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Based on record review, policy review, Emergency Department log and staff interview, the facility failed to enforce a policy to ensure compliance with the EMTALA requirements at 42 CFR 489.24 as evidenced by failure to maintain a central log for all individuals seeking emergency care and failure to provide evidence of a medical screening examination. These failures affected one (1) of 24 sampled patients, (Patient #21).

The findings included:

Based on record reviews and interviews conducted on 03/01/22 and 03/02/22, the facility failed to provide written evidence that a medical record was maintained and failed to provide written confirmation that a medical screening exam was provided. These failures affected one (1) of 24 sampled patients (Patient #21) as detailed in citations A 2405 and A 2406.

Based on record review, Emergency Department central log, 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 one (1) of 24 sample patients, (Patient #21).

The findings included:

Facility policy titled "EMTALA" (Emergency Medical Treatment and Labor Act) last revised 12/15/20 documents as follows:
Scope:
This policy applies to the following staff at Wellington Regional Medical Center: Administration, Registration, Employed Physicians, Dedicated Emergency Departments, including Freestanding Emergency Departments, On-Call Physicians, Hospital-based entities, Hospital Departments on and off campus, Urgent Care Centers/Clinics
Purpose: EMTALA 42 U.S.C., Section 1395dd and all Federal regulations and interpretive guidelines promulgated thereunder.
Central Log Procedure.
a. Hospital will maintain the Central Log in an electronic form in Midas.
b. All ancillary logs maintained by all Hospital Departments, including the Central Log.
c. The Central Log must contain at a minimum, the name of the individual the date, time and means of the individual's arrival, the individual's age, the individual's sex, the individual's record number, the nature of the individual's complaint, the individual's disposition, the individual's time of departure, and whether the individual: refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was stabilized and discharged; or expired.
d. A log entry for all individuals protected under EMTALA should be made by the appropriate individual. Further, in non-DED (Dedicated Emergency Department) departments of the hospital where an individual may present with an EMC (Emergency Medical Condition), the department will provide the necessary information from the point of contact to the DED for logging purposes.
e. The Central Log of individuals protected by EMTALA will be available within a reasonable amount of time for surveyor review and must be retained for a minimum of five years or as delineated by State regulation from the date of disposition of the individual.

1) Review of the Central ED Logs conducted on 03/01/22 revealed no evidence Patient #21 presented to the facility on 02/16/22 seeking emergency care.

Review of the report originated from the initial interaction desk, completed by the paramedic on duty, also known as "Yellow Band" dated 02/16/22 revealed Patient #21 presented at the facility at 7:22 PM with complains of dizziness, cough and chest pain.

Review of the electronic medical record system does not capture an ED visit on 02/16/22 for Patient #21.

It was determined the facility failed to maintain a record of every patient presenting to the emergency department, there is no record of Patient #21.

Interview with The ED Manager, conducted on 03/01/22 at 11:25 AM revealed upon surveyor inquiry, that there was a recent incident involving a patient in the ED, he recalls receiving a call and text on 02/16/22 from a nurse. One of the triage nurses was alleging the other triage nurse was refusing care to a patient. This was not the case and proceeded to explain the incident. Staff A alleged Staff B, the triage nurse, who was training her, refused to care for a patient because he asked the patient who had two children with her, if she had someone, they could call to take care of the kids, in case the patient gets admitted to the hospital. The two nurses argued in front of the patient, discussing the situation and the charge nurse was called. The Manager stated the nursing supervisor was called as well and advised the charge nurse that if needed, if the patient was admitted they could call Department of Children's and Families (DCF) to ensure the safety of the children. The staff did not refuse to provide care, they were inquiring about who can take care of the children in case of admission.

On 03/01/22 at 11:41 AM, The ED Manager, checked his phone and stated Staff A has given him the name of the patient (Patient #21) and stated staff A was putting the patient's information in the system, she was upset, signed off the computer and left the facility. The information was not saved and that is why the patient is not on the central log. The name provided was reported by Staff A. The Manager checked the computer system and verified there is no record of Patient #21 being in the ED on 02/16/22.
The manager also explained when the paramedic put the patient in the system, "SMS", the registration is not done until the triage nurse acknowledges the patient and then the file transfer to Cerner, the electronic medical record system.

Interview with Staff C, the Paramedic on duty on 02/16/22 was conducted on 03/01/22 at 11:51 AM. The paramedic explained her recollections of the events. "I don't remember too much", The patient came in, does not recall her complaint, she registered in the system, the patient waited in the lobby, maybe thirty-five minutes, no longer than an hour. The patient came in with two kids, the smaller kid had no shoes and was walking around. Staff C heard the staff and patient getting upset in the triage room, something to do with the patient having no one to get the kids. Staff C also recalls afterwards the patient sitting in the lobby calling someone, she thinks it was a hospital advocate. The patient appeared to be in no distress, clinically stable, no shortness of breath or severe pain, she was just upset.

Interview with The Nursing Supervisor on duty on 02/16/22, was conducted on 03/01/22 at 11:57 AM. The supervisor stated the charge nurse called her inquiring if Patient #21 was to be admitted, what would happen with the children. The supervisor told them the patient needs to be seen and never mentioned DCF to the charge nurse. The staff was asking her what to do if she gets admitted and she was told the patient was getting upset and wanted to talk to her. The supervisor stated at the time she was busy and did not get to talk to the patient. The facility process for parents that come in with children, is first trying to call family members, she has personally attended to children in the past until family arrives and they had one case where they called DCF, with the parent's consent, to care for the children during the hospital admission. The supervisor reiterated she told the ED staff the patient needed to be medically screened and they will work out the rest later, contacting DCF was not her advice.

Interview with The Director of Quality and the ED Director conducted on 03/02/22 at 8:40 AM revealed the facility does not have EMTALA policies and procedures addressing central logs, and who is responsible for their completion and accuracy.

Interview with Staff B, the triage Nurse on duty on 02/16/22, was conducted on 03/02/22 at 8:51 AM. Staff B reported while doing triage with another nurse, Patient #21 came in and sat down in the triage room, she had two children, ages two and four. He asked the patient so in case if you are admitted do you have anyone to pick up the children, the other triage nurse seemed angry, and told him, "you should not ask that question". Staff B replied he did not ask the question to mean anything. Staff A told him that he did not have the right to say that. He then calls the charge nurse and they told the patient that they did not have a problem taking care of her and wanted to proceed with the triage but the patient was upset and left. Staff C stated staff A was supposed to put the patient in the computer system and did not, she left soon after.
Staff B also shared the nursing supervisor talked to the charge nurse and mention DCF, just in case the patient gets admitted. The patient came with abdominal pain, he did not have time to get vital signs, but recalls the patient was in no acute distress, no acute pain, no shortness of breath, she was talking normally. Staff B also stated the patient's name was in the "Yellow Bin" not in Cerner system, the electronic medical record, because the patient left, and staff A did not put her in. Staff B confirmed he was orienting Staff A in the triage room.

Interview with The Charge Nurse on duty on 02/16/22, was conducted on 03/02/22 at 9:04 AM. The Charge nurse recalled one of the triage nurses called her, the patient came in with two kids and one of the nurses alleged the other nurse was refusing to provide care because of the children. By the time, she reached the triage area, the conversation was heated, and the patient was upset. The Charge Nurse stated the "SMS system sometimes get stuck, and you have to do shortcuts to get around it. The charge nurse stated the patient was stable with no signs of distress, the nursing supervisor told her let's see the patient and if the patient is admitted then DCF is the last resource. The patient was not present during the conversation with the nursing supervisor, so she could not overhear the discussion. Furthermore, the charge nurse stated what happens if she needs a CT (Computed Tomography) scan. The surveyor asked her to clarify what was the issue with the scan and asked the charge nurse if the scan was a concern because some has to "babysit" the children and she replied "Yes". The charge nurse confirmed the question regarding childcare does not have to be asked during triage and stated maybe the process needs to be changed, then clarified they don't ask that question all the time. The patient was upset and left, Staff A erased the information from the computer system when she signed off the computer and walked out from the facility. The charge nurse confirmed herself and Staff A have experience in the "SMS" system and know how to register patients.

