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Based on review of the Medical Emergency Team log, ED Central Log, Medical Staff Rules and Regulations, policies and procedures, tour, staff interviews, observations, credential files, and personnel files, it was determined that the facility failed to ensure that an approrpiate medicdal screening examination was provided for an individual after a prudent layperson observed and beleived that one visitor (Visitor #1) on hospital property was suffering from a possible emergency medical condition.

Findings were:

1. Cross refer to A-2406, as it relates to failure to provide an appropriate medical screening examination for Visitor #1.

Based on review of the Medical Emergency Team (MET) log, Emergency Department Central log, review of medical records, Medical Staff Bylaws Rules and Regulations, policies and procedures, credential and personnel files, staff interviews, and observations during a facility tour, it was determined that the facility failed to provide an appropriate medical screening examination that was within the capability of the hospital's emergency department to determine whether or not an emergency medical conditions existed, when a prudent layperson observed and beleived that a visitor (Visitor #1) on the facility's property suffering from a potential emergency medical condition.

Findings included:

1. Medical Emergency Team (MET) Log and Emergency Department (ED) Central Log

A review of the Medical Emergency Team (MET) Log revealed that on 4/29/19 at 3:25 p.m., the MET was activated for a visitor (name unknown) in the hospital snack bar with symptoms of weakness and being pale. The log revealed that the visitor refused treatment in the Emergency Department (ED).

Further review of the MET Log dated 1/1/19 through 5/31/19 revealed the following:
In January 2019, MET was activated a total of 224 times. Of these, nine (9) incidents involved non-patients in public areas. Of these nine (9), three (3) refused treatment in the ED.
In February 2019, MET was activated a total of 211 times. Of these, five (5) incidents involved non-patients in public areas. Of these five (5), one (1) did not include an outcome.
In March 2019, MET was activated a total of 195 times. Of these, three (3) incidents involved non-patients in public areas. Of these three (3), one (1) refused treatment in the ED.
In April 2019, MET was activated a total of 218 times. Of these, thirteen (13) incidents involved non- patients in public areas. Of these thirteen (13), three (3) refused treatment in the ED.
In May 2019, MET was activated a total of 266 times. Of these, three (3) incidents involved non-patients in public areas who were taken to the ED

The ED Central log dated 1/1/19 through 6/15/19 was reviewed.

2. Interviews

An interview with Security Officer (Security) DD took place in an administrative conference room on 6/18/19 at 10:15 a.m. Security DD recalled that he responded to a request for assistance with a visitor in the concession area who was not feeling well. Security DD observed Visitor #1 to be pale and sweaty and complained of nausea and abdominal pain. Visitor #1 explained that she was visiting a friend who was having surgery after a motor vehicle accident. Security DD called for assistance from the Medical Emergency Team (MET) and RN BB responded. Security DD recalled that RN BB told Visitor #1 that he could take her to the ED but that she would have to pay. Security DD recalled that RN BB reiterated this statement several times. Security DD and RN BB escorted Visitor #1 via wheelchair to the surgical waiting area to find her (Visitor #1) husband. Visitor #1 was assisted to the bathroom by her husband where they remained for 10 to 15 minutes. Security DD recalled that Visitor #1 required assistance with ambulation. Security DD stated that RN BB reiterated to Visitor #1's husband that he (RN BB) could take Visitor #1 to the ED but there would be a charge for the visit. Visitor #1 and her husband declined the ED at which point RN BB informed Security DD that he had other matters to take care and requested that Security DD escort Visitor #1 to their vehicle. Security DD recalled that Visitor #1 and her husband had limited English proficiency. Visitor #1 did not tell Security DD that money was a factor in her decision not to go to the ED.

