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Based on interview, policy review, record review and review of video surveillance, the hospital failed to provide an appropriate medical screening examination (MSE) to determine the presence of an emergency medical condition (EMC) after suggesting that the patient seek assistance at a different healthcare facility for one patient (#32) and failed to enter two patients (#17 and #32) into the Emergency Department (ED) central log out of 32 ED patient records reviewed. The hospital's ED average monthly census over the past six months was 264.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)," dated 11/15/22, showed that any person presenting to the ED shall receive a MSE and/or medical services necessary to stabilize the individual.

Review of the hospital's undated education document titled, "EMTALA: The Emergency Medical Treatment and Labor Act," provided to staff members on 12/12/22, directed staff that the EMTALA obligation began when a patient presented to the ED and requested examination or treatment for an EMC. The hospital must maintain a central log to track the care provided to each individual who presents to the hospital seeking care, whether the individual refused treatment, did not have an EMC, was admitted, treated, stabilized, transferred, or discharged.

Review of the hospital's Registration Desk and ED entrance videos for 12/05/22, showed at 2:37 PM, Patient #32 and a male arrived at the registration desk. The male signed the registration touchpad and was handed a patient identification (ID) bracelet. At 2:52 PM, video showed Staff O, Patient Access Representative, walked through the ED treatment area and reappeared in the waiting room at 2:53 PM. Staff O approached Patient #32 and the accompanying male and appeared to be talking with them. At 2:54 PM, the male stood and abruptly pushed the wheelchair with Patient #32 out of the ED entrance.

Although requested, there was no medical record or registration information for Patient #32.

Review of the hospital's document titled, "Un-coded Emergency Room Report," dated 01/23/23, showed that Patient #17 had been seen in the ED on 11/24/22 and billed for services during the visit. There was no entry in the document on 12/05/22 for Patient #32.

Although requested, the hospital did not have a policy which directed staff on the process for logging a patient into the ED central log.

Review of the hospital's ED central log from 08/22/22 through 01/23/23 showed no entry for Patient #17 on 11/24/22 or for Patient #32 on 12/05/22.

The hospital's failure to provide Patient #32 with a MSE and enter Patients #17 and #32 into the ED central log could have resulted in possible injury or death to patients who required immediate medical care.

Please refer to A-2405 and A-2406 for details.

Based on interview, policy review, record review and review of video surveillance, the hospital failed to enter two patients (#17 and #32) into the Emergency Department (ED) central log of 32 ED patient records reviewed. The hospital's ED average monthly census over the past six months was 264.

Findings included:

Although requested, the hospital did not have a policy which directed staff on the process for logging patients in the ED central log.

Review of the hospital's undated education document titled, "EMTALA: The Emergency Medical Treatment and Labor Act," provided to staff members on 12/12/22, directed staff that the hospital's EMTALA obligation began when a patient presented to the ED and requested exam or treatment for an emergency medical condition (EMC). The hospital must maintain a central log to track the care provided to each individual who presents to the hospital seeking care whether the individual refused treatment, did not have an EMC, was admitted, treated, stabilized, transferred, or discharged.

Review of the hospital's document titled, "Un-coded Emergency Room (ER) Report," dated 01/23/23, showed that Patient #17 had been seen in the ED on 11/24/22 and billed for services. There was no entry on the document on 12/05/22 for Patient #32.

Record review of the hospital's ED central log book from 08/22/22 through 01/23/23, showed no entry for Patient #17 on 11/24/22 and no entry for Patient #32 on 12/05/22.

Review of the hospital's Registration Desk and ED entrance videos for 12/05/22, showed at 2:37 PM, Patient #32 was pushed via wheelchair to the registration desk by an accompanying male. The male signed the registration touchpad and was handed a patient identification (ID) bracelet.

Review of a hospital electronic mail (email) document subjected with, "ER Nurses Meeting," dated 12/09/22, sent by Staff J, Executive Assistant/Policy Coordinator, directed all staff to attend a meeting on 12/12/22. Staff G, Patient Access Supervisor, was directed to ensure that all registration staff attended.

Review of the hospital's document titled, "ER Nurses Meeting," dated 12/12/22, showed that staff were educated on EMTALA violations. Registration staff were directed not to tell patients to go to the walk-in clinic.

During an interview on 01/23/23 at 4:20 PM, Patient #32, stated that she had presented to the ED on 12/05/22 and registered for treatment. She stated that she had signed no paperwork, her vital signs were not assessed and she left the ED without being seen.

During an interview on 01/26/23 at 10:30 AM, Patient #32's spouse, stated he drove his wife to the ED, obtained a wheelchair and brought her to the ED Registration Desk. The clerk at the desk had asked for her name, date of birth, and reason for the visit. He had signed consent to treat for Patient #32 on the electronic pad, and the clerk handed him an ID bracelet.

