Oro Valley Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases when a patient arrived at the hospital emergency department by ambulance for evaluation and treatment (Patient #1). Findings include: Hospital policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA)”, revealed: “ ...Comes to the Emergency Department means an individual who: ...has presented to the hospital’s dedicated emergency department and requests examination or treatment for a medical condition ...is on hospital property (including parking lot, campus, ambulance bay ...) or an off campus department of the Hospital ... and requests examination or treatment for what may be an emergency medical condition ...II. Medical Screening Examination. 1. Triage and Registration of Patients Prior to Medical Screening Examination (MSE) ...The triage nurse takes and documents vital signs, along with any other relevant observations, and assigns the patient an acuity level (ESI) that dictates the order in which the patient will be seen ....If a patient informs the ED registration staff that he/she is leaving the Hospital prior to receiving an MSE, staff should endeavor to persuade the patient to stay until he/she can be screened ....B. Medical Screening. When an individual comes to the emergency department (ED) requesting medical treatment, an appropriate MSE, within the capabilities of the ED ...shall be provided to determine whether an emergency medical condition (EMC) exists ...The Hospital must apply the screening process that it would perform on any individual coming to the ED in a non-discriminatory manner and regardless of payor source or ability to pay ....MSE shall be performed by qualified medical personnel (QMP), who may be an ED physician or other licensed practitioner appointed and approved by the Hospital’s Medical Staff ....” Hospital policy titled, “Triage”, revealed: “ ...Purpose: Provides a standardized systematic method of patient assessment to the appropriate triage category that will determine the priority in which patients are treated for their presenting complaint ...Guidelines: ...A Registered Nurse (RN) assesses all patients presenting to the Emergency Department ...A brief history is taken by the RN and a brief Medical Screening Exam (MSE) is done by the ED Physician. The ESI triage category of treatment priority is then assigned according to the individual patient assessment ....Triage categories are assigned to each patient according to the acuity system ....The triage nurse identifies patients needing immediate definitive care and initiates appropriate intervention. The triage process is an initial screen to rule out a medical emergency ....” Hospital document titled, “Critical Incident Communication”, revealed: “ ...Description ...EMS departed (Hospital #1) for (Hospital #2) prior to MSE, allegedly at the request of patient and noting (Hospital #1) did not have GI services ...Order of Event: 1. EMS transported the patient to (Hospital #1) obtaining immediate staff attention for code status (3)/condition. 2. Upon (Hospital #1) arrival, and in the ED hallway, EMS informs staff they inadvertently informed the incorrect hospital of patient arrival. 3. Charge nurse contacts ED provider to assess the patient and contacts the ED Director ...4. ED Provider reportedly was asked by EMS if the patient should be transported to (Hospital #2). The ED Provider reportedly inform the patient [he] wanted to stabilize, work up and transfer to (Hospital #2) for GI consult. 5. Patient reportedly stated [he] did not want to delay transfer and requested transport to (Hospital #2). ED Director informs staff to keep patient and complete MSE/work up. Staff informs ED Director that EMS departed to (Hospital #2). ED Director requests patient return ...6. EMS is contacted but close to (Hospital #2) ...8. Letter received by EMS Coordinator ...describing EMS account of events suggesting EMTALA violation ...Actions ...Immediate review of EMTALA expectations with staff and medical staff ...Expected completion: January 2024 ...Goodwill campaign with EMS ...Expected completion: Mid February 2024 ...Legal Counsel led live-education session. Audience: ED Providers, ED Nursing and Admissions. Expected completion: Mid March 2024 ....” Review of Patient #1’s EMS Runsheet dated 01/15/2024 revealed: “ ...1755 - arrival to (Hospital #1) ...1816 - arrival to (Hospital #2) ...PT requested transport to (Hospital #1) ...PM {sic}(paramedic) ...delivered a telemetry to the (Hospital #2) accidently stating we were transporting a PT ...with a chief