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Based on observation, interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA for two of 21 patients (Patient 1 and Patient 2) when:

1. Patient 1 came to the ED on 2/23/23 with chief complaint of leg swelling and hyperglycemia assigned to Nurse Practitioner (NP) 1, vital signs indicated Blood Pressure of 198/110 mmHg (millimeters of mercury - a unit of measurement, normal BP systolic pressure of less than 120 and a diastolic pressure of less than 80) and blood glucose of 593 milligrams per deciliter (normal range 70 to 90 mg/dl) and was sent to the lobby to wait. A complete work up for an emergency medical condition was not done and determination of stabilizing measures not considered. This resulted in Patient 1 waiting for over four hours in the lobby, a delay in determining whether an emergency condition existed and no further action was taken in the care of Patient 1. Patient 1 left after four hours and the hospital did not provide evidence of follow up. (Refer to A2406, Finding 1)

2. Patient 2 came to the ED on 2/23/23 with a chief complaint of leg swelling and assigned to NP 1, vital signs and laboratory work-up indicated a blood glucose level of 300 mg/dl, Potassium Level of 5.2 millimoles per liter (normal range 3.5 - 5.0 mmol/l ) and B-Type Natriuretic Peptide (type of blood test use to detects heart failure) of 377 picograms per milliliter (normal range less than 100 pg/ml) and was sent to the lobby to wait. A complete work up for an emergency medical condition was not done and determination of stabilizing measures not considered. This resulted in Patient 2 waiting for over 2 hours in the lobby, a delay in determining whether an emergency condition existed and no further action was taken in the care of Patient 2. Patient 2 left after two hours and the hospital did not provide evidence of follow up. (Refer to A2406, Finding 2).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner.

Based on interview and record review, the hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [EMC] exists) within the capability of the hospital's emergency department (ED) for two of 21 patients (Patient 1 and Patient 2) when:

1. Patient 1 came to the ED on 2/23/23 with chief complaint of leg swelling and hyperglycemia assigned to Nurse Practitioner (NP) 1, vital signs indicated Blood Pressure of 198/110 mmHg (millimeters of mercury - a unit of measurement, normal BP systolic pressure of less than 120 and a diastolic pressure of less than 80) and blood glucose of 593 milligrams per deciliter (normal range 70 to 90 mg/dl) and was sent to the lobby to wait. A complete work up for an emergency medical condition was not done and determination of stabilizing measures not considered.

These failures resulted in Patient 1 waiting for over four hours in the lobby, a delay in determining whether an emergency condition existed and no further action was taken in the care of Patient 1. Patient 1 left after four hours and the hospital did not provide evidence of follow up.

2. Patient 2 came to the ED on 2/23/23 with a chief complaint of leg swelling and assigned to NP 1, vital signs and laboratory work-up indicated a blood glucose level of 300 mg/dl, Potassium Level of 5.2 millimoles per liter (normal range 3.5 - 5.0 mmol/l ) and B-Type Natriuretic Peptide (type of blood test use to detects heart failure) of 377 picograms per milliliter (normal range less than 100 pg/ml) and was sent to the lobby to wait. A complete work up for an emergency medical condition was not done and determination of stabilizing measures not considered.

These failures resulted in Patient 2 waiting for over 2 hours in the lobby, a delay in determining whether an emergency condition existed and no further action was taken in the care of Patient 2. Patient 2 left after two hours and the hospital did not provide evidence of follow up.


Findings:

1. During a concurrent interview and record review on 7/26/23 at 9:20 a.m., with the Obstetrics Nursing Manager (ONM), the ED Log (the hospital's record of every patient who comes to the ED seeking care) for the months of February 2023 to July 2023, dated 7/11/23 was reviewed. The log indicated Patient 1 was a 42 year-old female who came to the ED via private vehicle on 2/23/21 at 2:42 p.m. with a chief complaint of swelling of hands and feet and diabetic (history of elevated blood glucose) and left without being seen (LWBS) at 8:15 p.m.

