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Based on review of facility documents, employee records, and staff interview (EMP) it was determined the facility failed to provide adequate EMTALA training to six of nine employees (EMP2, EMP14, PF4, EMP16, EMP19, and EMP20).

Findings:

A request was made for the facility policy regarding EMTALA Training requirements on November 1 and 2, 2022. None was provided.

Interview on November 2, 2022, with EMP3, at approximately 1340 revealed staff training requirements are determined by the completion of staff surveys to generate appropriate trainings.

Interview on November 2, 2022, with EMP1, at approximately 1345 revealed EMTALA training was required annually.

Interview on November 1, 2022, with EMP14, at approximately 0930 revealed EMP14 did not know what EMTALA was.

Review on November 2, 2022, of EMP14's education record revealed EMP14 had completed EMTALA training within the last 12 months.

Review on November 2, 2022, of EMP2's education record revealed EMP2 had not completed EMTALA training since April 14, 2020.

Interview on November 2, 2022, with EMP10, at approximately 1015 confirmed EMP2 did not complete annual EMTALA training as required by the facility.

Review on November 2, 2022, of PF4 revealed PF4 did not complete annual EMTALA training.

Interview on November 2, 2022, with EMP10, at approximately 1020 confirmed PF4 did not complete annual EMTALA training.

Interview on November 1, 2022, with EMP16, at approximately 0935 revealed EMP16 did not know what EMTALA was.

Review on November 2, 2022, of EMP16's education record revealed EMP16 completed EMTALA training September 2022.

Interview on November 1, 2022, with EMP19, at approximately 0940 revealed EMP19 had never heard of EMTALA and did not know what EMTALA was. EMP19 did not recall receiving EMTALA training.

Review on November 2, 2022, of EMP19's education record revealed EMP19 did not complete annual EMTALA training.

Interview on November 1, 2022, with EMP20, at approximately 0945 revealed EMP20 had never heard of EMTALA and did not know what EMTALA was. EMP20 did not recall receiving EMTALA training.

Review on November 2, 2022, of EMP20's education record revealed EMP20 did not complete annual EMTALA training.

Interview on November 2, 2022, with EMP22, at approximately 1020 confirmed EMP19 and EMP20 did not complete annual EMTALA training.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure nursing staff asked patients to sign an AMA (Against Medical Advice) form acknowledging the patient was leaving the Emergency Department (ED) without a medical screening, appropriate testing and analysis, a follow-up plan of care at discharge and understanding the risks of leaving the ED for nine of nine applicable ED medical records reviewed (MR2, MR3, MR5, MR6, MR7, MR11, MR17, MR20 and MR21); the facility failed to ensure appropriate medical screening examinations by a qualified provider were performed in order to determine whether an emergency medical condition existed for eight of eight applicable Emergency Department (ED) medical records reviewed (MR2, MR3, MR5, MR6, MR7, MR11, MR17, and MR21) and the facility failed to ensure a patient assigned an ESI of 2 received immediate treatment when presenting to the ED with signs and symptoms of an asthma attack for one of one applicable medical record reviewed (MR3).

Findings include:

Review on November 1, 2022, of the facility's "EMTALA System Policy," last reviewed August 12, 2022, revealed "Purpose To identify guidelines for providing the appropriate setting for conduction medical screening examinations To identify providers eligible to perform emergency medical screening examinations To comply with the Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C. 1395 and subsequent federal interpretive guidelines and state regulations ... Persons Affected All Geisinger employees. Policy Any person who comes to a facility requesting assistance for a potential emergency medical condition/emergency service will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists Persons with emergency conditions will be treated and their condition stabilized without regard to ability to pay for services. EMTALA does not apply to inpatients. The triage process recognizes that triage and a medical screening are two separate processes. Definitions Capability means that an organization provides the requested medical services ...Capacity means that the organization has available space and resources to provide the medically necessary emergency care. Emergency Medical Condition (which is determined by a qualified medical provider after conducting a medical screening examination) is defined as a medical condition manifesting itself by acute symptoms or sufficient severity (including severe pain, psychiatric disturbances, and /or symptoms of substance abuse) such that the absence of medical attention could reasonably be expected to result in: Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part ...Triage is a sorting process to determine the order in which patients will be provided a medical screening examination by a qualified medical person. Triage is not the equivalent of a medical screening examination and does not determine the presence or absence of an emergency medical condition. Procedure A hospital must provide for an appropriate medical screening examination within the capability of the hospital emergency department to any individual who comes to the emergency department and requests examination or treatment. The purpose of this screening examination is to 'determine whether or not an emergency medical condition exists.' If an emergency medical condition exist, then further medical treatment must be provided to stabilize the patient or the patient must be transferred to another facility in accordance with the policy. Requirements of a medical screening: The medical screening consists of an assessment and any ancillary testing or focused assessment based on the patient's chief complaint necessary to determine the presence or absence of an emergency medical condition. This may be a brief history and physical examination or may require complex ancillary studies and procedures such as, but not limited to, lab tests, fetal monitoring, EKG tracing or radiology exam. The medical screening is the process a provider must use to reach with reasonable clinical confidence whether a medical emergency does or does not exist. The medical screening must provide evaluation and stabilizing treatment within the scope of the hospital or facility's abilities and not consider a patient's ability to pay for services. The medical record will reflect the findings of the medical screening including results of any tests performed and analysis. Disposition of the patient will be documented with any education provided and a follow-up plan of care if the disposition of discharge is appropriate ...Patients who decide to leave prior to a disposition: If a patient decides to leave prior to a medical screening, the following steps should be taken if at all possible: Explain to the patient it is important to have the medical screening to rule out whether or not there is a medical condition that needs treatment. Inform the patient of the risks of not having a medical screening. Ask the patient to sign the AMA form acknowledging understanding the risks of leaving. It is recognized that at times the patient may refuse to sign this form ...Document on the medical record the above information including refusal to sign AMA documentation ..."

Review on November 2, 2022, of the facility's "5-Level Triage Implementation Using ESI" policy, last approved May 2022, revealed "Purpose Triage is the initial assessment and acuity sorting process for patients presenting to the Emergency Department. Triage is a tool to enhance patient safety as well as provide data to support operational decisions, provide quality initiatives, and clinical research. Triage seeks to decrease morbidity, disfigurement and patient pain, while being a positive experience for patients...Policy The Emergency Severity Index (ESI) is a research based 5-level triage acuity system approved by the Emergency Nurses' Association (ENA) and the American College of Emergency Physicians (ACEP) as a standard of practice. ESI triage supports the goal of timely routing the right patient to the right place at the right tie for the right reason. Acuity and complexity are summarized on a five-point scale, with Level 1 representing the highest acuity and Level 5 representing the lowest. Determination of the Levels is met by using an algorithm, pediatric fever considerations, danger zone vital signs, four-point questions, and resource utilization. The four-point decision questions are: 1. Is the patient dying? 2. Is this a patient who shouldn't wait? 3. How many resources does this patient need? The 5-Level Triage Algorithm categorizes ED patients by evaluating the patient's acuity and resource need. Level 1 - Is the patient dying? This patient requires immediate lifesaving interventions. This patient needs to be placed immediately in a treatment room and a physician notified that the patient needs immediate attention ...Level 2 - Is this patient who shouldn't wait? This patient is a high-risk patient who appears acutely ill, has acute altered mental status, severe pain greater than 7/10 (using good clinical judgement), meets pediatric criteria for fever or meets the danger vital sign criteria ...Level 3- How many resources will this patient need? This patient needs to be evaluated considering the number of anticipated resource interventions that the patient will need to reach a disposition. These are based on standards of care, not provider preference. Level 3 patients will use greater than 2 resources. Refer to ESI Resource Chart C and D Level 4 - This patient will need only one resource...Level 5 - This patient needs no resources... Triage levels are to be assigned only by an Emergency Department RN. All chest pain patients should receive an EKG within 10 minutes of arrival regardless of their ESI level. Then the patient will be triaged accordingly as determined by their EKG and clinical appearance (all EKGs will be shown to, timed, interpreted, and initialed by a provider). Patients with signs or symptoms suggestive of Acute Coronary Syndrome will be placed in a wheelchair and transported to the patient care area. Any non-medical staff, i.e. waiting room liaison or registration, coming in first contact with a patient presenting to the Emergency Department should ask the following questions. 1. Are you having chest pain, chest pressure, or chest heaviness? 2. Are you having these stroke symptoms? a. New onset of confusion b. Facial Droop c. One Sided weakness or unable to move one side d. Sudden inability to speak e. Loss of Vision f. Dizziness 3. Are you short of Breath? 4. Are you having the worst headache of your life? 5. Do you feel like you are going to "faint/pass out"? If a patient's answer is yest [sic] to any of these questions, the non-medical staff is to notify the triage/intake nurse or charge nurse immediately. Triage Procedures: 1. Patient presents to the Emergency Department. 2. The patient will be identified. 3. The person will receive an initial assessment pertaining to their chief complaint and assign an ESI triage level based on the ESI Guidelines. 4. If the patient is unable to be placed in a treatment room because of departmental capacity, ongoing evaluation of patients in the waiting room will occur hourly. ED staff will perform and document a visual check. Based on the patient condition. Vital signs may need to be rechecked. 5. The initial assessment and all re-evaluations will be documented in the medical record..."

Interview with EMP8 on November 1, 2022, at approximately 1040 revealed the area identified in the medical record as the Review of Systems is a review of the patients' ears, nose and throat, eyes, respiratory system, cardiovascular system, gastrointestinal system, genitourinary system, musculoskeletal system, skin, and neurological system. EMP8 revealed it is the completion of this area that determines whether an emergency medical condition exists.

1. Review of MR2 on November 1, 2022, revealed this patient presented to the Emergency Department (ED) by personal vehicle on September 13, 2022, at 1359 with a chief complaint of cold symptoms and tested positive for COVID in the last four days; the facility assigned MR2 an ESI level of 4 and this patent was taken to the ED waiting room.

Review of MR2 on November 1, 2002, revealed nursing documentation dated September 13, 2022, this patient left the ED waiting room at 1751.

There was no documentation in MR2 indicating nursing staff asked this patient to sign an AMA (Against Medical Advice) form acknowledging that MR2 understood the risks of leaving the ED and there was no documentation in MR2 indicating this patient refused to sign the AMA form.

Interview with EMP8 on November 1, 2022, at approximately 1045 confirmed MR2 presented to the ED on September 13, 2022, at 1359 with a chief complaint of cold symptoms and tested positive for COVID in the last four days; MR2 was assigned an ESI level of 4; was taken to the ED waiting room and that nursing documented this patient left the ED waiting room at 1751. EMP8 also confirmed there was no documentation in MR2 indicating nursing staff asked this patient to sign an AMA form acknowledging indicating this patient understood the risks of leaving the ED and there was no documentation in MR2 indicating this patient refused to sign the AMA form.

Review of MR11 on November 1, 2022, revealed this patient presented to the ED by personal vehicle on September 29, 2022, at 1128 for evaluation of a head injury following a fall from the sofa to the floor hitting the forehead on the floor; the facility assigned MR11 an ESI level of 4 and this patient was taken to the waiting room.

Review of MR11 on November 1, 2022, revealed nursing documentation dated September 29, 2022, indicating this patient left the ED waiting room at 1224.

There was no documentation in MR11 indicating nursing staff asked this patient to sign an AMA (Against Medical Advice) form acknowledging that MR11 understood the risks of leaving the ED and there was no documentation in MR11 indicating this patient refused to sign the AMA form.

