Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to prevent a delay in treatment for 1 patient (#27) of 35 medical records reviewed. The findings included: Review of facility policy "On-call Pay" dated 1/1/14, revealed "...designated on-call employees must be available to be reached electronically or by phone and must be able to report to work within thirty [30] minutes of being contacted..." Medical record review revealed Patient #27 was admitted to the Emergency Department (ED) at Facility A on 7/29/17 at 3:47 AM with complaints of right lower quadrant pain for 2 weeks. Further review revealed the patient had reported the onset of symptoms started on 7/15/17 and were not getting better and had a pain score of 9 [indicating severe pain]. Continued review revealed her Last Menstrual Period (LMP) was 9/1/15 and she had been on Depo-Provera (injections to prevent pregnancy). Further review revealed the patient was transferred to Facility B on 7/29/17 at 9:33 AM (5 hours and 14 minutes later). Medical record review of an Emergency Provider Report at Facility A dated 7/29/17 at 3:49 AM revealed the patient was evaluated by the ED physician. Further review revealed "...abdominal pain, nausea...urinary frequency...pain for 2 weeks...slowly worse...nausea..." Medical record review of a Laboratory Results Interpretation report from Facility A dated 7/29/17 at 4:25 AM revealed a Positive Pregnancy test. Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 4:35 AM revealed the Ultra Sound (US) Tech was called for a transvaginal ultrasound (pelvic ultrasound) order. Further review revealed "...called [named US tech]...no answer...left message on her voice mail..." Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 4:37AM revealed "...no call back from...US Tech...re-paged..." Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 4:41 AM revealed "...no call back from [named] US Tech...re-paged..." Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 5:05 AM revealed "...no call back from [named US Tech]...re-paged..." Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 5:05 AM revealed "...Nursing supervisor was notified of the multiple attempts to contact US Tech to no avail [no success]. Advised that following US Tech's shift begins at 7:00 AM MD [Medical Doctor] notified..." Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 5:11 AM revealed "...no call back from US Tech...re-paged..." Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 7:06 AM revealed "...[named US Tech] in US called and std [stated] she is here and will be down to get patient in just a few minutes..." Medical record review of an Ultrasound Transvaginal report at Facility A revealed the US was completed on 7/29/17 at 7:30 AM (3 hours and 5 minutes after the US was ordered). Medical record review of an Ultrasound Transvaginal report at Facility A dated 7/29/17 at 8:04 AM revealed the report was signed by [named radiologist]. Further review revealed "...impression...a live ectopic [outside the uterus] pregnancy at 9 weeks and 5 days of the right ovary...recommend stat Obstetrics and Gynecology [OB/GYN] consultation..." Medical record review of an Emergency Provider Report at Facility A dated 7/29/17 at 8:05 AM revealed the ED physician contacted the on-call OB/GYN physician for Facility A. Continued review revealed the patient requested to be transferred to Facility B because her OB physician was located there. Medical record review of an Emergency Medical Condition (EMC) form at Facility A dated 7/29/17 revealed the patient was transferred to Facility B at 9:33 AM with a diagnosis of [DIAGNOSES REDACTED] Review of a facility investigation report from Facility A dated 8/11/17 revealed "...ED Director and Assistant Chief Nursing Officer [ACNO] were made aware of patient issue r/t [related to] call received from Facility B with concern about patient transfer...delay in u/s [ultrasound] and direction provided...the delay in u/s [ultrasound] tech response was a schedule issue/confusion with tech who was sick and the covering technician..." Further review revealed "...review of patient medical record: 7/29/17: 3:47 AM: patient arrived in ED 4:00 AM: triaged with pain of 9. Right Lower Quadrant [RLQ] pain x [times] 2 weeks. Much worse that day with nausea and vomiting 4:30 AM: transvaginal u/s ordered. Positive Pregnancy Test U/S tech paged at 4:37 AM, 4:41 AM, 5:05 AM. Nursing supervisor notified at 5:05 AM. Advised that following US tech shift begins at 7:00 AM. MD notified. 7:06 AM: US tech on site and on way to get patient 8:00 AM: transvaginal u/s interpretation...live [DIAGNOSES REDACTED] at 9 weeks 5 days of the right ovary. Recommend stat [now] OB/GYN consultation. 8:05 AM: [named ED physician] and [named on-call OB/GYN] phone conversation 8:10 AM: pain 9 (scale of 1-10, indicating intense pain) 9:33 AM: pt. transferred to Facility B by EMS [emergency medical services]..." Medical record review of an Operative Report from Facility B dated 7/29/17 at 1:44 PM revealed "...procedure: diagnostic laparoscopy [surgical procedure in which a fiber optic instrument is inserted through the abdominal wall to view the organs in the abdomen or to permit a surgical procedure]...partial omentectomy [surgical procedure to remove thin fold of abdominal tissue]..." Interview with the Director of Imagining Services at Facility A on 9/6/17 at 11:10 AM, in the conference room, confirmed "...the US technicians are on call after 11:00 PM...the technician had notified me on Thursday [7/28/17] that she had strep throat and could not return to work...the schedule technician thought she was on call for the main hospital [not Facility A]...did not realize she was on call for [Facility A]...they had called her 3 times...the order was put in at 4:31 AM and the US was completed at 7:13 AM by the day shift US technician..." Further interview revealed "...they are responsible for their own schedules..." Telephone interview with the ED Medical Director at Facility A on 9/6/17 at 11:00 AM revealed the patient (MDS) dated [DATE] with a chief complaint of RLQ pain. Further interview revealed "...I saw the patient around 4:00 AM...she had no idea she was pregnant...her HCG came back elevated which indicated she was pregnant...after we got her labs back I ordered an Ultrasound to rule out an [DIAGNOSES REDACTED]..." Further interview confirmed "...there was a delay in the getting the US...the test was done around 7:30 AM which did reveal an [DIAGNOSES REDACTED]..." Telephone interview with ED Physician #2 at Facility A on 9/6/17 at 11:30 AM confirmed "...the patient came in with RLQ pain...her HCG [Human chorionic gonadotropin] [hormone produced during pregnancy] was positive indicating she was pregnant...the US was performed after I came in and showed a 9 week 5 day old right ovarian [DIAGNOSES REDACTED]...she said she had an OB/GYN physician at [Facility B] and had seen the physician to get her birth control...wanted to go to [Facility B]...the patient was very stable...no acute abdomen..."" Interview with the Cooperate Risk Manager at Facility A on 9/7/17 at 9:50 AM, in the conference room, revealed "...I was notified about the patient and the delay in getting the US...the technician did not realize she was on-call for Facility A and had not got anyone to cover for her due to sickness...they called her 3 times then they got in touch with the day shift technician who performed the US..." Continued interview confirmed "...the delay in the US has been discussed and referred to the department manager for follow up...the nursing supervisor was notified by the ED staff...further calls to the US staff were made and the day shift technician did the US as soon as she got in the facility..." Further interview revealed "...we discussed the delay in obtaining the US with our ED Medical Director and CMO [Chief Medical Officer]..." Interview with the Chief Nursing Officer (CNO) on 9/7/17 at 10:00 AM, in the conference room, revealed "...I was notified by the RM [Risk Manager] regarding the US and the patient's transfer..." Further interview confirmed "...there was a delay in getting the US..."

Based on facility policy review, review of facility Medical Staff Rules and Regulations, review of Tennessee Nurse Practice Act, medical record review, and interview, the facility failed to provide a medical screening examination (MSE) for 1 patient (#29) of 35 medical records reviewed. The findings included: Review of facility policy "EMTALA - Tennessee Medical Screening Examination and Stabilization" dated 06/2017, revealed "...hospital must provide an appropriate MSE within the capability of the hospital's emergency department...to any individual, including a pregnant woman having contractions...Only qualified licensed independent practitioner (LIP) with appropriate competencies and privileges...A qualified staff member who...is functioning within the scope of his or her license and in compliance with state law and appropriate practice acts...QMPS [qualified medical providers) may perform an MSE if licensed and certified, approved by the hospital's governing board...QMP's in the labor and delivery DED [designated emergency department] may be appropriately-approved RNs [Registered Nurse]..." Review of facility policy "Labor and Delivery Medical Screening" approved 09/2016, revealed "...In the Labor and Delivery setting, emergency medical screening examinations may be performed by...a Labor and Delivery Registered Nurse [RN] who has completed the Qualified Medical Provider (QMP) competencies [fetal monitoring training]...It is permissible for a Labor and Delivery Registered Nurse to conduct an emergency labor screening examination on a patient of 20 weeks gestation or greater utilizing the Obstetrical Medical Screening Tool..." Review of "Medical Staff Rules and Regulations - 2017" dated 03/2017, revealed "...qualified medical person provides medical screening...Qualified Medical Person or Personnel - means an individual other than a licensed physician who is certified in one of the following categories...Registered Nurse in Perinatal Services..." Review of the Tennessee Code Annotated 63-7-103 "...Title 63 Professions of the Healing Arts...Nursing...General Provisions..." dated 2016, revealed "...professional nursing includes...(A) Responsible supervision of a patient...(B) Promotion, restoration and maintenance of health or prevention of illness of others...(C) Counseling, managing, supervising and teaching of others...(D) Administration of medications and treatments as prescribed by a licensed physician...or nurse authorized to prescribe...(E) Application of such nursing procedures as involve understanding of cause and effect...(F) Nursing management of illness, injury or infirmity...