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Based on record review, interview, document review and policy review the hospital failed to follow policy and ensure emergency medical treatment and labor act (EMTALA) requirements were met by failing to 1. ensure a central log was completed for each patient that comes to the emergency department (ED); and 2. provide an appropriate medical screening examination (MSE) within the hospital's capabilities to determine whether an emergency medical condition (EMC) existed. Failure of the hospital's ED to log and track patients and failure to conduct an appropriate MSE has the potential for all patients to be discharged or leaving the ED with an unidentified EMC which may lead to deterioration of the patient's condition including death.

Findings Include:

Review of the Hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA); Transfer of Individuals with Emergency Medical Conditions," last revised 06/29/21, showed "a central log entry is made on each patient whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged."

Review of the Hospital's document titled, "Medical Staff Bylaws: Governance and Credentialing Manual," approved on 12/21/21, showed, "As initial and ongoing conditions for appointment/reappointment to the Medical Staff and for Clinical Privileges at the Hospital, as applicable, each practitioner shall: (a) provide appropriate, timely, quality medical, dental, or podiatric care . . . (h) serve on the Hospital's [ED] call roster . . . in a manner that is consistent with the requirements of (EMTALA) and related provisions . . . "

Review of the Hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA); Transfer of Individuals with Emergency Medical Conditions," last revised 06/29/21, showed, "[The hospital] provides triage to all individuals who present to an [ED] and request treatment for an [EMC] to determine the order in which they will be given a [MSE] by a qualified medical person (QMP) . . . the triage disposition process (TDP) is performed in accordance with the emergency severity index (ESI) 5-level triage system. The process provides monitoring and appropriate care, consistent with each patient's medical needs as determined by the triage examiner, prior to providing the MSE . . . Medical Screening Examination (MSE): the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not (sic) an EMC exists, or a woman is in labor. Such screening must be done within [hospital]'s capabilities and capacity. The MSE is an ongoing process, and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either stabilized or appropriately transferred. The MSE is completed by a QMP . . . "

Review of the Hospital policy titled, "Chest Pain Program" last revised 03/10/20, showed, ..."The Ascension Via Christi chest pain program provides 24/7 evaluation and treatment of adult patients with acute chest pain symptoms. Patients receive rapid evaluation for intervention to minimize acute coronary syndrome (ACS) morbidity and mortality. Chest pain services are available to all adult acute chest pain patients admitted through the emergency department, or adult inpatients/outpatients/visitors experiencing chest pain symptoms."


1. Review of a hospital document titled, "Dispatch Communication Sheet/Via Christy Hospital St Francis" dated 07/17/22 at 10:26 PM, showed a 52-year-old male (Patient 4) with complaint of dyspnea (shortness of breath) was being brought in by the emergency medical services (EMS) with and estimated time of arrival of 15 - 20 minutes.

Review of the Hospital's document titled, "ED Activity Log," dated 07/17/22 between the hours of 10:00 PM through 11:59 PM, showed Patient 4 was not entered onto the log. (Refer to Tag A2405)


2. Review of emergency medical services (EMS) call sheet dated 07/17/22 at 9:51 PM showed the ambulance was dispatched at 9:52 PM to Patient 4's home due to difficulty breathing and oxygen saturation at 77% (normal range is 95% to 100%). Further review showed the patient arrived at the Hospital's ED at 10:44 PM.

Review of the Hospital's ED's security footage dated 07/17/22 at 10:45 PM showed emergency medical technicians (EMTs) rolling Patient 4 into the ED and remained in the ED for six minutes before leaving with the patient.

Review of the hospitals document titled, "ED Activity Log" showed Patient 12's presented to the ED on 07/06/22 at 11:31 AM with complaints of chest pain and left without being seen.

Review of Patient 12's ED medical records showed that on 07/06/22 at 12:43 PM, Staff R, RN documented that the patient was not in the waiting room at 12:19 PM (48 minutes after arriving), 12:31 PM or 12:43 PM. Patient 12's disposition was documented as "left without being seen." Patient 12's record showed no evidence of triage or MSE being completed. (Refer to tag A2406)

Based on record review, interview, video review, document review, and policy review, the Hospital failed to ensure a central log was completed for 1 (Patient 4) of 25 patients reviewed. The failure to log and track patients has the potential or all patients to be discharged or leaving the ED with an unidentified emergency medical condition (EMC) which may lead to deterioration of the patient's condition including death.


Findings Include:


Review of the Hospital's document titled, "Dispatch Communication Sheet/Via Christi Hospital St. Francis," dated 07/17/22 at 10:26 PM, showed a 52-year-old male (Patient 4) with complaint of dyspnea (shortness of breath) was being brought in by the emergency medical services (EMS) with an estimated arrival of 15-20 minutes.

