HospitalInspections.org

Based on observation, review of video recordings, interview, review of medical record documentation for 15 of 24 individuals who presented to the hospital for emergency services (Patients 1, 3, 4, 6, 7, 8, 9, 12, 14, 15, 16, 17, 18, 23, and 24), review of the central log, review of internal investigation documentation and review of hospital policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured it met its EMTALA obligations in the following areas:
* To maintain a central log that was complete, and accurately reflected all individuals who presented for emergency services, the reasons they presented and their dispositions.
* To not dissuade individuals from staying to receive an MSE or otherwise delay examination and/or treatment in order to inquire about the individual's insurance or payment status.
* To provide MSEs for all individuals who present to the hospital for emergency services.
* To ensure the provision of MSEs by qualified practitioners.
* To obtain or attempt to obtain written and informed refusal of MSEs and treatment for individuals who refuse examination and treatment.

Findings included:

1. Refer to the findings identified under Tag C2405, CFR 489.20(r)(3) that reflects the hospital's failure to maintain a complete and accurate central log.

2. Refer to the findings identified under Tag C2406, CFR 489.24(a)&(c), that reflects the hospital's failure to ensure all individuals who presented for emergency services received an MSE and that MSEs were conducted by qualified practitioners.

Based on review of video recordings, interview, review of medical record documentation for 8 of 24 individuals who presented to the hospital for emergency services (Patients 1, 3, 6, 7, 9, 18, 23 and 24), review of the central log, review of internal investigation documentation and review of hospital policies and procedures it was determined that the hospital failed to develop and enforce EMTALA policies and procedures that ensured a central log was maintained for completeness, and accurately reflected all individuals who presented for emergency services, the reasons they presented and their dispositions including whether they refused treatment or they were refused treatment:
* An individual who presented to the hospital for emergency services was directed by hospital registration staff to go to another hospital. The central log lacked an entry to reflect the individual had presented to the hospital.
* Incomplete and unclear central log entries included chief complaints and dispositions.

Findings include:

1. The P&P titled "Transfers of Patients with Emergency Medical Conditions or Labor (EMTALA)" dated as last revised "February 2017" was reviewed and included the following:
* A Central Activity Log system is maintained and consists of departmental activity logs in TCH Family Birth Unit, TCH Emergency Department ... To ensure a record of the patient encounter in the ED Central Activity Log for all patients who present to the ED Registration or Family Birth Unit, staff will follow a provided standard script: Staff will ask 'Are you here to be seen?' If the answer is yes, staff will register the patient by first and last name and date of birth in the system, which populates the ED Central Activity Log."

2. Review of the central log for 09/10/2019 reflected there was no entry to show that Patient 1 had presented to the hospital. Refer to the detailed findings described at Tag C2406 that reflects Patient 1 presented to the hospital, did not receive an MSE and was not entered into the central log.

3. The central log reflected that Patient 3 presented to the ED on 10/08/2019 at 2251. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Unspecified."

4. The central log reflected that Patient 6 presented to the ED on 10/10/2019 at 1756. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Unspecified."

5. The central log reflected that Patient 7 presented to the ED on 10/10/2019 at 1837. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Unspecified."

6. The central log reflected that Patient 9 presented to the ED on 10/10/2019 at 2034. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Unspecified."

7. The central log reflected that Patient 18 presented to the FBC on 10/18/2019 at 1150. The log space for "Disposition" was blank.

8. The central log reflected that Patient 23 presented to the ED on 11/04/2019 at 1435. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Unspecified."

9. The central log reflected that Patient 24 presented to the ED on 11/05/2019 at 0534. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Unspecified."

Based on review of video recordings, interview, review of ED medical record documentation for 14 of 24 individuals who presented to the hospital for emergency services (Patients 1, 3, 4, 6, 7, 8, 9, 12, 14, 15, 16, 17, 18 and 24), review of internal investigation documentation and review of policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured that every individual who presented to the hospital for emergency services received an MSE within the hospital's capability and capacity by qualified practitioners, and that hospital staff did nothing to dissuade patients from staying at the hospital for the provision of an MSE:
* An individual who presented to the hospital for emergency services did not receive an MSE and instead was directed by hospital registration staff to go to another hospital ED.
* Other individuals who presented to the hospital for emergency services left the hospital before receiving an MSE for reasons that were unclear or unexplained or after insurance information had been obtained or discussed.
* An OB patient did not receive an MSE from a qualified practitioner.
* P&Ps and Medical Staff bylaws and rules and regulations, and the documentation provided as evidence of RN MSE competency, did not clearly delineate between the triage process and an MSE by RNs for OB patients.

Findings include:

1. a. The P&P titled "Transfers of Patients with Emergency Medical Conditions or Labor (EMTALA)" dated as last revised "February 2017" was reviewed and included the following:
* "All staff is obliged within an individual's level of expertise to direct people seeking help for a medical emergency, including women in labor, to the appropriate department or staff within the Tuality Healthcare organization to obtain help"
* "Emergency services and care means medical screening, examination, and evaluation by a physician or other health professional (to the extent applicable by law), to determine if an emergency medical condition or active labor exists and, if is does, the care, treatment, and surgery by a physician ..."
* "A woman is in true labor unless a physician certifies that, after a reasonable period of observation, the woman is in false labor ... (Any undelivered patient experiencing contractions or having other signs of labor is to be managed as an EMTALA patient.)"
* "An MSE must be provided to any person who comes to the ED/FBU and needs or requests examination or treatment for a medical condition. The individual may request the examination or it may be requested on his or her behalf."
* "Hospital personnel may not register persons who come to the emergency department requesting emergency services before the person receives a medical screening exam and any necessary stabilizing treatment if the person has an emergency medical condition unless: the registration does not include any inquiry into the person's method of payment or insurance status; or the registration process occurs during a natural delay during the persons's medical screening exam and necessary stabilizing treatment."
* "Patients must be examined and evaluated by a physician, or if not by a physician, by a physician assistant, nurse practitioner, Family Birth Unit registered nurse who has completed training and demonstrated competency or a certified nurse midwife who is consulting with the physician responsible for the transfer."
* "TRIAGE IS ONLY A PORTION OF THE MEDICAL SCREENING EXAM (MSE)."
* "Tuality Healthcare currently allows Family Birth Unit RN's, who have completed training and demonstrated competence to perform MSE exams in context of EMTALA for obstetric/labor patients only ... The hospital/facility must have a training program for the RN to teach the elements of the facility's medical screening examination protocols/algorithms. The RN must be able to demonstrate competency to perform the MSE prior to assignment as the qualified medical person responsible for completion of the MSE. This competency must be documented."

1. b. The FBC form provided as evidence that FBC RNs had been determined qualified and competent to perform MSEs was titled "Tuality Healthcare Onboarding Orientation Summary ... Department: Birth Center - Discipline: Triage." Two versions of the form with "Version" dates of 12/17/2018 and 10/19/2018 were reviewed and reflected "Triage is a separate skill set that is not appropriately performed until after completion of labor orientation." The forms contained a list of "items" to be evaluated as "Met" or "Not Met" and contained the following "items" that specified EMTALA or MSEs:
* "Define Medical Screening Exam"
* "Ensure discharge is in full compliance with CMS EMTALA guidelines"
* "Transport to higher level of care - EMTALA"
The other "items" were explicitly identified as "Triage" or were various obstetrical problems and conditions. When completed, the document reflected that an RN had been deemed competent to perform "Triage." The form was unclear in relation to what "items" on the list were considered to constitute an MSE to determine whether an EMC or labor existed. It did not reflect completion of an MSE "training program for the RN" and did not specify the RN was competent to perform an MSE.

1. c. The P&P titled "Response to Medical Emergencies On-Campus (Including Parking Lots)" dated as last revised "November 2015" was reviewed and included the following:
* "It is the policy of Tuality Healthcare to respond to medical emergencies on-campus or off-campus in compliance with ... [EMTALA]."
* "On-Campus: the physical area immediately adjacent to the Hospital and other areas and structures not strictly contiguous to the Hospital but located within 250 yards of the Hospital. This includes the Hospital parking lot, sidewalks and driveways, ..."
* "EMTALA is triggered when a person with a potential emergency is on hospital property, ..."
* "If there is a need to leave the building to provide assistance, patient care staff should summon additional help such as security staff or the nursing supervisor."

