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Based on video surveillance review, clinical record review, policy review and staff interview the facility failed to adopt and enforce policies and procedures to ensure compliance with the EMTALA requirements at 42 CFR 489.24. This failure affected 1 of 21 sampled patients (Patient #21)


The findings included:

Based on review of medical records, video surveillance review, policy and procedure review, and staff interviews, it was determined, the facility failed to ensure that an appropriate medical screening examination was provided as required, that was 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 existed after a request was made on an individual's behalf for an examination and treatment for 1 of 21 sampled patients (Patient #21). Please refer to findings in A- 2406.

Based on review of medical records, video surveillance review, policy and procedure review, and staff interviews, it was determined, the facility failed to substantiate the provision of emergency services for 1 of 21 sampled patients (Patient #21) as evidenced by lack of a medical screening exam within their capabilities and failure to provide care and treatment to stabilize the medical condition. Please refer to findings in A- 2407.

Based on policy review, medical record review, video surveillance review, Facility transfer logs and interviews, it was determined, the facility failed to substantiate the provision of emergency services for 1 of 21 sampled patients (Patient #21) as evidenced by lack of an appropriate transfer. The facility failed to provide medical treatment within its capacity to minimize the risks to the individual's health (prior to discharge), failed to contact the receiving facility to verify if it had available space and qualified personnel for the treatment of the individual; failed to obtain acceptance of the transfer and failed to ensure the transfer was effected through qualified personnel and transportation equipment, as required. Please refer to findings in A-2409.

Based on surveillance video, record review, policy review and interview, it was determined, the facility failed to ensure the central log included all individuals who presented to the Emergency Department (ED) seeking treatment. This failure affected 1 of 21 sampled patients (Patient #21).

The findings included:

Review of telephone video evidence provided by the complainant, conducted on 05/03/20 revealed Patient #21 presented to the Emergency Department (ED) on 04/04/20 at approximately 11:27 PM. The video shows Staff A, who was later identified as a Traveler Registered Nurse, speaking to Patient #21. Patient #21 wanted to validate by video that she came to the ED due to not sleeping well and rapid weight loss, she wanted to be checked, but understood due to the COVID-19 pandemic the facility had some restrictions. Patient #21 audibly had difficulty with her thoughts and speech. Staff A stated, they are trying to protect patients and wanted to ensure that only patients that had a true emergency were seen and suggested the patient try Benadryl to help the insomnia symptoms.

Review of the facility Surveillance Video conducted on 05/04/20 revealed Patient #21 presented to the ED on 04/04/20 at 10:25 PM. The video shows the patient entering the ED and stopping at the screening desk. Patient #21 had a conversation with Staff A, a few minutes later, at 10:27 PM, the patient took out her cell phone and recorded the interaction with the staff. Patient #21 left the facility at 10:29 PM. The facility surveillance video validates Patient #21 only interacted with Staff A during the ED visit.


Review of the facility central logs conducted on 05/04/20 failed to provide evidence that Patient #21 presented to the emergency department on 04/04/20 seeking care.

Interview with The Director of the ED and The ED Clinical Manager conducted on 05/05/20 at 10:24 AM revealed COVID-19 screening was implemented at the end of March, the main front door is open to the public from 6 AM to 9 PM and a staff member screens everyone coming into the facility. After hours the ED is the only entrance and a screener was placed at that door twenty-four hours a day, one staff from 7 PM to 7 AM and another staff from 7 AM to 7 PM. At the beginning the staff screening the ED entrance was ED staff either a nurse of a paramedic. Later, they expanded to Non-ED staff, mainly to preserve the ED staff for patient care. The facility also started to restrict visitations on March 23rd.
The Director was asked what type of training the screener received and explained the staff was told to ask screening questions, check temperature and provide a face mask. If the patient answers yes to any of the questions or had current symptoms of COVID, the screener would contact the triage or charge nurse and the ED staff would escort the patient to either the tent or one of the three negative pressure rooms in the ED. The Director provided copies of the questionnaire and ED process flow for COVID-19 response. Furthermore, The Director stated at no point, the staff was instructed to triage patients at the screening desk, they had two triage nurses one at the tent and one in the main ED. Upon inquiry, The Director explained there is no pandemic plan addressing any diversions of patients with non-COVID 19 complaints from the ED to any other location. The facility has not changed how patients are triaged or treated. The Director stated a registered nurse is not qualified to perform a medical screening exam.


