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Based on review of the facility's central log, medical records, Medical Staff Rules and Regulations, policies and procedures and interviews, it was determined the facility failed to ensure that one of 20 sampled patients (P#1)received an appropriate medical screening examination when P#1 presented to the Emergency Department (ED) on 8/17/21.

Findings were:

Cross refer A-2406, as it relates to the facility's failure to provide P#1 with an appropriate medical screening examination.

Based on a review of the facility's Emergency Department ED registration Log, Interviews with staff, and a review of policies and procedures, it was determined the facility failed to log one out of 20 sampled patients (P#1) into the ED Central Log.

Findings were:

A review of the facility's Emergency Department (ED) registration Log on 10/12/21 revealed that P#1 was not logged into the facility's ED's registration log.

An interview took place with the Patient Access Supervisor (PAS PP) on 10/13/21 at 11:01 a.m. in the Conference Room. PAS PP explained the registrar process. When a patients would come to the ED, the registrar would greet the patients and offer to assist the patients. If there were no other patients waiting in line, the registrar would enter the patient's name and date of birth into the computer system. PAS PP stated if there was a line of patients waiting, the patient would be given a clipboard with an intake sheet to fill out. PAS stated P#1's girlfriend filled out the intake sheet for P#1. PAS PP stated that when the Triage Nurse (RN EE) told Registrar LL not to enter the intake information into the system. Registrar LL sent an email to the registrar supervisors the evening of the incident, 8/17/21 at 11:58 p.m., because Registrar LL was concerned about the decision to allow P#1 to leave the ED.

An interview took place with the Director of Patient Access Services (PAD) on 10/13/2021 at 11:28 a.m. in the Conference Room. PAD stated that Registrar LL sent an email detailing the events on 8/17/21. RN EE who was the triage nurse and the director of the ED informed the charge nurse (RN BB) that evening that the facility was not going to treat P#1. Once Registrar LL was informed about not treating P#1 Registrar LL did not go any further into the registration process and did not enter the intake sheet for P#1 onto the ED registration log.

An interview took place with the Patient Access Representative (Registrar LL) on 10/13/21 at 3:35 p.m. in the Conference Room. Registrar LL said P#1's girlfriend's mother came into the ED looking for a wheelchair. Registrar LL stated when the registration paperwork was being filled out, Registrar LL asked P#1 what year he was born and how old he was. When Registrar LL realized P#1 was a minor, Registrar LL asked if P#1 had a parent or guardian with him. Registrar LL said she called the charge nurse (RN BB), and RN BB came to talk to the patient. When P#1 told RN BB what happened, RN BB asked if P#1's mother was present. P#1 indicated his mother was not present. Registrar LL said RN BB seemed confused and went into the triage area and asked the triage nurse/ED director (RN EE) what to do. RN BB came back to the waiting area and said that the ED could not treat P#1 due to the patient not having a parent or guardian with him. Registrar LL said the lady who had accompanied P#1 said she would take P#1 to a different hospital. Registrar LL stated she was not sure if she should enter P#1's information into the system, and the patient access supervisor (PAS RR) was not available to give the go-ahead to enter P#1 ' s information.

A review of policy #5023099, "EMTALA-Central Log," reviewed 6/3/2020, revealed that the facility would maintain a central log to include information of everyone who comes to the facility property or premises requesting treatment, including those patients presenting to Labor and Delivery. The policy further revealed that the log must contain the individual's name who comes to the Emergency Department (ED), whether the individual refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized, and transferred, or was discharged. The policy stated that the facility's staff should enter the patient in the log at the first point of contact. The facility's policy would finalize the central log after the medical screening and necessary treatment and stabilization. The policy stated that the facility would retain the central log for a minimum of five years.

Based on staff interviews, a review Medical Staff Bylaws, Quality/Regulatory Performance Improvement Committee meeting minutes, and a review of policies and procedures, it was determined that the facility failed to provide one patient of 20 sampled (P#1) with an appropriate medical screening within the capability of the facility.