1. d. The "Rules and Regulations of the Medical Staff of Tuality Community Hospital" dated as "Current 12/14/2017" were reviewed and included the following:
* Under "Section 11. Admissions and Discharges" the document reflected that "A [MSE] provided in compliance with [EMTALA] will be performed and documented by a physician, or a qualified medical person such as a, nurse practitioner, physician assistant, certified nurse midwife, or Birth Center Registered Nurse who has completed training and demonstrated competence to perform the MSE. If the MSE determines that the patient has an emergency medical condition or labor contractions and the patient requests or requires a transfer and the physician is not physically present, the physician shall determine risks and benefits of transfer over the phone in consultation with the registered nurse or nurse midwife, nurse practitioner, or physician assistants who may sign the risks and benefits summary."
* Under "Section VII. Emergency Department and OB/Newborn Coverage" the document reflected that: "Triage will be done by a registered nurse ... The Emergency Department provider will be the judge of priority of care and treatment based on assessment of the care needs ... Emergency Department Responsibilities ... Obstetrics Department Responsibilities ..." The section consisted of information specific to "physicians" and "providers" only, and included direction for medical staff on-call obligations. However, it was unclear whether there was medical staff coverage in either or both of those departments on a 24/7 basis by physicians or "providers."

The rules and regulations did not clearly delineate the role of RNs to perform triage, versus MSEs to determine whether an EMC exists, in the ED and FBC. The document contained no information that specified what an MSE consisted of, nor what training and competencies were necessary for a FBC RN "to perform the MSE." Further, where the document reflected occasions when "the physician is not physically present" and the MSE had determined there was an EMC or labor, it was not clear if that was in either or both the ED or FBC.

1. e. The P&P titled "Antepartum - Obstetric Triage - Observation Patient" dated as last revised "May 2016" reflected the policy was "To provide timely and consistent triage assessment and care to the unscheduled pregnant patient with acute obstetrical concerns and issues."

The P&P provided directions for "triage assessment" tasks and documentation, and notification and reporting to the "Obstetrical Care Provider." There were no references in the P&P to reflect whether the "Obstetrical Care Provider" was physically present, and no references to the provision of MSEs to determine whether EMCs existed.

1. f. The P&P titled "Admission of Patients to the Emergency Department" dated as last revised "February 2017" was reviewed and included the following:
* At no time will the provision of emergency service be based upon or affected by an individual's race, ethnicity, ... insurance status, economic status, or ability to pay."

1. g. The P&P titled "Discussing Insurance with Patients" dated as last revised "Jun 2013" was reviewed and included the following:
* "The Admitting staff will be responsible for advising our provider status to patients that inquire. Staff will also refer patients to their insurance companies for benefit quotes."
* "Discussions initiated by patients about insurance must occur after the patient has been seen by the provider."
* "Insurance information will be obtained at the time of full registration."
* "If asked whether or not Tuality Healthcare is a provider for their particular insurance, admitting staff will state, 'We will not refuse service to anyone regardless of his/or her insurance but each insurance carrier is different and I cannot predict what they will cover.'"
* "If the patient specifically asks to call their insurance company they will be directed to a courtesy phone. If they request that we call, staff will tell them, 'By law we cannot contact your insurance company about coverage until after you have been seen by a physician for a medical screening exam'."

1. h. The P&P titled "Patient Registration" dated as last revised "Jun 2016" was reviewed and included:
* "Indication of ... STAT transport/escort to the emergency department ... Under no circumstance during this time will staff ask the patient insurance or financial information."
* "When a patient presents to the [ED] window the Admitting staff do a STAT registration, verify two patient identifiers and place the armband on the patient ... Admitting staff will complete the registration (full registration) when appropriate; once they are in an ER room and have been screened by the provider, but not impeding the patient's treatment."
* "If a patient has been STAT registered and then chooses to leave the Tuality Campus, with or without notifying any Tuality Healthcare Emergency area personnel before being triaged or medically screened, staff will complete a full registration with the information available and document this in the New Insurance Comment field on the Insurance Summary tab."
* "On the Insurance Summary tab, staff will leave a canned or free-test note stating the full registration was completed with all required forms signed. Additional notation is mandatory when any registration information/insurance card scan/patient signature is missing and/or the patient's reason for declining a procedure. These notes are crucial for communication/documenting in the patient's record ..."

