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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in §489.24, related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

Findings:

1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag A2405 - Emergency Room Log - The facility failed to ensure that a central log was accurately maintained to include all patients seeking emergency care at the facility and to reflect the correct disposition of patients seen in the Emergency Department (ED). Specifically, one patient who presented to the ED on 3/22/18, with a complaint of chest pain was not entered on the central log (Patient A) and the disposition listed on the log was incorrect for 4 of 20 patients reviewed (Patients #3, #15, #19, and #20).

Tag A2406 - Medical Screening Exam - The facility failed to ensure a Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel (QMP) in 1 of 2 records reviewed for patients who presented to the facility for an emergency evaluation during a time when the facility was in lockdown (Patient A). This failure resulted in the delay of care for a patient experiencing an emergency medical condition.

Based on review of facility documents and staff interviews the facility failed to ensure that a central log was accurately maintained to include all patients seeking emergency care at the facility and to reflect the correct disposition of patients seen in the Emergency Department (ED). Specifically, one patient who presented to the ED on 3/22/18, with a complaint of chest pain was not entered on the central log (Patient A) and the disposition listed on the log was incorrect for 4 of 20 patients reviewed (Patients #3, #15, #19, and #20).

FINDINGS:

POLICY

According to the EMTALA (Emergency Medical Treatment & Active Labor Act) Central Log Policy, the hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination could be performed, whether he or she refused treatment, whether he or she was refused treatment or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged.

The procedure section of the policy read, A log entry for all individuals who have come to the hospital seeking medical attention or who appear to need medical attention must be made by the appropriate individual.

1. The facility failed to maintain a complete and accurate central log of patients who presented to the facility.

a) Review of an internal management report, entered at 3:28 p.m. on 3/23/18, showed an individual came to the emergency department (ED) on 3/22/18 with chest pain. The report indicated the patient spoke with a security officer at the ED and then left the ED and sought care at another acute care hospital. The report noted that a risk manager at the acute care hospital, that subsequently treated the patient on 3/22/18, called and reported the patient said the security officer told him the hospital couldn't admit anyone because of the lockdown that was in place.

Review of the electronic Central EMTALA Log for 3/22/18 revealed no entry for Patient A.

During an interview with the Director of Emergency Services, Adult Emergency Department (Director #2), on 5/2/18 at 9:00 a.m., Director #2 stated individuals who came to the ED but decided not to be seen would still be entered into the EMTALA log using an identification number issued by patient access. According to Director #2, the sex and approximate age of the individual was entered and left prior to triage was entered as the disposition type. Regarding the occurrence from 3/22/18, Director #2 stated "we didn't think about it but we should have gone back and entered that patient onto the log."

b) Patient #3 presented to the ED on 4/1/18 at 5:48 p.m. with complaints of right side head pain and vision changes. Review of the medical record indicated that after an examination had been conducted the practitioner discussed the risks and benefits of further diagnostic testing and specific procedures. Patient #3 was unsure how he wanted to proceed and asked to think about next steps. When the practitioner returned to the room at 6:55 p.m., Patient #3 had eloped from the emergency department.

Review of the EMTALA log for 4/1/18 listed the Disposition Category for Patient #3 as refused treatment and the Disposition Type as against medical advice.

c) Patient #15, a 79 year old male, presented to the ED on 4/17/18 at 12:29 p.m. with complaints of worsening abdominal pain, vomiting and diarrhea. Review of Patient #15's medical record indicated the patient was being seen by a vascular surgeon at a different acute care hospital for a complex medical condition. After consultation with Patient #15 and the vascular surgeon at the different acute care hospital, it was decided to transfer Patient #15 to that hospital for continuity of care.

Review of the EMTALA log for 4/17/18 listed the Disposition Type for Patient #15 as transferred to a critical access hospital.

d) Patient #19, a 17 year old male, presented to the ED on 4/4/18 at 1:28 a.m. with complaints of abdominal pain. Review of the medical record indicated Patient #19 required surgery and he was transferred to the care of a pediatric surgeon at a different acute care hospital.

However, review of the EMTALA log for 4/4/18 listed the Disposition Type for pediatric Patient #19 as transferred to a critical access hospital.

e) Patient #20, a 5 year old female, presented to the Pediatric ED on 4/4/18 at 4:40 p.m. with a sore throat and ear pain. Review of the medical record indicated Patient #20 was treated and discharged home in the care of her mother with instructions to follow up with the child's primary care physician.

However, review of the EMTALA Log for 4/4/18 listed the Disposition Place for pediatric Patient #20 as jail.

f) Director #2, was asked during the 5/2/18 interview who reviewed the EMTALA log for accuracy. Director #2 stated she reviewed the log for the adult emergency department daily. She would review the log in comparison to the patient's medical record to ensure accuracy. Director #2 stated she would review the medical record to ensure the treating practitioner entered the correct disposition category on the log and that the nurse entered the correct disposition type and place. When asked about the log discrepancies noted for Patient's #3, #15, #19 and #20, Director #2 stated that the electronic health record (EHR) software allowed for a limited number of disposition types and that sometimes the correct disposition type was not an option to select in the system. Director #2 stated "when I started here as the manager I brought up the discrepancy regarding [the EHR] and was told that it was a glitch in the software and to be honest I have not pursued the issue again."

Based on interviews and document review, the facility failed to ensure a Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel (QMP) in 1 of 2 records reviewed for patients who presented to the facility for an emergency evaluation during a time when the facility was in lockdown (Patient A). This failure resulted in the delay of care for a patient experiencing an emergency medical condition.

Findings include:

Facility policy:

According to EMTALA Medical Screening Examination and Stabilization Policy, an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and requests an examination or treatment for a medical condition. The hospital must provide an appropriate MSE within the capability of the hospital's emergency department (ED) to determine whether or not an EMC exists. The hospital must perform an MSE to determine if an EMC exists. It is not appropriate to merely "log in" or triage an individual with a medical condition and not provide an MSE. Triage is not equivalent to an MSE.

1. The facility failed to ensure all patients who presented to the facility seeking emergency medical treatment received a medical screening examination (MSE) to determine if an emergency medical condition existed.

a) Review of an internal management report, dated 3/23/18 at 3:28 p.m., revealed Patient A presented to the emergency department (ED) on 3/22/18 with a complaint of chest pain. According to the report a security officer greeted the patient as the ED was in a security lockdown status.

During an interview, on 5/2/18 at 11:20 a.m., with Hospital Security (HS) #3, he stated he was the person who greeted Patient A when the patient arrived at the ED on 3/22/18.

HS #3 stated his roll on 3/22/18 was to bring patients and visitors into the ED and check bags. HS #3 stated the ED was very busy that day and there were a "bunch of patients and visitors sitting in the lobby." He stated Patient A came into the ED and told him he was having "chest pain" and wanted to be seen. HS #3 said the patient asked how long it would take and he told the patient he didn't know how long it would take but they would put the patient at the head of the line and get him seen as soon as possible. HS #3 stated he pointed to where the emergency medical technician (EMT, the employee who completed the triage) was sitting and told Patient A he would be next in line. HS #3 stated he didn't know why the EMT did not come over to where the patient was and stated he did not request the EMT to come over. HS #3 stated Patient A kept asking "how long is it going to be" and HS #3 told the patient he couldn't give him an exact time but told the patient he could see the EMT.

During a tour of the ED, on 4/30/18 beginning at 11:50 a.m., Lead Security Officer #4 (LSO) and Director of Emergency Services, Adult Emergency Department #2 (Director) stated when the ED was in a lockdown status a registered nurse (RN) or EMT would be posted with the security officer at the ambulance bay and ED reception area. According to Director #2 the RN or EMT would gather medical information for the patients. However, there was no evidence an EMT or RN was posted with HS #3 during the lockdown on 3/22/18.

During a subsequent interview, on 5/2/18 at 10:00 a.m., Director #2 stated she was aware of the alleged EMTALA violation. She stated her understanding was the security officer tried to get the patient to talk with the EMT and it had not been communicated to the EMT that there was a patient with chest pain. According to Director #2 there were no intentional barriers to the patient being evaluated but they "could have communicated better."

Subsequently, the patient left the ED and was driven to another acute care hospital where he was admitted with a myocardial infarction (heart attack) and underwent an emergent cardiac catheterization (a procedure used to diagnose and treat cardiovascular conditions) for treatment.