Police officers brought a minor patient to the hospital by squad car, upon arrival at the emergency department ramp, the hospital advised by radio that they were on diversion. He entered the hospital emergency department and requested that a nurse come to the squad car, and requested that the hospital accept the patient. The officer stated that he was advised that the hospital did not have sufficient nurses trained to deal with the patient, refused the patient, and instructed him to take the patient to another hospital. No triage was performed and no record of the contact was found in the hospital’s records.
At the second hospital, the patient was triaged as emergent. The police officer considered the patient as risk because he had threatened self-harm, was acting “weird”, alternately screaming and being extremely withdrawn and not speaking, and was painted black.
Multiple citations
The hospital was cited for multiple violations from the single incident, including failure to provide a medical screening examination (A2406), failure to maintain medical records ( A2403), failure to log the patient (A2405), failure to provide stabilizing treatment (A2407), and failure to provide an appropriate transfer. (A2409)
Comments:
This is a classic example of how a facility can garner multiple citations from a single patient and greatly expand the scope of the necessary corrections and potential fines. By apparently ignoring the law and their own policies and procedures, the hospital violated virtually every provision of EMTALA according to the citation’s version of the facts.
Diversion:
This case resulted from a misunderstanding of the very concept of diversion, although the hospital policies correctly mandated that the patient should be seen even though the hospital was on diversion. EMTALA regulations specifically provide:
1. Once a patient is on the property, a patient cannot be diverted.
2. Even if you are on diversion, you must provide a medical screening examination and stabilizing care to any patient that presents,
3. A request by a police officer is a patient request and triggers EMTALA
4. At the very least, the hospital must assess the patient within its capabilities and arrange a medically appropriate transfer.
Log entries:
Every patient who presents must be logged in the log book or logging system. The fact that the patient did not actually receive care is not an exception. Once the patient is known to exist, they must be logged.
Medical records:
A medical record must be created for every patient who presents and all information known about a patient that leaves prior to treatment must be entered and maintained.
Appropriate transfer:
Many providers would object that this patient was not transferred, so the citation is not appropriate, but that completely ignores the definition of “transfer.” By law, a transfer includes any time the patient leaves the facility, including discharge, by a hospital employee or someone associated with hospital (such as private physicians). So refusing to see someone and directing them away is a “transfer”.
Transfers are only appropriate if the hospital:
1. Provides a medical screening examination utilizing the full capabilities of the facility
2. Stabilizes the patient to the extent feasible to reduce the risks from or during transfer
3. Physician certifies the transfer
4. Physician provides patient with written risks and benefits
5. Patient consents to the transfer
6. Advanced acceptance from the receiving facility
7. Transport by appropriate medical vehicle
8. With appropriate medical personnel
9. With necessary medical equipment
A2406-GA-2013-10-16
This case should be shared with law enforcement agencies. Very few police agencies have sufficient staffing to keep a squad out of service while hospitals attempt to evade their EMTALA responsibilities. If the agency has only one squad available and it is tied up by hospital ‘games’, their are other residents who are deprived of police protection for assaults, burglaries in progress, sexual assaults, fires, etc. Maybe it’s time for law enforcement agencies to lodge hospital compliance violations directly with the appropriate Federal agency.