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Based on policy review, medical record review, central log review, EMS (Emergency Services Personnel), staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

Based on hospital policy and procedure review, medical record reviews, physician and staff interview and Emergency Service personnel interviews, the hospital's DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for 5 of 31 reviewed patients who presented to the DED. (Patient #20, #25, # 27, #28, and #29).

~cross refer to Tag A2406

Based on reviews of the hospital policies and procedures, EMTALA log, and interviews, the facility failed to maintain a central log on each individual who presented to the emergency department seeking assistance as to whether or not the patient refused treatment, or whether the patient was transferred, admitted and treated, stabilized and transferred or discharged for 4 of 31 sampled patients (#25, #27, # 28, and #29).

The findings include:

Review of the hospital's policy and procedure titled, "EMTALA - Central Log" reviewed 04/14 revealed " ... A. The hospital will maintain a central log to track the care provided to each individual who comes to the hospital seeking emergency care. B. All logs will be available in a timely manner for surveyor review. C. The log will contain: *Name of the individual seeking assistance *Arrival time *Age *Sex * Means/Mode of arrival *Medical Record Number *Chief complaint *Disposition 1) patient refused treatment, 2) was refused treatment by the facility, 3) transferred, 4) admitted and treated, 5) stabilized and transferred, or 6) discharged. *Departure Time. D. All required fields of the log will be completed as soon as possible after the disposition of the patient.

Review of the hospital's central log revealed Patient # 25, Patient #27, Patient #28, and Patient #29 were not listed on the log.

Interview on 06/28/2022 at 0950 with PI #8 and RD #9 revealed the patients that present are included on the central log when the patient is keyed in the EHR (electronic health record) as "arrived" when arriving by EMS (Emergency Medical Services) in the ED. Interview revealed the patient may physically be in the emergency department, but in the EHR the patient arrival displays as pending until a nurse takes over care. The patients that come in via EMS have an estimated time of arrival. There is a gap between the estimated time of arrival and the arrival time which is the time the nurse takes over care of the patient. The root cause of the patient not making it to the log is EMS having to wait with patients. If the patient decides to leave while they are waiting with EMS, the nurse has to "arrive" the patient to accurately disposition the patient. Interview revealed if the patient is not arrived and not properly selecting the disposition will omit the patient from the log.

Based on hospital policy and procedure review, medical record reviews, physician and staff interview and Emergency Service personnel interviews, the hospital's DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for 5 of 31 reviewed patients who presented to the DED. (Patient #20, #25, # 27, #28, and #29)

The findings include:

Review of the "EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening" effective 02/2021, revealed " PROCEDURE: A. When a Medical Screening Examination Is Required: 1. A person presents on their own. 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. 2. A person presents in a ground or air ambulance owned and operated by the hospital. 3. A person present in a Non hospital owned ambulance ... a. An individual in a non-hospital owned ambulance that is on hospital property is considered to have come to the hospital's emergency department ... C. Medical Screening Examination: 1. A medical screening examination will be provided when an individual comes by him/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.

Review of the facility's "Emergency Department Triage Policy" Last Revised 11/2020 revealed "PURPOSE/SUPPORTING INFORMATION All patients presenting to the Emergency Department shall be evaluated by a Registered Nurse to determine the nature of their presenting complaints, their condition, and their priority for receiving a medical screening exam...PROCEDURE: A. Triage decisions are based on the 5 point Emergency Severity Index (ESI). B. Patients awaiting medical screening exam will be reassessed based on ESI or a minimum every 4 hours..Figure 2-2 ESI Triage Algorithm. v 4 Danger Vital Signs >8 yr ; Respiratory Rate > 20 consider ESI 2 High Risk Situation..."

1. Closed medical record review of Patient #20 revealed a 67 year old female who presented to the facility's emergency department on 06/09/2022 at 1408 via EMS for a chief complaint of chest pain. Review of EMS patient care report revealed at 1408 "....Pt (patient) registered and report given to the triage nurse. No significant changes in pt condition while waiting for bed..." Review revealed at 1530 BP 102/57, pulse 72, oxygenation 94% and respiratory rate 12. Further review revealed at 1620 "Pt began complaining of increased r (right) sided chest pain radiating to her r arm. Nitroglycerin (medication used to treat chest pain), .4 MG via SL (sublingual) given (by named EMS Staff member)... Authorization:via Protocol. Pt response: Improved..." EMS report review revealed at 1908 "Pt stating she would like to leave ER AMA (against medical advise). Pt advised of possible consequences if leaving before being seen by a doctor. Pt verbalized understanding of possible consequences and signature obtained.." Record review revealed Patient #20 signed EMS refusal (5 hours after arrival). Review of facility emergency department medical record revealed Patient #20 disposition set at 2043 "LWBS (left without being seen) before triage" and discharged at 2044.