During an interview on 01/25/23 at 11:30 AM, Staff O, Patient Access Clerk, stated that she had been working the registration desk on 12/05/22, when Patient #32 had presented for treatment. She had registered patient #32 and printed her patient ID bracelet. She entered her name, date of birth, and reason for her ED visit into the computer.

During an interview on 01/24/23 at 3:10 PM, Staff L, Quality Coordinator, stated that Patient #32 had presented to the ED on 12/05/22. Patient #32 had registered requesting evaluation in the ED, but she was not listed on the ED central log book.

Review of the medical record for Patient #17 showed that he presented to the ED on 11/24/22 at 8:35 PM, with complaint of a migraine (a headache that can cause severe throbbing pain or a pulsing sensation, usually on one side of the head). The record showed that Patient #17 was registered, triaged, received a medical screening examination (MSE), was given medications and was discharged home in stable condition on 11/24/22 at 9:49 PM.

During an interview on 01/23/23 at 4:25 PM, Staff I, Revenue Cycle Manager/Health Information Manager, stated that she was able to find Patient #17 on the computer-generated "Un-coded ER Report," through the hospital's billing system, but he was not listed in the handwritten ED central log. Staff I stated Patient #17 should be listed on both documents and the ED nurse "must not have written him in the log".

During an interview on 01/25/23 at 12:15 PM, Staff P, Registered Nurse (RN), ED Supervisor, stated that the completion of the ED central log was the ED RN's responsibility and that information was pulled from the patient's electronic health record. Every patient that presented to the ED would be registered, but the registration could be deleted if they left the hospital before they were triaged (process of determining the priority of a patient's treatment based on the severity of their condition) by the nurse or seen by the provider.

During an interview on 01/23/23 at 4:25 PM, Staff E, RN, stated that the ED nurses logged every patient into the ED central log book. She stated that if a patient was in the waiting room and left before triage, sometimes registration staff removed the patient from the tracker page by cancelling the registration and the patient would not be entered into the ED central log book.

During an interview on 01/23/23 at 4:45 PM, Staff H, Patient Access Representative, stated that all patients who present to be seen in the ED were asked their name and birth date and registered in the electronic health system. She stated that patients were asked to sign a consent for treatment, given a patient ID bracelet, asked to wait in the waiting area and the ED nurse was notified of the patient's complaint. Staff H stated that if a patient left the waiting area before being triaged, they would be removed from the registration tracker page by cancelling the registration.

During an interview on 01/25/23 at 11:25 AM, Staff D, Patient Access Representative, stated that if a patient registered and left before triage, the visit could be cancelled. She stated that the hospital still cancelled registrations for patients who left the ED waiting area after registering and before seeing the triage nurse.

During an interview on 01/25/23 at 11:40 AM, Staff N, Patient Access Representative, stated that if a patient registered to be seen in the ED and then left before the nurse triaged the patient, the registration could be cancelled. She stated that she had not been instructed to stop the practice of cancelling patients who registered and left before triage.

During an interview on 01/25/23 at 12:35 PM, Staff G, Patient Access Supervisor, stated that every patient was registered in the ED. Staff G stated that a registered patient visit could be cancelled if the hospital was not going to keep that visit "active". If the patient left before triage and was not seen by any medical personnel, that the visit could be cancelled. If the visit was cancelled, none of the registration information would remain in the computer system, including the signatures on the consent to treat documentation.

During an interview on 01/23/23 Staff K, Chief Nursing Officer (CNO), stated that she would expect every person that presented to the ED and requested treatment would be registered on the ED central log. The completion of the handwritten ED central log book was the ED RN's responsibility. The hospital did not have any policies specific to the ED central log book process.



39147

Based on interview, policy review, record review and video review, the critical access hospital (CAH) failed to provide an appropriate Medical Screening Examination (MSE) within its capacity and capability to determine if an emergency medical condition (EMC) existed for one patient (#32) of 32 patient records reviewed, who presented to the CAH's Emergency Department (ED) seeking care from 07/25/22 to 01/18/23.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)," dated 11/15/22, showed that any person presenting to the ED shall receive medical screening and/or medical services necessary to stabilize the individual.

Review of the hospital's undated education document titled, "EMTALA: The Emergency Medical Treatment and Labor Act," provided to staff members on 12/12/22, directed staff that the hospital's EMTALA obligation begins when a patient presents to the ED and requests exam or treatment for an EMC. Acute symptoms of sufficient severity such that the absence of immediate medical attention could result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part, could be the manifestation of an EMC.