1. i. The P&P titled "Patient Leaving Facility Against Medical Advice (AMA)" dated as last revised "July 2017" was reviewed and included the following:
* "Patients will be advised of the risks of leaving against medical advice and of the resources and follow-up available to them after discharge."
* "Promote strategies to reduce the likelihood that a patient will leave against medical advice, and if a patient wishes to be discharged early, to provide the best care possible under the circumstances."
* "An AMA - Leaving Facility Against Medical Advice - Patient's Release form ... should be completed for any patient expressing the desire to leave against medical advice (AMA)."
* "Staff will make every effort to identify the warning signs that may signal dissatisfaction with care and intervene to decrease the likelihood that the patient will leave AMA."
* "The patient should be advised of the risks of leaving AMA and advised to seek care elsewhere, contact a physician, or return to the emergency department as needed if symptoms worsen or the condition does not improve. Even if the patient cannot be convinced to stay for the completion of his or her treatment the care team should still give the patient his or her discharge instructions and prescriptions prior to the discharge."
* "Ensure that the care team is not providing misinformation about insurance and reimbursement. In most situations, insurance will cover their stay, even if patients choose to leave against medical advice. Ensure that erroneous information is not used in a misinformed attempt to coerce a patient to stay."
* "If the patient or designee refuses to sign, this will be stated on the form and signed by a witness who is an employee."
* "After the form is signed and witnesses, it becomes part of the medical record."
* "Document the chain of events, including the discussion of risks of leaving before treatment is complete, discharge teaching and resources provided for follow up care."

2. a. During interview with the hospital President, CNO, CMO, IO, AIO1 and AIO2 on 11/06/2019 beginning at 1140 they indicated they had received a report that on 09/10/2019 an individual, Patient 1, had been driven to the hospital's ED by a family member at the direction of the patient's PCP for medical and psychiatric evaluation secondary to physical and mental health changes. When the family member came into the ED to request assistance, it was not provided, and instead the family member returned to the patient in the car and called the police. Police arrived to the hospital parking lot and then escorted the individual and family member to another hospital. During the interview staff stated that the hospital began an investigation immediately and had planned and implemented corrective actions that included review of the hospital's policies and procedures, outreach to other community providers and local law enforcement, and development of a new comprehensive training module for medical providers, ED staff, registration staff, security staff, FBU staff, Urgent Care staff, supervisors and float RNs.

2. b. Review of the hospital's investigation documentation reflected that video recording of Patient 1's arrival at the hospital had been reviewed. The documentation reflected that "at 2:42pm 9/10/19 [an adult] enter (sic) the emergency department admitting window, [he/she] talked with a rep for a few minutes, then walked back to [his/her] vehicle in the parking lot. Sat in the card (sic) for a while talking to a passenger. [The adult] gets out of the vehicle and stands on our sidewalk talking on [his/her] phone. Then, at about 3:13pm, we observe a Hillsboro Police vehicle arrive in our parking lot, the officer gets out, talks to the [adult], then they both go to [the adult's] vehicle, a second police office arrives, then a young ... adult exits the vehicle and they place [him/her] in handcuffs then put [him/her] in a police vehicle and leave from Tuality property."

2. c. Review of the hospital's investigation documentation reflected that the registration employee on duty at the time Patient 1 arrived at the hospital had been interviewed by hospital staff. The registration employee had related his/her encounter with the family member. The registration employee stated that Patient 1's parent presented to the registration area and reported that Patient 1 was in the car outside and unwilling to come into the hospital. The employee stated that he/she informed the parent that "Tuality couldn't make someone check in" and that "options were to talk [him/her] into checking in ... or call the police and ask for a welfare check." The registration employee "indicated that [he/she] did not inform ED clinical staff about the individual in the parking lot because [he/she] was told in the past that nurses were not allowed to go out into the parking lot to treat patients" and "[He/she] also was not aware that there was a protocol for going out to the parking lot to help a patient but understood that in the future [he/she] would escalate the situation to other Tuality staff (Security Officer, Charge Nurse, Chain of Command, ED Provider.)

2. d. Review of the central log for 09/10/2019 reflected there was no entry to show that Patient 1 had presented to the hospital.

3. a. The central log reflected that Patient 3 presented to the ED on 10/08/2019 at 2251. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Unspecified" and the "Discharge Disposition" was recorded as "ED Dismiss Left w/out being seen Before Triage" at 2254.

