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Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases] by failing to provide a medical screening exam (MSE) and failed to log arrival to the Emergency Department (ED) for 1 patient (P-1), who came to the emergency department requesting examination and/or treatment for a medical condition, out of 21 patients reviewed for EMTALA requirements. This failed practice resulted in the potential for the patient to experience deterioration from an unidentified emergency medical condition, which posed a risk to her health and safety. Findings include:

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A-2405 Failure to keep an Emergency Department log with names of all persons arriving to the Emergency Department seeking Emergency Services

A-2406 Failure to complete a medical screening exam

Based on interview and record review, the facility failed to maintain a central log for 1 (P-1) of 21 patients coming to the hospital emergency department (ED) seeking emergency services resulting in inaccurate documentation of P-1's arrival to the emergency department. Findings include:

During an interview with the System Risk Manager (staff E) on 3/10/2025 at 1340, staff E said there was no documentation in the facility's system regarding P-1's arrival on hospital property on 2/21/2025. Staff E confirmed that P-1 had been brought to the ED on 2/21/2025 and provided security video documentation.

On 3/10/2025 at 1355 record review occurred of security video footage from 2/21/2025. Video footage revealed a police car arriving at the ED parking lot at 1706. P-1 was observed outside of the police car with the police officer (staff K). An additional officer (staff L) was visualized walking to the police car and then entering the building at 1710. Staff L was seen walking to the triage nurse's station and speaking with staff I, (registered nurse) at 1711. At 1716 staff L was visualized walking back to the police car where P-1 was located with staff K. At 1728 staff L walked back into the building to the security office. At 1732 the police car with P-1 left the facility's property.

On 3/17/2025 at 1230, an interview was conducted with staff L. Staff L was queried if she was at the facility on 2/21/2025 with staff K and P-1. Staff L stated she was at the facility with staff K and P-1 because staff K had transported P-1 to the hospital after a suicide attempt at his home. Staff L was then asked if she had spoken with the triage nurse (staff I) regarding P-1. Staff L stated she went in the building and spoke with staff I, and had informed her that there was a suicidal patient (P-1) outside with staff K. Staff L was asked if P-1 was registered as a patient. Staff L stated that P-1 was not registered. Staff L was queried if she was told not to bring the patient into the facility. Staff L stated, "No. I was told they (ED) were really swamped and stated it might be better to take him (P-1) to (facility B)."

On 3/10/2025 at 1130, review of facility's central log for a 6-month period (9/1/2024 - 3/9/2025) revealed no documented evidence that P-1 arrived at the facility and sought treatment on 2/21/2025.

An interview with registered nurse, staff I, occurred on 3/10/2025 at approximately 1545. Staff I was queried if she remembered a conversation with staff L on 2/21/2025 at approximately 1710 where the officer indicated P-1 was located in the parking lot for a suicide attempt. Staff I responded, "I do not recall." Staff I was asked if she could remember her shift on 2/21/2025 and if it was on diversion. Staff I stated she did not remember if the hospital was on diversion on 2/21/2025.

Review occurred of the document titled, "EMTALA Essentials for the Emergency Department," dated 07/22, reference number 9005056. The document read, "All persons presenting to the Emergency Department at (facility) requesting a medical evaluation will be registered and assessed..."

Review occurred of the policy titled, "System ED-8 Triage Guidelines for the Emergency Department," not dated. According to the policy the following is noted, "I) (Facility A) will provide hospital emergency care to all patients requesting emergency care who are on hospital property."

Based on interview and record review, the facility failed to provide a medical screening exam (MSE) for 1 (P-1) of 21 patients reviewed resulting in the potential for an untreated emergency medical condition and poor outcomes. Findings include:

On 3/10/2025 at 1100 review of the Emergency Department (ED) log from 9/10/2024 to 3/9/2024 revealed no evidence of P-1's arrival to the facility.

On 3/10/2025 at 1340 an interview was conducted with staff E, the System Risk Manager. According to staff E and review of video documentation, it was confirmed that P-1 was present at the facility on 2/21/2025. Staff E stated an investigation had been conducted when he was made aware of the patient (P-1) being brought to the facility. Staff E stated he was able to confirm a police car had brought an individual (P-1) to the facility for a suicide attempt but did not bring the patient into the ED.

On 3/11/2025 at 1115 an interview was conducted with staff M, Medical Director of the ED. Staff M was queried if a medical screening exam is required for all patients presenting to the ED. Staff M stated, "Yes...All patients receive a MSE unless they leave without being seen." Staff M was then queried if a MSE would be done on a patient in police custody in the parking lot area. Staff M stated, "Yes...It would not matter where, a MSE can be done anywhere on campus..."

On 3/17/2025 at 1235 staff L, police officer, confirmed P-1 was brought to the facility on 2/21/2025. Staff L was queried if the facility was aware that P-1 was in the parking lot. Staff L stated, "yes...they were really swamped and stated it might be better to take him (P-1) to (facility B)."

On 3/11/2025 at 1600 a review of the document titled, "EMTALA Essentials for the Emergency Department, dated 07/22, reference number 9005056." According to the document it revealed, "A medical screening exam will be completed by a qualified provider and documented in the patient ' s electronic health record. If an emergency medical condition exists or active labor is diagnosed, the patient will be provided with stabilizing care up to and including admission or transfer when appropriate..."

On 3/11/2025 at 1630 a review of the policy titled, "System Administration A-11 Treatment and Active Labor Act Compliance - EMTALA," policy code A-11, dated 06-07-02. According to the policy it revealed, "Any person who comes to the hospital ' s dedicated Emergency Department (ED), Labor and Delivery Department, or arrives on hospital property requesting treatment for what may be an emergency medical condition will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists."