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Based on review of policies and procedures, hospital documents, clinical records, 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.


Findings Include:

Hospital policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)", revealed: "...This policy applies to persons who come to an HonorHealth Dedicated Emergency Department (DED) seeking examination and treatment for what they believe to be an emergency medical condition or which a layperson might reasonably believe is an emergency medical condition...All HonorHealth staff must comply with EMTALA and related laws and requirements, including the following: A. Registration and Triage: HonorHealth will not delay providing a medical screening examination or necessary stabilizing treatment for any individual with an emergency medical condition by inquiring about an individual's ability to pay for care...All persons who present to an HonorHealth hospital campus with what they believe to be a medical emergency, or which a layperson would reasonably believe they are experiencing a medical emergency, must receive a medical screening examination...Qualified personnel (registered nurse, nurse practitioner, physician assistant, or physician) will conduct a triage examination to determine the order in which persons receive the medical screening examination...The triage nurse or other qualified personnel will periodically re-triage the person to determine whether he or she should have a higher medical screening priority...HonorHealth will provide a medical screening examination to all persons who present to an HonorHealth DED requesting emergency services...If the person refuses to sign a refusal of a medical examination and treatment form, HonorHealth personnel will document this fact on the unsigned form and include that form in the person's medical record...."

Hospital document titled, "Refusal of Screening Examination and Treatment", revealed: "...I, (the patient or parent/legal representative of the patient listed above) understand that the hospital has a duty to provide care and has offered to perform a medical screening examination and determine if an emergency medical condition exists. The risks associated with refusal have been explained to me by hospital personnel. These risks include, but are not limited to: ...Patient (or patient representative) Acknowledgement of Understanding: I understand that the hospital cannot provide treatment prior to performing a medical screening examination. I understand that by refusing the services offered I am doing so against the advice of the hospital staff. I understand that the availability of medical services, including examination and stabilizing treatment, as well as necessary transfer to another facility is not based on my ability to pay for these services. I have been given the opportunity to ask questions about the above information and my questions have been answered. I completely understand the consequences of my refusal...Reason for refusal of screening exam and treatment: ________...Reason form not signed: Patient refused to sign; Patient left without notice; patient called, but no answer 1st call time: _______, 2nd call time: ________, 3rd call time: _______.... "


Employee #4 confirmed on 05/09/2023 during a record review that two (2) of the twenty-one (21) patients left after triage and signed the Refusal of Medical Screen Exam and Treatment form. Employee #4 confirmed that two (2) of the twenty-one (21) patients Left After Triage and No Refusal of Medical Screen Exam and Treatment form was on file. Employee #4 confirmed that three (3) of the twenty-one (21) patients signed the Refusal of Medical Screen Exam and Treatment form and stated long wait has their reason.

Employee #6 confirmed on 05/09/2023 that a Medical Screening Examination had not been conducted on Patient #1 before Patient #1 left the ED.

Based on review of policies and procedures, hospital documents, clinical records, and staff interviews, it was determined the hospital failed to provide a Medical Screening Examination to Patient #1 who presented the ED on 02/23/2023 for complaints of jaundice.

Findings Include:

Patient #1 presented to the facilities dedicated Emergency Department (ED) on 02/23/2023 complaining of jaundice. Patient #1 was triaged upon arrived to the ED. After waiting for three (3) hours Patient #1 was reassessed and was informed to provid a urine sample. After waiting an additional half hour, Patient #1 decided to leave the hospital ED. Patient #1 signed the facilities refusal of medical screening exam and treatment form.

