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Based on observation and interview, the hospital failed to ensure required Emergency Medical Treatment and Labor Act (EMTALA- requires hospitals with emergency departments to provide a medical screening examination to any individual who comes to the emergency department or Labor and Delivery [L&D] unit and requests such an examination) signs were posted in the L&D registration/waiting room area.

Findings:

During an observation and interview, on 1/30/22, at 8:56 AM, with Director of Maternal/Child Services (DMCS), Director of Education and Staff Development (DESD), Manager of Operations for Maternal/Child Services (MOMC), and Licensing and Accreditation Registered Nurse (LARN), in the L&D registration/waiting room, no required EMTALA signs were observed. DMCS, DESD, MOMC, and LARN stated, there were no EMTALA signs posted, in the L&D registration/waiting room.

During a review of the hospital's policy and procedure (P&P) titled, "COBRA [Consolidated Omnibus Budget Reconciliation Act]/EMTALA Compliance," dated 9/19, the P&P indicated, "I. Purpose: To define the statutory requirement for providing a medical screening examination, emergency medical treatment and possible transfer of anyone presenting to any [hospital] facility. . . D. To establish the necessary definitions. . . that will be utilized at [the hospital] for defining appropriate and compliant level of care and procedures. . . d) To post conspicuously. . . a sign in a form specified by DHHS [Department of Health and Human Services- a cabinet-level executive branch department of the United States federal government created to protect the health of the U.S. people and providing essential human services] specifying the rights of individuals under EMTALA and its amendments with respect to examination and treatment for emergency medical conditions and women in labor. 1) The signs must be printed in English and other major languages common to the populations of the area served by the hospital. 2) The signs must be clearly readable at 20 feet or the expected vantage point of the patients. 3) The signs must be posted in places likely to be noticed by all individuals entering the ED, as well as those individuals waiting for examination and treatment in areas other than the traditional EDs (that is, at entrances, in admitting areas, in waiting rooms and in treatment areas)."

Based on interview and record review, the facility failed to maintain a Emergency Room Patient Log of each patient who came to the Emergency Department seeking emergency care when Patient 21 was not registered and included on the log. This failure resulted in Patient 21 having delayed emergency care that had potential to worsen or even cause death.

During an interview on 1/30/23, at 10 AM, with RN 2, RN 2 stated, she was working in the ED the night of 11/22/22. RN 2 stated, Patient 21's family member (FM) drove up to the ambulance entrance in their vehicle. RN 2 stated, Patient 21's FM got out of the car and stated to the staff that Patient 21 needed to be seen for her brain tumors and a fainting spell. RN 2 stated, Patient 21 refused to get out of the car. RN 2 stated, she asked Patient 21 her name, date, president, and her birthday. RN 1 stated, Patient 21 answered the questions correctly. RN 2 stated, since Patient 21 was alert and orientated, she could not "make her get out of the car." RN 2 stated, she told Patient 21's FM, he could call law enforcement to come out and they might be able to make her a legal psychiatric hold or make her get out of the car, but she (RN 2) could not. RN 2 stated, "I didn't see any reason to get a provider involved and didn't even think about it." RN 2 stated, no MSE or registration was completed for Patient 21.

During a concurrent interview and record review, on 1/30/23, at 3 PM, with Director of Licensing and Accreditation (DLA), Emergency Room Patient Log dated 11/22/22 and 11/23/22, was reviewed. DLA stated and verified, Patient 21 was not registered as a patient and was not entered into the Emergency Room Patient Log.

During a review of the facility's policy and procedure (P&P) titled, "COBRA/EMTALA Compliance," dated 2022, the P&P indicated, "K. 1. Agreement with the U.S. Department of Health and Human Services (DHHS) Medicare Participating hospitals must file certain agreements with DHHS and must maintain the following. . . F)To maintain a central log on each individual who comes to the ED seeking assistance and whether he/she: 1) Refused treatment; 2) Was refused treatment; 3) Was transferred; 4) Was admitted and treatment; or 5) Was stabilized and transferred or discharged.

Based on observation, interview, and record review, the hospital failed to follow Emergency Medical Treatment and Labor Act (EMTALA) regulations for providing medical screening exams (MSE) when a Qualified Medical Professional (QMP) did not provide an MSE to determine if an emergency medical condition existed for one of five sampled patients (Patient 21) who presented to the emergency department (ED) entrance with behavior changes. This failure resulted in Patient 21 leaving the hospital without an MSE, a delay of care and admission to another hospital's intensive care unit (specialty care unit).

