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

Findings included:

The hospital failed to ensure an appropriate 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 3 of 13 sampled patients with wait times greater than 4 hours in the ( #4 ,#9, and #28) emergency department waiting area.

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


Based on review of medical records, policy and procedure, and staff interviews, it was determined the facility failed to ensure the individual was informed of the risks and benefits of the medical examination and treatment that was refused for 1 (#4) of 30 sampled Emergency Department medical records reviewed.

~cross refer to 489.24(d)(2)(iii)(3) Stabilizing Treatment -Tag A2407

Based on policy and procedure review, medical record reviews, Administrative Supervisor Report, staff and physician interviews, the hospital failed to ensure an appropriate 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 3 of 13 sampled patients with wait times greater than 4 hours ( #4, #9, and #28).

Findings included:

Review of the hospital policy titled, "EMTALA" last revised July 1, 2019, revealed all patients presenting to a the DED or Labor and Delivery for evaluation to determine if an EMC (Emergency Medical Condition) exists will have an MSE (Medical Screening Examination by a physician or non-physician QMP (Qualified Medical Person)..."

The facility's policy titled, "EMTALA Medical Screening Examination and Treatment of Emergency Medical conditions", Policy Stat ID:8932839, effective 2/21 was reviewed. The Policy revealed in part, " The Medial Screening Examination is an ongoing process and the medical record must reflect continued monitoring based on the patients needs and must continue until the patient is either stabilized or transferred"


1. A closed medical record review of Patient #4 revealed a 33-year-old male who presented to the DED on 06/29/2021 at 1902 for left upper quadrant pain. Review of the Triage Note by RN (Registered Nurse) #4 dated 06/29/2021 at 1906 revealed, "complaints of upper abdominal pain for the past few hours, regular even and unlabored breathing, stable vital signs; Temperature 36.9 Celsius, Heart Rate 71, Respiratory Rate 20, Blood Pressure 121/77, and Oxygen Saturation (amount of oxygen carried by the blood) of 99% on room air." Review of the Triage note revealed pain present and no recorded pain score. Review of the DED orders revealed a CBC (Complete Blood Count), CMP (complete metabolic panel - electrolytes), lipase, and a urinalysis were ordered at 1908 by FNP (Family Nurse Practitioner)#1. Review revealed all blood lab work was collected at 1925. The facility failed to ensure that an appropriate medical screening examination was provided for Patient #4 on 6/29/2021. Review revealed there was no documentation of a nursing reassessment during the approximately five hours and fourteen minutes patient #4 was in the waiting room.

Telephone interview on 08/17/2021 at 1723 with FNP #1 revealed she did not recall patient #4, however reviewed the chart prior to interview. Interview revealed FNP #1 did not see or evaluate Patient #4. Interview revealed the MSE had not been started. Interview revealed there was a long wait time for a room the night Patient #4 presented to the DED, and she only placed orders on patient #4.


Interview on 08/18/2021 at 0845 with Patient Access Rep #2 revealed she did not recall patient #4. Medical Record was available for review during interview. Interview revealed that facility process was for a quick initial registration that included name and date of birth once the patient arrived. Interview revealed the full registration would be completed once a patient was seen by a provider. Interview revealed Patient #4's full registration information was entered after Patient #4 had left the DED and prior to a medical screening exam.


Interview requested with the EMT working in registration the night of 06/29/2021, informed by the Director of Patient safety they were unavailable for interview.

Interview on 08/18/2021 at 1114 with an EMT in Registration revealed that if a patient presented to her and informed her of their intent to leave, she would obtain their name and chief complaint and notify the Triage RN. Interview revealed patients often leave immediately after they have notified her, and the Triage RN does not have time to discuss the risks and benefits of staying. Interview revealed if the patient left prior to the nurse talking to the patient that the process is to put a note on the tracking board for the ED communication.


