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Based on interviews 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:

1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag A2402 - Posting of Signs -The facility failed to post signs in all applicable entrances and waiting rooms specifying the rights of individuals seeking examination and treatment for emergency medical conditions. Specifically there was no EMTALA signage at the main entrance to the hospital or in the two internal emergency department waiting rooms.

Tag A2405 - Emergency Room Log -The facility failed to ensure that central log was maintained to accurately reflect the correct disposition of patients seen in the Emergency Department (ED). Specifically, the disposition listed on the log was incorrect for 2 of 20 patients reviewed. (Patients #3 and #12).

Tag A2406 - Medical Screening Exam - The facility failed to provide a medical screening examination for patients presenting to the emergency department (ED) with an emergent medical condition. Specifically, the hospital failed to provide a medical screening exam for 2 of 20 patients (Patients #6 and #7) with behavioral health conditions.

Tag A2407- Stabilizing Treatment - The facility failed to appropriately secure, assess and stabilize patients with Emergency Medical Conditions within its capacity. Specifically, the hospital failed to provide adequate supervision for two patients (Patients #6 and #7) with emergent behavioral health conditions, allowing the patients to elope from the facility. The facility also failed to secure or attempt to secure written informed refusal from 5 of 20 patients discontinuing care against medical advice. (Patient #s 4, 5, 10, 11, and 12).

Based on observation and interviews the facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signage was posted at relevant locations in the facility.

1. The facility failed to post signs, specifying the rights of individuals seeking examination and treatment for emergency medical conditions at entrances and waiting areas used by patients seeking emergency services. Specifically, there was no EMTALA signage at the main entrance to the hospital or in designated waiting areas within the emergency department.

a) During a tour of the hospital lobby on 2/22/19 at 8:35 a.m. with Nurse Clinical Quality Specialist (Specialist) #1, no EMTALA signs were posted at the main entrance to the hospital. A patient representative (Representative #2) was stationed at the information desk located in the main lobby. Representative #2 stated that patients come to the main lobby seeking emergency services almost everyday she works. Representative #2 stated she works at the information desk every Thursday and Friday.

b) The nurse manager (Manager #3) of the Emergency Department (ED) joined the tour at 8:56 a.m. Manager #3 explained that when walk-in patients presented to the ED they were triaged at an intake area and then taken to a room within the ED for examination and treatment or placed in either of the two waiting areas within the ED. The Supertrack Internal Waiting Room and the Main Reception Room within the ED were toured. Neither waiting area contained signage relevant to EMTALA. Manager #3 stated that both waiting areas were used consistently by patients seeking care in the ED. When asked about EMTALA signage for the internal ED waiting rooms, Manager #3 stated that to his knowledge neither room has had EMTALA signage in the past "but that it would be a good idea."

Based on interviews and document review, the facility failed to ensure a central log was accurately maintained to reflect the correct disposition of patients seen in the Emergency Department (ED). Specifically, one patient (Patient #3) was entered in the central log as discharged when there was no indication in the medical record that the patient was treated and discharged from the ED; another patient (Patient #12) was discharged but entered in the central log as left against medical advice.

POLICY

According to the Medical Screening Examinations, Stabilizing Treatment and Appropriated Transfers (EMTALA) policy, UCH maintains a log of all individuals who request emergency services and care at a dedicated ED. The log documents the date, time, patient name, medical record number, chief complaint and disposition of the patient.

1. The facility failed to maintain a complete and accurate central log of patients who presented to the facility.

a) Review of the electronic EMTALA Log maintained by the facility indicated that Patient #3 came to the ED on 1/29/19 at 4:28 p.m. complaining of pelvic pain. Vital signs were obtained at 4:30 p.m. Review of the medical record indicated that at 4:53 p.m. the ED intake physician examined Patient #3 and determined the presence of a vaginal lesion. A urine sample was obtained at this time. According to the medical record, Patient #3 was taken to the main internal waiting room within the ED at 4:56 p.m.

There was no documentation in the medical record that the patient was ever transferred from the waiting room to a patient room within the ED for further evaluation and treatment. No additional lab tests, procedures, evaluations or medical decision making was noted in the medical record. No orders for discharge were present, nor was a discharge assessment or discharge instructions present. The EMTALA Log indicated Patient #3 was discharged at 7:59 p.m. on 1/29/19.

b) The EMTALA Log noted that Patient #12 came to the ED on 2/14/19 at 1:46 p.m. complaining of a loss of consciousness. The patient was evaluated and treated in the ED for more than four hours. At 6:50 p.m. the ED physician documented that the patient had no further complaints, she was given strict return precautions and instructions, and that she was stable for discharge. At 6:57 p.m. on 2/14/19 a registered nurse documented that Patient #12 verbalized understanding of discharge instructions and follow up care and she was taken to the discharge desk without difficulty. The EMTALA Log documented Patient #12 left against medical advice (AMA) at 6:58 p.m.

c) During an interview, on 2/27/19 at 12:54 p.m., the director of the emergency department (Director #4) stated she cochairs the EMTALA committee but did not look at the discharge disposition for accuracy. Director #4 stated the discharge disposition was most often entered by the physician.

Based on interview and record review, the facility failed to provide a medical screening examination for patients presenting to the emergency department (ED) with an emergent medical condition in 2 of 20 records (Patients #6 and #7) reviewed.

POLICY

According to the Medical Screening Examinations, Stabilizing Treatment and Appropriated Transfers (EMTALA) policy, all individuals who present to the ED seeking examination or treatment for a medical condition will receive a Medical Screening Examination (MSE) by a Healthcare provider or qualified healthcare professionals. No individual who requests emergency services or care or whose medical condition is unstable may be discharged or transferred for any reason unless the individual requests a transfer (or discharge) or the treating healthcare provider determines that the medical benefits outweigh the risk of transfer.

1. The facility failed to provide a MSE and treatment for a patient brought to the ED with an emergent medical condition (Patient #6). In addition the facility failed to provide sufficient monitoring and stabilizing treatment for a suicidal patient seeking emergency care (Patient #7). These failures allowed patients in behavioral health crisis to leave the facility prior to receiving appropriate examination, care and treatment.

a) Review of the medical record for Patient #6 showed the patient was brought to the ED on 8/7/19 at 12:10 p.m. a by a psychiatrist at a clinic located near the hospital. Prior to bringing the patient to the ED, the psychiatrist consulted with the ED physician and received transfer requests from the transfer center at the hospital. The Transfer Acceptance Note, entered by the ED physician, noted the patient was being transferred for a higher level of care and the patient "reports hearing voices, suicidal ideation, is actively psychotic and used meth[amphetamine] to rid himself of voices."

Upon arrival to the ED, vital signs and a Consent to Treat were obtained as part of the intake process. A MSE was not performed by a Qualified Medical Person prior to placing the patient in one of the internal ED waiting rooms at 12:14 p.m. An ED Note, entered by a registered nurse at 12:45 p.m., indicated the patient was not seen in the waiting room and did not answer when his name was called. The entry noted that security was asked to look for the patient. An ED Note entered by the same registered nurse at 2:28 p.m. documented the police department was contacted to report a missing person.

b) On 2/27/19 at 11:30 a.m. an interview with the ED nurse manager (Manager #3) was conducted. Manager #3 stated when patients presented as walk-in patients to the ED, the chief complaint and presenting vital signs were obtained by the health care technicians stationed at the entrance to the ED and then the patient was evaluated by the intake physician, prior to being placed into a patient room or an internal ED waiting room. Manager #3 reviewed the medical record for Patinet #6 and was unable to determine why a MSE was not performed by the intake physician for an accepted transfer patient experiencing psychosis.

c) Patient #7 came to the ED as a walk-in on 1/7/19 at 8:05 p.m. Review of the medical record showed Patient #7 was seen by the intake physician at 8:29 p.m. The patient came to the ED with suicidal ideations, worsening depression and reported a previous suicide attempt by overdose. She was taking multiple medications without improvement, causing her to feel increasingly hopeless. The patient's stated plan was to overdose. The intake physicain identified a working diagnosis of suicidal and ordered the patient to be placed in seclusion at 8:35 p.m. due to a safety risk to self and/or others.

The patient was placed in one of the internal waiting rooms in the ED without seclusion precautions in place pursuant to physician's orders. When staff went to the waiting room at 8:50 p.m. the patient was not present.

d) During an interview with Manager #3 on 2/27/19, he stated the facility had determined gaps in patient placement procedures in the internal waiting rooms in the ED, as well as inconsistent documentation expectations for nursing staff. Manager #3 stated a gap analysis had been conducted in June or July of 2018 and system process changes had been developed and were approved by the leadership team. Manager #3 stated the facility was in the implementation phase for the new process and that the nurse educator was drafting a roll out plan with a target date of July 1, 2019 to complete education for 100% of nurses and health care technicians regarding the new process; however it had not yet been implemented fully.

Based on interview and record review, the facility failed failed to secure or attempt to secure written informed refusal from patients who left the ED against medical advice, to ensure patients were educated regarding the potential consequences of their actions and in order for the patient to make an informed decision in 5 of 20 records reviewed (Patients #4, #5, #10, #11 and #12). This failure allowed patients to discontinue care and treatment without being informed of the risks of terminating treatment or the benefits of continued treatment..

POLICY

According to the Leaving Against Medical Advice policy, when an individual seeks emergency care and services in the Emergency Department or in any other area in the hospital and thereafter refuses further evaluation and/or necessary stabilizing treatment, he/she or the individual's legal representative must be informed of the risks and benefits to the individual of accepting or refusing the examination or further evaluation. All reasonable steps must be taken to explain the hospital's obligations to provide a full medical screening examination and to obtain the individual's written informed refusal on the Informed Consent to Refuse Examination or Treatment form. If the individual refuses to sign the form, document the refusal on the form and describe the examination or further evaluation that was refused in the patient's Electronic Health Record (EHR).