Findings:

During an interview on 1/30/23, at 9:08 AM, with RN 1, RN 1 stated, if a vehicle arrived at the ED entrance and the patient needed help, staff would go out to evaluate the patient. RN 1 stated, if the patient refused to get out of the car, he (RN 1) would try to assess the patient and he would encourage the patient to see a provider. RN 1 stated, he (RN 1) would get a provider to come out and evaluate the patient in case there was something going on with the patient and "they really needed to be seen."

During an interview on 1/30/23, at 9:23 AM, with Nurse Practitioner (NP), NP stated, if a vehicle arrived at the ED entrance with a patient, nursing staff would go out there and evaluate the patient. NP stated, if the patient refused to get out of the car for care and had a concerned family member, she expected the clinical staff to get a provider involved before the car left.

During an interview on 1/30/23, at 9:40 AM, with Emergency Room Physician (ERP), ERP stated, if a vehicle arrived at the ED entrance with a patient and the patient refused to get out of the car and there was a concerned family member, he expected clinical staff to get a provider involved, "to at least go out there and see what the situation is before the patient leaves and get a MSE."

During an interview on 1/30/23, at 9:52 AM, with the Nurse Supervisor (NS), NS stated, if a vehicle arrived at the ED entrance with a patient that refused to get out of the car after clinical staff evaluated them, she expected a provider to get involved to further evaluate the situation.

During an interview on 1/30/23, at 10 AM, with RN 2, RN 2 stated, she was working in the ED the night of 11/22/22. RN 2 stated, Patient 21's family member (FM) drove up to the ambulance entrance in their vehicle. RN 2 stated, Patient 21's FM got out of the car and stated to the staff that Patient 21 needed to be seen for her brain tumors and a fainting spell. RN 2 stated, Patient 21 refused to get out of the car. RN 2 stated, she asked Patient 21 her name, date, president, and her birthday. RN 1 stated, Patient 21 answered the questions correctly. RN 2 stated, since Patient 21 was alert and orientated, she could not "make her get out of the car." RN 2 stated, she told Patient 21's FM, he could call law enforcement to come out and they might be able to make her a legal psychiatric hold or make her get out of the car, but she (RN 2) could not. RN 2 stated, "I didn't see any reason to get a provider involved and didn't even think about it." RN 2 stated, no MSE was completed for Patient 21.

During an interview on 1/30/23, at 1:55 PM, with Interim Emergency Room Director (ERD), ERD stated, it was her expectation that if a patient arrived at the ED entrance and refused to get out of the car, an RN would go out to evaluate the patient. ERD stated, if the RN deemed the patient stable, alert, and orientated, the RN could not make the patient get out of the car and the patient should be allowed to leave. ERD stated, a provider should not have to get involved if the RN felt there was no concerns in patients' assessment. ERD stated, she was not sure if the hospital's governing body allowed RNs to do MSE's.

During an interview on 1/30/23, at 5:15 PM, with complainant/medical doctor (MD), MD stated, she saw Patient 21 at the ED where she worked and diagnosed Patient 21 with altered mental status (confusion), syncope (fainting episode), and brain tumors. MD stated, she recommended Patient 21 transfer to another hospital for higher level of care. MD stated, Patient 21's Family Member (FM) came back to her ED 2 days later and told her he went to two different hospitals, and both refused Patient 21 care. MD stated, Patient 21 arrived at [hospital] on 11/22/22. MD stated, Patient 21's FM told her that they pulled up to [hospital] ED entrance in their car and had a nurse and a security guard come out with a wheelchair. MD stated, Patient 21's FM said he explained to the nurse that Patient 21 had cancer with a new brain tumor, had fainted, and needed to be admitted. MD stated, Patient 21's FM also told the nurse he had medical records and images from the previous hospital. MD stated, the nurse then asked Patient 21 to get out of the car and get into the wheelchair. MD stated, Patient 21 refused to get out of the car stating she wanted to go home and didn't want to be seen. MD stated, the nurse asked Patient 21 standard questions, like birthday, year, president, and stated, Patient 21 answered the questions correctly. MD stated, the nurse told the Patient 21's FM that Patient 21 was allowed to refuse care and they could not make her get out of the car if she was alert and orientated. MD stated, Patient 21's FM went home and ended up calling 911 for an ambulance who brought her back to the ED where she works. MD stated, a repeat Cat Scan (CT- imaging study) of her brain showed that Patient 21's brain had increased swelling, Patient 21 ended up with a breathing tube and placed in the Intensive Care Unit. MD stated, the [hospital] did not do a medical screening exam or have a provider come out to evaluate the patient.

