HospitalInspections.org

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Based on interview, review of hospital policies and procedures, and document review, the hospital failed to develop and implement policies and procedures to provide a medical screening examination for patients presenting for emergency care in accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA).

Failure to ensure patients presenting to the emergency department receive a comprehensive medical screening examination (MSE) by a qualified medical professional to rule out an emergency medical condition risks poor health outcomes, injury and death.

Findings included:

The hospital refused to provide medical screening examinations for 3 of 23 patients when they presented to the emergency department for emergency care.


Cross Reference Tag# 2406

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Based on interview, review of hospital policies and procedures, and document review, the hospital failed to show evidence that 3 of 23 patients who presented to the hospital for emergency care received a medical screening examination (MSE) by a qualified medical professional (Patients #21, #22, and #23).

Failure to ensure patients seeking emergency medical care receive a comprehensive medical screening examination by a qualified medical professional risks poor health outcomes, injury and death.

Findings included:

1. A review of the hospital policy titled, "LL.026 EMTALA Medical Screening and Treatment of Emergency Medical Conditions," #16449378 effective date 09/19/24, showed that individuals coming to the hospital's dedicated emergency department (ED) seeking assessment or treatment for a medical condition, or coming to the hospital property requesting treatment for an emergency medical condition receive an appropriate medical screening examination by a physician or other qualified medical personnel. A qualified medical person or personnel means an individual other than a licensed physician who has demonstrated current competence in the performance of medical screening examinations and been approved by the hospital's governing board as qualified to administer medical screening examinations.

The hospital's policy titled, "Controlled Access Operations Procedure/Security Lockdown Levels and Response," number 13494856, effective date 04/23, showed guidelines for locking down the Trios Southridge Hospital in the event of an emergency situation in which partial, modified, or complete lockdown of the facility would be necessary. The determination to declare and/or initiate total or controlled lockdown will be at the discretion of the Chief Executive Officer (CEO), administrator-on-call, or the highest-ranking administrator in the facility. The policy showed that a Level 4 total hospital lockdown is the highest level of facility and perimeter security and may involve a life-threatening situation. During Level 4 total lockdown, all perimeter doors are secured, and no one is allowed to enter or exit the facility. Security personnel or designees will secure and staff all entry/exit points.

2. A review of the security shift activity report dated 06/08/25, showed that at 3:49 AM, the hospital was put on a Level 4 total lockdown following the arrival of a patient with a gunshot wound in the ED. The lockdown was discontinued at 6:42 AM. There were no additional notations between the lockdown was initiated and the time the lockdown was lifted.

3. On 07/10/25 at 3:24 PM, during an interview with the investigator, a patient access representative (Staff #1) stated that they were on duty in the ED on 06/08/25 when a patient with a gunshot wound arrived. The hospital was put on lockdown, and a security guard stood by the walk-in entrance to the ED. Staff #1 stated that they witnessed the security guard opening the door a few inches when anyone approached or attempted to enter the hospital and heard the security guard say they were not seeing patients right now because the hospital was on lockdown.

4. On 07/09/25 at 2:25 PM, during an interview with the investigator, a hospital supervisor (Staff #2) stated that they had spoken with the Chief Nursing Officer (CNO) at the time of the lockdown on 06/08/25, and the CNO agreed to alert the hospital leadership team of the Level 4 lockdown. The interview showed that Staff #2 notified the hospital security officer of the authorized lockdown and informed security staff that only those needing to be seen were allowed to enter the hospital. Staff #2 stated that they had received a phone call from another facility (Hospital B) that 3 patients arrived at Hospital B stating that they were turned away from the Trios ED because the hospital was on lockdown. Staff #2 stated that the information was received at the end of their shift, so they documented the information received and forwarded it to hospital leadership, including the ED Director, the CEO, the CNO, and the Director of Quality.


5. On 07/08/25 at 11:28 AM, during an interview with the investigator, the interim ED Director (Staff #3) stated that they read the hospital supervisor's report and received a phone call from Hospital B's ED Director about patient's being turned away from the ED on 06/08/25. Staff #3 stated they contacted the CNO and the Director of Quality about the EMTALA violation and recommended that the hospital self-report the incident to the Washington State Department of Health.

6. On 07/08/25 at 9:55 AM, during an interview with the investigator, the CNO (Staff #6) stated that the hospital reviewed the EMTALA incident but had not yet formalized a corrective action plan. Staff #6 stated that the hospital revised the lockdown policy within 2 weeks of the event, but staff had received no training regarding the new policy at the time of the investigation.


7. On 07/08/25 at 9:55 AM, during an interview with the investigator, the Director of Plant Services and Security (Staff #7) stated that they had spoken to all of the security guards individually about the lockdown event but had not kept any documentation of the items reviewed or attendance verification.

8. On 07/11/25 at 3:20 PM, the investigator contacted Hospital B by phone and email. Hospital B confirmed that 3 patients arrived in their ED on 06/08/25 after they were refused service at Trios Health during the lockdown (Patients #21, #22, and #23).

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