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Based on policy review, document review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's emergency department (ED) were listed on the ED central log and were provided an appropriate medical screening exam within the hospital's capabilities for 1 of 22 (Patient #21) sampled patients in order to determine if an emergency medical condition existed. The Hospital failed to fully implement its corrective actions for training and education to ensure compliance with EMTALA requirements and prevent further occurrences.

The findings included:

1. On 12/25/2023 gun shot wound (GSW) Patient #22 presented to the ED with a gang related gun shot wound. Nursing staff notified the Registration Clerk to limit visitor access to the ED due to safety concerns since the shooter had not been apprehended by law enforcement. Security Guard #1 initiated a lockdown of the ED based on nursing request, without authorization of Administration.

Patient #21 presented to the ED on 12/25/2023, while Security had the ED on lockdown. Security Guard #1 and Registration Clerk #3 advised the Stepmother of Patient #21, (who brought the Patient to the ED), that the hospital ED was on lock down for safety concerns. Patient #21 was not provided a medical screening exam for her emergency medical condition.

The hospital self reported the incident and submitted a Corrective Action Plan (CAP) to CMS on 2/12/2024; however the hospital failed to fully implement the CAP by training ED Registration staff and was determined to be out of compliance with EMTALA requirements.

Refer to 2405 and 2406.

Based on policy review, document review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's emergency department (ED) seeking medical attention were listed on the central log for 1 of 22 (Patient #21) sampled patients. The Hospital failed to fully implement its corrective actions for training and education to ensure compliance with EMTALA requirements.

The findings included:

1. Review of the hospital's "EMTALA- Medical Screening and Treatment of Emergency Medical Conditions" policy last revised 8/2023, revealed, "Definitions: E. Central Log is a log that a Hospital is required to maintain on each individual who comes to its emergency department or any location on the Hospital Property or Premises seeking assistance and that contains the disposition of each individual, whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged. The purpose of the central log is to provide a listing of each individual who comes to the Dedicated Emergency Department seeking examination or treatment for a medical condition, or who comes to the Hospital Property or Premises seeking care for an Emergency Medical Condition."

2. Review of the hospital's ED central log revealed no documentation Patient #21 had presented to the hospital's ED on 12/25/2023.

3. On 4/1/2024 at 10:30 AM, when questioned as to why Patient #21 was not on the hospital's ED central log, the Chief Nursing Officer (CNO) stated that on 12/25/2023 a gun shot wound (GSW) Patient (Patient #22) had presented to the ED with a gang related gunshot wound, the shooter was still at large and the hospital ED was put on high alert. The CNO stated the nursing staff directed the ED Registration staff to limit visitors into the ED due to possible safety concerns. The CNO stated the Security guard on duty interpreted the direction from the nurses to initiate lockdown of the ED. The CNO stated about one hour later the nursing staff realized the Security staff had misinterpreted the nurses' instructions and had placed the ED on lockdown and not allowing anyone ED access. The CNO verified the Risk Manager initiated an investigation and self-reported the potential violation to CMS.

4. In an interview on 4/1/2024 at 1:17 PM, the CNO stated there was no video footage of the 12/25/2023 incident.

5. In a telephone interview on 4/2/2024 at 10:11 AM, Patient #21's stepmother verified she did bring one of her stepdaughters to the hospital ED in December of 2023, but she could not recall the exact date. Patient #21's stepmother stated, "I can't recall the reason I brought her in." Patient #21's stepmother stated when she entered the hospital ED entrance she was informed by a female (name unknown) that the hospital was on lockdown and the patient could not be seen. When asked if the patient received any care, she stated she took her stepdaughter to taken her to a urgent care clinic the following day.

In a subsequent telephone interview on 4/3/2024 at 4:17 PM, Patient #21's stepmother stated she had spoken with her 20-year-old stepdaughter (Patient #21) and confirmed her 20-year-old stepdaughter was taken to the Hospital's ED in December 2023 for treatment of a fever and vomiting, and verified they were advised to leave the ED premises due to safety concerns and denied treatment.

The hospital failed to ensure all individuals presenting to the ED were placed on a log, as required by EMTALA regulations. In addition, the hospital failed to fully implement its CAP to address the EMTALA violation, by failing to fully educate the ED Registration staff on EMTALA requirements as it related to the hospital lockdown policy and in doing so was determined to be out of compliance.

Refer to 2406.

Based on policy review, document review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's emergency department (ED) were provided an appropriate medical screening exam within the hospital's capabilities for 1 of 22 (Patient #21) sampled patients in order to determine if an emergency medical condition existed. The Hospital failed to fully implement its corrective actions for training and education to ensure compliance with EMTALA requirements.

The findings included:

1. Review of the hospital's "EMTALA- Medical Screening and Treatment of Emergency Medical Conditions" policy last revised 8/2023, revealed, "PURPOSE: To ensure individuals coming to an affiliated Hospital's Dedicated Emergency Department seeking assessment or treatment for a medical condition...receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Labor Act ...42 U.S.C Section 1395...DEFINITIONS: ..Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists...POLICY: Any individual who comes to the Hospital Property or Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination provided by a physician or other Qualified Medical Personnel to determine whether or not an Emergency Medical Condition exits..."

2. Review of the hospital's Plan of Correction submitted to CMS on 2/12/2024, after the investigation into Patient #21 being refused medical treatment on 12/25/2023, revealed, Corrective Actions: [Named Hospital #1] will provide education to all contracted Security Guards and Registration/ Patient Access Staff on the following: 1. EMTALA and the responsibilities of the Hospital 2. Lockdown Policy Review and Implementation Instructions- Completion date 1/26/2024. [Named Hospital #1] will update General Hospital Orientation for all staff members to include a review of EMTALA and the Responsibilities of the Hospital- Completion Date 1/8/2024. [Named Hospital #1] has updated its lockdown policy. Specifically, the new policy requires either the house supervisor, Emergency Room (ER) charge nurse, or designee to be stationed at the entrance to the ER along with security personnel to provide medical assistance and appropriate direction for emergency medical services. It also clarifies that no patients should be refused care or treatment- Completion Date 1/26/2024. [Named Hospital #1] will perform auditing and monitoring of the EMTALA log, which reflects each individual who presents to the ER, to ensure no individuals are turned away from the ER. It will also conduct a review of any diversions and lockdowns to ensure EMTALA compliance.

3. Review of the hospital's ED central log revealed there was no documentation Patient #21 had presented to the hospital's ED on 12/25/2023. There was no documentation of a medical record for Patient #21.

Review of the central log revealed a gun shot wound (GSW) Patient #22 arrived to the hospital's ED via private vehicle on 12/25/2023 at 11:28 PM with a gunshot wound to his right shoulder. The record revealed the gun shot wound was gang related. Patient #22 was treated in the hospital's ED.

4. In an interview on 4/1/2024 at 10:30 AM, the Chief Nursing Officer (CNO) stated on 12/25/2023 GSW Patient #22 presented to the ED with a GSW, was triaged and taken into the ED for treatment. The CNO stated the nursing staff were notified the shooter had not been secured and the staff were informed it could have been gang related. The CNO stated the nursing staff directed the ED Registration staff to limit visitors into the ED due to possible safety concerns. The CNO stated the Security guard on duty interpreted the direction from the nurses to initiate lockdown of the ED.
The CNO stated about one hour later the nursing staff were notified by the Registration clerk that Patient #21 had presented to the hospital's ED for treatment and had been advised by Security and Registration the ED was on lockdown for safety concerns and Patient #21 was denied entry, care and treatment. The CNO verified the Risk Manager initiated an investigation and self-reported the potential violation to CMS.

5. In an interview on 4/1/2024 at 1:17 PM, the CNO stated there was no video footage of the 12/25/2023 incident.

6. In a telephone interview on 4/2/2024 at 10:11 AM, Patient #21's Stepmother verified she did bring one of her stepdaughters to the hospital ED in December of 2023, but she could not recall the exact date. Patient #21's stepmother stated, "I can't recall the reason I brought her in." Patient #21's stepmother stated when she entered the hospital ED entrance she was informed by a female (name unknown) that the hospital was on lockdown and the patient could not be seen. Patient #21's stepmother stated she left the premises with her stepdaughter. When asked if the patient received any care, she stated she took her stepdaughter to taken her to a urgent care clinic the following day.

