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Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

The hospital failed to ensure a timely medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 32 sampled patients (Patient #1).

~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2406

Based on policy and procedure review, medical record review, hospital data review and staff and physician interviews the hospital failed to ensure a timely medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 32 sampled patients (Patient #1).

The findings included:

Review of the "Emergency Medical Treatment and Labor Act (EMTALA) Compliance" policy, effective 07/27/2020, revealed "...PROCEDURE: Medical Screening Examination (MSE): 1. Any individual that presents on hospital property and requests....examination or treatment for a medical condition....will be provided a MSE to determine if an emergent medical condition exists. 2. The MSE will be performed within the capability and capacity of the hospital, including ancillary services, resources routinely available... ."

Dedicated Emergency Department [DED] medical record review, on 06/23-24/2021, revealed Patient #1 arrived by private vehicle to the DED of Campus B on 04/26/2021 at 2055. Review of "ED Triage Notes", date of service 04/26/2021 at 2117 [23 minutes after arrival], revealed "Pt [Patient] presents with headache and all over body rash after removing a tick from her Left hip Thursday." A nursing assessment that included "Airway ...Breathing ...Circulation ...Disability ..." at 2119 noted them as "Within Defined Limits". Pain at 2120 indicated a pain score of "0-No pain". Vital Signs at 2120 were Temperature [T] 98.1, Pulse Rate [P] 108, Respirations [R] 16, Blood Pressure [BP] 118/85 and SpO2 [Pulse oximetry - monitors a person's oxygen saturation] was 100% on room air. Patient #1 was assigned an ESI acuity of 3 [Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute]. At 2136 an order was placed for a urine and Complete Blood Count [CMP]. The CBC resulted normal at 2210 and at 2213 the pregnancy test resulted negative. The CMP resulted at 2230 with normal results except for CO2 abnormal low at 21 [Reference Range {RR} 22-32] and Calcium low at 8.8 [RR 8.9-10.3]. Vital signs were rechecked on 04/27/2021 at 0124 [4 hours, 4 minutes after first vital signs] and were T 98, P 61, R 15, BP 153/74 [elevated] and SpO2 99%. Record review did not reveal documentation of a pain reassessment or further notation of the patient's rash. Review of the ED Timeline revealed "Patient departed ED" at 0455 [8 hours after arrival] with a note by a Nurse Tech at 0456 that stated "Pt [patient] left, advised pt to stay". DED record review did not indicate that Patient #1 was moved from the waiting room to an ED bed, did not indicate Patient #1 ever saw a provider or saw a nurse after triage or that the patient's pain or rash was reassessed again after triage [7 ½ hours prior] and did not indicate that vital signs were re-evaluated prior to Patient #1 departing the ED [3 ½ hours after last vital signs]. Review of the "ED Care Timeline" revealed " ...05:26:32 ED Notes Pt's mother called from Tennessee, and advised that she would be filing a complaint. Explained the process (acuity, holding pts, the fact that pts are seen in triage and care is started their [sic], etc). Pt's mom states that she is 'fuirious' [sic] because her daughter called her and told her that she was 'going to die'. Apologized to mom, transferred her Patient Relations." Record review revealed " ...Coding Summary ...Discharge Information ...0539 ....left Against Medical Advice/left Without Being Seen/elopement ....Final Diagnoses ....Headache, unspecified ....Procedure and treatment not carried out due to patient leaving prior to being seen by health care provider."

Telephone interview on 06/23/2021 at 1330 with Nurse Tech (NT) #10 revealed the Tech did not recall Patient #1 nor the situation that night. NT #10 stated she always tried to get patients to stay. Interview revealed there were sometimes long waits and patients wanted to leave but she encouraged them to stay to be seen by a doctor because they did not know what could happen if they left. The NT further stated vital signs need to be checked in the waiting room every two hours but sometimes when they were very busy it would go over 2 hours.

Interview with the Triage Nurse for Patient #1, Registered Nurse (RN) #9, on 06/23/2021 at 1440, revealed the RN recalled the shift because it was very busy. Interview revealed a big reason for not being able to move patients was they did not have beds upstairs and had to hold patients in the ED. Interview revealed patients were sometimes even staying in the ED awaiting placement in skilled nursing. "Our hands are tied", the RN stated. RN #9 stated Patient #1 was stable to be in the waiting room. As for vital signs, the RN indicated every two hour vital signs "is good, but with 60 people it is hard to get back around."

Telephone interview on 06/23/2021 at 1510, with RN #11, the Charge Nurse revealed she spoke with Patient #1's family member who was very upset that the patient was not seen. Interview revealed the acuity was high and there were many patients in the ED lobby at the time. RN #11 indicated Patient #1 was still in the waiting room at the time of the phone call, she had texted her relative about not being seen. Interview revealed RN #11 did not see Patient #1. Interview revealed that based on what the Charge Nurse saw when looking that the record the patient was stable; she was there for a rash, vital signs were stable, was not tachycardic [elevated heart rate] and did not seem to be in distress. Interview revealed the ED was very busy with high acuity. The RN further stated that testing for Rocky Mountain Spotted Fever was not a triage protocol. RN #11 stated that as the Charge Nurse, she continually looked at patient information such as lab and xray results. If something was abnormal, those patients came back first, but if everything was the same then those patients had the longest waits. Interview revealed RN #11 "felt bad but could not give an exact timeframe" to when the patient would be seen but stated they would get the patient back and see her.

