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Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The hospital failed to ensure appropriate disposition of patients' visits on the ED log. See A-2405.

2. The hospital failed to provide a medical screening examination, to determine if Pt. #1 was experiencing a psychiatric medical emergency. See A-2406 A.

2. The hospital failed to ensure that the "Bylaws of the Medical Staff "included the person qualified to perform a medical screening examination. See A-2406 B.

3. The hospital failed to complete a physician certification regarding the benefits and risks of transfer. See A-2409.

Based on document review and interview, it was determined that for 3 of 22 patients' (Pt. #1, Pt. #21, and Pt. #22) clinical records reviewed for patients seeking care in the ED (emergency department), the hospital failed to ensure appropriate disposition of patients' visits was included on the ED log.

Findings include:

1. On 7/03/2024, the hospital's policy titled, "EMTALA Compliance" (1/2022) was reviewed and included, "... II. It is the policy of (Name of the Hospital) to provide medical evaluation and stabilizing treatment to all persons presenting to the Emergency Department... V. Procedure... K. Record Keeping and documentation. 1. Maintain a log of all patients who present to the Emergency Department..."

2. On 7/2/2024, the clinical record for Pt. #1 was reviewed. On 3/20/2024 at 11:24 AM, Pt. #1 was in the hospital's ED for psychiatric evaluation. Pt. #1 was checked out at 11:27 AM. The incident report for Pt. #1 indicated that on 3/20/2024, Pt. #1 was refused treatment in the ED. However, the ED log indicated that Pt. #1 was "Incorrectly Registered."

3. On 7/3/2024, the clinical record for Pt. #21 was reviewed. On 3/20/2024 at 7:04 PM, Pt. #21 was in the hospital's ED due to head hurting. Pt. #21 was checked out at 7:25 PM. The ED log indicated that Pt. #21 was "Incorrectly Registered."

4. On 7/3/2024, the clinical record for Pt. #22 was reviewed. On 6/18/2024 at 2:51 PM, Pt. #22 was in the hospital's ED due to left leg pain. Pt. #22 was checked out at 3:47 PM. The ED log indicated that Pt, #22 was "Incorrectly Registered."

5. On 7/3/2024 at approximately 1:30 PM, interviews were conducted with E #6 (Director of Inpatient Care Services) and E #8 (Vice President of Patient Care and Safety). E #6 and E #8 could not explain why Pt. #21 and Pt. #22 were incorrectly registered. E #6 and E #8 stated that the hospital does not review the ED log to ensure the disposition has been documented appropriately on the log. On 7/5/2024 at approximately 1:30 PM, E #8 stated that the hospital does not have a formalized process of identifying/defining the different dispositions used in the ED.

A. Based on document review and interview, it was determined that for 1 of 1 patient's (Pt. #1) clinical records reviewed with psychiatric complaints seeking care in the emergency department (ED), the hospital failed to provide a medical screening examination (MSE), to determine if Pt. #1 was experiencing a psychiatric medical emergency for two separate presentation to the ED on the same day. Subsequently, Pt. #1 returned to the ED by ambulance, police, and CFD (Chicago Fire Department) with petition for psychiatric evaluation.

Findings include:

1. On 7/02/2024, the hospital's policy titled, 'EMTALA (Emergency Medical Treatment and Active Labor Act) Compliance' (01/2022) was reviewed and included, " ...Policy: ...it is the policy of (the hospital) to provide medical evaluation and stabilizing treatment to all persons presenting to the Emergency Department ...V. Procedure: ...A. All persons who request examination or treatment in the Emergency Department shall receive an appropriate and prompt medical screening by an Emergency Physician or Emergency Department Mid-Level Provider to determine whether the person has an emergency medical condition ..."

2. The "ED (Emergency Department) Activity Log" for 3/20/2024 was reviewed and indicated that Pt. #1 presented to the ED at 11:24 AM. The log indicated that Pt. #1's ED encounter ended at 11:27 AM.(a duration of three minutes). The disposition for the encounter was noted as "incorrectly registered" (not treated by the emergency department).

3. On 7/02/2024, Pt. #1's clinical record for the ED visit on 3/20/24 at 11:24 AM was reviewed. Pt.#1 chief complaint was psychiatric evaluation. The clinical record included:

- On 3/20/2024 at 11:34 AM, the Charge Registered Nurse's (E #1) 'Clinical Discharge Summary' indicated that Pt. #1 checked into the hospital at 11:24 AM for a psychiatric evaluation and discharged at 11:27 AM. No triage assessment or medical screening exam was available for review.

4. On 7/02/2024, Pt. #1's clinical record for the ED visit on 3/20/2024 at 4:45 PM was reviewed. Pt. #1 presented to the ED by EMS (Emergency Medical Services) and CPD (Chicago Police Department) for a psychiatric evaluation. The clinical record included:

-On 3/20/2024 at 4:47 PM, the Physician's 'History and Physical' included, "...presenting to the ER (Emergency Room) ...for psychiatric evaluation ...petition filled out by CPD ...review of systems: ...unable to obtain due to: uncooperative patient ...workup: ...will obtain psychiatric screening labs. Anticipate psychiatric admission versus transfer ...awaiting psychiatric evaluation, transfer at this time ...". A psychiatric evaluation was not available for review.

