Eaton Rapids Medical Center

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 36887 Based on interview and record review, the facility failed to conduct a medical screening exam on 1 (P-3) of 34 patients reviewed resulting in the potential for unmet patient needs and poor patient outcomes. Findings include: During a discussion with Staff D on 3/18/2024 at 0900, she stated P-3 presented on 9/21/2023 at approximately 2350 to the Emergency Department (ED) ambulance bay via ambulance in police custody. Upon arrival to the ambulance bay, Physician Staff I met the patient, ambulance staff, and police in the ambulance bay and told them they had an all female staff with no security and if two police officers stayed she would accept the patient. The patient was reloaded into the ambulance by the paramedic and taken to a different facility approximately 10 miles away. There was no medical record present. On 3/19/2024 at 0940, review of facility RCA (root cause analysis) dated 9/2023 revealed statements given by both Physician Staff I and RN Staff K. Physician Staff I stated in an email to the ED Medical Director on 9/22/2023, “... I went out in the bay and said that they need to take the patient to (the acute care facility approximately 21 miles away) where there is the proper security. That I could not keep the patient here and jeopardize my staff unless the police want to stay here all night long with a patient which they did not say they would do. One of the paramedics said so you’re refusing the patient. I said I’m not refusing. I said we can’t keep him here unless I have police here all night long, because I am unable to transfer. I said (the acute care facility approximately 21 miles away) was more appropriate for the patients (sic) welfare... The doctor there called me because he had been told I refused the patient and he wanted to know what was going on...” RN Staff K stated in an email dated 9/22/2023 to ED Manager Staff A, “(Physician Staff I) went out to talk to EMS personnel, making them aware of our concerns and they (sic) safety of our staff, since we do not have security here. (Physician Staff I) suggesting that they take the patient to (the acute care facility approximately 21 miles away), where they (sic) are more resources to help take care of this patient... (Physician Staff I) stated, ‘they can come in, if the state police want to stay all night with the patient.’ EMS said, ‘Fine we will say you are refusing...’ (Physician Staff I) said, ‘I am not refusing, I am saying that he is not safe for our facility and our staff. We have two female nurses and a female doctor, with no security. If the police want to stay with the patient all night, that is fine.’ EMS loaded up the patient...” Physician Staff I stated on 3/19/2024 at 1425 during an interview EMS (emergency medical services) had not been able to obtain vital signs on the patient because he had been uncooperative. She met EMS and police in the ambulance bay. The patient had been handcuffed to the cart. She stated, “I told them I can’t take the patient unless 2 officers stay because we have no manpower to restrain him... The paramedic said, ‘Are you refusing’ and I told him no, I will take him if the officers stay.” Staff I was queried as to if the patient was hypoxic or in any respiratory distress to which she stated he was pink, appeared to have no difficulty breathing or shortness of breath, and was fighting restraint with his head and shoulders off the cart. Registered Nurse (RN) Staff K stated on 2/19/2024 at 1540 the paramedic was unable to give much information over the radio as the patient was too combative. She stated she went with Physician Staff I to the ambulance bay. When the ambulance doors opened, there was 1 local police officer, 2 state police officers, and 2 EMS staff trying to keep the patient restrained. Staff K stated Physician Staff I let them know it was “inappropriate for this patient to be here. She felt it was unsafe and that (the acute care facility approximately 21 miles away) would be a better fit... (Physician Staff I) did not refuse...” Review of the medical record from the receiving facility on 3/19/2024 at 0009 revealed P-3 was an 23-year-old male that was brought in via ambulance with police for agitation and altered mental status. P-3 was chased by police and had jumped into the river. After being pulled from the river, he was combative with police and ambulance personnel. He arrived handcuffed to the cart. Ambulance staff gave Versed 5 mg (milligrams) and Ketamine 250 mg IM (intramuscular) prior to arrival. He was described as “lethargic” and “combative.” Once in the hospital, P-3’s alcohol level was 320 mg/dl (milligrams per deciliter). Urine drug screen was positive for benzodiazapines and cannebenoids. At 0108, documentation indicated P-3 was intubated for respiratory failure. Review of facility policy #15166668 titled “(EMTALA) Emergency Medical Condition/Treatment/Transfer” last revised 1/16/2022 states, “Overview: a. In order to comply with the EMTALA requirements, (facility name) will provide the following to our patients and community: b. A medical screening examination to determine the presence of an emergency medical condition... c. Appropriate medical treatment in order to stabilize any emergency medical condition with in the capability of the health care system... Every person who presents to the hospital system seeking emergency medical treatment will be provided a medical screening examination to determine if an emergency medical condition or active labor exists. (The triage exam does not qualify as the medical screening examination.) *NOTE: EMTALA regulations recognize that patients seeking emergency medical care may present to alternate organizational owned areas within 250 yards of the actual hospital. 2. The medical screening examination will be provided within the capabilities of the department performing the exam, and will include the utilization of on-site ancillary services routinely available to the hospital system. 3. In the emergency department, aphysician will perform the medical screening examination. 4. The hospital/system will provide further examination and treatment within the staff and services available as may be required to stabilize the medical condition or transfer in accordance the EMTALA requirements... All medical records related to the assessment and treatment of the emergency medical conditon for which the individual presented shall be maintained.””