3. b. The ED record for Patient 3 was reviewed and reflected the following timeline:
* At 2252 the "Arrival Complaint" was recorded as "MVA Eval" by registration staff.
* At 2254 an RN recorded "Patient dismissed."

An unauthenticated electronic entry under "ED Dismiss" reflected "Patient brought in by police. Patient refused to be seen."

A "Triage/medical screening AMA consent" form in the record reflected that "I, [Patient 3] do hereby accept full responsibility for my decision to leave the hospital without a medical screening examination. I was advised of the benefits and risks of not receiving a medical screening examination which has been offered to me before signing this form. I understand that my decision to leave may result in deterioration of the condition for which I sought medical attention ... I understand that the Emergency Department would provide medical examination and treatment, regardless of my insurance requirements or ability to pay for services." The form was signed by Patient 3, dated "08/10/19" and was not timed. On the line for "Emergency Department staff" the form was signed by registration staff, dated 10/08/2019 and was not timed.

3. c. There was no other documentation in the record to reflect why the patient refused to be seen and left the hospital prior to an MSE. Although an AMA form was signed, it was not reviewed with the patient by clinical staff, there was no documentation on the form or in the record by clinical staff to reflect what "benefits and risks of not receiving a medical screening examination" had been discussed. The record lacked documentation of a clear "chain of events, including the discussion of risks of leaving before treatment is complete, discharge teaching and resources provided for follow up care" as required by the AMA policy and procedure.

4. a. The central log reflected that Patient 4 presented to the ED on 10/10/2019 at 1613. The "Discharge Disposition" was recorded as "ED Dismiss Left w/out being seen After Triage" at 1822.

4. b. The ED record for Patient 4 was reviewed and reflected the following timeline:
* At 1613 the "Arrival Complaint" was recorded as "Poss UTI."
* At 1652, the next entry, "Chief Complaint" was recorded as "Abdominal pain" and "Urinary frequency" by an RN.
* At 1652 an FNP ordered lab work.
* At 1654 the FNP recorded a provider note that reflected a "Brief History," partial physical exam and the tests ordered. No other information was in the note.
* At 1754 the FNP is "assigned as attending."
* At 1815 an RN recorded "Per admitting, pt signed AMA form and did not want to wait to be seen. Pt was seen by provider in triage, so this was an elopement."
* At 1817 registration staff recorded "Registration Completed."
* At 1821 the RN recorded "Patient roomed in ED To room 21H," after it had been reported the patient left.
* At 1822 the RN recorded "Patient discharged" and "Charting complete."

There was no other documentation by the FNP.

A "Triage/medical screening AMA consent" form in the record reflected that "I, [Patient 4] received a medical screening examination through the emergency department at this hospital. The medical screening examination shows that I do not have a medical emergency. I was advised of the benefits and risks of not receiving additional treatment which has been offered to me. I have insurance that may or may not pay for medical services offered at this hospital. I do not want to receive further treatment at this hospital. I understand I may return to the emergency room at any time." The form was signed by Patient 4, dated 10/10/2019 and was not timed. On the line for "Emergency Department staff" the form was signed by registration staff, dated 10/10/2019 and was not timed.

4. c. There was no other documentation in the record to reflect why the patient left the hospital prior to completion of the MSE. Although an AMA form had been signed, it was not reviewed with the patient by clinical staff, there was no documentation to reflect that the medical provider had determined there was no EMC, and there was no documentation to reflect what "benefits and risks" had been discussed with the patient. The record lacked documentation of a clear "chain of events, including the discussion of risks of leaving before treatment is complete, discharge teaching and resources provided for follow up care" as required by the AMA policy and procedure.

Further, the record reflected that the registration process was "completed" prior to completion of the MSE, and the record was unclear as to where the patient was during the process as it showed that the patient was not taken into an ED room until after registration. The record lacked documentation to reflect that hospital staff did or said nothing during the course of completing the registration process, which included inquiry into insurance and finances, to dissuade the patient from staying for completion of the MSE and treatment.

5. a. The central log reflected that Patient 6 presented to the ED on 10/10/2019 at 1746. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Unspecified" and the "Discharge Disposition" was recorded as "ED Dismiss Left w/out being seen Before Triage" at 1828.