Findings were:

An interview took place with the Patient Access Supervisor (PAS PP) on 10/13/21 at 11:01 a.m. in the Conference Room. PAS PP explained the registrar process. When a patients would come to the ED, the registrar would greet the patients and offer to assist the patients. If there were no other patients waiting in line, the registrar would enter the patient's name and date of birth into the computer system. PAS PP stated if there was a line of patients waiting, the patient would be given a clipboard with an intake sheet to fill out. PAS stated P#1's girlfriend filled out the intake sheet for P#1. PAS PP stated that when the Triage Nurse (RN EE) told Registrar LL not to enter the intake information into the system. Registrar LL sent an email to the registrar supervisors the evening of the incident, 8/17/21 at 11:58 p.m., because Registrar LL was concerned about the decision to allow P#1 to leave the ED.

An interview took place with the Director of Patient Access Services (PAD) on 10/13/2021 at 11:28 a.m. in the Conference Room. PAD stated that Registrar LL sent an email detailing the events on 8/17/21. RN EE who was the triage nurse and the director of the ED informed the charge nurse (RN BB) that evening that the facility was not going to treat P#1. Once Registrar LL was informed about not treating P#1 Registrar LL did not go any further into the registration process and did not enter the intake sheet for P#1 onto the ED registration log.

An interview took place with Security Officer (SO OO) on 10/13/21 at 2:02 p.m. in the Conference Room. SO OO said Security got a call from the city police department that someone had been assaulted and the individual was being brought to the ED on 8/17/21 at 9:46 p.m. When P#1 came to the ED, P#1 said he had been badly beaten and repeatedly kicked. SO OO said the ED Director/Triage Nurse (RN EE) and the Charge Nurse (RN BB) informed P#1 that since he did not have a legal guardian with him, he could not be treated. The patient left the ED at 9:50 p.m. to attempt to find treatment somewhere else. SO OO further said P#1 was tightly clutching his ribs, had difficulty breathing, and was never triaged. SO OO said he filed a report of the incident and informed the security supervisors and house supervisors of the situation.

An interview took place with the Patient Access Supervisor (PAS RR) on 10/13/21 at 3:10 p.m. in the Conference Room. PAS RR said he was away from the facility during the time of the incident. When PAS RR returned to the ED, the Registrar LL brought the intake sheet to PAS RR and told what had happened. PAS RR told Registrar LL that not entering patients into the registration log was a possible EMTALA violation. PAS RR further stated that anytime a patient comes to the ED, the patient would be entered into the system first thing, even if the individual did not stay at the ED. The registrar would try to get as much information as possible from the individual.


A review of the Medical Staff Bylaws, approved on 10/23/2018, Article V - Emergency Medical Screening, Treatment, Transfer, and On-Call Roster Policy, revealed that individuals who presented to the ED for care would be provided with a medical screening examination to determine whether that individual was experiencing an emergency medical condition. Examination would not be delayed inquiring about an individual ' s method of payment or insurance status, nor denied on account of the patient ' s inability to pay. All patients would be examined by qualified medical personnel, which was defined as a physician or a licensed independent practitioner with demonstrated competency performing an MSE and physician oversight. In the case of a woman in labor, a registered nurse trained in obstetric nursing could also perform a screening exam but could not diagnose a medical condition. Basic Responsibilities of Staff Membership (Section 3.3) included a statement that each member of the medical staff would abide by the Medical Staff Bylaws and other lawful standards, policies, Rules and Regulations.

A review of policy #5022887, EMTALA-Medical Screening and Treatment of Emergency Medical Conditions, reviewed 8/29/2020, revealed all individuals seeking assessment or treatment for a medical condition receive an appropriate Medical Screening Examination. The policy further revealed that the facility would stabilize the patient within the hospital's capabilities if an emergency condition is determined. The policy addressed only qualified medical personnel would perform the Medical Screening Examination (MSE).

Review of the Quality/Regulatory Performance Improvement Committee meeting minutes for June 14, 2021, revealed the ED was providing monthly reports to the Performance Improvement Committee. Review of the Committee minutes from September 28, 2021, revealed EMTALA was self-reported to the Department, and subsequent actions were taken and reviewed. Feedback from the Department was pending. Discussion followed with no other recommendations. ED operations and patient throughput were reviewed; improvement was noted in Left Without Treatment (LWOT), Against Medical Advice (AMA), and Length of Stay (LOS) for discharged patients impacted by ED holds (patients waiting for admission).