HospitalInspections.org

This STANDARD is not met as evidenced by:
Based on interviews, video footage, and document review, the facility failed to comply with the Medicare provider agreement as defined in 489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.
FINDINGS INCLUDE:

1. The facility failed to meet the following requirements under the EMTALA regulations:
*Tag 2406: (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department, as defined in paragraph (b) of this section, the hospital must- (i)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 medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws rules and regulations and who meets the requirements of 482.55 of this chapter concerning emergency services personnel and direction; and by the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition.
*Based on interviews, video footage, and document reviews, the facility failed to provide an appropriate medical screening examination (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations.
*Specifically, the facility failed to ensure a MSE was performed by a qualified medical professional (QMP) for one of one patients reviewed who presented to the emergency department (ED) with abdominal pain. (Patient #1).
*Refer to C2406, findings 1 through 7.

Medicare State Operations Manual; Appendix V - Interpretive Guidelines - Responsibilities of Medicare Participating Hospitals in Emergency Cases; A2406 MEDICAL SCREENING EXAM
CFR(s): 489.24(a) & 489.24(c)
(a) Applicability of provisions of this section.
(1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph
(b) of this section, the hospital must-
(i) 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 medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and
(ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the
hospital admits the individual as an inpatient for further treatment, the hospital's obligation under this section ends, as specified in paragraph (d)(2) of this section.
(2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or
relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met:
(A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period.
(B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan.
(C) The hospital does not discriminate on the basis of an individual's source of payment or ability to pay.
(D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol,
except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act.
(c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital's dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency
nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition.

Based on interviews, video footage review, and document reviews, the facility failed to provide an appropriate medical screening examination (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to ensure an MSE was performed by a qualified medical professional (QMP) for one of one sampled patient (1) who presented to the emergency department (ED) with complaints of abdominal pain.
Findings include:

1. Policy Review

Review of the provider's August 2017 revised and/or December 2022 EMTALA policy revealed:

"Purpose: To ensure that all patients coming to [provider name] requesting emergency services receive an appropriate Medical Screening Examination as required by the Medical Treatment and Active Labor Act (EMTALA), ...

Any patient who comes to [provider name] requesting emergency services is entitled to and will receive a Medical Screening Examination performed by individuals qualified to perform such examination to determine whether an emergency medical condition exists.

EMTALA: Refers to Sections ... which obligates hospitals to provide medical screening, treatment and transfer of individuals with emergency medical conditions...

In general, when an individual comes by him or herself or with another person to the emergency department of the hospital, and a request is made on the individual's behalf for a medical examination or treatment, the hospital must provide for 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 an emergency medical condition exists...

When a Medical Screening Examination is required: If an individual arrives at the hospital and is not technically in the emergency department, but on Hospital Property or Premises (as defined under this policy) and requests emergency care, he or she must receive a Medical Screening Examination within the capabilities of the facility, or if necessary, execute an appropriate transfer according to the guidelines of EMTALA and these policies.

The location in Which the Medical Screening Examination Should be Performed: The Medical Screening Examination and other emergency services need not to be provided in a location specifically identified as an emergency room or any emergency department. If an individual arrives at a facility and is not technically in the emergency department, but is on the premises of the hospital and requests emergency care, he or she is entitled to a medical screening examination... The hospital may use areas to deliver emergency services which are also used for other in-patient or out-patient services. Medical Screening Examinations or stabilization may require ancillary services available only in areas or facilities of the hospital outside of the emergency department.

The hospital is obligated to perform the Medical Screening Examination to determine if an emergency medical condition exists. It is not appropriate to merely "log in" a patient and not provide a Medical Screening Examination.

Individuals coming to the Emergency Department must be provided a Medical Screening Examination beyond initial triage. Triage is not equivalent to a Medical Screening Examination. Triage merely determines the "order" in which patients will be seen, not the presence or absence of an emergency medical condition.

The hospital must provide screening and stabilizing treatment within the scope of its abilities, as needed, to the individuals with the emergency medical conditions who come to the hospital for examination and treatment.
-Medical Screening Examinations must be performed by individuals who are: Determined qualified by hospital medical staff bylaws, rules, and regulations which are approved by the hospital's Board of Directors.