A phone interview with RN BB took place on 6/17/19 at 7:00 p.m. RN BB explained that he was a Registered Nurse (RN) and had been working on the Critical Care unit for several years. RN BB recalled that on 4/29/19 he was assigned to be the MET RN and responded to a request for assistance in the concession area. Upon arrival to the concession area, RN BB observed Visitor #1 leaning against a counter. Visitor #1 was alert, oriented, and pale in color. Visitor #1 explained that she was visiting a friend who was having surgery. Visitor #1 advised RN BB that her husband was in the surgical waiting area. RN BB stated that Security DD retrieved a wheelchair for Visitor #1 and she was assisted into the wheelchair. RN BB asked Visitor #1 if she wanted to go to the ED or go to find her husband. RN BB recalled that at some point in the dialogue, he told Visitor #1 that there may be a charge for going to the ED. RN BB further explained that MET RN's were instructed, over ten years ago, to disclose that there may be a charge incurred to any non-patient in public spaces who requested to go to the ED. RN BB recalled that Visitor #1 requested to go find her husband and was taken to the surgical waiting area. At some point during the dialogue, RN BB asked Visitor #1 if she had been out of the country recently, which she replied 'no'. RN BB explained that questions about foreign travel are routine in the ED and admission process. Once in the surgical waiting room, Visitor #1 stated that she needed to have a bowel movement and was assisted by her husband to the bathroom. RN BB asked Security DD to remain present in case assistance was required. After Visitor #1 was done in the bathroom, RN BB again asked her if she wished to go to the ED. RN BB stated that Visitor #1 and her husband were emphatic that they did not wish to go to the ED. RN BB asked the Security DD to escort Visitor #1 and her husband to their vehicle. RN BB recalled that he was assigned to care for Visitor #1's friend the next day in the critical care unit and spoke with Visitor #1. RN BB recalled that Visitor #1 hugged and thanked him for his assistance the previous day. RN BB stated that as a result of this incident, all MET nurses were reminded of the applicability of EMTALA with visitors. RN BB stated that at the time of this incident, he had recently completed the facility's mandatory annual competencies which included EMTALA. The facility failed to ensure that an appropriate medical screening examination was provided on for visitor #1, after a suggestion was made by a hospital staff member that visitor #1 could go to the ED, but would have to pay. As this suggestion resulted in Visitor #1 refusing to go to the ED for a medical screening examination.

An interview with MET Director (Director) AA took place on 6/17/19 at 2:00 p.m. in an administrative conference room. MET Director AA explained that in addition to MET, she was the Director of the Trauma Intensive Care Unit (ICU), Neurology ICU, and PICC Team. Staff assigned to MET included a Critical Care RN, a Critical Care Registered Respiratory Therapist (RRT), and a Critical Care Internal Medicine Resident. RN's assigned to be the MET RN for the shift were Critical Care RN's but did not have a patient assignment while assigned to MET. Hospital staff activated MET for clinical concerns about patients and non-patients. The MET responds to all areas on the hospital premises as well as all Code Blue (code announced when a patient or non-patient goes into cardiac or respiratory arrest). Director AA explained that one of the requirements to be a MET RN was to have an advanced certification such Critical Care Certification or be currently enrolled in a certification class.

Director AA recalled that on 4/29/19, RN BB was assigned to be the MET RN. Director AA observed RN BB in the hospital vending area attending to Visitor #1, who had complained of faintness. Director AA explained that she did not actively assist RN BB but did remain and observe in case RN BB required additional assistance. Director AA recalled that Security DD and another ancillary staff member were also present. Director AA recalled that RN BB assisted Visitor #1 into a wheelchair and asked if she wanted to go to the Emergency Department. Director AA could not hear Visitor #1's response. RN BB told Visitor #1 that there may be a charge for the ED. Director AA explained that it had been the practice of MET to inform non-patient's that a charge for the ED visit was possible. Visitor #1 requested to find her husband who was in the vicinity of the surgical waiting area. Director AA recalled that RN BB took Visitor #1 to the surgical waiting area accompanied by Security DD. RN BB later informed Director AA of the events that took place in the surgical waiting area. Once in the surgical lobby, Visitor #1 requested to go to the bathroom and her husband assisted her in the bathroom. Visitor #1's husband informed RN BB that she (Visitor #1) had ongoing gastrointestinal problems that caused her to frequent the bathroom. RN BB requested Security DD remain close by in the event assistance was needed. RN BB assisted Visitor #1 back into the wheelchair and asked her if she had been out of the country recently. RN BB again asked Visitor #1 if she wanted to go to the ED and she declined. RN BB informed Director AA that he spoke with Visitor #1 and her husband the next day as he was the RN assigned to care for Visitor #1's friend/family. Visitor #1 told RN BB that she felt better and thanked him for his assistance.

Director AA explained that after the incident was brought to her attention, she met one on one with all MET nurses and reviewed EMTALA regulations. All MET RN's were required to complete a computer-based learning module on EMTALA and sign an attestation. Director AA explained that all staff members were required to complete annual computerized learning that included a review of EMTALA obligations.

