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Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

The hospital failed to ensure a timely medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 32 sampled patients (Patient #5).

~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2406

Based on policy and procedure review, medical record review, hospital data review and staff and physician interviews the hospital failed to ensure a timely medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 32 sampled patients (Patient #5).

The findings included:

Review of the "Emergency Medical Treatment and Labor Act (EMTALA) Compliance" policy, effective 07/27/2020, revealed "...PROCEDURE: Medical Screening Examination (MSE): 1. Any individual that presents on hospital property and requests....examination or treatment for a medical condition....will be provided a MSE to determine if an emergent medical condition exists. 2. The MSE will be performed within the capability and capacity of the hospital, including ancillary services, resources routinely available... ."

1. Dedicated Emergency Department [DED] medical record review, on 06/23/2021, revealed Patient #5, a 40 year old, arrived to the Campus C DED on 04/27/2021 at 0130 [Visit #1] via private vehicle. Review of Triage Notes, at 0206 revealed "Patient arrived stating for about a week he has had a headache on the left side of his head that radiates to the back of his head. Reporting no nausea or vomiting. Endorses sensitivity to light." Vital signs at 0154 were Temperature [T] 98.2, Pulse Rate [P] 83, Respirations [R] 19, Blood Pressure [BP] 133/85, and SpO2 [pulse oximetry] 99% on room air. At 0207 a "Primary Assessment" was noted in the ED Care Timeline that indicated airway, breathing, circulation, and disability were all "Within Defined Limits". A Pain Assessment was completed at 0207 with a pain score of 8 [on a scale of 0-10 with 0 being no pain and 10 being the worst pain]. Patient #5 was assigned a patient acuity of 3 [on a scale of 1-5 with 1 being the most acute and 5 being the least acute]. At 0619 Timeline review revealed "Called for Triage x1" and at 0704 review revealed "...Called for Triage, Treatment, or Rooming x3..." and noted "...ED Disposition set to LWBS [left without being seen] after Triage. ..." Review did not reveal any indication anyone had seen the patient leave and did not reveal any further vital signs taken between 0154 and 0619 [4 hours 25 minutes]. Record review also did not reveal any labs ordered or obtained, and did not reveal another pain score [initial pain score 8] nor any pain medication offered or given during the patient's visit. Timeline review revealed "Final Diagnoses" of "Headache, unspecified" and noted "Procedure and Treatment not carried out due to patient leaving prior to being seen by health care provider." The patient never received an appropriate medical screening examination. The patient was not stabilized prior to discharge.

2. DED record review revealed Patient #5 returned to the Campus C DED on 04/27/2021 at 0721 [1 hour 2 minutes after the first Triage call and 16 minutes after the patient was dismissed from the system as LWBS]. The patient was noted to again arrive by private vehicle. A Triage Note at 0743 revealed "Patient reports left side of head and neck has been hurting for one week. Pain rated 10/10. Patient states he has not contacted pcp [Primary Care Provider] because he has no pcp. Took goody powder this morning to alleviate pain". A Primary Assessment completed at 0744 noted airway, breathing, circulation, disability as "Within Defined Limits". Vital signs at 0744 were T 97.9, P 69, R 16, BP 140/69 and SpO2 100% on room air. At 0746, Timeline review revealed a pain assessment with a score of 6 documented and at 0747 Patient #5 was assigned an acuity of 3. DED Record review did not reveal any documentation to indicate if it was known that Patient #5 had previously been in the ED that same day. At 1151 [4 hours 30 minutes after arrival] documentation noted "...Called for Triage, Treatment, or Rooming x 1." An ED note at 1154 indicated "...I called patient name twice in the lobby for a room and no one responded" and at 1205 it was noted that the patient was called a third time. Patient #5 was discharged out of the system at 1206 with a final diagnosis of "Headache, unspecified" noted along with the statement "Procedure and Treatment not carried out due to patient leaving prior to being seen by health care provider." The patient never received an appropriate medical screening examination. The patient was not stabilized prior to discharge.