2. Review on 08/18/2021 of the medical record for Patient #28 revealed the 84-year-old male arrived to the hospital's DED on 08/17/2021 at 1340 with a chief complaint of Left Foot Gangrene. Review revealed Patient #28 was triaged by RN (registered nurse) #6 at 1414 (34 minutes later) and assigned an ESI (emergency severity index) level of 3 (urgent-.Stable with multiple types of resources needed for treatment). Triage Documentation at 1414 revealed Patient #8's vital signs were documented as Temperature (T) 98.2 F, Blood Pressure (BP) 114/52, Pulse Rate (P) 73, Respiratory Rate (RR) 18, Oxygen Saturation (SpO2) 98% on room air and Pain 9 (on a scale of 1 to 10 with 10 being the worst). Review revealed Physician Orders signed by MD (Medical Doctor) #9 on 08/17/2021 at 1420 for a CBC (complete blood count), CMP (comprehensive metabolic panel) and XR (x-ray) Foot Complete, 3+ Views Left. Review of the H&P (History and Physical) revealed Patient #28 received an MSE (medical screening exam) by MD #10 on 08/18/2021 at 0422 (14 hours and 42 minutes after Patient #28's arrival). The H&P further revealed, "...He states that he was seen at (local hospital) last week. Was told he has gangrene in his foot ...however patient did not want to be admitted at that time because he wanted to go home to take care of some things. He presents tonight because of increasing pain ...states he has been this way for several weeks and has been progressively worsening. He has black toes ...along with purulent drainage ...denies fevers at home but has had some chills ...Denies history of diabetes ...Physical Exam ...Awake and alert. No acute distress. Appears comfortable ... Cardiovascular ...Unable to obtain pulses in bilateral feet, either with palpation or Doppler ... Respiratory ...Lungs clear to auscultation bilaterally ...Musculoskeletal ...left foot with black necrotic 4th and 5th toes and purulence drainage between these toes ...Neurological ...Alert and oriented x4 ...Medical Decision Making ...Patient was seen and examined ...Suspect peripheral artery disease as underlying etiology [cause] ...Labs reviewed, notable for leukocytosis. X-Ray with no evidence of osteomyelitis. Antibiotic coverage was provided with Vancomycin and Zosyn (both antibiotics). Will initiate Heparin (Blood Thinner). CT imaging ordered and pending ..." Record review revealed an RN Assessment was completed by RN #7 at 0447 (14 hours and 33 minutes after triage). Review revealed no additional nursing assessments were documented between the initial triage and the assessment by RN #7. Review of the H&P further revealed, "...There is no vascular coverage available at this time. Will attempt to arrange transfer...Record review revealed eight attempts to transfer Patient #28 were made between 0448 and 0724, but no beds were available. Review revealed Patient #28 was accepted for transfer by Hospital #9 at 0724 and his family was updated. Review of Laboratory results on 08/17/2021 at 1442 revealed, "...WBC (white blood count) 21.1 RR [reference range] 3.6-11.1, Hgb (hemoglobin) 12.4 [RR 14.0-18.0], Hct (hematocrit) 37.2% [RR 42.0-52.0], Platelets 284 [RR 165-353], Sodium 133 [ RR 136-145], Potassium 3.5 [RR 3.5-5.1], Chloride 98 [RR 98-107], CO2 (carbon dioxide) 22 [RR 22-31], BUN (blood urea nitrogen) 23 [ RR8-21], Glucose 123 [RR 70-105], Creatinine 1.1 [RR 0.9-1.5], Calcium 9.1 [RR 8.4-9.7], Anion Gap 13 [RR not provided], Lactic Acid 1.6 [RR 1.2-2.2], Covid-19 PCR Negative. Coagulation Studies resulted on 08/18/2021 at 0723 revealed PT (prothrombin time) 11.8 [RR 9.5-12.1], INR (international normalized ratio) 1.1 [RR 0.8-1.2], PTT (partial thromboplastin time) 30.2 [RR 23.9-30.7]. Radiology Results further revealed a 3 view X-Ray of the left foot completed on 08/17/2021 at 1437 that resulted as, "...IMPRESSION: No acute bony abnormality identified." Review of Radiology results further revealed a CT (computed tomography) Angio [angiogram - uses x-ray contrast images to analyze blood vessels for blockages] Abdomen Aorta Bilateral LE [lower extremity] Runoff completed on 08/18/2021 at 0648 resulted as, "...IMPRESSION: Suboptimal ...with appropriate opacification of the aorta however iliac and femoral vessels do not demonstrate optimal opacification...there appears to be bulky calcific severe SFA [superficial femoral artery] disease bilaterally ...likely severe right and moderate left common iliac artery narrowing ...focal abnormality of the left common iliac artery which might represent a small ulcer/dissection ...consider further evaluation with dedicated duplex ultrasound, given the suboptimal opacification..." Review of the Medication Administration Record (MAR) revealed Patient #28 was administered 4 mg of IV Morphine (narcotic pain medicine) at 0612, a 500 mL NS (IV fluid) bolus at 0614, 3.375 grams of IV Zosyn (antibiotic) at 0625, and a Heparin (blood thinner) bolus of 6,000 units, a continuous Heparin infusion of 18 units/kg/hr (per kilogram, per hour and 1,000 mg of IV Vancomycin (antibiotic) at 0726. Physician Orders signed by MD #10 on 08/18/2021 at 0730 revealed, "Transfer...(Hospital #9)..." Review of Patient #28's Vital Signs on 08/18/2021 at 0842 revealed, T 98.2, BP 115/52, P 73 and RR 18. Record review revealed, Patient #28 left the ED at 0855.

