HospitalInspections.org

Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §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 regulations:

Tag 2406: (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph. (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital ' s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. Based on interviews and document reviews, the facility failed to provide an appropriate medical screening examination (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to ensure a MSE was performed by a qualified medical professional (QMP) for one of one patients reviewed who presented to the emergency department (ED) with chest pain. (Patient #10)

Based on interviews and document reviews, the facility failed to provide an appropriate medical screening examination (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to ensure a MSE was performed by a qualified medical professional (QMP) for one of one patients reviewed who presented to the emergency department (ED) with chest pain. (Patient #10)

Findings include:

Facility policies:

According to the EMTALA policy, qualified medical providers will perform an appropriate MSE, within the capability of the facility, for any individual who comes to the ED and requests examination or treatment of any medical condition. A request is considered to have been made for an examination or treatment of any medical condition in the ED if a prudent layperson would conclude from the individual's appearance or behavior that there is a need for examination or treatment of any medical condition. Staff and affiliated providers must know and comply with EMTALA.

Furthermore, a QMP will perform the MSE, for any individual requesting examination or treatment, and within the capabilities of the hospital, whether the individual presented directly to the ED or elsewhere on hospital property. Additionally, triage alone does not constitute an appropriate MSE.

The policy defines an Emergency Medical Condition (EMC) as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

A MSE is described as the process, conducted by a QMP, required to determine-within reasonable clinical confidence-whether an EMC exists. The MSE may range from a brief history and physical to a more complex evaluation involving ancillary studies, depending on the patient's presentation. The MSE is an ongoing process and represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures, depending on the patient's presenting symptoms. A MSE is not an isolated event, but an ongoing process that begins with, but typically does not end with, triage or intake. The MSE is conducted by an individual(s) determined to be qualified by the hospital's Medical Staff By-Laws, Rules and Regulations. The MSE is an ongoing process that begins with, but is not limited to, triage or intake.

Triage is defined as the clinical assessment of an individual's presenting signs and symptoms at the time of presentation at the hospital in order to prioritize when the individual will be seen by a physician or other qualified medical provider.

According to the Combative or Disruptive Person (Code Gray) Response policy, providers will work in coordination with the Security Supervisor during patient assistance calls to ensure that interventions are consistent with the treatment philosophy and plan for the patient. All Security assistance calls will be discussed post-event by the healthcare providers, the Security Supervisor, and other officers and staff involved in the event. Staff will notify their supervisor of any concerns that arise and the measures that were taken to resolve them. All incidents of workplace violence will be reviewed. The Safety and Security Managers and the Environment of Care Committee will review security incidents to identify patterns of potential violence. The reports will be evaluated, and recommendations for workplace design changes, procedural changes, or employee training will be made as necessary. All acts of workplace violence initiated by staff members will be evaluated by the Human Resources Department. A Code Grey is defined as an acting out, combative, disruptive, or violent individual that staff members are unable to redirect and is a danger to injure themselves or others without immediate intervention.

References:

The Emergency Services Technician Paramedic I-Emergency Department Job Description read, the Pivot technician was responsible for providing patient care under the direction of a physician and reporting changes in physical, mental, and emotional conditions to medical staff.

The Managing Disruptive Behavior pathway. provided by the facility on 6/11/25 read, staff should call a Code Gray and notify the attending physician to perform a bedside assessment when a patient exhibits disruptive behaviors and is not actively assaulting or attempting to harm another person.

1. The facility failed to ensure a MSE was performed by a QMP to rule out an EMC.

A. Document Review

i. Medical record review revealed after Patient #10 presented to the ED with chest pain, they were not triaged, and a MSE was not performed.

a. On 4/21/25 at 9:45 p.m., Patient #10 presented to the ED with chest pain. At 9:59 p.m., emergency service technician (EMT) #2 attempted to obtain Patient #10's vital signs.

Review of EMT #2's ED note revealed Patient #10 informed EMT #2 the blood pressure cuff was hurting their arm. EMT #2 reassured Patient #10 the blood pressure cuff would release shortly, and Patient #10 became agitated and cursed at them. In response to Patient #10's outburst, EMT #2 called security to have the patient escorted out of the ED.

Further review of Patient #10's medical record revealed, EMT #2 failed to inform a QMP of Patient #10's presentation to the ED and their request for medical evaluation and treatment. Additionally, EMT #2 failed to notify a QMP of the disruptive behavior exhibited by the patient and the involvement of security personnel to remove the patient from the ED.

Upon request, the facility was unable to provide evidence Patient #10 was seen by a QMP to determine if the patient had an EMC.

This was in contrast to the EMTALA policy, the Managing Disruptive Patients pathway, and the Emergency Services Technician Paramedic I-Emergency Department job description.

According to the EMTALA policy, a MSE should have been provided to Patient #10 when they presented to the facility and requested an examination or treatment. The policy further stated a QMP should have performed the MSE based on the patients presenting signs and symptoms to rule out an EMC.

