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An investigation of a self reported EMTALA violation, complaint numbered TN00032729, was conducted on November 5, 2013. Review of the facility self reported Fact Statement revealed the facility reported the ncident to the Tennessee Bureau of Licensure and Registration on October 14, 2013 and also implemented corrective actions. CMS is not proceeding with a termination of your Medicare provider agreement. Facility was notified by overnight mail on January 7, 2014.


Based on review of a self reported EMTALA violation notification, medical record review, review of facility policy, observation, interview, and review of employee education, the facility failed to provide a medical screening examination for one patient (#1) of thirty patients reviewed.

The findings included:

Review of a Fact Statement submitted by the facility on October 14, 2013, revealed the facility identified and reported a potential Emergency Medical Treatment and Labor Act (EMTALA) violation of failing to provide a medical screening examination to a patient seeking medical examination and treatment. The Fact Statement revealed on September 5, 2013, at approximately 7:00 p.m., a twenty-two year old female patient arrived by car at the Emergency Department (ED) of the facility. According to Registrar #1, after taking and completing a Sign-in sheet, the patient returned from the lobby seating area to the ED front desk window and asked Registrar #1 if the registration form had been changed, and if there were forms for the patient to complete to indicate why the patient came to the ED. Registrar #1 instructed the patient to complete Sections A and B on the form and the question was on the form. The patient stayed at the window, completed the form, gave the form to Registrar #1, and returned to the lobby seating area. Further review revealed Registrar #1 was entering the data into the computer on patient #1 and another patient, while talking to co-workers in the registration area, when patient #1 returned to the window, became agitated, began yelling at Registrar #1, and reached a hand through the registration window. Another registrar (registrar #2) walked into the area where Registrar #1 and the patient were, saw what was occurring, and told a staff member to contact the Security Department. Further review revealed two Security Officers (#1 and #2) responded to the ED. When the SO went to the lobby seating area, patient #1 was agitated and cursing in front of staff members and other patients. Further review revealed SO #2 asked the patient if they could speak with the patient outside, and the patient partially responded to the request for the patient to calm down, but the patient continued to yell and curse. Further review revealed the patient indicated the registration staff had treated the patient unfairly, and after calming down, the patient was allowed to go back into the ED lobby. Further review revealed the SO advised the patient of the facility's policy on verbal and physical abuse against staff members and those behaviors would not be tolerated, and the patient acknowledged understanding. Further review revealed the staff told the SO the patient was trying to reach a hand through the window and trying to get to Registrar #1. The SO had not been advised of this previously and stated, "...if that is true, then (patient #1) will have to leave ..." Continued review revealed the SO asked the patient to step outside and asked the patient if had put a hand through the window. The patient admitted had and also admitted to making threats to staff members. The SO told the patient would have to leave due to the threats and the patient indicated would leave and go to another facility. Further review revealed, as the SO was escorting the patient to the car, the ED Registered Nurse (RN) came outside and called the patient's name. The SO asked the patient if the patient wanted to go back into the ED and told the patient would have to calm down. The patient indicated did not want to go back into the ED and began cursing again.

Medical record review of patient #1 Emergency Department (ED) registration Sign-in Sheet for Emergency Services dated September 5, 2013, with no time documented, revealed the patient signed in with complaints of "foot pain". Further review revealed "1st call for triage 19:30 (7:30 p.m.)" and no information documented in the triage notes below the triage time.

Medical record review of the Emergency Patient Record dated September 5, 2013, at 1948 (7:48 p.m)., written by ED Registered Nurse (RN) #1, revealed, "...went to call pt (patient)...pt outside with security...was informed per (by) registration that as pt. was signing in, (patient #1) became violent and was reaching through the glass in attempt to get girl at front desk...we called security and (patient #1) has been escorted off the campus because (patient #1) was running around cussing everyone out and reaching through the glass at us...pt. was walking around rapidly, yelling at security, pt. off campus per security..." Further medical record review revealed, "Primary Impression: LPT (left prior to triage)...disposition: Routine Home/Self care."

Medical record review of an amendment note on the Emergency Patient Record dated September 10, 2013, at 9:42 a.m., written by ED RN #1, revealed, "...late entry-I went to lobby and called pt for triage. I was informed that patient was outside. (Patient #1) refused to come in stating 'you have some rude staff'. Patient in NAD (no additional stress), ambulatory with steady gait..."

Review of facility policy Emergency Department Patient Triage, policy #19.020.004, last revised on March, 2013, revealed, "...it is the policy of (Named Facility), that upon presentation to the ED, all patients will be triaged by a Registered Nurse..."

Review of facility policy, EMTALA-Tennessee Medical Screening Examination and Stabilization, last revised on March 2013, revealed, "...an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and (1) the individual or a representative acting on the individuals behalf request an examination or treatment for a medical condition..."

