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Based on medical record review, policy review, and patient and staff interview, it was determined the facility failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24: Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Refer to A - 2406 as it relates to the facility's failure to provide an appropriate MSE for 2 of 25 patients (Patient #11 and #24) whose records were reviewed.

Refer to A - 2407 as it relates to the facility's failure to provide an appropriate stabilizing treatment for 1 of 25 patients (Patients #11) whose record was reviewed.

Refer to A - 2408 as it relates to the facility's delay in providing approrpriate treatment for 2 of 25 patients (Patients #24 and #25) whose records were reviewed.

Refer to A - 2409 as it relates to the facility's failure to ensure an appropriate transfer for 5 of 6 patients (Patients #1, #2, #3, #4 and #5) who were transfered and whose records were reviewed.

Noncompliance with 42 CFR Part 489.24 had the ability to negatively affect all patients who presented to the ER seeking emergency care.

Based on policy review, record review, and staff interview, it was determined hospital staff failed to ensure the MSE was sufficient to determine whether an EMC existed for 2 of 25 patient (Patient #11 and #24) whose records were reviewed. This put all patients presenting to the ER for emergency medical care at risk for a negative outcome. Findings include: A facility policy titled "EMTALA MERICAL SCREENING" dated 9/19/23, stated "Every patient presenting to Syringa Hospital & Clinics ("SHC") property requesting medical examination or treatment will receive an appropriate medical screening examination within the capability of the hospital, including ancillary services routinely available, to determine whether an emergency medical condition exists."

The policy also stated "LOCATIONS AND CIRCUMSTANCES THAT REQUIRE MEDICAL SCREENING:

Medical Screenings are performed at...SCH Emergency Department for any patient who presents to the department requesting medical examination or treatment for any medical condition including a pregnant person with contractions, or if the patient is unable to speak, a condition that a prudent layperson would believe needs exam or treatment..." This policy was not followed. Examples include:

1. Patient #11 was a 38 year old male who presented to the ER with a chief complaint of "body aches, fever, HA, dizziness/lightheaded for 'couple days."" Patient #11's medical record included a note titled "Emergency Documentation" dated 1/14/25 at 6:46 PM. It included Provider A attempted to take medical history and Patient #11 was "not forthcoming." The note also included when Provider A asked the patient to speak up and Patient #11 responded with derogatory comments. Patient #11's medical record documented Provider A "informed the pt he was no longer welcome on Syringa Premises given his comportment."

Provider A further documented "I am concerned as I do believe that the patient is legitimately ill. He meets sepsis criteria and may meet severe sepsis, but I was unable to ascertain prior to the pt leaving. His comportment, belligerence and volatility make it impossible for him to be safely treated here at this time, though."

A Nursing note in Patient #11's medical record documented at 6:18 PM stated, "Pt holding head with rt [right] arm resting on side rail of gurney, mother on cell phone speaker. Difficult to understand pt's speech. MD asking pt to speak up, conversation between [MD] and pt escalated. MD instructing pt to discharge out of ER. Pt voice not leaving. MD states will notify police for trespassing, MD requesting RN to notify police"

An additional nursing note included in Patient #11's medical record, dated 1/14/25 at 6:30PM documented, "Pt discharged ambulatory to private vehicle. ER tech followed pt out of building."

ER RN A and ER Technician were interviewed on 3/11/25 beginning at 3:15 PM. Both ER RN A and the ER Technician confirmed they were working in the ER when Patient #11 presented to the hospital. ER RN A remembered the referenced patient. She reported that Patient #11 appeared sick and had a high fever. ER RN A also reported that Patient #11 "was in a wheelchair, disoriented and withdrawn" and it took some discussion, but she was able to get a blood draw. ER RN A further reported the patient was difficult to interview when the doctor was present.

ER RN A confirmed that the doctor told the Patient #11 he would have to leave the ER. The ER Technician confirmed that she watched Patient #11 leave the ER and confirmed that no information on where to receive additional medical services was provided.

Provider A was interviewed on 3/12/25 beginning at 3:30 PM. Provider A was asked if in his opinion the patient received an MSE and he stated, "we took his vitals." When asked if the patient received care elsewhere or if he knew the disposition of the patient Provider A stated, "he left, I don't know."