Interview with The ED Medical Director on 05/05/20 at 11:02 AM, revealed the facility did extensive planning to deal with the COVID-19 pandemic, it was complicated and detailed, it included participation from all areas to ensure patient safety. The screener position was created so they could monitor everyone entering the facility and minimize transmission. The duties were to check body temperature and complete the screening questions, which evolved over time as changes were made to the screening criteria. The position was not created to do medical triage. The facility did not make any changes to the ED process, all patients are triaged and only a physician or midlevel can perform a medical screening exam. The screener position was not a barrier for patients to come to the ED, it was to appropriately screen patients or visitors, we want to see patients. There were no restrictions as to who can come in or not, the patients with positive COVID 19 screening were taken to the tent or isolation room for triage and then seen by the provider.


Phone Interview with Staff A, a Traveler Registered Nurse, conducted on 05/05/20 at 2:30 PM, while accompanied by the Chief Nursing Officer, Director of Quality and The Risk Manager revealed her recollection of Patient #21. The patient came to the ED, seemed in no physical distress, right minded and had general complains of weight loss and changes in sleeping pattern. Again, the patient appeared in no distress and was informed that we were ensuring that only emergent patients were seen in the ED due to the COVID-19 pandemic. The patient then stated that at times she had issues remembering things and for the record, she wanted to record the encounter, she pulled her cell phone and Staff A consented to the video recording. Staff A explained she worked the screening desk on 04/03/20 and 04/04/20, she is a traveler nurse with no emergency room experience.
Staff A stated she typically works in the medical-surgical or telemetry unit and had no training on EMTALA laws since nursing school. That is a topic that is typically brushed over.
Her duties while working the COVID-19 screening desk included asking patients if they had any respiratory symptom, check their temperature and encourage patients to see their primary care physician for symptoms that appear as routine matters. Staff A was asked who gave her instructions or guidelines as to which patients should be encouraged to see their own doctor versus which patients should be allowed to go in the emergency room, and Staff A replied she could not remember who gave her those instructions, she is a traveler nurse, maybe a supervisor, but is not sure. It was more to suggest to patients to see their doctor than having specific guidelines.
Upon inquiry, Staff A stated there were other patients that came into the ED seeking care and were encouraged to see their primary care physician instead, maybe five patients or so during her two shifts at the screening desk. She recalls another patient with chronic pain, and he had already seen his primary care doctor for that issue. She suggested to patients if the problems were not emergent, maybe they should follow up with their doctor. The patients were agreeable and always told them if their status changes, please come back to the ED. Staff A does not recall any patients coming back during her shift.
Staff A was asked who was her resource if she had any questions regarding patients symptoms, who should be encouraged to leave and follow up with their primary doctor, and she replied the triage nurse was available to her and if a patient had questionable symptoms meaning, not sure if they could follow up with their primary care doctor or be seen in the ED, she would contact the triage nurse. She recalls maybe she did so about fifteen times and recalls eight of those patients were admitted to the hospital and the other ones were seen and discharged from the ED.


Interview with the Chief Nursing Officer (CNO), The Director of Quality and The Risk Manager on 05/05/20 at 2:43 PM revealed The CNO reiterated the screener had a simple job, take a temperature, provide a mask and ask the COVID-19 screening questions. There should have never been a discussion about suggesting or encouraging patients to follow up with their primary care doctor. During this time, visitation was restricted and maybe she misunderstood the instructions or took it out of content.


Phone interview with Staff B, Triage Registered Nurse, conducted on 05/06/20 at 4:07 PM revealed he was on duty on 04/04/20, he recalls some patients were concerned about coming into the ED due to the COVID-19 virus and he would reassure them. Staff B stated if the screener called him with any questions, it was mainly for that issue. They were not triaging and encouraging patients to leave the ED. He was not instructed to suggest to patients to leave the ED and follow up with their doctor. The process did not change, all patients were triaged and seen by a provider for a medical screening exam and he has no knowledge of any patients being denied access to the ED.


Facility policy titled," EMTALA", last reviewed 04/19 documents "The purpose of this policy is to set forth policies and procedures for Good Samaritan Medical Center use in complying with the requirements of the Emergency Medical Treatment and Labor Act.
The facility must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment or whether such individuals were treated, admitted, stabilized and or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or medical screening examination. The central log must be kept as required by administrative policy AD1.11 Records Management and its Record Retention Schedule."

