue swelling. IMPRESSION: Fractures and foreign bodies as described." --6:07 a.m., ED physician #9 ordered irrigation of the wound, Posterior right leg splint, Crutches, and Wound dressing, the nurse noted that these were completed at 6:18 a.m. --6:08 a.m., the nurse noted that ED physician #9 ordered the patient to be discharged . ED physician #9 noted that the patient was discharged to home, that his/her impression was that the patient had broken bones in the right foot from a gunshot wound, and that the patient's condition had improved. ED physician #9 noted that the patient was provided with a work release form for three (3) days and a referral to follow-up with the Orthopedic Surgeon (#1) in two (2) to three (3) days. ED physician #9 further noted that the patient was being discharged with prescriptions for Augmentin (antibiotic) 875 milligrams 20 tablets one (1) tablet by mouth twice a day, Motrin (mild to moderate pain pill) 800 milligrams 30 tablets one (1) tablet by mouth three (3) times a day as needed for pain, Percocet (moderate to severe pain pill) 5/325 milligrams 15 tablets one (1) or two (2) tablets by mouth every four (4) to six (6) hours as needed for pain. --6:16 a.m., the nurse noted that the patient's VS were: P68, R 18, BP 142/87, PO 99% on room air. The nurse noted that crutches were dispensed and that teaching was completed. The nurse also noted that an Ace wrap posterior (back) lower leg splint (used to stabilize the leg and help to alleviates extremity pain, swelling, and further soft tissue injury and promotes wound and bone healing) was applied to the right leg and that the ED physician (#9) checked the splint. The nurse noted that circulation, movement, and sensation remained intact. ED physician #9 noted that the patient (#2) had complained of gunshot wound to the right foot, with no loss of consciousness. --6:17 a.m., the nurse noted that the patient was discharged home with crutches in stable condition. In addition, the nurse noted that the patient's home medications and discharge instructions were reviewed with the patient and that the patient's discharge pain level was six (6) on a scale of one (1) to 10. --6:18 a.m., ED physician #9 noted that the patient had an acute (sudden onset) deformity, pain, and puncture wound on the right foot and that all other systems were negative. --6:20 a.m., ED physician #9 noted that the patient appeared to be in no acute distress, had normal range of motion with painful movement of the right foot, was oriented to person, place, time and situation. The physician further noted that the patient had a 2.5-centimeter (.98 inch) diameter gunshot wound that "goes through and through". --6:36 a.m., the nurse noted that the patient left the ED. Medical Record Patient #21. Review of patient #21's medical record revealed the patient presented to the South Campus ED as a walk-in on 05/28/17 at 11:52 a.m. with complaints of a gunshot wound to the right foot. The triage nurse noted that the patient was an ESI level 2 ... (High risk situation. Severe pain/distress ...requires help quickly but not immediately) and that the patient was placed in a trauma room at 11:54 a.m... The triage nurse also noted that the patient reported that his wife shot him in the foot with 357 magnum and that the patient had no known allergies. Nurses' and the ED physician's notes revealed the following: --11:58 a.m. portable x-ray of the right foot was ordered and performed, results revealed multiple broken bones in the top of the right foot. Blood work was ordered, completed, and reviewed by the ED physician (#4). Review of the Final CT report of the right foot revealed in part, 1. Extensively comminuted fractures at the base of first metatarsal and at the first cuneiform ...Multiple tiny metal fragments are seen mixed with pieces of bone. 2. Smaller fractures at the base of the second metatarsal and at the second cuneiform. 3. Small fracture at the base of the third cuneiform. 4. Vertical fracture through the navicular." --11:59 a.m. the patient's vital signs were documented as 98.7-90-20-142/101, 97% on room air, patient "appears uncomfortable, Behavior is anxious", and pain as 10/10. --12:03 p.m. Zofran 4 mg and Toradol (Non-steroidal anti-inflammatory medication used to decrease pain, swelling and fever) 30 mg was administered IVP. --12:04 p.m. Morphine 4 mg and Ancef 2 grams was administered IV and Tetanus Toxoid 0.5 ml was administered intramuscularly into the left upper arm. --12:06 p.m. physician #4 noted that the patient #21 reported being shot in the right foot by his wife, that the patient had no loss of consciousness, and that police were notified. Physician #4 noted that the physical examination revealed range of motion in all extremities, good blood flow to the arteries in the foot, no nerve damage, and entrance and exit wounds to the top of the foot. --12:29 p.m. physician #4 ordered, "Consult Orders: Physician #1 (surgery-ortho) Ordered." --12:44 p.m. nurses' notes indicated that the patient appeared uncomfortable and that the patient's pain was now 6/10. --12:45 p.m. the patient's vital signs were 79-18-150/97-96% on room air. --12:46 p.m. nurses' notes indicated that a 20 gauge IV was placed in the patient's right hand and the GSW was irrigated with Betadine solution. --12:54 p.m. nurses' notes indicated that a posterior short leg splint was applied as ordered. --1:00 p.m. physician #4 noted that The diagnosis was [DIAGNOSES REDACTED]"regarding historical points, exam findings, and any diagnostic results, supporting the admit diagnosis. Data reviewed: vital signs, nurse's notes, lab tests results (s), radiologic studies. After a detail discussion of the patient's case, care is transferred to (Name of trauma Physician at the Main Campus) Patient has an emergent medical condition" The admission plans were discussed with the patient and patient #21 agreed with the plan. --1:05 p.m. Disposition Summary -physician #4 ordered the transfer to the Main Campus. The diagnosis was [DIAGNOSES REDACTED] --1:18 p.m. EMS transport was arranged and report was called to the receiving nurse. --1:24 p.m. the patient signed the consent to treat forms. --1:27 p.m. the nurse noted that the transfer form was scanned into the chart. --1:32 p.m. the nurse noted that the patient had no adverse reactions to the drugs the patient had received. --1:33 p.m. nurses' notes indicated that the patient left the ED in stable condition and that the patient's pain at the time of transfer was 6/10. --Physician #4's discharge notes indicated that the patient was transfer to the Main Campus in fair condition with a GSW and broken bones in the top of the right foot. Physician #4 indicated that the patient was accepted at the Main Campus by an accepting physician for trauma services not available at the South Campus On- Call Schedules The on-call schedules for the South Campus ED were reviewed for the months of October 2016 and May 2017. The review revealed that Orthopedic Surgeons were on 10/15/2016 when Patient #2 presented and on 5/28/2017 when patient #21 presented to the hospital. The hospital had the capability of the staff and facilities available at the hospital to provide further medical evaluation and treatment as required to stabilize patient #2 and #21. Interview An observational tour of the ED was conducted on 06/11/18 at 9:15 a.m. with the Chief Nursing Officer/Chief Operating Officer (CNO/COO #3) and ED Manager (EDM #2). The EDM (#2) said that if there is a consultation with a specialist on-call the expectation is that the on-call physician will come into the ED if requested by the ED physician. The EDM (#2) said that to his/her knowledge the South Campus has had no problems with on-call physicians responding when called. The EDM (#2) said that all staff receive EMTALA training annually.

