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Based on hospital policy review, review of the hospital's complaint log, patient and staff interviews, the Hospital's administrative staff failed to ensure emergency department (ED) staff:

1) maintained a complete ED log per hospital policy for 1 of 24 patients reviewed (Patient #21) who presented to the ED seeking medical care. Failure to maintain a complete ED log resulted in the hospital's inability to track the care provided to each individual who comes to the hospital seeking care for a potential emergency medical condition (EMC).

2) provided the appropriate medical screening examination (MSE) per hospital policy for 1 of 24 sampled patients (Patient #21) within their capabilities for patients that presented to the ED seeking medical care from 6/1/23 to 12/3/23. Failure to provide an appropriate MSE places patients at risk for an undiagnosed emergency medical condition resulting in a deterioration in health and at a potential risk for death.

Findings include:

1. Review of policy "Emergency Medical Treatment and Labor Act (EMTALA)", dated 12/2022, revealed in part "If an individual presents to the dedicated emergency department (DED) and makes a request for medication, a qualified medical professional (QMP) must perform an MSE in compliance with this Policy to determine if an emergency medical condition (EMC) exists. If so, the DED must comply with this Policy for treatment and/or Stabilization of an EMC...The DED shall register such individual's presentation to the DED in the ED Log... The individual's medical record shall include documentation of the medication requested and, if no EMC exists following the QMP's MSE, the QMP shall document the individual's visit to the DED as a non-emergency...All individuals presenting to a DED, and for whom examination or treatment is requested, shall be registered and a medical record shall be created..."

2. On 12/6/23 the hospital provided a copy of their complaint log. The complaint log included the following complaint information related to Patient #21:

a. On 10/30/23 at approximately 3:00 PM, Patient #21 presented to the registration desk and asked for a Lovenox (injectable medication used to thin the blood) injection and Patient #21 reported the hospital staff denied the patient care.

b. On 10/30/23 at approximately 3:00 PM, Patient Registration Associate C had asked Patient #21 for Patient #21's name and date of birth and told Patient #21 that Patient #21 did not have an appointment. Patient Registration Associate C had offered to register Patient #21 for the ED, but according to the complaint event report, Patient #21 denied the need for the ED. Patient Registration Associate C did report that a ED CNA/tech F did come out and speak to Patient #21.

3. During an interview on 12/6/23 at 10:00 AM, Patient #21 reported a prior history of antiphospholipid syndrome (a disease that causes the blood to clot). Patient #21 reported a low international normalized ratio (INR) (finger prick blood test that monitored the blood's ability to clot) on Patient #21's home machine on 10/30/23 at approximately 11:30 AM. Due to Patient #21's INR being low (indicated an increased risk for developing a blood clot), Patient #21 reported at home this would indicate the need to self-administer Lovenox (a medication used to help decrease the risk for blood clot formation). Patient #21 had forgotten the Lovenox at home (in a neighboring state). Patient #21 called the patient's primary provider and asked the provider to call the Lovenox prescription into a local pharmacy. Later in the day, Patient # 21 had not heard from the provider so Patient #21 decided to seek help at the local hospital's ED. Patient #21 reported going to the ED on 10/30/23 at approximately 3:00 PM. Upon entering the ED, Patient #21 spoke with hospital registration staff. According to Patient #2, the hospital registration staff informed the patient that the patient would have to make an appointment. Patient #21 attempted to explain to the hospital registration staff, that due to a blood clotting disorder, Patient #21 needed a Lovenox injection. The hospital registration staff again informed the patient of the need to make an appointment. Patient #21 left the ED without being seen. Patient #21 reported that as soon as they got in Patient #21's friend's vehicle to leave, Patient #21's provider called back and sent a prescription for 3 pre-filled syringes of Lovenox to a local pharmacy. Patient #21 reported that they did call and complain to the hospital about being denied treatment.

4. Review of the hospital's ED log for 10/30/23 revealed a lack of an entry in the log for Patient #21. The hospital did not have evidence of documentation of a medical record for Patient #21.

5. During an interview on 12/12/23 at 9:00 AM, Patient Registration Associate C reported the only thing they recalled about Patient #21 was that one of the ED nurses came out and talked with the patient, but Patient Registration Associate C could not remember which nurse spoke with the patient. Patient Registration Associate C could not recall if she offered for Patient #21 to be seen in the ED. Patient Registration Associate C denied ever turning away a patient seeking ED care.

6. During an interview on 12/7/23 at 5:21 PM, ED CNA/Tech F did not recall speaking to Patient #21. ED CNA/Tech F explained that if a hospital registration staff requested a staff person come out to speak with a patient, an ED registered nurse (RN) would have gone out to speak with the patient.