Telephone interview on 06/23/2021 at approximately 1300 with Nurse Tech (NT) #13 revealed the NT did not recall Patient #5. Interview revealed patients were placed in ED rooms as rooms became available. Interview revealed a patient's vital signs should be checked every two hours in the lobby or based on request. NT #13 stated if a patient was in the ED lobby as long as this patient was, vital signs should have been rechecked.

Telephone interview on 06/24/2021 at 1000 with the Registered Nurse (RN) #14 who triaged Patient #5 on his second visit, revealed RN #14 recalled the triage note but could not place the patient. Interview revealed RN #14 was "very detail oriented and if I had known it was his second visit I would have documented it, 100%." Interview revealed that sometimes the staff members discussed a patient's leaving prior to being seen but she did not recall discussion about this patient. In regards to the 10 out of 10 pain noted in the triage note and the 6 out of 10 in the assessment, RN #14 stated the patient must have told her he was 10 out of 10 pain earlier but was now a 6. Interview revealed there were no lab protocols for this patient and the nurse anticipated an IV (intravenous) or possible CT (Computerized Tomography) which was why Patient #5 was triaged an acuity 3. The RN stated there had been an uptick in ED patient acuity at the hospital. Interview further revealed the ED at Campus C had 25 beds and it was not uncommon to have 11 to 12 patients in the ED waiting for beds to become available "upstairs" [inpatient units]. In regards to Patient #5, interview revealed it was safe for the patient to be in the waiting room; vital signs were ok and the pain had been going on for a week. RN #14 stated in regards to reassessment/vital signs the staff did the best they could, but sometimes due to how busy they were they could not do it.

Telephone interview with MD #16 on 06/24/2021 at 1130 revealed Medical Doctor (MD) #16 did not recall Patient #5. Interview revealed when patients were in the waiting room the physician was "100% dependent on the triage nurse" to make him aware of any concerns. Interview revealed nurses came to him if something was "worrisome", including when patients wanted to leave. MD #16 stated with Patient #5, he had no concerns about the waiting in the ED lobby/ waiting room. Interview revealed pain scales are very subjective and there was nothing to indicate Patient #5 needed to come back right away. Further interview revealed MD #16 thought the wait times at the hospital were "terrible but it sounds like it is happening everywhere." MD #16 further stated the reality was "the biggest issue now is patients in the ED waiting for an inpatient bed."

Review of data prepared and presented by the hospital titled "Current [Hospital system name] Community" revealed data for two dates/ times: 04/26/2021 at 2200 and 04/27/2021 at 0600. Review of the 04/26/21 data related to Campus C revealed at 2200 there were 11 patients holding in the ED awaiting a room elsewhere and 23 patients in the lobby with the longest wait time being 7.50 hours. At 0600 on 04/27/2021 [potentially around the time Patient #5 departed the ED], data review revealed 24 patients holding at Campus C for beds elsewhere and 17 patients waiting in the ED lobby with the longest wait time 7.55 hours. The 0600 data indicated 155 patients had been seen and 13 had LWBS [left without being seen] for a percentage of 8.39% of ED patients.

Review of other data revealed the hospital collected and evaluated metrics related to the DEDs which among others included boarding hours, time from admit order to an inpatient floor at Campus B, and left without being seen. In relation to left without being seen, review of the graph presented for the four combined campuses revealed ED LWBS numbers had steadily increased from March through June's current data and was now approaching 10%.

In summary, Patient # 5 made two visits, one where the patient arrived 04/27/2021 at 0130 and did not respond when called at 0619 [4 hours, 49 minutes later] and one where the patient presented 04/27/2021 at 0720 and did not respond when called at 1154 (4 hours 34 minutes later). No reassessment or vital signs were noted in the record and there was no indication the hospital was aware the patient was in the ED within a couple hours of returning. The patient was never evaluated by a qualified medical provider. The patient never had a second set of vital signs performed. The patient never received an appropriate medical screening examination. The patient was not stabilized prior to discharge.