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Based on review of the hospital EMTALA (Emergency Medical Treatment and Labor Act) policies, staff interview, and medical record reviews the hospital failed to ensure patients presenting to the emergency room (ER) received a medical screening examination (MSE) within the capability of the hospital's emergency department , including ancillary services routinely available to determine whether or not an EMC existed for nine (9) patients (#1, #3, #4, #7, #8, #9, #10, #11, and #12) of twenty-one (21) sampled patients.

Refer to findings in Tag - A2406.

Based on review of the hospital EMTALA (Emergency Medical Treatment and Labor Act) policies, staff interview, and medical record reviews the hospital failed to ensure patients presenting to the emergency room (ER) received a medical screening examination (MSE) within the capability of the hospital's emergency department , including ancillary services routinely available to determine whether or not an EMC existed for nine (9) patients (#1, #3, #4, #7, #8, #9, #10, #11, and #12) of twenty-one (21) sampled patients.


Findings included:

Review of the medical record for Patient # 1 revealed he came to the emergency room with a chief complaint of chest pain at 12:00 PM on 10/18/2022. His vital signs were documented during triage at 12:02 PM as follows: blood pressure 165/105 (A normal Blood Pressure reading: to be less than 120/80), 91 pulse, 20 respirations, 98.2 temperature, and 100% oxygen saturation on room air. Further review of the ED (emergency department) documentation showed he left without treatment at 4:08 PM, for a total of 4 hours and 8 minutes spent in the ED. The record review showed Patient # 1 did not receive a medical screening examination (MSE) to determine if he had an emergency medical condition (EMC).

An interview was conducted with Staff B, RN (registered nurse) and Staff C, RN on 1/18/23 at approximately 11:00 A.M., during the record review. Staff B and C confirmed Patient #1 did not receive an MSE.

Record review was done with Staff A, RN on 1/18/2023 at 11:08 A.M., who confirmed the findings.


A review of the ED record for Patient #3 reflected an arrival on 1/10/23 at 7:31 PM with a chief complaint of shortness of breath. The triage documentation at 7:52 PM showed an ESI (Emergency Severity Index) of 3 (emergency screening index: an ESI is a number assigned indicating the acuity of the patient. 1 is emergent, 5 is the least serious). Documentation included vital signs (VS). There was not a documented MSE, and the ED log indicated Patient #3 left without treatment (LWOT) at 2:45 AM on 1/11/23, seven hours and fourteen minutes after her arrival.

A review of the emergency department (ED) documentation for Patient #4 showed he presented to the ED on 1/11/23 at 9:39 PM with a chief complaint of chest pain. His emergency screening index (ESI) was marked "3 urgent". His vital signs were documented by triage at 9:42 PM. At 1:18 AM on 1/12/22 he was seen by an APRN (advanced practice registered nurse), three hours and thirty-nine minutes after his arrival.

In an interview during the record review with Staff A, RN, she said as soon as a bed is available they are brought back to see a provider. The goal is to get them from triage to a bed. Staff A also stated that the new process is, if you go out and call their name and walk around the ER and they don't answer, then they are coded an LWOT (left without treatment) and taken out of the system.

Review of the ED record for Patient #7 revealed she presented to the ED on 1/10/23 at 9:49 PM with a chief complaint of epigastric pain. The triage documented an ESI 3, urgent, and the following vital signs (VS): blood pressure (BP) 163/100, temperature 98.4, pulse 100, respiratory rate (RR) 17, and oxygen saturation 100% at 12:03 AM on 1/11/23. At 5:19 AM she was marked as an LWOT on the ED log, seven hours and thirty minutes after she checked in. There was no documentation of an MSE.

Review of the documentation in the ED record for Patient #8 reflected an arrival on 1/11/23 at 12:23 AM with a chief complaint of boil under left arm. The triage documentation indicated an ESI 4 and VS were documented at that time as well. Further review of the record revealed no further documentation after triage and the patient was marked as LWOT at 5:20 AM on the ED log. There was no documentation an MSE was done.

A review of the ED documentation for Patient #9 reflected an arrival on 1/10/23 at 10:52 PM with a chief complaint of back pain. The patient was triaged at 11:06 PM and assigned an ESI 5 with VS documented. There was no further documentation after triage. The ED log reflected she LWOT at 5:19 AM, six hours and twenty-seven minutes after Patient #9 signed in.

