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Based on review of clinical records, policies and procedures, and staff interviews, it was determined the Hospital failed to ensure all staff were familiar with and complied with their EMTALA policies and procedures as evidenced by:

The hospital's "EMTALA Policy for Emergency Department Services and Patient Transfers" included the following:
"...All Hospital staff and Medical Staff whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy...."

A-2405 Central Log: The hospital failed to ensure that all patients who presented to the ED were entered into the central log. Patient #1 was brought into the hospital by Emergency Medical Services (EMS) personnel. The EMS personnel were told to take the patient to a hospital that had psychiatric services. The patient was not entered into their central ED log.

A-2406 Medical Screening Exam: The hospital failed to provide a medical screening examination to a patient who was brought in by emergency medical services (EMS) and exhibited altered mental status. EMS personnel were told to take the patient to another hospital that provided psychiatric services (Patient #1).

Based on review of Emergency Department (ED) logs, policies and procedures, and staff interviews, it was determined the hospital failed to ensure that all patients who presented to the ED were entered into the central log. Patient #1 was brought into the hospital by Emergency Medical Services (EMS) personnel. The EMS personnel were told to take the patient to a hospital that had psychiatric services. The patient was not entered into their central ED log.

Findings include:

The hospital's "EMTALA Policy for Emergency Department Services and Patient Transfer" included the following: "...The Hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE...."

Refer to Tag A-2406. Patient #1 was taken to Santa Cruz Valley Regional Hospital (SCVRH) by EMS on 11/25/2021. The patient was described by EMS personnel as "verbally aggressive" and refused assessment because he did not trust the physician and staff. EMS personnel were told to take the patient the patient to another hospital. The patient was not entered in the central ED log.

Staff #2 and Staff #3 acknowledged policies and procedures were not followed after the surveyor reviewed the hospital's policies and procedures with them.

Based on reviews of clinical records, hospital policies and procedures, and staff interviews, it was determined the hospital failed to provide a medical screening examination to a patient who was brought in by emergency medical services (EMS) and exhibited altered mental status. EMS personnel were told to take the patient to another hospital that provided psychiatric services (Patient #1).

Findings include:

The hospital's policy and procedure titled "EMTALA Policy for Emergency Department Services and Patient Transfers" included the following: "1. Definitions:...B. 'Comes to the Emergency Department' For purposes of this policy, an individual is deemed to have 'come to the emergency department' if the individual: 1. Presents at a dedicated emergency department, and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. 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 for a medical condition...II. Policy...If an individual comes to the Emergency Department: A. The Hospital will provide an appropriate medical screening examination within the capability of the Hospital's Dedicated Emergency Department, including ancillary services routinely available, to determine whether an emergency medical condition exists...F. Refusal of Treatment...If the Hospital offers further examination and treatment and informs the individual or the person acting on the individual's behalf of the risks and benefits of the examination and treatment but the individual or person acting on the individual's behalf does not consent to the examination and treatment, the Hospital must take all reasonable steps to have the individual or the person acting on the individual's behalf acknowledge their refusal of further examination and treatment in writing. The medical record must contain a description of the examination, treatment or both if applicable, that was refused by or on behalf of the individual; the risks/benefits of the examination and/or treatment; the reasons for refusal; and if the individual refused to acknowledge their refusal in writing, the steps taken to secure the written informed refusal. Hospital personnel involved with the individual's care or witness the individual refusing consent must document the patient's refusal in the medical record..."

Documentation in the hospital's Medical Staff Rules and Regulations (Article I. General) included: "...A report is required for all Emergency Department visits...."

Documentation in the EMS "Pre Hospital Care Report" dated 11/25/2021 revealed they were dispatched to a residence where they found "an elderly man" (Patient #1) outside. The patient was described to be, "disoriented and weak." There were family/friends present that reported the patient had been missing for approximately 45 minutes. Documentation in the report included: "...Pt alert was able to state his name but any other question asked he would not make sense and would state out loud "NO" unknown reason why he would say that...Upper extremities pt would keep his hands engaged in open position, was shaking slightly on touch hands felt very cold to touch, would not be able to close his hands on demand and would keep them clenched open...Family had stated that pt has never acted out like this before reassuring us that pt has always been healthy, is very talkative, never to be disoriented like he is now, denied any drug or alcohol use, denied history of dementia, later one family friend advised to be his care giver and roommate...pt now requesting to be transported to Green Valley hospital...Moved gurney to his location pt unable to get up on his own, took three of us to lift patient onto gurney and secure into ambulance. Once in ambulance pt had become verbally aggressive...contact SCVRH (Santa Cruz Valley Regional Hospital) gave report advised ETA of our arrival, no questions or orders. Arrived SCVRH at 1649hrs pt hands became relaxed, had warmed up patient significantly since we first made patient contact, advised pt friend to report to the front desk to help register pt into system, we continued into the ER, patient did become verbally aggressive again loud enough for attending doctor and charge nurse to come out to us and find out patient status. Doctor (Physician #1) and Charge Nurse (Staff #6) attempt to gather information from patient, patient then was verbally aggressive towards (Physician #1), pt cooperative towards (Staff #6), pt advised (Staff #6) 'I don't trust these people and want to see his credentials' D(Physician #1) tried showing his name tag stating that is all his credentials he can see at the moment. (Physician #1 attempt to reason with patient, patient remained verbally aggressive. (Physician #1) advised that they would not seen him at this hospital that we need to divert and go north and transport pt to a hospital specialized for psychiatric behavior...Secured pt back in ambulance, began transport to (Hospital #2) at 1702 hrs...."

Patient #1 arrived at Hospital #2 at approximately 5:32 p.m.. The patient received a Medical Screening Examination and the ED physician's documentation included: "...brought in for evaluation of altered mental status. Patient's friend, who is his caretaker, reports that patient was at his baseline until this morning when she noted that he was swelling up and take care of himself, however today he just sat in his incontinent urine. He stated to her that he felt "goofy" but was unable to specify further. He was at family dinner today when he wandered off and they found him approximately 30 minutes later in the desert. No fevers, cough, chest pain, shortness of breath, unilateral weakness. No history of alcoholism, usually has 1 glass of wine with dinner. Friend states he did fall approximately a week ago, onto his hands and knees, did not hit his head. Per the caretaker, he is normally alert and oriented x3, though he is somewhat forgetful....88-year-old male presenting for evaluation of altered mental status starting this morning and brought in after being found wandering the desert for about 30 minutes. ABCs intact, no focal neurologic deficits, patient is alert and oriented. However, during my conversation with the patient he is extremely paranoid and will not speak because he thinks I am not a doctor and I am impersonating someone else. He is seeing people walking in the room that myself and the nurse cannot see. He does not want his caregiver in the room. As he has no focal neurologic deficits and is alert and oriented, I am more concerned for acute delirium from an infectious source or dehydration, rather than intracranial pathology. He has a mildly elevated white count, with left shift. UA is negative for infection. He has an AKI (acute kidney injury), unclear if this is a new AKI or an AKI on CKD (chronic kidney disease) as we have no past records. Lactate is elevated, repeat is below 2 after fluids. EKG shows T wave inversions, but troponins are 41 x2, low concern for ACS (acute coronary syndrome). I was called to bedside as patient is getting dressed and is trying to leave. Nursing was unable to verbally redirect the patient. Medical restraints for nonviolent behavior ordered due to concerns of him hurting himself or wandering out of the ER. Due to his agitation, he required sedation for CT head and CXR...On reevaluation, patient is now calm and resting quietly. Now the patient has been medicated, it is difficult to obtain a reevaluation of his mental status due to sleepiness. As the source of patient's altered mental status has not been found, patient will require admission for treatment of his AKI and further work-up of the altered mental status. As there are no hospital beds available, patient will likely spend the night in the ED awaiting admission in the morning....

The Emergency Services Follow-up Record dated (Patient Care Transfer) 11/26/2021 at 1:38 a.m. included: "...
CT head shows no acute intracranial abnormality...Chest x-ray shows bilateral interstitial opacities concerning for multifocal pneumonia/COVID-19...Given patient's evidence of multifocal pneumonia I have ordered a COVID-19 test. Patient's repeat BMP (basic metabolic panel) returned again with hyperkalemia of 5.9. Patient has not been given anything for his hyperkalemia thus I have ordered insulin with dextrose, IV Lasix, and Lokelma...The patient was signed out in stable condition...The final disposition is pending repeat labs and close monitoring of potassium...." The patient was admitted as an inpatient on 11/26/2022 with diagnoses including acute encephalopathy, anemia acute kidney injury, and altered mental status, and discharged on 12/03/2021.

Physician #1 was not available for an interview, and Staff #6 was no longer employed at the hospital.

Interviews were conducted with Staff #2 and Staff #3 on 05/03/2022. Staff #2 reported she was contacted by Hospital #2 and informed of a possible EMTALA violation involving Patient #1. Staff #2 reported she notified Staff #3. Staff #3 stated an investigation was completed which included obtaining statements from the ED physician (Physician #1) and the ED Registered Nurse (RN) (Staff # who were present when Patient #1 arrived. Both Physician #1 and Staff #6 acknowledged in the statements that Patient #1 was brought in by EMS, however, the elderly patient refused to be assessed, and EMS was directed to take the patient to a hospital in Tucson. Both Staff #2 and Staff #3 stated EMTALA did not apply in this situation. The surveyor referenced the hospital's EMTALA policies and procedures based on EMTALA regulations, and both Staff #2 and Staff #3 acknowledged the policies and procedures were not followed.