8. Interviews with ED RN staff scheduled on 10/30/23 revealed none of the RNs had spoken with Patient #21.

See A 2406 for further detailed information.

Based on review of the hospital's complaint log, patient and staff interviews, the Acute Care Hospital's administrative staff failed to ensure hospital emergency department (ED) staff maintained a complete ED log for 1 of 24 patients reviewed (Patient #21) who presented to the Emergency Department (ED) seeking medical care. Failure to maintain a complete log may result in the hospital's inability to track the care provided to each individual who comes to the hospital seeking care for a potential emergency medical condition (EMC).

Findings include:

1. On 12/6/23 the hospital provided a copy of their complaint log. The complaint log included the following complaint information related to Patient #21:

a. On 10/30/23 at approximately 3:00 PM, Patient #21 presented to the registration desk and asked for a Lovenox (injectable medication used to thin the blood) injection and Patient #21 reported the hospital staff denied the patient care.

b. On 10/30/23 at approximately 3:00 PM, the Patient Registration Associate C had asked Patient #21 for Patient #21's name and date of birth and told Patient #21 that Patient #21 did not have an appointment. The Patient Registration Associate C had offered Patient #21 to be registered for the ED but according to the complaint event report, Patient #21 denied the need for the ED. Patient Registration Associate C did report that a ED CNA/tech F did come out and speak to Patient #21.

2. During an interview on 12/6/23 at 10:00 AM, Patient #21 reported a prior history of antiphospholipid syndrome (a disease that causes the blood to clot). Patient #21 reported a low international normalized ratio (INR) (finger prick blood test to monitor the blood's ability to clot) on Patient #21's home machine on 10/30/23 at approximately 11:30 AM. Due to Patient #21's INR being low (indicated an increased risk for developing a blood clot), Patient #21 reported at home this would indicate the need to self-administer Lovenox (a medication used to help decrease the risk for blood clot formation). Patient #21 had forgotten the Lovenox at home (in a neighboring state). Patient #21 called the patient's primary provider and asked the provider to call the Lovenox prescription into a local pharmacy. Later in the day, Patient # 21 had not heard from the provider so Patient #21 decided to seek help at the local hospital's ED. Patient #21 reported going to the ED on 10/30/23 at approximately 3:00 PM. Upon entering the ED, Patient #21 spoke with hospital registration staff. According to Patient #2, the hospital registration staff informed the patient that the patient would have to make an appointment. Patient #21 attempted to explain to the hospital registration staff, that due to a blood clotting disorder, Patient #21 needed a Lovenox injection. The hospital registration staff again informed the patient of the need to make an appointment. Patient #21 left the ED without being seen. Patient #21 reported that as soon as they got in Patient #21's friend's vehicle to leave, Patient #21's provider called back and sent a prescription for 3 pre-filled syringes of Lovenox to a local pharmacy. Patient #21 reported that they did call and complain to the hospital about being denied treatment.

3. Review of the hospital's ED log for 10/30/23 revealed a lack of an entry in the log for Patient #21.

4. During an interview on 12/12/23 at 9:00 AM, Patient Registration Associate C reported the registration staff did not keep a log of the ED patients.

5. During an interview 12/27/23 at 12:37 PM, the ED Service Leader explained when registration staff checked a patient into the ED, the patient information populated in the hospitals electronic tracking software and the ED log. The ED Service Leader confirmed that hospital registration staff did not check Patient #21 into the ED; and therefore, Patient #21 did not show up on the ED log.

Based on review of the hospital's complaint log, patient and staff interviews, the Acute Care Hospital's administrative staff failed to ensure the Emergency Department (ED) staff provided, within the hospital's capabilities, an appropriate medical screening examination (MSE) to 1 of 24 emergency patients reviewed (Patient #21). Failure to provide an appropriate MSE to all patients presenting to the ED seeking medical care places them at risk for an undetected emergency medical condition.

Findings include:

1. On 12/6/23 the hospital provided a copy of their complaint log. The complaint log included the following complaint information related to Patient #21:

a. On 10/30/23 at approximately 3:00 PM, Patient #21 presented to the registration desk and asked for a Lovenox (injectable medication used to thin the blood) injection and Patient #21 reported the hospital staff denied the patient care.

b. On 10/30/23 at approximately 3:00 PM, Patient Registration Associate C had asked Patient #21 for Patient #21's name and date of birth and told Patient #21 that Patient #21 did not have an appointment. Patient Registration Associate C had offered to register Patient #21 for the ED, but according to the complaint event report, Patient #21 denied the need for the ED. Patient Registration Associate C did report that a ED CNA/tech F did come out and speak to Patient #21.