-On 3/22/2024 at 10:04 AM, the Physician's 'History and Physical' included, "...summary: (Pt. #1) presents ER with agitated combative behavior warranting inpatient psychiatric care ...(Addendum): discussed with (Psychiatrist /MD #5), states hospital cannot accomodate (Pt. #1's) complex medical and psychiatric needs ...needs higher level of care, agrees with transfer, case accepted at (outside hospital) ...". A psychiatric evaluation was not available for review.

5. On 7/02/2024, the hospital's 'Safety Events' for Pt. #1, dated 3/22/2024, was reviewed and included, " ...No: (Safety Event number) 24-859 ...Comments: 3/22/2024 at 3:30 PM by (anonymous source) ... (Pt. #1) arrived for (psychiatric evaluation) at 11:20 AM, due to recent admission ED charge nurse (E #1) had (Pt. #1) escorted out by security without being evaluated by doctor. The safety event report indicated that the event was investigated, and findings included that (Pt. #1) was seen in the ED three times that day and 5 times over the week for the same concerns, discharged from (hospital) on 3/20/2024 and (Pt. #1) called EMS (emergency medical services) and brought back to (hospital) for "no just cause" and since (Pt. #1) was already seen and discharged, (Pt. #1) did not need another evaluation as Pt. #1 was just malingering (falsification or profound exaggeration of illness). The investigation report noted that (Pt. #1) was homeless, wanted placement, and was violent and aggressive to staff, EMS, and CFD. (Pt. #1) was petitioned by CFD, admitted to psychiatry unit. Pt. #1 was discharged after 48 hours. No other follow-up or documentation of event was available for review.

6. On 7/03/2024 at approximately 11:28 AM an interview with the Director of Quality (E #7) was conducted. E #7 stated (E #5/Previous Director of Emergency Services) performed the investigation for the event but is no longer a hospital employee. E #7 stated that E #5 did not provide any documentation of the investigation. E #7 stated that EMTALA was discussed at a manager meeting in April 2024, but no further investigation or interventions have been implemented since Pt. #1's event.

7. On 7/05/2024 at 8:55 AM an interview with the Chief Medical Officer (MD #1) was conducted. MD #1 stated that every person that presents to the ED is required to receive a medical screening evaluation.


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B. Based on document review and interview, it was determined that the hospital failed to ensure the "Bylaws of the Medical Staff "included the person qualified to perform a medical screening examination.

Findings include:

1. On 7/2/2024, the hospital's 'Bylaws of the Medical Staff' (adopted in June 2021) was reviewed. The Bylaws did not include who had been deemed qualified to perform medical screening exams in the Emergency Department (ED)

2. On 7/2/2024 at approximately 12:15 PM, an interview was conducted with MD #1 (Chief Medical Officer). MD #1 stated that the qualified person allowed to conduct medical screening examination is in the hospital's policy and not in the Bylaws.

3. On 7/3/2024 at approximately 1:30 PM, E #8 (Vice President of Patient Care and Safety) also confirmed that the qualified persons allowed to conduct medical screening examination is not in the Bylaws. E #8 stated that the Bylaws are approved by the hospital's governing body.

Based on document review and interview, it was determined that for 2 of 5 patients (Pt. #4 and Pt. #6) clinical records reviewed for transfers, the hospital failed to complete a physician certification regarding the risks and benefits of transfer.

Findings include:

1. The hospital's policy titled, "EMTALA Compliance" (1/2022) was reviewed and included, "... V. Procedure... A physician certifies in writing that... patient should be transferred because the medical benefits of the transfer outweigh the risk to the patient..."

2. On 7/2/2024, the clinical record for Pt. #4 was reviewed. On 7/1/1024, Pt. #4 was brought to the hospital's ED (emergency department) due to lightheadedness and palpitations. The clinical record indicated that Pt. #4 had atrial fibrillation (irregular rapid heart beat) with rapid ventricular response (irregular heart rhythm) and a test showing aortic dissection (a tear in a large blood vessel). The clinical record indicated that Pt. #4 required a higher level of care to stabilize Pt. #4's emergency medical condition. The clinical record lacked a physician certification regarding the risks and benefits of the transfer.

3. On 7/2/2024, the clinical record for Pt. #6 was reviewed. On 6/18/2024, Pt. #6 was brought to the ED due to gastrointestinal bleeding. The clinical record indicated that Pt. #6 required a higher level of care to stabilize Pt. #6's emergency medical condition. The clinical record lacked a physician certification regarding the risks and benefits of the transfer.

4. On 7/5/2024 at approximately 9:00 AM, findings were discussed with E #8 (Vice President of Patient Care and Safety) and MD #1 (Chief Medical Officer). E #8 confirmed that Pt. #4 and Pt. #6's clinical record did not include physician certification regarding the risks and benefits of transfer. MD #1 stated that the ED attending physician is responsible to make sure that the certification of the risks and benefits of transfer is completed.