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2. Patient #24's medical record was reviewed. Patient #24 was a 73 year old female who had an ER visit on 6/24/24 at 10:46 AM and was discharged at 11:59 PM with chief complaint of severe abdominal pain and back pain. Patient #24's ED record documented ED triage at 11:01 AM. However, subsequent clinic note by PA at 11:05 AM stated "Pt was triaged in the WIC [walk in clinic] with severe upper abdominal pain ... Pt has a pulse of 40 bpm [beats per minute], was cold and clammy with nausea and lightheadness [sic] unable to sit still or lay down ... pt was immediately transferred to the ER in a wheelchair." Patient #24 was provided an MSE in the ED on 6/24/24 at 11:07 AM.

Registration Clerk A in the ED was interviewed on 3/11/25 beginning at 3:42 PM. She was asked what happens when someone comes to the ED and requests to be seen. She said she "generally encourages them to go to the ER." She stated registration will say, "we also have a walk-in clinic." Registration Clerk A did not remember Patient #24.

The Quality Director was interviewed on 3/11/25 at 3:52 PM and was asked about the process of when a patient presents to the ED asking to be seen. She said if they come to the ED and say, "I need to be seen" the patient is then asked, "do you want to be seen in the ER versus the clinic?" She was asked if the ED desk was for the ED only and she shared that the desk was for the ED and hospital services and that the WIC had a registration desk downstairs through a different entrance.

The Quality Director was interviewed 3/12/25 beginning at 10:30 AM and the medical record of Patient #24 was reviewed in her presence. The Quality Director confirmed that the record demonstrated the patient was triaged in the ED and sent to the clinic before receiving an MSE. The Quality Director confirmed that this did not follow the policy for ED visits.

Registration Clerk B in the ED was interviewed on 3/12/25 beginning at 9:39 AM. She was asked how the registration process works if a patient presented saying they felt unwell and wanted to be seen. She stated she asks, "What's going on?" and offers them the option of being seen in the ED or the WIC. She said she refuses to answer a patient if they inquire about cost or time to wait to be seen and has the patient decide on where they would like to be seen.

It was unclear what procedure was followed when a patient presents to the ED desk and requested to be seen.

The hospital failed to ensure all patients received an MSE.

Based on policy review, record review, ER log review, and staff interview, it was determined hospital staff failed to ensure the patient received stabilizing treatment prior to discharge or transfer for 1 of 25 patients (Patients #11) whose records were reviewed. This put all patients presenting to the ER for emergency medical care at risk for a negative outcome. Findings include:

The facility had a EMTALA Medical Screening policy dated 9/19/23, that stated "Persons with emergency medical conditions will be treated and their condition stabilized without regard to ability to pay for services." The policy defines stabilize as "providing medical treatment of the patient's condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during a transfer of the individual from a facility." This policy was not followed. An example includes:

Patient #11 was a 38 year old male who presented to the ER with a chief complaint of "body aches, fever, HA, dizziness/lightheaded for 'couple days.'" Patient #11's medical record included a note titled "Emergency Documentation" dated 1/14/25 at 6:46 PM. It included Provider A attempted to take medical history and Patient #11 was "not forthcoming." The note included that Patient #11 made "derogatory comments" to Provider A. The note also included when Provider A asked the patient to speak up, Patient #11 made further derogatory comments, and the note included Provider A "informed the pt he was no longer welcome on Syringa Premises given his comportment."

Provider A further documented, "I am concerned as I do believe that the patient is legitimately ill. He meets sepsis criteria and may meet severe sepsis, but I was unable to ascertain prior to the pt leaving. His comportment, belligerence and volatility make it impossible for him to be safely treated here at this time, though."

A nursing note in Patient #11's medical record documented at 6:18 PM, "Pt holding head with rt arm resting on side rail of gurney, mother on cell phone speaker. Difficult to understand pt's speech. MD asking pt to speak up, conversation between [MD] and pt escalated. MD instructing pt to discharge out of ER. Pt voiced not leaving. MD states will notify police for trespassing, MD requesting RN to notify police"

An additional nursing note included in Patient #11's medical record dated 1/14/25 at 6:30PM documented, "Pt discharged ambulatory to private vehicle. ER tech followed pt out of building."

Patient #11's ER patient summary dated 1/14/25 at 7:16 PM, after the patient left the hospital, was included in Patient #11's medical record and documented no follow up instructions or education. Additionally, there was no patient signature on the signature page indicating that the patient received the discharge information.

ER RN A and ER Technician working with Patient #11 were interviewed on 3/11/25 beginning at 3:15 PM. The nurse remembered Patient #11. The nurse reported Patient #11 appeared sick and had a high fever. ER RN A also reported that Patient #11 "was in a wheelchair, disoriented and withdrawn" and it took some discussion, but she was able to get a blood draw. ER RN A further reported the patient was difficult to interview when the doctor entered. ER RN A confirmed the doctor told the patient he would have to leave the ER. The ER Technician confirmed that she watched the patient leave the ER and confirmed that information on other providers or where to receive medical services was not provided.

Provider A was interviewed on 3/12/25 at 3:30 PM. Provider A was asked if in his opinion the patient received an MSE and he stated, "we took his vitals." Provider A confirmed that Patient #11 did not receive treatment for his symptoms. When asked if the patient received care elsewhere or if he knew the disposition of the patient Provider A stated, "he left, I don't know."

The facility failed to ensure all patients presenting to the ER were provided with stabilizing treatment.

Based on policy review, record review, incident log review, and staff interview, it was determined hospital staff failed to provide an MSE and treatment in a timely manner for 2 of 25 patient (Patients #24 & #25) whose records were reviewed. This put all patients presenting to the ER for emergency medical care at risk for a negative outcome. Findings include:

A facility policy titled, "EMTALA Medical Screening" dated 9/19/23 stated, "Every patient presenting to Syringa Hospital & Clinics ("SHC") property requesting medical examination or treatment will receive an appropriate medical screening examination within the capability of the hospital, including ancillary services routinely available, to determine whether an emergency medical condition exists." This policy was not followed. Examples include:

1. Patient #24 was a 73-year-old female who presented to the ER on 6/24/24 at 10:46 AM with severe abdominal and back pain. She was discharged at 11:59 PM the same day. The patient's ER record indicated triage at 11:01 AM. However, a subsequent clinic visit note from the Rural Health Clinic, documented by a PA at 11:05 AM (4 minutes after ER triage), stated, "Patient was triaged in the WIC [walk in clinic] with severe upper abdominal pain. The patient had a pulse of 40 bpm, was cold and clammy, with nausea and lightheadedness, unable to sit still or lie down. The patient was immediately transferred to the ER in a wheelchair." This showed that after triage in the ER, Patient #24 was registered and seen at an attached Rural Health Clinic, examined by a PA, and then transferred back to the ER.

The incident report was reviewed, included an incident for Patient #24 reported on 6/28/24. The incident report documented "Pt came to ER, was down to clinic without medical screening. Pt ended being sent right back up for suspected triple A [abdominal aortic aneurysm]. At the time, ER was expecting a code and had two other pts. One receiving blood and going to obs. No documentation of provider being aware and doing a medical screening."

The Quality Director was interviewed 3/12/25 beginning at 10:30 AM and the medical record of Patient #24 was reviewed. The Quality Director confirmed the record demonstrated Patient #24 was triaged in the ED and sent to the clinic before receiving an MSE. The Quality Director confirmed that this did not follow the policy for ED visits.

Registration Clerk A was interviewed on 3/11/25 beginning at 3:48 PM. Registration Clerk A was asked if a patient could be sent down to the Walk In Clinic when presenting to the ER. Registration Clerk A reported it "could happen, but not often." Registration Clerk A did not specifically remember Patient #24.

2. Patient #25 was a 56-year-old female who presented to the ER on 7/23/24 at 4:01 PM and was transferred to another facility via Life Flight at 3:35 AM on 7/24/24.

The incident report was reviewed, included an incident for Patient #25 reported on 7/23/24. Patient #25 incident report documented, "When the patient presented to me at I quick registered her and called the ER at 4:03 ... The ER had 2 beds full and took back a patient who needed a catheter check before laying on my patient ... At 4:31 I called the ER nurse phone to let them know the patient was getting worse. No one answer the phone. I then called EXT 127 and spoke with ER RN A. She said they needed to clean a bed and then would get her back to the ER. Floor nurse came up to the counter to give us an update on another patient and I mentioned to that I had a patient who I was concerned about that the ER had not taken back or lad eye on yet. She said she would try to find the clinical nurse manager and see what could do. At approximately 4:55 PM my gut was telling to get someone to at least lay eye on her. I walked down to the ER and asked ER RN A if she could please lay eyes on my patient. ER RN A came up to the waiting room with me and evaluated the patient."

Patient #25's medical record included a nursing note at 4:55 PM (54 minutes after the initial presentation), stating, "Patient in waiting area. Alert to self and DOB [date of birth], unable to recall the year. Significant others and friends with patient report that she is deteriorating. Patient recalls having a wound on the foot for 2 days. Awaiting ED bed."

At 5:01 PM (one hour after the initial presentation), a nursing note stated "[Provider B] at bedside, received orders." The medical record further noted that labs were drawn at 5:10 PM, followed by vitals and an X-ray at 5:30 PM on 7/23/24. A nursing note at 5:01 PM indicated, "Patient was seen in the Walk-In Clinic and advised to come to the ED. The patient has a foot wound and altered mental status."

