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Based on policy and procedure review, medical record review and interview, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements. See A2405 and A2406 for details.

Based on clinical record review, policy review, and interview, it was determined the facility failed to ensure 1 (#1) of 20 (#1-#20) patient was placed on the Emergency Department (ED) Log. Failure to place the patient on the ED Log did not ensure the facility had a means of tracking the patient for emergency medical treatment. The failed practice affected Patient #1 and had the likelihood to affect all patients presenting to the ED. Findings follow:

A. Review of Policy and Procedure "EMTALA: Stabilization and Transfer", revised October 2017, showed a central log on each person who comes to the ED seeking medical treatment or examination and whether he or she refused treatment or voluntarily left without receiving a Medical Screening Exam (MSE) or treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred or was discharged.

B. Review of the ED Log dated from 05/01/2024 to 06/20/2024 showed no evidence Patient #1 was registered on the ED Log.

C. During an interview on 07/16/24 at 1:00 PM, the Director of Nursing confirmed the findings in A and B.

Based on clinical record review, policy review, and interview, it was determined the facility failed to ensure 1 (#1) of 20 (#1-#20) patient received an appropriate and timely medical screening exam (MSE). Failure to provide an appropriate and timely MSE did not ensure the facility was aware of whether Patient #1 had an emergency medical condition, which caused a delay in medical treatment. The failed practice affected Patient #1 and had the likelihood to affect all patients presenting to the Emergency Department (ED). Findings follow:

A. Review of Policy and Procedure "EMTALA: Stabilization and Transfer", revised October 2017, showed the following:
1) MSE-A non-discriminatory screening process that includes all necessary testing and required on-call physician evaluation services within the capability of the Hospital to conclude, with reasonable clinical confidence, the absence of any legally defined EMC (emergency medical condition), or, in the presence of an EMC, reflects continued monitoring according to the Presenting Individual's needs and continues until s/he is stabilized or appropriately transferred.
2) Any individual who is brought to, or presents to, Hospital Property and requests an unscheduled examination or treatment for a medical condition, or who has an unscheduled examination or treatment requested for him/her.
3) With respect to an EMC, means to provide such medical treatment of the EMC necessary to assure that, within reasonable medical probability, no material deterioration of the condition is likely to result from or occur during or immediately after the transfer or discharge of an individual from a facility.
4) Any individual who presents on Hospital Property and requests unscheduled examination or treatment by the Hospital for what may be a medical condition or has such request made on his or her behalf must be sent or transported, as appropriate, to the Emergency Department for registration, triage, MSE, and any appropriate stabilizing treatment and/or transfer. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment.
5) Hospital will provide a MSE to all Presenting Individuals, regardless of their ability to pay. Triage assessment by an RN does not count as a MSE.
6) If the transfer is due to Hospital's lack of capability to stabilize a person, the Emergency Department Physician/Attending Physician must certify in writing that, based on the information available at the time of transfer, the medical benefits expected from the medical treatment available at another facility outweigh the increased risks to the person from the transfer. The certification will contain a summary of the risks and benefits upon which this decision is based. If the physician is not physically present at Hospital at the time the person is transferred, then another physician may sign the certification in consultation with the physician making the determination and such physician will later countersign the certification.
7) A central log on each person who comes to the ED seeking medical treatment or examination and whether he or she refused treatment or voluntarily left without receiving a MSE or treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred or was discharged


B. During an interview on 07/16/24 at 1:00 PM, the Director of Nursing confirmed the findings in A and B.

C. Review of video monitoring dated 06/16/24 at 9:42 PM, showed a patient entering the ED waiting room with a lower extremity injury. The patient was limping and was trying to not place their weight on their left foot. After speaking with the registration staff and Resource Nurse the patient left the ED waiting room area on 06/16/24 at 9:44 PM with assistance from family/friend. There was no evidence the patient was registered before leaving.

D. During an interview on 07/16/24 at 1:00 PM, the Chief Operations Officer confirmed the findings in D.

E. During an interview with the Director of Admissions on 07/16/24 at 10:25 AM, he stated the admission process in the ED is as follows: enter the patient into the log, information goes to the triage person, or they are called based on the patient's stated symptoms, if the patient is in obvious distress, then the registration staff "arrive" the patient and call the triage staff immediately. He stated that all the registration staff received EMTALA training and that the staff do not defer patients to another facility.

F. During an interview with the Pharmacist on 07/16/24 at 2:10 PM, she stated and confirmed that as far as she knew the facility had never had the anti-venom in the pharmacy and available for patient use.

G. During a telephone interview with ED Registration Staff #1 (individual that spoke to Patient #1 at registration desk) on 07/17/24 at 2:29 PM, she stated that regarding the incident with the patient on 06/16/24 that she did not recall if there was a conversation with the patient and the Resource Nurse about going to another facility for treatment, but she did recall that someone said that the facility did not have any anti-venom. She also stated that she knew that the process was to never turn anyone away that came into the ED for treatment.

H. During a telephone interview with the Resource Nurse on 07/16/24 at 2:38 PM, she stated, she does not recall why the patient was not checked in or an MSE was not performed but she did recall that the ED nurses told her that the facility did not have any anti-venom and she stated she told the patient that (named hospital) did have the anti-venom. She also confirmed that the patient should have been registered, triaged and if needed, assisted to their car if they chose to go to the other hospital for treatment.