Interview with EMP8 on November 1, 2022, at approximately 1125 confirmed MR11 presented to the ED by personal vehicle on September 29, 2022, at 1128 for evaluation of a head injury following a fall from the sofa to the floor hitting the forehead on the floor; the facility assigned MR11 an ESI level of 4; this patient was taken to the waiting room and that nursing documented this patient left the ED waiting room at 1224. EMP8 also confirmed there was no documentation in MR11 indicating nursing staff asked this patient to sign an AMA form acknowledging indicating this patient understood the risks of leaving the ED and there was no documentation in MR11 indicating this patient refused to sign the AMA form.

Review of MR5 on November 1, 2022, revealed this patient presented to the ED by personal vehicle on September 13, 2022, at 1326 for evaluation and treatment of chest pain and shortness of breath after walking; the facility assigned MR5 an ESI level of 3 and this patient was taken to the ED waiting room.

Review of MR5 on November 1, 2022, revealed nursing documentation dated September 13, 2022, indicating this patient left the ED waiting room at 2157.

There was no documentation in MR5 indicating nursing staff asked this patient to sign an AMA form acknowledging that MR5 understood the risks of leaving the ED and there was no documentation in MR5 indicating this patient refused to sign the AMA form.

Interview with EMP8 on November 8, 2022, at approximately 1055 confirmed MR5 presented to the ED by personal vehicle on September 13, 2022, at 1326 for evaluation and treatment of chest pain and shortness of breath after walking; the facility assigned MR5 an ESI level of 3; this patient was taken to the ED waiting room and that nursing documented this patient left the ED waiting room at 2157. EMP8 also confirmed there was no documentation in MR5 indicating nursing staff asked this patient to sign an AMA form acknowledging this patient understood the risks of leaving the ED and there was no documentation in MR5 indicating this patient refused to sign the AMA form.

Review of MR7 on November 1, 2022, revealed this patient presented to the ED by personal vehicle on September 13, 2022, at 1939 for evaluation and treatment of abdominal pain; the facility assigned MR7 an ESI level of 3 and this patient was taken to the ED waiting room.

Review of MR7 on November 1, 2022, revealed nursing documentation dated September 13, 2022, indicating this patient left the ED waiting room at 2355.

There was no documentation in MR7 indicating nursing staff asked this patient to sign an AMA form acknowledging that MR7 understood the risks of leaving the ED and there was no documentation in MR7 indicating this patient refused to sign the AMA form.

Interview with EMP8 on November 1, 2022, at approximately 1115 confirmed MR7 presented to the ED by personal vehicle on September 13, 2022, at 1939 for evaluation and treatment of abdominal pain; the facility assigned MR7 an ESI level of 3; this patient was taken to the ED waiting room and that nursing documented this patient left the ED waiting room at 2355. EMP8 also confirmed there was no documentation in MR7 indicating nursing staff asked this patient to sign an AMA form acknowledging this patient understood the risks of leaving the ED and there was no documentation in MR7 indicating this patient refused to sign the AMA form.

Review of MR17 on November 1, 2022, revealed this patient presented to the ED by personal vehicle on September 13, 2022, at 1548 for evaluation and treatment of surgical complications which include back and abdominal pain and shortness of breath; the facility assigned MR17 an ESI level of 3 and this patient was taken to the ED waiting room.

Review of MR17 on November 1, 2022, revealed nursing documentation dated September 13, 2022, indicating this patient left the ED waiting room at 1940.

There was no documentation in MR17 indicating nursing staff asked this patient to sign an AMA form acknowledging that MR17 understood the risks of leaving the ED and there was no documentation in MR17 indicating this patient refused to sign the AMA form.

Interview with EMP8 on November 1, 2022, at approximately 1120 confirmed MR17 presented to the ED by personal vehicle on September 13, 2022, at 1548 for evaluation and treatment of surgical complications which include back and abdominal pain and shortness of breath; the facility assigned MR17 and ESI level of 3; this patient was taken to the ED waiting room and that nursing documented this patient left the ED waiting room at 1940. EMP8 also confirmed there was no documentation in MR17 indicating nursing staff asked this patient to sign an AMA form acknowledging this patient understood the risks of leaving the ED and there was no documentation in MR17 indicating this patient refused to sign the AMA form.

Review of MR20 on November 1, 2022, revealed this patient presented to the ED on September 12, 2022, at 1318 for a psychiatric evaluation; the facility assigned MR20 an ESI level of 3 and admitted to suicidal ideations and thoughts of hurting others. There was no documentation in MR20 indicating the time this patient left the ED waiting room.

There was no documentation in MR20 indicating nursing staff asked this patient to sign an AMA form acknowledging that MR20 understood the risks of leaving the ED and there was no documentation in MR20 indicating this patient refused to sign the AMA form.

Interview with EMP5 on November 1, 2022, at approximately 1000 confirmed MR20 presented to the ED on September 12, 2022, at 1318 for a psychiatric evaluation; the facility assigned MR20 an ESI level of 3; MR20 admitted to suicidal ideations and thoughts of hurting others and there was no documentation in MR20 indicating the time this patient left the ED. EMP8 also confirmed there was no documentation in MR20 indicating nursing staff asked this patient to sign an AMA form acknowledging this patient understood the risks of leaving the ED and there was no documentation in MR20 indicating this patient refused to sign the AMA form.

Review of MR20 on November 1, 2022, revealed this patient returned to the ED by ambulance on September 12, 2022, at 1930 on a 302 commitment (Involuntary psychiatric commitment) indicating MR20 throwing things and threatening to kill someone if not seen. Nursing documentation dated September 12, 2022, revealed MR20 was in the ED earlier in the day and had gotten frustrated with the wait time and left.

Interview with EMP5 on November 1, 2022, at approximately 1030 confirmed MR20 returned to the ED by ambulance on September 12, 2022, at 1930 on a 302 commitment (Involuntary psychiatric commitment) indicating MR20 throwing things and threatening to kill someone if not seen and that nursing documented MR20 was in the ED earlier in the day and had gotten frustrated with the wait time and left.

Review of MR3 on November 1, 2022, revealed this patient presented to the ED by ambulance on September 13, 2022, at 1900 for evaluation and treatment of an asthma attack; the facility assigned MR3 an ESI level of 2; and this patient was taken to the waiting room.

Review of MR3 on November 1, 2022, revealed nursing documentation dated September 13, 2022, indicating this patient left the ED waiting room at 1947.

There was no documentation in MR3 indicating nursing staff asked this patient to sign an AMA form acknowledging that MR3 understood the risks of leaving the ED and there was no documentation in MR3 indicating this patient refused to sign the AMA form.

Interview with EMP8 on November 1, 2022, at approximately 1050 confirmed MR3 presented to the ED by ambulance on September 13, 2022, at 1900 for evaluation and treatment of an asthma attack; the facility assigned MR3 an ESI level of 2; was taken to the waiting room and that nursing documented this patient left the ED at 1947. EMP8 also confirmed there was no documentation in MR3 indicating nursing staff asked this patient to sign an AMA form acknowledging this patient understood the risks of leaving the ED and there was no documentation in MR3 indicating this patient refused to sign the AMA form.

Review of MR6 on November 1, 2022, revealed this patient presented to the ED by personal vehicle on September 13, 2022, at 1529 for evaluation and treatment of abnormal laboratory results; the facility assigned MR6 an ESI level of 2 and this patient was taken to the ED waiting room.

Review of MR6 on November 1, 2022, revealed nursing documentation dated September 13, 2022, indicating this patient left the ED waiting room at 1944.

There was no documentation in MR6 indicating nursing staff asked this patient to sign an AMA form acknowledging that MR6 understood the risks of leaving the ED and there was no documentation in MR6 indicating this patient refused to sign the AMA form.

Interview with EMP8 on November 1, 2022, at approximately 1100 confirmed MR6 presented to the ED by personal vehicle on September 13, 2022, at 1529 for evaluation and treatment of abnormal laboratory results; the facility assigned MR6 an ESI level of 2; this patient was taken to the ED waiting room and that nursing documentation indicating this patient left the ED waiting room at 1944. EMP8 also confirmed there was no documentation in MR6 indicating nursing staff asked this patient to sign an AMA form acknowledging this patient understood the risks of leaving the ED and there was no documentation in MR6 indicating this patient refused to sign the AMA form.

Review of MR21 on November 1, 2022, revealed this patient presented to the ED by personal vehicle on September 12, 2022, at 1123 for evaluation and treatment of abnormal laboratory results; the facility assigned MR21 an ESI level of 2 and this patient was taken to the ED waiting room.

Review of MR21 on November 1, 2022, revealed nursing documentation dated September 12, 2022, indicating this patient left the ED waiting room at 1811.

There was no documentation in MR21 indicating nursing staff asked this patient to sign an AMA form acknowledging that MR21 understood the risks of leaving the ED and there was no documentation in MR21 indicating this patient refused to sign the AMA form.

Interview with EMP5 on November 1, 2022, at approximately 1030 confirmed MR21 presented to the ED by personal vehicle on September 12, 2022, at 1123 for evaluation and treatment of abnormal laboratory results; the facility assigned MR21 an ESI level of 2; this patient was taken to the ED waiting room and that nursing documented this patient left the ED waiting room at 1811. EMP8 also confirmed there was no documentation in MR21 indicating nursing staff asked this patient to sign an AMA form acknowledging this patient understood the risks of leaving the ED and there was no documentation in MR21 indicating this patient refused to sign the AMA form.

2. Review of MR2 on November 1, 2022, revealed this patient presented to the ED by personal vehicle on September 13, 2022, at 1359 with a chief complaint of cold symptoms and tested positive for COVID in the last four days; the facility assigned MR2 an ESI level of 4 and this patent was taken to the ED waiting room.

Review of MR2 on November 1, 2022, revealed no documentation OTH1 performed an appropriate medical screening examination to determine whether an emergency medical condition existed from when this patient presented to the ED at 1359 to when MR2 left the ED waiting room at 1751.

Interview with EMP8 on November 1, 2022, at approximately 1045 confirmed there was no documentation OTH1 performed an appropriate medical screening examination on MR2 to determine whether an emergency medical condition existed when this patient presented to the ED at 1359; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR2 left the ED waiting room at 1751.

Review of MR11 on November 1, 2022, revealed this patient presented to the ED by personal vehicle on September 29, 2022, at 1128 for evaluation of a head injury following a fall from the sofa to the floor hitting the forehead on the floor; the facility assigned MR11 an ESI level of 4 and this patient was taken to the waiting room.

Review of MR11 on November 1, 2022, revealed no documentation OTH3 performed an appropriate medical screening examination to determine whether an emergency medical condition existed when this patient presented to the ED at 1128; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR11 left the ED waiting room at 1224.

Interview with EMP8 on November 1, 2022, at approximately 1125 confirmed there was no documentation OTH1 performed an appropriate medical screening examination on MR11 to determine whether an emergency medical condition existed when this patient presented to the ED at 1128; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR11 left the ED waiting room at 1224.

Review of MR5 on November 1, 2022, revealed this patient presented to the ED by personal vehicle on September 13, 2022, at 1326 for evaluation and treatment of chest pain and shortness of breath after walking; the facility assigned MR5 an ESI level of 3 and this patient was taken to the ED waiting room.

Review of MR5 on November 1, 2022, revealed no documentation OTH1 performed an appropriate medical screening examination to determine whether an emergency medical condition existed when this patient presented to the ED at 1326; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR5 left the ED waiting room at 2157.

Interview with EMP8 on November 8, 2022, at approximately 1055 confirmed there was no documentation OTH1 performed an appropriate medical screening examination on MR5 to determine whether an emergency medical condition existed when this patient presented to the ED at 1326; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR5 left the ED waiting room at 2157.

Review of MR7 on November 1, 2022, revealed this patient presented to the ED by personal vehicle on September 13, 2022, at 1939 for evaluation and treatment of abdominal pain; the facility assigned MR7 an ESI level of 3 and this patient was taken to the ED waiting room.

Review of MR7 on November 1, 2022, revealed no documentation CF1 performed an appropriate medical screening examination on MR7 to determine whether an emergency medical condition existed when this patient presented to the ED at 1939; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR7 left the ED waiting room at 2355.

Interview with EMP8 on November 1, 2022, at approximately 1115 confirmed there was no documentation CF1 performed an appropriate medical screening examination on MR7 to determine whether an emergency medical condition existed when this patient presented to the ED at 1939; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR7 left the ED waiting room at 2355.

Review of MR17 on November 1, 2022, revealed this patient presented to the ED by personal vehicle on September 13, 2022, at 1548 for evaluation and treatment of surgical complications which include back and abdominal pain and shortness of breath; the facility assigned MR17 an ESI level of 3 and this patient was taken to the ED waiting room.

Review of MR17 on November 1, 2022, revealed no documentation CF1 performed an appropriate medical screening examination on MR17 to determine whether an emergency medical condition existed when this patient presented to the ED at 1548; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR17 left the ED waiting room at 1940.

Interview with EMP8 on November 1, 2022, at approximately 1120 confirmed there was no documentation CF1 performed an appropriate medical screening examination on MR17 to determine whether an emergency medical condition existed when this patient presented to the ED at 1548; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR17 left the ED waiting room at 1940.

Review of MR3 on November 1, 2022, revealed this patient presented to the ED by ambulance on September 13, 2022, at 1900 for evaluation and treatment of an asthma attack; the facility assigned MR3 an ESI level of 2; and this patient was taken to the waiting room.

Review of MR3 on November 1, 2022, revealed no documentation CF1 performed an appropriate medical screening examination on MR3 to determine whether an emergency medical condition existed when this patient presented to the ED at 1900; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR3 left the ED waiting room at 1947.

Interview with EMP8 on November 1, 2022, at approximately 1050 confirmed there was no documentation CF1 performed an appropriate medical screening examination on MR3 to determine whether an emergency medical condition existed when this patient presented to the ED at 1900; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR3 left the ED waiting room at 1947.

Review of MR6 on November 1, 2022, revealed this patient presented to the ED by personal vehicle on September 13, 2022, at 1529 for evaluation and treatment of abnormal laboratory results; the facility assigned MR6 an ESI level of 2 and this patient was taken to the ED waiting room.

Review of MR6 on November 1, 2022, revealed no documentation OTH1 performed an appropriate medical screening examination on MR6 to determine whether an emergency medical condition existed when this patient presented to the ED at 1529; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR6 left the ED waiting room at 1944.

Interview with EMP8 on November 1, 2022, at approximately 1100 confirmed MR6 was assigned an ESI level of 2 which met the criteria for the patient to be placed in a treatment room, but the patient was directed to the ED waiting room. There was no documentation OTH1 performed an appropriate medical screening examination on MR6 to determine whether an emergency medical condition existed when this patient presented to the ED at 1529; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR6 left the ED waiting room at 1944.

Review of MR21 on November 1, 2022, revealed this patient presented to the ED by personal vehicle on September 12, 2022, at 1123 for evaluation and treatment of abnormal laboratory results; the facility assigned MR21 an ESI level of 2 and this patient was taken to the ED waiting room.

Review of MR21 on November 1, 2022, revealed no documentation OTH1 performed an appropriate medical screening examination on MR21 to determine whether an emergency medical condition existed from when this patient presented to the ED at 1123; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR21 left the ED waiting room at 1811.

Interview with EMP5 on November 1, 2022, at approximately 1030 confirmed MR21 was assigned an ESI level of 2 which met the criteria for the patient to be placed in a treatment room, but the patient was directed to the ED waiting room. There was no documentation OTH1 performed an appropriate medical screening examination on MR21 to determine whether an emergency medical condition existed when this patient presented to the ED at 1123; there was no documentation a medical screening examination was completed on this patient while waiting in the ED and that MR21 left the ED waiting room at 1811.

3. Review of MR3 on November 1, 2022, revealed this patient presented to the ED by ambulance on September 13, 2022, at 1900 for evaluation and treatment of