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Based on clinical record review, facility document review, staff and other involved personnel interviews, the facility staff failed to ensure compliance with EMTALA requirements at 42 CFR ?489.24, Special responsibilities of Medicare hospitals in emergency cases.

The findings include:

The facility staff failed to ensure an appropriate MSE (Medical Screening examination) and necessary stabilizing treatment were provided to Patient #21, who had been brought to the emergency department (ED) by a "family member/significant other" and requested assistance for the patient. The family member/significant other came into the ED and stated the "patient" was out in the car and had been psychotic and was in need of help.
According to investigation/interviews, the family member of Patient #21 was "encouraged" to seek medical assistance elsewhere by the on-duty Emergency Department Physician.
Further detailed information is found within this report, specifically at:
42 CFR ?489.24 (a) (1) (i) (C-2406)
42 CFR ?489.24 (d) (1) (i) (C-2407)

Based on staff interview, facility document review, and in the course of complaint investigation, it was determined the facility staff failed to ensure an appropriate medical examination (MSE) was provided for one of 21 (twenty one) patients, Patient #21,who had been brought to the emergency department (ED) by a "family member/significant other" and requested assistance for the Patient. The family member/significant other came into the ED and stated the "patient" was out in the car and had been psychotic and was in need of help.
The findings included:
A "self reported" event was received by the RO (Regional Office) of 1/26/15 and forwarded to the SA (State Agency) for further investigation. According to the report, on 1/5/15, a "male family member" presented to the freestanding ED and approached the registration desk. The "family member" stated to the Registrar that he had a "female patient" in his vehicle who was psychotic and manic. He stated the patient had been this way for a week and her physician recommended she be taken to the ED. The family member questioned whether he could move his car to the ambulance entrance and escort the patient though that entrance. The family member indicated the patient became agitated in the presence of law enforcement and there were deputies present in the ED at that time. The Registrar stepped away from the desk and spoke with the ED physician who stated to the registrar the ED was not a psychiatric facility and to inform the family member of this fact. The registrar refused to do this, so the physician stated he/she would speak with the family. The ED physician entered the waiting area and spoke with the family member. The physician claimed he/she offered to see the patient but the family member declined and said he would take her to another facility. The patient was never entered into the ED logs. The patient left the ED without an appropriate MSE (Medical screening examination) and stabilizing treatment.
On 2/2/15 at 12:00 p.m., the survey team entered the facility in order to conduct the investigation of the reported event. A tour of the ED was conducted. Staff member #4 was interviewed concerning treatment of patients and EMTALA regulations and stated he/she was aware of the circumstances of the reported incident, when interviewed as to whether he/she had knowledge of any EMTALA violations at this facility. Staff #4 stated he/she had been informed about the incident on the day it occurred and had reported it to his/her supervisor. Staff #4 stated that, "Every patient is treated here no matter what. We should not turn patients away or discourage them from receiving care...We do not know who the patient was. We did not get a name. The family member did not give that information and did not sign in..."
On 2/2/15 at 1:50 p.m., Staff #5 was interviewed. Staff #5 stated he/she had been informed of the concern by one of his/her staff "right after it happened". Staff #5 stated it was reported to the "supervisor".
At 3:00 p.m. on 2/2/15, the surveyor interviewed Staff # 6, who was the registrar on duty at the time Patient #21 arrived to the ED. Staff #6 stated, "A gentleman came in and said he had a female out in his car that had been psychotic for two weeks and he didn't know what to do with her, that her doctor said to bring her to the emergency room. He said she had a fear of law enforcement and there were two sheriffs in the ED at that time, so he wanted to know if he could bring her through the ambulance entrance. I went back to ask and there was no one at the nurses station except for (name of physician) and I asked him/her about it. He/she said that I should tell the gentleman that we were not a psychiatric facility and that he should take her (the patient) somewhere else. I told him I absolutely would do no such thing, that it was not right and also I could loose my job. He/she then said he/she would go out and talk with him. When I went back out the man was not there, but he came back in and said he had gone to the car and given her some medication to calm her so he could get her to come in. (Name of physician) came out and I heard him/her tell the gentleman that we were not a psych facility and that he should take her (the patient) somewhere else. The man told him/her that she (the patient) had been recently seen at (another hospital) and had been a patient there so (name of physician) told him he (the family member) should take her (the patient) back there. He (the physician) told the man he would be happy to see her (the patient) here but that it would take too much time because she would have to be transferred anyway and it would be easier if he(the family member) took her himself. There was another registrar present at that time. (Name of physician) then turned around and said. "Are you ladies alright with that?" I didn't say anything. I just looked at him/her because he/she knew I wasn't alright with it...I went to the charge nurse and told him/her what happened and he/she said it needed to be reported so he/she reported to his/her supervisor and I reported to mine...after this happened, and administration started asking questions, the doctor (name of physician) was still working and he/she would not speak to me or even look at me. It upset me because I was afraid he/she may retaliate..."