Patient #25's Emergency Documentation signed by Provider B on 7/23/24 at 8:07 PM documented "Upon arrival patient noted to be acutely confused and somewhat delirious."

The Quality Director was interviewed 3/12/25 beginning at 10:30 AM and the medical record of Patient #25 was reviewed. The Quality Director confirmed the record demonstrated the patient presented to registration at 4:01 PM was triaged into the ED at 5:01 PM. The Quality Director confirmed the record demonstrated the MSE was documented at 8:07 PM. When asked when the MSE was completed the Quality Director stated, "There is no way to tell when the MSE was completed." The Quality Director confirmed this did not follow the policy for ER visits.

ER RN B was interviewed 3/11/25 beginning at 3:15 pm. When asked if there would be a time a patient would be waiting in the waiting area for ER triage for an hour, ER RN B responded, "I would lay eyes on them especially if registration had called back." ER RN B further stated, "I would document laying eyes on the patient."

It was unclear through documentation why Patient #25 had to wait for an hour before being seen by the ER nurse or ER provider and why four hours elapsed between registration and the documented MSE.

The facility failed to ensure all patients presenting to the ER were provided with an appropriate triage assessment and MSE in a timely manner.

Based on review of hospital policy, patient record, and staff interview, the facility failed to obtain complete and documented consent for transfer for 5 of 6 patients (Patients #1, #2, #3, #4, #5) whose records were reviewed and who had been transferred. This failed practice placed patients at risk of unsafe or potentially inappropriate transfer. Findings include:

A hospital policy titled "EMTALA MEDICAL SCREENING," dated 9/19/23 was reviewed. The policy stated, "EMTALA transfers must meet certain conditions:" listed were several bullet points one of which was "SHC must complete a written transfer certification form that documents the reason for requested transfer, that the transfer benefits outweigh the risks, and that the patient is aware of risks and benefits of transfer." This policy was not followed. Examples include the following incomplete transfer certification forms:

1. Patient #1's medical record was reviewed. The medical record showed Patient #1 was a 57 year old male who presented to the hospital ER on 10/28/24 with "acute aphasia, paraplegia x 3 limbs."

Review of patient record showed the "EMTALA/TRANSFER CONSENT FORM" was not complete as it was not indicated on the form if the patient consented to the transfer or if the patient requested the transfer.

2. Patient #2 was a 64 year old male who presented to the ER on 11/19/2024 with right lower abdominal pain that radiates to the right flank and hip. Patient #2's medical record was reviewed.

The medical record contained a document titled, "EMTALA/TRANSFER CONSENT FORM." This form was not complete as it did not indicate if the patient had an emergent condition or if the patient had been stabilized.

3. Patient #3 was a 73 year old male presented to the ER on 12/06/24 with "balance issues. Patient also reporting some right upper quadrant pain." Patient #3's medical record was reviewed.

The medical record contained a document titled, "EMTALA/TRANSFER CONSENT FORM". This form was not complete as it did not indicate if the patient had an emergent condition or if the patient had been stabilized or if the patient consented to the transfer or if the patient had requested the transfer.

4. Patient #4 was a 70 year old male who presented to the ER on 1/28/25 with complaints of wanting his catheter removed and on examination frostbite was discovered. Patient #4's medical record was reviewed.

The medical record contained a form titled, "EMTALA/TRANSFER CONSENT FORM". This form was not complete as it did not indicate if the patient requested the transfer or consented to the transfer.

5. Patient #5 was a 84 year old male who presented to the ER on 3/12/25 with complaints of chest pain for 3 days that radiated to the left arm with numbness and nausea. Patient #23's medical record was reviewed.

The medical record contained a form titled, "EMTALA/TRANSFER CONSENT FORM." This form was not complete as it did not indicate if the patient had an emergent condition or if the patient had been stabilized.
Additionally, the form did not indicate if the patient consented to the transfer or if the patient requested the transfer.

The Director of Quality was interviewed on 3/12/25 at 10:37 AM and the above patient charts were reviewed in her presence. She was asked if she would expect the transfer forms to be filled out completely and she stated that she would expect forms to be complete. She agreed that the records did not have complete transfer forms.

The hospital failed to ensure complete and accurate transfer documentation was provided to the receiving facility. Failure to include essential documentation can lead to delays in treatment, medication errors and inadequate continuity of care, compromising patient safety and well-being.



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