In a subsequent telephone interview on 4/3/2024 at 4:17 PM, Patient #21's stepmother stated she had spoken with her 20-year-old stepdaughter (Patient #21) and confirmed her 20-year-old stepdaughter was taken to Hospital #1's ED in December for treatment of a fever and vomiting. The Stepmother verified she was advised to leave the premises due to safety concerns and denied treatment.

7. In an interview on 4/1/2024 at 3:25 PM, ED Registration Clerk #4 stated she was not sure about the specifics of the Lockdown policy and further stated she did not recall any re-training on the lockdown protocols since December 2023.

8. In a telephone interview on 4/2/2024 at 10:31 AM, ED Registration Clerk #1 verified she worked from 4:00 PM until 11:00 PM on 12/25/2023, when GSW Patient #22 presented to the ED with a GSW. ED Registration Clerk #1 stated the Security Guard #1 locked the ED down after talking with the nursing staff about potential safety concerns. ED Registration Clerk #1 stated she was not aware any patient was turned away as she left her shift at 11 PM and was relieved by ED Registration Clerk #3. When asked if she had additional training on the lockdown policy and what the expectations were of ED Registration staff, she stated, "No, I don't really know what to do." ED Registration Clerk #1 stated she was not sure of the process to follow if it ever happened again.

9. In a telephone interview on 4/2/2023 at 10:39 AM, ED Registration Clerk #3 verified she was working on 12/25/2023 when GSW Patient #22 patient was being treated in the ED. ED Registration clerk #3 stated she was present when the Security Guard #1 informed Patient #21 on 12/25/2023 that the ED was being secured for safety and they were not accepting patients. ED Clerk #3 stated at the time she did not know that was an EMTALA violation, but she had since been educated.

10. In an interview on 4/2/2024 at 10:56 AM, Registration Clerk #2 stated she was not clear on the expectation of ED Registration staff for a lockdown, and she felt she needed additional training.

11. In an interview on 4/2/2024 at 11:09 AM, the Registration Team Coordinator, direct Supervisor of ED Registration staff, stated the registration staff would do as directed by the nurses or security staff during a lockdown. When asked if her ED Registration staff had been re-trained since the incident on 12/25/2023, the Registration Team Coordinator stated, "I don't think everyone [all registration staff] has been reiterated on it [policy], No..."

12. In a telephone interview on 4/2/2023 at 2:01 PM, Nurse #1 verified she was working on 12/25/2023 in the hospital ED when GSW Patient #22 presented with the GSW injury. Nurse #1 stated there was a lot of traffic in the ED after GSW Patient #22's arrival, and based on law enforcement reports that the perpetrator had not been apprehended. Nurse #1 instructed the Registration Clerk assigned to the ED to restrict patient only admittance into the ED, from the ED waiting room. Nurse #1 stated she did not instruct her to limit patients from entering the ED seeking treatment, she only asked them not to allow visitors into the ED treatment area with patients, due to safety concerns. Nurse #1 stated "There was never a decision to lockdown." Nurse #1 stated Security made the decision to lockdown without nursing knowledge.

13. In a telephone interview on 4/2/2024 at 2:25 PM, Security Guard #1 verified she was working on 12/25/2023, and nursing staff directed her and the Registration Clerk to limit traffic into the ED due to GSW Patient #22. Security Guard #1 stated she initiated a lockdown and verified she was present with ED Registration Clerk #3 when Patient #21 presented for treatment on 12/25/2023. Security Guard #1 verified she did tell Patient #21's Stepmother the ED was on lockdown and they were not accepting patients. Security Guard #1 stated she was now aware that EMTALA requirements and during a lockdown, patients seeking treatment would be provided care.

14. In an interview on 4/3/2024 at 9:13 AM, the Risk Manager (RM) verified the training for ED Registration staff/clerks had not been completed. The RM stated she had requested to attend a staff meeting of the ED Registration staff but had not completed the training as outlined in the corrective action plan submitted to CMS on 2/12/2024.

The hospital failed to provide Patient #21 an appropriate medical screening examination after she presented to the ED and a request was made for an evaluation. In addition, the hospital failed to fully implement its CAP to address the EMTALA violation, by failing to fully educate the ED Registration staff on EMTALA requirements as it related to the hospital lockdown policy and in doing so was determined to be out of compliance.