On 2/2/15 at 3:20 p.m., the survey team was informed by Staff # 1 and 3 that the physician was no longer employed by the hospital. Staff #3 stated, "This was brought to my attention by (Staff #1) because he/she had contacted the director of risk and then contacted me...I did not reach out to the registrar, but did reach out to (name of physician)...(name of physician) is no longer providing services for any of our facilities. The CMO (Chief Medical Officer) in conjunction with the CEO (Chief Executive Officer) made that decision...we will be doing education and haven't set a date for it yet but it will be in addition to the required annual EMTALA training. It will be done in forty-five days..." Staff #3 also stated the other registrar who was present at the time the incident occurred was "off on leave" and not available, however the "other registrar" first "sided with the doctor" when interviewed, and then "changed his/her story that he/she was not able to hear because the physician had his/her back to him/her"...
At 4:00 p.m. on 2/2/15 the surveyors further interviewed Staff #4. Staff #4 stated, "It was a (race) female with a history of bipolar having a severe manic episode. The gentleman who brought her was visibly upset and panicked. We had the police here for another patient who was agitated and because the nurses were tied up so (name of physician) went out and talked with the gentleman. After I was told what happened, I called (name of supervisor/director). I have been concerned that this would happen with this particular physician and I have voiced some concern regarding his/her attitude before this...my experience with (name of physician) was that I felt very frequently he/she would walk into a room and tell a patient reasons why they should be anywhere but here...I saw that happening a lot, but he/she never said he/she would not care for them and in fact, gave excellent care...but would say to staff, "I am not a dermatologist etcetera, but I am happy to see him/her..."
On 2/3/15 at 12:30 p.m., the surveyors inquired as to the corrective plan - removal measures outlined in the letter to CMS dated 1/26/15. Staff # 3 stated "some" of the removal measures had not been implemented as of yet. The surveyors inquired as to the status of each removal measure and were informed as follows:
A. The actions of the ED Physician were reported to the Peer review Committee for review..."We just had Peer review on 1/28/15, but this was not discussed. It will be discussed at the 3/28/15 meeting..."
B. The ED Physician was counseled...(This was completed according to evidence from the Medical Director and interview 2/3/15 12:50 p.m.)
C. (Initials of hospital) ED staff members at all of our campuses were educated on EMTALA requirements..."This is not implemented yet. We are still working on the education part..." (Physician re-education was documented by ED Medical Staff meeting January 22, and Med Exec meeting minutes January 21, 2015.)
D. (Initials of hospital) ED staff members were re-educated on procedures for escalating EMTALA questions to their supervisors. "This is not completed yet..."
E. (Initials of hospital) reviewed with ED staff members the response plan for patients that were outside the ED but on hospital property within 250 yards of the main building and present for en emergency medical condition. "This is not completed yet..."
Staff # 3 stated that she would be working on a plan of action for the above issues and it would be submitted "by the end of March."
On 2/3/15 at 12:50 p.m., the surveyors interviewed the Medical Director (Staff # 7) for the facility. Staff #7 stated, "I was informed the next day, I believe, and when I found out about it was the first time I spoke to (name of physician), however, we had many conversations about this...I did an EMTALA review with all of the physicians...they were either present in person or on the conference call...there is required annual training through (name of physician group) but secondary to this incident we bolstered the training..."
The survey team reviewed a document dated 1/22/15, "(Name of physician group) ED Meeting Minutes". This document evidenced "EMTALA Review (presented by Staff #7) Detailed discussion of definitions and interpretation of law, focusing specifically on: EMTALA definition, EMTALA and ambulances, Central log, Emergency Medical Condition, Prudent layperson Observer, Hospital Property, Medical Screening Exam, Qualified Medical Personnel, and "Comes to the Emergency Department". Case reviewed and group discussion of possible outcomes, options for management. Online EMTALA training for all providers required yearly."