Interview with The Senior Clinical Analyst conducted on 03/02/22 at 10:20 AM clarified the "Yellow Band "is a space holder, the staff puts the patient's name and complaint, so the triage nurse can assess and meet the needs of the community by prioritizing care. The "Yellow Band" system has no interaction with "Cerner" (electronic medical record system) or the "SMS" (registration system). When the patients reached the triage step, then the systems interact with each other. There is no way to audit the "Yellow Band" data, is only a tracking board and she has no knowledge of any available reports to validate all the patients that presented to the ED and were placed on the yellow band holding site or tracking board.

Interview with The ED Manager conducted on 03/02/22 at approximately 10:53 AM, provided the contact information for Staff A, the second triage nurse, who resigned after the event.

On 03/02/22 at approximately 11:20 AM, the Senior Clinical Analyst stated she is not able to run a report for the unattached patients, meaning patients that came in the ED but did not get registered. The corporate office is working on the report and will submit to surveyor when available.

Interview with The ED Manager on 03/02/21 at 11:25 AM revealed further clarification of the system and stated the Yellow Band shows the actual time of patient's arrival; confirmed the time posted on the medical record and the central log is the time the triage nurse registers the patient.

Interview with The ED Director and The Medical Director on 03/02/22 at approximately 11:41 MD (Medical Doctor) explained the facility used to have a Kiosk in the ED lobby, due to COVID-19, the kiosk was removed, and the paramedic enters the data for the patients in the "Yellow Band" system.

Upon review of the Yellow Band report provided by the facility on 03/02/22 at 4:03 PM, discrepancies were noted. Three random names were selected (Patients #22, #23 and #24). The patients were not captured on the ED central log.
Interview with The Director of Quality, ED Director and ED Manager on 03/03/22 at 10:58 AM revealed the following:
Patient #22 captured on the Yellow Band report on 02/17/22 at 2:13 PM with complaints of elevated blood pressure. The staff explained the patient was referred by the surgical center on 02/17/22 and never showed up.
Patient #23 captured on the Yellow Band report on 02/16/22 at 6:24 PM with complaint of finger injury. The staff stated there are no medical records for the patient, the facility staff stated is possible the patient came in and left or that a referral was made from an outside source and the staff puts them in the yellow band system, so the staff is aware they are expecting them. There is no way to know who put them in the system and when. There is no way to know if the patient came in the ED and left before being seen.
Patient #24 captured on the Yellow Band report on 02/16/22 at 8:08 PM with complaint of left eye pain. The staff stated there are no medical records for the patient, the facility staff stated is possible the patient came in and left or that a referral was made from an outside source. There is no way to know if the patient presented to the ED or not.

Interview with Staff A, who is no longer employed at the facility, was conducted on 03/03/22 at 12:12 PM. Staff A recalled the incident involving Patient #21. The patient arrived to the triage area with two kids, saying she has been waiting for an hour; the patient was taken to the triage room and Staff B asked her if she had someone to stay with the kids, the patient replied no and while the patient was explaining her symptoms, Staff B asked again, if she had someone to pick up the kids, the patient responded no, is only me and them. Staff A then proceeded to register the patient and Staff B told her to wait, because they needed to figure out her situation, meaning the kids. Staff A told him, that he was not supposed to ask that question and they exchange words, they argued. Then Staff B called the charge nurse, after explaining the situation the charge nurse agreed with Staff B, that they needed to figure out the children situation in case the patient needed a CT scan or was admitted. Staff A stated she was very upset and told them she was leaving; she left the triage room. On her way out she could overhear the patient saying to Staff A and the charge nurse that they were threatening her with calling DCF to take her kids away. Staff A clocked out and when leaving the ED, the patient was in the lobby, she believes she was trying to reach the nursing supervisor for help. The patient was still in the ED when she left. Staff A was asked if she forgot to save the patients information in the computer system and replied, there is no need to save the information, it remains there until you delete it and she did not delete it, why would she, the patient was still there.
Staff A was questioned if she had witnessed any patients being deleted from the ED yellow band system and replied, yes, she recalls Staff B was showing her how to delete a patient that same evening, the patient came in with finger injury, waited too long and left. At that time, she did not know the patient deletion meant the patient was deleted from the ED log, but soon after she figured it out. In addition, Staff A stated if the patient leaves before being triaged and registered, the nurses delete them, that is what they do. It is not Staff B's process, is everyone. Only patients that have been triaged are then closed out with leaving without being seen.

It is noted Patient #23 fits the description and time given by Staff A.


2) Review of the ED Central Logs and the Yellow Band report dated 02/16/22 validates the Central Log does not accurately capture the patient's arrival time. The time noted in the Yellow Band which is the time the patient interacts with the paramedic and gives the chief complaint upon arrival to the facility is different than the time noted on the central logs and medical records.

Please refer to interviews documented above, validating the staff acknowledges the central log is capturing triage time, the first step in registering the patient in the electronic medical record system.


3) Review of the central logs dated 09/2021 thru 02/2022 revealed multiple blanks regarding the disposition of the patients.
The central log dated 02/16/22 validates the facility failed to document the patient's disposition on 37 patients.

Interview with The Director of Quality and The ED Director on 03/02/22 at 8:40 AM revealed the facility does not have an assign individual to ensure accuracy and maintenance of the central logs.

Based on policy review, record review, Emergency Department central log and interview, it was determined, the facility failed to provide a medical screening exam for one (1) of 24 sampled patients (Patient #21) to determine if an emergency medical condition (EMC) exists and if so to provide care and treatment to relieve or eliminate the condition.

The findings included:

Facility policy titled "EMTALA" (Emergency Medical Treatment and Labor Act) last revised 12/15/20 documents as follows:
Triage is a sorting process to determine the order in which individuals will be providing an MSE (Medical Screening Exam) by a physician or QMP (Qualified Medical Professional) based on presenting signs and symptoms. Triage is not the equivalent of an MSE and does not determine the presence or absence of an EMC (Emergency Medical Condition).

Hospital will provide an individual with an appropriate Medical Screening Examination within the Capability available to the emergency department, to determine whether or not an Emergency Medical Condition there has been a request for medical care by an individual within a Dedicated Emergency Department; (b) an individual requests emergency medical care on Hospital Property, other than in a Dedicated Emergency Department; or (c) a Prudent Layperson Observer would recognize that an individual in a
Dedicated Emergency Department or on Hospital Property requires emergency treatment or examination, though no request for treatment is made. If an Emergency Medical Condition is determined to exist, Hospital must provide either: (a) further medical examination and any necessary Stabilizing Treatment within the Capabilities of the staff and facilities available at Hospital, or (b) an Appropriate Transfer to another medical facility. Hospital shall provide Medical Screening Examinations and Stabilizing Treatment to any individual regardless of age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state or local law.
Procedure:
When a Medical Screening Examination is Required:
An individual MUST receive an MSE within the capabilities of the hospital DED, including ancillary services routinely available, to determine whether or not an EMC exists, or with respect to a pregnant woman having contractions, whether the woman is in labor, and whether or not the treatment requested is explicitly for an emergency condition if:
The individual comes to the DED, including by transfer from another hospital, and a request is made on his or her behalf for examination or treatment for a medical condition.
The individual arrives on the Hospital Property other than a DED and a request is made on the individual's behalf for examination or treatment of the EMC.