1. The facility failed to inform patients of the risks when refusing further evaluation and/or stabilizing treatment and obtain written informed refusal from patients leaving against medical advice in 5 of 20 records reviewed. (Patients # 4, 5, 10, 11 and 12). This failure allowed patients to discontinue care and treatment without being informed of the risks of terminating treatment or the benefits of continued treatment.

a) Patient #4 came to the ED on 10/18/18 at 4:17 p.m. with complaints of worsening pelvic pain. A computerized tomography (CT) scan (a series of x-ray images taken from different angles) was completed, identifying ovarian cysts. At 10:18 p.m. the ED provider documented the patient did not want to wait for a gynecology consult and that the patient has the capacity to make her own healthcare decisions and despite attempts to encourage her to remain for further workup, the patient declined and left against medical advice. There was no Informed Consent to Refuse Examination or Treatment form in the medical record and the risks of the discontinuation of treatment were not identified to the patient. The patient walked out of the ED and was discharged against medical advice.

b) Patient #5 came to the ED on 1/5/19 at 4:15 p.m. with shortness of breath and a productive cough. The ED provider diagnosed pneumonia and hypoxemia (low levels of oxygen in the blood) and recommended the patient be admitted for antibiotic treatment. The patient refused to be admitted as an inpatient but did agree to be admitted to observation in the ED. Treatment and medication administration were documented in the medical record throughout the evening on 1/5/19. At 11:40 p.m. an evaluation for home oxygen therapy was conducted by a respiratory therapist. Discharge instructions including medications and home oxygen therapy were present in the medical record as was a return to work excuse dated 1/6/19. There was no Informed Consent to Refuse Examination or Treatment form in the medical record, however a letter titled "Statement of Patient Leaving Against Medical Advice" was present, signed only by a physician assistant. There was no documentation that Patient #5 was informed of the risks listed for refusing further care or that she was given an opportunity to sign the document indicating her understanding of the risks.

c) Patient #10 was brought by ambulance to the ED, from the airport on 2/24/19 at 8:15 a.m., after experiencing stomach pains with vomiting and chest pressure during a flight. The ED provider documented the need to obtain a CT Pulmonary Angiography (an x-ray of the blood vessels) in order to determine whether Patient #10 had a blood clot in her lungs. However the patient refused the test. The physician documented that Patient #10 was informed that she could die if she did not receive this test and that the patient was "sober, competent has decision-making capacity." There was no Informed Consent to Refuse Examination or Treatment form in the medical record signed by the patient acknowledging the risks in refusing the test and no indication that Patient #10 was offered and refused to sign the document. Patient #10 was discharged against medical advice (AMA).

d) Patient #11 was brought to the ED by ambulance on 2/13/19 at 2:47 p.m. after feeling ill at home. He was found to be hypoglycemic (low blood sugar) and hypertensive (high blood pressure). Following diagnostic testing and treatment in the ED, a decision was made at 7:04 p.m. to admit the patient to the hospital. However, the patient was not admitted to the hospital. There was no further documentation from medical or nursing staff regarding disposition until three days later on 2/16/19 at 1:04 a.m. when a physician documented, on the ED Provider Note, the patient insisted he wanted to leave AMA, had decision making capacity, understood risks of death, permanent disability." There was no Informed Consent to Refuse Examination or Treatment form in the medical record signed by the patient acknowledged the risks in refusing continued care and no indication that Patient #11 was offered and refused to sign the document.

e) Patient #12 came to the ED on 2/14/19 at 1:46 p.m. with complaints of syncopal (fainting) episodes. A series of tests and procedures were conducted in the ED to try to determine the cause of the syncope and eliminate the presence of serious medical conditions.

Conflicting disposition notes were in the record. At 3:55 p.m. an ED physician documented that inpatient admission was planned, however the patient elected to leave against medical advice (AMA) since the patient reported improvement following treatment and medication administration. There was no Informed Consent to Refuse Examination or Treatment form in the medical record signed by the patient acknowledging the risks in refusing continued care and no indication that Patient #12 was offered and refused to sign the document. The disposition listed for Patient #12 on the EMTALA log was AMA.

At 6:50 p.m. on 2/14/19 a different ED physician documented that the patient had no further complaints, that she was given strict return precautions and instructions and that she was stable for discharge. At 6:57 p.m. on 2/14/19 a registered nurse documented that Patient #12 verbalized understanding of discharge instructions and follow up care and she was taken to the discharge desk without difficulty.

f) During an interview with Manager #3 on 2/27/19, he stated Emergency Department staff and providers are expected to comply with the applicable sections of the Leaving Against Medical Advice policy.