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Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare-participating hospitals in emergency cases as evidenced by:

A2406: Medical Screening Examination: The hospital failed to provide a Medical Screening Examination (MSE) to Patient #3 who presented to the Emergency Department (ED) with chest pain. The patient left without treatment after waiting approximately 12 hours without being evaluated by a physician. The patient went to a different acute care hospital directly after leaving Banner University Medical Center Tucson and was admitted. Additional record reviews revealed MSE's were not provided to the following patients: Patient #1, Patient #4, Patient #8, and Patient #21.

Based on reviews of clinical records, policies and procedures, hospital documents, logs and records, and staff interviews, it was determined the hospital failed to provide a Medical Screening Examination (MSE) to Patient #3 who presented to the Emergency Department (ED) with chest pain. The patient left without treatment after waiting approximately 12 hours without being evaluated by a physician. The patient went to a different acute care hospital directly after leaving Banner University Medical Center Tucson and was admitted. Additional record reviews revealed MSE's were not provided to the following patients: Patient #1, Patient #4, Patient #8, and Patient #21.

Findings include:

The hospital's policy and procedure titled, "EMTALA-Medical Screening Examination and Stabilization Treatment," (Policy Number 1330, Version 13, Effective 11/04/2020) included: "An appropriate MSE will be offered to individuals on the Campus of Banner Hospitals with a Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested, or, in the absence of such a request, whose appearance or behavior would cause a prudent layperson observer to believe that such individuals need an emergency examination or treatment...An MSE will be conducted to determine whether the Patient has an EMC (emergency medical condition)...The MSE is an ongoing process requiring continuous monitoring based upon the Patient's needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred."

The hospital's "Emergency Department Standards of Care" (Policy Number 629, Version 10, Effective 01/26/2022) revealed triage assessments completed by Registered Nurses (RN's) were to include the assignment of an Emergency Severity Index (ESI) score from 1 to 5 with an ESI 1 score requiring immediate life-saving interventions and ESI 5 requiring no resources needed. An ESI 2 score was defined as: "High-risk situation or confused/lethargic/disoriented or severe pain distress." Reassessments, "Occurs according to the patient's clinical presentation or any significant clinical event with the minimum requirements as follows...ESI 2 = Documented reassessments every 1 hour until hemodynamically stable, then minimally every 4 hours or per admitting unit standard of care."

Patient #3

Patient #3 presented to the ED on 6/1/2022 at 8 a.m. by Emergency Medical Services (EMS) with a chief complaint of chest pain and shortness of breath. The patient was triaged by a Registered Nurse (RN) at 8:10 a.m. who assigned an ESI of 2. Blood was drawn at 12:02 p.m. and resulted at 12:36 p.m. The patient's sodium level was documented to be 126 mmol/L (low) with the normal reference range being 134-137 and her sodium level was documented to be 92 mmol/L with a normal reference range of 95-108. An EKG was performed at 8:20 and a chest x-ray was performed at 9:45 a.m. The patient's mental status was documented to be "Alert and Responsive" at 8:10 a.m. and 1:50 p.m. and vital signs were recorded at 8:10 a.m., 1:50 p.m., and 5:47 p.m. The hospital's "Refusal of Examination" form scanned into the clinical record included the following handwritten note: "We didn't refusal (sic)...Never got to see a doctor in 12 hr." There was a signature on the patient/patient's representative line which was not dated or timed. Documentation in the ED Chronological View of the clinical record revealed the patient checked out at 10:02 p.m. on 6/1/2022, a period of approximately 12 hours after arrival during which time an MSE was not completed.