Additionally, according to the Emergency Services Technician Paramedic I-Emergency Department Job Description, EMTs were responsible for providing patient care under the direction of a physician. EMT #2 should have reported changes in Patient #10's physical, mental, and emotional conditions to the physician.

Lastly, according to the Managing Disruptive Behavior pathway, when Patient #10 exhibited disruptive behaviors and was not actively assaulting or attempting to harm another person, staff should have notified the physician to perform an assessment of the patient and should have called a Code Grey. However, upon request, the facility was unable to provide evidence a Code Gray was called.

B. Interviews

i. On 6/11/25 at 11:01 a.m., an interview was conducted with EMT #2. EMT #2 stated obtaining the patient's vital signs was a critical component of the intake process. They further stated vital signs assisted with determining a patient's acuity (the level of urgency that guides treatment timing). EMT #2 stated patients complained the blood pressure cuff squeezed their arm tightly and caused pain and discomfort. EMT #2 stated if a patient refused to have their blood pressure checked, the patient was educated on the importance of checking their blood pressure. EMT #2 further stated patients could refuse a blood pressure check, and the refusal should be documented in the patient's electronic medical record (EMR). EMT #2 stated even if a patient refused to have their blood pressure checked, they were still required to be evaluated by a provider.

EMT #2 stated when patients became disruptive or aggressive, staff contacted security to assist with de-escalation. EMT #2 stated an overhead announcement would be made throughout the ED to alert the ED provider and charge nurse to respond to the situation. Additionally, EMT #2 stated before a patient was escorted out of the ED, the ED providers were required to assess the patient to ensure they were medically stable.

EMT #2 stated it was not within their scope of practice to perform a MSE, or to determine if a patient had an EMC. EMT #2 stated it was important to have a QMP perform a MSE for patients who presented to the ED with chest pain. EMT #2 stated chest pain could indicate the presence of a life-threatening cardiac condition, and the patient could experience rapid decompensation, which could cause patient death.

ii. On 6/9/25 at 10:27 a.m., during observations in the ED an interview was conducted with emergency service pivot lead technician (Pivot Lead) #1. Pivot Lead #1 stated their role in the ED involved screening patients upon presentation to assess the level of critical needs the patient required. Pivot Lead #1 stated the screening performed by the EMT was not a triage or a MSE. Pivot Lead #1 stated a MSE was performed by the medical provider. Pivot Lead #1 stated the facility was required to provide every patient with a MSE by a QMP, as mandated by the EMTALA law.

Furthermore, Pivot Lead #1 stated security staff were called to help de-escalate patients when a patient was uncooperative or rude during the intake process. Pivot Lead #1 stated patients who became agitated, refused to follow directions, used profane or threatening language, or acted violently were escorted out of the facility by security staff. Pivot Lead #1 stated the medical provider would be notified of the patient's removal based on the discretion of the intake staff and their assessment of the situation. Pivot Lead #1 further stated intake staff had the ability to decide if a patient should be removed from the ED before the MSE was performed.

Pivot Lead #1's statement contrasted with the Emergency Services Technician Paramedic I-Emergency Department Job Description. The job description read, the Pivot technician was responsible for providing patient care under the direction of a physician and reported changes in physical, mental, and emotional conditions to medical staff. However, Patient #10's presentation to the ED was not reported to the medical provider, nor was the change in their emotional condition and their removal from the ED.

iii. On 6/11/25 at 12:17 p.m., an interview was conducted with ED charge nurse (Charge RN) #4. Charge RN #4 stated patients were not asked to leave the ED, or escorted out by security, before a provider performed a MSE. Charge RN #4 stated the medical provider would be called to immediately assess a patient if there was an implied or assumed threat to the safety of the patient or others. Charge RN #4 further stated the patient would be moved to a private room in the main ED where the medical provider could safely perform a MSE.

This was in contrast to Patient #10's medical record which revealed staff did not relocate the patient or attempt de-escalation before security was contacted to remove the patient from the ED.

iv. On 6/11/25 at 2:36 p.m., an interview was conducted with ED Physician #3. Physician #3 stated a MSE was used to determine whether or not a patient was experiencing an EMC and if they were at risk for immediate harm.

Physician #3 stated a Pivot technician was not a QMP and was not qualified to perform a MSE. Physician #3 further stated it was not within the Pivot technician's scope of practice to decide whether or not a patient should be evaluated by a physician. Physician #3 stated if a patient refused to have their blood pressure checked, the Pivot technician should alert the medical provider and arrange for the patient to be moved to a private ED room to ensure the medical provider could perform a MSE.

These interviews contrasted with Patient #10's medical record, which revealed the provider had not been informed the patient had presented with chest pain and there was no evidence the patient had received a MSE. Additionally, there was no evidence intake staff had notified the provider when Patient #10 became agitated and security had been contacted to remove the patient from the ED.