Based on a review of Emergency Medical Services documentation, patient #1's emergency department (ED) record, interview, video, and other information on 11/27-28/18, it was determined that the hospital failed provide a timely and sufficient medical screening examination for patient #1. Patient #1 (P1) was a patient with a recent diagnosis of [DIAGNOSES REDACTED]. The condition can also cause life-threatening blood clots within the circulatory system. Per family, P1 was also noted to be recently diagnosed with [DIAGNOSES REDACTED] Patient #1 had been placed on a cardiac monitor by the paramedic for transport which confirmed P1's atrial fibrillation. An Emergency Medical Services (EMS) form which documented patient #1's condition revealed a starting time of 0206 with vitals of, respirations (R) 30 rapid, heart rate (HR) of 126 regularly irregular, a blood pressure (BP) 156/86 and oxygen saturation of 88 on 10 liters of oxygen (nml oxygen saturation greater than 90%). A verbal report from EMS to the ED prior to P1 arrival to the hospital revealed in part, " Priority 2 ...history of afib and hypertension, stage 4 cancer, history of deep vein thrombosis (DVT-blood clots in the legs), home oxygen ...non-rebreather @10 liters, [oxygen saturation] to 90's, heart rate 110-140, BP 156/86, right now (patient) is afib." P1 arrived to the ED at 0220 and per direction of the Emergency Department Manager, was immediately taken to a resuscitation room #3. Documentation indicated that once in the room, a higher priority patient came to the ED, and P1 was taken back to the triage area to be triaged. Vitals documented at 0237 revealed a BP of 142/84, P 108, R 17 (non-labored), temperature 96.1, Pain 0, and oxygen (O2) saturation 96% on Non-rebreather mask. The triage nurse assigned an Emergency Severity Index of 3 which meant P1 was urgent, but stable. Interview with the triage RN during the survey on 11/27/18 at 1044 revealed in part that the triage RN thought P1 was on a cardiac monitor, but the RN did not review the cardiac monitor and reported no knowledge of P1 being in atrial fibrillation. Video revealed the triage RN remained sitting at the triage station with no attempts to transfer P1 to a hospital cardiac monitor. Nor did the triage nurse feel for a pulse or obtain vital signs other than by report from EMS. The triage RN documented in the medical record in part, "Pt. presents to ER/Triage via EMS __ on stretcher with c/o shortness of breath and diaphoretic since 0030 ...New arrival is blurry and doubled vision ...complaint: SICK." In addition to no mention of Afib, no mention of DVT was noted. Following triage, P1 was wheeled to a "staging area," [hallway] at 0239 that is usually attended by an RN for patients on gurneys who were awaiting room placement. However, per the triage RN, no RN was in attendance at that time. The triage RN stated that the Charge Nurse would "pick up on" the staging area. P1 remained on the paramedic cardiac monitor. Vitals from the monitor at 0346 revealed a BP of 150/87, regularly irregular P of 115, and R of 33. At 0408, vitals from the monitor revealed a BP of 135/70, P of 136, and R of 33. At that time, P1 was taken off the monitor by the emergency medical technician (EMT). Video confirmed that no RN or other hospital staff had approached or spoken with P1 since the triage time of 0241, though the EMT or Paramedic had inquired regarding a room. Per video review, at 0510, the family member of P1 left the area as did an EMT. They returned with a physician who examined P1 in the staging area. P1 was subsequently moved to a room at 0514 where a 12-lead EKG was completed at 0526. The EKG revealed P1 to be experiencing a heart rate of 36 beat per minute, with multiple detected cardiac abnormalities. The physician wrote at 0510 in part, "Patient seen initially on EMS stretcher, having arrived at 0241 and triaged. I saw the patient at approximately 0510hr. Patient was being attended by EMS on NRB in moderate respiratory distress able to speak in very short words ...Upon my initial evaluation in EMS stretcher, attempted to expedite with RN patient be placed in a medical treatment room ..." While attempting to transfer P1 from the ambulance gurney to the stretcher in the room, P1 became unresponsive. Family indicated that P1 had decided on Do Not Resuscitate (DNR) and P1 was not resuscitated. A physician note of 0530 revealed in part, "(Discussed with) family to confirm DNR/DNI. Informed family that at this the likely diagnosis is [DIAGNOSES REDACTED]" Review of all available information confirms that the hospital failed to take responsibility for oversight of care when P1 presented to the hospital with shortness of breath and a rapid irregular pulse, and failed to perform a timely medical screening exam consistent with the patient's presenting symptoms and history.

Based on observation in the Emergency Department at Prince George Hospital Center in the lobby and ambulance entrance, the hospital failed to conspicuously post EMTALA signage. In the lobby of the hospital on July 14, 2015 at 8:50am the surveyor noted an EMTALA Notice about 11 " x 8 " (bold black letters on white paper) posted at waist level at the registration desk and the signage in the ambulance bay area is not visible if a curtain is drawn. For both of these areas the signage is not visible as evident by hospital staff search for minutes with the surveyors to find the signage. In addition in the L&D suite there was no EMTALA signage although many patients are directly admitted to this area and registration will come from the ED to this area to register patients. The hospital failed to post signage in places likely to be noticed by individual ' s entering the Emergency Department and failed to post signage in the to the Labor & Delivery suite to inform patients of their rights regarding EMTALA.

Based on a review of medical records and other documentation along with interviews with staff during a survey at Bowie Health Center (BHC) conducted on 7/14/15, it was determined that the facility's transfer policy is not as specific as actual practice and does not sufficiently address the transfer of critically-ill patients. BHC is the provider-based off-campus free-standing emergency care provider for the hospital. Every patient requiring any level of hospital admission has to be transferred to a hospital. The receiving hospital is determined by the patient's medical condition and level of care needed, patient preference, or the need for specialized services. If the preferred receiving hospital has no appropriate beds, is on emergency department or ICU re-route, or otherwise lacks the capacity to receive a critically ill patient, the patient is to be transferred to Prince George's Hospital Center emergency department. In reviewing the policy entitled "Transfers from BHC to Other Healthcare Facilities," dated 10/8/13, during the survey on 7/14/15, it was noted that the policy did not provide guidance or time limitations for how many phone calls should be made to try to find an appropriate receiving hospital for critically ill patients. The policy also did not define a time limit for making calls and waiting for call-backs before sending the patient to the on-campus emergency department at the hospital. During an interview on 7/14/15, the Medical Director of BHC described a "three-strikes" rule, whereby the BHC physician may make up to three calls to find a receiving hospital before sending the patient to the on-campus ED. Review of quality data at BHC on 7/14/15 revealed an event from 2014 in which a BHC physician called five or six hospitals before finding one that had the capacity to care for a critically ill patient who ultimately died before transport arrived. Interviews with other BHC leadership on 7/14/15 confirmed that the three-strikes rule was implemented following that event. While a medical record review of 20 patients chosen from the list of transfers for April 2015 showed no delays associated with calling multiple receiving hospitals, failing to incorporate such an important rule into written policy places other patients at risk for a delay in transfer.