(b) the practice of professional nursing does not include acts of medical diagnosis or the development of a medical plan or care..." Continued review did not specify Registered Nurses were permitted to complete Medical Screening Examinations under the Tennessee Nurse Practice Act. Medical record review revealed Patient #29 presented to Facility A on 8/3/17 at 3:39 AM at 38 weeks gestation with complaints of contractions and a pain score of 6 (severe pain). Further review revealed a vaginal examination and fetal heart monitoring was done by a Registered Nurse (RN). Further review revealed no documentation the patient was provided a MSE by a physician, physician's assistant (PA), or advanced practice nurse (APN) prior to being discharged home at 5:30 AM. Medical record revealed Patient #29 returned to Facility A on 8/3/17 at 3:06 PM (9 hours and 36 minutes later) for complaint of contractions with a pain score of 9 (severe pain). Further review revealed a vaginal examination and fetal heart monitoring was done by a RN. Further review revealed no documentation the patient was provided a MSE by a physician, PA, or an APN prior to being discharged home on 8/3/17 at 5:30 PM. Interview with Facility A's Women's Service Director on 9/6/17 at 4:00 PM, in the conference room, revealed some Obstetrics (OB) patients who present in labor are not seen by a physician, PA, or APN, and are only seen by a RN. Continued interview confirmed OB RNs provide a MSE for patients in possible labor and "...a Hospitalist...laborist..." is available every night from 7:00 PM to 7:00 AM and every weekend from 7:00 PM Friday to 7:00 AM on Monday. Further interview confirmed a MSE was not provided by a licensed physician, PA, or APN.

For documentation purposes: Facility A is Parkridge East Hospital (a satellite facility of Parkridge Medical Center) located at 941 Spring Creek Road, Chattanooga, TN . Facility B is Erlanger Medical Center located at 975 East Third Street, Chattanooga, TN (located 6 miles from Facility A). Based on review of facility policy, review of facility Medical Staff Rules and Regulations, review of the Tennessee Nurse Practice Act, medical record review, review of facility investigation, and interview, the facility failed to provide a medical screening examination (MSE) by a qualified medical provider (QMP) for 1 patient (#29) and failed to prevent a delay in treatment for 1 patient (#27) of 35 medical records reviewed. Refer to A-2406 Refer to A-2408

Based on review of facility policies, review of Medical Staff Rules and Regulations 2017, review of a facility letter, review of medical records, review of an audio recording, and interviews, the facility failed to accept an appropriate transfer of 1 patient (#4) of 37 patients reviewed. The findings included: Review of facility policy "EMTALA-Transfer Policy" approved 03/2016 revealed, "...A hospital with specialized capabilities...shall accept from a transferring hospital an appropriate transfer of an individual with an EMC [Emergency Medical Condition] who requires specialized capabilities if the receiving hospital has the capacity to treat the individual..." Review of the facility policy "EMTALA-Provisions of On-Call Coverage" approved 01/2017 revealed, "...The on-call physician does not have the authority to refuse an appropriate transfer on the behalf of the facility...Only the CEO [Chief Executive Officer], Administrator-on-Call ("AOC"), or a hospital leader who routinely takes administrative call has the authority to verify that the facility does not have the capability and capacity to accept a transfer. Any transfer request which may be declined must first be reviewed with this individual before a final decision to refuse acceptance is made. This requirement applies to all transfer requests..." Review of Medical Staff Rules and Regulations - 2017 dated 3/2017 revealed, "...Each medical staff member shall comply with the hospital EMTALA policies..." Review of a letter from the facility dated 7/7/17 revealed, "...Parkridge Medical Center...may constitute a potential violation of the Emergency Medical Treatment and Labor Act (EMTALA) as Parkridge unintentionally misrepresented that the hospital did not have the capability to accept the transfer of a patient...On June 5, 2017 at 7:44 PM...[Facility B] contacted Tristar Transfer Center to request the transfer of [Patient #4] who was diagnosed with a ST-Elevated Myocardial Infarction (STEMI) [heart attack]...[Facility B] indicated cardiology services were not available at their facility and reported the patient requested to be transferred to Parkridge...the on-call cardiologist [MD #1] questioned the transfer to Parkridge, asking if [Facility C] had been contacted and also noting that he did not believe that Parkridge had a helipad...The Transfer Center Representative also attempted to intercede and reported that Parkridge did have a helipad...the On-Call Cardiologist continued to advise that it would be best to transfer the Patient to [Facility C] again indicating he did not believe Parkridge had a helipad...Parkridge's Intake Center Representative contacted Parkridge Administration and confirmed that Parkridge did have a helipad..." Further review of the letter revealed the facility believed this incident was a possible violation of EMTALA requirements and implemented these interventions to prevent additional violations: A. On June 5, 2017, the On-Call Cardiologist was advised that the hospital did have a helipad and that declining the transfer request of the Patient was inappropriate. This information was also re-iterated via email to the On-Call Cardiologist on July 5, 2017. B. The On-Call Cardiologist was not paid for call coverage on June 5, 2017, as a result of the inappropriate declination of the transfer request. C. On June 8, 2017, the Division Ethics and Compliance Officer discussed the incident with the Transfer Center Director, specifically regarding the importance of immediately notifying the AOC prior to any official potential declinations. D. On June 13, 2017, the On-Call Cardiologist was also reminded of the hospital's EMTALA obligations, noting that all transfer requests