Review of the Hospital's Administrative Supervisor Report dated 08/16/2021 revealed the DED went on Diversion 08/16/2021 at 1548 and remained on Diversion through 08/18/2021 (last day of survey). Review of the Diversion Form dated 08/16/2021 at 2340 revealed, "ER with 9 holds at this time. No telemetry monitors available in house ...Unable to downgrade patient needs ...evaluate later ...to see if it is appropriate to place any monitored COVID + patients in CCU as staffing and beds permit...16 patients in the ED waiting area." The Diversion Form dated 08/17/2021 at 0751 revealed 14 patients held in the ED, with 7 patients in the waiting room ...Will continue "until beds and staffing become available."

Interview on 08/18/2021 at 1405 with the ED Nurse Director revealed the expectation was that either the Triage or CN (Charge Nurse) reassessed patients at least every 4 hours. Interview further revealed the DED went on diversion beginning 08/16/2021 at 1548 and currently remained on diversion to all counties except for (rural county) because that county did not have any other nearby hospitals.

Interview on 08/18/2021 at 1615 with the Interim CNO (Chief Nursing Officer) revealed, the CN was typically responsible for reassessing patients in the DED's waiting room. Interview revealed the CN and Directors have all been in staffing lately due to the number of Covid positive patients and patients holding in the DED. The CNO stated that patients were being held in the DED due to the shortage of inpatient nurses and the hospital's inability to open all their available beds for placement. Interview further revealed the hospital had some newly graduated nurses in orientation and 2 travel nurses starting in the next few weeks and that would help to expedite ED throughput and decrease the number of patients being boarded in the emergency department.

Interview on 08/18/2021 at 1745 with MD #8, the ED Medical Director, revealed the long wait times in the emergency department was a recent occurrence due to inpatient beds being used for Covid positive patients. MD #8 stated he worked at the DED for 31 years and had "never seen this...this is unprecedented." Interview revealed the ED Provider Group staffed several hospitals in the area and all the hospitals were experiencing the same problems.

Interview on 08/19/2021 at 1045 with MD #9 revealed the past 2-3 months in the emergency department had been "highly atypical" and on Tuesday, 08/17/2021 the hospital's DED "had the longest wait times he had ever seen." Interview revealed the wait times were largely due to not having enough inpatient staffing; which resulted in not being able to move admitted patients out of the DED. MD #9 stated, "really there are no beds anywhere." MD #9 stated that he periodically checked the tracking board on 08/17/2021 and became concerned when he saw a patient that had been waiting for 9 hours, but the DED was already on diversion and "the delays were unavoidable." Interview revealed nursing reassessments and vitals should be done every 4 hours, but "it's a volume issue..." Interview revealed the hospital had 12-16 ED holds (patients waiting for an inpatient bed) per day recently. MD #9 stated, "In this case for a patient to wait 15 hours to be seen, I can't understand that. It should not happen...but we're seeing patients as fast as we can."