The "Medical Executive Committee" meeting minutes for 1/21/15 were reviewed. The minutes documented, "Ethics and Compliance Committee Update: (name of director) presented an update on EMTALA. It was noted: EMTALA REQUIREMENTS: Individuals must be evaluated and provided with medical support services and/or transfer arrangements that rare consistent with the capability of the institution and the well-being of the patient; Hospitals must have a list of physicians who are on-call to provide treatment necessary to stabilize an individual with an emergency medical condition; Hospital must have privileged physicians with skill sets to provide care that is consistent with the services it provides; Medical Executive Committee must review on-call schedule and make recommendations to CEO when formal changes are to be made or when legal or operational issues arise..."
The facility policy on EMTALA was also reviewed. The policy stated, in part: "EMTALA- Definitions and General Requirements: PURPOSE: To require, in conjunction with state-specific policies, that a hospital with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to any individual, including every infant who is born alive, at any stage of development who comes to the Emergency Department and requests such an examination as required by the Emergency Medical Treatment and Labor Act (EMTALA) 42 U.S.C. Section 1395dd and all Federal regulations and interpretive guidelines promulgated thereunder. POLICY: The hospital with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development who comes to the Emergency Department an appropriate Medical Screening Examination (MSE) 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 (EMC) exists, regardless of the individuals ability to pay. The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED), when an individual requests emergency medical care of hospital property, other than in a DED, or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made..."
The policy "Dealing with and Reporting Misconduct" was reviewed and documented: We rely on you to report potential misconduct so that we may take corrective action and implement changes to prevent a similar violation from occurring...REPORTING CHANNELS: Your Supervisor, Human Resources Department, Facility Ethics and Compliance Officer, The Ethics Line..."
"Behavioral Health, Guidelines for Patient Care Management" was reviewed and documented in part: "Patients with emotional or behavioral disorders present with special needs. According to the scope of care and service (name of hospital) does provide inpatient and outpatient behavioral health treatment and care, Should a patient present to (name of facility) with a behavioral health disorder, processes will be implemented to facilitate patient safety, stabilize the patient and provide for a safe disposition...A. Emergency Department Guidelines: 1. Any patient, including patients with behavioral health (psychiatric) conditions who present to the Emergency Department or hospital grounds for treatment must be provided with an appropriate medical screening examination to determine of the patient is suffering from an emergency medical condition. triage is NOT the equivalent of a medical screening examination...."
The survey team discussed the concerns related to the patient not being provided with an MSE or stabilizing treatment and that there was no identification of the patient for follow-up, on 2/3/15 at 3:00 p.m.

Based on staff interview, facility document review, and in the course of a complaint investigations, it was determined the facility staff failed to ensure stabilizing treatment was provided for one of 21 (twenty one) patients, Patient #21, who was brought to the emergency department (ED) by a "family member/significant other" and requested assistance for the Patient. The family member/significant other came into the ED and stated the "patient" was out in the car and had been psychotic and was in need of help.
The findings included:
On 2/2/15 at 12:00 p.m., the survey team entered the facility in order to conduct the investigation of an event where a caregiver/patient reportedly arrived at the emergency department, requesting assistance. Reportedly a physician suggested the patient be taken to a different hospital, this was suggested prior to the patient being examined (medical screening exam) or stabilizing treatment provided.
A tour of the ED was conducted. Staff member #4 was interviewed concerning treatment of patients and EMTALA regulations and stated he/she was aware of the circumstances of the reported event, when interviewed as to whether he/she had knowledge of any EMTALA violations at this facility. Staff #4 stated he/she had been informed about the incident on the day it occurred and had reported it to his/her supervisor. Staff #4 stated that, "Every patient is treated here no matter what. We should not turn patients away or discourage them from receiving care...We do not know who the patient was. We did not get a name. The family member did not give that information and did not sign in..."
On 2/2/15 at 1:50 p.m., Staff #5 was interviewed. Staff #5 stated he/she had been informed of the concern by one of his/her staff "right after it happened". Staff #5 stated it was reported to the "supervisor".
