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Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases as evidenced by:

A-2405: Central ED Log: The hospital failed to ensure a patient (Patient #1) who was brought to the Emergency Department (ED) by ambulance was entered into the dedicated ED Log.

A-2406 Medical Screening Examination: The hospital failed to provide a Medical Screening Examination (MSE) to a patient (Patient #1) who was taken to the Emergency Department by ambulance.

Hospital policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" revealed: "...Definitions: Transfer: Means the movement of a patient outside the Hospital's facilities at the direction of a designated physician or QMP...Medical Screening Examination Requirements: All patients who present to the Hospital's DED or on Hospital Property and request examination or treatment of a potential EMC, shall receive an appropriate MSE...A physician or QMP must perform the MSE to determine if an EMC exists...A transfer is appropriate under EMTALA when all the following conditions are met: The hospital has provided medical treatment within its capability (including consultation with an on-call physician, if necessary) that minimizes the risks to the patient's health, and...A representative of the receiving facility has confirmed the availability of space and qualified personnel for the treatment of the patient and confirmed the receiving facility's agreement to accept the transfer...The physician or QMP in consultation with the physician is responsible for determining the appropriate mode of transport, equipment, and transporting professionals to be used for the transfer...The hospital shall maintain a central log of each patient who presents to the hospital's DED (dedicated emergency department) or on hospital property seeking medical treatment and whether he or she refused treatment, was refused treatment, was transferred prior to stabilization, was admitted and treated, was stabilized and transferred, or was discharged...."

Hospital policy titled: "Emergency Department Nursing Triage" revealed: "...All patients receive a rapid triage assessment including: Chief complaint, allergies, vital signs, other information...whenever possible patients are immediately placed into open treatment spaces and triage is performed at the bedside...."

Patient #1 arrived at the hospital ED on 01/15/2022 at 2158 via EMS transport from a memory care center after pulling out sutures from a previous head injury causing bleeding from the wound. Patient #1 was quick registered at on 01/15/2022 at 2158 and fully registered on 01/16/2022 at 0158. At approximately 02:21 on 01/16/2022, Patient #1 had not received a triage or MSE and the EMS crew made the decision to leave the ED with the patient and proceed to the ED of Hospital #2.

Patient #1 was not listed on the hospital's ED Central Log for 01/15/2022 or 01/16/2022.

A secondary "back up" log was provided by the facility. Review of the secondary "back up" log revealed thirty-three (33) patients including Patient #1 that were not listed on the ED Central Log from 00:01 on 01/15/2022 through 05:01 on 01/16/2022.

Patient #1 nurse note dated 01/16/2022 at 02:21 revealed: "pt never removed from gurney. brought in by Mesa EMS and sat in hallway for two+ hours. EMS decided to take patient to another facility. EMS was advised before arrival that we were on divert with no beds in ED, ICU, M/S or Tele.... "

Further review of Patient #1 ED record failed to reveal evidence that Patient #1 had a triage or MSE performed before leaving the ED with EMS for another facility.

Employee #2 confirmed during an interview on 09/06/2022 that Patient #1 was not listed on the ED Central Log. Employee #2 stated that when a patient registers in the ED, the patient is automatically added to the ED Central Log by computer. Employee #2 could not explain why not all patients cross over to the Central Log at time of registration, stating it was an interfacing issue.

Employee #1 confirmed during an interview on 09/06/2022 that Patient #1 had not had a nursing triage or an MSE performed by a physician or QMP at the time the patient left the ED with the EMS crew.

Based on review of policies and procedures, hospital logs/documents, and staff interviews, it was determined the hospital failed to ensure a patient (Patient #1) who was brought to the Emergency Department (ED) by ambulance was entered into the dedicated ED Log.
Findings include:

The hospital's policy and procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" revealed: "..The hospital shall maintain a central log of each patient who presents to the hospital's DED (dedicated emergency department) or on hospital property seeking medical treatment and whether he or she refused treatment, was refused treatment, was transferred prior to stabilization, was admitted and treated, was stabilized and transferred, or was discharged...."

Patient #1 was not listed on the hospital's ED Central Log for 01/15/2022 or 01/16/2022.

