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Based on Staff interviews, Facility document for Patient Instructions for patient who present for Admissions, review of the facility's policies, review of E-mails-COVID-19 testing, review of the central Emergency Department (ED) Log, and review of the facility's video footage, it was determined the facility failed to ensure an individual who came to the facility's ED seeking assistance was provided an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for one (1) of twenty (20) sampled patients, Patient #1. Refer to findings in Tag A-2406.

Based on observations, interviews, facility document, record review, review of the facility's policy, review of the central Emergency Department (ED) Log, and review of the facility's video, it was determined the facility failed to ensure all individuals who came to the facility's ED seeking assistance, were placed in the central log for one (1) of twenty (20) sampled patients, Patient #1. Additionally, the facility's policy related to ED Log failed to implement/ address disposition of the ED patient.


The findings include:

1. Observations:

Observations of the ED registration area, on 01/21/2021 and 01/22/2021, revealed the ED entrance was the only available entrance for individuals to enter the hospital. Continued observation revealed ED registration staff was also responsible for registering any individual that came into the hospital for lab work, radiology, or a specialty clinic. Further observation revealed when an individual walked up to the plexi-glass barrier (not a window that opened and shut as alleged by the complainant) at the registration area, RC's greeted the individual with "how may I help you?" During observation, there were patients that came to the registration desk and needed to check in for appointments in other areas of the hospital. There was no observation of the RC completing the flow sheet for those individuals. There was no observation of individuals requesting to be seen in the ED during the investigation.


2. Video Footage

Review of the video footage, dated 01/01/2021 from 3:00 PM to 5:00 PM, revealed during the reviewed time-frame footage, (2) employees and an individual delivering a package were observed to enter the facility. The delivery person exited almost immediately. Continued review of the footage revealed, at approximately 4:50 PM, Patient #1 entered the facility. There was not a camera angle to determine if Patient #1 had a conversation with RC #2; however, Patient #1 was seen to exit the facility approximately two (2) to three (3) minutes later, as stated in the complainant's allegation.

3. ED Log Review:

Review of the facility's central ED Log, dated 01/01/2021, revealed the ED saw six (6) or seven (7) patients in a twenty-four (24) hour period; Patient #1's name did not appear on the ED log, for that 24-hour period, as presenting to the ED to be seen, even though per his/her interview (Patient #1), and the facility's video, Patient #1 presented to the ED registration desk, on 01/01/2021.


4. Flow Sheet Review:

Review of the flow sheet, dated 01/01/2021, revealed Patient #1's name was not listed as presenting to the ED for treatment.


5. Policy and Procedure Review

a.) The facility's policy titled, "Initial Screening Assessment and Flow of Patients in the Emergency Department," (flow sheet), review date 07/05/2017, was reviewed. The policy revealed in part, "when an individual arrived to the ED, he/she would be greeted by the registration clerk (RC) who would fill out a sign-in sheet with the following information: 1a) patient name; 1b) time of arrival; 1c) complaint; 1d) social security number; 1e) date of birth; and 1f) family doctor. " The facility failed to ensure that the ED Log policy included disposition of the ED patient.


6. Facility Document Review:

Review of the facility's document Instructions for Patients Who Present to Admissions, undated, revealed if an individual presented to the registration desk experiencing any of the following: fever or chills, cough, shortness of breath, fatigue, body aches, loss of taste or smell, sore throat, nausea, or vomiting/diarrhea, he/she should be asked if wanting to be just COVID tested or needing to be seen by a doctor. If wanting to be tested only, the person would be directed to the parking lot for outpatient testing, during the hours oupatient testing was being done. Further review revealed if the person was wanting to be seen by a doctor and not in respiratory distress, he/she would be given a mask and placed in an ED triage room for further services.

Interviews:

Interview with the Complainant (Patient #1), on 01/21/2021 at 7:53 PM, revealed he/she presented to the ED, on 01/01/2021 about 4:50 PM, with fever, chills, diarrhea, loss of taste, muscle aches, headache, and congestion (COVID-19 symptoms). Patient #1 further stated he/she did not ask the Registration Clerk for a COVID-19 test. Continued interview with Patient #1 revealed that RC #2 asked how she could help Patient #1. Patient #1 stated he/she told RC #2 he/she had a fever and symptoms of COVID-19. Patient #1 stated that RC #2 immediately told him/her that he/she would have to come back, on 01/04/2021, because there was no one at the facility to administer a COVID-19 test or help Patient #1 because of the holiday. Continued interview with Patient #1 revealed RC #2 did not ask Patient #1's name, what presenting symptoms were, or offer an ED assessment; RC #2 just said "sorry" and closed the window. Patient #1 stated he/she was in/out of the building in about one (1) minute. Further interview with Patient #1 revealed his/her expectation was to have been seen in the ED. Patient #1 stated the next morning he/she presented to another hospital about thirty (30) minutes away from his/her home. Patient #1 stated he/she was examined, given a COVID-19 rapid test (negative), and given prescriptions for a steroid dose pack, inhalers, cough syrup, and instructed to take Vitamin C, Vitamin D, and Zinc. Patient #1 stated his/her COVID Antigen test had a positive result, approximately four (4) to five (5) days later.