During the exit conference on 6/18/19 at 3:00 p.m. in an administrative conference room Chief Medical Officer (CMO) FF stated that until this incident, he had been unaware of a practice of informing non-patients that there may be a cost associated with a visit to the ED.

3. Policies and Procedures

Review of the facility's policy number LL.EM.2 titled ' EMTALA - Medical Screening Examination and Stabilization Policy', last reviewed 2/18 revealed in part: The purpose of the policy was to establish guidelines to provide appropriate medical screening examinations ("MSE") and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA, 42 U.S.C. § 1395dd, and all Federal regulations and interpretive guidelines promulgated thereunder..

Further review of the policy revealed that an EMTALA obligation was triggered when an individual came to a dedicated emergency department ("DED") and:
1. the individual or a representative acting on the individual's behalf requested an examination or treatment for a medical condition; or
2. a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needed an examination or treatment of a medical condition.
Such obligation was further extended to those individuals who presented elsewhere on hospital property requesting examination or treatment for an emergency medical condition ("EMC"). Further, if a prudent layperson observer would believe that the individual was experiencing an EMC, then an appropriate MSE, within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of on-call physicians), would be performed. The MSE must be completed by an individual (i) qualified to perform such an examination to determine whether an EMC exists, or (ii) with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. If an EMC was determined to exist, the individual was provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilization treatment was applied in a non-discriminatory manner (e.g., no different level of care because 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).

The policy revealed that an MSE was required when an individual arrived on the hospital property, either in the DED or property other than the DED, did not request for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment.

The policy revealed the following regarding the extent of the MSE:
a. The hospital must perform an MSE to determine if an EMC existed. It was not appropriate to merely "log in" or triage an individual with a medical condition and not provide an MSE. Triage was not equivalent to an MSE. Triage entailed the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual was screened by a physician or other QMP.
b. An MSE was the process required to reach, with reasonable clinical confidence, the point at which it was determined whether the individual had an EMC or not. An MSE was not an isolated event. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital.
c. The individual was continuously monitored according to the individual's needs until it was determined whether or not the individual had an EMC, and if he or she did, until he or she was stabilized or appropriately admitted or transferred. The medical record reflected the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer.
d. The extent of the necessary examination to determine whether an EMC existed was generally within the judgment and discretion of the physician or other QMP that performed the examination function according to algorithms or protocols established and approved by the medical staff and governing board.
e. The MSE varied based on the individual's signs and symptoms:

The hospital was required to provide an MSE and necessary 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.

Further review of the policy revealed that only the following individuals performed an MSE:
1. A qualified physician with appropriate privileges;
2. Other qualified licensed independent practitioner (LIP) with appropriate competencies and privileges; or
3. A qualified staff member who:
a. was qualified to conduct such an examination through appropriate privileging and demonstrated competencies;
b. was functioning within the scope of his or her license and in compliance with state law and applicable practice acts (e.g., Medical or Nurse Practice Acts);
c. was performing the screening examination based on medical staff approved guidelines, protocols or algorithms;
d. was approved by the facility's governing board as set forth in a document such as the hospital bylaws or medical staff rules and regulations, which document has been approved by the facility's governing body and medical staff. It was not acceptable for the facility to allow informal personnel appointments that could change frequently.

QMPs performed an MSE if licensed and certified, approved by the hospital's governing board through the hospital's by-laws, and only if the scope of the EMC is within the individual's scope of practice. The designation of QMP was set forth in a document approved by the governing body of the hospital. Each individual QMP approved to provide an MSE under EMTALA was appropriately credentialed and met the requirements for annual evaluations set forth in the protocol agreements with physicians and the State's medical practice act, nurse practice act or other similar practice acts established to govern health care practitioners. Only appropriately credentialed APRNs, PAs and physicians performed MSEs in the DED.

An MSE, stabilizing treatment, or appropriate transfer was not delayed in order to inquire about the individual's method of payment or insurance status or conditioned on an individual's completion of a financial responsibility form, an advance beneficiary notification form, or payment of a co-payment for any services rendered. The facility followed reasonable registration processes for individuals for whom examination or treatment was required. Reasonable registration processes could include asking whether the individual was insured, and if so, what that insurance was, if these procedures did not delay screening or treatment or unduly discourage individuals from remaining for further evaluation. The hospital could seek non-payment information from the individual's health plan about the individual, such as medical history. Requests for payment of copays, deductibles or a deposit for the encounter were not to be made until after completion of an MSE and the provision of any necessary stabilization treatment.