must be accepted unless Parkridge does not have the capability and capacity to provide the requested care. E. On June 13, 2017, the On-Call Cardiologist was advised that according to Parkridge policy, on-call physicians do not have the authority to decline transfer requests, as the AOC should be contacted to make the final determination as to whether Parkridge has the capability and capacity to accept or deny a transfer request. F. On July 5, 2017, a letter was sent to all on-call physicians reminding the physicians of Parkridge's EMTALA policies and advising that on-call physicians do not have the authority to decline transfer requests, as the CEO or AOC should be contacted to make the final determination as to whether Parkridge has the capability and capacity to accept or deny a transfer request. G. On July 7, 2017, this incident was reported by Parkridge to the Tennessee Bureau of Health Licensure and Registration. H. The On-Call Cardiologist was assigned an EMTALA educational course with a required completion date of July 31, 2017. Review of the medical record from Facility B revealed Patient #4 (MDS) dated [DATE] at 7:32 PM with complaint of chest pain. Further review of the medical record physician's notes dated 6/5/17 revealed, "...Primary Impression: Acute ST segment elevation myocardial infarction [heart attack]..." Further review of the medical record revealed nurses notes on 6/5/17 at 7:50 PM which stated, "...AIR EVAC [helicopter ambulance] CALLED AT THIS TIME..." Further review of the nurses notes revealed, "...[MD #1/On-Call Cardiologist at Facility A] REPORTS THAT PT [patient] NEEDS TO GO TO [Facility C] AND TO CALL AND SET UP ACCEPTANCE THERE..." Further review of nurses notes revealed the patient left Facility B on 6/5/17 by Air Ambulance at 8:20 PM transferred to Facility C. Review of the medical record from Facility C revealed Patient #4 was admitted there on 6/5/17 at 9:42 PM by air ambulance with diagnosis of ST-Elevated Myocardial Infarction (heart attack). Further review of the record revealed air ambulance notes dated 6/5/17 at 9:19 PM which stated, "...patient initially requested transfer to [Facility A] however the ED staff states they were unable to obtain acceptance...[Facility C] was contacted and accepted..." Further review of the medical record revealed the patient had a Cardiac Catheterization (a tiny flexible tube is inserted in the blood vessels of the heart for diagnosis and treatment) performed on 6/5/17 at 10:11 PM. Further review of the medical record revealed the patient was monitored overnight in Facility C's Intensive Care Unit and then moved to a step-down unit. Further review of the medical record revealed the patient was discharged home in stable condition on 6/7/17. Review of an undated and untimed audio recording of a telephone conversation between Facility A's Transfer Center Staff (TCS) and MD #1 revealed, "...[TCS] They are going to fly him...[MD #1] Where are they landing?...[TCS] at the helipad...[MD #1] Which helipad?...[TCS] at [Facility A] you all have one somewhere...[MD #1] I don't know where it is...[MD #1] [Facility C] has a helipad..." Further review of this recording revealed a telephone conversation between TCS and Facility A's nursing office (NO) which revealed, "...[TCS] where is your helipad?...[NO] Behind the hospital...[TCS] Doctor [MD #1] is telling them that you don't have a helipad...he denied a transfer for a STEMI [heart attack]...[NO] He can't deny it for that, we have a helipad...[TCS] He conferenced the physician at [Facility B] and he denied accepting..." Physician (MD) #1 was interviewed by telephone on 7/31/17 at 1:30 PM. MD #1 confirmed he was the cardiologist on-call at Facility A on 6/5/17, and he remembers Patient #4's requested transfer on that date. MD #1 stated "...I did not refuse to accept the patient...I told them I did not think [Facility A] had a helipad and I thought it would be better if he was taken to [Facility C]...it was because I did not know we had a helipad here...I called them back to accept the transfer, but the patient had already been transferred to [Facility C]...I have never refused to accept a transfer...I could have treated him here but I thought there was no place for the helicopter to land with him...I never knew we had a helipad here..." Interview with the Administrator On-Call (AOC #1) on 7/27/17 at 12:15 AM, in Facility A's Quality Department's conference room, revealed she was the AOC on duty on 6/5/17 and she remembers the attempted transfer of Patient #4 from Facility B to Facility A on 6/5/17. AOC #1 stated she was called by the transfer center employee who told her, "...[MD #1] had denied acceptance of a transfer from [Facility B] because we do not have a place to land the helicopter..." AOC #1 stated she told the transfer center "...'we will accept the patient,' but he had already denied it...the patient had been sent to [Facility C] already..." Further interview revealed MD #1 should not have denied acceptance of a transfer without consulting and involving the AOC. Further interview with AOC #1 revealed, "...This should have come to the AOC...the physicians are not supposed to deny a transfer without the AOC being involved..." Further interview with AOC #1 revealed Facility A had a helipad, and had both the capacity and capability to treat Patient #4 on 6/5/17. Interview with the Chief Operating Officer and the Ethics and Compliance Director on 7/31/17 at 2:11 PM, in Facility A's Quality Management conference room, revealed the Facility has implemented the following corrective actions and as a result this was considered a past non compliance.