Based on review of medical records, video surveillance review, policy and procedure review, and staff interviews, it was determined, the facility failed to ensure that an appropriate medical screening examination was provided as required, that was 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 existed after a request was made on an individual's behalf for an examination and treatment for 1 of 21 sampled patients (Patient #21).


The findings included:

Review of telephone video evidence provided by the complainant, conducted on 05/03/20 revealed Patient #21 presented to the Emergency Department (ED) on 04/04/20 at approximately 11:27 PM. The video shows Staff A, who was later identified as a Traveler Registered Nurse, speaking to Patient #21. Patient #21 wanted to validate by video that she came to the ED due to not sleeping well and rapid weight loss, she wanted to be checked, but understood due to the COVID-19 pandemic the facility had some restrictions. Patient #21 audibly had difficulty with her thoughts and speech. Staff A stated, they are trying to protect patients and wanted to ensure that only patients that had a true emergency were seen and suggested the patient try Benadryl to help the insomnia symptoms.


Review of the facility Surveillance Video conducted on 05/04/20 revealed Patient #21 presented to the ED on 04/04/20 at 10:25 PM. The video shows the patient entering the ED and stopping at the screening desk. Patient #21 had a conversation with Staff A, a few minutes later, at 10:27 PM, the patient took out her cell phone and recorded the interaction with the staff. Patient #21 left the facility at 10:29 PM. The video validates Patient #21 only interacted with Staff A during the ED visit.

Review of the electronic clinical records conducted on 05/04/20 provides no evidence of a medical record for Patient #21, including the provision of a medical screening examination on 04/04/20.


Interview with The Director of the ED and The ED Clinical Manager conducted on 05/05/20 at 10:24 AM revealed COVID-19 screening was implemented at the end of March, the main front door is open to the public from 6 AM to 9 PM and a staff member screens everyone coming into the facility. After hours the ED is the only entrance and a screener was placed at that door twenty-four hours a day, one staff from 7 PM to 7 AM and another staff from 7 AM to 7 PM. At the beginning the staff screening the ED entrance was ED staff either a nurse of a paramedic. Later, they expanded to Non-ED staff, mainly to preserve the ED staff for patient care. The facility also started to restrict visitations on March 23rd.
The Director was asked what type of training the screener received and explained the staff was told to ask screening questions, check temperature and provide a face mask. If the patient answers yes to any of the questions or had current symptoms of COVID, the screener would contact the triage or charge nurse and the ED staff would escort the patient to either the tent or one of the three negative pressure rooms in the ED. The Director provided copies of the questionnaire and ED process flow for COVID-19 response. Furthermore, The Director stated at no point, the staff was instructed to triage patients at the screening desk, they had two triage nurses one at the tent and one in the main ED. Upon inquiry, The Director explained there is no pandemic plan addressing any diversions of patients with non-COVID 19 complaints from the ED to any other location. The facility has not changed how patients are triaged or treated. The Director stated a registered nurse is not qualified to perform a medical screening exam.


Interview with The ED Medical Director on 05/05/20 at 11:02 AM, revealed the facility did extensive planning to deal with the COVID-19 pandemic, it was complicated and detailed, it included participation from all areas to ensure patient safety. The screener position was created so they could monitor everyone entering the facility and minimize transmission. The duties were to check body temperature and complete the screening questions, which evolved over time as changes were made to the screening criteria. The position was not created to do medical triage. The facility did not make any changes to the ED process, all patients are triaged and only a physician or midlevel can perform a medical screening exam. The screener position was not a barrier for patients to come to the ED, it was to appropriately screen patients or visitors, we want to see patients. There were no restrictions as to who can come in or not, the patients with positive COVID 19 screening were taken to the tent or isolation room for triage and then seen by the provider.