During a concurrent interview and record review on 7/26/23 at 9:20 a.m., with the ONM, Patient 1's ED medical record, dated 2/23/23 was reviewed. Record indicated Patient 1 reported her pain level was a 5 on a scale of 0-10 (10 is most severe). Patient 1 was assessed by the triage nurse and assigned an Emergency Severity Index (ESI) level of 3 (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient's condition and the resources needed, ESI 1 being the most serious). The chief complaint comment section indicated generalized swelling of legs, face and hands for a month. Non-compliant with meds. Fasting POC [point of care glucose meter] at home in 300's mg/dl. ED post prandial [after a meal] 569 [mg/dl]. There was no listed ED diagnosis. The record indicated the nursing triage was completed eight minutes (2:50 p.m.) after the patient arrived in the ED.

During a concurrent interview and record review on 7/26/23 at 9:30 a.m., with the ONM, Patient 1's ED medical record, dated 2/23/23 was reviewed. Record indicated, " ... 2/23/23 at 2:53 p.m. Orders by [NP 1] ... CBC (Complete Blood Count, a type of blood test) with Automated Differential, collected at 2:57 p.m. ... HEMOGLOBIN A1C (a blood test for sugar level), collected at 2:57 p.m. ... COMPREHENSIVE METABOLIC PANEL W/ GFR (a type of blood test to determine the function of the body such as dehydration), collected at 2:57 p.m. ... Urinalysis (urine test to determine infection) and culture if indicated, collected at 2:45 p.m. ... 2/23/23 at 2:58 p.m. Glucose, POC [Point of Care] 593 [reference range 70 - 99] Flag HH [high high] ... 2/23/23 at 3:00 pm Orders by [NP 1] ... URINALYSIS & CULTURE IF INDICATED ... 2/23/23 at 3:01 p.m. Orders by [NP 1] ... NaCl 0.9% (Sodium Chloride, salt) Ordered Dose: 1,000 ml (milliliter - unit of measurement) Frequency: NOW Line: Peripheral IV (intravenous) Anterior; Proximal; Right Arm by [RN 2] Performed: 2/23/23 4:10 p.m. Dose/Rate/Duration 30 minutes ... Insulin REGULAR human Injection Vial 10 Units Frequency: NOW Route: Intravenous [No record that this order was carried out or Patient refusal] ..." The ONM stated there was no record that [NP 1] physically examined the patient before or after ordering various labs, infusion of 1,000 ml of Sodium Chloride via IV (intravenously, flexible tube placed inside a vein, usually in the hand or arm to administer fluids or medicines) and 10 units of regular insulin [via IV].

During a concurrent interview and record review on 7/26/23 at 9:39 a.m., with the ONM, Patient 1's ED medical record, dated 2/23/23 was reviewed. Record indicated, " ... 2/23/23 at 5:55 p.m. [Second set of vitals collected by ERT 3] Temp - [blank] Pulse 94 Resp 18 BP 170/102 O2Sat 99 (room air) Weight - [blank] ... 2/23/23 at 5:58 p.m. Glucose, POC 447 [reference range 70 - 99] Flag H [high] ... 2/23/23 at 6:02 p.m. Glucose, POC 447 [reference range 70 - 99] Flag H [high] ... 2/23/23 @ 7:50 p.m. ED notes by [ERT 1] ... "Patient called to notify us that she left and that she does not want her insurance billed because she left without being seen." The ONM stated [Patient 1] was in the ER waiting area for approximately four hours and there was no record that [NP 1] physically examined the patient.

During a concurrent interview and record review on 7/27/23 at 10:35 a.m., with Nurse Practitioner (NP) 1, Patient 1's ED medical record, dated 2/23/23 was reviewed. NP 1 confirmed that he worked on 2/23/23 and assigned himself as the ER provider for Patient 1. NP 1 stated he ordered blood work and normal saline after seeing patient's elevated blood sugar level [from Electronic Health Record, EHR]. NP 1 stated the ideal process was to examine the patient first then order labs and treatments. NP 1 stated, "It was a busy day and some ER nurses are not comfortable ordering labs and treatments [for standardized medical conditions, a set of laboratory work up or procedures for common medical conditions such as chest pain, abdominal pain, nausea and vomiting, etc.] so I do it." NP 1 stated he did not physically examine the patient before or after ordering various labs, infusion of 1,000 ml of normal saline via IV and 10 units of regular insulin via IV.