At 3:00 p.m. on 2/2/15, the surveyor interviewed Staff # 6, who was the registrar on duty at the time of the incident. Staff #6 stated, "A gentleman came in and said he had a female out in his car that had been psychotic for two weeks and he didn't know what to do with her, that her doctor said to bring her to the emergency room. He said she had a fear of law enforcement and there were two sheriffs in the ED at that time, so he wanted to know if he could bring her through the ambulance entrance. I went back to ask and there was no one at the nurses station except for (name of physician) and I asked him/her about it. He said that I should tell the gentleman that we were not a psychiatric facility and that he (the family member) should take her (the patient) somewhere else. I told him/her I absolutely would do no such thing, that it was not right and also I could loose my job. He/she (the physician) then said he/she would go out and talk with him. When I went back out the man was not there, but he came back in and said he had gone to the car and given her some medication to calm her so he could get her to come in. (Name of physician) came out and I heard him/her tell the gentleman that we were not a psych facility and that he should take her somewhere else. The man told him/her (the physician) that she (the patient) had been recently seen at (another hospital) and had been a patient there so (name of physician) told him (the family member) he should take her (the patient) back there. He/she (the physician) told the man he/she would be happy to see her (the patient) here but that it would take too much time because she would have to be transferred anyway and it would be easier if he (the family member) took her himself. There was another registrar present at that time. (Name of physician) then turned around and said, "Are you ladies alright with that?" I didn't say anything. I just looked at him/her because he/she knew I wasn't alright with it...I went to the charge nurse and told him/her what happened and he/she said it needed to be reported so she reported to her supervisor and I reported to mine...after this happened, and administration started asking questions, the doctor (name of physician) was still working and he/she would not speak to me or even look at me. It upset me because I was afraid he may retaliate..."
On 2/2/15 at 3:20 p.m., the survey team was informed by Staff # 1 and 3 that the physician was no longer employed by the hospital.
At 4:00 p.m. on 2/2/15 the surveyors further interviewed Staff #4. Staff #4 stated, "It was a white female with a history of bipolar having a severe manic episode. The gentleman who brought her was visibly upset and panicked. We had the police here for another patient who was agitated and because the nurses were tied up so (name of physician) went out and talked with the gentleman. After I was told what happened, I called (name of supervisor/director). I have been concerned that this would happen with this particular physician and I have voiced some concern regarding his attitude before this...my experience with (name of physician) was that I felt very frequently he/she would walk into a room and tell a patient reasons why they should be anywhere but here...I saw that happening a lot, but he/she never said he/she would not care for them and in fact, gave excellent care...but would say to staff, "I am not a dermatologist etcetera, but I am happy to see him/.her..."
On 2/3/15 at 12:30 p.m., the surveyors inquired as to the removal measures outlined in the letter to CMS (Centers for Medicare Medicaid Services) dated 1/26/15. Staff # 3 stated "some" of the removal measures had not been implemented as of yet.
Staff # 3 stated that she would be working on a plan of action for the above issues and it would be submitted "by the end of March."
On 2/3/15 at 12:50 p.m., the surveyors interviewed the Medical Director (Staff # 7) for the facility. Staff #7 stated, "I was informed the next day, I believe, and when I found out about it was the first time I spoke to (name of physician), however, we had many conversations about this...I did an EMTALA review with all of the physicians...they were either present in person or on the conference call...there is required annual training through (name of physicians group) but secondary to this incident we bolstered the training..."
The "Medical Executive Committee" meeting minutes for 1/21/15 were reviewed. The minutes documented, "Ethics and Compliance Committee Update: (name of director) presented an update on EMTALA. It was noted: EMTALA REQUIREMENTS: Individuals must be evaluated and provided with medical support services and/or transfer arrangements that rare consistent with the capability of the institution and the well-being of the patient; Hospitals must have a list of physicians who are on-call to provide treatment necessary to stabilize an individual with an emergency medical condition; Hospital must have privileged physicians with skill sets to provide care that is consistent with the services it provides; Medical Executive Committee must review on-call schedule and make recommendations to CEO when formal changes are to be made or when legal or operational issues arise..."
The facility policy on EMTALA was also reviewed. The policy stated, in part: "EMTALA- Definitions and General Requirements: PURPOSE: To require, in conjunction with state-specific policies, that a hospital with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to any individual, including every infant who is born alive, at any stage of development who comes to the Emergency Department and requests such an examination as required by the Emergency Medical Treatment and Labor Act (EMTALA) 42 U.S.C. Section 1395dd and all Federal regulations and interpretive guidelines promulgated thereunder. POLICY: The hospital with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development who comes to the Emergency Department an appropriate Medical Screening Examination (MSE) 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 (EMC) exists, regardless of the individuals ability to pay. The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED), when an individual requests emergency medical care of hospital property, other than in a DED, or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made..."
The survey team discussed the concerns related to the patient not being provided with an MSE or stabilizing treatment and that there was no identification of the patient for follow-up on 2/3/15 at 3:00 p.m.