Extent of Medical Screening Examination
1. Vital signs and other medical data collection) required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists or a woman is in labor.
2. Simple process involving a brief history and physical examination to a complex process that also involves performing ancillary services and procedures.
3. The MSE is to be conducted to the extent necessary, by physicians and/or other QMP to determine whether an EMC exists.

No Delay in Medical Screening Examination. Once EMTALA is triggered, Hospital must not delay in providing an MSE or, if an Emergency Medical Condition is determined to exist, necessary Stabilizing Treatment.

Review of the report originated from the initial interaction desk, completed by the paramedic on duty, also known as "Yellow Band" dated 02/16/22 revealed Patient #21 presented at the facility at 7:22 PM with complains of dizziness, cough and chest pain.

Review of the electronic medical record system does not capture an ED visit on 02/16/22 for Patient #21.

Review of the facility emergency department central logs and electronic medical records conducted on 03/01/22 revealed the facility failed to perform a medical screening exam for every patient presenting to the emergency department seeking emergency medical treatment, there is no evidence Patient #21 received a medical screening examination by a qualified person on 02/16/22.

Interview with The ED Manager, conducted on 03/01/22 at 11:25 AM revealed upon surveyor inquiry, that there was a recent incident involving a patient in the ED, he recalls receiving a call and text on 02/16/22 from a nurse. One of the triage nurses was alleging the other triage nurse was refusing care to a patient. This was not the case and proceeded to explain the incident. Staff A alleged Staff B, the triage nurse, who was training her, refused to care for a patient because he asked the patient who had two children with her, if she had someone, they could call to take care of the kids, in case the patient gets admitted to the hospital. The two nurses argued in front of the patient, discussing the situation and the charge nurse was called. The Manager stated the nursing supervisor was called as well and advised the charge nurse that if needed, if the patient was admitted they could call Department of Children's and Families (DCF) to ensure the safety of the children. The staff did not refuse to provide care, they were inquiring about who can take care of the children in case of admission.

On 03/01/22 at 11:41 AM, The ED Manager, checked his phone and stated Staff A has given him the name of the patient (Patient #21) and stated staff A was putting the patient's information in the system, she was upset, signed off the computer and left the facility. The information was not saved and that is why the patient is not on the central log. The name provided was reported by Staff A. The Manager checked the computer system and verified there is no record of Patient #21 being in the ED on 02/16/22.
The manager also explained when the paramedic put the patient in the system, "SMS", the registration is not done until the triage nurse acknowledges the patient and then the file transfer to Cerner, the electronic medical record system.

Interview with Staff C, the Paramedic on duty on 02/16/22 was conducted on 03/01/22 at 11:51 AM. The paramedic explained her recollections of the events. "I don't remember too much", The patient came in, does not recall her complain, she registered in the system, the patient waited in the lobby, maybe thirty-five minutes, no longer than an hour. The patient came in with two kids, the smaller kid had no shoes and was walking around. Staff C heard the staff and patient getting upset in the triage room, something to do with the patient having no one to get the kids. Staff C also recalls afterwards the patient sitting in the lobby calling someone, she thinks it was a hospital advocate. The patient appeared to be in no distress, clinically stable, no shortness of breath or severe pain, she was just upset.

Interview with The Nursing Supervisor on duty on 02/16/22, was conducted on 03/01/22 at 11:57 AM. The supervisor stated the charge nurse called her inquiring if Patient #21 was to be admitted, what would happen with the children. The supervisor told them the patient needs to be seen and never mention DCF to the charge nurse. The staff was asking her what to do if she gets admitted and she was told the patient was getting upset and wanted to talk to her. The supervisor stated at the time she was busy and did not get to talk to the patient. The facility process for parents that come in with children, is first trying to call family members, she has personally attended to children in the past until family arrives and they had one case where they called DCF, with the parent's consent, to care for the children during the hospital admission. The supervisor reiterated she told the ED staff the patient needed to be medically screened and they will work out the rest later, contacting DCF was not her advice.