Review of emergency medical services (EMS) call sheet dated 07/17/22 at 9:51 PM showed the ambulance was dispatched at 9:52 PM to Patient 4's home due to difficulty breathing and oxygen saturation at 77% (normal range is 95 to 100%). Further review showed the patient arrived at the Hospital's ED at 10:44 PM. Further review showed EMS arrived at Hospital 2 at 11:00 PM.

Review of the Hospital's ED's security footage on 07/17/22 at 10:45 PM showed emergency medical technicians (EMTs) rolling Patient 4 into the ED. Several hospital staff are seen approaching the patient. It appears that the hospital staff are interacting with the patient and EMTs. Then at 10:51, the EMTs are seen wheeling the patient out of the hospital.

Review of the Hospital's document titled "ED Activity Log," dated 07/06/22 to 07/20/22, showed Patient 4 was not entered onto the log upon arrival to the hospital on 07/17/22 at 10:45 PM.

Based on record review, interview, video review, document review, and policy review the Hospital failed to ensure emergency medical treatment and labor act (EMTALA) requirements were met by failing to provide an appropriate medical screening exam (MSE) within the hospital's capabilities to determine whether an emergency medical condition (EMC) existed for 2 patients (Patient 4 and 12) of 25 reviewed. The failure to conduct an appropriate MSE has the potential for all patients to be discharged or leaving the ED with an unidentified EMC which may lead to deterioration of the patient's condition including death.


Findings Include:


Patient 4

Review of emergency medical services (EMS) call sheet dated 07/17/22 at 9:51 PM showed the ambulance was dispatched at 9:52 PM to Patient 4's home due to difficulty breathing and oxygen saturation at 77% (normal range is 95 to 100%). Further review showed the patient arrived at the Hospital's ED at 10:44 PM.

Review of a hospital document titled, "Dispatch Communication Sheet ..." dated 07/17/22 at 10:26 PM, showed a 52-year-old male (Patient 4) with complaint of dyspnea (shortness of breath) was being brought in by the EMS with and estimated time of arrival of 15 - 20 minutes.

Review of the Hospital's ED's security footage dated 07/17/22 at 10:45 PM showed emergency medical technicians (EMTs) rolling Patient 4 into the ED. Several hospital staff are seen approaching the patient. It appears that the hospital staff are interacting with the patient and EMTs. Then at 10:51 PM, the EMTs are seen wheeling the patient out of the hospital.

During an interview on 07/21/22 at 8:05 AM, Staff D, Infection Control Director (previously Director of Quality), stated that the hospital does not have a medical record for Patient 4.

During an interview on 7/21/22 at 3:28 PM the Staff I, Patient Access Representative stated that "if patients are too sick, they get a room no matter what." "We never stop taking patients". When asked about the evening of 7/17/22, the patient access representative stated, "In my experience when we get so full, we start putting patients in hall beds or put psych patients in recliners instead of beds and put more severe patients in beds. We usually keep open a respiratory and cardiac room. I don't recall if those rooms were full that night, but they usually get ICU (Intensive Care Unit) beds pretty fast."

During an interview on 07/21/22 at 3:53 PM, Staff H, MD stated that an EMS report upon arrival to the Emergency Department on 07/17/22 for Patient 4 was as follows: " ...sats (saturations) of 77% en route, improved with nebulizer (a device that changes medication from a liquid to a mist so you can inhale it into your lungs) treatment, 90% upon arrival, hypertensive, dyspneic (difficulty breathing), tachycardic (fast heart rate), dialysis patient ..." Staff H, MD stated, "I remember because it was an unusual event. EMS brought patient in, he was having trouble breathing and short of breath, O2 sat (oxygen saturation) low at home, bought in on O2 (oxygen) 8 L (liters) because they had given a breathing treatment. Came in with sats (saturations) in mid 90's. They came in the door, protocol is to meet patient at door if they appear in distress, he had O2 (oxygen) on so I got up and saw the patient immediately."

Staff H, MD stated, "EMS usually asks nursing where to go and were directed to waiting room. No room available due to staffing. I don't think that's uncommon for patients to go to the waiting room while trying to get a bed. EMS did not think patient was appropriate for the waiting room, I agreed that patient needed a room. I did my evaluation and at some point, EMS asked again where patient was going, and nursing again directed that patient needed to go to the waiting room temporarily or they could take patient to ambulance and wait until a room opened up. It was at that point that EMS said they were taking patient to another hospital.

