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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag 2405: Logs. Based on document reviews and interviews, the facility failed to ensure all individuals who came to the emergency department (ED) seeking assistance were documented on the centralized EMTALA log in one of one medical records reviewed of a patient who presented to the ED for treatment but was instructed to go to the facility's outpatient clinic instead (Patient #1).

Tag 2406: Appropriate Medical Screening Examination. Based on document reviews and interviews, the facility failed to provide an appropriate Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. The facility failed to ensure all individuals presenting to the emergency department (ED) for treatment received an MSE in one of one medical records reviewed of a patient who presented to the ED for treatment but was instructed to go to the facility's outpatient clinic instead (Patient #1).

Based on document reviews and interviews, the facility failed to ensure all individuals who came to the emergency department (ED) seeking assistance were documented on the centralized EMTALA log in one of one medical records reviewed of a patient who presented to the ED for treatment but was instructed to go to the facility's outpatient clinic instead (Patient #1).

Findings include:

Facility policy:

According to the Admission Policies and Patient Care in the ED policy, Procedure: A. patient will stop at the nurse's desk, if appropriate, and give name, date of birth, and any other information to start the admissions process. The patient will sign consent for treatment and will be evaluated for bed placement. All this is to occur simultaneously. B. The patient will be placed in a treatment room where nursing staff will obtain vital signs, history, and chief complaint and record. Physician will be notified immediately of any emergent findings. C. Admissions will complete the admissions process in a timely manner while the patient is in the treatment room, verifying demographic information, obtaining insurance information and making necessary corrections/additions in the computer. They will then print a face sheet for the record which they will place in the appropriate area in the ED. D. Prepare for physical assessment of the patient. Place the patient in a gown if appropriate for the patient's chief complaint. Perform nursing physical exam and record. Notify physician that the patient is ready to be seen with report, i.e. chief complaint, signs and symptoms, and vital signs. E. Patient will have been entered in the ED log and a chart will be readied for physician with identifying stickers placed on all sheets of the chart.

Reference:

According to the Clinic Reference posted in the emergency department: We at the facility are dedicated to addressing your healthcare needs. We have opened a walk-in clinic to help address your acute care concerns. Clinic hours are Monday-Friday, 8 AM until 8 PM, any patient needing to be seen after 6 PM will need to call the office first.

If you have any of the following symptoms, you may be served at our clinic: cuts, burns, rashes, and bites; flu and strep testing; flu symptoms; colds and fever; allergies; sinus infections; strep throat; sore throat; earaches; laryngitis; pink eye or conjunctivitis; nausea, vomiting or diarrhea; splinter or other foreign body removal; urinary tract infections; and sutures removal.

Chronic Conditions: If you are seeing a provider for a Chronic or ongoing issue, we will not be able to assist you with that issue in the Walk-in Clinic. Examples of Chronic or ongoing conditions are: diabetes, high blood pressure, cancer, arthritis, etc.

Pricing may be more favorable at the walk-in clinic. Our (the clinic's) average visit cost is $150.00.
Being seen in the ER for the above issues may result in an average charge of: $1,237.35.
Insurance: All copays will apply to the walk-in visit. For self-pay patients, the copay will be $25 dollars for established and $50 for non-established patients. Financial assistance may be available to those that qualify.

1. The facility failed to include anyone presenting to the ED for an assessment on the EMTALA log (ED log).

a. Medical record review of Patient #1 revealed the patient presented to the ED on 4/12/23 at 8:44 a.m. to be seen for a sore throat. According to the ED Nursing Notes, Patient #1 presented to the ED earlier that day and was told she qualified for the walk-in clinic. The patient was escorted to the hallway where the walk-in clinic was located and was told if the clinic could not help her to return to the ED. The ED Nursing Notes further read that Patient #1 returned to the ED after the patient reported the clinic staff was rude and that she would not see a physician there.