Interview with The Director of Quality and the ED Director conducted on 03/02/22 at 8:40 AM revealed the facility does not have EMTALA policies and procedures addressing central logs, and who is responsible for their completion and accuracy.

Interview with Staff B, the triage Nurse on duty on 02/16/22, was conducted on 03/02/22 at 8:51 AM. Staff B reported while doing triage with another nurse, Patient #21 came in and sat down in the triage room, she had two children, ages two and four. He asked the patient so in case if you are admitted do you have anyone to pick up the children, the other triage nurse seemed angry, and told him, "you should not ask that question". Staff B replied he did not ask the question to mean anything. Staff A told him that he did not have the right to say that. He then calls the charge nurse and they told the patient that they did not have a problem taking care of her and wanted to proceed with the triage but the patient was upset and left. Staff C stated staff A was supposed to put the patient in the computer system and did not, she left soon after.
Staff B also shared the nursing supervisor talked to the charge nurse and mention DCF, just in case the patient gets admitted. The patient came with abdominal pain, he did not have time to get vital signs, but recalls the patient was in no acute distress, no acute pain, no shortness of breath, she was talking normally. Staff B also stated the patient's name was in the "Yellow Bin" not in Cerner system, the electronic medical record, because the patient left, and staff A did not put her in. Staff B confirmed he was orienting Staff A in the triage room.

Interview with The Charge Nurse on duty on 02/16/22, was conducted on 03/02/22 at 9:04 AM. The Charge nurse recalled one of the triage nurses called her, the patient came in with two kids and one of the nurses alleged the other nurse was refusing to provide care because of the children. By the time, she reached the triage area, the conversation was heated, and the patient was upset. The Charge Nurse stated the "SMS system sometimes get stuck, and you have to do shortcuts to get around it. The charge nurse stated the patient was stable with no signs of distress, the nursing supervisor told her let's see the patient and if the patient is admitted then DCF is the last resource. The patient was not present during the conversation with the nursing supervisor, so she could not overhear the discussion. Furthermore, the charge nurse stated what happens if she needs a CT (Computed Tomography) scan. The surveyor asked her to clarify what was the issue with the scan and asked the charge nurse if the scan was a concern because some has to "babysit" the children and she replied "Yes". The charge nurse confirmed the question regarding childcare does not have to be asked during triage and stated maybe the process needs to be changed, then clarified they don't ask that question all the time.

Interview with Staff A, who is no longer employed at the facility, was conducted on 03/03/22 at 12:12 PM. Staff A recalled the incident involving Patient #21. The patient arrived to the triage area with two kids, saying she has been waiting for an hour; the patient was taken to the triage room and Staff B asked her if she had someone to stay with the kids, the patient replied no and while the patient was explaining her symptoms, Staff B asked again, if she had someone to pick up the kids, the patient responded no, is only me and them. Staff A then proceeded to register the patient and Staff B told her to wait, because they needed to figure out her situation, meaning the kids. Staff A told him, that he was not supposed to ask that question and they exchange words, they argued. Then Staff B called the charge nurse, after explaining the situation the charge nurse agreed with Staff B, that they needed to figure out the children situation in case the patient needed a CT scan or was admitted. Staff A stated she was very upset and told them she was leaving; she left the triage room. on her way out she could overhear the patient saying to Staff A and the charge nurse that they were threatening her with calling DCF to take her kids away. Staff A clocked out and when leaving the ED, the patient was in the lobby, she believes she was trying to reach the nursing supervisor for help. The patient was still in the ED when she left.


Based on record reviews and interviews with the staff present during the event, it was determined, the staff actions delay Patient #21 from receiving a medical screening exam. The facility staff prioritized the need of child care prior to triage and completion of the medical screening exam.