During an interview on 07/22/22 at 2:11 PM Staff P, Registered Nurse (RN), stated that the charge nurse is responsible for assigning incoming patients from ambulances to a room and that it is sometimes necessary to triage at bay doors or send to triage to determine acuity, or the waiting room if the case is not severe. If patients required monitoring by telemetry, they would try to get them back into a room as soon as possible. Staff P stated that she walked in on the situation with Patient 4 on 07/17/22. Staff P stated that she was a trauma travel nurse that night and when she was not doing trauma, she was assisting with intake. Staff P stated that there was a bunch of patients coming in at the same time. Staff P stated that Staff H (ED physician) had just triaged the patient and we were trying to locate a room and agreed that he was not appropriate for the waiting room. Staff P stated that Staff H completed an interview and knew that the patient needed a room or hall bed. Staff P stated that the charge nurse, Staff G said that Patient 4 had to go to the waiting room or back to the truck.

During an interview on 07/22/22 at 3:16 PM, Staff Q, EMT, stated that Staff G, Charge Nurse, had told them (the EMS crew) that they did not have any space for the patient and that they had to wait with the patient on the truck, shrugged his shoulders and walked away. Staff Q stated that no hospital staff tried to stop them from leaving with the patient.

Further review of emergency medical services (EMS) call sheet dated 07/17/22 at 9:51 PM showed EMS arrived at Hospital 2 with Patient 4 at 11:00 PM.

During an interview on 07/25/22 at 12:30 PM, Patient 4 stated that on Sunday [07/17/22] he was having difficulty breathing and was taken by ambulance to [above-named Hospital]. Patient 4 stated that he was wheeled in, and that [Staff H, MD] gave him an assessment. Patient 4 stated that another doctor [Charge Nurse] across the room yelled that they did not have room for him, that he didn't have time, he had a "hemo-something" patient. Patient 4 stated that they would have to wait in triage or on the truck. Patient 4 stated that the EMT stated, "Dude, we're out." Patient 4 stated that he went to [Hospital 2] and was admitted to ICU.

Review of Patient 4's medical record from Hospital B, dated 07/17/22 showed Patient 4 was assessed by the ED physician and admitted to the ICU.


Patient 12

Review of Patient 12's medical record showed the patient presented to the ED on 07/06/22 at 11:31 AM complaining of "chest pain." At 12:43 PM Staff R, RN documented that the patient was not in the waiting room at 12:19 PM (48 minutes after arriving), 12:31 PM or 12:43 PM. Patient 12's disposition was documented as "left without being seen." Patient 12's record showed no evidence of triage or MSE being completed.

During an interview on 07/28/22 at 11:37 AM, Patient 12 stated, "I was driving with my child when I got chest pain and I have a heart issue. It scared me so I drove straight to the ER. I walked in and told the person at the front desk that I was having chest pain, dizziness, tingling in my hands and shortness of breath and also that I have a heart condition. She pointed towards the east and told me to go to another desk. I walked over there but wasn't sure where to go. There were several people there, all busy. One was on the phone, another typing at a computer. Another patient that was waiting pointed out who I needed to talk to. That girl gave me a bracelet and told me to sit down. ... I sat down and after waiting for a while I told her I was still having trouble and she just said someone would be with me "in a minute." I called my husband when I first got to the hospital and he returned my call exactly 27 minutes later and told me to go somewhere else since I'd been waiting over 30 minutes. I drove myself to [Hospital 2]. They immediately treated me and did a heart scan."

Review of Patient 12's medical record from Hospital B showed that the patient presented to the ED on 07/06/22 at 12:04 PM complaining of chest pain. Documentation in the medical record showed an ED physician initiated a medical screening examination at 12:10 PM.

During an interview on 07/27/22 at 2:33 PM, Staff R, RN stated she was the triage nurse on duty 07/06/22. Staff R, RN was asked to review the medical record for Patient 12's ER visit on 07/06/22. She verified documenting a disposition note stating the patient "left without being seen" and stated Patient 12 was not in the waiting room at 12:19 PM, 12:31 PM, and 12:43 PM. "I would have picked up her chart that registration had, and I would have called her name ...I usually call two or three times per instance so I make sure that everybody can hear me and I'm pretty loud when I do that ..." Staff R, RN stated about registration, " ...they will usually notify me immediately (for a patient in distress or chest pain) but typically what happens is they put the most urgent patient charts "up and down" in the triage rack, and the less urgent ones (patient charts) are placed horizontally (in the triage rack)." Staff R, RN was not able to recall if she was verbally informed by registration if Patient 12 was presenting with chest pain. "It does not look like I did a triage or talk to the patient [Patient 12] at all."

During an interview on 07/28/22 at 3:30 PM, Staff S, Registrar, stated that when a patient presents to the ER with chest pain, the process is to immediately tell the tech and the triage nurse because it is considered a priority for triage. If available, anyone with chest pain would be taken immediately to one of two triage rooms for an immediate EKG. Staff S was not able to recall Patient 12 but stated that if Patient 12 was asked to wait in the waiting room "the triage rooms must have been full." Staff S was unable to recall Patient 12 being in the waiting room for an extended amount of time or repeating her concerns of chest pain. Staff S again stated that she would have verbally informed the RN of any patient presenting with chest pain.