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Based on facility policy review, record review, and interview, the facility failed to meet the requirements for Emergency Treatment and Labor Act (EMTALA) by failing to provide a medical screening exam (MSE) for an individual who presented to the Emergency Department (ED). The deficiency affected 1 (Patient 2) of 20 sampled patients.

The facility implemented corrective actions to correct the identified deficient practice from 09/11/25, to include staff training and quizzes related to EMTALA requirement; thus, past noncompliance was cited.

Findings Include:

The facility failed to provide a medical screening examination for an individual that presented to the Emergency Department. (Refer to tag C2406).

PAST NONCOMPLIANCE VERIFICATION

The facility implemented the following corrective actions:

- A facility document titled, " [The Facility ' s Name] Board of Trustees Meeting, " dated 09/24/25, indicated that the " EMTALA Education " was discussed. The Board of Trustees meeting documents included documents for a presentation titled, " EMTALA " and included educational information.

- An email from the DON, dated 09/11/25, revealed that the DON assigned EMTALA training and a quiz in the software system the facility used for communication and education, for all staff. Per the email, due to staff who worked as needed, the due date was set for 01/31/26; however, the email revealed that full-time staff were required to complete the training as soon as possible. The email revealed all training materials were also attached to the email, including EMTALA fact sheets, a PowerPoint regarding ensuring EMTALA compliance, a document with the definition of a MSE and emergency medical condition, and a PowerPoint titled, " What is EMTALA? "

- Interviews with staff revealed they had recently received EMTALA education and were knowledgeable that anyone who presented to the ED would be seen in the ED and not sent to the facility ' s clinic.

After review and verification of the facility's corrective actions, to include staff education and interviews with staff, the survey team determined the facility implemented the above corrective actions beginning on 09/11/25 and conducted ongoing education and monitoring; therefore, past noncompliance was cited.

Based on facility policy review, record review, and interview, the facility failed to provide a medical screening exam (MSE) for an individual that presented to the emergency department (ED) for 1 (Patient 2) of 20 sampled patients.

The facility implemented corrective actions to correct the identified deficient practice beginning on 09/11/25, to include staff training and quizzes related to Emergency Treatment and Labor Act (EMTALA) requirement; thus, past noncompliance was cited.

Findings Include:

Review of a facility policy titled, "[The Facility's Name] EMTALA," dated 07/20/17, indicated, "[The Facility's Initials] provides a MSE and necessary stabilizing treatment to any individual regardless of diagnosis (e.g. [exempli gratia; for example], labor, AIDS), financial status (e.g., uninsured, Medicaid), race, age, sex, color, ethnicity, national origin (e.g., Hispanic or Native American surnames), sexual orientation, and/or disability. An EMTALA obligation is triggered when an individual comes to an ED and elsewhere on Hospital property, such as," which included, "A. an entrance area," "B. An admitting areas," "C. Waiting rooms," "D. Labor & delivery," "E. Psychiatry," "F. Urgent care clinics," and "G. Treatment areas located on hospital property." The policy continued, "1. when the individual or a representative acting on the individual's behalf requests an examination or treatment for an EMC [emergency medical condition]; or 2. A prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination for or treatment of an EMC." The policy revealed, "In these circumstances, an appropriate MSE, within the capabilities of the Hospital's ED (including ancillary services routinely available and the availability of on-call providers), shall be performed."



Review of Patient 2's "Nurse Note," dated 09/05/25 at 2:49 PM and electronically signed by Registered Nurse (RN) 3, revealed that Patient 2 arrived at the ED with a family member at 1:40 PM. The note indicated that the family member stated that Patient 2 had been running a fever for two days. The note revealed, "This nurse to ask patient [the patient's family member acting on behalf of the minor patient] if [Patient 2] would like to be seen in the clinic or ER [emergency room], patient undecided." The note indicated that Certified Nurse Assistant (CNA) 5 called the clinic and asked if there were any openings, and the clinic staff stated that there would be an appointment available at 2:30 PM. The note revealed, "Patient stated they did not want to wait that long and would rather be seen as ER." Per the note, the patient and their family member were then escorted to a triage room. The note indicated that at 1:44 PM, RN 3 performed an assessment and attempted again to have the patient seen in the clinic, explaining that they would be seen faster and at a lower cost for the fever. The note revealed, "patient refused and stated they would prefer to be seen by the ER provider." The note indicated that at 1:52 PM, RN 3 attempted to call the on-call provider, as well as the provider's extension, but received no answer. Per the note, Medical Assistant (MA) 6 was then contacted about the incoming ER patient, who then told RN 3 to bring the patient to the clinic. The note indicated that RN 3 told MA 6 that multiple attempts had been made to reach the provider and that the family member had refused clinic evaluation. The note indicated that RN 3 was then placed on hold. Per the note, at 1:55 PM, MA 6 got back with RN 3 and stated that the provider had specifically instructed that the patient be sent to the clinic and that the provider would go in if necessary. The note indicated that at 2:06 PM, the patient and their family member were escorted to the clinic, where they checked in at the desk and were assisted to the seating area.