During a concurrent interview and record review on 7/27/23 at 10:46 a.m., with NP 1, Patient 1's ED medical record, dated 2/23/23 was reviewed. NP 1 confirmed the triage nurse assigned the Patient 1 a Level 3 ESI. NP 1 stated patients with Level 3 ESI should be initially assessed [MSE] by a provider within 20 to 30 minutes after completion of triage. NP 1 stated [Patient 1] was in the ER for more than four hours and MSE was not conducted by him or another provider. NP 1 stated [Patient 1] did not have an MSE according to the facility's policy [MSE Procedures in the ED, "MSE - an exam done by qualified medical person to determine whether or not an emergency medical condition exits ... a. Triage does not qualify as a Medical Screening exam ..."]. NP 1 stated, "The MSE starts when I see the patient. A year ago, the process was changed by [Hospital]. We currently conduct triage first then MSE. Prior to the change, the Triage Nurse and NP 1 conducts the triage and MSE at the same time. It was a good process."

During a concurrent interview and record review on 7/27/23 at 11:43 a.m., with the Hospital's Chief Medical Officer and Emergency Room Provider (CMO), Patient 1's ED medical record, dated 2/23/23 was reviewed. CMO confirmed the triage nurse assigned the Patient 1 a Level 3 ESI. CMO stated patients with Level 3 ESI should be initially assessed [MSE] by a provider within 20 to 30 minutes after completion of triage. CMO confirmed Patient 1 was in the ER waiting area for approximately 4 hours and was not seen by NP 1 for MSE. CMO stated, "Ideally triage and MSE occur at the same time. It was our historical process. It's ideal. We were asked by an external entity during COVID-19 pandemic to change our process in the ED. We are trying to get back to that model." CMO stated MSE is a process of evaluating, stabilizing and transferring patient as appropriate. He stated MSE is complete once the patient is admitted to the floor, discharged to home or appropriately transferred to another facility. CMO did not respond to questions regarding timely MSE for Patient 1.

During a phone interview on 7/27/23, at 1:07 p.m., with Patient 1, Patient 1 stated she believes she was discriminated because of her race and color of skin. Patient 1 stated she felt her condition was severe and she should have been seen by the emergency provider.

During a concurrent interview and record review on 7/27/23 at 2: 56 p.m., with the Emergency Room Nurse Manager (ERM), Patient 1's ED medical record, dated 2/23/23 was reviewed. ERM confirmed the triage nurse assigned the Patient 1 a Level 3 ESI and was in the ER waiting area for approximately four hours and left without being seen by a provider. ERM stated waiting for more than four hours in the ER waiting area was not a normal wait time at [Hospital]. ERM avoided answering the question on the approximate time a patient with a high blood sugar level and Level 3 ESI can be seen by a provider for MSE after triage.

During a concurrent interview and record review on 7/28/23 at 10:34 a.m., with the CMO, the hospital's practice management dashboard (metrics to measure staff's performance) and EMTALA Log for February 2023, dated 7/28/23 were reviewed. The dashboard indicated, NP 1 cases (patient) per hour was 2.2. CMO stated, "the national average for mid-level was 2.0 cases per hour. For February 2023 our median time was 1.9 patients per hour." The EMTALA Log for February 2023 indicated NP 1 was assigned to 28 patients on 2/23/23.