Interview with RC #2, on 01/21/2021 at 11:11 AM, revealed she did not remember Patient #1 presenting to the ED, on 01/01/2021 during her shift, but when she asked how she could help a presenting individual, she certainly would not have turned anyone away if he/she had requested to be seen in the ED. RC #2 stated she was aware of EMTALA components and had yearly training on it. When RC #2 was asked what she would have done if an individual had come in and reported the same symptoms as Patient #1, she stated she would have registered the individual, put him/her in the Triage room as a possible COVID-19 case, and alerted the nurse. RC #2 stated she had been educated to ask "how may I help you?" to any person who came to the registration desk.

Interview with the Chief Nursing Officer (CNO), on 01/21/2021 at 9:47 AM, revealed Patient #1's name did not appear on the flow sheet or the ED Log, on 01/01/2021. She stated all patients who presented to the ED requesting to be seen should be entered on the flow sheet and ED log. Interview with the Admissions Director, on 01/21/2021 at 10:34 AM, revealed all admissions staff (registration clerks) received EMTALA training on hire and yearly. She also stated staff was educated to ask individuals "how may I help you?" so they could be assisted to the appropriate area of the hospital.

Interview with RC #1, on 01/21/2021 at 10:34 AM, revealed she received yearly EMTALA training and was aware of the components of EMTALA. Continued interview revealed an "Emergency Department Screening Form" (flow sheet) was used when an individual presented requesting to be seen in the ED. She stated it collected basic information but did have a place to document the reason an individual presented to the ED. RC #1 stated she had been educated to ask "how may I help you?" Further interview revealed if an individual reported possible COVID-19 signs and symptoms, she would document that on the form, give the patient a mask, if he/she did not already have one, put him/her in the Triage room (room with a door), and alert the nurse and/or medical provider there was a possible COVID case to be seen.

Interview with RC #3, on 01/22/2021 at 10:30 AM, revealed she had received yearly EMTALA training and was familiar with the components of EMTALA. RC #3 further stated she had been educated to ask individuals "how may I help you?" because the ED registration desk was a multi-functional access point for other areas of the hospital. Continued interview revealed that the registration staff assisted all individuals that came into the hospital, whether it was to direct them to a specialty clinic, to have lab/radiology, or to be seen in the ED; RC's needed to know how the individual needed to be helped. RC #3 stated there were appointments for areas in the hospital such as labs or radiology after hours, nights, weekends, and holidays. When asked how she would have responded if an individual presented with COVID-19 symptoms, RC #3 stated she would have had the patient don a mask, if he/she did not already have one, put him/her in the Triage room (room with a door), and alert the nurse and/or medical provider there was a possible COVID case to be seen.

Additional interview with the CNO, on 01/22/2021 at 10:02 AM, revealed she was aware of the components of EMTALA and its regulations. Further interview revealed it was her expectation for an individual to be greeted by the RC and asked how the RC could help him/her. If the individual stated he/she wanted to be seen, the RC would then begin to fill out the flow sheet, adding whether the patient elected to be seen in the after-hours clinic or the ED; if he/she stated "the ED," the ED process would continue from there. The CNO further stated the Registration area did not have a window that could be shut (observation revealed there was not a window, just a plexi-glass barrier). Continued interview revealed during review of the aforementioned video footage with the State Survey Agency (SSA) Surveyor, there was not a camera angle that showed whether Patient #1 talked with RC #2, it just showed the coming/going of Patient #1.

Based on Staff interviews, Facility document for Patient Instructions for patient who present for Admissions, review of the facility's policies, review of E-mails-COVID-19 testing, review of the central Emergency Department (ED) Log, and review of the facility's video footage, it was determined the facility failed to ensure an individual who came to the facility's ED seeking assistance was provided an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for one (1) of twenty (20) sampled patients, Patient #1.


