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Based on record reviews 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 when a patient arrived at the hospital emergency department by ambulance for evaluation and treatment (Patient #1).

Findings include:

Hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", revealed: " ...Definitions ...Ambulance Parking occurs when hospital staff refuses to release EMS staff or equipment and prevents EMS staff from transferring patients from the ambulance stretcher to a hospital bed or gurney, thereby delaying the Medical Screening Examination or stabilizing treatment of a patient who arrives via EMS ....II. Medical Screening Examination. A. Triage and Registration of Patients Prior to Medical Screening Examination (MSE) ...The triage nurse takes and documents vital signs, along with any other relevant observations, and assigns the patient an acuity level (ESI) that dictates the order in which the patient will be seen ....Patients will be asked to remain in waiting areas until they are called for the MSE ...B. Medical Screening. When an individual comes to the emergency department (ED) requesting medical treatment, an appropriate MSE, within the capabilities of the ED ...shall be provided to determine whether an emergency medical condition (EMC) exists ...The Hospital must apply the screening process that it would perform on any individual coming to the ED in a non-discriminatory manner and regardless of payor source or ability to pay. Ambulance Parking is never appropriate and could result in an EMTALA violation ...."

Review of Patient #1 medical record revealed Hospital #2 had accepted Patient #1 as an ED to ED transfer from Hospital #2. Further review of the medical record revealed the hospital failed to provide a Medical Screening Examination (MSE) to Patient #1 upon Emergency Department by ambulance.

Employee #6 confirmed during an interview conducted on 03/06/2024 that Patient #1 was an accepted transfer from Hospital #2 with diagnosis of NSTEMI, arrived by ambulance, and triaged with acuity of 3. Employee #6 also confirmed Patient #1 waited for more than two hours for a bed. Employee #6 further confirmed Patient #1 medical screening examination was delayed.

Based on record reviews and staff interviews, it was determined that the hospital failed to provide an appropriate Medical Screening Examination to (8) out of twenty (20) patients who presented to the ED for examination and treatment (Patients #1, #2, #4, #9, #10, #12, #14, #19).

Findings include:

Hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", revealed: " ...Definitions ...Ambulance Parking occurs when hospital staff refuses to release EMS staff or equipment and prevents EMS staff from transferring patients from the ambulance stretcher to a hospital bed or gurney, thereby delaying the Medical Screening Examination or stabilizing treatment of a patient who arrives via EMS ....II. Medical Screening Examination. A. Triage and Registration of Patients Prior to Medical Screening Examination (MSE) ...The triage nurse takes and documents vital signs, along with any other relevant observations, and assigns the patient an acuity level (ESI) that dictates the order in which the patient will be seen ....Patients will be asked to remain in waiting areas until they are called for the MSE ...B. Medical Screening. When an individual comes to the emergency department (ED) requesting medical treatment, an appropriate MSE, within the capabilities of the ED ...shall be provided to determine whether an emergency medical condition (EMC) exists ...The Hospital must apply the screening process that it would perform on any individual coming to the ED in a non-discriminatory manner and regardless of payor source or ability to pay. Ambulance Parking is never appropriate and could result in an EMTALA violation ...."

Hospital policy titled, "Refusal for Treatment - AMA", revealed: " ...Definitions: ...3. Left With Out Treatment (LWOT): patient presents seeking care but leaves before being seen or treated by a physician ....Instructions: ...5. Left Without Treatment (LWOT) ...a. LWOTS include patients who leave before triage (LBT) and patients who leave prior to Medical Screening Exam (LPMSE) ...b. If a patient verbalizes they cannot wait to be seen either prior to triage or after triage but prior to the Medical Screening exam, if possible, an attempt is made for the UC/ED/OB nurse to talk with the patient prior to their departure ...."

Hospital document titled, "ED Throughput Committee Meeting" dated 02/15/2024, revealed: " ...I. Last Month Metrics: (January 1 - January 31) ...Door to Triage 10 min ...Door to provider (doctor) 138 min (PA) 90 min ...IV Current Topics: ...Concern for Flow: It seems as though providers are signing up for MSE's but taking a very long time to see the patient and then later review the results and dispo the patients ...."

Hospital document titled, "NW Tucson ER January Department Meeting" dated 01/2024, revealed: " ...Current Metrics ...Average Arrival to Provider Exam Minutes ...Goal 20 mins ...6-Jan ...135 ...13-Jan ...109 ...20-Jan ...127 ...27-Jan ...97 ...MTD ...118 ...."

Review of Patient #1's medical record from Hospital #2 dated 01/23/2024 revealed: " ...Date of Visit: 01/23/2024 15:28 ...Visit CC: Fall Injury ...IVPB Medication Administered: Heparin ...Dose: 570Units/Hr ...Rate: 15.7ml/hr ...Date/Time Stopped: Heparin infusing at stated rate at the time of transfer out of (Hospital #2) ED ...22:40 - Patient has been received by (Provider #1) at (Hospital #1) with ER to ER transfer ....24-Jan-2024 ...00:45 ...Patient is going direct to ED accepted by (Provider #1). Patient ETA to (Hospital #1) ED is 2.5 hrs from now ....Altered Labs: #1 Trop - 91.5 ...#2 Trop - 217.2 ...D-Dimer 1.97 ...Diagnosis (reason for transfer) NSTEMI, multiple recent falls ...Time Left 01:10 Date 01/24/24 ...."

Review of Patient #1's EMS Runsheet dated 01/24/2024 revealed: " ...Narrative ...Troponin elevated at 91.5 with repeated Troponin level increased at 217.2 and a D-Dimer of 1.97. Pt was treated with 2 IV access points ...Heparin bolus 2800units at 2130hrs, and continued on Heparin drip of 570units/hr or rate of 15.7ml/hr - IV access site 20ga left A/C. 18ga Right A/C NS Lock. Pt referred to (Hospital #1) ED, accepting physician (Provider #1) for non-STEMI and multiple falls ....(Hospital #1) contacted at 0115hr with pt's ETA ....Continued on Dx drip of 15.7ml/hr ....(Hospital #1) recontacted at 0232hrs with pt's 15 min ETA. Upon arrival pt transported in on stretcher with Heparin IV pump and cardiac monitor. Pt registered with charge RN and was directed to wait in the hall. (Hospital #1) performed an initial 12-lead assessment approx. 30min after arrival. Awaited for a room till 0445hrs. Approx 2 hours and 50minutes wait time ....RN ...arrived and received report. Heparin drip clamped off and taken off IV pump. RN advised ....Arrive Dest: 01/24/2024 02:41 ...Signatures ...Printed Name: RN ...(Hospital #1) ED ...Signature Reason: Transfer of Patient Care ...Date/Time of Signature: 01/24/2024 04:52 ...."

Review of Patient #1's medical record from Hospital #1 dated 01/24/2024 revealed: " ...ED Events Information ...Arrive ...02:56 ...Triage ...02:56 ...Bed Assign ...05:01 ...Quick Triage ...Chief Complaint ...Transfer from (Hospital #2) Presented to (Hospital #2) ER for multiple falls, dx with NSTEMI. On heparin gtt at 11.9u/kg/hr ...Mode of Arrival: Ambulance ...Systolic Blood Pressure: 162mmHg ...Diastolic Blood Pressure: 89 mmHg ...Time seen: ...05:44 ...History of Presenting Illness ...Patient's [niece] reports [she] went to the restroom and could not get up and fell ...unaware if [she] lost consciousness but this is not the first time that this has happened before. Patient presenting without any chest pain, shortness of breath ...Medical Decision Making ...had a ground-level fall and was seen at an outside hospital. They did not identify any evidence of trauma, and were going to release [her], but [her] troponin came back elevated ...transferred here for evaluation by cardiology for an NSTEMI ...EKG was reassuring without evidence of ischemia. No evidence of STEMI at this time ....Pt arrived from outside hospital on a Heparin drip ....Cardiac Markers ...Troponin HS ...Collected Date/Time ...1/24/2024 05:30 ...Result ...399.9 ...Reference Range [0.0-54.0] ...Troponin HS ...Collected Date/Time ...1/24/2024 10:14 ...Result ...309.3 ...Reference Range [0.0-54.0] ...."

A total of 20 ED medical records were randomly selected for review including patients who were transferred, admitted, discharged home, or left before medical screening examination (MSE).

Review of 20 ED medical records revealed seven (7) patients did not receive a MSE.

1. Patient #2, arrived 02/01/2024 03:27, triaged 03:28, ESI 3, LWOT 04:25, Time elapsed: 58 minutes
2. Patient #4, arrived 02/05/2024 19:55, triaged 20:03, ESI 3, LWOT 22:31, Time elapsed: 2 hours 36 minutes
3. Patient #9, arrived 01/03/2024 15:11, triaged 15:46, ESI 4, LWOT 19:23, Time elapsed: 4 hours 12 minutes
4. Patient #10, arrived 01/04/2024 03:13, triaged 03:18, ESI 3, LWOT 08:05, Time elapsed: 4 hours 42 minutes
5. Patient #12, arrived 01/14/2024 19:17, triaged 19:32, ESI 4, LWOT 23:03, Time elapsed: 3 hours 46 minutes
6. Patient #14, arrived 01/24/2024 01:37, triaged 02:14, ESI 3, LWOT 04:20, Time elapsed: 2 hours 43 minutes
7. Patient #19, arrived 12/19/2024 12:24, triaged 12:36, ESI 3, LWOT 14:50, Time elapsed: 2 hours 26 minutes

Employee #6 confirmed during an interview conducted on 03/06/2024 that Patient #1 was an accepted transfer from Hospital #2 with diagnosis of NSTEMI, arrived by ambulance, and triaged with acuity of 3. Employee #6 also confirmed Patient #1 waited for more than two hours for a bed. Employee #6 further confirmed Patient #1 waited 2 hours and 48 minutes for a medical screening examination. Employee #6 further confirmed Patient #1 medical screening examination was delayed.

Employee #7 confirmed during an interview conducted on 03/06/2024 that the door to doctor time in the ED was 60.01 minutes two weeks ago, and 32.07 minutes one week ago. Employee #6 and Employee #7 also confirmed there was a long wait time to see a provider in the ED, and patients would leave before receiving a MSE.

Based on record reviews and staff interviews, it was determined the Hospital delayed examination and treatment for one (1) patient (Patient #1), who was an accepted transfer from another hospital, and presented to the Emergency Department via Emergency Medical Services (EMS) transport.

Findings include:

Hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", revealed: " ...Definitions ...Ambulance Parking occurs when hospital staff refuses to release EMS staff or equipment and prevents EMS staff from transferring patients from the ambulance stretcher to a hospital bed or gurney, thereby delaying the Medical Screening Examination or stabilizing treatment of a patient who arrives via EMS ....II. Medical Screening Examination. A. Triage and Registration of Patients Prior to Medical Screening Examination (MSE) ...The triage nurse takes and documents vital signs, along with any other relevant observations, and assigns the patient an acuity level (ESI) that dictates the order in which the patient will be seen ....Patients will be asked to remain in waiting areas until they are called for the MSE ...B. Medical Screening. When an individual comes to the emergency department (ED) requesting medical treatment, an appropriate MSE, within the capabilities of the ED ...shall be provided to determine whether an emergency medical condition (EMC) exists ...The Hospital must apply the screening process that it would perform on any individual coming to the ED in a non-discriminatory manner and regardless of payor source or ability to pay. Ambulance Parking is never appropriate and could result in an EMTALA violation ...."

Review of Patient #1's medical record from Hospital #2 dated 01/23/2024 revealed: " ...Date of Visit: 01/23/2024 15:28 ...Visit CC: Fall Injury ...IVPB Medication Administered: Heparin ...Dose: 570Units/Hr ...Rate: 15.7ml/hr ...Date/Time Stopped: Heparin infusing at stated rate at the time of transfer out of (Hospital #2) ED ...22:40 - Patient has been received by (Provider #1) at (Hospital #1) with ER to ER transfer ....24-Jan-2024 ...00:45 ...Patient is going direct to ED accepted by (Provider #1). Patient ETA to (Hospital #1) ED is 2.5 hrs from now ....Altered Labs: #1 Trop - 91.5 ...#2 Trop - 217.2 ...D-Dimer 1.97 ...Diagnosis (reason for transfer) NSTEMI, multiple recent falls ...Time Left 01:10 Date 01/24/24 ...."

Review of Patient #1's EMS Runsheet dated 01/24/2024 revealed: " ...Narrative ...Troponin elevated at 91.5 with repeated Troponin level increased at 217.2 and a D-Dimer of 1.97. Pt was treated with 2 IV access points ...Heparin bolus 2800units at 2130hrs, and continued on Heparin drip of 570units/hr or rate of 15.7ml/hr - IV access site 20ga left A/C. 18ga Right A/C NS Lock. Pt referred to (Hospital #1) ED, accepting physician (Provider #1) for non-STEMI and multiple falls ....(Hospital #1) contacted at 0115hr with pt's ETA ....Continued on Dx drip of 15.7ml/hr ....(Hospital #1) recontacted at 0232hrs with pt's 15 min ETA. Upon arrival pt transported in on stretcher with Heparin IV pump and cardiac monitor. Pt registered with charge RN and was directed to wait in the hall. (Hospital #1) performed an initial 12-lead assessment approx. 30min after arrival. Awaited for a room till 0445hrs. Approx 2 hours and 50minutes wait time ....RN ...arrived and received report. Heparin drip clamped off and taken off IV pump. RN advised ....Arrive Dest: 01/24/2024 02:41 ...Signatures ...Printed Name: RN ...(Hospital #1) ED ...Signature Reason: Transfer of Patient Care ...Date/Time of Signature: 01/24/2024 04:52 ...."

Review of Patient #1's medical record from Hospital #1 dated 01/24/2024 revealed: " ...ED Events Information ...Arrive ...02:56 ...Triage ...02:56 ...Bed Assign ...05:01 ...Quick Triage ...Chief Complaint ...Transfer from (Hospital #2) Presented to (Hospital #2) ER for multiple falls, dx with NSTEMI. On heparin gtt at 11.9u/kg/hr ...Mode of Arrival: Ambulance ...Systolic Blood Pressure: 162mmHg ...Diastolic Blood Pressure: 89 mmHg ...Time seen: ...05:44 ...History of Presenting Illness ...Patient's [niece] reports [she] went to the restroom and could not get up and fell ...unaware if [she] lost consciousness but this is not the first time that this has happened before. Patient presenting without any chest pain, shortness of breath ...Medical Decision Making ...had a ground-level fall and was seen at an outside hospital. They did not identify any evidence of trauma, and were going to release [her], but [her] troponin came back elevated ...transferred here for evaluation by cardiology for an NSTEMI ...EKG was reassuring without evidence of ischemia. No evidence of STEMI at this time ....Pt arrived from outside hospital on a Heparin drip ....Cardiac Markers ...Troponin HS ...Collected Date/Time ...1/24/2024 05:30 ...Result ...399.9 ...Reference Range [0.0-54.0] ...Troponin HS ...Collected Date/Time ...1/24/2024 10:14 ...Result ...309.3 ...Reference Range [0.0-54.0] ...."

Employee #6 confirmed during an interview conducted on 03/06/2024 that Patient #1 was an accepted transfer from Hospital #2 with diagnosis of NSTEMI, arrived by ambulance, and triaged with acuity of 3. Employee #6 also confirmed Patient #1 waited for more than two hours for a bed. Employee #6 further confirmed Patient #1 waited 2 hours and 48 minutes for a medical screening examination. Employee #6 further confirmed Patient #1 medical screening examination was delayed.