Review of facility policy Patient Access-Procedure for Emergency Department Registration-Compliance EMTALA/QMP program, dated July 25, 2005, revealed, "...it is the policy of the Patient Access Department to adhere to EMTALA standards and state laws when performing Emergency Department (ED) patient registration. Every patient presenting in the Emergency Department is entitled to a Medical Screening Examination and stabilizing treatment for an emergency medical condition..."

Observation on November 4, 2013, at 9:05 a.m., in the ED, revealed staff and patients leaving the ED and no regulatory violations observed. Further observation and review revealed all patients in the ED received a medical screening and were either treated, admitted, transferred appropriately, or left AMA (Against Medical Advice). Continued observation revealed new patients coming into the ED were registered and triaged for treatment. Further observation revealed all patients in the ED were observed to have call lights within reach. Continued observation in the ED lobby revealed EMTALA signage posted in public viewing areas.

Observation on November 5, 2013, at 2:30 p.m., in the ED, revealed new patients coming into the ED were triaged directly back to the ED for treatment, and bedside registration was done after the patients were triaged.

Telephone interview on November 5, 2013, at 8:40 a.m., with patient #1 (who was indicated in the complaint), revealed the patient presented to the Emergency Department on September 5, 2013. Further interview revealed the patient was given a sign in sheet to fill out indicating the patient's chief complaint and basic demographical information. Further interview revealed, "...filled the information out and took the sheet back to the registration desk and went and sit back down in the Emergency Department (ED) lobby...a few minutes later...went back up to the registration desk...the registration clerk had an attitude...I asked (clerk) if (clerk) had a problem...the clerk was talking to someone else and was shaking...head...it made me mad and...(clerk) just had a problem...I was yelling and they called security on me...never threatened anyone...it just made me mad..." Further interview revealed the security guard came to the ED, talked with the patient, and took the patient outside. Continued interview revealed the patient came back into the ED with the security officer and then was taken back outside by the security officer. Further interview revealed, "...security officer told me the hospital policy was I had to leave the facility since I had threatened the registration clerk...stayed outside and never went back into the (ED) after that..." Continued interview revealed the patient left the facility, was never seen by a nurse or a physician at the facility, and did not seek treatment at another facility.

Interview with the Risk Manager on November 5, 2013, at 9:20 a.m., in the conference room, revealed the alleged incident was reported to the risk manager the next day, September, 6, 2013. Further interview revealed the ED charge nurse had called the ED Nurse Manager on September 5, 2013, and told the ED manager patient #1 had come to the ED and left prior to seeing the doctor. Continued interview revealed the facility started an investigation immediately. Further interview revealed, "...we reviewed the surveillance tape of the registration area, which does not include audio recording, but we could see the patient was very upset and was visually using the hands...it does not appear the patient was trying to strike the employees...we think it was just a miscommunication between the employees and the patient..." Continued interview revealed the registration clerks felt threatened, called security, and when the officers came to the ED, they took the patient outside to try to calm the patient down. Further interview revealed once the officers felt they had calmed the patient down, the patient came back in the ED, and once again became upset and started yelling and cursing at the staff. Continued interview revealed, "...once the officer came back in the ED, the staff told SO #2 the patient had tried to strike at the staff and asked if the patient was going to be removed from the ED...at that point the SOs took the patient outside and informed the patient due to the situation, the patient would have to leave the facility premises...nursing was not aware of the incident and the charge nurse or the nursing supervisor was not notified of the situation...the ED nurse went out to call the patient back for triage and found the patient outside in the parking lot with the SOs...tried to get the patient to come back in but the patient would not come back inside...the patient stated the registration staff were rude...no aggressive behavior by the staff was reported or no suggestions of any inappropriate behavior exhibited from our employees to the patient...the ED staff, registrars, charge nurses, nursing supervisors and security officers all went through retraining for EMTALA, and CPI (Crisis Prevention Intervention)..." Continued interview revealed the investigation was started and Risk Management, the Compliance Department, the ED Manager, the Director of Plant Operations, the Director of Patient Access, and the Corporate Offices were all notified of the situation.

Interview with the Director of Patient Access on November 5, 2013, at 9:30 a.m., in the conference room, revealed, "...the registration staff felt the environment was not safe when the patient started yelling and they described the patient reached through the glass window toward the staff...they called security to come to the ED...once the SOs came to the ED, they talked with the patient and took the patient outside to try to calm the patient down...the patient did come back into the ED lobby after that and started yelling at (registrar #1), who was the initial contact person when the patient came into the ED...(registrar #1) took the patient's actions as being physically aggressive toward the employees...there was never any suggestions made regarding registrar #1 making inappropriate gestures toward the patient...we have never had any behavior issues with any of the employees involved in this situation..."

Telephone interview with RN #1, on November 5, 2013, at 9:50 a.m., revealed the RN was on duty September 5, 2013, when patient #1 presented to the ED. Further interview revealed the RN only saw the patient outside of the ED lobby when the nurse went to call the patient back for triage. Continued interview revealed, "...went out into the lobby and was told the patient was outside with the SOs...when I called the patient's name, the SO told me they had asked the patient to leave...I told the SO the patient was here to be seen in the ED...when I asked the patient if...wanted to be seen in the ED, the patient stated 'oh no, you have some rude staff' and would not come back into the ED..." Further interview revealed the patient was very upset, yelling, and walked away from the RN. Continued interview revealed, "...when I went back into the ED I told the charge nurse about the situation and documented the situation in the nurses notes...did not see any of the employees using any inappropriate behaviors toward the patient..." Further interview revealed the employee had attended EMTALA training and had received counseling regarding the incident.