Phone Interview with Staff A, a Traveler Registered Nurse, conducted on 05/05/20 at 2:30 PM, while accompanied by the Chief Nursing Officer, Director of Quality and The Risk Manager revealed her recollection of Patient #21. The patient came to the ED, seemed in no physical distress, right minded and had general complaints of weight loss and changes in sleeping pattern. Again, the patient appeared in no distress and was informed that we were ensuring that only emergent patients were seen in the ED due to the COVID-19 pandemic. The patient then stated that at times she had issues remembering things and for the record, she wanted to record the encounter, she pulled her cell phone and Staff A consented to the video recording. Staff A explained she worked the screening desk on 04/03/20 and 04/04/20, she is a traveler nurse with no emergency room experience.
Staff A stated she typically works in the medical-surgical or telemetry unit and had no training on EMTALA laws since nursing school. That is a topic that is typically brushed over.
Her duties while working the COVID-19 screening desk included asking patients if they had any respiratory symptom, check their temperature and encourage patients to see their primary care physician for symptoms that appear as routine matters. Staff A was asked who gave her instructions or guidelines as to which patients should be encouraged to see their own doctor versus which patients should be allow to go in the emergency room, and Staff A replied she could not remember who gave her those instructions, she is a traveler nurse, maybe a supervisor, but is not sure. It was more to suggest to patients to see their doctor than having specific guidelines.
Upon inquiry, Staff A stated there were other patients that came into the ED seeking care and were encouraged to see their primary care physician instead, maybe five patients or so during her two shifts at the screening desk. She recalls another patient with chronic pain, and he had already seen his primary care doctor for that issue. She suggested to patients if the problems were not emergent, maybe they should follow up with their doctor. The patients were agreeable and always told them if their status changes, please come back to the ED. Staff A does not recall any patients coming back during her shift.
Staff A was asked who was her resource if she had any questions regarding patients symptoms, who should be encouraged to leave and follow up with their primary doctor, and she replied the triage nurse was available to her and if a patient had questionable symptoms meaning, not sure if they could follow up with their primary care doctor or be seen in the ED, she would contact the triage nurse. She recalls maybe she did so about fifteen times and recalls eight of those patients were admitted to the hospital and the other ones were seen and discharged from the ED.


Interview with the Chief Nursing Officer (CNO), The Director of Quality and The Risk Manager on 05/05/20 at 2:43 PM revealed The CNO reiterated the screener had a simple job, take a temperature, provide a mask and ask the COVID-19 screening questions. There should have never been a discussion about suggesting or encouraging patients to follow up with their primary care doctor. During this time, visitation was restricted and maybe she misunderstood the instructions or took it out of context.


Phone interview with Staff B, Triage Registered Nurse, conducted on 05/06/20 at 4:07 PM revealed he was on duty on 04/04/20, he recalls some patients were concerned about coming into the ED due to the COVID-19 virus and he would reassure them. Staff B stated if the screener called him with any questions, it was mainly for that issue. They were not triaging and encouraging patients to leave the ED. He was not instructed to suggest to patients to leave the ED and follow up with their doctor. The process did not change, all patients were triaged and seen by a provider for a medical screening exam and he has no knowledge of any patients being denied access to the ED.


Facility policy titled EMTALA" last reviewed 04/19 documents" The purpose of this policy is to set forth policies and procedures for Good Samaritan Medical Center use in complying with the requirements of the Emergency Medical Treatment and Labor Act.
Definitions: Comes to the Emergency Department, for purposes of this policy, an individual is deemed to have "come to the emergency department if the individual: Presents at a dedicated emergency department, ad requests examination or treatment for a medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individuals' appearance or behavior, that the individual needs examination or treatment for a medical condition or presents on hospital property, other than a dedicated emergency department, and request examination or treatment for what may be an emergency medical condition, or has such a request made on his or her behalf.
Emergency Medical Condition means: a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in either: placing the health of the individual in serious jeopardy, serious impairment to bodily functions and serious dysfunction of any bodily organ.
Qualified Medical Person means an individual or individuals determined qualified by Hospital Bylaws or rules and regulations to perform a Medical Screening Examination. In this facility qualified medical personnel are limited to physicians, physician assistants, nurse practitioners and registered nurses who have been deemed qualified to certify false labor in conjunction with physician certification.
Policy:
The facility will provide an appropriate medical screening examination within the capability of the hospital dedicated emergency department, including ancillary services routinely available, to determine whether or not an emergency medical condition exists and will provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition, or arrange for transfer of the individual to another medical facility in accordance with the procedures set forth.
Triage and Registration:
As soon as practical after arrival, individuals who come to the emergency department should be triaged in order to determine the order in which they will receive a medical screening examination.
Triage is not a medical screening examination, as it does not determine the presence or absence of an emergency medical condition, but rather, simply determines the order in which individuals will receive a medical screening examination.
Registration may not delay the provision of an appropriate medical screening examination or any necessary stabilizing medical examination and treatment in order to inquire about the individual's method of payment or insurance status.
Refusal of Treatment:
If the facility offers further examination and treatment and informs the individual or the person acting on the individuals behalf of the risk and benefits of the examination and treatment but the individual or person acting on the individual's behalf does not consent to the examination and treatment, the facility must take all reasonable steps to have the individual or the person acting on the individual's behalf acknowledge the refusal of further examination and treatment in writing. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual; the risk and benefits of the examination and or treatment,; the reasons for refusal; and if the individual refused to acknowledge their refusal in writing, the steps taken to secure the written informed refusal. Hospital personnel involved with the individual's care or witnessing the individual refusing consent must document the patient's refusal in the medical record."