Based on review of medical records, ambulance trip reports, Emergency On-schedules Medical Staff Rules and Regulations, Emergency Provider Agreement, Physician Credentialing Files, Policies and Procedures, observational tours, Operating Room Logs, House Supervisor's Report and staff interviews, it was determined that the facility failed to provide an appropriate Medical Screening Examination within the capability of the hospital emergency room , on- call Orthopedic physician, that was routinely available to the emergency department, to determine whether or not an emergency medical condition existed for two (2) of 24 sampled medical records patients for patient #'s 2 and 21 presented to the Emergency Department respectively with gunshot wounds. Findings were: Medical record #2: Review of the patient's medical record (#2) revealed the patient presented to the facility's South Campus as a walk-in patient on 10/15/16 at 4:51 a.m. with complaints of a self-inflicted gunshot wound to the right foot. The triage (assessment by a nurse to determine the priority in which patients will be seen based on their presenting signs and symptoms) nurse noted that the patient was an ESI level 1 (Emergency Severity Index level of 1- patients that require life, limb, or organ saving interventions) and the patient was immediately placed in a room. The triage nurse also noted that the patient ambulated with assistance and had received no care of the wound prior to arrival. In addition, the triage nurse noted that the patient was allergic to shrimp, was on no home medications, and that the patient denied loss of consciousness at the time of the injury. Nurses' and the ED physician's notes revealed the following: --4:51 a.m., ED physician #9 ordered an x-ray of the right foot - results revealed four (4) of the bones in the top of the right foot were broken into multiple pieces and that there were numerous metallic foreign bodies in the surrounding area and generalized soft tissue swelling. --4:51 a.m., ED physician #9 ordered Tetanus - [DIAGNOSES REDACTED] - Pertussis Toxoid 0.5 milliliter intramuscular injection, administered at 5:05 a.m. to the right upper arm. --4:53 a.m., ED physician #9 ordered an intravenous (IV) lines, at 5:08 a.m., the nurse noted that a 20 gauge (size of IV catheter) IV was inserted into the patient's right inner elbow area, and at 5:11 a.m., the nurse noted that a 16 gauge IV was placed in the patient's left upper arm. --4:54 a.m., ED physician #9 ordered Ancef (antibiotic) 2 grams intravenously, administered at 5:07 a.m. --5:01 a.m., ED physician #9 ordered Morphine (medication used to treat pain) 4 milligrams administer intravenously, Zofran ( medication used to prevent nausea and vomiting) 4 milligrams administer intravenously, Normal saline 0.9% administer intravenously, the nurse noted that these were administered at 5:10 a.m. ED physician #9 noted that the patient had been medically screened. --5:06 a.m., the nurse noted that the patient's Glasgow Coma Scale score (assessment of eye movement, verbal response, and motor (movement) response) was 15 (normal 15) and trauma score was 12 (a score of 3-10 needs immediate care, 11 needs urgent care, and a 12 the care can be delayed). --5:10 a.m., the nurse documented the patient's vital signs (VS) as: temperature (T) 98.0 (normal 97.8-99.1), pulse (P) 87 (normal 60-100), respirations (R) 20 (normal 12-18), blood pressure (BP) 146/97 (normal 90/60-120/80), pulse oxygenation (PO - amount of oxygen in the blood) 98% (normal 95-100%) on two (2) liters of oxygen by nasal cannula, and right foot pain level was 10 on a scale of one (1) to 10 with one (1) being mild pain and 10 being severe pain. --5:29 a.m., financial registration completed. --5:39 a.m., the nurse documented the patient's VS as: P 65, R 18, BP 137/89, PO 100% on two (2) liters of oxygen by nasal cannula. --5:44 a.m., Final x-ray of Right foot completed. "Findings: There are comminuted fractures of the medial cuneiform tarsal bone and the first, second and third metatarsal bones. There are numerous foreign body densities surrounding the metatarsal bones. There is generalized soft tissue swelling. IMPRESSION: Fractures and foreign bodies as described." --6:07 a.m., ED physician #9 ordered irrigation of the wound, Posterior right leg splint, Crutches, and Wound dressing, the nurse noted that these were completed at 6:18 a.m. --6:08 a.m., the nurse noted that ED physician #9 ordered the patient to be discharged . ED physician #9 noted that the patient was discharged to home, that his/her impression was that the patient had broken bones in the right foot from a gunshot wound, and that the patient's condition had improved. ED physician #9 noted that the patient was provided with a work release form for three (3) days and a referral to follow-up with the Orthopedic Surgeon (#1) in two (2) to three (3) days. ED physician #9 further noted that the patient was being discharged with prescriptions for Augmentin (antibiotic) 875 milligrams 20 tablets one (1) tablet by mouth twice a day, Motrin (mild to moderate pain pill) 800 milligrams 30 tablets one (1) tablet by mouth three (3) times a day as needed for pain, Percocet (moderate to severe pain pill) 5/325 milligrams 15 tablets one (1) or two (2) tablets by mouth every four (4) to six (6) hours as needed for pain. --6:16 a.m., the nurse noted that the patient's VS were: P68, R 18, BP 142/87, PO 99% on room air. The nurse noted that crutches were dispensed and that teaching was completed. The nurse also noted that an Ace wrap posterior (back) lower leg splint (used to stabilize the leg and help to alleviates extremity pain, swelling, and further soft tissue injury and promotes wound and bone healing) was applied to the right leg and that the ED physician (#9) checked the splint. The nurse noted that circulation, movement, and sensation remained intact. ED physician #9 noted that the patient (#2) had complained of gunshot wound to the right foot, with no loss of consciousness. --6:17 a.m., the nurse noted that the patient was discharged home with crutches in stable condition. In addition, the nurse noted that the patient's home medications and discharge instructions were reviewed with the patient and that the patient's discharge pain level was six (6) on a scale of one (1) to 10. --6:18 a.m., ED physician #9 noted that the patient had an acute (sudden onset) deformity, pain, and puncture wound on the right foot and that all other systems were negative. --6:20 a.m., ED physician #9 noted that the patient appeared to be in no acute distress, had normal range of motion with painful movement of the right foot, was oriented to person, place, time and situation. The physician further noted that the patient had a 2.5-centimeter (.98 inch) diameter gunshot wound that "goes through and through". --6:36 a.m., the nurse noted that the patient left the ED. The Discharge Instructions were signed by the patient (#2) and included the following: Thank you for using Atlanta Medical Center South Campus for your care today. It is important for you to know that the examination, treatment and x-ray reading you have received in the Emergency Care Center today have been rendered on an emergency basis only and are not intended to be a substitute for an effort to provide complete medical care. You should contact your follow-up physician as it is important that you let him or her check you and report any new or remaining problems since it is impossible to recognize and treat all elements of an injury or illness in a single emergency care center visit. The discharge instructions for today's visit are outlined below: --broken bones in the foot, --Augmentin 875 milligrams 20 tablets one (1) tablet by mouth twice a day, --Motrin 800 milligrams 30 tablets one (1) tablet by mouth three (3) times a day as needed for pain, --Percocet 5/325 milligrams 15 tablets one (1) or two (2) tablets by mouth every four (4) to six (6) hours as needed for pain, --Selected Referral with Orthopedic Surgeon in (Physician #1 name was listed) two (2) to three (3) days, and --Work release form for three (3) days. The patient signed that he/she "hereby acknowledge that I have received and understand the above instructions and prescriptions (If any). I acknowledge that failure to follow-up with the above doctors as directed will release the ED physicians of any responsibility for any adverse outcome or worsening of my condition, I also understand that my signature authorizes Atlanta Medical Center South Campus to release all or any part of my medical record (including, if applicable, information pertaining to AIDS/HIV testing, mental health records, and drug/alcohol treatment) to the referred physician(s) listed above. --6:40 a.m., the Consent to Routine Procedures and Treatments and Financial Responsibility Statement was signed by a staff member and noted that the patient had given verbal consent for treatment. On-Call Schedules The hospital's October 2016 on call schedule was reviewed. The on-call schedule revealed that on October 15, 2016 the hospital had capability to provide the ancillary services of the on-call Orthopedic physician (#1) that was available prior to discharging patient #2 from the hospital's ED on 10/15/2016. There was no documented evidence of ED physician (#9) calling the on-call Orthopedic Surgeon (#1) to request that the on-call physician come into the ED to see the patient. Review of the patient's (#2) medical record from hospital A revealed the patient presented to hospital A at 8:01 a.m. The patient signed the consent to treat at 8:06 a.m. At 8:20 a.m., the triage nurse assessed the patient assigned the patient as a level two (2) priority. The triage nurse noted the following: patient arrived by private automobile, has a gunshot wound to the right foot, reports treatment at Wellstar Atlanta Medical Center's South Campus, has a dressing to the right foot and reports that he/she (patient) noticed bleeding through the bandage and came to the hospital (A), and temperature 100.4, pulse 65, respirations 16, and blood pressure 149/107. --At 9:50 a.m., the ED physician noted that the patient had a shotgun wound to the right foot and reported being treated at Wellstar Atlanta Medical Center's South Campus. The physician noted that the patient reported that the previous treatment had included x-rays of the right foot, receiving antibiotic medication, and pain medication. The physician further noted that while in the car (travel time from Wellstar Atlanta Medical Center's South Campus to hospital A is approximately 