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Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases as evidenced by:

Tag A-2405: Logs

The ED staff failed to maintain documentation that Patient #1 was brought in by Emergency Medical Services (EMS) for possible ingestion of a poisonous substance. The patient was not treated and EMS left with the patient.

Tag A-2406 Appropriate Medical Screening Examination:

The hospital failed to ensure Patient #1 received a medical screening examination after being brought in by EMS for possible ingestion of a poisonous substance.

The cumulative effect of these systematic deficient practices resulted in the hospital's inability to ensure the provision of compliance with 489.24 EMTALA requirements related to maintaining a central ED Log and Appropriate Medical Screening Examination.

Based on review of the Emergency Department's (ED) central log, the Emergency Medical Services (EMS) Patient Care Record and Dispatch Record and staff interviews, it was determined the ED staff failed to maintain documentation that Patient #1 was brought in by Emergency Medical Services (EMS) for possible ingestion of a poisonous substance. The patient was not treated and EMS left with the patient.

Findings include:

The hospital's policy and procedure titled "EMTALA Guidelines for Emergency Department Services & Patient Transfers" (Reference #ED.005) included: "The admitting representative will register all patients presenting to the hospital for emergency care providing that this process does not create a delay in treatment or emergency medical care." The policy and procedure did not specifically address the requirement that a central log be maintained that includes the patient name, whether the patient refused treatment, was refused treatment, or whether the patient was transferred, admitted and treated, stabilized and transferred, or discharged.

Documentation in the EMS Patient Care Record dated 03/04/2020, revealed the EMS staff arrived at the hospital's ED at 6:39 p.m. The Emergency Medical Technician (EMT) documented the hospital refused to see or treat the patient, and the patient was transported to another hospital. Documentation in the EMS Dispatch Report confirmed the EMS unit arrived at the hospital at "1839" (6:39 p.m.) and left at "1907" (7:07 p.m.).

There was no documentation in the hospital's ED central log that the patient was brought in, not provided with treatment and taken to another hospital by EMS.

Staff #1 acknowledged Patient #1 was brought in to the ED on the evening of 03/04/2020, and that there was no record of the patient being there.

Based on reviews of clinical records, policies and procedures, and staff interviews, it was determined the hospital failed to ensure Patient #1 received a medical screening examination after being brought in by Emergency Medical Services for possible ingestion of a poisonous substance. This deficient practice poses the risk of harm to patients that may have a medically emergent condition leaving without treatment.

Findings include:

The hospital's policy and procedure titled "EMTALA Guidelines for Emergency Department Services & Patient Transfers" (Reference #ED.005) included: "DEFINITIONS...The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not...POLICY...All patients presenting to Green Valley Hospital's Emergency Department seeking care...must be accepted and evaluated regardless of the patient's race, religion, national origin, age, sex, or ability to pay...The patient's medical condition shall be triaged promptly by a registered nurse...The Emergency Department physician will provide an appropriate medical screening examination (MSE) on all patients seeking treatment to determine if an emergency medical condition exists. All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis."

The policy and procedure titled "Triage and Emergency Severity Index (ESI)" (Reference #ED0.11) included: "The registered nurse will evaluate and categorize each patient upon arrival to the Emergency Department into either resuscitative, emergency, urgent, semi-urgent or routine categories...All patient information is documented in the patient's medical record...All patients will be triaged and assigned an ESI level."

Documentation in the EMS Patient Care Record dated 03/04/2020 revealed the ambulance unit responded to a call regarding the "overdose/poisoning" of a patient under the age of 18 years. The patient was described to be alert but responding in "inappropriate words." The patient was loaded into the unit for transport to a hospital in Tucson. The EMT's documentation included: "En Route, patient began to be combative and was not following commands and managed to get off gurney and stand on bed with force. EMT (name) proceeded to help get him back on the gurney but was still being combative even after reassuring him and trying to make him comfortable and help with the needs of patient. Later, we had to pull over because patient wanted to jump out the ambulance. Paramedic (name) gave patient 5 mg of Midazolam via IM to left shoulder. Pt proceeded to be combative, so we transported to nearest hospital in Green Valley at 1839 (6:39 p.m.) Green Valley hospital refused to take the patient in because 'they do not have a peds (pediatric) unit and no room for the patient and requested to speak with law enforcement.' Pt was then transported to (name of Hospital #2). Pt remained combative throughout transport. Pt vitals were unable to be assessed as we tried to get vitals but patient refused...." The ambulance unit left Santa Cruz Valley Regional Hospital at 7:07 p.m. and arrived at Hospital #2 at 7:43 p.m.

Documentation in the patient's clinical record from Hospital #2 included: "(Patient #1) with a history of anxiety and depression presents by EMS after suspected ingestion of [jimson weed] which occurred at around 5 p.m. On arrival, the patient is hemodynamically stable, but he is altered, unable to participate in meaningful history taking review of systems. He appears to be hallucinating...He appears to be responding internal (sic) stimuli and is not redirectable; he was given 5 mg Haldol IM to adequate effect...Pt ultimately admitted to PICU for further management...Concern by guardian for possible SI (suicidal ideation) with ingestion, although patient not reporting this explicitly to provider."

Staff #4 stated during an interview on 03/25/2020 that the EMS staff presented to the ED unannounced with Patient #1. Staff #4 said he approached the EMS staff and asked why they were there. The EMS staff provided the patient's history, and Staff #4 asked them what it was they (EMS staff) wanted them to do, as the patient was laying quietly on the gurney. Staff #4 acknowledged telling the EMS staff that Santa Cruz Valley did not have a pediatric unit. Staff #4 stated the EMS staff left with the patient without notifying anyone, but that services were not denied to the patient. He acknowledged there was no documentation that the patient was in the ED for 25 minutes.