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Based on clinical record review, surveillance video review and staff interview the facility failed to adopt and enforce a policy to ensure compliance with the EMTALA requirements at 42 CFR 489.24 as evidenced by failure to maintain an accurate Central Log for all individuals seeking emergency care. Additionally, the facility failed to ensure that an appropriate medical screening examination was provided for an individual. These failures affected 1 of 21 sampled patients (Patients #21).

The findings included:


1. Based on clinical record review, surveillance video review and interviews conducted on 05/17/21 and 05/18/21, the facility failed to provide written evidence that a patient, who presented to the Emergency Department (ED) seeking medical care was registered in the ED central log. This failures affected 1 of 21 sampled patients (Patient #21) as detailed in citation A 2405.


2. Based on policy review, medical record review, Video surveillance review, Central log review, and interviews, it was determined the facility failed to 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 existed for 1 (#21) of 21 sampled patients.

Based on record review, video surveillance review, policy review and interview, it was determined, the facility failed to ensure the central log included all individuals who presented to the Emergency Department (ED) seeking treatment. This failure affected 1 of 21 sample patients (Patient #21).


The findings included:

Facility policy titled "EMTALA Central Log" last reviewed on April 2021 documents "This policy reflects guidance under the Emergency Medical Treatment and Labor Act (EMTALA) and associated state laws only. It does not reflect any requirements of the Joint Commission or other regulatory entities. Each facility should ensure it has policies and procedures to address such additional requirements. No facility may edit this policy in a manner that would remove existing language in order to indicate additional facility procedures or requirements necessary to carry out the provisions of the policy within the facility.
Policy: The hospital will maintain a Central Log containing information on each individual who requests emergency services or care or whose appearance or behavior would cause a prudent layperson observer to believe the individual needs examination or treatment, whether he or she left before a medical screening examination could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred admitted or treated, stabilized and transferred or discharged.
The central log includes the patient logs from the traditional ED and either by direct or indirect reference, patient logs from any other areas of the hospital that may be considered dedicated emergency department's or where an individual may present for emergency services or receive a medical screening exam, such as labor and delivery.
Procedure:
All hospitals must maintain the Central Log in an electronic format. An electronic template that includes all federal requirements for EMTALA is available on Medictech for each market or division to customize.
The Central Log, including all additional logs incorporated into the Central Log by reference, shall be maintained in the same manner and with the same central core information. The logs must contain at a minimum, the name of the individual and whether the individual refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged or expired.
A log entry for all individuals who have come to the hospital; seeking medical attention or who appear to need medical attention must be made by the appropriate individual. Further.
The Central Log of individuals who have come to the hospital seeking medical attention or who appear to need medical attention will be available within a reasonable amount of time for surveyor review and must be retained for a minimum of five years from the disposition of the individual."


Review of the surveillance video conducted on 05/17/21 at 3:48 PM while accompanied by the Director of the ED and The Director of Patient Safety revealed on 05/02/21 at approximately 6:07 PM, a police officer enters the facility with a patient (Patient #21) thru the ambulance entrance. The video shows the officer and Patient #21 going to the nurses' station and talking to the staff with paperwork on hand. Then the officer is seen escorting the patient to a sitting area in the hallway. The officer and patient remained in the area until approximately 6:43 PM, then the officer and patient are seen going back to the nurses' station and talking to a nurse. At approximately 6:57 PM, the officer is seeing grabbing the paperwork from the desk and leaving the facility with Patient #21.

Review of the facility Emergency Department Central Logs dated 05/02/21 revealed the facility failed to maintain a record of every patient presenting to the emergency department, there is no record of Patient #21.

Phone interview with Staff A, a Registered Nurse, conducted on 05/18/21 at 9:38 AM revealed her recollection of the events on 05/02/21. Staff A recalls the police officer brought in Patient #21, they were very busy, there was no room to place the patient at the time and the officer did not want to wait. Staff A stated they did not turn anyone away, she did explain to the officer they were on diversion, the officer was not aware of that, and they were trying to make room while maintaining patient safety.

Interview with Staff C, a Registered Nurse, conducted on 05/18/21 at 10:21 AM revealed on 05/02/21, she was working as the charge nurse. Staff C recalls a police officer bringing in Patient #21. The charge nurse asked the officer if the patient was violent and he replied yes, she glanced at the paperwork, gave the paperwork back to the officer and advised the officer to wait in the designated area. This day was extremely busy, there was no room for this patient and repeatedly asked the officer to wait until they made room. The patient was not safe out of handcuffs, and she could not take the patient until there was a room available. Staff C stated the officer was uncooperative, and later heard he had removed the handcuffs. During this time, another patient was dropped off, an overdose, this patient was unresponsive, and her efforts were to assist with this situation. When that was taken care of, the officer and the patient were gone.
Staff C elaborated that at one point the officer uncuffed the patient, and the officer was told that he needed to hold on to this patient, and that he needed to wait. The officer came back to the desk and dropped off the paperwork. Staff C kept telling him that he needed to hold on to the paperwork until they make room for the patient. Staff C was not aware when the officer left with Patient #21 and reiterated, she did not refuse the patient, they just asked the officer to wait until they could safely accommodate the patient.
Staff C was then asked at what point she registers the patient in the system and explained that she did not accept Patient #21, the patient is logged in the ED registry when is safe, after the handoff between the police and the hospital.