...1) the emergency department physician on duty is responsible for the general care of all patients presenting themselves to the emergency department...

*Central Log:
Purpose: To track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition. -The log must contain:
The name of the individual seeking assistance,
The disposition: patient refused treatment, was refused treatment by the facility, transferred, admitted and treated, stabilized and transferred, discharged.
The log entry should be made at the first point of contact. This would normally take place at triage."

2. ED video footage reviewed for 4/14/25 from 6:51 p.m. through 7:12 p.m. revealed:
*At 6:59 p.m. 2 persons entered the ED through the ambulance entrance. Those persons were identified and Patient #1 and a non-family member.
*At 7:03 p.m. Patient #1, accompanied by a non-family member, and ED Staff registered nurse (RN) F were observed entering room 121.
-The room was designated as a waiting room for the ED and was located next to the ambulance entrance.
*At 7:10 p.m. Patient #1, accompanied by a non-family member, were observed leaving the ED through the ambulance area.
*There was no observation of a qualified medical professional or any other ED staff having entered the room to complete an MSE to determine an emergency medical condition existed or not.

3. Review of the provider's 3/1/25 through 7/29/25 ED log revealed patient #1 presented to the ED on 4/15/25 at 8:49 a.m. with complaints of abdominal pain after she had been seen at the clinic. Diagnostic impressions supported the patient had a bowel obstruction and required a higher level of care than the critical access hospital (CAH) could provide. Patient #1 was discharged from the ED at 11:15 a.m. and was transferred to an acute care hospital by ground ambulance. There was no documentation to support the patient had presented to the ED on 4/14/25 at 6:59 p.m. with complaints of abdominal pain for the past two days and no relief from pain medications.

4. Review of patient #1's first ED presentation and subsequent ED medical record review revealed:
Patient #1 presented to the ED on 4/14/25 at 6:59 p.m., accompanied by a non-family member with complaints of increased abdominal pain for the past couple of days with no relief from pain medications.
-ED Staff RN F obtained vital signs, listened to the patient's bowel sounds over the patient's clothing, and palpated patient's stomach. Patient #1 left the ED without an MSE completed by a qualified medical professional.
-The hospital was unable to provide a Medical Record for Patient #1 who presented to the ED on 4/14/25 at 6:59 p.m. furthermore, Patient #1 was not evident on the provider's Central Log for 4/14/25.

Subsequently Patient #1 presented to the ED for a second time on 4/15/25 at 8:49 a.m. after being seen at an on-campus clinic where the patient's primary physician provided a diagnosis of bowel obstruction.
-Patient #1 complained of increased abdominal pain, no bowel movement for several days, and recent nausea and vomiting of coffee ground emesis (vomiting); with no relief from pain medications or laxatives.
-ED treatments were inclusive of intravenous (IV) fluids (for hydration), placement of a nasal gastric (NG) tube (flexible tube inserted through the nose and into the stomach), administration of pain and anti-nausea medications.
-Patient #1's ED condition was documented as serious.
-Patient #1 was discharged from the ED on 4/15/25 at 11:15 a.m.., and transferred to hospital for higher level of care, where Patient #1 expired.