Telephone interview with Medical Doctor (MD) #12, on 06/23/2021 at 1645, revealed the MD was Executive Medical Director for the ED and also worked as a physician during part of the time Patient #1 was in the ED. Interview revealed MD #12 did not see Patient #1 during the visit, the patient remained in the waiting room 8 hours and was not seen by a physician. Interview revealed over the past 6 months the hospital had seen a peak in boarding patients [patients in ED awaiting beds elsewhere] . On that particular night, interview revealed, 36 patients were boarding and with the decrease in ED beds at night sometimes boarding patients could exceed the ED capacity. Normally, the MD stated, the department dropped down to two main pods at night, 30 beds, and on those heavy nights when there were many patients boarding and in the ED waiting they would attempt to call in extra help, but " ...take away 100% of rooms ... crush throughput ...only 1's and 2's get through. MD #12 stated that vital signs should be checked per policy but when "boarders" got backed up and waiting room patients got backed up, how could they monitor vital signs on that number of patients? During interview the MD indicated 47 patients were currently in the waiting room and 34 admitted patients were on the ED board waiting for inpatient beds. Interview revealed the MD was not aware of any patients who had been harmed by a delay in getting them back. Specifically in relation to Patient #1, MD #12 stated the patient was afebrile, her BP was slightly high but in general had reassuring vital signs. Interview revealed Patient #1 "...was not at risk" by the delay, was "stable in the waiting room".

Review revealed Patient #1 presented to an Urgent Care Facility associated with the hospital. Review of Patient #1's Urgent Care visit revealed Patient #1 arrived to Urgent Care on 04/27/2021 at 0905 [4 hours 10 minutes after the 0455 note that indicated the patient left and 3 hours 26 minutes after the patient was documented under "Coding Summary" as left without being seen] with a chief complaint of "Tick Bite". Review of a Triage Note, at 0932, revealed " ...Pt presents with tick bite last Thursday to left hip area; pt now had lower abdominal pain, rash all over body, and generalized aches. Timeline review revealed Patient #1 was assigned a patient acuity of 4. Review of the Provider Note, electronically signed at 1000, indicated Patient #1 " ... presents with tick bite last Thursday to left hip area; pt now had lower abdominal pain, rash all over body, and generalized body aches.... She went to the emergency room and waited a number of hours, but has children to take care of so she had to leave without getting treated....Review of Systems Constitutional: Negative, HENT [head, ear, nose, throat]: Negative. Gastrointestinal: Positive for abdominal pain Genitourinary: Negative. Skin: Positive for rash ....ED Triage Vitals ...BP ....0934 121/77 ....Pulse Rate ....98 ....Resp ....17 Temp ....98.2 ....SpO2 ....98%....Pain Score ....0933 5 ....Physical Exam ....General: She is not in acute distress. Appearance: Normal appearance ....She is not ill-appearing, toxic-appearing or diaphoretic ....Abdominal ...Mild lower abdominal tenderness without guarding or rebound ....Skin ....Dramatic total body erythematous papular rash [type of rash with small red bumps] without petechia [pinpoint round spots on the skin] but involving palms. No lesions in mouth ....Final diagnoses Tick bite ....Rash and nonspecific skin eruption ....ED Prescriptions .... doxycycline [antibiotic] ....Take 1 table (100 mg total) by mouth 2 times daily ... ." Further Timeline review revealed Patient #1 was discharged from Urgent Care at 0957 in stable condition.

Review of information received from the hospital showed data for 04/26/2021 at 2200 and 04/27/2021 at 0600. Review of the 4/26/2021 at 2200 data revealed Campus B, where Patient #1 presented, had 32 patients holding in the ED for a bed elsewhere and 53 patients waiting in the ED waiting room lobby. Data review revealed the longest wait time was 9.50 hours. At 0600 on 04/27/2021, data review revealed 32 patients were holding in the ED and 37 patients were waiting in the ED lobby with the longest wait time being 13.2 hours. The 0600 data indicated that 292 patients had been seen with 24 patients who "left without being seen" for a LWBS percent of 8.22%.

Review of other data revealed the hospital collected and evaluated metrics related to the DEDs which among others included boarding hours, time from admit order to an inpatient floor at Campus B, and combined left without being seen data. Review of the average minutes from admit order to inpatient floor at Campus B, received 06/25/2021, revealed the minutes had decreased from 547 the week of 04/25/2021 to 310 the week of 06/14/2021. In relation to left without being seen, review of the graph presented for the four combined campuses revealed ED LWBS numbers had steadily increased from March through June's current data and was approaching 10%.

In summary, Patient # 1 arrived to the DED of Campus B on 04/26/2021 at 2055. Vital signs were rechecked once at 0130 on 4/27/2021. Patient # 1 then continued to wait and LWBS at 0555, 8 hours after arrival. She returned to an Urgent Care Center the next morning and was treated with an antibiotic. There was no indication of a discussion regarding the risks and benefits of leaving without being seen. The patient did not receive an appropriate medical screening examination. The patient was not stabilized prior to leaving.