During a review of Patient 1's "Clinic Medical Record" (CMR, a document that provides resident contact details, insurance information, diagnoses, treatments, medications, and clinic visits), dated 2/23/23, the CMR indicated Patient 1 is a 42 year old female who has multiple disease conditions, including uncontrolled Diabetes Mellitus Type 2 (persistent high level of blood sugar), Hypertension (high blood pressure), Anxiety (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), Depression (a persistent feeling of sadness and loss of interest), and Lump (swelling) in Bilateral Breasts. CMR indicated, Patient 1 was seen in the clinic on 2/23/23 at 9:15 a.m. for medication refill.

During a review of the hospital's document titled, "Qualification/Scope of Practice/Functions Nurse Practitioner - Emergency Department," undated, the document indicated, " ... Scope of Practice/Functions ... Takes an appropriate medical history and performs appropriate physical exam and document findings which are approved and signed by the sponsoring physician within forty-eight (48) hours ... Orders lab tests, routine x-rays and routine therapy ... Performs a medical screening exam in accordance with approved Hospital protocol to determine whether or not an emergency medical condition exists. Triage does not qualify as a medical screening exam ..."

During a review of the hospital's policy and procedure (P&P), "Triage Policy," dated 9/16/21, the P&P indicated, "... B. ESI - Emergency Severity Index: Emergency Severity Index is a five-level triage system that categorizes emergency department patients by evaluating patient acuity and resources. C. Resource: a diagnostic test, procedure and therapeutic treatment that is likely to be utilized in order to make a disposition of the patient. 1. A resource is: a. Labs, EKG, X-ray, CT, MRI, US, IV fluids, IV/IM or nebulized medications, specialty consultation (simple = 1, complex - 2) ... ESI Level 1: the patient requires immediate medical care. The presenting problem is a threat to life, limb, or organ ... b. ESI Level 3: Conditions that could pose a potential threat to patient's health requiring timely emergency intervention and would benefit from evaluation and /or treatment. c. If yes to 2 or more resources, consider danger zone vital signs ... 12. Triage may be performed in conjunction with RME (Rapid Medical Evaluation)/MSE (Medical Screening Exam) by a provider ..."

During a review of the hospital's policy and procedure (P&P), "Medical Screening Examination Standardized Procedures in the Emergency Department," dated 12/20/22, the P&P indicated, "... PURPOSE ... To describe the role of the Emergency Department Physician Assistant/Nurse Practitioner in the performance of a medical screening exam (MSE), in keeping with the provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA) ... D. Medical Screening Exam 1. An exam done by qualified medical person to determine whether or not an emergency medical condition exists. a. Triage does not qualify as a Medical Screening Exam - it determines the order in which the patients will have a Medical Screening Exam ... PROCEDURES ... C. Obtain pertinent history. D. Assessment 1. Review vital signs, blood pressure, and abnormal findings. 2. Perform relevant physical exam ... G. Documentation 1. Results of medical screening exam will be documented on the electronic health record ..."

During a review of the hospital's policy and procedure (P&P), "Compliance with Emergency Medical Treatment (EMTALA)," dated 3/22/22, the P&P indicated, "... PURPOSE ... A. To describe and comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) for physicians and staff and its application to [Hospital] ... P. Qualified Medical Screening Professional: 1. Physician 2. Registered Nurses in Labor in Delivery, Nurse Practitioner, or Physicians' Assistant ... PROCEDURE ... B. The hospital will provide emergency services and care without regard to an individual's race, ethnicity, national origin, citizenship, age, sex, sexual orientation ... 3. Triage is not equivalent to a medical screening examination. Triage merely determines the "order" in which patients will be seen, not the present or absence of an emergency medical condition ..."

According to the Centers for Disease Control and Prevention article titled, "Type 2 Diabetes," dated 4/18/23, the article indicated, " ... More than 37 million Americans have diabetes (about 1 in 10), and approximately 90-95% of them have type 2 diabetes. Type 2 diabetes most often develops in people over age 45, but more and more children, teens, and young adults are also developing it ... What Causes Type 2 Diabetes? Insulin is a hormone made by your pancreas that acts like a key to let blood sugar into the cells in your body for use as energy. If you have type 2 diabetes, cells don't respond normally to insulin; this is called insulin resistance. Your pancreas makes more insulin to try to get cells to respond. Eventually your pancreas can't keep up, and your blood sugar rises, setting the stage for prediabetes and type 2 diabetes. High blood sugar is damaging to the body and can cause other serious health problems, such as heart disease, vision loss, and kidney disease ..."

