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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:

A2405: The hospital's failure to ensure Patient #2's presentation to the Emergency Department (ED) requesting emergency services was documented on their central ED log.

A2406: The hospital's failure to ensure a pediatric patient (Patient #2) received a medical screening examination after presenting with trouble breathing. The patient was with a family member who was not the legal guardian. The family member was told the patient would not be seen until the legal guardian arrived. The family member became upset and was told by a security officer to leave with the patient prior to the patient being evaluated by a provider.

Based on review of clinical records, hospital policies/procedures, hospital internal documents, and interviews, it was determined the hospital failed to ensure Patient #2's presentation to the Emergency Department (ED) requesting emergency services was documented on their central ED log.

Findings include:

The hospital's policy and procedure titled "Compliance/EMTALA: Registration, Triage, and Medical Screening Exam" includes: "Valleywise Health will maintain a list of each person covered by EMTALA who comes to the ED. This log must state, at a minimum, whether the person refused treatment, was refused treatment, was admitted and treated, stabilized and transferred, or discharged."

Refer to Tag 2406 for specific details of Patient #2. Information obtained from the patient's family member and with the patient's legal guardian revealed Patient #2, a minor, was taken to the ED located off-site from the main hospital on 4/16/2021. There was no documentation on the dedicated ED logs that the patient was there on that day. The hospital was able to locate documentation in the form of a grievance that the minor patient was taken by a family member to that ED on that day but was told to leave prior to receiving a medical screening examination.

Staff #3 stated during an interview on 04/07/2021 that the patient should have been registered into the hospital's electronic medical record system ED log.

Based on reviews of clinical records, hospital policies and procedures, hospital documents, and staff interviews, it was determined the hospital failed to ensure a pediatric patient (Patient #2) received a medical screening examination after presenting with trouble breathing. The patient was with a family member who was not the legal guardian. The family member was told the patient would not be seen until the legal guardian arrived. The family member became upset and was told by a security officer to leave with the patient prior to the patient being evaluated by a provider.

Findings include:

The hospital's policy and procedure titled, "Compliance/EMTALA: Registration, Triage, and Medical Screening Exam" included: "4. Medical Screening Exam...a. Valleywise Health will provide a medical screening examination (MSE) to all persons who present at the Valleywise Health Medical Center requesting emergency services, regardless of their ability to pay....d. The purpose of an MSE is to determine whether the person seeking emergency services has an EMC...8. Consent Requirements...a. Consent to Examination and Treatment. Valleywise Health may provide a medical screening examination and necessary stabilizing treatment to persons only with the person's consent. An unaccompanied minor may request, and consent to, examination or treatment for an emergency medical condition. Valleywise Health personnel should not delay the medical screening examination or stabilizing treatment to obtain parental consent."

Information obtained from the patient's family member and with the patient's legal guardian revealed Patient #2, a minor, was taken to the ED located off-site from the main hospital on 4/16/2021. There was no documentation on the dedicated ED logs that the patient was there on that day. The hospital was asked if there was any documentation of a grievance submitted and they located and presented a report for review. The documentation revealed the hospital received a concern on 04/16/2021 regarding the "attitude" of a security officer and staff at the Maryvale Emergency Department on that date when a pediatric patient was brought in by a family member who was not the legal guardian. The patient reportedly had a history of "respiratory failure problems" with fluid in her lungs and had been vomiting "non-stop" on the day of presentation. The family member was told by staff that the patient could not been seen without the legal guardian present. The family member was upset and and loudly voiced concerns to the staff and to the security officer who were present that the patient was going to pass out. The security officer allegedly commented that the patient could go somewhere else to pass out. The family member confronted the security officer who directed the family member and patient to leave and they did so without the patient being evaluated by a physician or other qualified medical person. The patient was taken to another ED for care and treatment. The report included an interview with the security officer (Staff #7) regarding the incident. Staff #7 reported hearing the registration staff member telling the family member that they could not see the patient without a parent present. Staff #7 felt the family member was being disrespectful to the registration staff and told him/her, "...if registration said a parent is needed to be present, then you need to wait and stop yelling." The family member and patient left a while later. The family member walked back into the ED a short while later and approached Staff #7 "demanding" his badge number. The family member refused to leave and Staff #7 escorted him/her out the front entrance at which time he/she got in a vehicle and left.

A review of the clinical records from Hospital #2 revealed the patient presented there on 04/16/2021 on or around 11:18 a.m. with complaints of sore throat, cough, nausea, vomiting and headache. The patient received a medical screening examination and received breathing treatments via nebulizer and a dose of dexamethasone. The patient was then discharged home.

An interview was conducted with Staff #7 on 10/7/2021. Staff #7 was asked what his role was in the Maryvale ED and he responded, "Keeping the peace." Staff #7 indicated he did not recall the incident but then said he did recall an incident similar to what was described. Staff #7 said the family member was cursing at staff and he eventually told him/her to leave. Staff #7 was asked to clarify at what point a security officer would intervene with a patient or visitors in the ED. Staff #7's direct supervisor was present during the interview and said the security officers only intervene at the direction of nursing staff. Staff #7 was asked if nursing staff directed him to tell the family member and patient to leave and he said he could not remember. There was no documentation in the hospital's report that nursing staff directed Staff #7 to intervene and make the family member and patient leave.

Staff #3 stated during interviews on 10/7/2021 that minor patients who present without a legal guardian should be triaged and receive a medical screening examination (MSE) even if the legal guardian is not present. Consent for treatment should be obtained after the MSE.