HospitalInspections.org

Based on medical record reviews, policy review, Kiosk Registration, Central Emergency Department Log, video surveillance, and interviews it was determined, the facility failed to ensure that a central log was maintained on each individual who comes to the Emergency Department (ED) seeking treatment/assistance. This failure affected 1 of 20 sampled ED patients (Patient #1).

Refer to findings to Tag A 2406

Based on medical record reviews, policy review, Kiosk Registration, Central Emergency Department Log, video surveillance, and interviews it was determined, the facility failed to ensure that a central log was maintained on each individual who comes to the Emergency Department (ED) seeking treatment/assistance. This failure affected 1 of 20 sampled ED patients (Patient #1).


The findings included:

Facility policy Titled "EMTALA-Central Log" dated 06/2018 documents "The hospital shall 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 needed 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 and treated, stabilized and transferred or discharged."


Review of the Central ED Logs conducted on 04/08/19 revealed no evidence Patient #1 presented to the facility on 01/03/19 seeking emergency care.

Review of the report originated from the registration kiosk dated 01/03/19 revealed Patient #1 presented at the facility at 9:14 PM and the entry was deleted as abandoned.

Review of the facility surveillance video on 04/09/19 at 11:45 AM revealed evidence Patient #1 presented to the facility on 01/03/19 at approximately 9:15 PM and inputted her information at the registration kiosk. The video shows the patient (#1) going to the restroom, the charge nurse and security guard had a conversation, and the nurse was nodding her head left to right, indicating a no motion. Upon patient return to the ED lobby, the guard had a conversation with the patient and escorted the patient out of the facility.

A phone interview with the Security Guard conducted on 04/09/19 at 5:40 PM revealed he was on duty on 01/03/19. The guard recalled the events related to Patient #1's departure from the ED and explained the patient presented with complaints of pain. He spoke to the charge nurse to advise of the patient's condition, to inquire if they could take her in the back sooner. The Charge nurse advised him that they will not be seeing the patient, she was in the ED the day before or two days ago, cannot recall exactly and there is nothing else they can do for her. The charge nurse told the guard to relay to the patient that if she comes back again the police will be called. When the patient returned from the restroom, the guard explained to Patient #1 what the charge nurse said and escorted her out of the department.


Interview with The Director of the ED conducted on 04/08/19 at 9:40 AM revealed Patient #1 completed a negative review in Google and the marketing representative forwarded the details for further review. The Director explained the patient alleged when she came into the ED the charge nurse send her away and two days later, the patient ended up at another hospital. The Director contacted Patient #1 and the patient explained she was in rehab at the time, staying in an assisted living facility and came to the hospital for pain. The security guard, after speaking to the charge nurse, told her that she comes here too much and that she was just here two days prior and had a prescription for Tramadol (pain medicine) and she should get it filled. The security guard escorted her out of the ED and she sat on the bench outside crying for an hour. The Director stated the facility initiated a full investigation and confirmed Patient #1 was turned away. The facility self-reported the incident and the ED staff has received education related to EMTALA rules and regulations. As part of the corrective action, the facility is auditing the self registration kiosk data starting March 2019. If the reports show a patient was deleted, the director is looking for the reason. The security guards have been instructed to document every patient that leaves the department without being seen. The guards complete a form with the description of the patient and the reason for leaving. The Director explained the facility also reviews the security films to ensure compliance.

The facility failed to ensure that their policy and procedure as evidenced by failing to enter patient #1 in the facility's Central log on 1/3/2019, when she presented seeking medical assistance.

Based on policy review, medical record reviews, facility surveillance video, Registration Kiosk, and interview, 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 an emergency medical condition existed for 1 of 20 sampled patients (Patient #1).

The findings included:


Facility policy titled "EMTALA-Medical Screening Exam and Stabilization Policy" dated 06/17 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 exists; to any individual who requests 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 report originated from the registration kiosk dated 01/03/19 revealed Patient #1 presented at the facility at 9:14 PM and the entry was deleted as abandoned.

Review of the facility surveillance video on 04/09/19 at 11:45 PM revealed evidence Patient #1 presented to the facility on 01/03/19 at approximately 9:15 PM and inputted her information at the registration kiosk. The video shows the patient going to the restroom, the charge nurse and security guard had a conversation, and the nurse was nodding her head left to right, indicating a no motion. Upon patient return to the ED lobby, the guard had a conversation with the patient and escorted the patient out of the facility.

A review of the clinical records from Facility B revealed that Patient #1 presented to that facility on 01/10/2019 with complaints of generalized pain. Patient #1 was consequently admitted to Facility B with a diagnosis of urinary tract infection.