According to the Centers for Disease Control and Prevention article titled, "5 Surprising Facts About High Blood Pressure," dated 12/13/22, the article indicated, " ... Uncontrolled high blood pressure raises the risk for heart disease and stroke, which are leading causes of death in the United States ... 1. High blood pressure may be linked to dementia. Recent studies show that high blood pressure is linked to a higher risk for dementia, a loss of cognitive function. Timing seems to matter. Evidence suggests that having uncontrolled high blood pressure during midlife (ages 44 to 66) creates a higher risk for dementia later in life ... 5. Women and African Americans face unique risks when it comes to high blood pressure. Women with high blood pressure who become pregnant are more likely to have complications during pregnancy than those with normal blood pressure. High blood pressure during pregnancy can harm a mother's kidneys and other organs, and it can lead to premature delivery and low birth weight babies ..."


2. During a concurrent interview and record review on 7/26/23 at 9:41 a.m., with the Obstetrics Nursing Manager (ONM), the ED Log for the months of February 2023 to July 2023, dated 7/11/23 was reviewed. The log indicated Patient 2 was a 51 year-old female who came to the ED via private vehicle on 2/23/23 at 1:43 p.m. with a chief complaint of leg swelling, and left without being seen (LWBS) at 4:06 p.m. The ONM stated LWBS refers to when a patient leaves after having been through the triage process but has not been seen or evaluated by a physician or nurse practitioner.

During a concurrent interview and record review on 7/26/23 at 9:45 a.m., with the ONM, Patient 2's ED medical record, dated 2/23/23 was reviewed. Record indicated Patient 2 presented to the ED with a chief complaint of leg swelling. Patient 2 was assessed by the triage nurse and assigned an Emergency Severity Index (ESI) level of 3. Record indicated Patient 2's medications were reviewed by the Triage Nurse. Her medications include albuterol inhaler (medication for shortness of breath), atorvastatin (medication for elevated cholesterol), furosemide (medication for fluid retention), losartan (medication for high blood pressure), metoprolol (medication for high blood pressure), rivaroxaban (medication to prevent blood clot), sacubril/valsartan (medication to manage heart failure) and spironolactone (medication for high blood pressure and to remove excess fluids in the body). ONM stated the nursing triage was completed seven minutes (1:50 p.m.) after the patient arrived in the ED.

During a concurrent interview and record review on 7/26/23 at 9:59 a.m., with the ONM, Patient 2's ED medical record, dated 2/23/23 was reviewed. Record indicated, " ... 2/23/23 at 1:57 p.m. Ordering Provider [NP 1] ... COMPREHENSIVE METABOLIC PANEL W/ GFR ... N-TERM PRO-B NATRIURETIC PEPTIDE ... PROTROMBIN TIME/INR (PT/INR, a type of blood test to measures the time it takes for a clot to form in a blood sample), CBC WITH AUTOMATED DIFFERENTIAL ... 2/23/23 at 2:56 p.m. Result status ... Potassium 5.2 mmol/L ... Reference Range 3.5 - 5.1 mmol/L ... Flag H [high] ... Glucose 300 mg/dL ... Reference Range 70 - 100 mg/dL ... Flag H ... Creatinine (a type of blood test to determine the function of kidneys) 1.29 mg/dL ... Reference Range 0.5 - 1.10 mg/dL ... Flag H ..." The ONM stated there was no record that [NP 1] physically examined the patient before or after ordering various labs and after the laboratory results were added in Patient 2's medical record.