Based on review of facility policy, review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), review of medical staff rules and regulations, medical record review, and interviews, the facility failed to provide a Medical Screening Examination by a Qualified Medical Provider for 2 patients (#34 and #37) of 37 patients reviewed, and failed to accept the appropriate transfer of 1 patient (#4) when the facility had the capacity and capability to treat the patient. Refer to 2406 for failure to provide a medical screening examination. Refer to 2411 for failure to accept an appropriate transfer.

Based on review of facility policy, review of medical staff rules and regulations, review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), medical record reviews, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Person (QMP) for 2 patients (#34 and #37) of 37 patients reviewed. The findings included: Review of facility policy "EMTALA - Tennessee Medical Screening Examination and Stabilization" dated 06/2017 revealed, "...hospital must provide an appropriate MSE within the capability of the hospital's emergency department...to any individual, including a pregnant woman having contractions...Only the following individuals may perform an MSE...A qualified physician with appropriate privileges...Other qualified licensed independent practitioner (LIP) with appropriate competencies and privileges...A qualified staff member who...is functioning within the scope of his or her license and in compliance with state law and appropriate practice acts...QMPs may perform an MSE if licensed and certified, approved by the hospital's governing board...QMPs in the labor and delivery DED [designated emergency department] may be appropriately-approved RNs [Registered Nurse]..." Review of facility policy "Labor and Delivery Medical Screening" approved 09/2016 revealed, "...In the Labor and Delivery setting, emergency medical screening examinations may be performed by...a Labor and Delivery Registered Nurse [RN] who has completed the Qualified Medical Provider (QMP) competencies...It is permissible for a Labor and Delivery Registered Nurse to conduct an emergency labor screening examination on a patient of 20 weeks gestation or greater utilizing the Obstetrical Medical Screening Tool..." Review of "Medical Staff Rules and Regulations - 2017" dated 03/2017 revealed, "...qualified medical person provides medical screening...Qualified Medical Person or Personnel - means an individual other than a licensed physician who is certified in one of the following categories...Registered Nurse in Perinatal Services..." Review of the Tennessee Code Annotated 63-7-103 "...Title 63 Professions of the Healing Arts...Nursing...General Provisions..." dated 2016, revealed "...professional nursing includes...(A) Responsible supervision of a patient...(B) Promotion, restoration and maintenance of health or prevention of illness of others...(C) Counseling, managing, supervising and teaching of others...(D) Administration of medications and treatments as presribed by a licensed physician...or nurse authorized to prescribe...(E) Application of such nursing procedures as involve understanding of cause and effect...(F) Nursing management of illness, injury or infirmity...(b) the practice of professional nursing does not include acts of medical diagnosis or the development of a medical plan or care..." Continued review revealed the Code did not specify Registered Nurses were permitted to complete Medical Screening Examinations under the Tennessee Nurse Practice Act. Medical record review revealed Patient #34 presented to the facility's East campus on 7/3/17 at 2:26 PM with complaint of 37 weeks pregnant with contractions. Further review of the medical record revealed the patient was assessed by an RN with fetal heart monitoring and a vaginal exam being provided by an RN. Further review of the medical record revealed no documentation of the patient being provided a MSE by a physician, physician's assistant (PA), or advanced practice nurse (APN) prior to being discharged home at 4:47 PM. Further review of the medical record revealed the patient returned to the facility on [DATE] at 11:59 PM for complaint of labor and elevated blood pressure. Further review of the medical record revealed the patient was admitted on [DATE] at 6:01 AM. Medical record review revealed Patient #37 presented to the facility's East campus on 6/25/17 at 2:15 AM for complaint of being 36 weeks pregnant with contractions. Further review of the medical record revealed the patient was assessed by an RN with a vaginal exam and fetal heart monitoring being provided by an RN. Further medical review revealed no documentation of the patient being provided a MSE by a physician, PA, or APN prior to being discharged home on 6/25/17 at 10:40 AM. Further review of the medical record revealed the patient returned to the facility on [DATE] at 8:15 AM and delivered her baby on 7/6/17 at 12:43 PM. Interview with the Womens Service Director on 8/1/17 at 11:42 AM, in the Labor and Delivery classroom at the facility's East campus, confirmed on the first 7/3/17 visit, Patient #34 was not provided a MSE by a physician, PA, or APN. Further interview confirmed Patient #34 was assessed by an RN only during the first 7/3/17 visit. Further interview revealed pregnant patients presenting in possible labor to the facility's East campus may routinely be provided a MSE by an RN only. Further interview revealed the East campus provides 24 hour labor and delivery (L&D) services and has a physician that specializes in L&D in the hospital each night from 7:00 PM to 7:00 AM and every weekend from Friday at 7:00 PM to Monday at 7:00 AM. Interview with the Womens Service Director on 8/1/17 at 11:58 AM, in the Labor and Delivery classroom at the facility's East campus, confirmed on the 6/25/17 visit Patient #37 was not provided a MSE by a physician, PA, or APN. Further interview confirmed Patient #37 was assessed by an RN only during the 6/25/17 visit.