5. Interview on 7/29/25 at 2:08 p.m. with ED Staff RN F who was present on 4/14/25 when Patient #1 first presented to the ED revealed:
*She confirmed patients who presented to the ED had to be screened and under no circumstances could they be denied treatment or an assessment.
*Sometimes patients would present to the ED to have their stitches checked or blood pressure (b/P) taken.
*She stated, "Obviously, the nurses cannot tell the patients if they should be seen or not."
*She stated, "We have to do a walk-in log now that is signed by two nurses ever since an incident and complaint occurred."
*She stated, "Before that, we just did a call-in log for those who called."
*The incident and complaint occurred a few months ago, and she had been involved with Patient #1 and the family friend who had presented to the ED through the ambulance door.
*The family friend had done most of the talking and Patient #1 kept repeating she did not want to be there or seen.
*Patient #1 had stated her friend drove her there and again, she did not want to be there.
*ED Staff RN F had walked the patient and Patient #1's family friend to a room for more privacy.
-Both ED rooms had been occupied by other patients.
*The family friend was a nurse. She had been concerned about Patient #1 because:
-Patient #1 had a history of colon cancer with bowel obstructions in the past.
-Patient #1's abdomen had been more distended over the past two days, and the family friend did not have a stethoscope to listen for bowel tones.
-Patient #1 had been having abdominal pain for the past two days and there was no relief from the pain medications.
*The family friend had taken Patient #1 to the ED to have the someone listen to Patient #1's abdomen to make sure they were present.
*ED Staff RN F had:
-Listened to the abdomen and heard bowel tones.
-Completed soft palpitations (putting pressure on the stomach to check for pain with her hands) of the abdomen. The patient had no pain from palpitation during that assessment.
-Told Patient #1 several times that she had the option to be seen by the practitioner since she was already there.
*Several times the patient refused to be seen by the physician and stated and she wanted the least invasive treatment and that she would go to the clinic the next day.
*ED Staff RN F stated, "The patient was adamant she did not want to be seen."
*They had discussed other options, such as taking Miramax (medication that helps promote a bowel movement).
*Medical Doctor (MD) E:
-Was in-house at the time of the incident, and ED Staff RN F had updated him on the status and situation of Patient #1.
-Was provided the information of Patient #1's courtesy screening results and the patient's history of bowel obstructions greater than 5 years ago.
-Had no instructions for Patient #1 and did not assess or complete an MSE.
*ED Staff RN F stated, "[The practitioner] told me he felt I had done everything I could and there was nothing further they could do."
*ED Staff RN F was not able to diagnose or complete an MSE on the ED patients.
-That had been the responsibility of the physicians and practitioners.
*ED Staff RN F walked Patient #1 and the family friend out into the hallway and repeated three or four times "Are you sure you don't want to be seen?" Patient #1 refused and again stated she wanted the least invasive treatment and would try Miralax at home.
*ED Staff RN F recommended that Patient #1 be seen in the clinic the next day, in case there were further complications.
*The ED nursing staff had recently been re-educated on their EMTALA policy after that incident and a walk-in log was initiated.

Interview on 7/29/25 at 11:07 a.m. with ED Staff RN C revealed:
*ED Staff RN C worked on the medical floor and in the ED when assigned.
*ED Staff RN C could not refuse to triage anyone who presented to the ED.
*If a patient refused to be seen, the ED staff were required to document that on the ED log.
*Within the past month, the provider had implemented a walk-in log to be completed at the nurses' station for those patients who presented to the ED but did not want to be seen by the physician. ED Staff RN C stated:
-"Or they might just want a b/p checked because they were not feeling right or it felt high."
-"Or the clinic doctor told them to check their b/p over the weekend and they didn't have a b/p cuff to do that so we would check it for them."
-"The clinic sometimes tells them to stop at the ED and have it [b/p] checked."
-"They might need help with changing a pain patch, something small like that."
*When patients presented to the ED for a b/p check they could have provided the patients with the results and recommendations, but could not tell them what to do from the results of their b/p check.
*ED Staff RN C was not sure what the MSE was but she knew she could not have assessed the patients to determine if an emergency medical condition existed.
-The physicians would have done that after she had completed her initial triage assessment to determine their chief complaint.