A phone interview with the Security Guard conducted on 04/09/19 at 5:40 PM revealed he was on duty on 01/03/19. The guard recalled the events related to Patient #1 departure from the ED and explained the patient presented with complaints of pain. He then spoke to the charge nurse to advise of the patient's condition, to inquire if could take her in the back sooner. The Charge nurse advised him that they will not be seeing the patient, she was in the ED the day before or two days ago, cannot recall exactly and there is nothing else they can do for her. The charge nurse told the guard to relay to the patient that if she comes back again the police will be called. When the patient returned from the restroom, the guard explained to Patient #1 what the charge nurse said and escorted her out of the department.

There is no evidence the facility provided Patient #1, within the capabilities of the staff and facilities available at the hospital, an appropriate medical screening examination to determine whether or not an emergency medical condition existed on 01/03/2019.

with a medical examination and treatment, as required to stabilize the medical condition.

Interview with The Director of the ED conducted on 04/08/19 at 9:40 AM revealed Patient #1 completed a negative review in Google and the marketing representative forwarded the details for further review. The Director explained the patient alleged when she came into the ED and the charge nurse sent her away and two days later, the patient ended up at another hospital. The Director contacted Patient #1 and the patient explained she was in rehab at the time, staying in an assisted living facility and came to the hospital for pain. The security guard after speaking to the charge nurse told her that she comes here too much and that she was just here two days prior and had a prescription for Tramadol (pain medicine) and she should get it filled. The security guard escorted her out of the ED and she sat on the bench outside crying for an hour. The patient stated that she is homeless and agrees that she comes often, usually comes from pain control and never had this happened before. The patient was grateful for the phone call.

The facility initiated a full investigation, interview with security guard revealed he indeed recalled the patient. Patient #1 had many paraphernalia with her and he did tell her she had to leave the facility based on the charge nurse instructions. The Director ran a search for the patient's name and found her account had been deleted. This action prompted the audits and changes to limit the access to this data to the charge nurses and if any discrepancies, they are verified by the director or the manager. The Director interviewed the charge nurse who denied the events. The facility then pulled the security films and confirmed the patient was giving the correct account of events. The facility self-reported the incident and the ED staff has received education related to EMTALA rules and regulations. The Director stated she feels this particular charge nurse was the problem, she was not very nice and other staff had made comments she did not like the homeless population. The nurse was suspended pending the outcome of the investigation and she resigned two days after her suspension. The facility has reported her actions to the Board of Nursing. As part of the corrective action the facility is auditing the self registration kiosk data starting March 2019. If the reports show a patient was deleted, the director is looking for the reason. The security guards have been instructed to document every patient that leaves the department without being seen. The guards complete a form with description of the patient and the reason for leaving. The Director explained the facility also reviews the security films to ensure compliance.

Interview conducted with The Ethics and Compliance Officer (ECO) on 04/09/19 at 9:17 AM revealed Patient #1's complaint came thru the facility website. The officer was reading the reviews and notice the patient allegation dated 01/22/19 and a generic response provided by the marketing department. She reached out to director of marketing and inquired regarding the status. The director of marketing explained anytime she sees a negative review, she will forward the concern to the corresponding director. In this case, she had just sent the information to the director of the ED. Then, she approached the director of the ED and was told the patient was contacted and was waiting for a call back. The Officer presented email communication with the director of marketing and the director of the ED on 01/23/19.
Later that day, the Director of the ED spoke to Patient #1 and reported to her, the incident could probably be a violation. The patient described the security guard and nurse and gave details such as date of service and time of the event. The facility initiated an internal investigation, reported the concern to the corporate office and the director interviewed the staff. The nurse involved was placed on investigated suspension pending the outcome. A few days later, the nurse gave her resignation. The review the security footage, revealed the nurse body language was very noticeable, she was instructing the security guard something and waving her fingers in a no motion. Due to this incident, it was determined the ED staff needed a refresher on EMTALA and the entire security staff should know their role and EMTALA laws. The Officer reached out to the division ECO and found appropriate material for their training, two classes in Healthstream (educational program), one is EMTALA for administrators on call and a good option for a live session and other courses related to EMTALA definitions and requirements. The facility has held numerous live classes to accommodate all shifts. As a result, the facility has changed some of the practices, if anything clinical needs to be communicated to a patient, the security guard will not be giving the information, a nurse needs to deliver clinical information. If a patient in the ED waiting room has clinical questions, the security staff has to get at least a registered nurse, not a paramedic or a clerk to address the concerns. In addition, the director is auditing the kiosk data and any changes made. The Officer continues to make random rounds and communicating with staff and patients.

Interview with The Medical Director, Emergency Department, conducted on 04/09/19 at 12:07 PM revealed the event related to Patient #1 had no provider involvement, the charge nurse made the decision to turn away the patient. The facility has implemented EMTALA education to providers to remain proactive and continue their due diligence. All patients are to be evaluated and treated to ensure they are medically stable. The facility will continue to monitor and self-report any further incidents.