complaint of vomiting blood ...Upon arrival to (Hospital #1), PM ...confirms that they had given the relay to the wrong hospital. The staff confirm that “this is probably not the most appropriate facility to take [him] to anyways, we do not have a surgical GI staff”. The charge nurse summons an ER physician to communicate this statement to the PT ...PM ...confirms diversion to (Hospital #2) and immediately initiated transport ...to (Hospital #2). (Hospital #2) re-contacted via telemetry to confirm the PT is unstable ....” Review of Hospital #1 ED log revealed Patient #1 checked in on 01/15/2024 at 17:55 and checked out at 18:00. Review of Patient #1’s medical record from Hospital #1 dated 01/15/2024 revealed triage was not completed, and there was no documentation of vital signs, acuity level, and observations. Review of Patient #1’s medical record from Hospital #1 dated 01/15/2024 revealed: “ ...ED Disposition Summary Entered On: 01/18/2024 14:20 ...Performed On: 01/18/2024 14:18 ...Left Before Triage ...Comments Nursing: pt arrived via EMS without notice, GI bleed/pancreatic CA/known esophageal varices, tele relay called to (Hospital #2) in error by EMS. When provider and nursing spoke to EMS and stated that OVH does not have gi services, EMS took patient without notice to (Hospital #2) ....ED Documents Physician ...Patient presents to ED complaining of vomiting bright red blood. I was pulled into the triage desk to examine patient on the gurney as EMS was asking if patient should be sent to (Hospital #2) immediately. Patient is reported a hospice patient with a history of a pancreatic mass and esophageal varices and had an episode of vomiting bright red blood ....Per EMS report [he] was hemodynamically stable on route. There was some confusion as patient states [he] thought [he] was going to (Hospital #2) not NW oro valley. Patient began requesting EMS to take [him] to (Hospital #2). I did inform patient that we did not have GI available at our hospital and patient ultimately require to be transferred to (Hospital #2) for endoscopy and possible banding but I wished to start the evaluation and treatment of patient’s suspected upper GI blood ....I explained that although patient would ultimately likely require transfer I wished to ensure [he] was stable for transfer ...Patient stated [he] did not want to delay transfer and [he] was insistent that [he] wanted to be brought over to (Hospital #2) right away. I did look at the Zoll monitor that EMS had and noted [his] most recent BP was 126/91 and noted that patient had HR of 90 and 98% on room air. [He] did appear pale cachectic and chronically ill appearing but was not actively vomiting blood, had unlabored respirations and was in no acute distress. I did not further examine patient ...I was pulled in to reexamine another patient who was ultimately activated as a STEMI. When I went to reassess patient I was informed that EMS had left and the patient was no longer on our premises ....Electronically Signed on 01/18/2024 14:55 ....” Employee #7 confirmed during an interview conducted on 03/04/2024 that Patient #1 arrived on 01/15/2024 by ambulance unannounced. Employee #7 also confirmed an ED provider spoke with Patient #1 and EMS in the ED hallway, and informed them Hospital #1 did not have GI specialist. Employee #7 also confirmed the ED provider stepped away to assess a STEMI patient, and when they returned to evaluate Patient #1 further, it was discovered EMS and Patient #1 had left the facility. Employee #7 further confirmed Patient #1 was not registered, triaged, and did not receive a medical screening examination before they left to Hospital #2. Employee #1 confirmed during an interview conducted on 03/04/2024 that Patient #1 leaving the ED without a medical screening examination was investigated. Employee #1 also confirmed all ED personnel, including ED providers, nursing and registration staff, had been re-educated on EMTALA after the 01/15/2024 incident. Employee #1 further confirmed the hospital also reached out to EMS and discussed the hospital’s obligation under EMTALA.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the hospital failed to provide a Medical Screening Examination to a patient who presented to the ED for examination and treatment (Patient #1). Findings include: Hospital policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA)”, revealed: “ ...Comes to the Emergency Department means an individual who: ...has presented to the hospital’s dedicated emergency department and requests examination or treatment for a medical condition ...is on hospital property (including parking lot, campus, ambulance bay ...) or an off campus department of the Hospital ... and requests examination or treatment for what may be an emergency medical condition ...II. Medical Screening Examination. 