5. b. The ED record for Patient 6 was reviewed and reflected the following timeline:
* At 1746 "Arrival Complaint" was recorded as "Thumb Lac."
* At 1818 an RN recorded "Per admitting, pt LWBS."
* At 1828 the RN recorded "Patient dismissed."

5. c. There was no other documentation in the record, including an AMA form, to reflect why the patient left prior to an MSE and whether efforts were made "to identify the warning signs that may signal dissatisfaction with care and intervene to decrease the likelihood that the patient will leave AMA" as required by the AMA policy and procedure.

6. a. The central log reflected that Patient 7 presented to the ED on 10/10/2019 at 1837. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Unspecified." and the "Discharge Disposition" was recorded as "ED Dismiss Left w/out being seen Before Triage" at 1905.

6. b. The ED record for Patient 7, a 13-year-old, was reviewed and reflected the following timeline:
* At 1837 "Arrival Complaint" was recorded as "Collar Bone Pain."
* At 1905 an RN recorded "Patient dismissed" and "Pt lwbs without triage or mse att."

There was no documentation in the record to reflect who, if anyone, accompanied the 13-year-old patient to the ED.

A "Triage/medical screening AMA consent" form in the record reflected that "I, [Patient 7] do hereby accept full responsibility for my decision to leave the hospital without a medical screening examination. I was advised of the benefits and risks of not receiving a medical screening examination which has been offered to me before signing this form. I understand that my decision to leave may result in deterioration of the condition for which I sought medical attention ... I understand that the Emergency Department would provide medical examination and treatment, regardless of my insurance requirements or ability to pay for services." Both the patient signature line and the "Emergency Department staff" signature line were signed with illegible entries, dated 10/10/2019 and were not timed.

6. c. There was no other documentation in the record to reflect why the 13-year-old patient left the hospital prior to an MSE. Although an AMA form was signed, it was unclear if it had been reviewed with the patient, or a parent or other representative, by clinical staff, there was no documentation on the form or in the record by clinical staff to reflect what "benefits and risks of not receiving a medical screening examination" had been discussed. The record lacked documentation of a clear "chain of events, including the discussion of risks of leaving before treatment is complete, discharge teaching and resources provided for follow up care" as required by the AMA policy and procedure.

7. a. The central log reflected that Patient 8 presented to the ED on 10/10/2019 at 2009. The "Discharge Disposition" was recorded as "ED Dismiss Left w/out being seen After Triage" at 2210.

7. b. The ED record for Patient 8 was reviewed and reflected the following timeline:
* At 2051 an RN recorded "Chief Complaint" as "Leg Pain."
* At 2053 an FNP ordered X-Rays.
* At 2114 an RT recorded "Imaging Exam Started."
* At 2210 the RN recorded "Patient Dismissed" and "Pt eloped att after triage, mse, and xrays performed. Pt signed out ama with admitting prior to leaving."
* At 2219 the FNP recorded a provider note that reflected a "Brief History," partial physical exam and the tests ordered. No other information was in the note.

A "Triage/medical screening AMA consent" form in the record reflected that "I, [Patient 8] received a medical screening examination through the emergency department at this hospital. The medical screening examination shows that I do not have a medical emergency. I was advised of the benefits and risks of not receiving additional treatment which has been offered to me. I have insurance that may or may not pay for medical services offered at this hospital. I do not want to receive further treatment at this hospital. I understand I may return to the emergency room at any time." The form was signed by Patient 8, dated 10/10/2019 and was not timed. On the line for "Emergency Department staff" the form was signed by registration staff, dated 10/10/2019 and was not timed.

7. c. There was no other documentation in the record to reflect why the patient left the hospital prior to completion of the MSE. Although an AMA form had been signed, it was not reviewed with the patient by clinical staff, there was no documentation to reflect that the medical provider had determined there was no EMC, and there was no documentation to reflect what "benefits and risks" had been discussed with the patient. The record lacked documentation of a clear "chain of events, including the discussion of risks of leaving before treatment is complete, discharge teaching and resources provided for follow up care" as required by the AMA policy and procedure

8. a. The central log reflected that Patient 9 presented to the ED on 10/10/2019 at 2034. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Unspecified." and the "Discharge Disposition" was recorded as "ED Dismiss Left w/out being seen Before Triage" at 2203.