Based on review of medical records, video surveillance review, policy and procedure review, and staff interviews, it was determined, the facility failed to ensure the provision of emergency services within the capabilities of the hospital and failure to provide care and treatment to stabilize the medical condition for 1 of 21 sampled patients (Patient #21).

The findings included:

Review of telephone video evidence provided by the complainant, conducted on 05/03/20 revealed Patient #21 presented to the Emergency Department (ED) on 04/04/20 at approximately 11:27 PM. The video shows Staff A, who was later identified as a Traveler Registered Nurse, speaking to Patient #21. Patient #21 wanted to validate by video that she came to the ED due to not sleeping well and rapid weight loss, she wanted to be checked, but understood due to the COVID-19 pandemic the facility had some restrictions. Patient #21 audibly had difficulty with her thoughts and speech. Staff A stated, they are trying to protect patients and wanted to ensure that only patients that had a true emergency were seen and suggested the patient try Benadryl to help the insomnia symptoms.


Review of the facility Surveillance Video conducted on 05/04/20 revealed Patient #21 presented to the ED on 04/04/20 at 10:25 PM. The video shows the patient entering the ED and stopping at the screening desk. Patient #21 had a conversation with Staff A, a few minutes later, at 10:27 PM, the patient took out her cell phone and recorded the interaction with the staff. Patient #21 left the facility at 10:29 PM. The facility surveillance video validates Patient #21 only interacted with Staff A during the ED visit.

Review of the electronic clinical records conducted on 05/04/20 provides no evidence of a medical record for Patient #21, including the provision of stabilization treatment on 04/04/20.

Interview with The Director of the ED and The ED Clinical Manager conducted on 05/05/20 at 10:24 AM revealed COVID-19 screening was implemented at the end of March, the main front door is open to the public from 6 AM to 9 PM and a staff member screens everyone coming into the facility. After hours the ED is the only entrance and a screener was placed at that door twenty-four hours a day, one staff from 7 PM to 7 AM and another staff from 7 AM to 7 PM. At the beginning the staff screening the ED entrance was ED staff either a nurse of a paramedic. Later, they expanded to Non-ED staff, mainly to preserve the ED staff for patient care. The facility also started to restrict visitations on March 23rd.
The Director was asked what type of training the screener received and explained the staff was told to ask screening questions, check temperature and provide a face mask. If the patient answers yes to any of the questions or had current symptoms of COVID, the screener would contact the triage or charge nurse and the ED staff would escort the patient to either the tent or one of the three negative pressure rooms in the ED. The Director provided copies of the questionnaire and ED process flow for COVID-19 response. Furthermore, The Director stated at no point, the staff was instructed to triage patients at the screening desk, they had two triage nurses one at the tent and one in the main ED. Upon inquiry, The Director explained there is no pandemic plan addressing any diversions of patients with non-COVID 19 complaints from the ED to any other location. The facility has not changed how patients are triaged or treated. The Director stated a registered nurse is not qualified to perform a medical screening exam.


Interview with The ED Medical Director on 05/05/20 at 11:02 AM, revealed the facility did extensive planning to deal with the COVID-19 pandemic, it was complicated and detailed, it included participation from all areas to ensure patient safety. The screener position was created so they could monitor everyone entering the facility and minimize transmission. The duties were to check body temperature and complete the screening questions, which evolved over time as changes were made to the screening criteria. The position was not created to do medical triage. The facility did not make any changes to the ED process, all patients are triaged and only a physician or midlevel can perform a medical screening exam. The screener position was not a barrier for patients to come to the ED, it was to appropriately screen patients or visitors, we want to see patients. There were no restrictions as to who can come in or not, the patients with positive COVID 19 screening were taken to the tent or isolation room for triage and then seen by the provider.