Hospital policy titled, "Against Medical Advice: Informed Refusal/Withdrawal of Treatment or Leaving the Hospital ", revealed: "...Patients with mental capacity to consent to care who express a desire to leave without treatment or to leave the hospital Against Medical Advice (AMA) prior to a planned release are provided an explanation with information related to the medical risks associated with their action, so that they make an informed decision...The patient/LAR (legally authorized representative) request to leave AMA, Refusal of Treatment/Transfer should be documented in the patient ' s medical record...Patients who leave AMA or Refuse Treatment are to be provided with a safe discharge, which includes as applicable, the following: discharge instructions, follow-up care instructions, education, prescriptions...The patient/LAR will be asked to sign the applicable AMA form ...If the patient/LAR refuses to sign the AMA form the following actions shall be taken: The patient/LAR refusal to sign the AMA form will be documented on the form by the attending physician/provider or nursing. Staff members who were present when the form was offered and refusal by patient/LAR to sign was made will sign as witnesses to the refusal. Circumstances of the refusal are charted in the patient's medical record by the attending physician/provider and nursing with a summary of the facts leading up to the refusal, what occurred at the time of refusal, and notification of the attending physician/provider...."

Hospital policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)", revealed: "...This policy applies to persons who come to an HonorHealth Dedicated Emergency Department (DED) seeking examination and treatment for what they believe to be an emergency medical condition or which a layperson might reasonably believe is an emergency medical condition...All HonorHealth staff must comply with EMTALA and related laws and requirements, including the following: A. Registration and Triage: HonorHealth will not delay providing a medical screening examination or necessary stabilizing treatment for any individual with an emergency medical condition by inquiring about an individual's ability to pay for care...All persons who present to an HonorHealth hospital campus with what they believe to be a medical emergency, or which a layperson would reasonably believe they are experiencing a medical emergency, must receive a medical screening examination...Qualified personnel (registered nurse, nurse practitioner, physician assistant, or physician) will conduct a triage examination to determine the order in which persons receive the medical screening examination ...The triage nurse or other qualified personnel will periodically re-triage the person to determine whether he or she should have a higher medical screening priority...HonorHealth will provide a medical screening examination to all persons who present to an HonorHealth DED requesting emergency services...If the person refuses to sign a refusal of a medical examination and treatment form, HonorHealth personnel will document this fact on the unsigned form and include that form in the person's medical record....."

Hospital policy titled, "Network Emergency Department Operating Policy", revealed: "...The Emergency Departments (ED) are located on the first floor of each HonorHealth campus, are DNV accredited and provide care 24 hours/day, 7 days/week ...Scottsdale Shea Medical Center is a 37-bed comprehensive care department hat functions as a Primary Stroke Center and a Prepared Advanced Pediatric Center, Chest Pain Receiving Center, and a base station-communication room ...The Emergency Department will: a. Deliver quality care to each individual presenting to the Emergency Department requesting treatment or in need of treatment, b. Provide triage, assessment and treatment ...Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity.

A request was made for an ED Assessment/Reassessment policy. The facility did not provide the requested policy.

A request was made for an ED Triage/Emergency Severity Index (ESI) policy. The facility did not provide the requested policy.

Hospital document titled, "Refusal of Screening Examination and Treatment", revealed: "...I, (the patient or parent/legal representative of the patient listed above) understand that the hospital has a duty to provide care and has offered to perform a medical screening examination and determine if an emergency medical condition exists. The risks associated with refusal have been explained to me by hospital personnel. These risks include, but are not limited to: ...Patient (or patient representative) Acknowledgement of Understanding: I understand that the hospital cannot provide treatment prior to performing a medical screening examination. I understand that by refusing the services offered I am doing so against the advice of the hospital staff. I understand that the availability of medical services, including examination and stabilizing treatment, as well as necessary transfer to another facility is not based on my ability to pay for these services. I have been given the opportunity to ask questions about the above information and my questions have been answered. I completely understand the consequences of my refusal ...Reason for refusal of screening exam and treatment: ________...Reason form not signed: Patient refused to sign; Patient left without notice; patient called, but no answer 1st call time: _______, 2nd call time: ________, 3rd call time: _______.... "