During an interview on 10/07/25 at 3:35 PM, RN 3 stated that the Director of Nursing (DON) had sent education regarding EMTALA on an education and communication software that the facility used and completed the related tasks by email. She stated that the education included fact sheets about EMTALA and the associated responsibilities. RN 3 stated that it was sent through email and notification using their education and communication software approximately two weeks prior. She stated that the reason for the education was that the DON identified a violation that had occurred and wanted to provide an update. RN 3 stated that she had been the nurse on duty when the EMTALA violation occurred involving Patient 2 and was notified a few days later. She stated that the DON asked her to write a statement, which she did. She stated that she recalled that Patient 2 was accompanied to the ED with another individual, who requested the patient be seen. RN 3 stated that she asked whether the patient wanted to be seen in the ED or clinic, and the family member stated that they did not care. She stated that there had been an ongoing issue with providers preferring that patients who were not critical be seen in the clinic. She stated that staff called the clinic, which stated they had a 2:40 PM appointment available, and the patient's family member said they did not want to wait. RN 3 stated that the patient was taken to triage, where they were asked a second time and again the family member said they wanted to be seen by the on-call provider. She stated that the provider on call was identified as Nurse Practitioner (NP) 1. RN 3 stated that she called the on-call provider but could not reach her. She stated that she then called the scribe, MA 6, who explained that she could not get a hold of the provider. RN 3 stated that she informed the scribe that they already had the patient in triage. She stated that the scribe spoke to NP 1 while RN 3 was on hold for about five minutes and was told to send the patient to the clinic. RN 3 stated that she then informed the patient's family member, who verbalized understanding, and the staff escorted the patient to the clinic. RN 3 stated that she later contacted the DON to file a complaint regarding what had occurred. She stated that was the first time such an incident had happened. She stated that the provider on call typically did not feel it was appropriate to send patients to the clinic. Per RN 3, since the violation, the process had changed, and providers were now instructed to see patients in the ED if they arrived there. RN 3 stated that when the issue with Patient 2 was reviewed, only vital signs had been obtained. RN 3 stated that she did not speak directly with NP 1 or NP 2, as there was only one provider in the clinic at the time. RN 3 acknowledged that she had told the patient's family member the clinic would be cheaper than the ED, and stated that was her mistake. She stated that the DON discussed the issue with her. RN 3 stated that her intention had not been to push the patient to the clinic.

During an interview on 10/08/25 at 3:09 PM, the DON stated that on 09/05/25, she had not been in the office. She stated that RN 3 sent her a message using healthcare communication software, but because she was gone, she did not receive it until the following week. She stated that upon returning, she reviewed the message, which prompted her to investigate further. The DON stated that she audited all the ED charts and compared them to the ED log. She stated that while reviewing the log, she looked into the case involving Patient 2 and saw an ED admission and nursing notes documented by RN 3. The DON stated that upon reading the note, she "got sick to her stomach." She stated that she immediately contacted the Risk Manager (RM) and went to speak with the Chief Executive Officer (CEO), reporting a possible EMTALA violation. She stated that an investigation was conducted, which included a review of both the electronic ED log and the paper log, as well as obtaining staff statements and self-reports. The DON stated that the investigation revealed conflicting stories. The DON stated that she believed the clinic had been informed the patient did not want to wait and had declined to be seen there. She stated that NP 1 had always shown up in the past, and she was not aware of any prior instance of her failing to do so. The DON stated that all three nurses and providers covering on-call duties had indicated that, if a case was not emergent, they would rather have the patient seen in the clinic, however, the Chief Medical Director (CMD), the Medical Director, and Chief of Staff became very upset after learning of the situation. The DON stated she believed an EMTALA violation had occurred, and that nursing staff required additional education and training. The DON stated that as part of the corrective measures, she compiled electronic presentations, MSE fact sheets, and Federally Qualified Health Center educational materials on EMTALA, which were distributed through email and uploaded to the software system they use for education and communication, shortly after 09/11/25. The DON stated that two electronic presentations and a quiz were created for all hospital staff and providers, and she was in the process of grading them. The DON stated that the education materials were also presented during a board meeting the following week, and the CEO included the EMTALA education in the board's agenda. She stated that staff had been reminded of expectations that if a patient presented to the ED, they were to be seen in the ED and receive an MSE. The DON reiterated that the CMD confirmed the event was considered an EMTALA violation and reinforced expectations that if anyone arrived at the ED, they must be seen there. She stated that the new process and training clarified that any patient who arrived through the ED must be seen in the ED, and that providers were required to complete an MSE for every such case.

PAST NONCOMPLIANCE VERIFICATION

The facility implemented the following corrective actions:

- A facility document titled, "[The Facility's Name] Board of Trustees Meeting," dated 09/24/25, indicated that the "EMTALA Education" was discussed. The Board of Trustees meeting documents included documents for a presentation titled, "EMTALA" and included educational information.

- An email from the DON, dated 09/11/25, revealed that the DON assigned EMTALA training and a quiz in the software system the facility used for communication and education, for all staff. Per the email, due to staff who worked as needed, the due date was set for 01/31/26; however, the email revealed that full-time staff were required to complete the training as soon as possible. The email revealed all training materials were also attached to the email, including EMTALA fact sheets, a PowerPoint regarding ensuring EMTALA compliance, a document with the definition of a MSE and emergency medical condition, and a PowerPoint titled, "What is EMTALA?"

- Interviews with staff revealed they had recently received EMTALA education and were knowledgeable that anyone who presented to the ED would be seen in the ED and not sent to the facility's clinic.

After review and verification of the facility's corrective actions, to include staff education and interviews with staff, the survey team determined the facility implemented the above corrective actions beginning on 09/11/25 and conducted ongoing education and monitoring; therefore, past noncompliance was cited.