Interview on 06/29/2022 at 1215 with Paramedic # 39 revealed he recalled Patient # 20. Interview revealed EMS staff had to treat the patient due to the complaint of chest pain. Interview revealed they have treatment protocols. Interview revealed the patient was tired of waiting. Interview revealed the ED staff never attempt to get a refusal of treatment from a patient waiting with EMS staff. Interview revealed he did notify ED staff Patient #20 was wanting to leave but they did nothing because Patient #20 was "still under the care of EMS staff in the hallway".

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

Interview on 06/24/2022 at 1250 with the previous Emergency Department Administrative Coordinator revealed when a patient voices a desire to leave the emergency department without completing treatment or a medical screening exam, a written refusal is attempted and risks and benefits are explained to the patient. Interview revealed the charge nurse is made aware and notifies the the physician. Interview revealed patients waiting with EMS staff for triage and room placement should also have a written refusal by emergency department staff prior to leaving the facility.

2. Closed medical record review of Patient # 25 revealed a 92 year old female who presented to the facility's emergency department via EMS on 05/31/2022 at 1722 for a chief complaint of syncope. Review of the EMS patient care report revealed Patient #25 was alert and oriented with a BP of 132/89, pulse 81, respiratory rate 18. Review of EMS patient care report revealed "EMS arrives at receiving. One EMS crew member went into receiving to register patient. Triage notified EMS as long as patient had mask on patient could come inside to stage in hallway. With mask in place on patient, patient was transferred into receiving. EMS asked to stage in hallway until room became available. During wait time patient was assisted to bathroom. While waiting for room patient slept on stretcher. After extensive wait time, EMS asked triage if patient could be triaged due to patients stability and that there were ALS (advanced life support) interventions at that time. Triage nurse declined stating she did not want patient to sit in the lobby with family due to syncopal episode as patient's chief complaint, Charge nurse was consulted and she advised patient could not be triaged for same. EMS notified the wait time could extend another 9 hours possibly. Patient and family were advised of further extended wait times. Patient and patient's family decided to take patient to another facility for treatment. Another set of vital signs were obtained, refusal..explained to them... EMS assisted patient transferring from wheelchair to front seat of POV (privately owned vehicle)." Patient #25 signed an EMS Refusal releasing them from EMS care. Review revealed Patient left EMS care at 2110. Review revealed patient care was never transferred to emergency department personnel and Patient #25 left the facility with family after waiting 3 hours and 48 minutes.

Interview on 06/29/2022 at 1015 with Paramedic #38 revealed she was the EMS personnel who transported Patient #25 to the emergency department. Interview revealed the patient's vital signs were stable and she was capable to sit in triage with family to prevent in a delay in triage. Interview revealed no nursing staff triaged the patient while waiting. Interview revealed the emergency department staff say "she's your patient, she's in your care until we take report". Interview revealed the family was tired of waiting and wanted to take the patient to another hospital. Interview revealed EMS personnel made the charge nurse aware and the hospital staff do not speak to the patient's prior to departure. EMS staff assisted the patient to family's car.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

Interview on 06/24/2022 at 1250 with the previous Emergency Department Administrative Coordinator revealed when a patient voices a desire to leave the emergency department without completing treatment or a medical screening exam, a written refusal is attempted and risks and benefits are explained to the patient. Interview revealed the charge nurse is made aware and notifies the the physician. Interview revealed patients waiting with EMS staff for triage and room placement should also have a written refusal by emergency department staff prior to leaving the facility.



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3. Closed medical record revealed Patient #27 was a 76-year-old female brought to the emergency department (ED) by emergency medical service (EMS) on 05/23/2022 at 2049 with a complaint of vomiting. Review of the EMS run report revealed EMS arrived in the ED with Patient #27 at 2052. Review of the ED Timeline revealed the hospital documented Patient #27's arrival in the ED as 0139 (4 hours 47 minutes after EMS arrived with the patient). Review revealed the ED disposition was set to "LWBS before Triage" at 0142 (4 hours 50 minutes). Review of the medical record revealed no MSE and no documentation of risk and benefits were discussed with Patient #27 by hospital staff prior to her leaving the ED.

Telephone interview on 06/28/2022 at 1359 with EMS #6 revealed he transported Patient #27 to the ED. Interview revealed when they arrived in the ED there were already 3 or 4 other EMS with stretchers with patients waiting to be seen. Interview revealed EMS #6 checked in with the triage nurse. Interview revealed a hospital staff member came to the stretcher and asked Patient #27 questions and then put a wrist band on the patient. Interview revealed after five hours waiting and not being see or evaluated, Patient #27 decided she was going to leave. Interview revealed EMS #6 notified the charge nurse of Patient #27 wanting to leave. Interview revealed the charge nurse notified EMS #6 the patient (Patient #27) did not need to sign anything for the hospital because they were not a patient of the hospital. Interview revealed EMS #6 had Patient #27 sign an EMS Refusal releasing them from EMS care. Interview revealed the hospital front desk staff called a taxi for Patient #27 to leave.