The findings include:

1. Policies and Procedures
Review of the facility's policy titled, "Medical Screening Exam," revised 02/12/2015, defined a medical screening exam (MSE) as a process, the details of which depended upon the presenting individual's circumstances, and could consist of a history and physical or utilization of any routinely available ancillary tests, necessary to reach a determination as to whether an emergency medical condition existed.

Review of the facility's policy titled, "Initial Screening Assessment and Flow of Patients in the Emergency Department," (flow sheet), review date 07/05/2017, stated all patients that presented to the ED of the facility and requested emergency medical treatment were, by law, to have an appropriate medical screening exam (MSE). Continued review revealed the initial screening exam provided an overall assessment to determine if an emergency medical condition existed in those patients seeking treatment in the Emergency Department (ED), to comply with the Emergency Medical Treatment and Labor Act (EMTALA) requirements.

2. Instructions for Patients Who Present to Admissions

Review of the facility's document titled " Instructions for patients Who Presented to Admissions undated, revealed if an individual presented to the registration desk experiencing any of the following: fever or chills, cough, shortness of breath, fatigue, body aches, loss of taste or smell, sore throat, nausea, or vomiting/diarrhea, he/she should be asked if wanting to be just COVID tested or needing to be seen by a doctor. If wanting to be tested only, the person would be directed to the parking lot for outpatient testing, during the hours outpatient testing was being done. Further review revealed if the person was wanting to be seen by a doctor and not in respiratory distress, he/she would be given a mask and placed in an ED triage room for further services.

3. Emergency Department Log

Review of the central ED Log, for 01/01/2021, revealed Patient #1 was not listed as presenting to the ED for treatment.


4. Video Footage
Review of the video footage, dated 01/01/2021 from 3:00 PM to 5:00 PM, revealed during the reviewed time-frame footage, (2) employees and an individual delivering a package were observed to enter the facility. The delivery person exited almost immediately. Continued review of the footage revealed, at approximately 4:50 PM, Patient #1 entered the facility. There was not a camera angle to determine if Patient #1 had a conversation with RC #2; however, Patient #1 was seen to exit the facility approximately two (2) to three (3) minutes later.

5. E-mails- COVID-19 testing

Review of a facility e-mail, dated 12/08/2020 at 5:28 PM, from the Administrative Director of the Laboratory to the Lab Department, revealed effective 12/08/2020, Drive by COVID testing would be done between the hours of 7:00 AM to 4:00 PM.

Review of a facility e-mail, dated 12/22/2020 at 1:29 PM, from the Administrative Director of the Laboratory to the Lab Department, revealed the COVID testing protocol for the holidays. The e-mail stated there would be no Drive by Covid testing. However, a test would be done for anyone who had been sick at least two (2) to three (3) days or anyone who had been exposed for at least five (5) days.

6. Staff Interviews

Interview with the Complainant (Patient #1), on 01/21/2021 at 7:53 PM, revealed he/she presented to the ED, on 01/01/2021 about 4:50 PM, with fever, chills, diarrhea, loss of taste, muscle aches, headache, and congestion. Patient #1 further stated he/she did not ask the Registration Clerk (RC) for a COVID-19 test. Continued interview with Patient #1 revealed that RC #2 asked how she could help Patient #1. Patient #1 stated he/she told RC #2 he/she had a fever and symptoms of COVID-19. Patient #1 stated that RC #2 immediately told him/her that he/she would have to come back, on 01/04/2021, because there was no one at the facility to administer a COVID-19 test or help Patient #1 because of the holiday. Continued interview with Patient #1 revealed RC #2 did not ask Patient #1's name, what presenting symptoms were, or offer an ED assessment; RC #2 just said "sorry" and closed the window. Patient #1 stated he/she was in/out of the building in about one (1) minute. Further interview with Patient #1 revealed his/her expectation was to have been seen in the ED. Patient #1 stated the next morning he/she presented to another hospital about thirty (30) minutes away from his/her home. Patient #1 stated he/she was examined, given a COVID-19 rapid test (negative), and given prescriptions for a steroid dose pack, inhalers, cough syrup, and instructed to take Vitamin C, Vitamin D and Zinc. Patient #1 stated his/her COVID Antigen test had a positive result, approximately four (4) to five (5) days later. The facility failed to ensure the following for patient #1 as evidenced by failing to ensure:
1. an appropriate medical screening examination was provided which was within the capability of ED to determine whether or not an emergency medical condition existed as stated in the facility's policy and procedure;
2. The Receptionist Clerk followed the e-mail dated 12/22/2020 testing protocol for COVID -19 testing during the holiday (New Years Day);
3. The facility's document titled "Instructions to patients who Present to Admissions" was followed, for patients who presented to the ED with symptoms of COVID-19 and or instructing the patient if he/she wanted to be seen by an MD not in respiratory distress, and given a mask and placed in the ED triage for further services. Patient #1 was not placed in ED triage for further services (MSE) and not given a mask.