i. Review of the Daily ED Log revealed Patient #1 was entered into the log on 4/12/23 at 8:44 a.m. for a complaint of sore throat and dental pain. There were no further entries in the log for Patient #1 on 4/12/23 to document when Patient #1 previously presented to the ED as referenced in the medical record.

b. Review of the policy Admission Policies and Patient Care in the ED revealed the procedure of admitting a patient in the ED. The policy listed the steps of the procedure, which began with obtaining patient information, placing the patient into a treatment room, completing paperwork, placing the patient into a gown if appropriate, and performing a nursing physical exam. The next step listed was to enter the patient into the ED log. There was nothing noted in the policy that addressed entering every individual that presented to the ED into the log, as required by the regulation.

c. On 4/26/23 at 3:19 p.m., an interview with the unit secretary (Secretary) #8 was conducted. Secretary #8 described the process of checking patients into the ED, which included entering the patients into the computer and having the nurse check vital signs. Secretary #8 stated only patients who were formally registered and placed in a treatment room were entered into the ED log. Secretary #8 further stated if patients were not registered to be seen in the ED, they were not entered into the ED log.

d. On 4/26/23 at 3:33 p.m., an interview with registered nurse (RN) #1 was conducted. RN #1 explained the process of checking patients into the ED which included communicating with patients at the waiting room intercom and nurses station window. RN #1 stated patients walked up to the waiting room intercom and were buzzed in after telling the unit secretary they needed to be seen. RN #1 stated patients then came into the ED and approached the window, communicating their complaint to the unit secretary and nurse sitting behind her. If the patient's complaint met criteria from the Clinic Reference posted on the outer window, patients were told they qualified to be seen at the walk-in clinic upstairs and were directed to the clinic. RN#1 said anyone who was registered to be seen in the ED would be placed on the log. RN#1 explained any patients who entered the ED and chose to go to the walk-in clinic were not registered on the ED log.

e. On 4/27/23 at 8:16 a.m., an interview with RN ED director (Director) #4 was conducted. Director #4 discussed the process of checking patients into the ED, which included interacting with patients through the intercom in the waiting room and at the nurses station window. Director #4 stated once patients were at the window in the ED they were addressed by the unit secretary and asked what their complaints were. Director #4 explained there was a reference list of symptoms at the nurses' station that the unit secretary utilized to direct patients to appropriate care.

Director #4 described the registration log process as only including patients who were registered to be seen as ED patients. Director #4 said patients sent to the walk-in clinic were not placed on the ED log. Director #4 explained the importance of an ED log was to keep track of the volume of patients who came to the ED, what time they came in, what their complaints were, and if they were transferred out.

Based on document reviews and interviews, the facility failed to provide an appropriate Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. The facility failed to ensure all individuals presenting to the emergency department (ED) for treatment received an MSE in one of one medical records reviewed of a patient who presented to the ED for treatment but was instructed to go to the facility's outpatient clinic instead (Patient #1).

Findings include:

Facility policies:

According to the policy Medical Screening Examination (MSE), all individuals presenting to the Emergency Department (ED) and requesting medical treatment are entitled to a medical screening exam.
An MSE is defined as a screening of sick, wounded, or injured persons in the emergency department to determine whether the person has an emergency medical condition. Screening/assessment is to be done by a registered nurse in consultation with the emergency department physician.

The MSE will include but not be limited to the following assessment: chief complaining, vital signs, mental status evidence of abnormalities, general appearance-patient looks sick, skin looks poorly perfused, shows signs of dehydration, and ability to walk.

If urgent or emergent, the patient may be placed immediately into an exam room in the emergency department. If non-emergent and there is a bed available in the emergency department, the patient will be placed there. Under the circumstances that no bed is available, the patient may be placed in the emergency department waiting room until a patient room is available. Contact will be made with the patient hourly to keep the patient updated on bed availability and check patient for worsening of condition, until the patient is placed into a room.

