WHAT IS EMTALA?
The Emergency Medical Treatment and Labor Act, passed in 1986, aims to protect public access to emergency treatment and prevent hospitals from inappropriately transferring patients to other hospitals.
Medicare-participating hospitals must provide medical screening and stabilization for anyone with a medical emergency, regardless of legal status or ability to pay.
If the hospital is unable to stabilize the patient, or at the patient's request, an appropriate transfer can be made.
Source: Centers for Medicare & Medicaid Services.
It's been more than a year now since Melton "Gene" Scott, 70, drove himself and his wife to Memorial Hospital so she could undergo a lung procedure.
Around noon in the waiting room that day, Scott's daughters noticed that his speech was slurred and the left side of his face was slack. They rushed him through the halls to Memorial's emergency room.
They told nurses they were worried their father was having a stroke.
But it took nearly six hours before Memorial emergency room doctors finally diagnosed a stroke and decided to transfer Scott to Erlanger -- missing the critical window for treatment that could have dissolved the blood clot in his brain. And at Erlanger, Memorial documentation led physicians to believe Scott's stroke had only just started, meaning even more critical time was lost.
Scott never drove again. The former draftsman and welder, who helped create the iron fences and stairs around the Tennessee Aquarium, was never the same man. He died eight months later in hospice care.
Scott's case and that of another Memorial ER patient prompted a Medicare investigation. The federal agency concluded in April that the hospital violated requirements spelled out in the Emergency Medical Treatment and Labor Act.
The violation, classified as "immediate jeopardy," is the most harsh of EMTALA violations. Medicare threatened severing its contract with Memorial if a response was not issued within days.
Documents obtained by the Times Free Press through a Freedom of Information Act request detail the two patients' emergency scenarios in 2012, later investigated by Tennessee surveyors working on behalf of the Centers for Medicare & Medicaid Services.
"We have determined that the deficiencies are so serious that they constitute an immediate threat to the health and safety of any individual who comes in your hospital with an emergency medical condition," CMS' April 3 letter to Memorial CEO James Hobson states. "Continuation of these deficiencies could result in the termination of Memorial Health Care System from the Medicare program."
Memorial quickly sent a response that included a required "plan of correction." The termination notice was rescinded, and at this point, the hospital is back in compliance, CMS officials said.
"Memorial Health Care System complies with its obligations as outlined in EMTALA, as well as all federal and state guidelines governing acute care hospitals," Memorial officials said in a statement Friday. "Memorial has responded to the complaint ... and received notification from that agency that the complaint was satisfactorily resolved and Memorial Health Care System is in full compliance."
The hospital has stated that its plan of correction is "not an admission that the alleged deficiencies exist," but shows CMS that "there is no immediate threat to the health and safety of any individual."
Still, CMS has sent notices of the violation to the federal Office of the Inspector General, which reviews each case and determines whether to enforce any fines or additional penalties.
"Any time there's an immediate jeopardy finding, the government finds it very serious," said Franklin, Tenn., attorney Jeff Moseley, who represents hospitals throughout the U.S. on matters involving EMTALA.
The two patients listed in Memorial's EMTALA "statement of deficiencies" were listed as Patient No. 9 and Patient No. 3.
PATIENT No. 9
Patient No. 9 has since been identified as Melton "Gene" Scott, 70. On March 26, 2012, Scott -- who was waiting for his wife in a visitor area -- was admitted to Memorial's ER around noon with symptoms of stroke.
He spent about five hours in the emergency department -- which included an initial diagnosis of Bell's palsy, a CT scan and copious documentation of strokelike symptoms -- but was not given tissue plasminogen activator (tPA), a drug that can be used within a three-hour window to dissolve blood clots.
A neurologist eventually reached by phone expressed concern that Scott was having a stroke and that the window had been missed. He recommended Scott be transferred to Erlanger. The doctors' logs at Erlanger show Scott was in critical condition after he arrived around 6 p.m.
Relying on Memorial documentation, Erlanger physicians thought Scott's stroke symptoms had started around 5 p.m., further delaying time-appropriate treatment.
"The transfer was not timely for the diagnosis of [stroke] and it appeared that [Memorial] had the capability to treat the patient," the investigator's conclusion states. "As a result, the patient arrived at [Erlanger] too late for definitive treatment for stroke."
Memorial has contested these findings, saying a physician's initial misdiagnosis was not an EMTALA violation, and that surveyors incorrectly interpreted the timelines in medical logs.
PATIENT NO. 3
This patient has not been publicly identified. He came to Memorial on May 17, 2012, complaining of severe leg pain after jumping from a 20-foot wall onto concrete.
The emergency room physician considered the injury a trauma and contacted Erlanger about a transfer without consulting the orthopedic surgeon who was on call -- a required procedure.
The patient was prepped for transfer, but his legs were not splinted and intravenous support was removed.
"The facility failed to ensure a patient with multiple orthopedic injuries was stabilized with intravenous access and splints for orthopedic injuries before transfer to another facility," the surveyor's conclusion states.
Erlanger Health System later reported this allegation to state and federal authorities.
Memorial has contested the findings, saying Patient No. 3 did not require an assessment from a specialist to justify transfer to a trauma hospital, and that splints did not constitute "stabilizing treatment" because the fractures were not "at risk for worsening during transfer."
Sources: Centers for Medicare and Medicaid Services Statement of Deficiencies; Memorial Healthcare System's Plan of Correction
EMTALA investigations typically begin with complaints made at the state level.
Scott's son, Michael, originally complained about his father's treatment to the Tennessee Department of Health.
His mother also filed a lawsuit against Memorial in March, representing herself. Since the CMS findings, however, Michael Scott says the family has decided to have the case voluntarily dismissed so they can file a sturdier lawsuit under a new attorney.
Because of the pending lawsuit, Michael Scott declined to comment for this story.
The second case listed in Memorial's violation concerned a man with serious leg injuries after he took a 20-foot plunge onto pavement. CMS later said that patient was not properly screened before being transferred to Erlanger, and that he had neither splints nor IVs before he was loaded into the ambulance.
Erlanger hospital submitted that complaint to state and federal officials. Erlanger officials did not respond to requests for comment regarding the matter.
After a complaint is filed in Tennessee, cases are handed over to contracted surveyors for assessment.
"Reviews are conducted to determine if an individual had an emergency medical condition that had not been treated or had not been stabilized before being transferred," said Brooke Tweddell, a representative for Qsource, a Tennessee nonprofit health care quality improvement consultancy that contracts with CMS to handle such surveys.
After a hospital found in violation submits its plan of correction, the facility will be resurveyed and reviewed at an unannounced visit before it can be found in compliance.
In a cover letter sent with its plan of correction, Memorial disputes the CMS findings, saying disagreement with a physician's medical judgment does not constitute an EMTALA violation.
"[Memorial] is a valuable asset to the community it serves," the letter from Hobson states. "[Memorial] believes that it is complete compliance with EMTALA and has taken prompt and comprehensive actions to ensure that it remains in compliance with EMTALA."
CMS emphasizes that EMTALA violations are "snapshots in time," not overall pictures of a hospital.
Moseley, too, said that an immediate jeopardy violation can speak to the severity of one or two cases -- "not necessarily a pattern."
Contact staff writer Kate Harrison at firstname.lastname@example.org or 423-757-6673.