Hospital document titled, "Patient Relations Worksheet", dated: 05/09/2023 revealed a grievance was filed on behalf of Patient #1. " ...Comments: 04/05/2023 11:15 by Employee #6; patient arrived at 1514; complaint eye jaundice for 1 month; urine collected while patient was in the lobby; The ED is not first come first service. We take patients back by acuity, those at higher risk go back first. Unfortunately the wait time to see a provider can be lengthy at time ...Patient made an inbound call on 04/05/2023 0854 to dispute the charges on [her] hospital account. The patient stated [she] visited the Emergency department on 2/23/2023 and waited for 5 hours. [She] stated there were other patients who came in after [her] and were seen before which cased {sic} (caused) [her] to become upset. When the patient asked when [she] would be seen, [she] was informed that [she] would need to continue to wait. The patient decided to leave and was not treated ...The patient also advised [she] signed a form to refuse the treatment ...."

A review of Patient #1 medical record dated 02/23/2023 revealed: " ...Chief Complaint: Jaundice Comment: pt (patient) states eyes are jaundiced from one month ...Arrive time 02/23/2023 1514 ... Acuity: Urgent ...Mode of arrival: Privately Owned Vehicle (POV) ...ED Disposition: LWBS after Triage ...Lab Results: UA with Micro ...Collection Time 02/23/2023 183 ...1 Results time 02/23/2023 1853 ... Color: yellow Clarity: Hazy, Glucose: 50, Bili: Negative, Ketone: Negative, Specific Gravity: 1.013 Blood UR: Negative, pH: 6.0, Protein: Negative, Urobili: <2.0, Nitrite: Positive, Leukocytes: Moderate ...Bacteria: Moderate ...Culture Urine (Final Results) Notes recorded on 02/26/2023 at 1220. Urine Culture: Spoke with patient ...Pt denies any urinary symptoms. Pt reports [she] is concerned about [her] liver. Pt states [she] has an appointment with [her] PCP tomorrow. Informed patient to return to ED for any further concerns. 02/26/2023 0234 Reviewed by [Dr. Garnes] and [he] requested patient be contacted and inquire if [she] has any urinary symptoms. [She] came to ED for jaundice in [her] eyes. [She] never saw a provider and a urine sample was sent from the lobby. [She] was LWOT. If [she] is having urinary symptoms [he] recommends a script for Keflex 500mg TID x 5 days be called into [her] pharmacy ...ED Vitals: 02/23/2023 1522 Temp: 98.9F Pulse: 83 Resp: 16 BP: 134/55 SpO2: 99% Wt: 56.7kg 02/23/2023 1825 Temp: 98.6F Pulse: 74 Resp: 16 BP: 139/68 SpO2: 96%...ED Events: Patient arrival in ED 02/23/2023 1514, Triage Started 02/23/2023 1522, Triage Completed 02/23/2023 1525, Patient dismissal 02/23/2023 1902 ..."

Further review of patient #1 medical record revealed a signed Refusal of Medical Screening Exam and Treatment form dated 02/23/2023 1901.

A total of 21 ED medical records were randomly selected for review included patients who were transferred, admitted, or left before Medical Screening Examinations. Two (2) of the twenty-one (21) patients left after triage and signed the Refusal of Medical Screen Exam and Treatment form. Two (2) of the twenty-one (21) patients Left after triage and no Refusal of Medical Screen Exam and Treatment form was on file. Three (3) of the twenty-one (21) patients signed the Refusal of Medical Screen Exam and Treatment form and stated long wait has their reason.

Observation while on tour of the Emergency Department on 05/09/2023 revealed a paramedic at the registration desk who provided a quick triage and assessment.

Employee #6 confirmed on 05/09/2023 that Patient #1 waited three (3) hours to be reassessed. Employee #6 confirmed that Patient #1 should have been reassessed within 2 hours of [her] previous vital assessment. Employee #6 confirmed that one (1) month ago the facility hired paramedics to assist with registration. Employee #6 confirmed that the paramedic provides a quick triage, confirm chief complaint and reassess patient in the lobby.