Based on facility policy review, review of Bylaws Of The Medical Staff, medical record review, review of physician call schedules, review of audio recordings, and interviews, the facility failed to provide on-call ENT/Otolaryngology (a physician specializing in treating diseases of ears, nose, and throat) physician services, for 1 patient (#14) of 34 Emergency Department (ED) patients reviewed. Review of the facility's investigations, communications, and action plans revealed the facility had identified the past non-compliance and had placed interventions (primarily directing the ED physicians and Administrators on Call to bypass the Transfer Center and bypass the physician specialists on call and accept all appropriate transfers) and the facility is currently in compliance with 42 CFR 489.20 and 489.24, Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. Refer to A 2404 for failure to provide on-call physician.

Based on facility policy review, review of Bylaws Of The Medical Staff, medical record review, review of physician call schedules, review of audio recordings, review of credentialing files, and interviews, the facility failed to provide on-call ENT/Otolaryngology (a physician specializing in treating diseases of ears, nose, and throat) physician services for 1 patient (#14) of 34 Emergency Department (ED) patients reviewed. Review of the facility's investigations, communications, and action plans revealed the facility had identified the past non-compliance and had placed interventions in place (primarily directing the ED physicians and Administrators on Call to bypass the Transfer Center and bypass the physician specialists on call and accept all appropriate transfers) and the facility is currently in compliance with 42 CFR 489.20 and 489.24, Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. The findings included: Review of the facility's policy EMTALA-Provision of On-Call Coverage last revised 3/2013, revealed, "...Physicians on the list must be available after the initial examination to provide treatment...Immediate availability...or to secure a qualified alternate...Arrival or response to the DED (Dedicated Emergency Department) within a reasonable timeframe...The on-call physician has a responsibility to provide specialty care services as to needed...The on-call list maintained for the main hospital Emergency Department shall be the on-call list for the hospital, including any Off-Campus Provider-based Emergency Departments " Review the facility's Bylaws of the Medical Staff dated 2014 revealed, "...Obligations of Active Staff...accept emergency on-call coverage for emergency care services within his/her clinical specialty...or arrange a suitable alternative..." Review of the medical record revealed Patient #14 presented to the ED at Hospital #1's West campus (A satellite facility of Hospital #1 with a DED but no surgical or medical inpatient services. The West Campus is located 28 miles from Hospital #1's Main campus, a 275-bed hospital which did have surgical and inpatient services) on 1/23/16 at 3:24 AM, with a police officer, for complaint of auditory and visual hallucinations and paranoia. Further review of the medical record revealed the patient had a Medical Screening by a physician beginning at 3:24 AM, which included a physical examination and laboratory tests. The patient was medically cleared and diagnosed with Homicidal Ideation and Paranoia, and a consultation with Crisis Intervention services was made on 1/23/16 at 4:30 AM. The patient was kept on 1:1 (one to one) observation and was assessed by Crisis Response staff. The physician signed a commitment form for the patient and arrangements were made for transfer to an area psychiatric hospital on [DATE] at 6:20 AM. Review of the medical record revealed Patient #14 complained of a sore throat on 1/23/16 at 8:45 AM and was re-evaluated by the physician. Further medical record review revealed on 1/23/16 at 9:02 AM the physician applied topical analgesia, treated the patient with oral pain medication, then performed a strep swab (laboratory test for group A Streptococcus infection) and attempted twice to aspirate a tonsillar pillar abscess without success. The patient was treated with Rocephin 1 gram IM (an injection into the muscle of antibiotics to fight the infection) and Dexamethasone 8 mg (milligrams) IM (an injection into the muscle of a steroidal anti-inflammatory drug to reduce swelling) at 9:15 AM on 1/23/16. Review of the medical record revealed a CT Scan (computerized tomography scan, a series of computer assisted 3 dimensional x-ray images) was ordered by the ED Physician on 1/24/16 10:21 PM and revealed "...Tonsillitis with right peritonsillar abscess..." Review of the medical record revealed a nurses note dated 1/24/16 at 11:27 PM stating, "...Spoke to...at...transfer center to arrange transfer to...main for admission ..." Further review of nurse's note dated 1/24/16 at 11:33 PM revealed, "...spoke to...at transfer center, arranging ER to ER transfer..." Review of the transfer form revealed Patient #14's transfer form was completed on 1/25/16 at 1:00 AM to transfer the patient by ambulance from Hospital #1's West Campus to