Review of the documentation in the emergency department record for Patient #10 revealed an arrival on 1/10/23 at 9:10 PM with a chief complaint of abdominal pain. Review of the triage documentation showed an ESI of 3 with VS documented. The only other documentation in the record was of a respiratory rate (RR) at 12:37 AM. The ED log reflected Patient #10 LWOT at 5:17 AM. An MSE was not in the record.

Review of the ED record for Patient #11 revealed an arrival on 1/10/23 at 5:40 PM with a chief complaint of abdominal pain. The triage documentation completed at 6:00 PM reflected an ESI 3 and VS were documented at that time. There was no documentation an MSE was completed by a provider. The ED log reflected the patient LWOT at 10:17 PM, four hours and thirty-seven minutes after she signed in.

Review of the ED record for Patient #12 reflected a check-in time of 1:03 AM on 1/10/23, with a chief complaint of headache. The triage documentation at 1:35 AM showed an ESI 3. His documented VS at that were BP 168/98, temperature 98.4, pulse 106, RR 18, and oxygen saturation 99%. There was no documentation reflecting an MSE was completed, and the ED log indicated he LWOT at 7:54 AM, six hours and fifty-seven minutes after he signed in.

An interview was conducted with the director of the ED at 1:19 PM on 1/18/23 during the record reviews. The ED director said the nurse or tech calls out their name. If there is no response they walk around the whole ER. It's a big ER. They check the bathroom and the front door. It doesn't take too long to walk it. The pedi (pediatric) waiting room is not in the adult waiting room. It's around the corner. They also go there and call them. There's a bathroom there so they call there also. It may take two or three minutes to walk the whole emergency room. They call their name several times and then they notify the nurse who takes them out of the system. An LWOT is no MSE. The staffing was changed to have more front loaded staff out there. There is someone at the door and someone at the lobby. There is a nurse helper to engage with folks and watch for decompensation in the lobby. There are two zones open twenty-four hours. A third zone is open 9 AM to 1 AM, and the fourth zone is back to 9 AM to 1 AM because it was 11 AM to 11 PM. We are trying to capture all that volume. Standing orders start in triage. The work up is started on the patient so they are not just standing around. There is a a mid-level looking at the board and reviewing the orders that have been completed to see if they need to be upgraded or need additional orders. They communicate with the AOD (administrator on duty) and let them know if someone needs to come back. Sometimes when it's very busy a mid-level goes out to triage and starts seeing patients there. It is not daily. It is something the medical director and AOD do together. It's a specific zone. Every zone has a physician, a mid-level, nursing and techs in it. They are like a mini ER. The mid level who is in the red zone is the one who goes to triage to start evaluating patients.


Review of the EMTALA (Emergency Medical Treatment and Labor Act) Compliance Plan, last reviewed 4/2013 reflected the following:
Policy
Any person who comes to a hospital facility requesting assistance for a potential emergency medical condition/emergency services will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists
WHEN IS A MEDICAL SCREENING EXAMINATION REQUIRED?
A medical screening examination is required when an individual:
" seeks care at the hospital Emergency Department for which EMA provides services
" arrives anywhere on the hospital premises for which EMA provides services and states that he or she has an emergency and requests emergency care
WHAT ARE THE REQUIREMENTS OF A MEDICAL SCREENING?
" The medical screening consists of an assessment and any ancillary tests or focused assessment based on the patient's chief complaint necessary to determine the presence or absence of an emergency medical condition. This may be a brief history and physical examination or may require complex ancillary studies and procedures such as (but not limited to) lab tests, fetal monitoring, EKG, radiology procedures, or specialty consultation.
" The medical screening examination is the process a provider must use to reach with reasonable clinical confidence whether a medical emergency does or does not exist.
" The medical screening must provide evaluation and stabilizing treatment within the scope of the hospital or facilities abilities and not consider a patient's ability to pay.
" The medical screening examination may require consultation with, or evaluation by, on-call specialty physicians.

WHO MAY PERFORM THE MEDICAL SCREENING?
The Medical Screening must be performed by:
" Physicians, Physician Assistants, and Nurse Practitioners. These professionals will function within the scope of their license and certification with approval by the Board of Directors of the hospitals with which EMATB is contracted. Non-physician qualified personnel who perform the Medical Screening utilize protocols approved by the Medical Staff and the hospital Board of Directors.


The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to ensure that individuals who comes to the hospital's facility requesting assistance for a potential emergency medical condition received a medical screening examination performed by a qualified provider to determine whether or not an emergency medical condition existed for Patient #'s: 1, 3, 4, 7, 8, 9, 10, 11, and 12.