Review of the hospital's ED entrance video for 12/05/22, showed Patient #32 arriving at the ED registration desk, via wheelchair at 2:37 PM. She was accompanied by her spouse. She was wheeled toward the waiting area at 2:40 PM. At 2:45 PM, Staff O, Patient Access Clerk, appeared on screen and opened the doorway to the ED treatment area for another visitor. At 2:52 PM, Staff O, walked through the ED treatment area door. She returns on screen at 2:53 PM, where she approached Patient #32 and her spouse. Staff O appeared to be talking to them. At 2:54 PM, Patent #32's spouse stands and abruptly pushes the wheelchair with Patient #32 out of the ED entrance.

Review of the hospital's Registration Desk video for 12/05/22, showed Patient #32 was at the desk at 2:37 PM. At 2:38 PM, Patient #32's spouse can be seen signing the registration keypad. At 2:39 PM, Staff O, Patient Access Clerk, hands Patient #32's identification bracelet to her spouse. At 2:40 PM, Patient #32's spouse pushes her towards the waiting area of the ED.

Review of the hospital's document titled, "Emergency Room (ER) Nurses Meeting," dated 12/12/22, showed that staff were educated on EMTALA violations, by power point. Registration staff were directed not to tell patients to go to the walk-in clinic. All ED providers and nursing staff were to review all policies related to EMTALA.

Although requested, the hospital was unable to provide an ED medical record for Patient #32.

Although requested, the hospital was unable to provide documentation showing Patient #32 had been placed on the ED Patient Log.

Review of Patient #32's ED Medical Record from Hospital B (nearby CAH) showed that she presented on 12/05/22 at 3:34 PM (approximately 1 hour after leaving Scotland County Hospital) with a chief complaint of multiple syncopal (to faint) episodes, weakness, and dehydration. In addition, she complained of epigastric (middle upper abdomen, below the ribs) abdominal pain and left knee discomfort. Her medical history included gastric bypass (a weight loss surgery that creates a small pouch out of the stomach which then connects to the small intestines; a common complication can be ulcers or bleeding, which may present with epigastric pain, nausea, and/or chronic anemia [low amounts of oxygen rich blood, causes paleness and weakness]). During one of her syncopal episodes, she twisted her left knee that had just recently undergone arthroscopic (a fiber-optic video camera is inserted into a joint to diagnose and treat joint problems) exam. She also stated that she had been taking ibuprofen (a medication that is used for treating pain, fever, and inflammation) for several days after having a tooth extraction. Her initial blood pressure (BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80) was 84/56, with a pulse rate (the number of heart beats per minute, normal range for adults is 60 to 100 bpm) of 100 bpm. Initial laboratory results showed that her hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body; normal range 12.7 to 14.7 gm/dl) was 10.2 gm/dl and her hematocrit (Hct, measures the percentage of red blood cells in your blood; normal range 38 to 44%) was 32%. (H&H, used to measure red blood cell numbers, checked to rule out anemia) She had an elevated lactic acid (can be indicative of a severe medical illness in which the blood pressure is low and too little oxygen is reaching the body's tissues; high levels may lead to a life threatening condition; normal range would be less than 2.0 mmol/L, severe levels would be greater than 4.0 mmol/L) of 5.1 mmol/L. Her stool was positive for blood. After five hours, two liters of intravenous (IV, in the vein) fluids and the initiation of continuous IV fluids, Patient #32's systolic blood pressure reached 100 or above. She was diagnosed with a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra). She remained in the ED for 24 hours being monitored. There were multiple attempts made to transfer Patient #32 to a higher level of care, but no beds were available. She remained tachycardic (abnormally rapid heart rate, greater than 100 beats per minute), but her blood pressure improved. She was then placed in observations status until a transfer could be accomplished. She had presented with septic (life threatening condition when the body's response to infection injures its own tissues and organs) shock upon admission. There was concern of a possible peptic ulcer (open sores that develop on the stomach lining, may cause pain, nausea, and bleeding) with associated upper gastrointestinal (GI, refers to the stomach and intestines) bleed and anemia.

Review of Hospital B's transfer documentation, dated 12/06/22 at 8:28 PM, showed that Patient #32 had been diagnosed with sepsis due to a UTI. She ultimately developed an upper GI bleed and was in need of an endoscopy (a procedure to examine the interior of a hollow organ or cavity of the body with a lighted tube with a camera).

Review of the Hospital B's "Prehospital Care Report," dated 12/06/22 at 9:15 PM, showed that she was transferred by Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) to a higher level of care at Hospital C (an Acute Care Hospital) for further examination and stabilizing treatment. Patient #32 arrived at Hospital C at 11:04 PM.

During a phone interview on 01/25/23 at 11:30 AM, Staff O, Patient Access Clerk, stated that she had been working the registration desk on 12/05/22, when Patient #32 had presented for treatment. She had obtained Patient #32's name, date of birth and reason for her visit. She entered the information into the computer and printed Patient #32's identification bracelet. She stated that she had informed Patient #32 and her spouse that the ED was full and that it could be a couple of hours before she would be seen. Staff O, informed them of an attached walk-in clinic where Patient #32 could be examined and have x-rays (test that creates pictures of the structures inside the bod/y-particularly bones) taken. Staff O stated that when she told them about the walk-in clinic, Patient #32's spouse became irritated. He told her that they could just go to another hospital. He then pushed the wheelchair with Patient #32 out of the ED.

During an interview on 01/23/23 Staff K, Chief Nursing Officer (CNO), stated that she was notified by Hospital B of the potential EMTALA issue with Patient #32. The hospital determined that Patient #32 was registered, but never triaged or treated. Patient #32 left before being seen by the ED nurse or provider. Staff K did not reach out to Patient #32 after her visit. She was unaware if or when anyone from the hospital had checked on the patient.

During an interview on 01/24/23 at 3:10 PM, Staff L, Quality Coordinator, stated that she had received a call from Hospital B on 12/06/22. Hospital B informed her of a potential EMTALA violation related to Patient #32. Hospital B did not provide her with any specifics, just the patient's name. Staff L stated that she was able to determine that Patient #32 had presented to the ED on 12/05/22, and was able to review video of the encounter. Patient #32 had registered in the ED, but she was not listed on the ED Log Book. She had not been seen by the ED nurse or the provider, and there was no medical record created. Staff L was unaware if any staff from the hospital had reached out to Patient #32.

During an interview on 01/25/23 at 12:15 PM, Staff P, RN, ED Supervisor, stated that she had been working the ED on 12/05/22. She had been informed by Staff O, Patient Access Clerk, that a patient had registered to be seen. Staff P, stated that she had told Staff O, to let the patient know that there were no rooms available and she was unsure how long the wait may be. She told the clerk to let the patient know that they may want to go to the walk-in clinic. She did not tell Staff O to direct the patient to the clinic.

During an interview on 01/25/23 at 12:35 PM, Staff G, Patient Access Supervisor, stated that Patient #32's spouse had signed the registration pad, that signature and the attached documentation, was deleted when the computer system updated and deleted the visit.

During a phone interview on 01/23/23 at 4:20 PM, Patient #32, stated that she had presented to the ED on 12/05/22 and registered for treatment. She had experienced multiple falls at home. She thought she might have injured her leg during one of the falls. She had recently had arthroscopic surgery on her left knee. Her husband had taken her blood pressure at home, it was 60/39. She thought the falls may have been related to her low blood pressure. She stated that they had waited around 10 to 15 minutes, when the registration clerk had approached them. The clerk had been instructed to inform them that they could be waiting for a few hours before they would be seen. The clerk had suggested that they could go to the walk-in clinic to be treated, but that the ED had been "slammed". She stated that she had signed no paperwork and was not assessed in any way, nor were her vital signs taken. They left the ED without being seen.

During a phone interview on 01/26/23 at 10:30 AM, Patient #32's spouse, stated that she had been "passing out" at home due to her low blood pressure. He had taken her blood pressure before going to the ED, it had been 60/30. When they arrived, he obtained a wheelchair, then brought Patient #32 to the ED Registration Desk. The clerk at the desk had asked for her name, date of birth, and reason for the visit. They told the clerk that she had suffered multiple falls that day, her blood pressure was low, and she may have injured her leg. About 15 to 20 minutes later, the same clerk came to them and said that they would have a really long wait. She told them that there was the walk-in clinic available that could see her. The clinic was capable of examining her and ordering any x-rays if needed. He stated that the clerk did tell them they were welcome to wait. They decided to leave and go to a different hospital, Hospital B. He then stated that it took Hospital B around nine hours to stabilize Patient #32's blood pressure. Hospital B then transferred Patient #32 to Hospital C for further examination and stabilizing treatment. She remained in Hospital C for several days.

During a phone interview on 02/02/23 at 8:45 AM, Staff Q, Advanced Registered Nurse Practitioner, Hospital B, stated that he had been the provider that evaluated Patient #32 on 12/05/22 at Hospital B. Based on Patient #32's reported symptoms and her surgical history, he was immediately concerned about the possibility of her having some kind of bleed. She had undergone gastric bypass, had complained of multiple syncopal episodes, stated her blood pressure was low, and had been taking ibuprofen for several days after a tooth extraction. The probability of her having a GI bleed was very high. She remained in Hospital B's ED for over 24 hours, waiting for a transfer bed. She required an endoscopic evaluation and possible cauterization, which Hospital B was not equipped to do.