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Based on observation, interviews, and document reviews, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

FINDINGS

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

C-2406: Applicability of Provisions of this Section (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must-(i) Provide an appropriate medical screening examination 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 exists. Based on observations, interviews, and document reviews, the facility failed to ensure a patient who presented to the dedicated emergency department (ED) received a medical screening examination (MSE) to determine the presence of an emergent medical condition in one of one patients reviewed who presented to the ED escorted by law enforcement. (Patient #7)

Based on observations, interviews, and document reviews, the facility failed to ensure a patient who presented to the dedicated emergency department (ED) received a medical screening examination (MSE) to determine the presence of an emergent medical condition in one of one patients reviewed who presented to the ED escorted by law enforcement. (Patient #7)

Findings include:

Facility policy:

According to the Emergency Treatment and Labor Act (EMTALA) policy, this policy applies to all individuals seeking or needing an examination or treatment for emergency medical services who come to the hospital's dedicated emergency department or on hospital property, even if they present at a location other than the dedicated emergency department. Hospital property includes parking lots, sidewalks, and any additional buildings owned by the hospital within 250 yards.

The hospital will provide an appropriate MSE within the capability of the hospital's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether an emergency medical condition exists. The examination will be conducted by an individual(s) determined qualified by hospital bylaws or rules and regulations.

Reference:

According to the Medical Staff Rules and Regulations for appropriate screening examinations, all persons presenting in the emergency room must receive an appropriate medical screening by qualified medical personnel to determine whether an emergency medical condition exists. "Qualified Medical Personnel" consists of such categories of personnel as have been designated by the Board from time to time and may include a physician, or Allied Health Professional (AHP) member of the Medical Staff or an Allied Health Professional (AHP) with appropriate privileges or a registered nurse. No person will be denied access to treatment or accommodations that are available and medically indicated.

1. The facility failed to ensure a patient who presented for treatment in the ED received a MSE to determine the presence of an emergent medical condition.

A. Document Review

i. Review of the Emergency Room Register revealed Patient #7 presented with the police department (PD) to the ED on 4/4/25 at 3:45 p.m.

ii. On 5/27/25 at 5:14 p.m., upon request, the facility was unable to provide a medical record for Patient #7's visit to the ED on 4/4/25 at 3:45 p.m.

iii. Review of email correspondence sent on 4/5/25 at 9:11 a.m. to the chief nursing officer (CNO) from a separately certified facility revealed there had been a potential EMTALA violation.

iv. Review of the facility's EMTALA 2025 Action Plan revealed Patient #7 had been at the facility for 30 minutes and had not been brought in to the ED for an immediate MSE. Patient #7 and PD officers had been asked to wait outside. Additionally, Guard #1 did not understand that a provider was required to see Patient #7 immediately, even if a mental health evaluation could not be completed right away. Further review of the EMTALA 2025 Action Plan revealed security staff were to receive education on current EMTALA rules.

v. On 5/27/25 at 5:14 p.m., upon request, the facility was unable to provide evidence of EMTALA education which had been provided to security staff.

B. Observation

i. On 6/2/25 at 5:15 p.m., observation of video surveillance footage from 4/4/25 was conducted. At 3:48 p.m., Patient #7 presented to the ED entrance handcuffed with two PD officers. At 3:54 p.m., security guard (Guard) #1 met Patient #7 and the two PD officers in the ED entrance. At 4:11 p.m., Patient #7 and one of the PD officers walked outside. At 4:14 p.m., Provider #2 arrived at the ED entrance, spoke with one of the PD officers in the ED entrance, and then re-entered the ED. At 4:16 p.m., Patient #7 and the two PD officers walked away from the ED.

Video surveillance revealed Patient #7 did not re-enter the ED, and Provider #2 did not see or speak to Patient #7 before they left the ED.

This was in contrast to the EMTALA policy which read, the hospital would provide an appropriate MSE within the capability of the hospital's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether an emergency medical condition existed. The examination would be conducted by an individual(s) determined qualified by hospital bylaws or rules and regulations.

Additionally, video surveillance revealed Patient #7 appeared calm, non-aggressive, and stood with their hands cuffed behind their back throughout their duration of time in the ED entrance.

C. Interviews

i. On 5/28/25 at 8:47 a.m., an interview was conducted with certified nursing assistant (CNA) and ED check-in clerk (Clerk) #3. Clerk #3 stated two PD officers and Patient #7 had entered the ED entrance. Clerk #3 also stated other patients in the waiting area were upset because Patient #7 was loud and used foul language. Clerk #3 stated they had asked Guard #1 to speak with the PD officers. Additionally, Clerk #3 stated Patient #7 was not seen in the ED by the nurses or Provider #2.

ii. On 5/28/25 at 12:45 p.m., an interview was conducted with Guard #1. Guard #1 stated PD officers brought Patient #7 to the facility for an evaluation. Guard #1 stated Patient #7's behavior was inappropriate and they informed PD officers to wait with Patient #7 outside while the room was cleaned and prepared.

This was in contrast to video surveillance review which revealed Patient #7 appeared calm, non-aggressive, and stood with their hands cuffed behind their back throughout their duration of time in the ED entrance.

Guard #1 also stated they informed PD officers they were required to stay with Patient #7 for 12 hours. Additionally, Guard #1 stated they were not aware of EMTALA requirements and had not yet performed the EMTALA training with other security officers.

iii. On 6/2/25 at 4:44 p.m., an interview was conducted with Provider #2. Provider #2 stated Patient #7 did not receive a MSE. Provider #2 stated Guard #1 was not qualified to provide an MSE and was also not qualified to assess for behavioral health emergencies. Additionally, Provider #2 stated patients were at risk if security guards sent them away without a MSE.

iv. On 5/28/25 at 2:19 p.m., an interview was conducted with CNO #4. CNO #4 stated all action items listed in the EMTALA 2025 Action Plan had been completed.

This was in contrast to the interview with Guard #1 who stated they and other security guards had not completed EMTALA training. This was also in contrast to the EMTALA 2025 Action Plan which revealed security staff should have received education on current EMTALA rules.