The performance of the MSE and the provision of stabilizing treatment was NOT conditioned on an individual's completion of a financial responsibility form, an advance beneficiary notification form, or payment of a co-payment for any services rendered.

Continued review of the policy revealed that individuals who inquired about financial responsibility for emergency care were provided a response by a staff member who had been well trained to provide information regarding potential financial liability. The staff member providing information on potential financial liability should clearly inform the individual that the hospital will provide an MSE and any necessary stabilizing treatment, regardless of his or her ability to pay. Individuals who believe that they have an EMC should be encouraged to remain for the MSE.

If an individual refused to consent to examination or treatment and indicated his or her intention to leave prior to triage or prior to receiving an MSE or if the individual withdrew the initial request for an MSE, facility personnel must request that the individual sign the Waiver of Right to Medical Screening Examination Form that was part of the Sign-In Sheet or document on the Sign-In Sheet the individual's refusal to sign the Waiver of Right to Medical Screening Examination Form. If an individual refused to sign a consent form, the physician or nurse must document that the individual had been informed of the risks and benefits of the examination and/or treatment but refused to sign the form.

Further review of the policy revealed that if an individual left the facility without notifying facility personnel, this must be documented upon discovery. The documentation reflected that the individual had been at the facility and the time the individual was discovered to have left the premises. Triage notes and additional records must be retained. If the individual left prior to transfer or prior to an MSE, the information was documented on the individual's medical record. If an individual had not completed a Sign-In Sheet, an ED staff member completed a sheet and if the individual's name was not known, a description of the individual leaving was entered on the form. All individuals who presented for evaluation or treatment were entered on the Central Log.

Review of the Medical Staff Rules and Regulations, last revised 4/19/19, Section 6 titled, 'Medical Screening Examination' revealed that any individual who presented to the ED and requested examination or treatment was provided with a medical screening examination (MSE). The purpose of the MSE was to determine if the individual was having an emergency condition. An MSE was performed by a physician or resident physician. In the case of a pregnant woman, the MSE could be performed by a Labor and Delivery Registered Nurse in consultation with a physician with appropriate clinical privileges.

The following additional policies were reviewed: ED Triage, ED Evaluation and Treatment of the Pregnant Patient, EMTALA Central Log, EMTALA Provision of On-Call Coverage, EMTALA Signage, EMTALA Transfer, EMTALA Medical Screening Examination, Patient Grievance and Complaint Management.

4. Sample Emergency Department Medical Record Review

A review of twenty (20) ED patient medical records (Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, Patient #19, Patient #20, Patient #21) that included twelve (12) (Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #19) patients that were escorted to the ED by a MET member, did not reveal any EMTALA violation concerns.

5. Personnel and Credential File Review

Review of three (3) staff files (Director AA, RN BB, Director EE) revealed that each file contained all required documentation that included EMTALA training. Review of one (1) credential file (ED Medical Director CC) revealed that all required documentation was present including EMTALA training.

6. Meeting Minutes

Review of the Quality and Safety Committee meeting minutes for July 2018 through May 2019 revealed that Quality and Patient Safety were standing agenda items. Meeting minutes dated 11/7/18 revealed that EMTALA Annual Quality Performance was presented that included a discussion of EMTALA cases elsewhere and recommendations moving forward.

7. Observation

A tour of the ED was conducted on 6/17/19 at 3:00 p.m. accompanied by ED Director EE and ED Quality Improvement Manager. During the tour it was observed that the main ED entrance had appropriate EMTALA signage in both, English and Spanish. Two uniformed security guards were stationed at the entrance. All persons were screened with a metal detector prior to entry into the waiting area. Upon entry to the ED lobby, patients were entered into the electronic ED central log. The triage area had of three (3) rooms staffed by RN's at all times. A mid-level provider such as a Nurse Practitioner was in the triage area daily from approximately 8:00 a.m. until 12:00 a.m. depending on the volume of patients. The mid-level provider performed the MSE in the triage area and assigned a treatment area based on the screening exam. It was stated that registration was not completed until the patient had received an MSE and patients were never told that payment was expected. It was stated that a list of specialty on-call physicians was electronic and could be accessed by any staff member.