Interview with RC #2, on 01/21/2021 at 11:11 AM, revealed she did not remember Patient #1 presenting to the ED, on 01/01/2021 during her shift, but when she asked how she could help a presenting individual, she certainly would not have turned anyone away if the individual had requested to be seen in the ED. RC #2 stated she was aware of EMTALA components and had yearly training on it. When RC #2 was asked what she would have done if an individual had come in and reported the same symptoms as Patient #1, she stated she would have registered the individual, put him/her in the Triage room as a possible COVID-19 case, and alerted the nurse.

Interview with the Admissions Director, on 01/21/2021 at 10:34 AM, revealed all admissions staff (registration clerks) received EMTALA training on hire and yearly. She also stated staff was trained to ask presenting individuals "how may I help you?" so they could be assisted to the appropriate area of the hospital.

Interview with RC #1, on 01/21/2021 at 10:34 AM, revealed she received yearly EMTALA training and was aware of the components of EMTALA. Continued interview revealed an "Emergency Department Screening Form" was used when an individual presented requesting to be seen in the ED. She stated it collected demographic information but did have a place to document the reason an individual presented to the ED. Further interview revealed if an individual reported possible COVID-19 signs and symptoms, she would document that on the form, give the patient a mask, if he/she did not already have one, put him/her in the Triage room (room with a door), and alert the nurse and/or medical provider there was a possible COVID case to be seen.

Interview with RC #3, on 01/22/2021 at 10:30 AM, revealed she had received yearly EMTALA training and was familiar with the components of EMTALA. RC #3 further stated she had been educated to ask individuals "how may I help you?" because the ED registration desk was a multi-functional access point for other areas of the hospital. Continued interview revealed that the registration staff assisted all individuals that came into the hospital, whether it was to direct them to a specialty clinic, to have lab/radiology, or to be seen in the ED; RC's needed to know how the individual needed to be helped. RC #3 stated there were appointments in other areas of the hospital such as lab and radiology after hours, nights, weekends, and holidays.
When asked how she would have responded to an individual presenting with COVID-19 symptoms, RC #3 stated she would have had the patient don a mask, if he/she did not already have one, put him/her in the Triage room (room with a door), and alert the nurse and/or medical provider there was a possible COVID case to be seen.

Interview with Registered Nurse #1 (worked 01/01/2021, 7:00 AM to 7:00 PM), on 01/21/2021 at 9:52 AM, revealed she aware of the components of EMTALA and that anyone who presented to the ED should be seen. However, she did not know that Patient #1 had presented to the ED, on 01/01/2021.

Interview with the Advanced Practice Registered Nurse (APRN), on 01/21/2021 at 10:00 AM, revealed the nurse understood the regulations of EMTALA, which required anyone who presented to the ED and requested to be seen should have a medical screening examination. The APRN stated she was not aware Patient #1 had presented to the ED, on 01/01/2021.

Interview with the Chief Nursing Officer (CNO), on 01/22/2021 at 10:02 AM, revealed she was aware of the components of EMTALA and its regulations. Further interview revealed it was her expectation for an individual to be greeted by the RC and asked how the RC could help him/her. If the individual stated he/she wanted to be seen, the RC would then begin to fill out the flow sheet, adding whether the patient elected to be seen in the after-hours clinic or the ED; if he/she stated "the ED," the ED process would continue from there. The CNO further stated the Registration area did not have a window that could be shut ( just a plexi-glass barrier). Continued interview revealed during review of the aforementioned video footage with the State Survey Agency (SSA) Surveyor, there was not a camera angle that showed whether Patient #1 talked with RC #2, it just showed the coming/going of Patient #1.

Interview with the Administrator, on 01/22/2021 at 10:02 AM, revealed he expected all staff to follow EMTALA regulations. In addition, he stated all staff received EMTALA training annually and upon hire. The Administrator stated if an individual came to the registration desk and asked to be seen in the ED, the ED process would start, and he/she would be seen by a clinician to receive a medical screening exam.