During a review of the facility's policy and procedure (P&P) titled, "COBRA/EMTALA Compliance," dated 2022, the P&P indicated, "II. DEFINITIONS: E. "Comes to the Emergency Department" (ED)- 2. The individual presents on hospital property. . . and requests (or has a request made on his/her behalf) an examination or treatment for what may be an emergency medical condition. H. Emergency Medical Condition: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances. . . such that the absence of immediate medical attention could reasonable be expected to result in: a) placing the health of the patient in serious jeopardy; or b) Serious impairment to bodily functions; or c) Serious dysfunction of any bodily organ or part. I. Emergency Medical Treatment and Active Labor Act (EMTALA). . . requiring all hospitals. . . to conduct appropriate medical screening examinations on all patients presenting to the ED. The hospital is then obligated to treat and stabilize and, if necessary, appropriately transfer patients suffering from identified emergency condition. M. Hospital Property- The entire main hospital campus (including parking lots, sidewalks, and driveways) defined as: . . . structures owned and operated by the hospital within 250 yards of the main buildings. P. Medical Screening Examination- The process required to reach with reasonable clinical confidence., the point at which it can be determined whether a medical emergency does or does not exist. V. PROCEDURE: A. Medical Screening Requirement 1. If an individual comes to the ED, the hospital must provide for an appropriate medical screening examination within the capability of the hospitals ED. . . to determine whether an emergency medical condition exist. B. Examination, Evaluation, and Consultation d) The hospital must take all reasonable steps to obtain the patient's informed refusal. E) 1) Under EMTALA, the categories of personnel who may perform the medical screening. . . must be designated in the medical staff bylaws or rules and regulations.


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Base on interview and record review, the facility failed to facilitate an appropriate transfer when the hosptial did not complete the Transfer Form (physician signed certification of the risks and benefits of transfer) and the Patient Transfer Acknowledgement (consent) for one of five sampled transferred patients (Patient 2). This failure had the potential for Patient 2's responsible party to be unable to make informed decisions before consenting to the transfer and the receiving hosptial to be unaware of Patient 2's medical history.

Findings:

During a review of Patient 2's "Emergency Documentation" (EDD), dated 10/11/22, the "ED" indicated, Patient 2 went to the emergency room (ER) with a complaint of shortness of breath and chest pain. Patient 2 had a history of high blood pressure and abnormal blood sugar levels. Patient 2's electrocardiogram (EKG- diagnostic test to determine the electrical activity of the heart and to rule out a heart attack) showed a STEMI (S-T-Elevated Myocardial Infarction "AKA" heart attack). The hospital transferred Patient 2 to another hospital for cardiac catheterization (medical procedure to diagnose and/or treat some heart problems).

During a concurrent interview and record review, on 1/30/23, at 2:39 PM, with Director of Licensing and Accreditation (DLA), Patient 2's "Medical Record (MR)," dated 10/11/22, was reviewed. DLA stated, there were no transfer forms or Patient 2's consent for transfer found in the medical record. DLA stated, anyone transferred to another facility should have these forms filled out.

During an interview on 1/30/23, at 2:50 PM, with Emergency Room Director (ERD), ERD stated, if a patient came into the emergency department (ED) and was diagnosed with a heart attack and needed a procedure, there was not a lot of time to fill out the paperwork. ERD stated, "I think we already had an ambulance in the ER at the time. Patient 2 needed to be transferred, and that ambulance just took [Patient 2] to [a second hospital]."

During a review of the facility's policy and procedure (P&P) titled,"COBRA/EMTALA Compliance," dated September 2022, the P&P indicated, "e) Transfer Summary- 1) The records transferred with the patient include a transfer summary signed by the transferring physician, which contains relevant transfer information. The transfer summary must at a minimum, contain the following: (n) The transfer creates no medical hazard to the patient. Neither the transferring physician nor the transferring hospital is required to duplicate in the transfer summary information contained in other; medical record transferred with the patient. A copy of the transfer summary must be given to the patient prior to transfer. D. Transfer of Patient with Emergency Medical Condition: 2. C) Physician Certification: 1) A physician has signed a certification that based upon the information available at the time of transfer, the medical benefits reasonable expected from the provision of appropriate; medical treatment at another medical facility outweigh any increased risks to the patients. . . The physician will complete and sign the physician certification. The certification must include a summary of the risks and benefits upon which the certification is based. In addition, the patient record will document an evaluation of the patient immediately prior to the departure from the hospital."