Phone Interview with Staff A, a Traveler Registered Nurse, conducted on 05/05/20 at 2:30 PM, while accompanied by the Chief Nursing Officer, Director of Quality and The Risk Manager revealed her recollection of Patient #21. The patient came to the ED, seemed in no physical distress, right minded and had general complaints of weight loss and changes in sleeping pattern. Again, the patient appeared in no distress and was informed that we were ensuring that only emergent patients were seen in the ED due to the COVID-19 pandemic. The patient then stated that at times she had issues remembering things and for the record, she wanted to record the encounter, she pulled her cell phone and Staff A consented to the video recording. Staff A explained she worked the screening desk on 04/03/20 and 04/04/20, she is a traveler nurse with no emergency room experience.
Staff A stated she typically works in the medical-surgical or telemetry unit and had no training on EMTALA laws since nursing school. That is a topic that is typically brushed over.
Her duties while working the COVID-19 screening desk included asking patients if they had any respiratory symptom, check their temperature and encourage patients to see their primary care physician for symptoms that appear as routine matters. Staff A was asked who gave her instructions or guidelines as to which patients should be encouraged to see their own doctor versus which patients should be allowed to go in the emergency room, and Staff A replied she could not remember who gave her those instructions, she is a traveler nurse, maybe a supervisor, but is not sure. It was more to suggest to patients to see their doctor than having specific guidelines.
Upon inquiry, Staff A stated there were other patients that came into the ED seeking care and were encouraged to see their primary care physician instead, maybe five patients or so during her two shifts at the screening desk. She recalls another patient with chronic pain, and he had already seen his primary care doctor for that issue. She suggested to patients if the problems were not emergent, maybe they should follow up with their doctor. The patients were agreeable and always told them if their status changes, please come back to the ED. Staff A does not recall any patients coming back during her shift.
Staff A was asked who was her resource if she had any questions regarding patients symptoms, who should be encouraged to leave and follow up with their primary doctor, and she replied the triage nurse was available to her and if a patient had questionable symptoms meaning, not sure if they could follow up with their primary care doctor or be seen in the ED, she would contact the triage nurse. She recalls maybe she did so about fifteen times and recalls eight of those patients were admitted to the hospital and the other ones were seen and discharged from the ED.


Interview with the Chief Nursing Officer (CNO), The Director of Quality and The Risk Manager on 05/05/20 at 2:43 PM revealed The CNO reiterated the screener had a simple job, take a temperature, provide a mask and ask the COVID-19 screening questions. There should have never been a discussion about suggesting or encouraging patients to follow up with their primary care doctor. During this time, visitation was restricted and maybe she misunderstood the instructions or took it out of context.


Phone interview with Staff B, Triage Registered Nurse, conducted on 05/06/20 at 4:07 PM revealed he was on duty on 04/04/20, he recalls some patients were concerned about coming into the ED due to the COVID-19 virus and he would reassure them. Staff B stated if the screener called him with any questions, it was mainly for that issue. They were not triaging and encouraging patients to leave the ED. He was not instructed to suggest to patients to leave the ED and follow up with their doctor. The process did not change, all patients were triaged and seen by a provider for a medical screening exam and he has no knowledge of any patients being denied access to the ED.

Facility policy titled " EMTALA" last reviewed 04/19 documents "The purpose of this policy is to set forth policies and procedures for Good Samaritan Medical Center use in complying with the requirements of the Emergency Medical Treatment and Labor Act.
Individuals who have an Emergency Medical Condition, If, after a medical screening examination, it is determined that an individual has an emergency medical condition, the facility must within the capability and capacity of the staff and facilities available, provide treatment necessary to stabilize the individual, at which time the individual may be discharged or admit the individual in order to stabilize the individual or if stabilization of the individual is beyond the capabilities or capacity of the facility, arrange for appropriate transfer of the individuals to another medical facility in accordance with this policy."

Based on policy review, medical record review, video surveillance review, transfer logs reviews and interviews, it was determined, the facility failed to substantiate the provision of emergency services for 1 of 21 sampled patients (Patient #21) as evidenced by lack of an appropriate transfer. The facility failed to provide medical treatment within its capacity to minimize the risks to the individual's health (prior to leaving the facility), failed to contact the receiving facility to verify if it had available space and qualified personnel for the treatment of the individual; failed to obtain acceptance of the transfer and failed to ensure the transfer was effected through qualified personnel and transportation equipment, as required.