Interview on 08/19/2021 at 1135 with RN #6, the Triage Nurse, revealed "Tuesday [08/17/2021] was not typical ...and I did not get to reassess my patients that day..." RN #6 stated that she visually scanned the waiting room periodically "to see if anyone looked like they needed to be reassessed." RN /6 stated that she told all the patients to let her or the EMT (Emergency Medical Technician, at registration desk) know of any changes. Interview revealed the DED had no beds available and was on diversion when RN #6 arrived to work on 08/17/2021. RN #6 stated that it was the busiest day she's had since working at the hospital.

3a. Review on 08/18/2021 of the open medical record for Patient #9 revealed the 71-year old female arrived to the Emergency Department (ED) on 08/17/2021 at 0041 for an evaluation of "chest pain." Record revealed Patient #9 was assessed and triaged at 0043 and assigned an ESI (emergency severity index) of 3-urgent by Registered Nurse (RN) #5 with complaints of " chest soreness " and vital signs at 0043 were documented as Temperature (T) 97.9 F, Heart Rate (HR) 61, Blood Pressure (BP) 165/80, Respiratory Rate (RR) 16, and Oxygen Saturation (amount of oxygen in the blood) (O2) of 95% on room air, with a numeric pain score of 4 (on a scale of 1-10 with 10 being the worst) and was alert and oriented. Review of Orders placed/Interventions performed revealed orders for CBC (Complete Blood Count), CMP (complete metabolic panel), Troponins (measures heart muscle damage), CXR (chest x-ray) and ECG (electrocardiogram) were collected at 0048. Additional Troponins and ECG's were collected at 0218, and 0348. Post Triage disposition-after labs, ECG and CXR, patient to the lobby awaiting bed placement. Review of MD #3's MSE (Medical Screening Exam) on 08/17/2021 at 0707 (6 hours and 26 minutes after Patient #9's arrival to the DED) revealed, "...Physical Exam: general: alert, mild distress. Skin: warm, dry. Head: no trauma, normocephalic. ENT: Mucous membranes moist, Neck: trachea midline, no adenopathy, no tenderness. Eye: normal conjunctiva, sclera clear. Cardiovascular: Normal rate Regular Rhythm, normal peripheral perfusion. Respiratory: lungs CTA, respirations non-labored. Chest Wall: no deformity. Anterior tenderness reproduces complaint. Gastrointestinal: soft, non-distended, no tenderness, no guarding. Extremities: no deformity, no trauma. Neurological: LOC appropriate for age, speech normal. Psychiatric: cooperative, affect appropriate for age ...Medical Decision Making: Differential diagnosis myocardial infarction coronary artery disease anxiety chest wall pain gastroesophageal reflux disease ...Assessment and Plan: 1. Chest wall pain." Review of Lab, ECG and CXR revealed results were within normal range. Record review revealed no further nursing assessments were documented for Patient #9 until 08/18/2021 at 0707 (6 hours and 26 minutes after the initial triage assessment). Review revealed no other vital signs were taken, or medications were given. Record review revealed ED disposition: discharged home by MD #3 on 08/18/2021 at 0730 with a diagnosis of "Non-specific chest pain."

Interview on 08/18/2021 at 1755 with MD #5, the ED Provider on 08/17/2021, revealed "...the last 3 days have been the busiest days ever as far as acuity and admits."

