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Based on policy review, medical record review, and interviews, the hospital failed to develop a policy that addressed how staff was to provide an appropriate medical screening examination (MSE) for a patient who presented to the emergency department (ED) for services and could not wear a mask. This resulted in failure of the ED to provide an appropriate MSE within the capability of the hospital to determine whether an emergency medical condition (EMC) existed for one of 20 sampled patients (Patient 1).

Findings Include:

Review of the policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA); Transfer of Individuals with Emergency Medical Conditions," revised 06/24/19, showed ". . . A medical screening examination (MSE) was defined as "The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC [emergency medical condition] exists or a woman is in labor. Such screening must be done within AVCH's [Ascension Via Christi Hospital] capability and capacity. . .."

Review of the hospital policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA); Transfer of Individuals with Emergency Medical Conditions," revised 06/24/19, showed the hospital "provides triage to all individuals who present at an AVCH [facility name] location and request treatment for an emergency medical condition (EMC) to determine the order in which they will be given a Medical Screening Examination (MSE) by a qualified medical person (QMP). All such individuals receive the MSE and appropriate medical care within the facility's ability to provide care. . . G. Medical Screening Examination (MSE): The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists or a woman is in labor. Such screening must be done within AVCH's capabilities and capacity. The MSE is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either stabilized or appropriately transferred. The MSE is completed by a QMP . . ." There was no documented evidence that the policy addressed a plan for treating patients who present who cannot or won't wear a mask.

Review of Patient 1's electronic medical record (EMR) showed Patient 1 came to the ED with abdominal pain and dizziness. The EMR showed no documented evidence that hospital staff performed an MSE to determine whether Patient 1 had an EMC during Patient 1's ED visit on 03/14/21 (Refer to A-2406).

Based on policy review, medical record review, and staff interviews, the hospital failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department (ED) to determine whether an emergency medical condition (EMC) existed for one of 20 sampled patients (Patient 1).

Findings Include:

Review of Patient 1's "Face Sheet" showed, she arrived on 03/14/21 at 1:11 PM, was discharged on 03/14/21 at 2:15 PM, and "Diagnosis: AB [abdominal] PAIN, NUMBNESS."

Review of the undated "Instructions & [and] Maps for Door Screeners Screening Guidelines" showed ". . . EVERYONE must wear a mask. The only exceptions: child under 2 or incapacitated adult (unable to remove mask on their own). . ."

During an interview on 05/12/21 at 9:38 AM, Health Screener (HS) stated she covered the COVID questions and temperature screening for Patient 1 on 03/14/21. The HS told Patient 1 she needed to wear a mask. The HS stated that Patient 1 told her she couldn't wear a mask, and that she had a letter stating she was exempt from wearing a mask. The HS stated that she told one of the techs who was there at the time that Patient 1 said she couldn't wear a mask. The HS stated that she had training about how to handle patients who appear without a mask. The HS stated they were taught not to allow anyone in without a mask. The HS stated that she was supposed to call security, but she didn't because Patient 1 told her she had a letter, and she told Patient 1 to address the letter with the registration representative.


Review of Patient 1's "Encounter Location History" located under the "Reporting Portal" showed, Patient Registration Representative (PRR) registered Patient 1.

During an interview on 05/12/21 at 8:18 AM, Patient Registration Representative (PRR) stated that her job is to register patients when they present to ED for treatment. PRR stated that she asked Patient 1 if she could put her mask on, and Patient 1 told PRR she couldn't. PRR stated, "I'm new and didn't want to get in a confrontation, so I told her she was okay right now, but they will probably ask you to put one on." PRR stated Patient 1 again told her that she (Patient 1) couldn't wear a mask. PRR stated Patient 1 told her that she had a note from her doctor, but PRR stated, "that's not my place so I didn't pursue the issue [meaning addressing the letter]."


Review of Patient 1's electronic medical record (EMR), with Clinical Infomatics (CI) Staff A navigating the EMR, showed an ED Nursing note, located under the "Documentation" tab, dated 03/14/21 at 2:09 PM by ED Registered Nurse (EDRN) Staff C that showed, "I asked if I was being recorded and patient wouldn't answer. Patient started yelling it was a HIPPA [sic] violation to make her wear a mask and if we refused to treat her, it was an emtala (emergency medical treatment and labor act) violation. Patient was yelling her medical problems out loud and saying what we were doing was a HIPPA [sic] and emtala violation. She never entered the triage room but stated we had taken her in. Notified charge nurse, EDRN Staff CC. Staff CC came out and spoke with the patient. Patient started misquoting me and Staff CC. Staff CC tried to say quit putting words in my mouth. Patient had daughter on speaker phone, yelling. Security was called. Patient was asked to leave after she was verbally abusive. Security escorted out. She called police."


There was no documented evidence in Patient 1's EMR that Patient 1 received a triage assessment and/or a MSE during the visit on 03/14/21 when she presented to the ED seeking assistance for abdominal pain..

During an interview on 05/10/21 at 12:42 PM, CI Staff A confirmed she saw no other documentation in Patient 1's EMR related to the encounter on 03/14/21 (meaning no triage note or MSE).