8. b. The ED record for Patient 9, who had an "Arrival Complaint" of "abd pain," contained similar findings to those identified for Patients 3, 6 and 7 above in this deficiency.

9. a. The central log reflected that Patient 12 presented to the ED on 10/18/2019 at 1827. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Rib Pain." and the "Discharge Disposition" was recorded as "Left without being seen" at 1950.

9. b. The ED record for Patient 12 included notes recorded by an RN at 1950 that reflected "Prelim Triage Complete" and "LWBS after triage." There was no documentation by a physician or other provider to reflect he/she received an MSE and no documentation to reflect why the patient left prior to an MSE. The record contained similar findings to those identified for Patients 3, 6 and 7 above in this deficiency, except that Patient 12 and registration staff erroneously signed the section of the AMA form that reflected that he/she had received an MSE and was leaving after an MSE had been completed.

10. a. The central log reflected that Patient 14 presented to the ED on 10/18/2019 at 1837. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Upper Arm Pain" and the "Discharge Disposition" was recorded as "Left without being seen" at 2048.

10. b. The ED record for Patient 14 included a note recorded by an RN at 1930 that reflected "Prelim Triage Complete." The next note was recorded by the RN at 2048 and reflected "Patient dismissed" and "Pt eloped ATT." There was no other documentation in the record, including an AMA form, to reflect why the patient left prior to an MSE and whether efforts were made "to identify the warning signs that may signal dissatisfaction with care and intervene to decrease the likelihood that the patient will leave AMA" as required by the AMA policy and procedure.

11. a. The central log reflected that Patient 15 presented to the ED on 10/18/2019 at 1945. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Low Back Pain" and the "Discharge Disposition" was recorded as "Left without being seen" at 2259.

11. b. The ED record for Patient 15 included a note recorded 2259, more than three hours after arrival, that reflected the patient was not in the waiting room. There was no other documentation in the record, including an AMA form, to reflect why the patient left prior to an MSE and whether efforts were made "to identify the warning signs that may signal dissatisfaction with care and intervene to decrease the likelihood that the patient will leave AMA" as required by the AMA policy and procedure.

12. a. The central log reflected that Patient 16 presented to the ED on 10/18/2019 at 2127. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Abdominal Pain" and the "Discharge Disposition" was recorded as "Left without being seen" at 2310.

12. b. The ED record for Patient 16 included a note recorded by an RN at 2155 that reflected "Prelim Triage Complete." The next note was recorded by the RN at 2310 and reflected "Patient dismissed." There was no documentation by a physician or other provider to reflect he/she received an MSE and no documentation to reflect why the patient left prior to an MSE. The record contained similar findings to those identified for Patients 3, 6 and 7 above in this deficiency, except that Patient 16 and registration staff erroneously signed the section of the AMA form that reflected that he/she had received an MSE and was leaving after an MSE had been completed.

13. a. The central log reflected that Patient 17 presented to the ED on 10/19/2019 at 0043. The entry in the log space for "Primary Chief Complaint Name" was recorded as "Vomiting" and the "Discharge Disposition" was recorded as "Left without being seen" at 0200.

13. b. The ED record for Patient 17, a one-year-old child, reflected the following timeline:
* At 0046 an RN recorded "Per [parent] pt has been vomiting x 3-4 hours [prior to arrival] ... had diarrhea last night and currently has rash on perineum ... fussier than normal."
* At 0051 the child's HR was recorded as 165.
* At 0054 an RN recorded "Patient acuity ... Urgent."
* At 0104 the child's HR was recorded as 160. The HR was not taken again during the ED encounter.
* At 0108 the RN recorded "Patient roomed in ED To room 05."
* At 0111 an order for an oral medication tablet was placed by a physician.
* At 0117 an RN recorded administration of the medication.
* At 0136 registration staff recorded "Registration Completed."
* At 0137 registration staff recorded "Pt is not covered on ins at this time, provided [parent] with financial services card."
* At 0138 an RN recorded "Triage Completed."
* At 0200 the next note was recorded by the RN as "Patient discharged."
* At 0209 an RN filed a note that reflected "HR remains elevated, likely related to reduced oral intake and borderline dehydration. Responded well to [medication] and woul