HospitalInspections.org

Based on clinical record review, interviews and document reviews, the facility failed to ensure compliance with EMTALA requirements at 42 CFR 489.24: Special Responsibilities of Medicare Hospitals in Emergency Cases.

The facility staff failed to provide a Medical Screening Examination (MSE) for a patient presenting for evaluation of respiratory distress and failed to maintain a central log for ED (Emergency Department).

The hospital staff informed EMS (Emergency Medical Service) providers after their arrival to the ED with the patient, that the patient would have to be transported to the main campus ED for treatment.

Cross reference:
§489.24(a) (1)(i) - Applicability of Provisions of this Section
A-2405
A-2406

Based on document review and interviews, hospital staff failed to maintain a central log to include all individuals presenting to the free standing emergency department (FSED) seeking assistance, and whether they refused treatment, were refused treatment, transferred, admitted and treated, stabilized and transferred, or discharged. For one (1) of twenty (20) patients included in the survey sample, Patient #3.

The findings include:

Anonymous source reported via web a possible EMTALA violation occurring on April, 22, 2025, in which a patient was refused treatment and redirected to another ED. Review of the emergency department log failed to find evidence that Patient #3 presented to the free standing emergency department (FSED) on April 22, 2025, or the disposition of the patient. Review of central log didn't find evidence of Patient #3 presenting to the FSED for care, and whether they refused treatment, were refused treatment, transferred, admitted and treated, stabilized and transferred, or discharged.

Although, review of Patient #3's medical record failed to provide evidence the patient had presented to the FSED, an audit of Patient #3's chart within the entire health system for all persons who accessed it on April 22, 2025, found that staff at the FSED accessed the chart at multiple times with the first entry recorded on April 22, 2025, at 6:09 AM. Review of EMS (Emergency Medical Services) "Patient Care Report" revealed that on April 22, 2025 the EMS transit left Patient #3's residence at 5:59 AM and 6:06 AM alerted the hospital of their arrival.

Interviews with Staff #4, EMS #1 and Patient #3 indicated the patient was taken on April 22, 2025 to the FSED where staff refused to provide treatment and directed EMS staff to transport Patient #3 to the ED located on the main hospital campus for care.

Review of policy "EMTALA - Central Log" effective 02/2025 reveals under "Procedure 3. The
logs must contain at a minimum, the name of the individual and whether the individual:
· refused treatment,
· was refused treatment,
· was transferred,
· was admitted and treated,
· was stabilized and transferred,
· was discharged, or
· expired."

Cross reference §489.24(a)(1)(i)
A-2406

Based on interviews, clinical record and document reviews, the hospital staff failed to provide a Medical Screening Examination (MSE) for one patient (Patient #3) who presented to a FSED (Free Standing Emergency Department (ED)) requesting treatment for respiratory distress. FSED staff instructed EMS staff (Emergency Medical Services) to transport Patient #3 to the ED located on the main hospital campus.

The findings include:

Interviews
During the course of the survey, surveyor made multiple attempts to interview EMS Staff #1. On June 02, 2025, at 10:46 AM, EMS Staff #1 returned the surveyor's call. EMS #1 recalled that on April 22, 2025, at approximately 6:00 AM, they presented with Patient #3 to the FSED. Upon arriving at the FSED they took Patient #3 inside. At that time, they were told by two individuals at the desk, known to them as nurses, that the patient is "banned" from the FSED, and instructed EMS Staff #1 to take Patient #3 to the ED located on the main hospital campus, approximately 10 miles across town.

During the course of the survey, surveyor made multiple attempts to contact Patient #3 by phone. On June 02, 2025 at 10:38 AM, Patient #3 returned the surveyor's call and during the phone interview explained that EMS took them to the FSED that morning (unclear about dates) and after going in, they had to "load me back up" and take me to the "big hospital" (main campus). The patient had the impression that EMS had called it in to the wrong hospital. Patient #3 stated they had never been denied treatment or had to leave before.