30 minutes) his/her (patient #2) noticed his/her (patient) foot had started bleeding through the bandage. In addition, the ED physician noted that the patient reported severe pain that was described as achy and that he/she (patient #2) had taken two (2) Naproxen (non-steroidal anti-inflammatory drug used to reduce pain, swelling, and fever) 500 mg prior to arrival. The ED physician noted that the patient had a large wound to the top of the right foot and a larger wound to the bottom of the right foot with a foreign body protruding that was easily removed and appeared to be part of the bullet. --Physician orders included blood work that revealed the patient had an elevated white blood cell count of 15.2 (normal 3.4-10.8), x-rays of the right foot that revealed numerous metallic fragments throughout the foot with broken metatarsal bones, intravenous fluids that were started at 10:22 a.m., Zosyn (antibiotic) 4.5 grams intravenously that was started at 10:22 a.m., and an orthopedic consult. --At 1:45 p.m., the orthopedic physician noted that the patient had noticed that his/her (patient #2) foot had started bleeding while driving home. The physician noted that the patient had moderate soft tissue damage to the top of the foot and extensive soft tissue damage to the bottom of the foot with visible pieces of the plastic shell casing. The orthopedic physician further noted that the patient had no active problems at the time of the examination. The orthopedic surgeon suggested transferring the patient to a trauma center. --The ED physician filled out the transfer form which revealed the patient was accepted at Wellstar Atlanta Medical Center's Main Campus by one of the facility's ED physicians. The transfer form included documentation of the risks and benefits, that the patient had been stabilized for transfer, that the patient was being transferred by ambulance, and that portions of the medical record was sent to the accepting facility. --The transferring nurse documented that he/she called report to the receiving nurse and that the patient left the facility on 10/15/16 at 3:12 p.m. Review of the ambulance trip report revealed the ambulance attendants turned over the patient's care to the Main Campus staff at 4:01 p.m. The ambulance trip report revealed that patient had a penetrating wound with swelling and that the bleeding was controlled. During transport the ambulance report noted that the patient's Glasgow Coma Scale score was 15 (normal), the patient had no pain, and vital signs remained within normal limits. The ambulance report revealed that the patient reported that after being discharged from Wellstar Atlanta Medical Center South Campus the wound to his/her (the patient) right foot wound would not stop bleeding so the patient went to hospital A for further treatment. The ambulance report revealed the wound was redressed prior to transport, that the patient had a 20-gauge intravenous line intact with normal saline running at 100 milliliters per hour. The ambulance report revealed the patient remained stable during transport to Wellstar Atlanta Medical Center Main Campus. Review of the patient's (#2/#8 same patient) medical record revealed the patient presented to the facility's Main Campus by ambulance as a transfer from hospital A on 10/15/16 at 3:50 p.m. Upon arrival at Wellstar Atlanta Medical Center Main Campus the patient was triaged as an ESI 1. The triage nurse noted that the patient's vital signs were within normal limits. --3:48 p.m. ED physician #7 ordered blood work which included a complete blood cell count, results revealed the patient's white blood cell count (signifies infection) was 11.2 (normal 5.0-10.0), red blood cell count (carries oxygen to the tissue) was 3.98 (normal 4.6-6.0), hemoglobin (carries oxygen) was 12.1 (normal 14.0-18.0), and hematocrit (volume of red blood cells in the blood) 36.2 (normal 42.0-52.0) --3:55 p.m. ED physician #7 examined the patient. --4:20 p.m. A family member signed the Consent to Routine Procedures and Treatments and Financial Responsibility Statement. --4:25 p.m. The patient signed an Informed Consent for incision and debridement (I&D - to clean out the wound site) with possible fixation of the broken bones in the right foot. --4:32 p.m. ED physician #7 noted that the patient had a gunshot wound to the right foot and that the patient had severe pain to the right foot. The physician noted that the patient had strong pulses in the foot, intact sensation to the toes, and could move his/her (patient) toes. ED physician #7 further noted that the patient had no pain with ankle movement. ED physician #7 noted that the skin was torn away from the top and bottom of the right foot but there was no active bleeding. --4:44 p.m. ED physician #7 ordered a computerized tomography (CT scan) without contrast of the patient's right foot. This report revealed extensive fragmented broken bones in the right foot. --4:45 p.m. ED physician #7 noted that the plan was for the patient to be admitted . Nurses' notes indicated the patient left the ED in a stable/improved condition. --4:51 p.m. The Admission History and Physical report revealed the patient reported that he/she had a shotgun strapped to the inside of his/her leg and that the gun went off firing buck shot into the top of the patient's right foot. This report noted that the patient reported going to hospital A for treatment of continued pain and bleeding from the right foot wound. The report revealed the plan was to admit the patient to Orthopedic Services with plans for a surgical procedure / I&D with closed reduction with pinning versus open reduction with internal fixation of the broken bones. --5:43 p.m. ED physician #7 noted that Orthopedic Services had been notified and that Graduate Resident (#6) was at the patient's bedside. ED physician #7 noted that the patient was to be admitted with broken bones in the right foot to Orthopedic Surgeon #5. --8:22 p.m. Nurses' notes indicated the patient left the ED in a stable/improved condition. --10/16/16 Orthopedic Surgeon #12 performed the I&D of the patient's right foot. The physician noted that a wound vac (used to increase circulation and healing to the site) was applied and that a second I&D was planned for later that week. --10/17/16 The patient signed a second Informed Consent for an I&D procedure. --10/18/16 Orthopedic Surgeon #12 performed a second I&D of the patient's right foot. The operative note revealed the right leg was splinted and that the patient would be non-weight bearing on the right lower extremity. --Review of subsequent blood work revealed that the patient's complete blood cell count remained essentially the same during this admission. Documentation revealed that during this admission the patient car included: antibiotics, pain medications, intravenous fluids, evaluation and treatment by physical therapy and occupational therapy, and evaluation by case management. Documentation revealed the patient was taught to apply wet-to-dry dressings and was discharged home with prescriptions for pain medications and antibiotics and a referral to follow-up with the Orthopedic Surgeon (#12) in 10-14 days. The Discharge Summary revealed the patient had no complications during this admission. The patient signed receipt and understanding of the discharge paperwork on 10/20/16. Medical Record #21: Review of patient #21's medical record revealed the patient presented to the South Campus ED as a walk-in on 05/28/17 at 11:52 a.m. with complaints of a gunshot wound to the right foot. The triage nurse noted that the patient was an ESI level 2 ... (High risk situation. Severe pain/distress ...requires help quickly but not immediately) and that the patient was placed in a trauma room at 11:54 a.m... The triage nurse also noted that the patient reported that his wife shot him in the foot with 357 magnum and that the patient had no known allergies. Nurses' and the ED physician's notes revealed the following: --11:58 a.m. portable x-ray of the right foot was ordered and performed, results revealed multiple broken bones in the top of the right foot. Blood work was ordered, completed, and reviewed by the ED physician (#4). Review of the Final CT report of the right foot revealed in part, 1. Extensively comminuted fractures at the base of first metatarsal and at the first cuneiform ...Multiple tiny metal fragments are seen mixed with pieces of bone. 2. Smaller fractures at the base of the second metatarsal and at the second cuneiform. 3. Small fracture at the base of the third cuneiform. 4. Vertical fracture through the navicular." --11:59 a.m. the patient's vital signs were documented as 98.7-90-20-142/101, 97% on room air, patient "appears uncomfortable, Behavior is anxious", and pain as 10/10. --12:03 p.m. Zofran 4 mg and Toradol (Non-steroidal anti-inflammatory medication used to decrease pain, swelling and fever) 30 mg was administered IVP. --12:04 p.m. Morphine 4 mg and Ancef 2 grams was administered IV and Tetanus Toxoid 0.5 ml was administered intramuscularly into the left upper arm. --12:06 p.m. physician #4 noted that the patient #21 reported being shot in the right foot by his wife, that the patient had no loss of consciousness, and that police were notified. Physician #4 noted that the physical examination revealed range of motion in all extremities, good blood flow to the arteries in the foot, no nerve damage, and entrance and exit wounds to the top of the foot. --12:29 p.m. physician #4 ordered, "Consult Orders: Physician #1 (surgery-ortho) Ordered." --12:44 p.m. nurses' notes indicated that the patient appeared uncomfortable and that the patient's pain was now 6/10. --12:45 p.m. the patient's vital signs were 79-18-150/97-96% on room air. --12:46 p.m. nurses' notes indicated that a 20 gauge IV was placed in the patient's right hand and the GSW was irrigated with Betadine solution. --12:54 p.m. nurses' notes indicated that a posterior short leg splint was applied as ordered. --1:00 p.m. physician #4 noted that The diagnosis was [DIAGNOSES REDACTED]"regarding historical points, exam findings, and any diagnostic results, supporting the admit diagnosis. Data reviewed: vital signs, nurse's notes, lab tests results (s), radiologic studies. After a detail discussion of the patient's case, care is transferred to (Name of trauma Physician at the Main Campus) Patient has an emergent medical condition" The admission plans were discussed with the patient and patient #21 agreed with the plan. --1:05 p.m. Disposition Summary -physician #4 ordered the transfer to the Main Campus. The diagnosis was [DIAGNOSES REDACTED] --1:18 p.m. EMS transport was arranged and report was called to the receiving nurse. --1:24 p.m. the patient signed the consent to treat forms. --1:27 p.m. the nurse noted that the transfer form was scanned into the chart. --1:32 p.m. the nurse noted that the patient had no adverse reactions to the drugs the patient had received. --1:33 p.m. nurses' notes indicated that the patient left the ED in stable condition and that the patient's pain at the time of transfer was 6/10. --Physician #4's discharge notes indicated that the patient was transfer to the Main Campus in fair condition with a GSW and broken bones in the top of the right foot. Physician #4 indicated that the patient was accepted at the Main Campus by an accepting physician for trauma services not available at the South Campus. The hospital failed to ensure that their EMTALA policy and procedure was followed as evidenced by failing to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department, which ancillary services (Orthopedic surgeon) were available when patient #21 presented to the hospital , with an identified emergency medical condition. Review of the South Campus ED on-call schedules for May 2017 revealed that physician #1 was the Orthopedic surgeon on-call on 5/28/2017 when patient #21 presented to the hospital. The on-call schedules had an attachment that required on-call physicians to "Please Read Carefully" the following: ALL DOCTORS WHO TAKE ED CALL MUST --respond by phone within 30 minutes to a call from the ED physician; and --come to the ED as soon as possible upon request from the ED physician ...The physician covering your ER call must be on staff at AMC and have privileges to provide the service. Review of the facility's Medical Staff Rules and Regulations, revised 01/20/16, revealed the following: --Article 10. Miscellaneous: Section 8. Screening, Stabilization, and Transfer of Individuals with Emergency Medical Conditions (EMC): (a) Patients presenting with EMC shall be screened, stabilized, and/or transferred pursuant to Hospital Policy for Screening, Stabilization and Transfer of Individuals with EMC. (b) " MSE " means the screening process required to determine with reasonable clinical confidence whether an EMC does or does not exist. (c) "Qualified Medical Person" (QMP) means an individual or individuals in one of the following professional categories who has demonstrated current competence to perform a MSE: 1. ED Physician, ED Physician's Assistant, ED Certified Nurse Practitioner. --Article 12. ED: Section 1. Patient Evaluation: For each person who presents at the ED and who requests an examination or treatment of a medical condition, the emergency physician has the responsibility to perform an appropriate MSE to determine whether an EMC exists. If the patient does have an emergency, the emergency physician will arrange for appropriate stabilization treatment and after care (i.e., admission, surgery, etc.) and transfer if necessary, pursuant to Hospital Policy for Screening, Stabilization and Transfer of Individuals with EMC. --Section 2. Care of Patients: A MSE will be performed pursuant to Hospital Policy for Screening. Stabilization and Transfer of Individuals with EMC. Review of the ED Provider Agreement, effective 04/01/16, revealed the hospital's ED physicians are contracted to provide medical services through an agreement with a professional services provider. The agreement 04/01/16 outline the provision of medical services will be provided in compliance with: --The Hospital's Policies and Procedures, Rules and Regulations, and Bylaws of the Medical Staff. --Current standards of medical practice. --Applicable federal, state and local laws. --Standards and requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Credentialing File Review for Physician #1 Review of the "Clinical Privileges in Orthopaedic Surgery" for Physician #1 that was approved by the hospital's Department Chair on 10/24/2017 was reviewed. The clinical privileges revealed the "CORE PRIVILEGES IN ORTHPPAEDIC SURGERY" for Physician #1 that were requested and accepted, revealed in part, "Admission, work-up provision of non-surgical and surgical care to patients of all ages ... Orthopedic Surgery Core Procedure List: Performance of History and Physical ...Debridement of soft tissue ...Fracture fixation ...Management of infectious and inflammation of bones, joints and tendon sheaths ...Open reduction and internal/external fixation of fractures and dislocations of the skeleton ...treatment of extensive trauma, excluding pelvis or spine." Review of facility policies and procedures that were in place in October 2016 included but was not limited to the following: 1. ESI 5 LEVEL TRIAGE: An instrument that categorizes ED patients by evaluating both patient acuity and resource needs. Resource needs are the number of resources a patient is expected to consume in order for a disposition decision to be reached. --Level l: Requires immediate life, limb, or organ saving interventions. This patient is unable to wait and must be placed immediately in a treatment room. --Level Il: High risk situation, confused, lethargic, disoriented, severe pain/distress, unstable vital signs requires help quickly but not immediately. --Level Ill: Situation requires 2 or more resources (Including but not limited to laboratory testing, radiology studies, medications, intravenous fluid procedures J consults), patient has stable vital signs. --Level IV: Situation requires 1 resource. --Level V: Situation requires zero resources. 2. EMERGENCY MEDICAL TREATMENT AND LABOR ACT-EMTALA, policy number AMC-RI.280, last reviewed/revised 05/17, effective 02/14/01, revealed the purpose was to set forth policies and procedures for Hospital ' s use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA). Definitions: A. " Capacity " encompasses such things as numbers and availability of qualified staff, beds and equipment, as well as the Hospital ' s past practices of accommodating patients in excess of its occupancy limits. B. " Capability " defined as the staff, equipment and specialty or specialist services available to care for a patient with an EMC C. " Comes to the ED " For purposes of this policy, an individual is deemed to have " come to the ED " if the individual: Presents at a dedicated ED, and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual ' s appearance or behavior, that the individual needs examination or treatment for a medical condition; D. " EMC " means: 1. A medical condition manifesting itself by acute symptoms of [DIAGNOSES REDACTED] a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or b. Serious impairment to bodily functions, or c. Serious dysfunction of any bodily organ or part. H. " MSE " is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. A MSE is not an isolated event. It is an ongoing process that begins, with the initial assessment by a Qualified Medical Person and ends when enough information has been gathered to determine the patient does not have an EMC. I. " Qualified Medical Person " or " Qualified Medical Personnel " means an individual or individuals in one of the following professional categories who has demonstrated current competence to perform a MSE 1. ED: Emergency Medicine Physician, ED Physician ' s Assistant, ED Certified Nurse Practitioner ... J. " To Stabilize " or " Stabilize " or " Stabilized " means: With respect to an EMC, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer or discharge of the individual from the Hospital. IV. POLICY: If an individual comes to the ED: A. The Hospital will provide an appropriate MSE within the capability of the Hospital ' s Dedicated ED, including ancillary services routinely available, to determine if an " EMC " exists; ... V. PROCEDURE: A. Triage and Registration 1. Triage a. As soon as practical after arrival, individuals who come to the ED should be triaged in order to determine the order in which they will receive a MSE. b. Triage is not a MSE, as it does not determine the presence or absence of an EMC, but rather, simply determines the order in which individuals will receive a MSE. 2. Registration a. The Hospital may not delay the provision of an appropriate MSE or any necessary stabilizing medical examination and treatment in order to inquire about the individual's method of payment or insurance status. B. MSE 1. The Hospital shall provide a MSE to all individuals who have come to the ED. 2. The MSE is the examination of the patient by the QMP required to determine within reasonable clinical confidence whether an EMC does or does not exist. The examination should be tailored to the patient ' s complaint, and depending on the presenting symptoms, the MSE may represent a spectrum ranging from a simple process involving only a brief history and physical examination, to a complex process that also involves performing ancillary studies, procedures etc. 3. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred. The MSE, and ongoing patient assessment, must be documented in the medical record. 4. The MSE must be provided in a non-discriminatory manner. The examination provided to an individual must be the same MSE that the QMP would provide to any individual coming to the Hospital ' s dedicated ED with those signs and symptoms, regardless of ability to pay. D. Individuals Who Do Not Have An EMC 1. If, after the MSE is completed, a physician or other QMP determines that an individual does not have an EMC, the individual may be discharged . 2. discharged individuals who do not have an EMC must receive at the time of discharge, follow-up instructions with written or electronic homecare instructions. INTERVIEWS: An observational tour of the ED was conducted on 06/11/18 at 9:15 a.m. with the Chief Nursing Officer/Chief Operating Officer (CNO/COO #3) and ED Manager (EDM #2). The EDM (#2) said that the MSE is performed by a physician, Nurse Practitioner, or Physician's Assistant. The EDM (#2) explained that although the South Campus only has one (1) trauma room (#22) that is utilized for trauma patients, there are trauma carts available in e

Based on review of medical records,policies and procedures, ambulance reports, Police Department reports, and interviews the facility failed to ensure that the medical record contained documentation that individuals were informed of the risks and benefits to individuals who do not consent to further treatment for 1 (#19) of 20 sampled patients. Findings Include: Ambulance Trip Report Review of the ambulance Patient Care Report for Patient #19 revealed: A call was received on 6/19/2016 at 5:33 PM and an ambulance unit arrived at Patient #19's residence at 5:47 PM. Patient #19 was found standing and complained of high blood sugar. Patient #19 did not appear in distress, and no alteration in mental status was observed. Vital signs were: pulse 112, respirations 18, blood pressure 132/86, oxygen saturation 96%. An IV (intravenous) was inserted by ambulance staff at 5:50 PM. The unit had been en route to another hospital, but was diverted at 5:59 PM, and had arrived at Wellstar Atlanta Medical Center at 6:24 PM. Medical Record Review Wellstar Atlanta Medical Center Review of Patient #19's medical record revealed that the fifty-eight year (58) old patient was transported by ambulance to the facility's emergency department on 6/19/16 at 6:38 PM with a complaint of high blood sugar. The patient signed a Consent for Treatment, which included acknowledgment of receipt of Patient Rights and Advance Directive status on 6/19/16 at 7:45 PM. The patient was triaged by a registered nurse on 6/19/16 at 6:52 PM, and designated as level 2 (emergent). Vital signs were: Temperature: 98.9; Heart Rate: 113; Respiratory Rate -18; Blood Pressure: 114/78; and oxygen saturation of 100% on room air. Pain 0/10. The nurse noted that EMS stated that the patient's blood sugar had been high for two (2) weeks, had blurred vision, and urinary frequency. The patient's behavior was agitated and anxious. The D.O. (Doctor of Osteopathy) performed a medical screening examination on 6/19/16 at 7:07 PM, noting that Patient #19 was calm, cooperative, alert and oriented to person, place, and time, and was lucid. Patient #19 complained of high blood sugar (465) for eleven (11) days. Past medical history included coronary artery disease, (CAD), congestive heart failure, asthma, chronic obstructive lung disease (COPD), heart attack, diabetes, and post-traumatic stress disorder (PTSD). Orders included: 7:07 PM: intravenous catheter, complete blood count (CBC), urinalysis 7:09 PM: urine drug screen The orders were completed at 8:53 PM, which revealed a glucose of 540, and were negative for drugs. Interventions: At 8:53 PM, an RN noted critical lab value- Glucose 540, confirmed and reported to the D.O. Additional orders by the D.O. at 8:53 PM included: Normal saline, 1000 ml bolus Regular insulin 10 ten units IV (intravenously). On 6/19/16 at 9:12 PM the D.O. noted that after obtaining consent, he/she had reviewed records of a recent hospitalization . The D.O. had noted that Patient #19 had a history of substance abuse, and had ordered a urine drug screen on the patient. Patient #19 had become belligerent, was yelling, and refused further treatment because the drug screen was ordered. On 6/19/16 at 9:37 PM, an RN noted that Patient #19 refused all treatments, and had become verbally aggressive and threatening to staff. The house supervisor was notified and came to speak to Patient #19. When Patient #19 continued to be aggressive, security was called. East Point police were called after patient #19 continued to be aggressive to all staff. The patient was escorted off the hospital property by the East Point police at 9:37 PM. There was no documentation in the medical record to indicate that on 6/19/2016 Patient #19 was informed/explained the risks and benefits of further treatment and evaluation. Police Department Reports The (name of city) Police Department incident investigation report dated 9/20/2016 at 11:31 was reviewed. The report narrative section revealed in part, "On September 20, 2017 at approximately 11:15 am, (police officers names)were dispatched to (Law Enforcement Center) ...to an incident occurred ... at (Atlanta Medical Center) ...Upon contact with the complainant Patient #19 , he stated that he was a patient at Atlanta Medical Center from June 6-15th 2016, and had asked for a patient advocate and was denied. Patient #19 had an argument with the doctor and was escorted out of the hospital by Police ...He was provided a victims' right card along with a case number." The Transit Authority Police Department Supplemental Report dated 6/19/2016 was reviewed. The report revealed in part, "On 6/19/2017 at 2155 (9:55 PM) while on patrol at (named transit station) I was dispatched to ...injured person at ....gate. I made contact with patient #19 who stated that his blood sugar levels was possibly high and requested an ambulance. (Name of Ambulance) rescue ...arrived on scene at 2202 (10:10 PM). Patient #19 was treated on scene, and transported to (Name of) acute care hospital for further evaluation." Medical Record Review from Acute Care Hospital for Patient #19 The medical record review revealed that Patient #19 arrived at the acute care hospital on [DATE] at 10:37 PM. Documentation by the attending physician on 6/20/2016 at 12:08 AM revealed in part, " ...[AGE] year old ...with a history of CAD (Coronary Artery Disease) s/p (status/post) 5 vessel CABG (Coronary Artery Bypass Graft) in 2008, with placement of 3 stents this month, DM (diabetes Mellitus), HTN (Hypertension) ...presenting with Hyperglycemia and chest pain ...reports his blood glucose normally runs in the mid-high, 200s but for the past week it has been running in the 400s. He states he is fully compliant with his regimen of Lantus and insulin. For the past week, he has been experiencing worsening blurry vision, polyuria, anxiety, muscle spasms, diaphoresis, dry mouth, abdominal pain, nausea and increased thirst. He has also periods of retrosternal burning chest pain that radiates to this left arm and back and neck ...30 pound weight loss over the past month ...his troponin peaked at 0.18 on 6/7/16 ... Physical Exam: Constitution ...oriented to person, place and time ...appears well developed and well nourished... Vision intact to confrontation testing ...Midline sternotomy scar, well-healed Medical Decision Making: ...Blood glucose found to be 402, Anion Gap 11. Creatinine (measurement of Creatinine levels in blood to evaluate renal function) 2.0 (1.18 on 6/10/16 ...Troponin (testing done to diagnose heart attacks) <0.3 ...00:30 Will hydrate with NS (normal Saline), give Morphine ...admit to CDU (Clinical Decision {Unit for Observation}) for serial troponins and hydration ...8:27 am ...Discharge Summaries (Continued) Medical Decision Making Narrative ...CDU Course ...serial EKG's and cardiology consult. EKG showed diffuse TWI (T Wave Inversion) consistent with previous when stents were placed ...Cardiology saw patient and feel pain was not cardiac related given no EKG changes and neg (negative) trops (troponin).. .Patient had diabetes education consult and BG (blood glucose) has recovered to 252. Patient is ready for discharge to home with PCP (Primary Care Provider) and cardiology follow-up." Policy and Procedure Review of facility policy AMC-RI.280, Emergency Medical Treatment and Labor Act - EMTALA, effective 2/14/2001, reviewed/revised May 2017, revealed, in part, " ...V. PROCEDURE: ...F. Refusal of treatment 1. Of the hospital offers further examination and treatment and informed the individual or the person acting on the individual's behalf of the risks and benefits of not receiving the examination and treatment, but the individual or person acting on the individual's behalf refuses the examination and treatment, the Hospital shall take all reasonable steps to have the individual or the person acting on the individuals behalf acknowledge their refusal of further examination and treatment in writing (against medical advice form). Documentation in the medical record should include information provided to the individual or to the person acting on the individual's behalf. Documentation in the medical record should include information related to the medical screening exam, further examination, and treatment that is being offered to the individual including the risks and benefits of not continuing the examination and treatment. Interviews Telephone interview with the D.O. (Credential #5) on 5/31/2017 at 2:25 PM revealed that he/she had been employed in the facility's ER for approximately one and a half years, and had been trained in EMTALA. The D.O. stated that he/she wore scrubs with his/her name on them, wore a name badge, and always introduced him/herself to patients upon entering the room. The D.O. vaguely recalled patient #19, stating that he/she believed the patient had become upset when asked about a history of past drug use. The D.O. explained that patients had been found to be less than completely honest at times, while the physician needed to know if there was something else going on. The D.O. further stated that asking this question would usually not be upsetting to the patient, and, he/she didn't know if there was something else going on. The D.O. stated that during an initial patient assessment, the physician would assess if the patient was under the influence or confused. The physician would assess the patient for appropriate eye contact, appropriate responses to questions, and ability to provide medical history beyond the present or previous day. If the patient was alert and oriented to person, place, time, and situation, and able to make sound decisions, then, by law the physician could not do anything to force care. The patient can leave if they wish and can refuse treatment, even if he/she did not think it was in their best interest. The D.O. also stated that if a patient refused treatment, it is considered as refusing care. If a patient did not wish care, they are discharged . He/she further stated that discharge instructions were usually provided regardless of AMA status because his/her job was to take care of the patient. He/she also explained that staff called security if a patient became aggressive towards staff and that sometimes the house supervisor got involved to see if there was anything else that could be done, or if there was a misunderstanding. There was no documentation in the medical record to indicate that information related to further treatment was offered to Patient #19 on 6/19/2016 of the risks and benefits of not continuing treatment as stated in the facility's policy and procedure. There was also no documentation of a description of the treatment that was refused by patient. Interview with the Director of Quality and Patient Safety on 5/31/2017 at 3:05 PM in the conference revealed that the security guard should have documented a report of the incident involving patient #19, but that none could be found. He/she also stated that the security guard was no longer employed at the facility.

Based on review of medical records,policies and procedures, ambulance reports, Police Department reports, and interviews the facility failed to ensure that the medical record contained documentation that individuals were informed of the risks and benefits to individuals who do not consent to further treatment for 1 (#19) of 20 sampled patients. Refer to findings in Tag A-2407.

2. Based on review of the facility's transfer logs, review of transfer center audio recordings, review of on-call schedules, staff interviews, and review of facility policies, the facility refused to accept from transferring hospitals within the boundaries of the United States an appropriate transfer of individuals who required such specialized capabilities and facilities because the receiving hospital had the capacity to treat two (2) (#17 and 18) of twenty (20) sampled medical records reviewed. Refer to findings in Tag A-2411. Findings include: Review of the facility's transfer log for 4/11/2015 revealed that the transfer center received a request to transfer: Patient #17, with the diagnosis of [DIAGNOSES REDACTED]"denied", "not medically necessary" - Insurance 'A'. 7/7/2015 Review of transfer center recording with the Market Compliance Officer and the Clinical Informatics Director, revealed the following conversation (as transcribed by the surveyor, some portions difficult to hear): Telephone call to MD #9 (on call for internal medicine) Transfer center: (intro) I have a patient from xxxxx Hospital (A) with diagnosis of [DIAGNOSES REDACTED] MD #9: Why are you calling me? If the patient is sick enough to be in the hospital, then it is unsafe. Why are you sending the patient? Transfer center: Insurance 'A', maybe? MD #9: well, it doesn't matter if it's unsafe or not, so long as they get paid, huh? What's their name? Transfer center: (provides pt #17's name) MD #9: (provides Pt. #17) name) with pancreatitis. And what am I supposed to do? Transfer center: I can get you in touch with the sending physician, would you like to speak to him? MD #9: Not particularly, I just need to know where the patient will be sent - to Hospital 'B'. to the ER? to the roof? where? Transfer center: They didn't say, they usually connect you with the attending doctor, would you like to speak to him? I can grab our admin RN, and she can let you know what beds are available... MD #9: (sighs) Just tell them to call me when the patient gets here. Transfer center: So you are accepting the patient? MD #9: Yeah. Transfer center: Telemetry bed? MD #9: Yeah. Transfer center: And you want to be called when they get there? MD #9: Yeah. Transfer center: Will the patient be traveling by ground? MD #9: How would I know? I don't know how they're sending the patient. The patient shouldn't be sent. That's an unsafe admission. I guess by ambulance. I guess you should know that, shouldn't you? Transfer center: I'm just here at the Transfer Center and facilitate the transfer Dr. Would you like me to call xxxxxxx, the admin for you? MD #9: That's okay if you want to, just make it quick. Transfer center: Okay, I will call him/her, I have her direct number. Just hold on for a minute.(admin RN answers and introduction made by the transfer center) Admin RN: Good morning. What can I do for you? MD #9: No, what can I do for you? Transfer Center: (explains the transfer) admin RN: You don't want to be connected with the attending, correct? MD #9: Just tell me what you want me to do. I'm supposed to be taking ER call and they told me to call this number, period. Admin RN: So you're not Internal Medicine admission tonight? MD #9: Yeah, I am. That's right. admin RN: Okay, that's why I'm calling you. MD #9: Okay. What am I supposed to do? Admin RN: There's a patient at xxxx hospital (A) with insurance they don't take and the patient is in the ER with pancreatitis and they want us to accept the patient here and since you're the Internal Medicine service here, you'll have to accept the patient. Well, you don't have to accept the patient, but that's why they are calling you. MD #9: Well that's an unsafe admission. If the patient is sick enough to be transferred, I mean sick enough to be admitted to the hospital with pancreatitis, you know, it's a little, it's contrary to good medicine to move the patient around simply because they don't take the insurance. That's uh, but I know you all don't care about that, so what am I supposed to do? Admin RN: You can either accept the patient; talk to the transferring MD over there, and let them explain what's going on over there. I barely, I only knew about this because the ER called me to take the patient and we have to go through the transfer line and get the internal medicine Dr on call to accept the patient. I can't accept the patient. MD #9: Well I really don't want to do that. I don't, uh, if the patient is sick. Do you understand what I'm saying? Admin RN: I understand what you're saying. I understand exactly what you're saying, but, I mean, you can either accept or deny for whatever reason you have.MD #9: Yeah, well, uh, this doctor, who is the doctor? Do you have the number for the ER?admin RN: I have the direct number for the emergency room , yes. MD #9: What's the doctor's name? Admin RN: Dr xxxxx. Would you like me to get him on the line for you? MD #9: Okay admin RN: Alright just one minute. (phone call is made, ER transferring MD answers the phone)ER Dr: Transferring hospital. Can you hear me? MD #9: Yeah, I hear you. ER Dr: Well, I'm calling about a patient I have, (provides pt #17's name), a [AGE] years old. He/she came here with complaints of diabetes, abdominal pain, nausea and vomiting. He/she's been NPO for the last 3 days. You could tell he/she was miserable, his/her abdomen was distended and a little bit tender. We did a whole work up. His/her lipase was 1583; no known history of pancreatitis; not a heavy drinker. (provides lab values) elevated LFT; Alkaline phosphate 142; blood glucose 347; CT scan for lipase of 1583; ALP 133; AST 57; urine negative; white count normal. CT scan showed evidence of prominence in the bile duct and pancreatic duct and he/she will probably need an ERCP as an inpatient (endoscopic retrograde cholangiopancreatography- a procedure that uses a flexible scope and X-rays to look at the bile duct and the pancreatic duct). We've been giving him/her fluids and pain control. MD #9: Why are you transferring the patient, because of insurance 'A'? No, I'm not going to take him/her. I'm not going to do that. This patient sounds sick, and you're going to transfer him/her just because of insurance?ER Dr: He/she looks better than he might sound. MD #9: Yeah, no. I'm not going to take him/her. ER Dr.: Alright that's fine. Thank you. MD #9: Thank you.(call ends) Telephone interview with MD #9 on 7/7/2015 at 4:30 PM revealed that the physician recalled the situation and stated that he/she was on call for internal medicine the day the transfer center called to transfer the patient. He/she explained that the sending hospital had a pattern of calling when the patient did not have insurance, and would try to push the patient (#17) a certain way. He/she further explained that the patient's clinical condition was not stable- the patient's enzymes were off, the patient was dehydrated, and did not sound well. He/she was vomiting, and not stable. MD #9 stated that he/she did not want to move the patient around just because of the insurance status. The Dr. continued on stating that it would benefit him/her to take the patient because he/she would get paid. He/she surmised that apparently, that hospital didn't take Insurance 'A', so they call to find someone else to take the patient, and that it would be okay if the patient was stable, but if the patient is unstable, he/she needs to stay where he/she is. The MD reiterated that he/she had spoken to the ER doctor, and, the patient didn't sound stable. MD #9 further stated that he/she had never been trained in EMTALA, and do not know what it was. The hospital's emergency room Call schedule for April 2015 was reviewed. Review of the On-call schedule validated that on 2/11/2015 an Internal Medicine Physician was on call when the transferring hospital called Wellstar AMC requesting a transfer for Patient #17. Review of the requested bed census report dated 4/11/2015, revealed the following units had beds available (Capacity): Medical Surgical Unit bed capacity was 31, the census was 24, beds available were 7; and the Medical Unit bed capacity was 22, the census was 15, and beds available were 7. The facility failed to accept from a referring hospital (B) Patient an appropriate transfer on 4/11/2015 Patient #17 who required such specialized services of the Internal Medicine Physician (Capability). The hospital also had capacity on 4/11/2015. Review of the facility's transfer log for 2/17/2016 revealed that the transfer center received a request to transfer: Patient #18, a fifty-one (51) year old patient with the diagnosis of [DIAGNOSES REDACTED]"denied", "not medically necessary". 