Interview with the ED Director conducted on 05/18/21 at 10:35 AM revealed the scheduled charge nurse called off and Staff C was put on that position by default. This is her first shift as the charge nurse and it is the charge nurse responsibility to ensure all patients coming into the ED with police are registered in the central log.

Based on policy review, medical record review, Video surveillance review, Central log review, and interviews, it was determined the facility failed to 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 existed for 1 (#21) of 21 sampled patients.

The findings included:

Facility policy titled "Emtala-Medical Screening Examination and Stabilization Policy" last reviewed 04/21 documents "An EMTALA obligation is triggered when an individual comes to a dedicated emergency department and the individual or a representative acting on the individual behalf requests an examination or treatment for a medical condition.... A hospital must provide an appropriate medical screening exam within the capabilities of the hospital emergency department, including ancillary services routinely available to determine whether or not an emergency medical condition exist; to any individual who request such examination, an individual who has such a request made on his or her behalf... an medical screening exam shall be provided to determine whether or not the individual is experiencing an emergency medical condition."

Review of the surveillance video conducted on 05/17/21 at 3:48 PM while accompanied by the Director of the ED (Emergency Department) and the Director of Patient Safety revealed on 05/02/21 at approximately 6:07 PM, a police officer enters the facility with a patient (Patient #21) through the ambulance entrance. The video shows the officer and Patient #21 going to the nurses' station and talking to the staff with paperwork on hand. Then the officer is seen escorting the patient to a sitting area in the hallway. The officer and patient remained in the area until approximately 6:43 PM, then the officer and patient are seen going back to the nurses' station and talking to a nurse. At approximately 6:57 PM, the officer is seeing grabbing the paperwork from the desk and leaving the facility with Patient #21.

Review of the facility emergency department central logs and electronic medical records conducted on 05/17/21 revealed the facility failed to perform a medical screening exam for patient #21 on 5/2/2021, arriving to the facility with the police officer.

The Certificate of Professional Initiating Examination dated 5/2/2021 (4:54 p.m.) for patient #21 was reviewed. The document revealed a social worker from Hospital B filled out the form indicating patient #21's "Diagnosis of Mental Illness : Opioid use disorder. " Further documentation revealed because of the Mental Illness, " b. Individual is unable to determine for himself/herself whether examination is necessary AND . . .b. There is substantial likelihood that without care or treatment the individual will cause serious bodily harm to ...self and others or the near future, as evidenced by recent behavior....Section II "Supporting evidence... Pt. is reporting that he is suicidal -wants to leave treatment. Reports he does not care if he overdoses and dies. He states he wants to harm himself now." The Medical Record from Hospital B where Patient #21 was taken by the Police Officer was reviewed. Hospital B's medical record revealed that patient #21 presented to the facility on 5/2/2021 at 7:17 PM, and received an appropriate medical screening examination . Patient #21 was appropriately transferred to an in-patient psychiatric facility on 5/2/2021 to receive psychiatric care and treatment.


Phone interview with Staff A, a Registered Nurse, conducted on 05/18/21 at 9:38 AM, revealed her recollection of the events on 05/02/21. Staff A recalls the police officer brought in Patient #21, they were very busy, there was no room to place the patient at the time and the officer did not want to wait. Staff A stated they did not turn anyone away, she did explain to the officer they were on diversion, the officer was not aware of that, and they were trying to make room while maintaining patient safety.

Interview with Staff C, a Registered Nurse, conducted on 05/18/21 at 10:21 AM revealed on 05/02/21, she was working as the charge nurse. Staff C recalls a police officer bringing in Patient #21. The charge nurse asked the officer if the patient was violent and he replied yes, she glanced at the paperwork, gave the paperwork back to the officer and advised the officer to wait in the designated area. This day was extremely busy, there was no room for this patient and repeatedly asked the officer to wait until they made room. The patient was not safe out of handcuffs, and she could not take the patient until there was a room available. Staff C stated the officer was uncooperative, and later heard he had removed the handcuffs.
During this time, another patient was dropped off, an overdose, this patient was unresponsive, and her efforts were to assist with this situation. When that was taken care of, the officer and the patient were gone.
Staff C elaborated that at one point the officer uncuffed the patient, and the officer was told that he needed to hold on to this patient, and that he needed to wait. The officer came back to the desk and dropped off the paperwork. Staff C kept telling him that he needed to hold on to the paperwork until they make room for the patient. Staff C was not aware when the officer left with Patient #21 and reiterated, she did not refuse the patient, they just asked the officer to wait until they could safely accommodate the patient.
Staff C was then asked at what point she registers the patient in the system and explained that she did not accept Patient #21, the patient is logged in the ED registry when it is safe, after the handout between the police and the hospital.

Interview with the ED Director conducted on 05/18/21 at 10:35 AM revealed the scheduled charge nurse 'called off' and Staff C was put on that position by default. This is her first shift as the charge nurse and is the charge nurse responsibility to ensure all patients coming into the ED with police are registered in the central log and will subsequently receive a medical screening exam. The facility failed to ensure that there Policy was followed as evidenced by failing to provide an appropriate medical screening examination was provided for Patient #21 on May 2, 2021 as stated in their EMTALA policy