During a concurrent interview and record review on 7/27/23 at 10:50 a.m., with Nurse Practitioner (NP) 1, Patient 2's ED medical record, dated 2/23/23 was reviewed. NP 1 confirmed that he worked on 2/23/23 and assigned himself as the ER provider for Patient 2. NP stated, "I ordered the labs for the patient [Patient 2] as part of the standards, basic labs such as CBC, PT/INR, CMP, PBNP, and Troponin. The triage nurse was not comfortable in placing the orders so I did it." NP 1 stated the ideal process was to examine the patient first then order labs and treatments. NP 1 stated, "It was a busy day and some ER nurses are not comfortable ordering labs and treatments [for standardized medical conditions] so I do it." NP 1 stated he did not physically examine the patient before or after ordering various labs.

During a concurrent interview and record review on 7/27/23 at 10:57 a.m., with NP 1, Patient 2's ED medical record, dated 2/23/23 was reviewed. NP 1 confirmed the triage nurse assigned Patient 2 a Level 3 ESI. NP 1 stated patients with Level 3 ESI should be initially assessed [MSE] by a provider within 20 to 30 minutes after completion of triage. NP 1 stated Patient 2 was in the ER for more than two hours and MSE was not conducted by him or another provider. NP 1 stated Patient 2 did not have an MSE according to the facility's MSE policy.

During a concurrent interview and record review on 7/27/23 at 11:49 a.m., with the Hospital's CMO, Patient 2's ED medical record, dated 2/23/23 was reviewed. CMO confirmed the triage nurse assigned the Patient 2 a Level 3 ESI. CMO stated patients with Level 3 ESI should be initially assessed [MSE] by a provider within 20 to 30 minutes after completion of triage. CMO confirmed Patient 2 was in the ER waiting area for approximately 2 hours and was not seen by NP 1 for MSE. CMO stated MSE is a process of evaluating, stabilizing, and transferring patient as appropriate. He stated MSE is complete once the patient is admitted to the floor, discharged to home, or appropriately transferred to another facility.

During a concurrent interview and record review on 7/27/23 at 3:08 p.m., with the Emergency Room Nurse Manager (ERM), Patient 2's ED medical record, dated 2/23/23 was reviewed. ERM confirmed the triage nurse assigned the Patient 2 a Level 3 ESI and was in the ER waiting area for approximately two hours and left without being seen by a provider. ERM stated waiting for more than two hours in the ER waiting area for MSE was not a normal wait time at [Hospital]. ERM avoided answering the question on the approximate time a patient with a high level of blood glucose and Level 3 ESI can be seen by a provider for MSE after triage.

During a review of the hospital's document titled, "Qualification/Scope of Practice/Functions Nurse Practitioner - Emergency Department," undated, the document indicated, " ... Scope of Practice/Functions ... Takes an appropriate medical history and performs appropriate physical exam and document findings which are approved and signed by the sponsoring physician within forty-eight (48) hours ... Orders lab tests, routine x-rays and routine therapy ... Performs a medical screening exam in accordance with approved Hospital protocol to determine whether or not an emergency medical condition exists. Tirage does not qualify as a medical screening exam ..."

During a review of the hospital's policy and procedure (P&P), "Triage Policy," dated 9/16/21, the P&P indicated, "... B. ESI - Emergency Severity Index: Emergency Severity Index is a five-level triage system that categorizes emergency department patients by evaluating patient acuity and resources. C. Resource: a diagnostic test, procedure and therapeutic treatment that is likely to be utilized in order to make a disposition of the patient. 1. A resource is: a. Labs, EKG, X-ray, CT, MRI, US, IV fluids, IV/IM or nebulized medications, specialty consultation (simple = 1, complex - 2) ... ESI Level 1: the patient requires immediate medical care. The presenting problem is a threat to life, limb, or organ ... b. ESI Level 3: Conditions that could pose a potential threat to patient's health requiring timely emergency intervention and would benefit from evaluation and /or treatment. c. If yes to 2 or more resources, consider danger zone vital signs ... 12. Triage may be performed in conjunction with RME (Rapid Medical Evaluation)/MSE (Medical Screening Exam) by a provider ..."