3b. Record review on 08/18/2021 revealed Patient #9 returned to the DED at 1306 for an evaluation of "chest pain since yesterday." Record review revealed Patient #9 was assessed and triaged at 1355 and assigned an ESI of 3-urgent by RN #12 with complaints of " chest pain since yesterday ...vital signs taken at triage were documented as T 98.2 F, HR 54, BP 110/65, RR 18, O2 at 97% on room air, with a numeric pain score of 8. Record review revealed that Patient #9 was roomed in ER-23 at 2035. Review of the DED Physician orders revealed CBC, Troponins, ECG and CXR were ordered at 1400 by MD #4. Review of the Physician orders revealed Troponins and ECG were repeated at 1539 and 1709. Review revealed MD #4 performed Patient #9's MSE (Medical Screening Exam) on 08/18/2021 at 2036. Review of the DED Provider Note revealed, "History of Present Illness...She presents today for evaluation of anterior chest discomfort. She states she went to the chiropractor yesterday and he performed a procedure on her that she believes may have made her chest wall sore...Physical Exam: Vital signs reviewed. No hypoxia. Blood pressure stable. Heart rate is stable. Afebrile. Normal respiratory effort. General: Awake and alert. No apparent distress. Appears comfortable: Skin: Normal temperature. No rash. Color normal. Head: Normocephalic. Atraumatic. Eyes: Pupils equal and reactive. EOMI. ENT: Airway is grossly patent. Mucous membranes moist. Nares patent. Neck: Supple. No appreciable mass or fullness. Trachea midline. Cardiovascular: Regular, no audible murmur. No edema. Chest: Normal thoracic excursion. No subcutaneous emphysema. Lungs: Breathing is non-labored. Clear to auscultation. Breath sounds equal bilaterally. Abdomen/GU: Soft, nondistended. No tenderness. Extremities: ROM is intact. No deformity. Back: Normal Alignment. Neuro: Normal mental status. Awake and alert. Cranial nerves grossly intact. No acute motor deficits identified. No acute speech changes. Psych: Cooperative. Affect is normal ...Initial Assessment and Decision Process: Patient presents today for evaluation of chest discomfort ...EKG demonstrates no acute changes. Troponin, high sensitivity, has been performed and has "ruled out" myocardial infarction. No further ED intervention is indicated is indicated at this time. She is advised to follow up with her primary care provider for reassessment and further treatment. She has been referred to Cardiology several times in the past for outpatient cardiac evaluation ...Assessment/Plan: Chest Pain ..." Review of Lab, ECG and CXR revealed results were within normal range. Record review revealed no additional nursing assessments were documented until 08/18/2021 at 2036 (6 hours and 41 minutes after the initial triage assessment). Review revealed no other vital signs were taken, or medications were given. Record review revealed Patient #9 was discharged home by MD #4 on 8/18/2021 at 2104 with a diagnosis of "Chest Pain."

Interview on 08/18/2021 at 1615 with the Interim CNO (Chief Nursing Officer) revealed, the CN was typically responsible for reassessing patients in the DED's waiting room. Interview revealed the CN and Directors have all been in staffing lately due to the number of Covid positive patients and patients holding in the DED. The CNO stated that patients were being held in the DED due to the shortage of inpatient nurses and the hospital's inability to open all their available beds for placement. Interview further revealed the hospital had some newly graduated nurses in orientation and 2 travel nurses starting in the next few weeks and that would help to expedite ED throughput and decrease the number of patients being boarded in the emergency department.

Interview on 08/18/2021 at 1730 with RN #10, the discharge nurse on 08/18/2021, revealed "...The past few weeks have been an outlier with staffing and census."

Interview on 08/18/2021 at 1745 with MD #8, the ED Medical Director, revealed the long wait times in the emergency department was a recent occurrence due to inpatient beds being used for Covid positive patients. MD #8 stated he worked at the DED for 31 years and had "never seen this...this is unprecedented." Interview revealed the ED Provider Group staffed several hospitals in the area and all the hospitals were experiencing the same problems.

Telephone Interview on 08/19/2021 at 0830 with RN #11, the triage nurse on 08/18/2021, revealed "...It's been so busy the last few nights and we're getting people back as fast as we can, but we have to go by acuity level ..." Interview revealed that all lab work, EKG, and CXR was completed before the patient was sent to the lobby to wait, and results were reviewed by the ED Physicians as soon as they resulted.

Patient #28 and Patient #9 had delayed medical screening examinations. Patient #28 waited greater than 14 hours and Patient #9 waited greater than 6 hours before they were seen by a provider. Record reviews revealed no additional nursing assessments were documented after the initial Triage assessments. Review revealed Patient #28 was found to have an EMC (emergency medical condition) that warranted his transfer and Patient #9 presented to the DED twice for the same complaint. Review failed to reveal any documentation that Patient #28 and Patient #9 were being monitored in the lobby after presenting with their respective complaints and awaiting their MSE's.

Based on review of medical records, policy and procedure, and staff interviews, it was determined the facility failed to ensure the individual was informed of the risks and benefits of the medical examination and treatment that was refused for 1 (#4) of 30 sampled Emergency Department medical records reviewed.

The findings were:


The facility's Policy titled, "EMTALA Medical Screening and Treatment of Emergency Medical Conditions" Policy Stat: ID 8932839. Origin 08/2017, Last reviewed 10/2019 was reviewed. The Policy revealed in part, "Special Circumstances: Withdrawal of Request for Examination. 1. If a patient withdraws his or her request for a examination or treatment, an appropriately trained individual from the emergency department staff should discuss the medical issues related to a voluntary withdrawal. In the discussion, the emergency department staff member should:
a. Offer the patient further medical examination and treatment, as may be required to identify and stabilize an Emergency Medical Condition;
b. Inform the patient of the benefits of the examination and treatment, and the risks of withdrawal prior to receiving the examination and treatment; and
c. Use reasonable efforts to get the patient to sign a from indicating that the patient has refused the recommended examination/treatment. The form should contain a description of risks discussed and of the examination and/or treatment that was a refused."

Closed medical record review for Patient #4 revealed a 33-year-old male who presented to the DED on 06/29/2021 at 1902 for left upper quadrant pain. Review of the Nursing Flowsheets dated 06/30/2021 at 0020 by RN #3 revealed , ... "ED Reason for leaving ... Wait too long..." Further review of Nursing Flowsheets dated 06/30/2021 at 0036 revealed, Patient left prior to MSE ... "Review revealed no documentation of Risks and Benefits of leaving versus waiting to be seen were provided to the patient prior to patient #4's departure from DED.

Telephone interview on 08/17/2021 at 1723 with FNP #1 revealed she did not recall patient #4, however reviewed the chart prior to interview. The interview revealed that FNP #1 was not aware Patient #4 was leaving and did not attempt to review risks and benefits with Patient #4.


Interview on 08/18/2021 at 0915 with RN #3 revealed she did not recall Patient #4. Patient #4's medical record was available for review during interview. Interview revealed if she documented that a patient left due to "wait too long" it did not mean she visualized the patient leaving. Interview revealed often patients let registration staff know they were leaving, and she was then notified by registration staff. Interview revealed often by the time the Triage RN was able to get to the lobby to review risks and benefits with patients, the patients had left the department.

Interview on 08/18/2021 at 0925 with RN #4 revealed she did not recall Patient #4. Medical Record was available for review during interview. Interview revealed if a patient is leaving the DED from the waiting room the facility process is to have either a nurse or a provider comes out to the lobby to discuss the risks and benefits and offer a medical screening exam. Interview revealed if a patient refused to stay the patient was asked to sign a leaving Against Medical Advice form and the risks and benefits of leaving versus staying for treatment were reviewed with the patient. Interview revealed if the patient notified the EMT (Emergency Medical Technician) from registration that they were leaving there were times where the patients would not wait for the nurse to come talk with them and would leave prior to receiving the risks and benefits.

Interview on 08/18/2021 at 1102 with the Director of the DED revealed the expectation of staff when a patient informs a staff member of their intent to leave is for the Triage Nurse or the Charge Nurse to talk with the patient, review the risks and benefits of leaving versus staying, and ask the patient to sign a Leaving Against Medical Advice form.


Interview on 08/18/2021 at 1114 with an EMT in Registration revealed that if a patient presented to her and informed her of their intent to leave, she would obtain their name and chief complaint and notify the Triage RN. Interview revealed patients often leave immediately after they have notified her, and the Triage RN does not have time to discuss the risks and benefits of staying. Interview revealed if the patient left prior to the nurse talking to the patient that the process is to put a note on the tracking board for the ED communication.