1. Triage and Registration of Patients Prior to Medical Screening Examination (MSE) ...The triage nurse takes and documents vital signs, along with any other relevant observations, and assigns the patient an acuity level (ESI) that dictates the order in which the patient will be seen ....If a patient informs the ED registration staff that he/she is leaving the Hospital prior to receiving an MSE, staff should endeavor to persuade the patient to stay until he/she can be screened ....B. Medical Screening. When an individual comes to the emergency department (ED) requesting medical treatment, an appropriate MSE, within the capabilities of the ED ...shall be provided to determine whether an emergency medical condition (EMC) exists ...The Hospital must apply the screening process that it would perform on any individual coming to the ED in a non-discriminatory manner and regardless of payor source or ability to pay ....MSE shall be performed by qualified medical personnel (QMP), who may be an ED physician or other licensed practitioner appointed and approved by the Hospital’s Medical Staff ....” Hospital document titled, “Critical Incident Communication”, revealed: “ ...Description ...EMS departed (Hospital #1) for (Hospital #2) prior to MSE, allegedly at the request of patient and noting (Hospital #1) did not have GI services ...Order of Event: 1. EMS transported the patient to (Hospital #1) obtaining immediate staff attention for code status (3)/condition. 2. Upon (Hospital #1) arrival, and in the ED hallway, EMS informs staff they inadvertently informed the incorrect hospital of patient arrival. 3. Charge nurse contacts ED provider to assess the patient and contacts the ED Director ...4. ED Provider reportedly was asked by EMS if the patient should be transported to (Hospital #2). The ED Provider reportedly inform the patient [he] wanted to stabilize, work up and transfer to (Hospital #2) for GI consult. 5. Patient reportedly stated [he] did not want to delay transfer and requested transport to (Hospital #2). ED Director informs staff to keep patient and complete MSE/work up. Staff informs ED Director that EMS departed to (Hospital #2). ED Director requests patient return ...6. EMS is contacted but close to (Hospital #2) ...8. Letter received by EMS Coordinator ...describing EMS account of events suggesting EMTALA violation ...Actions ...Immediate review of EMTALA expectations with staff and medical staff ...Expected completion: January 2024 ...Goodwill campaign with EMS ...Expected completion: Mid February 2024 ...Legal Counsel led live-education session. Audience: ED Providers, ED Nursing and Admissions. Expected completion: Mid March 2024 ....” Review of Patient #1’s EMS Runsheet dated 01/15/2024 revealed: “ ...1755 - arrival to (Hospital #1) ...1816 - arrival to (Hospital #2) ...PT requested transport to (Hospital #1) ...PM {sic}(paramedic) ...delivered a telemetry to the (Hospital #2) accidently stating we were transporting a PT ...with a chief complaint of vomiting blood ...Upon arrival to (Hospital #1), PM ...confirms that they had given the relay to the wrong hospital. The staff confirm that “this is probably not the most appropriate facility to take [him] to anyways, we do not have a surgical GI staff”. The charge nurse summons an ER physician to communicate this statement to the PT ...PM ...confirms diversion to (Hospital #2) and immediately initiated transport ...to (Hospital #2). (Hospital #2) re-contacted via telemetry to confirm the PT is unstable ....” Review of Hospital #1 ED log revealed Patient #1 checked in on 01/15/2024 at 17:55 and checked out at 18:00. Review of Patient #1’s medical record from Hospital #1 dated 01/15/2024 revealed triage was not completed, and there was no documentation of vital signs, acuity level, and observations. Review of Patient #1’s medical record from Hospital #1 dated 01/15/2024 revealed: “ ...ED Disposition Summary Entered On: 01/18/2024 14:20 ...Performed On: 01/18/2024 14:18 ...Left Before Triage ...Comments Nursing: pt arrived via EMS without notice, GI bleed/pancreatic CA/known esophageal varices, tele relay called to (Hospital #2) in error by EMS. When provider and nursing spoke to EMS and stated that OVH does not have gi services, EMS took patient without notice to (Hospital #2) ....ED Documents Physician ...Patient presents to ED complaining of vomiting bright red blood. I was pulled into the triage desk to examine patient on the gurney as EMS was asking if patient should be sent to (Hospital #2) immediately. Patient is reported a hospice patient with a history of a pancreatic mass and esophageal varices and had an episode of vomiting bright red blood ....Per EMS report [he] was hemodynamically stable on route. There was some confusion as patient states [he] thought [he] was going to (Hospital #2) not NW oro valley. Patient began requesting EMS to take [him] to (Hospital #2). I did inform patient that we did not have GI available at our hospital and patient ultimately require to be transferred to (Hospital #2) for endoscopy and possible banding but I wished to start the evaluation and treatment of patient’s suspected upper GI blood ....I explained that although patient would ultimately likely require transfer I wished to ensure [he] was stable for transfer ...Patient stated [he] did not want to delay transfer and [he] was insistent that [he] wanted to be brought over to (Hospital #2) right away. I did look at the Zoll monitor that EMS had and noted [his] most recent BP was 126/91 and noted that patient had HR of 90 and 98% on room air. [He] did appear pale cachectic and chronically ill appearing but was not actively vomiting blood, had unlabored respirations and was in no acute distress. I did not further examine patient ...I was pulled in to reexamine another patient who was ultimately activated as a STEMI. When I went to reassess patient I was informed that EMS had left and the patient was no longer on our premises ....Electronically Signed on 01/18/2024 14:55....” Review of Patient #1’s medical record from Hospital #2 dated 01/15/2024 revealed: “ ...ED Arrival Time: 01/15/2024 18:18 ...Chief Complaint. Pt c/o vomiting blood, became hypotensive en route after vomiting 500mL BRB {sic}(bright red blood). Pt has Hx varices and pancreatic CA ....History of Present Illness ...history of neuroendocrine pancreatic cancer, DNR/DNI, who presents per EMS to the emergency department today for vomiting BR blood. Per EMS this patient is enrolled in home hospice and threw up blood once at home before EMT’s arrived ...Vital Signs ...18:36 ...Heart Rate 105bpm ...Systolic Blood Pressure 68mmHg <LLOW ...Diastolic Bloodd Pressure 56 mmgHg LOW ...Medical Decision Making ...EMS gave 2mL of push dose epi along with starting IV fluids and Zofran ...[he] clearly communicates that [he] does not want to be intubated and wants no cardiac resuscitation ....I involve the case manager to see if we can get the patient admitted to an inpatient hospice unit ...it is late at night and inpatient hospice placement cannot be accomplished ...I speak with ICU nurse practitioner explaining the reason for the ICU bed on hospice care observation status and [she] accepts ...Disposition: Admit: time 01/15/2024 19:27 ....” Employee #7 confirmed during an interview conducted on 03/04/2024 that Patient #1 arrived on 01/15/2024 by ambulance unannounced. Employee #7 also confirmed an ED provider spoke with Patient #1 and EMS in the ED hallway, and informed them Hospital #1 did not have GI specialist. Simultaneously, Employee #7 was called by the charge nurse, and Employee #7 provided instructions to complete medical screening examination and stabilize Patient #1 before transfer to Hospital #2. Employee #7 also confirmed the ED provider stepped away to assess a STEMI patient, and when they returned to evaluate Patient #1 further, it was discovered EMS and Patient #1 had left the facility. Employee #7 further confirmed Patient #1 was not registered, triaged, and did not receive a medical screening examination before they left to Hospital #2. Employee #7 confirmed when the incident of Patient #1 leaving without a MSE was acknowledged, Patient #1 registration to ED was completed to ensure they were included in the ED central log. Employee #7 also confirmed documentation of the incident was added to Patient #1’s medical record after leadership was made aware of the event. Employee #1 confirmed during an interview conducted on 03/04/2024 that Patient #1 leaving the ED without a medical screening examination was investigated. Employee #1 also confirmed all ED personnel, including ED providers, nursing and registration staff, had been re-educated on EMTALA after the 01/15/2024 incident. Employee #1 further confirmed the hospital also reached out to EMS and discussed the hospital’s obligation under EMTALA.”