According to the Low Acuity Screening Process; Management of Non-urgent Patients policy, the purpose is to provide all patients who present to the ED for medical treatment of care with an MSE performed by a physician or qualified medical person, in accordance with state and federal law to provide guidelines for the screening of patients with non-urgent (level 2) conditions or complaints that may be acute or of a chronic nature, that do not require treatment in an emergent manner or may be treated by another part of the healthcare system. Triage/MSE Process: the physician does the MSE.

According to the Vital Signs policy, inquire if the patient is having any pain, if the patient does have pain, determine the degree of pain using 0-10 pain scale or Wong-Baker scale. Record level of pain in computer with other vital signs and/or unit-specific form under pain documentation.

Abnormal vital signs (outside the standard parameters) should be reported to the physician within 30 minutes unless specific orders were given to report differently. Staff taking vital signs shall record them and if not the patient's primary nurse, shall report abnormal vital signs immediately to the primary nurse. Notification of the physician shall be recorded in the patient's record.

Adult vital sign parameter reference includes calling a physician for temperature above 101.5 degrees, heart rate below 50 or above 120, respiratory rate less than 12 or greater than 28, systolic blood pressure less than 90 or greater than 180, SAO2 (pulse oximetry) less than 90%.

References:

According to the Clinic Reference posted in the emergency department: We at the facility are dedicated to addressing your healthcare needs. We have opened a walk-in clinic to help address your acute care concerns. Clinic hours are Monday-Friday, 8 AM until 8 PM, any patient needing to be seen after 6 PM will need to call the office first.

If you have any of the following symptoms, you may be served at our clinic: cuts, burns, rashes, and bites; flu and strep testing; flu symptoms; colds and fever; allergies; sinus infections; strep throat; sore throat; earaches; laryngitis; pink eye or conjunctivitis; nausea, vomiting or diarrhea; splinter or other foreign body removal; urinary tract infections; and sutures removal.

Chronic Conditions: If you are seeing a provider for a Chronic or ongoing issue, we will not be able to assist you with that issue in the Walk-in Clinic. Examples of Chronic or ongoing conditions are: diabetes, high blood pressure, cancer, arthritis, etc.

Pricing may be more favorable at the walk-in clinic. Our (the clinic's) average visit cost is $150.00.
Being seen in the ER for the above issues may result in an average charge of: $1,237.35.
Insurance: All copays will apply to the walk-in visit. For self-pay patients, the copay will be $25 dollars for established and $50 for non-established patients. Financial assistance may be available to those that qualify.

According to the Medical Staff Rules and Regulations, all individuals presenting to the Emergency Department and requesting medical treatment are entitled to a medical screening examination. A medical screening examination will be performed by a licensed physician, physician assistant, or nurse practitioner working in the Emergency Department.

1. The facility failed to ensure a medical screening exam (MSE) was conducted on each individual presenting to the ED for services.

a. Medical record review of Patient #1 revealed the patient presented to the ED on 4/12/23 at 8:44 a.m. to be seen for a sore throat. According to the ED Nursing Notes, Patient #1 presented to the ED earlier that day and was told she qualified for the walk-in clinic. The patient was escorted to the hallway where the walk-in clinic was located and was told if the clinic could not help her to return to the ED. The ED Nursing Notes further read that Patient #1 returned to the ED after the patient reported the clinic staff was rude and that she would not see a physician there.

Patient #1 then received an MSE, which included obtaining a streptococcus rapid screen (a test to assess for strep throat), an influenza rapid smear (a test to assess for influenza), and a coronavirus test. The test results revealed the patient was positive for streptococcus and Covid 19 and was sent home with prescriptions for Paxlovid (an antiviral medication used to treat Covid 19) and amoxicillin (an antibiotic used to treat strep throat) and instructions on how to take care of herself at home.

There was no evidence of Patient #1's previous encounter at the ED, when ED staff instructed the patient to receive care at the facility's outpatient clinic (Cross-reference A-2405). In addition, there was no evidence of Patient #1 receiving an MSE by a physician from her previous encounter at the ED.