Interview with the Clinical ED Manager on November 5, 2013, at 9:50 a.m., in the conference room, revealed, "...the physician was never involved in the situation, never seen the patient or knew about the situation...the patient did not receive a medical screening evaluation while in the ED..."

Interview with the ED Medical Director on November 5, 2013, at 11:00 a.m., in the ED waiting room, revealed, "...any patient who comes to the ED should receive a medical screening by a licensed qualified medical practitioner...was told the patient was very hostile..." Continued interview revealed the patient's medical record was very limited on information because the patient was not seen by a physician while in the ED on September 5, 2013. Further interview revealed, "...security talked with the patient..."

Interview with SO #2 on November 5, 2013, at 1:35 p.m., in the conference room, revealed, "...called to the ED by the registration staff...patient was verbally threatening to the registration staff...when we got to the ED there were three people telling us what happened and the patient was yelling and cursing in the ED lobby...we asked the patient to step outside the ED lobby and the patient was cooperative...we were trying to de-escalate the situation as quickly as possible...the patient was upset and said ...did not feel anyone wanted (patient #1) in the facility...the patient said the registration staff was rude...the patient told us...would go to another hospital to be seen...it all happened so fast...we were just trying to calm the situation as much as possible...when I went back inside, I asked the registration employees to write a statement for our records...our report was turned in to our supervisor...did not notify the charge nurse or nursing supervisor...the registration employees told us they had notified their supervisor..." Further interview revealed the employee had attended EMTALA training and had received counseling regarding the incident.

Telephone interview with the ED charge RN on November 7, 2013, at 2:50 p.m., revealed the charge nurse was not aware of the incident until the patient had left the facility. Further interview revealed RN #1 told the charge nurse patient #1 had come to the ED for treatment, had been taken outside by the security officer, and had left the facility without having a medical screening. Further interview revealed, "...RN #1 went out to triage the patient...the patient was outside with the officers...the RN asked the patient if the patient wanted to come back in for evaluation, and the patient declined." Further interview revealed the charge nurse notified the clinical manager on September 5, 2013, and informed the manager the patient had not had a medical screening. Further interview revealed the employee had attended EMTALA training and had received counseling regarding the incident.

Interview with the Risk Manager on November 5, 2013, at 3:00 p.m., in the conference room, confirmed the patient did not receive a medical screening examination and the facility failed to stabilize the patient's emergency medical condition.

Review of the facility self reported Fact Statement revealed the facility reported the incident to the Tennessee Bureau of Licensure and Registration on October 14, 2013, and implemented the following corrective actions:
(1) Corrections were made on the facility ED Central log. The patient was originally documented in the ED Central Log as arriving by ambulance and Leaving Prior to Triage. The ED Central log was revised to show the patient was a walk-in patient and was refused treatment.
(2) Registrar #1, Registrar #2, SO #1, and SO #2 were counseled on the importance of ensuring each patient coming to the ED for examination and treatment received an appropriate medical screening examination.
(3) Registrar #1, Registrar #2, SO #1, and SO #2 were counseled a patient cannot be removed from the premises without involvement of a member of Administration or the Nursing Supervisor.
(4) Security officers now have access to EMTALA training via on-line education and are assigned the course as mandatory training and as part of New Employee Orientation training before they are able to work in any hospital unit.
(5) The ED RN was counseled on the importance of ensuring each patient coming to the ED for examination and treatment received an appropriate medical screening examination.
(6) The ED RN was counseled on ensuring when a patient indicated they were going to leave the ED without receiving a medical screening examination, the patient was advised of the risks associated with leaving without receiving a medical screening examination and the benefits of staying for a medical screening evaluation.
(7) The ED RN was counseled on the importance of requesting any patient who indicated they were leaving without receiving a medical screening evaluation, sign a Waiver to Right to Medical Screening Examination form or document the patient was asked to sign the form. The ED RN completed the web-based EMTALA training course on January 14, 2013.
(8) ED staff members, registrars, nursing supervisors, and security personnel were re-educated on EMTALA regulations.
(9) The EMTALA policies were reviewed with all staff members, charge nurses, nursing supervisors, security personnel, and registrars to re-educate staff members on the appropriate procedures to be followed when a patient presents to the ED for examination and treatment.
(10) ED registrars received de-escalation training to enable recognition of early signs of escalating behavior and how to diffuse a situation before it becomes a crisis.

Based on reivew of the Fact Statement and review of facility EMTALA training, all staff had completed education on EMTALA violations by October 31, 2013. The facility has not had any EMTALA violations since the reported violation on September 5, 2013.