During a review of the hospital's policy and procedure (P&P), "Medical Screening Examination Standardized Procedures in the Emergency Department," dated 12/20/22, the P&P indicated, "... PURPOSE ... To describe the role of the Emergency Department Physician Assistant/Nurse Practitioner in the performance of a medical screening exam (MSE), in keeping with the provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA) ... D. Medical Screening Exam 1. An exam done by qualified medical person to determine whether or not an emergency medical condition exists. a. Triage does not qualify as a Medical Screening Exam - it determines the order in which the patients will have a Medical Screening Exam ... PROCEDURES ... C. Obtain pertinent history. D. Assessment 1. Review vital signs, blood pressure, and abnormal findings. 2. Perform relevant physical exam ... G. Documentation 1. Results of medical screening exam will be documented on the electronic health record ..."

During a review of the hospital's policy and procedure (P&P), "Compliance with Emergency Medical Treatment (EMTALA)," dated 3/22/22, the P&P indicated, "... PURPOSE ... A. To describe and comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) for physicians and staff and its application to [Hospital] ... P. Qualified Medical Screening Professional: 1. Physician 2. Registered Nurses in Labor in Delivery, Nurse Practitioner, or Physicians' Assistant ... PROCEDURE ... B. The hospital will provide emergency services and care without regard to an individual's race, ethnicity, national origin, citizenship, age, sex, sexual orientation ... 3. Triage is not equivalent to a medical screening examination. Triage merely determines the "order" in which patients will be seen, not the present or absence of an emergency medical condition ..."

According to the Centers for Disease Control and Prevention article titled, "Heart Failure," dated 1/5/23, the article indicated, " ... Heart failure happens when the heart cannot pump enough blood and oxygen to support other organs in your body. Heart failure is a serious condition, but it does not mean that the heart has stopped beating ... Certain medical conditions can increase your risk for heart failure, including Coronary artery disease (CAD) (the most common type of heart disease), heart attacks, Diabetes, High blood pressure, Obesity, Other Conditions Related to Heart Disease, and Valvular Heart Disease ... What are the symptoms of heart failure? Common symptoms of heart failure include shortness of breath during daily activities, having trouble breathing when lying down, weight gain with swelling in the feet, legs, ankles, or stomach, and generally feeling tired or weak ..."

According to the Centers for Disease Control and Prevention article titled, "Type 2 Diabetes," dated 4/18/23, the article indicated, " ... More than 37 million Americans have diabetes (about 1 in 10), and approximately 90-95% of them have type 2 diabetes. Type 2 diabetes most often develops in people over age 45, but more and more children, teens, and young adults are also developing it ... What Causes Type 2 Diabetes? Insulin is a hormone made by your pancreas that acts like a key to let blood sugar into the cells in your body for use as energy. If you have type 2 diabetes, cells don't respond normally to insulin; this is called insulin resistance. Your pancreas makes more insulin to try to get cells to respond. Eventually your pancreas can't keep up, and your blood sugar rises, setting the stage for prediabetes and type 2 diabetes. High blood sugar is damaging to the body and can cause other serious health problems, such as heart disease, vision loss, and kidney disease ..."

According to the Centers for Disease Control and Prevention article titled, "5 Surprising Facts About High Blood Pressure," dated 12/13/22, the article indicated, " ... Uncontrolled high blood pressure raises the risk for heart disease and stroke, which are leading causes of death in the United States ... 1. High blood pressure may be linked to dementia. Recent studies show that high blood pressure is linked to a higher risk for dementia, a loss of cognitive function. Timing seems to matter. Evidence suggests that having uncontrolled high blood pressure during midlife (ages 44 to 66) creates a higher risk for dementia later in life ... 5. Women and African Americans face unique risks when it comes to high blood pressure. Women with high blood pressure who become pregnant are more likely to have complications during pregnancy than those with normal blood pressure. High blood pressure during pregnancy can harm a mother's kidneys and other organs, and it can lead to premature delivery and low birth weight babies ..."