During an interview on 05/10/21 at 3:50 PM, EDRN Staff CC stated that she was the charge nurse in ED on 03/14/21. Staff CC stated that she did not remember documenting anything related to Patient 1. Staff CC stated that EDRN Staff C called her from triage and told her about a patient that was refusing to wear a mask and asked her to come speak with the patient. Staff CC stated that Patient 1 told her that she (Patient 1) had a medical condition and had a note from her doctor that exempts her from wearing a mask. Staff CC stated that she asked Patient 1 if she had the documentation on her, and Patient 1 stated he/she did. Staff CC asked if he/she could see the documentation, and Patient 1 said, "No it's a HIPAA [sic] [Health Insurance Portability and Accountability Act] violation." When asked by the surveyor if Patient 1 told her (Staff CC) what the medical condition was, Staff CC stated, "Patient 1 told me she had anxiety but didn't go into details with me." Staff CC stated that while Staff C continued to triage other patients, Staff CC pulled Patient 1 around the corner away from triage. Staff CC stated that Patient 1, "was being loud, and the waiting room was full." Staff CC stated that he/she offered a face shield when Patient 1 said she couldn't wear a mask. Staff CC stated that Patient 1 said that she, "couldn't wear that either". Staff CC stated that she explained to Patient 1, "because of safety, the state mandate to wear a mask, and for the safety of others and herself, that they needed some sort of facial protection/barrier for her." Staff CC stated that Patient 1, "was getting belligerent and verbally abusive, and EDRN Staff DD came out and heard the commotion and asked where security was. Staff DD suggested they call security. Patient 1 continued to argue, so I [Staff CC] suggested we wheel her outside and get fresh air." Staff CC stated that she didn't know why Patient 1 was there . . . she hadn't seen her history." Staff CC stated that she suggested, "they go outside, because she wasn't wearing a mask and everyone in the waiting room was wearing a mask." Staff CC stated after Patient 1, Security Officer (SO) Staff EE, SO Staff FF, and Staff CC were outside in front of the ED, SO Staff EE told her "they had this and for me to just go back in and they would talk with Patient 1." Staff CC stated that she then went back inside the ED. When asked twice by the surveyor if Staff CC knew whether Patient 1 had an EMC when she rolled Patient 1 outside, Staff CC stated, "No, I hadn't seen his/her medical history."


During a telephone interview on 05/12/21 at 8:30 AM, EDRN Staff C stated that because of COVID, the hospital has a "screener up front who is usually a nurse on light duty, and patients get screened when coming through the door." Staff C stated, "The patient then goes to registration and tells them [the registration representative] what their complaint is." Staff C stated, "The ED tech who is an EMT [emergency medical technician] or a paramedic is also at the [registration]desk. She (Patient 1) complained of abdominal pain and dizziness, I think." Staff C stated, "...it was a Sunday afternoon and we were full." Staff C stated she, "Heard a ruckus outside [triage] and Emergency Department Emergency Medical technician (EDEMT) was trying to get Patient 1's weight. She stated when EDEMT tried to get Patient 1's weight, EDEMT asked Patient 1 to put on a mask. Staff C stated that Patient 1 started raising her voice and EDEMT asked Patient 1, "to put a mask on to protect (her) and others, because the ED had COVID positive or patients suspected of COVID present". Staff C stated that she stepped up and asked what was the problem, and Patient 1 stated, "He [EDEMT] wants me to wear a mask or you won't see me." Staff C stated Patient 1 said she had, "Two letters from a doctor saying (she) didn't have to wear one because (she) had been sexually abused." Staff C stated that she couldn't put Patient 1 in the room closest to the triage 1 room, because another patient was being isolated in there. Staff C stated that she offered Patient 1 a shield to wear instead of a mask, but she refused that as well. Staff C stated that EDRN Staff CC continued speaking with Patient 1, so she {Staff C) could continue to triage patients. When asked if the hospital has a protocol regarding patients who present to the ED and cannot wear a mask, Staff C stated, "No we treat everybody." Staff C confirmed he/she did not perform a triage assessment of Patient 1, and Patient 1 was not seen by a qualified medical provider and did not have a MSE to determine whether she had an EMC..


Review of Patient 1's "Disposition Documented Entered On: 3/14/2021 14:09 CDT (Central Daylight Time) Performed On: 3/14/2021 14:07 CDT by [name of EDRN Staff C]," located under the "Documentation" tab, showed ". . .Patient Condition-Disposition: Satisfactory . . . ED Discharged to: Left without being seen . . . Patient Left department: Left without treatment ED Reason for Leaving: Other. Patient was unwilling to put on a mack [sic] or face shield to protect others. Stated she had notes from doctors because she had been sexually abuse [sic]. Repeatedly asked her to please put on her mask. Child with her was recording our conversation ED Refusal of Treatment form Signed: Did not read form just left. . ."

During an interview on 05/12/21 at 9:50 AM, Emergency Department Registered Nurse Manager (EDRNM) stated EDRN Staff CC had talked to her about someone in ED who couldn't wear a mask. EDRNM stated that she told EDRN Staff CC that, "Staff had to put on full PPE in order to provide a MSE." She stated that she told EDRN Staff CC the ED nurses, "had to provide a MSE even though the patient didn't put on a mask." EDRNM stated she's "not aware of a policy that addresses how the screener is to handle a patient who appears and refuses to wear a mask."

During an interview on 05/12/21 at 8:00 AM, the ED Medical Director (EDMD) stated, when asked by the surveyor if the hospital has a protocol or policy regarding how to handle a patient who presents to the ED for treatment and can't wear a mask, "staff should treat the patient as though they have COVID [Coronavirus], completely garb in PPE [personal protective equipment], and get the patient to an exam room if one is available to have a MSE. If a room isn't available, they should social distance the patient. . . I would hate to have that patient in the waiting room with other patients." When asked by the surveyor if any patient should ever be sent away and not be treated because they don't wear a mask, EDMD stated "No, we have to follow EMTALA and examine a patient, stabilize them . . ." EDMD stated he was not aware of the situation with Patient 1 before the surveyor arrived on 04/10/21.

Review of Patient 1's medical record from Acute Care Hospital B showed she arrived in the ED on 03/14/21 at 3:26 PM approximately 1 hour and 15 minutes after being refused a MSE at Ascension Via Christi.