2. During an interview on 12/6/23 at 10:00 AM, Patient #21 reported a prior history of antiphospholipid syndrome (a disease that causes the blood to clot). Patient #21 reported a low international normalized ratio (INR) (finger prick blood test that monitored the blood's ability to clot) on Patient #21's home machine on 10/30/23 at approximately 11:30 AM. Due to Patient #21's INR being low (indicated an increased risk for developing a blood clot), Patient #21 reported at home this would indicate the need to self-administer Lovenox (a medication used to help decrease the risk for blood clot formation). Patient #21 had forgotten the Lovenox at home (in a neighboring state). Patient #21 called the patient's primary provider and asked the provider to call the Lovenox prescription into a local pharmacy. Later in the day, Patient # 21 had not heard from the provider so Patient #21 decided to seek help at the local hospital's ED. Patient #21 reported going to the ED on 10/30/23 at approximately 3:00 PM. Upon entering the ED, Patient #21 spoke with hospital registration staff. According to Patient #2, the hospital registration staff informed the patient that the patient would have to make an appointment. Patient #21 attempted to explain to the hospital registration staff, that due to a blood clotting disorder, Patient #21 needed a Lovenox injection. The hospital registration staff again informed the patient of the need to make an appointment. Patient #21 left the ED without being seen. Patient #21 reported that as soon as they got in Patient #21's friend's vehicle to leave, Patient #21's provider called back and sent a prescription for 3 pre-filled syringes of Lovenox to a local pharmacy. Patient #21 reported that they did call and complain to the hospital about being denied treatment.

3. Review of the hospital's ED log for 10/30/23 revealed a lack of an entry in the log for Patient #21. The hospital did not have evidence of documentation of a medical record for Patient #21.

4. During an interview on 12/12/23 at 9:00 AM, Patient Registration Associate C reported working as a hospital registration staff for the last 11 years. Patient Registration Associate C reported receiving training on Emergency Medical Treatment and Labor Act (EMTALA) one time in person during orientation. Patient Registration Associate C reported the only thing they recalled about Patient #21 was that one of the ED nurses came out and talked with the patient, but Patient Registration Associate C could not remember which nurse spoke with the patient and whether or not Patient Registration Associate C had asked for someone to come out and speak with the patient. Patient Registration Associate C could not recall if she offered for Patient #21 to be seen in the ED. Patient Registration Associate C reported that they remembered that the security officer was doing his normal rounds and ended up walking through while Patient #21 was still present. The security officer did not have any interaction with the patient. Patient Registration Associate C reported that she never spoke to the security officer. Patient Registration Associate C denied ever turning away a patient seeking ED care.

5. During an interview on 12/7/23 at 5:50 PM, Security Officer H reported he was sitting in the registration area when he observed Patient #21 get louder and louder when talking with Patient Registration Associate C. Security Officer H reported Patient #21 walked out of the registration area and hospital. Security Officer H, asked Patient Registration Associate C about their interaction with Patient #21. Security Officer H reported Patient Registration Associate C informed him that Patient #21 needed a "shot" and the patient's physician had not sent orders for the shot. Security Officer H recalled walking outside with the intention of trying to talk Patient #21 into being seen in the ED, but he did not find Patient #21 and had no interaction with Patient #21.

6. During an interview on 12/7/23 at 5:21 PM, ED CNA/Tech F did not recall speaking to Patient #21. ED CNA/Tech F explained that if a hospital registration staff requested a staff person come out to speak with a patient, an ED registered nurse (RN) would have gone out to speak with the patient.

7. During an interview on 12/12/23 at 11:00 AM, ED RN I (worked the ED on 10/30/23 during the time frame the patient would have been present) did not recall speaking to Patient #21.

8. During an interview on 12/28/23 at 1:30 PM, ED RN K (worked the ED on 10/30/23 during the time frame the patient would have been present) did not recall speaking to Patient #21.

9. During an interview on 12/5/23 at 8:30 AM, ED Service Leader reported hospital staff completed education on EMTALA training at orientation and completed annual online competency modules. Hospital management staff presented EMTALA reminders weekly on Fridays and at monthly unit meetings.

10. During an interview on 12/7/23 9:00 AM, Director of Registration reported all registration staff received EMTALA training in person at orientation, email reminders about EMTALA law were sent out periodically and all registration computers have a bright pink laminated EMTALA law sign on them.