During the interview on May 29,2025 at 8:25 AM Staff #4 indicated they were made aware of a possible EMTALA violation on April 22, 2025, in which a patient was refused treatment. Their investigation revealed Patient #3 had been identified as a "no trespass" individual because of disruptive behavior on September 11, 2024. Staff #4 explained that when an individual is identified in this way the electronic health record is triggered to produce a "pop up" screen when the individual's name is entered into the system. When Patient #3 arrived at the FSED and their name was entered into the computer in the morning on April 22, 2025, the pop up screen indicated the patient had a no trespass notice and alerted staff to call security. Instead, staff told the EMS Staff #1 that Patient #3 could no be seen there and needed to be transported to the ED on main hospital campus or another ED for treatment. Per Staff #4, EMS Staff #1 transported the patient to the main campus ED. Staff #4 further indicated that education was provided to individuals involved in the incident. Evidence of education provided to the surveyor included:
a) An email sent to all FSED staff on April 25, 2025, stating they were aware of a recent EMTALA violation involving a patient being turned away and informing them that individuals directly involved will receive a written notice;
b) "Safety Huddle" dated January 24, 2025, stating "we cannot screen calls"and "let the patient come in", have the physician evaluate the patient and determine actions to be taken; and
c) Evidence of annual assignments of EMTALA training to FSED staff via the computer based learning system used by the hospital.
There was no further evidence of FSED or hospital wide EMTALA related training occurring after the incident.

Interviews on May 29, 2025, were conducted with Staff #5, #12, #13, and #15 (nurses) and Staff #8 and #14 (physicians) who regularly work at the FSED.
Of these individuals only Staff #15 indicated knowledge of the incident. Staff #15 recalled they were told by Staff #4 that a patient who had been "trespassed" had been turned away. Staff #15 indicated they weren't working that shift and their last EMTALA education was possibly January.

The two nurses identified as involved in the incident (Staff #16 and Staff #17) were not made available for interview.

Medical record review
Review of Patient #3's medical record revealed the patient arrived to the main campus ED via EMS on April 22, 2025, at 6:28 AM with a complaint of shortness of breath. Patient #3 was triaged, received a medical screening exam, treatment and was discharged at 8:50 AM. Patient #3's medical record failed to provide evidence the patient had presented to the FSED. However, an audit of Patient #3's chart within the entire health system for all persons who accessed it on April 22, 2025, found that staff at the FSED accessed the chart at multiple times with the first entry recorded on April 22, 2025, at 6:09 AM.

Hospital's documents review
Review of the ED log for the FSED failed to provide evidence Patient #3 presented to the FSED at any time on April 22, 2025. An audit of Patient #3's chart for all persons who accessed the record on April 22, 2025, found that staff at the FSED first accessed the chart on that day at 6:09 AM.

Review of hospital policy "Notice of No Trespass" effective 06/2024 read in part, "Exceptions/EMTALA: A. Exceptions to comply with Federal Regulations: 1. The only exception to this No Trespass Notice is related to an individuals need to access emergency medical care at the Hospital. In keeping with our EMTALA obligations, should the barred individual need emergency medical care, they may come to the Hospital Emergency Department for such care. 2. Upon arrival, a board certified Medical Staff Member has to determine if the care being sought by the barred individual is emergent or not before Security can proceed with removal/ Law Enforcement notification of a Trespass Violation per code of Virginia 18.2-119."

Review of hospital policy "Virginia EMTALA - Medical Screening Examination and Stabilization Policy" effective 02/2025 reveals under in section "j. Off-Campus Provider-Based Emergency Department" in part, "If an individual presents to an off-campus provider-based emergency department, ..., he or she must be provided an appropriate MSE just as he or she would if the presentation was at the main campus emergency department. Should the individual require additional screening for stabilizing care by a physician specialist, he or she will be moved to the main campus or another non-HCA facility for the additional care required. "