A secondary "back up" log was provided by the facility. Review of the secondary "back up" log revealed thirty-three (33) patients that were not listed on the ED Central Log from 00:01 on 01/15/2022 through 05:01 on 01/16/2022.

Employee #2 confirmed during an interview on 09/06/2022 that Patient #1 was not listed on the ED Central Log. Employee #2 stated that when a patient registers in the ED, the patient is automatically added to the ED Central Log by computer. Employee #2 could not explain why not all patients cross over to the Central Log at time of registration, stating it was an interfacing issue.

Based on review of clinical records, policies and procedures, and staff interviews, it was determined the hospital failed to provide an MSE to Patient #1, who presented to their ED by ambulance on 01/15/2022 at approximately 21:58 and left without being seen with EMS to another facility at approximately 02:21 on 01/16/2022.

Hospital policy titled: "Emergency Medical Treatment and Active Labor Act (EMTALA) " revealed: "...Definitions:...Medical Screening Examination Requirements: All patients who present to the Hospital's DED or on Hospital Property and request examination or treatment of a potential EMC, shall receive an appropriate MSE...A physician or QMP must perform the MSE to determine if an EMC exists...."

Hospital policy titled : "Emergency Department Nursing Triage" revealed: "...All patients receive a rapid triage assessment including: Chief complaint, allergies, vital signs, other information...whenever possible patients are immediately placed into open treatment spaces and triage is performed at the bedside...Patients are triaged into one of the five Emergency Severity Index (ESI) levels and triage algorithm...Level 1: patients who require immediate evaluation and treatment with the use of many resources. Level 2: patients who require evaluation and treatment as soon as possible with reassessment as needed requiring multiple resources. Level 3: Stable; patient who could wait for evaluation and treatment requiring multiple diagnostic and therapeutic resources. Level 4: Stable patients who could wait for evaluation and treatment requiring one therapeutic diagnostic resource. Level 5: Stable patients who could wait for evaluation and treatment and require minimal or no resources...If a patient has been assessed as ESI level 1 or 2, the patient is brought to the ED treatment area expeditiously and an ED attending is notified...."

Patient #1 arrived at the hospital ED on 01/15/2022 at 2158 via EMS transport from a memory care center after pulling out sutures from a previous head injury causing bleeding from the wound. Patient #1 was quick registered at on 01/15/2022 at 2158. Patient #1 was fully registered on 01/16/2022 at 0158. EMS remained with the patient and were told that there would not be a bed available for Patient #1 until 0600-0700 at the earliest. EMS crew contacted it's base and the decision was made to take the patient to another facility. Patient #1 left via ambulance with the EMS crew on 01/16/2022 at approximately 0234.

Patient #1 nurse note dates 01/16/2022 at 02:21 revealed: "...pt never removed from gurney. brought in by Mesa EMS and sat in hallway for two+ hours. EMS decided to take patient to another facility. EMS was advised before arrival that we were on divert with no beds in ED, ICU, M/S or Tele...."

Further review of Patient #1's ED record from Hospital #1 failed to reveal any documentation that the nursing staff had triaged or assessed the patient while the patient was in the ED, or had a Medical Screening Examination (MSE) performed by a physician or QMP.

Patient #1 EMS record narrative revealed: "...Patient #1 arrived at the hospital ED on 01/15/2022 at 2158 via EMS transport from a memory care center after pulling out sutures from a previous head injury causing bleeding from the wound...crew waited an extended period of time due to lack of available hospital beds. During the wait, pt began to bleed through head dressing, a secondary bandage was applied to the head...Charge nurse at approximately 0135 informed the potential for a bed for the patient would be at the earliest 0600-0700...."

Review of Patient #1 ED record from Hospital #2 revealed a triage time of 02:34. A physician exam was completed at 04:05.

Employee #1 confirmed during an interview on 09/06/2022 that triage and the MSE usually take place once the patient has been offloaded and the EMS crew has handed the patient off to the ED RN. Employee #1 confirmed Patient #1 was not triaged at time of arrival and did not receive a MSE prior to EMS taking the patient to another facility.