9/8/2016 Review of transfer center recording revealed the following conversation (as transcribed by the surveyor): 9/8/2016 Review of transfer center recording revealed the following conversation (as transcribed by the surveyor, some portions difficult to hear): Conversation #1 Transfer Center - Atlanta Medical Center, you are on a recorded line, this is Transfer Center, how may I help you? Hospital C ED Physician - Hey Transfer Center, this is Hospital C (transferring Hospital) ED Physician, calling you from Name of Transferring Hospital (Hospital C).. I have a patient I would like to transfer. We have no beds and do not expect any empty beds today. Transfer Center - Alright, let me get a new one opened, so you do not have to repeat too much to me here, ok? Hospital C ED Physician - Ok, Ok Transfer Center - And you are trying to go to Atlanta Medical Center Main Campus, correct? Hospital C ED Physician - Yes. Transfer Center - And you are calling from Hospital C? Hospital C ED Physician - Correct. Transfer Center - Hospital C ..., new name? Hospital C ED Physician - Hospital C in (a city in), GA. Transfer Center - And what's you requesting service? Hospital C ED Physician - Hospitalist. Transfer Center - And where is the patient currently located at your facility? Hospital C ED Physician - In emergency room number 4. Transfer Center - And doctor, your name again? Hospital C ED Physician - (spells out his/her name) Transfer Center - And a good call back number? Hospital C ED Physician - (gives phone number) Transfer Center - Patients last name? Hospital C ED Physician - Patient #18 last name Transfer Center - First name? Hospital C ED Physician - Patient #18 first name Transfer Center - Date of birth? Hospital C ED Physician - Patient #18 date of birth Transfer Center - Any flu like symptoms? Hospital C ED Physician - No Transfer Center - Any foreign travel in the last 3 weeks? Hospital C ED Physician - No Transfer Center - Diagnosis? Hospital C ED Physician - Acute Pancreatitis and Cholelithiasis without [DIAGNOSES REDACTED]. Transfer Center - Acute Pancreatitis and [DIAGNOSES REDACTED]? Hospital C ED Physician - No, no, no Cholelithiasis, no [DIAGNOSES REDACTED]. Gallbladder stones and acute Pancreatitis. Transfer Center - And their not a Department of Corrections Patient, correct? Hospital C ED Physician - Say that again? Transfer Center - Are they a Department of Corrections patient? Hospital C ED Physician - What does it mean? Transfer Center - Are they coming from a jail? Hospital C ED Physician - No Transfer Center - OK Hospital C ED Physician - I was like, ok, nobody ask me this question. Transfer Center - Is the referral, a emergency medical condition at this time? Hospital C ED Physician - Yes Transfer Center - Does your facility have the capabilities to care for the patient? Hospital C ED Physician - We have no beds. Transfer Center - Ok, hold on one moment for me. The request is not traumatic, is it? Hospital C ED Physician - No Transfer Center - Will they need an ICU bed? Hospital C ED Physician - No Transfer Center - Is this an emergent request or a non-emergent, just looking for a higher level of care? Hospital C ED Physician - Higher level of care, we have no beds. I would like to admit the patient here and I spoke with my facility, they not expect we have four surgical patients and we have no beds and they not expect to have a bed. Transfer Center - Perfect, can I go ahead and get a face sheet and a H&P sent over to us? Hospital C ED Physician - Wow, this is new. H&P? So, I'm not going to speak to a physician? Transfer Center - You will, but, I need case manager for this approval. Hospital C ED Physician - ok Since its non-emergent and we are looking for a higher level of care. Hospital C ED Physician - What if I say it is emergent, then you don't need an H&P? Transfer Center - Hold on, let me go back and find out. Nope, then I just need a face sheet. Hospital C ED Physician - Ok, lets just do emergent then. Transfer Center - Alright, the fax number over here is (Fax number given) and I will go ahead and page internal medicine and I will give you a call right back. Hospital C ED Physician - Thank you. Transfer Center - Thank you Hospital C ED Physician - Bye Bye Transfer Center - Bye Conversation #2 Transfer Center - Atlanta Medical Center, you are on a recorded line, this is transfer center, how may I help you? Physician #4 - Hey, this is Physician #4 Transfer Center - Hey Physician #4, thanks for giving me a call back. We have a transfer request from Hospital C, on a fifty-one year old male with Acute Pancreatitis and Cholelithcytis. Would you like his/her name and date of birth or can I connect you with the sending? Physician #4 - Why are they sending him/her? Transfer Center - Because they have no beds. He/she said they are not anticipating to have beds for days. Physician #4 - What's the insurance? Transfer Center - Hold on, I was just pulling that up. They are self-pay. Physician #4 - yea, well I'm not going to be able to take that patient. Transfer Center - Ok, should I just put on, and the reason you are not going to take? Physician #4 - Because it's nothing to do with the higher level of care. That's just, they don't have a bed, that's bull. They don't even know how many people are going to be discharged today. That's not a real reason. Transfer Center - Ok, I will let them know. Physician #4 - Alright, Thanks Transfer Center - Thank you Conversation #3 Dial tone, phone ringing Hospital C ED - Emergency Department, may I help you? Transfer Center - Hey Piedmont ED, this is Transfer Center, over here at the AMC transfer center. Is Hospital C ED Physician around? Hospital C ED - one second, hey Hospital C ED Physician (placed on hold) Hospital C ED Physician - Hello, this is Hospital C ED Physician Transfer Center - Hello, this is Transfer Center, over here at the AMC transfer center. I'm calling to let you know that I have spoken to administration and they are denying the patient. Hospital C ED Physician - Why? Transfer Center - I explained to him/her what was going on with the Acute Pancreatitis, Cholelithcytis, gall stones and all of that and he/she said, so, why are they transferring. I said, lack of beds at this time. And he/she said no, they don't know what their discharges will be, they can keep the patient. Hospital C ED Physician - That's why I'm calling you, because I know what my discharges are going to be, I have four people coming out of OR and we have no beds. That's why I'm calling you. Transfer Center - And I explained to him/her that you wouldn't have beds for days, is what you said. Hospital C ED Physician - Correct. Alright, I'm going to call other hospital. What else can I do? I've been calling already. You are the fourth hospital I am calling. Transfer Center - I'm sorry doctor. Hospital C ED Physician - I transfer patient to Tennessee, then they are going to complain about this denial. Thank you Transfer Center - Thank you The hospital's emergency room Call schedule for February 2016 was reviewed. Review of the On-call schedule validated that on 2/17/2016 an Internal Medicine Physician was on call when the transferring hospital called Wellstar AMC requesting a transfer for Patient #18. Review of the requested bed census report dated 2/17/2016, revealed the following units had beds available (Capacity): Medical Surgical Unit bed capacity was 31, the census was 28, beds available were 3; and the Medical Unit bed capacity was 22, the census was 21, and bed available was 1. The facility failed to accept from a referring hospital (B) Patient an appropriate transfer on 2/17/2016 Patient #18 who required such specialized services of the Internal Medicine Physician (Capability). The hospital also had capacity on 2/17/2016. Telephone interview with MD #4 on 9/8/2016 at 10:15 AM revealed that he/she had been on call for the facility for the past sixteen (16) years, and admitted eight (8) to thirteen (13) patients monthly. MD #4 stated that he/she had become aware of EMTALA requirements approximately one (1) year ago, had attended a couple of meetings in the past two (2) or three (3) months, and now understood. The MD explained that the Transfer Center contacted the MD on call for the service requested, not the ER MD, and that he/she was on call for Internal Medicine (IM) Services. The physician had no recollection of the transfer request for patient #18. Interview with the ER Medical Director in the conference room on 7/7/2015 at 5:21 p.m. revealed that all MDs should be aware of EMTALA. He/she stated that the hospital is in the process of training all on-call physicians on EMTALA and that he/she had spoken to on-call physicians in the past regarding EMTALA regulations. The MD stated that someone in administration reviews the transfer log daily. The medical director added that he/she had not been made aware of any denied transfers. Review of facility policy #AMC-RI.280, EMTALA, effective date February 14, 2001, current reviewed/revision date August 2015, III. Procedure I. Obligation to Accept Transfers, revealed that to the extent that the Hospital has specialized capabilities (including capabilities available through the Hospital's on-call roster) or facilities, such as a shock-trauma unit or a neonatal intensive care unit, that are not available at the transferring facility, the Hospital shall accept appropriate transfers of an individual needing such specialized capabilities or facilities if the Hospital has the capacity to treat the individual.

1. Based on medical record review(s), staff interview(s), review of the facility's policy and procedures the facility failed to ensure that the risks and benefits of the transfers were documented on the certification transfer form as stated in the facility's policy for 4 of 20 (#2, #14, #15 & #16) sampled medical records reviewed. Refer to findings in Tag A-2409. 2. Based on review of the facility's transfer logs, review of transfer center audio recordings, review of on-call schedules, staff interviews, and review of facility policies, the facility refused to accept from transferring hospitals within the boundaries of the United States an appropriate transfer of individuals who required such specialized capabilities and facilities because the receiving hospital had the capacity to treat two (2) (#17 and 18) of twenty (20) sampled medical records reviewed. Refer to findings in Tag A-2411.

2409 Based on medical record review(s), staff interview(s), review of the facility's policy and procedures the facility failed to ensure that the risks and benefits of the transfers were documented on the certification transfer form as stated in the facility's policy for 4 of 20 (#2, #14, #15 & #16) sampled medical records reviewed. Findings include: Medical record review revealed: Patient #2 was transported to the facility's ER by ambulance on 4/11/15 at 11:39 AM with complaints of suicide attempt, overdose. Triage notes reveal that EMS stated patient took 11 Phentermine (an appetite suppressant) and 6 caffeine (pills) at midnight in a suicide attempt. After receiving stabilizing treatment, the patient was transferred in stable condition to View Point (psychiatric hospital) 4/11/15 at 8:36 PM. Review of the patient's transfer form and physician's notes revealed that it did not include the reason for transfer, MD certification, or risks and benefits of transfer. Telephone interview with MD # 3 on 9/8/16 at 12:10 PM revealed that he/she had worked in the facility's ER for approximately six (6) years, and been trained in EMTALA, and was aware of the requirement to document Risks and Benefits. The MD did not recall the patient. He/she stated that the nurse sometimes completed the form and that he/she usually did document risks and benefits in the medical record. Patient #14 was transported to the facility's ER by ambulance on 2/15/15 at 6:52 PM with complaints of Medical clearance/depressed. Triage notes reveal the patient was transferred from a Behavioral Health System Hospital (psych) for clearance. The patient was alert and oriented to person, place, and time; having visual hallucinations appeared sad and complained of a headache. The patient was transferred back to the Behavioral Health System hospital on [DATE] at 1:54 AM with final diagnoses of UTI (urinary tract infection) and depression. Review of the patient's transfer form and physician's notes revealed that the risks and benefits of the transfer had not been documented. Patient #15 was transported to the facility's ER by ambulance on 2/15/15 9:11 PM with complaints of epigastric pain (pain in the upper abdomen below the ribs). Triage notes reveal the patient's epigastric pain was relieved with Nitroglycerine (used to prevent or treat chest pain), and, the patient also complained of nausea and vomiting. After receiving stabilizing treatment, the patient was transferred to a (named) Medical Center on 2/16/15 at 3:16 AM. Review of the patient's transfer form and physician's notes revealed that the risks and benefits of the transfer had not been documented. Telephone interviews with MD # 7 revealed: On 9/8/2016 at 10:55 AM, the MD stated that he/she had worked in the facility's ER for eleven (11) years, and had been trained in EMTALA. In a subsequent interview on 9/9/2016 at 8:20 AM, MD #7 stated that he/she had reviewed the medical records, and confirmed that it was his/her signature on the certification for transfer for patient #'s #14 and #15). Regarding patient #14, the MD explained that the patient had been in a psychiatric facility for one (1) month, and found to be having worsening hallucinations. The ER MD had discovered the patient also had a urinary tract infection, which he/she treated, and had contacted the psychiatric facility to transfer the patient back there, which was a usual occurrence if there was no reason to keep the patient. The MD noted that he/she documented the need for transfer to another facility had been discussed, and the patient was aware. Patient #16 was transported to the facility's ER by ambulance on 10/14/15 at 11:48 AM with a diagnosis of altered mental status. Triage notes revealed that the patient complained of an episode of syncope (dizziness) and an altered mental status. The patient had a history of seizures and noncompliance with medications. After receiving stabilizing treatment, the patient was transferred to another hospital on [DATE] at 4:27 PM via EMS. Review of the patient's transfer form and physician's notes revealed that the risks and benefits of the transfer had not been documented. Interview with MD # 8 on 9/9/2016 at 11:05 AM revealed that he/she had no recollection of the patient. After reviewing patient #16's medical record, the physician confirmed that neither the Transfer Form nor the physician notes contained Risks and Benefits of transferring the patient. The MD stated that the record did note that the transfer had been discussed, and the patient had agreed, and, he/she was certain that the risks and benefits would have been included in that discussion. The Director of Clinical Informatics confirmed the absence of Risks and Benefits documentation in the medical records for patients' #'s 2, 14, 15 and 16. Policy and Procedure review: The facility's Policy and procedure titled Emergency Medical Treatment and Labor Act. Policy #: AMC-RL280, Effective Date: February 14, 2001, reviewed/Revision Date: August 2015 was reviewed. The policy revealed in part, "IV. POLICY: ... H ...b. With certification: The individual may be transferred ...if a physician or ...another qualified medical person in consultation with a physician has certified that the medical benefits expected from the transfer outweigh the risks." The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that the risks and benefits of the transfer were documented for patient #'s 2, 14. 15 and 16.

Based on observation, staff interview, and policy review, the facility failed to post required EMTALA signs in places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment as evidenced by no postage of EMTALA signage the facility's emergency room waiting room. Findings include: During an ER tour on 7/6/2015 at 10:13 AM with the Market Compliance Officer and ER Director, it was observed that the ER waiting room did not contain required EMTALA signage. The Market Compliance Officer and the ER Director acknowledged the absence of the signage upon discovery. Review of facility policy #AMC-RI.280, EMTALA, effective date February 14, 2001, current reviewed/revision date December 2014, III. entitled, Procedure K. Posting of Signs, revealed the Hospital shall post conspicuously, in the "dedicated emergency departments" and all areas in which individuals routinely present for treatment of emergency medical conditions and wait prior to examination and treatment, (such as entrance, admitting areas, waiting room or treatment room) signs in the format that specifies rights of an individual under the law with respect to examination and treatment for emergency medical conditions and of women who are pregnant and are having contractions. At the survey's close, the required signage had not been posted.