The findings included:


Review of telephone video evidence provided by the complainant, conducted on 05/03/20 revealed Patient #21 presented to the Emergency Department (ED) on 04/04/20 at approximately 11:27 PM. The video shows Staff A, who was later identified as a Traveler Registered Nurse, speaking to Patient #21. Patient #21 wanted to validate by video that she came to the ED due to not sleeping well and rapid weight loss, she wanted to be checked, but understood due to the COVID-19 pandemic the facility had some restrictions. Patient #21 audibly had difficulty with her thoughts and speech. Staff A stated, they are trying to protect patients and wanted to ensure that only patients that had a true emergency were seen and suggested the patient try Benadryl to help the insomnia symptoms.


Review of the facility Surveillance Video conducted on 05/04/20 revealed Patient #21 presented to the ED on 04/04/20 at 10:25 PM. The video shows the patient entering the ED and stopping at the screening desk. Patient #21 had a conversation with Staff A, a few minutes later, at 10:27 PM, the patient took out her cell phone and recorded the interaction with the staff. Patient #21 left the facility at 10:29 PM. The facility surveillance video validates Patient #21 only interacted with Staff A during the ED visit.

Review of the electronic clinical records conducted on 05/04/20 provides no evidence of a medical record for Patient #21, including the provision of an appropriate transfer on 04/04/20. There is no evidence the facility contacted the receiving facility to verify if it had available space and qualified personnel for the treatment of the individual. There is no evidence the facility obtained acceptance of the transfer and there is no evidence the transfer was affected through qualified personnel and transportation equipment, as required.

Review of the Facility B clinical records conducted on 05/06/20 revealed Patient #21 presented to the facility on 04/05/20 at 1:42 AM with flight of ideas, disorganized thinking, insomnia, thyroid problems, anxiety and paranoia. The patient had a medical emergency condition, requiring stabilization and admission to an inpatient psychiatric unit for further treatment. Patient #21 was discharged home on 04/09/20 with medications and follow up care.


Interview with The Director of the ED and The ED Clinical Manager conducted on 05/05/20 at 10:24 AM revealed COVID 19 screening was implemented at the end of March, the main front door is open to the public from 6 AM to 9 PM and a staff member screens everyone coming into the facility. After hours the ED is the only entrance and a screener was placed at that door twenty-four hours a day, one staff from 7 PM to 7 AM and another staff from 7 AM to 7 PM. At the beginning the staff screening the ED entrance was ED staff either a nurse of a paramedic. Later, they expanded to Non-ED staff, mainly to preserve the ED staff for patient care. The facility also started to restrict visitations on March 23rd.
The Director was asked what type of training the screener received and explained the staff was told to ask screening questions, check temperature and provide a face mask. If the patient answers yes to any of the questions or had current symptoms of COVID, the screener would contact the triage or charge nurse and the ED staff would escort the patient to either the tent or one of the three negative pressure rooms in the ED. The Director provided copies of the questionnaire and ED process flow for COVID 19 response. Furthermore, The Director stated at no point, the staff was instructed to triage patients at the screening desk, they had two triage nurses one at the tent and one in the main ED. Upon inquiry, The Director explained there is no pandemic plan addressing any diversions of patients with non-COVID 19 complaints from the ED to any other location. The facility has not changed how patients are triaged or treated. The Director stated a registered nurse is not qualified to perform a medical screening exam.


Interview with The ED Medical Director on 05/05/20 at 11:02 AM, revealed the facility did extensive planning to deal with the COVID 19 pandemic, it was complicated and detailed, it included participation from all areas to ensure patient safety. The screener position was created so they could monitor everyone entering the facility and minimize transmission. The duties were to check body temperature and complete the screening questions, which evolved over time as changes were made to the screening criteria. The position was not created to do medical triage. The facility did not make any changes to the ED process, all patients are triaged and only a physician or midlevel can perform a medical screening exam. The screener position was not a barrier for patients to come to the ED, it was to appropriately screen patients or visitors, we want to see patients. There were no restrictions as to who can come in or not, the patients with positive COVID 19 screening were taken to the tent or isolation room for triage and then seen by the provider.