Hospital #2 . Further review of the transfer sheet revealed the medical benefits of the transfer were, "...Obtain a level of care/service unavailable at this facility...Service ENT/Admission..." Review of a physician's addendum note dated 1/25/16 at 1:06 AM, revealed the physician reassessed Patient #14 for continued complaint of throat pain and the doctors note stated, "...The patient's clinical condition seems to be worsening and his pain persists. It was decided to obtain a CT Scan to see the extent of the peritonsillar abscess. The patient has an abscess measuring 2.4 inches in diameter...It was decided to transfer the patient to a facility for in patient management of this condition..." Review of the medical record from Hospital #2 (a large medical center located 26.9 miles from Hospital #1's West Campus) revealed Patient #14 (MDS) dated [DATE] at 2:58 AM and was admitted as an inpatient with diagnosis which included Right Peritonsillar Abscess and Tonsillitis, Reported History of Homicidal Ideation, more likely, Paranoia and Auditory Hallucinations secondary to Methamphetamine Use, and Polysubstance Abuse. Further review of the medical record revealed the patient was seen by an ENT/Otolaryngologist and had an Incision and Drainage of the Peritonsillar Abscess while still in the ED on 1/25/16. Further review revealed the patient's medical and mental condition improved significantly and he was discharged home in stable condition on 1/26/16. Review of Hospital #1's Emergency Department Unattached Call Schedule for January 2016 revealed the facility had an ENT/Otolaryngologist on call 1/23/16, 1/24/16, and 1/25/16. The schedule showed ENT/Otolaryngology on call coverage every night except 1/1, 1/2, and 1/18 in January 2016. Review of an undated and untimed recording, identified by the Compliance Officer and Risk Manager as the recording of a conversation regarding Patient #14's transfer to the main campus on 1/25/16, between the facility's Transfer Center and the main campus ED Physician revealed the ED Physician told the Transfer Center, "...don't send unless [ENT on-call physician] agrees to take patient..." Review of an undated and untimed recording, identified by the Compliance Officer and Risk Manager as the recording of a conversation regarding Patient #14's transfer to the main campus on 1/25/16, between the facility's Transfer Center and the facility's on-call ENT/Otolaryngologist revealed the on-call physician was asked if he would be available to treat the patient and the ENT told the Transfer Center, "...No, I would not be available to come in and evaluate...transfer to [Hospital #2] or [Hospital #3]..." Review of an undated and untimed recording, identified by the Compliance Officer and Risk Manager as the recording of a conversation regarding Patient #14's transfer to the main campus on 1/25/16, between the facility's Transfer Center and the ED physician at the West Campus revealed the Transfer Center staff told the West ED physician, "[Hospital #1 main campus] is not able to take the patient there...ENT unable to come in and see the patient..." Review of physician credentialing files revealed Physician #1 is a licensed Medical Doctor, Board Certified in Otolaryngology, and had privileges at this facility which included Otolaryngological procedures. Telephone interview with Physician #1 (the ENT on-call on 1/25/16) on 3/16/16 at 3:00 PM, revealed he did not remember Patient #14's case or the phone call from the Transfer Center. Interview with the Marketing Compliance Officer and the Risk Manager on 3/15/16 at 1:14 PM, in the Risk Management Conference Room, revealed they had investigated the incident that involved Patient #14 and confirmed Physician #1 was on-call for ENT coverage on 1/25/16 and had told the transfer center he was unavailable to see the patient if transferred to the main campus ED. Further interview confirmed the on-call physicians were to be available to examine and treat patients in the Main Campus ED when needed for their specialty. Further interview revealed the ENT physician had stated he was busy at another facility when the transfer center had contacted him on 1/25/16. Further interview revealed the on-call ENT physician had not notified this facility's ED or Medical Staff Office of his unavailability. Review of a letter from the facility given to the surveyor on 3/15/16, during the entrance conference, revealed, "...Enclosed is a set of facts that we have determined constitutes a potential violation of the Emergency Medical Treatment and Labor Act ("EMTALA")...declined the transport of a patient when the facility appeared to have the capability and capacity to accept the request...On 1/24/16 at 11:22 PM...House Supervisor was contacted by...Transfer Center to request...