The patient presented to Hospital #2 after leaving Banner University Medical Center-Tucson. A review of medical records obtained from Hospital #2 revealed an arrival time of 10:45 p.m. on 6/1/2022. The patient received an MSE at 12:23 a.m. on 6/2/2022 which included the following: "...presents with dyspnea, generalized weakness, fatigue, decreased appetite and muscle cramps that began about 3 days ago. Patient states she is having nausea and vomiting as well as diarrhea. She has vomited once today and had 2 episodes of nonbloody watery diarrhea. Patient also complains of chest pain, epigastric abdominal pain and mild dyspnea. No fevers or chills. Denies any urinary symptoms. She has no unilateral leg swelling. Labs reviewed... CMP (Comprehensive Metabolic Profile) shows a sodium of 122. BUN and creatinine are unremarkable. Normal LFTs and lipase. Normal troponin. Chest x-ray shows no acute process. Most likely her fatigue, muscle cramps and generalized weakness are from the low sodium. Patient is on spironolactone and hydrochlorothiazide. We will give her 500 cc bolus of normal saline, IV infusion of normal saline 75 mL/h order urine sodium, serum and urine osmolarity for further for quantification of her hyponatremia. Will admit to the medicine service...."

Patient #1

Patient #1 presented to the ED on 5/13/2022 at 12:46 p.m. The patient was triaged by an RN who documented the patient reporting that she had dizziness and weakness in both legs and collapsed twice that day. The patient also reported having fevers for one week, that she was on dialysis and had a history of a previous stroke with right sided weakness and left sided numbness. The patient was assigned an ESI 2.

A "Physician Triage Exam" dated 5/13/2022 at 3:48 p.m. included: "The patient presents with 3 episodes of collapsing due to weakness earlier today. Pt has hx of stroke in the past with residual numbness to L and weakness to R leg...Patient is awake, alert. Speaking clearly and cogently. No respiratory difficulty. Additional focused exam: able to walk without falling, no gait disturbance, grossly neurologically intact...There are currently no available rooms in the emergency department. As there are no rooms currently available, the patient will wait for a room in the lobby. Patient is currently safe to wait for an available room. The patient's additional diagnostic work up is currently pending..." A CT Scan was ordered at 1:02 p.m. and performed at 3:16 p.m. Results of the CT of the patient's head/brain included: "Findings of mild communicating hydrocephalus, new from 10/11/2021. Interval enlargement of the fourth ventricle with anterior displacement of the brainstem..."

Documentation in the Left Without Treatment/Elopement form revealed the patient was called at 10 p.m. to be taken back to a room in the ED but there was no answer. There was no documentation that the MSE was completed between 3:48 p.m. and when the patient was called at 10 p.m., a period of approximately six hours.

There was additional documentation in the clinical record that she contacted her Neurologist on 5/16/2022 regarding her concern with the results she located on the patient portal of the CT scan performed on 5/13/2022. The Neurologist contacted the patient and advised her to return to the ED. The patient returned to the ED on 5/16/2022 at 4:43 p.m. The ED Triage RN's documentation included: "Pt left lobby on Friday, had CT done...CT was sent to neurologist, neurologist sent here for potential stroke, pt reports dizziness, blurry vision left eye...Hx previous stroke in Oct...." The patient was assigned an ESI 2. Documentation on the Left Without Treatment / Elopement form revealed there was no answer when the patient was first called to go back to a room in the ED at 2 a.m. on 5/17/2022, a period of almost 10 hours without documentation of an MSE.

Patient #1 presented to the ED on 5/13/2022 and 5/16/2022 with concerns of a possible stroke. The patient did not receive MSE's during either visit.

Patient #4:

Patient #4 presented to the ED on 06/01/2022 at 3 a.m. The patient was triaged by an RN at 3:12 a.m. who documented the patients chief complaint was: "Generalized edema, feels like drowning, Dx (diagnosed) with heart failure in Jan 2022 but not on medications due to no primary care at the moment and insurance issues. Currently using meth and marijuan (sic) trying to cut down. The patient was assigned an ESI of 2. The patient's course of events in the ED lobby was documented in the clinical record:

- 3:12 a.m. Vital Signs BP: 135/99 / Pulse (P): 105 / Respiratory Rate (RR): 22 / Oxygen saturation: 96% on Room Air
- 3:31 a.m. Lab work ordered and collected (nursing order)
- 3:31 a.m. EKG ordered (nursing order)
- 4:22 a.m. EKG performed
- 4:53 a.m. Vital Signs BP: 148/113 (High) / P: 105 (High) / RR: 20 / O2 sat: 99% on 3 Liters O2
- 9:11 a.m. Vital Signs BP 149/112 (High) / P: 101 (High) / RR: 18 / O2 sat: 97%
-12:28 p.m. Chest x-ray ordered (physician order) but not performed

The hospital's Left Without Treatment / Elopement form revealed the first call for the patient to back to an ED room was at 6:38 p.m. on 6/1/2022, a period of over 15 hours during which time no Medical Screening Examination was performed.

Patient #8

Patient #8 presented to the ED on 6/9/2022 at 1:23 p.m. The patient was triaged by an RN at 1:28 p.m. who documented the patient's chief complaint was: "ALS (Amyotrophic Lateral Sclerosis). Vent dependent. pt reports CP (chest pain) and SOB (shortness of breath) x (times) a few days, worse today." The patient was assigned an ESI 2. An ED physician's RME Note/Initiation of MSE at 1:54 p.m. included: "The patient presents with chest pain in the setting of ALS. On the vent. I was not able to examine this patient upon their arrival. I evaluated the nurses triage note and vital signs...There are currently no available rooms in the emergency department. As there are no rooms currently available, the patient will wait for a room in the lobby. Patient is currently safe to wait for an available room. The patient's additional diagnostic work up is currently pending. Lab work was ordered at 1:54 p.m., however there was no documentation that blood was drawn and sent to the Lab. Vital signs were obtained at 6:21 p.m. A chest x-ray was ordered at 5:03 p.m. which was performed at 7:48 p.m. with findings including "bibasilar atelectasis."

Documentation in the hospital's Left Without Treatment/Elopement form revealed there was no answer when the patient was first called by ED staff to go back to a room in the ED at 3:20 a.m. on 6/10/2022, a period of approximately 14 hours after arrival. There was no documentation that an MSE was performed during that time.

Patient #21

Patient #21 presented to the ED on 9/9/2022 at 3:46 p.m. The patient was triaged at 3:56 p.m. with a blood sugar level of 519 mg/dL during triage. The normal reference blood glucose level is 70-106 mg/dL. The patient reported weakness, nausea and vomiting and that she had given herself insulin at home one hour prior to arrival. The patient was assigned an ESI of 2. Labwork was ordered at 3:59 p.m. obtained and sent to the Lab at 4:11 p.m. and the patient's glucose level was reported to be critically high at 540 mg/dL. The Critical Results were called to an RN in the ED at 5:08 p.m. There was no documentation that the results were communicated by the RN to an ED provider. The patient signed a Refusal of Examination form on 9/9/2022 at 7:53 p.m. There was no documentation the patient had an MSE or treatment offered for the critically high glucose level during the four-hour period of time the patient was in the ED.

The hospital provided the following information specific to Emergency Department volumes for the period from May 2022 through October 2022:

May 2022:
# of patients who presented: 6,155
# of patients who left without treatment (MSE): 758
# of patients who left AMA (against medical advice): 111

June 2022:
# of patients who presented: 5,178
# of patients who left without treatment: 526
# Number of patients who left AMA: 75

July 2022:
# of patients whopresented: 5,539
# of patients who left without treatment: 1,189
# of patients who left AMA: 63

August 2022:
# of patients who presented: 6,001
# of patients who left without treatment: 847
# of patients who left AMA: 100

September 2022:
# of patients who presented: 6,698
# of patients who left without treatment: 895
# of patients who left AMA: 34

October 2022:
# of patients who presented: 5,904
# of patients who left without treatment: 1,045
# Number of patients who left AMA: 38

November 1 to November 14, 2022:
# of patients who presented: 2,924
# of patients who left without treatment: 497

Hospital leadership acknowledged during interviews that they were aware of the numbers of patients who were leaving without treatment and continued to develop action plans to address the issues.