Phone Interview with Staff A, a Traveler Registered Nurse, conducted on 05/05/20 at 2:30 PM, while accompanied by the Chief Nursing Officer, Director of Quality and The Risk Manager revealed her recollection of Patient #21. The patient came to the ED, seemed in no physical distress, right minded and had general complaints of weight loss and changes in sleeping pattern. Again, the patient appeared in no distress and was informed that we were ensuring that only emergent patients were seen in the ED due to the COVID 19 pandemic. The patient then stated that at times she had issues remembering things and for the record, she wanted to record the encounter, she pulled her cell phone and Staff A consented to the video recording. Staff A explained she worked the screening desk on 04/03/20 and 04/04/20, she is a traveler nurse with no emergency room experience.
Staff A stated she typically works in medical-surgical or telemetry and had no training on EMTALA laws since nursing school. That is a topic that is typically brushed over.
Her duties while working the COVID 19 screening desk included asking patients if they had any respiratory symptom, check their temperature and encourage patients to see their primary care physician for symptoms that appear as routine matters. Staff A was asked who gave her instructions or guidelines as to which patients should be encouraged to see their own doctor versus which patients should be allowed to go in the emergency room, and Staff A replied she could not remember who gave her those instructions, she is a traveler nurse, maybe a supervisor, but is not sure. It was more to suggest to patients to see their doctor than having specific guidelines.
Upon inquiry, Staff A stated there were other patients that came into the ED seeking care and were encouraged to see their primary care physician instead, maybe five patients or so during her two shifts at the screening desk. She recalls another patient with chronic pain, and he had already seen his primary care doctor for that issue. She suggested to patients if the problems were not emergent, maybe they should follow up with their doctor. The patients were agreeable and always told them if their status changes, please come back to the ED. Staff A does not recall any patients coming back during her shift.
Staff A was asked who was her resource if she had any questions regarding patients symptoms, who should be encouraged to leave and follow up with their primary doctor, and she replied the triage nurse was available to her and if a patient had questionable symptoms meaning, not sure if they could follow up with their primary care doctor or be seen in the ED, she would contact the triage nurse. She recalls maybe she did so about fifteen times and recalls eight of those patients were admitted to the hospital and the other ones were seen and discharged from the ED.


Interview with the Chief Nursing Officer (CNO), The Director of Quality and The Risk Manager on 05/05/20 at 2:43 PM revealed the CNO reiterated the screener had a simple job, take a temperature, provide a mask and ask the COVID 19 screening questions. There should have never been a discussion about suggesting or encouraging patients to follow up with their primary care doctor. During this time, visitation was restricted and maybe she misunderstood the instructions or took it out of context.


Phone interview with Staff B, Triage Registered Nurse, conducted on 05/06/20 at 4:07 PM revealed he was on duty on 04/04/20, he recalls some patients were concerned about coming into the ED due to the COVID 19 virus and he would reassure them. Staff B stated if the screener called him with any questions, it was mainly for that issue. They were not triaging and encouraging patients to leave the ED. He was not instructed to suggest to patients to leave the ED and follow up with their doctor. The process did not change, all patients were triaged and seen by a provider for a medical screening exam and he has no knowledge of any patients being denied access to the ED.


Facility policy titled "Facility policy titled EMTALA" last reviewed 04/19 documents "The purpose of this policy is to set forth policies and procedures for Good Samaritan Medical Center use in complying with the requirements of the Emergency Medical Treatment and Labor Act.
Transfer of unstable individuals:
A decision regarding patient transfer may be made by either patient request or physician certification.
Upon individual request: an individual may be transferred if the individual or the person acting on the individual behalf is fully informed of the risk of the transfer, the alternative to the transfer and of the facility obligations to provide further examination and treatment sufficient to stabilize the individuals emergency medical condition, and to provide for an appropriate transfer.
With Certification:
The individual may be transferred if a physician or, should a physician no physically be present at the time of the transfer, another qualified medical person in consultation with a physician, has certified that the medical benefits expected from transfer outweigh the risks. The date and time of the certification should be close in time to the actual transfer. A certification that is signed by a non-physician qualified medical person shall be countersigned by the responsible physician within twenty-four hours. Individual states have additional requirements for the content of the certification or memorandum of transfer.
Transfer of an individual with an unstabilized emergency medical condition to another facility, the transfer shall be carried out in accordance with the following procedures:
The facility within its capacity, provide medical treatment that minimizes the risk to the individual's health and in the case of a woman who is having contractions, the health of the unborn child.
A representative of the receiving facility must confirm that:
The receiving facility has available space and qualified personnel to treat the individual and the receiving facility agrees to accept transfer of the individual and to provide appropriate medical treatment.
The facility must send the receiving facility copies of all pertinent medical records available at the time of transfer.
The transfer must be affected through appropriate health professional and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer."