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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 42 CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare-participating hospitals in emergency cases as evidenced by:

A2406: Medical Screening Examination: The hospital failed to provide a Medical Screening Examination (MSE) to Patient #4 who presented to the Emergency Department (ED) by ambulance. The patient left without treatment after waiting approximately 1.5 hours in the ambulance bay without being assessed/triaged for an MSE by a qualified medical provider. The patient was taken to another hospital by the ambulance crew.

Findings include:
The hospital's EMTALA policy and procedure included: "...3. When an EMS provider brings an individual to the Hospital with a Dedicated Emergency Department and the Hospital does not have the capacity or capability to provide an immediate medical screening exam and if needed, stabilizing or an appropriate transfer, the Hospital must still assess the individual upon arrival to ensure that the individual is appropriately prioritized based on presenting
signs and symptoms. Hospital should assess whether the EMS can appropriately monitor the individual's condition. 4. Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSE...."
Patient #4 presented to the ED by ambulance on January 21, 2023. The patient remained in the ambulance bay for approximately 1.5 hours and then stated he wanted to go to another hospital. The patient was not triaged nor a Medical Screening Examination performed. Staff #4 documented the patient left without treatment and
the ambulance crew "agreed" to transport the patient to another hospital. Refer to Allegation #2 for more details related to Patient #4. Refer to Tag 2406 for further details. Staff #1 and # 2 agreed Staff #4 did not follow hospital EMTALA policies and procedures.

Based on review of hospital policies and procedures, reviews of Emergency Department
(ED) clinical records, pertinent hospital documents, and staff interviews, it was determined the hospital failed to ensure a Patient #4 who came in by ambulance with unstable vital signs was assessed for triage and Medical
Screening Examination for a period of 1.5 hours before the patient was taken to another hospital by the ambulance crew.

Findings include:
The hospital's EMTALA policies and procedures included the following: "A. Medical Screening Examination ("MSE"). 1. An appropriate MSE will be offered to individuals on the Campus of Banner Hospitals with a Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested, or, in the absence of such a request, whose appearance or behavior would cause a prudent layperson observer to believe that such individuals need emergency examination or
treatment...."
The policy also included: "...3. When an EMS provider brings an individual to the Hospital with a Dedicated Emergency Department and the Hospital does not have the capacity or capability to provide an immediate medical screening exam and if needed, stabilizing or an appropriate transfer, the Hospital must still assess the individual upon arrival to ensure that the individual is appropriately prioritized based on presenting signs and symptoms. Hospital should assess whether the EMS can appropriately monitor the individual's condition. 4. Triage establishes the order in which an individual will be evaluated and is not considered an emergency
MSE...."

The investigation included reviews of ED records randomly selected from the hospital's ED Logs.

Patient #4's clinical record. Patient #4 presented to the ED by ambulance on January 21, 2023 at 3:43 p.m. Documentation in the ambulance company's Patient Care Report revealed they responded to the skilled nursing facility where he resided. The patient was described to be alert and oriented and appeared to be "diaphoretic."
The following vital signs were recorded on the Patient Care Report:
-3:23 p.m.: Blood Pressure 87/52; Pulse 130;
Respirations 23
-3:28 p.m.: Blood Pressure 90/54; Pulse 89;
Respirations 24
-3:32 p.m.: Blood Pressure 94/59; Pulse 120;
Respirations 25
-3:37 p.m.: Blood Pressure 90/58; Pulse 103;
Respirations 22
The patient's temperature was recorded to be 102 degrees Fahrenheit and the EKG interpretation was "atrial fibrillation."

The record contained a "Banner Health EMS Report Form" dated January 21, 2023 at 3:29 p.m. and the documentation included the communication type which was "Redphone" and the Transport Unit. The patient's Chief
Complaint, "fever; 100-160 tachy." Documentation underneath the Chief Complaint included: "Pt registered. Waited 1 hr & req (requested) to LWOT (Leave Without Treatment). (Name of Ambulance Company) crew agreed to
take pt. to VA (Veterans Administration). The form included a section for Vitals, one line for "Initial" and another line for "Second." The line for "Initial" had a Blood Pressure of 82/54 and oxygen saturation level of 99% recorded. There were no other vital signs recorded nor was the entry documented. The line for "Second" had a
Blood Pressure of 90/56, Pulse 60-160, Rhythm "A-fib," LOC/GCS (cognitive status) 15, and Temperature of 99.0. There was no documentation as to what time these vital signs were taken or by whom, the RN or by the ambulance crew. The form was signed by Staff #4. The documentation included: "...Upon arrival to the hospital patient was unloaded and brought inside...waited with the crew for an hour for a bed to open up. Patient stated 'I want to go to the VA, no one asked me." Patient was transported to the VA...." The patient left the facility on or around 5:02 p.m., a period of approximately 1.5 hours. There was no documentation in the record that the patient was assessed at the time of arrival, appropriately monitored based on his symptoms, or the status of the patient at the time
he left in the care of the ambulance company.

Patient #4's ED record was reviewed by Staff #2 who reported the patient was not triaged upon arrival by ambulance because they were waiting for a room to open in the ED. Staff #2 explained that the RN assigned to answer in-coming calls from EMS units who was also responsible for triaging patients in the ambulance bay. The
hospital's policy and procedures documented above were reviewed with Staff #2 during a subsequent interview and it was determined the policy was not followed.

Based on review of Patient #4's ED record, hospital policies and procedures, and staff interviews, it was determined the hospital failed to ensure the patient was assessed for priority or monitored appropriately based on his presenting
symptoms. The patient left the ambulance by area in the care of the ambulance crew to be taken to a different hospital without having a Medical Screening Examination.