This was in contrast with the Medical Screening Examination (MSE) policy which read all individuals presenting to the Emergency Department (ED) and requesting medical treatment were entitled to a medical screening exam. The policy further read that the screening and assessment was to be done by a registered nurse in consultation with the emergency department physician.

b. On 4/26/23 at 3:33 p.m., an interview with registered nurse (RN) #1 was conducted. RN #1 explained the process of registering a patient in the ED began with the patient approaching the nurses' station window and communicating their complaint to the unit secretary. RN #1 stated there was a clinic reference posted on the nurses' station window that listed criteria for referring patients to the facility's walk-in clinic. RN #1 stated the list was used by either the unit secretary or the RN initiating contact with the patient. RN #1 further stated patients who met the criteria from the list were advised by the nurse that they could seek care at the facility's walk-in clinic. RN #1 stated patients who chose to seek care at the clinic were then directed to the staircase or elevator that led to the clinic.

c. On 4/26/23 at 12:35 p.m., an interview with the charge nurse at the ED (RN #2) was conducted. RN #2 stated when patients arrived at the ED nurses' station window, they were evaluated by the Unit Secretary and an RN. RN #2 stated nurses used the clinic reference document posted on the nurses' station window to determine if patients qualified for the walk-in clinic. RN #2 said if patients met the criteria to be seen in the clinic, patients were directed to go upstairs to the walk-in clinic.

d. On 4/26/23 at 12:10 p.m., an interview with the outpatient walk-in clinic office assistant (Assistant) #3 was conducted. Assistant #3 stated when patients were sent to the clinic from the ED, the medical assistant and nurse practitioner at the clinic would assess the patient and discuss whether or not the patient was a candidate for the clinic or if the patient needed to return to the ED for treatment. Assistant #3 further stated there were times when patients needed to be sent back to the ED for treatment, at which point the patient would be escorted to the ED by the medical assistant or nurse practitioner.

e. On 4/27/23 at 8:16 a.m., an interview with RN ED director (Director) #4 was conducted. Director #4 explained the process of registering patients who walked into the ED began with the patient telling the unit secretary what they needed. Director #4 stated the unit secretary and the RN would utilize the clinic reference list posted on the nurses' station window to determine if the patient's symptoms were considered emergent or not emergent. Director #4 stated if the unit secretary and RN decided the symptoms were not emergent, the patient would be sent to the clinic for treatment.

Director #4 stated an MSE was expected to be performed by a physician. Director #4 explained the importance of a physician-conducted MSE was to show how to initiate care and what was needed to treat the patient. Director #4 further explained the physician was the only one who could make diagnostic decisions and determine the course of the patient's care. Director #4 then stated all patients should have received an MSE before leaving the ED; however, Director #4 noted that patients were not always receiving an MSE. Director #4 further stated facility guidelines were not being followed in that patients were sent to the outpatient clinic without an appropriate exam in the ED.

f. On 4/26/23 at 12:35 p.m., an interview with the director of physician clinics (Director) #5 was conducted. Director #5 stated patients were escorted from the ED to the walk-in clinic when it was determined by staff in the ED that they did not require ED services. Director #5 said on rare occasions when patients were directed to the walk-in clinic from the ED and were then triaged by clinic staff, patients were told by clinic providers they needed to go back to the ED because their symptoms or complaints were too severe for the walk-in clinic.

g. On 4/26/23 at 3:48 p.m., an interview with the ED physician (Physician) #6 was conducted. Physician #6 stated all patients registered and placed in an ED treatment room received an MSE. Physician #6 said all MSEs were completed by an MD only as there were no midlevel providers (nurse practitioners or physician assistants) in the ED. Physician #6 said MSEs were important to establish when patients' needs were acute or non-acute or if patients were compromised in any way. Physician #6 stated he was not aware that patients presenting to the ED were offered by ED staff to go to the walk-in clinic if their symptoms met hospital-established criteria.