[Patient #14]...be moved from...West...to the main campus...was diagnosed with a peritonsillar abscess...would need to be seen by an Otolaryngologist...The transfer center then contacted...ED Physician regarding the request...The ED Physician responded that he accepted the transfer request but the On-Call ENT would need to evaluate the Patient...On 1/25/16 at approximately 12:00 a.m., the Transfer Center Representative telephoned the On-Call ENT and asked if he was available to evaluate a patient in the ED. The On-Call ENT stated he was unavailable and recommended transferring the patient to another facility...In a discussion with the On-Call ENT he claimed he was at another facility when the Transfer Center contacted him about the transfer request...Medical Staff Office (MSO) and ED had not been notified that he would be unavailable...the Transfer Center notified West's ED Physician...and facilitated a transfer...the patient was transferred..." Interview with the Marketing Compliance Officer and the Risk Manager on 3/15/16 at 1:14 PM, in the Risk Management Conference Room, revealed their investigation identified additional information. The West Campus did not have an ENT on-call there, but the Main Campus did have an ENT on call. Patient #14 was a Certificate of Need (CON) patient committed to a psychiatric facility for but there were no ICU Beds available, and this patient having been committed for Homicidal Ideation and Paranoia and required an ICU bed or a bed in the ED with 1:1 observations. At the time of the referral, the ICU was full with no beds available and the ED had 3 patients on hold in the ED for an ICU bed. Review of the facility's actions to correct the EMTALA violation revealed, "...we have taken immediate measures to ensure this type of incident does not occur in the future..." The facility's interventions were verified during the survey and included: 1. On 3/7/16 the CEO spoke with the On-Call ENT about his obligations under EMTALA and explained the ENT must present to the ED upon request when he is scheduled for call coverage 2. On 3/7/16 the 1/24/16 incident that involved the on-call ENT refusing to accept an in-house transfer from the West campus to the Main Campus was submitted to Medical Staff Peer Review. At the next Peer Review Committee on April 12, 2016, this case will be reviewed then. 3. On 3/8/16 the CEO sent a letter to all physicians taking on-call coverage notifying them of their obligations under EMTALA regulations, which require the physicians to come to the ED upon request. 4. On 3/4/16 the Medical Director spoke with all ED physicians about the requirement to accept all transports and transfers when the facility has the capability and capacity to provide the care requested. The ED physicians are going to bypass the specialist and the transfer center and accept any transfers that are requested if they have the capacity and capability to treat. 5. On 3/15/16 the Chief Nursing Executive and the Ethics and Compliance Officer (ECO) met with all Administrators on Call (AOCs) and explained the importance of gathering information from the transfer center representative to ensure a declined transfer is appropriate. 6. The Facility ECO and Division ECO (DECO) developed an improved process for ED staff and House Supervisors to utilize when a transport vs a transfer (a transfer is from another hospital, the transport is from one of the satellite hospitals) is requested. The ECO and DECO also incorporated scenarios involving behavioral health patients. 7. The Facility ECO and Division ECO developed scripting for the ED staff, House Supervisors and Transfer Center Representatives to utilize when a transport vs a transfer is requested. This scripting is going to be an algorithm form that helps staff make decisions regarding transfers vs transports and provides scripted responses for physicians that refuse transfers or transports. 8. On or before 4/11/16, the Transfer Center Director will review appropriate scripting with the Transfer Center Representatives and provide education on the difference between a transfer and a transport. Until this is completed, the ED medical staff and hospitalist have been told to bypass the Transfer Center and accept any appropriate transfers requested. 9. EMTALA education with all House Supervisors and AOC which was completed 3/15/16. Similar education is provided to the ED Nursing Staff every year now, and updated education has already been provided 3/4/16. The new scripting is being developed and education on this will be provided when it is developed. 10. All ED physicians have been assigned the Sullivan EMTALA training course. The required completion date for all ED Physicians is 4/15/16. 11. All house supervisors, including the House Supervisors at issue, are assigned the online Health Stream EMTALA Education Course. The required completion date is 4/25/16. The Marketing Compliance Officer confirmed she is currently in the process of entering all the House Supervisors and Managers into the computer system and will monitor for completion of all education. Interview with the Marketing Compliance Officer (MCO) and the Risk Manager on 3/15/16 at 1:14 PM, in the Risk Management Conference Room, revealed 100% of patient transfers and transports are being audited for appropriateness and completeness of transfers. Further interview revealed 100% of incoming transfer and requests for transfer are being reviewed by the ED Directors and the MCO for compliance with EMTALA requirements. Completion of all EMTALA education and training is being monitored by the ED Directors and the MCO.