Interview on 7/29/25 at 11:30 a.m. with ED Staff RN D revealed:
*When a patient presented to the ED the staff could not refuse to triage the patient to determine if an emergency situation existed or not.
*ED Staff RN D could not have given patients the option to not be seen or go to the clinic instead.
*ED Staff RN D would have completed an initial triage assessment and then the physician would have completed the MSE to determine if an emergency situation existed.
*If a patient presented to the ED and just wanted their b/p checked, they could have done that for patient. ED Staff RN D stated, "But we can't tell them what to do with the results." "If they want advice or some type of treatment I tell them they have to be seen in the ED."
*In the past, they would not have logged the b/p check anywhere. ED Staff RN D stated, "Sometimes a cardiologist tells them [the patients] they need their b/p checked and so they come to have us for [b/p] checking."
*A walk-in log had recently been initiated for those patients who presented to the ED and wanted a b/p check or something minor looked at.
-If they refused to be seen by the physician when recommended, that now had to be charted on the walk-in log and signed by two nurses.
*The completed walk-in and call-in logs had been placed in the director of nursing's (DON) folder at the nurses' station.
-ED Staff RN D was not aware of what happened with those logs after that.
*The call-in logs had been used to document those patients who called in requesting treatment recommendations.
-They could have provided basic information for an infant or child who needed Tylenol (over-the-counter pain and fever-redoing medication) and the parent wants to confirm the dosage.
*There was staff re-education provided on the EMTALA process within the past three months and the walk-in log was the only change in the provider's processes for the ED.

Interview on 7/29/25 at 2:26 p.m. with ED Staff medical doctor (MD) E who was present on 4/14/25 when Patient #1 first presented to the ED revealed:
*ED Staff MD E recalled the evening when Patient #1 presented to the ED and had left without having an MSE completed.
*ED Staff MD E was not concerned that an EMTALA occurred.
*ED Staff MD E knew ED Staff RN F took Patient #1 to a room but could not hear the conversation taking place inside the room and was not aware of what ED Staff RN F had done.
*ED Staff MD E had heard ED Staff RN F talking to Patient #1 as she was leaving the ED and telling Patient #1 that she had the option to be seen.
*ED Staff RN F reported a courtesy screen was completed for Patient #1, bowel tones were noted, and the patient's stomach was soft and non-tender.
*ED Staff MD E stated, "I was fine with her going home. No, I did not see the patient, only when she was leaving."
-ED Staff MD E stated, "The patient did not seem upset and wanted to try something at home first. We can't make them be seen, they have the option to leave. I did not talk to her at all."

Interview on 7/30/25 at 1:33 p.m. with RN I revealed:
*She had been the quality and risk coordinator and sometimes worked in the ED.
*Each department would determine the quality measures they wanted to monitor and reviewed them at the quality and risk meeting.
*The ED had not been reviewed as a part of the quality meeting and RN I was unaware of any concerns or quality measures they had been monitoring independently.
*RN I had questioned leadership staff if she needed to be asking about EMTALA concerns or address any ED measures in the meeting.
-No one had responded to her question.
-RN I had little to no guidance on what should have been discussed or reported to the quality meeting to review and address.
*Any concerns RN I had heard about the ED had been through hearsay or casual conversations.
*RN I had heard that a patient presented to the ED and was told she could wait until the clinic was open.
-That patient had presented to the ED the next day, was discharged to a higher level of care and passed away days later.
-It had not been discussed in the quality and risk meeting, and when she asked about it, there was no response to her question.
*RN I stated most of the patients who presented to the ED were admitted, but there were times when a patient presented and they just wanted a b/p taken or something minor checked.
*RN I agreed that when a nurse checks a patient's b/p, listens to the abdomen for bowel tones or palpates for tenderness, those actions were considered nursing tasks and a type of screening should have been initiated.
*RN I had not realized those nursing tasks or screenings had initiated the EMTALA process.
*RN I agreed that when a patient left without an MSE being completed by the ED's MD, that patient had left against medical advice (AMA).
*There was the option available in the medical record for staff to initiate and complete a record for any patients leaving AMA.
*A walk-in log had been initiated and was to be completed when patients presented to the ED for a courtesy screen and were not seen.
-The walk-in log had recently been created shortly after the patient who presented to the ED was not screened, and passed away a couple of days later.
-Two nurses had to sign the walk-in log for verification.
*The last EMTALA training RN I recalled was completed as part of her annual training.
-RN I had missed the provider's June staff meeting but they recently started to record the staff meetings and send them to staff over email email.
-RN I was unsure if there had been a deadline or a completion date assigned for her to have listened to the meetings or to have confirmed that she had read those emails.

6. Review of the provider's 2025 Quarterly Quality report revealed there was no documentation to support the ED had been a part of the quality meetings. There were no quality measures in place for the ED to monitor to ensure all patients who presented to the ED had been properly triaged by the nurse and an MSE was completed by the MD or a practitioner to determine if an emergency medical condition existed.

Review of the provider's 1/14/25 Medical Staff By-Laws and Rules and Regulations revealed no documentation to support what the process and requirements had been for the completion of an MSE by the physicians or practitioners on all patients who had presented to the ED

7. Interview on 7/30/25 at 4:23 p.m. with director of nursing (DON) A and human resources (HR) B revealed:
*It had been common practice for people from the community to come into the ED and request the staff to check non-emergent concerns and complete a courtesy screen. Such as:
-Requesting a b/p to be taken because they were experiencing a headache or their b/p felt high.
-Requesting to have stitches looked at to make sure they were not infected.
*DON A and HR B agreed:
-The ED was dedicated and required to assess, treat, and appropriately triage emergent situations.
-That a patient could have presented anywhere on the hospital campus, and they had an obligation to treat them.
-When a patient presented to the ED or on their campus, the patient had a concern that required them to be assessed and appropriately triaged.
*DON A and HR B had not realized that:
-As soon as the nurse started a courtesy screen, such as checking a patient's b/p or listening to bowel tones, a service had been initiated by the staff and that had initiated the EMTALA process.
-As a dedicated ED, they did not have the capability of completing non-emergent services such as checking a b/p, listening to bowel tones, or checking stitches to ensure they were not infected.
-That every patient who presented to the ED was required to have an MSE completed by a competent medical personnel such as the physician or practitioner per their EMTALA policy.
*DON A and HR B were aware the nursing staff initiated the triage process, but they did not have the capability to determine if an emergency medical situation existed.
-Only qualified medical personnel, such as the physician or practitioner had the capability to do that.
*DON A:
-Was not sure an EMTALA concern was initiated the evening of 4/14/25 when Patient #1 presented to the ED.
-Was not aware of the potential EMTALA until the administrator had received a call from a family member who was concerned about what occurred on 4/14/25 when Patient #1 presented to the ED.
-Along with the administrator and HR B, had interviewed ED Staff RN F. ED Staff RN F had been directly involved with the incident involving Patient #1 on 4/14/25.
-They felt ED Staff RN F had done everything to encourage Patient #1 to have an MSE completed but Patient #1 had refused and left the ED.
-Stated Patient #1 refused to be seen and told ED Staff RN F that she wanted to do the least invasive thing.
-Agreed that was considered AMA and the ED Staff had the capability to initiate a medical record for those situations when a patient would leave without being seen.
-Interviewed ED Staff MD E who was present the evening of 4/14/25 when Patient #1 first presented to the ED. ED Staff MD E had not seen Patient #1 to complete an MSE and had stated "You can't make a patient be seen."
-Had re-educated the ED nursing staff at their monthly meeting in May on EMTALA requirements. DON A would have left the meeting notes and education at the nurses' station for those who had not attended to read/sign/date upon completion. DON A had not re-checked to make sure all of the staff who had not attended the meeting had completed the education. DON A had also emailed the education to the ED staff, but there was no process in place to ensure the ED staff had checked and read those emails.
-Had not included the practitioners and physicians in the re-education of EMTALA requirements. DON A agreed they were a part of the ED and should have been included in that education to ensure they understood and were following those EMTALA and MSE requirements.
-Had no monitoring process in place after the incident on 4/14/25 to ensure the ED staff had understood the EMTALA education and was implementing those requirements.
-Had started a walk-in log for those patients who presented to the ED and requested the staff to complete a courtesy screen but refused to be admitted.
-Had not considered the incident on 4/14/25 when Patient #1 presented to the ED and left without an MSE to have been an issue or to have created the potential for an EMTALA to occur.
-Confirmed the ED was not reviewed or monitored through their quality and risk process to ensure they had met all of CMS requirements as a dedicated ED. DON A agreed it should have been.