Telephone interview on 06/29/2022 at 0904 with RN #5 that documented Patient #27's arrival to the ED revealed she vaguely remembered Patient #27. Interview revealed EMS brings the patients in, gives report to the charge nurse/coordinator and depending on the situation and if a bed is available, they either take the patient to a room or they stay with the patient until a room becomes available. Interview revealed RN #5 did not remember and probable did not talk with Patient #27 about risk of leaving without being seen nor the benefit of staying and being evaluated by a provider when a bed was available. RN #5 stated it is the nursing staff and/or the hospital staff responsibility to talk with the patient to explain they are trying to get a spot for the patient to be seen by the provider.

4. Closed the medical record revealed Patient #28 was a 76-year-old male brought to the emergency department (ED) by emergency medical service (EMS) on 05/23/2022 with a complaint of vomiting. Review of the EMS run report revealed EMS arrived in the ED with Patient #28 at 2052. Review of the ED Timeline revealed the hospital documented Patient #28's arrival in the ED as 0139 (4 hours 47 minutes after EMS arrived with the patient). Review revealed the ED disposition was set to "LWBS before Triage" at 0142 (4 hours 50 minutes after EMS arrived with the patient). Review of the medical record revealed no MSE and no documentation of risk and benefits were discussed with Patient #28 by hospital staff prior to him leaving the ED.

Telephone interview on 06/28/2022 at 1359 with EMS #6 revealed he transported Patient #28 to the ED. Interview revealed when they arrived in the ED there were already 3 or 4 other EMS with stretchers with patients waiting to be seen. Interview revealed EMS #6 checked in with the triage nurse. Interview revealed a hospital staff member came to the stretcher and asked Patient #28 questions and then put a wrist band on the patient. Interview revealed after five hours waiting and not being see or evaluated, Patient #28 decided she was going to leave. Interview revealed EMS #6 notified the charge nurse of Patient #28 wanting to leave. Interview revealed the charge nurse notified EMS #6 the patient (Patient #28) did not need to sign anything for the hospital because they were not a patient of the hospital. Interview revealed EMS #6 had Patient #28 sign an EMS Refusal releasing them from EMS care. Interview revealed the hospital front desk staff called a taxi for Patient #28 to leave.

Telephone interview on 06/29/2022 at 0904 with RN #5 revealed she vaguely remembered Patient #28. Interview revealed EMS brings the patients in, gives report to the charge nurse/coordinator and depending on the situation and if a bed is available, they either take the patient to a room or they stay with the patient until a room becomes available. Interview revealed RN #5 did not remember and probably did not talk with Patient #28 about risk of leaving without being seen nor the benefit of staying and being evaluated by a provider when a bed was available. RN #5 stated it is the nursing staff and/or the hospital staff responsibility to talk with the patient to explain they are trying to get a spot for the patient to be seen by the provider.

5. Review of the medical record revealed Patient #29 was a 53-year-old male brought to the emergency department (ED) by emergency medical service (EMS) on 06/13/2022 at 1501 with a complaint of AMS (altered mental status) EKG (electrocardiogram-recording of electrical signals in the heart) showing RBB (right bundle branch block). Review of the EMS run report revealed EMS arrived in the ED with Patient #29 at 1518. Review of the ED Timeline revealed the hospital never documented Patient #29's arrival in the ED. Review revealed Patient #29 had blood collected for lab test at 1527 by "EMS Collector". Review revealed the ED disposition was set to "LWBS before Triage" on 06/14/2022 at 0101 (10 hours after EMS arrived with the patient). Review of the medical record revealed no MSE and no documentation of risk and benefits were discussed with Patient #29 by hospital staff prior to him leaving the ED.

Telephone interview on 06/29/2022 at 1103 with EMS #7 revealed he transported Patient #29 to the ED. Interview revealed Patient #29 had AMS and was started on IVF (intravenous fluids). Interview revealed EMS #7 arrived in the hospital on 06/13/2022 at 1518. Interview revealed there were no beds and EMS had to stay with and monitor Patient #29. Interview revealed EMS #7 monitored Patient #29 from arrival time in the hospital of 1518 until he signed off shift at 1916 when EMS #7 gave report to the oncoming EMS crew.

Telephone interview on 06/29/2022 at 1406 with RN #4 revealed she did not remember Patient #29.