HospitalInspections.org

Based on a review of the medical record, video recordings, ED log, policies and procedures, and staff interviews, it was determined that the facility failed to provide appropriate treatment within its capacity and capability for 14 patients P(#5,9,11,13,15,20,22,23,24,25,26,27,28,29) out of 30 sampled patients.

Findings were:

Cross refer to A-2406, as it relates to the facility's failure to provide 14 patients P (#5,9,11,13,15,20,22,23,24,25,26,27,28,29) with an appropriate Medical Screening Examination (MSE).

Cross refer A-2407, as it relates to the facility's failure to provide 14 patients P(#5,9,11,13,15,20,22,23,24,25,26,27,28,29) with stabilizing treatment.

Cross refer to A-2408 as it relates to the facility's failure to follow the hospital's work instructions of providing an appropriate MSE before inquiries about individual's insurance or payment status of 7 patients P(#5,9,11,13,20,22,29).

Based on a review of the medical record, video recordings, Emergency Department (ED) log, policies and procedures, Emergency Medical Services (EMS) trip report, and staff interviews, it was determined that the facility failed provide 14 patients P (#5,9,11,13,15,20,22,23,24,25,26,27,28,29) out of 30 sampled patients with an appropriate and ongoing Medical Screening Examination (MSE).

Findings were:

Review of the EMS trip report dated 12/5/21 revealed that the EMS crew received a call from a health care provider's office regarding a 50-year-old patient who needed to be transported to an emergency room. The report indicated that the crew arrived at the patient's side at 5:34 p.m. Patient (P) #13 was in a room on a hospital-type bed on the arrival of the EMS crew. The report noted that P#13 had been driving when she started having chest pain and shortness of breath, P#13 went to the health care provider's office (urgent care center) for evaluation and treatment. The urgent care center treated P#13 and ordered her to be transported to the ED for further assessment and treatment. P#13 was transported on the stretcher with all belts in place. Patient (P) #13's vital signs (temperature, pulse/heart rate, respiration, blood pressure, and oxygen saturation) were within normal limits. The report indicated that Patient #1 was a low acuity (severity) and that the patient had no change in condition enroute to the hospital. Documentation revealed the ambulance arrived at the hospital at 5:56 p.m. P#13 was turned over to paramedic pair in the ED hallway due to no ED rooms available.

A review of Patient #13' s ED medical record revealed P#13 arrived in the ED on 12/5/21 at 6:01 p.m. At 6:01:19 p.m. P#13 was registered using quick check-in features by Navigation Specialist (NS) HH, P#13 complaint was chest pain and shortness of breath. At 6:29 p.m. NS HH completed P#13's registration. P#13 signed the facility's request for treatment and authorization form at 6:31 p.m.. P#13's registration was completed before triage and MSE.

At 7:00 p.m. The Nurse practitioner (NP) (DD) evaluated P#13, NP DD orders at 7:46 p.m. Included laboratory tests, X-rays, electrocardiogram (EKG) (measures electrical signals in your heart).

At 7:52 p.m. blood work was obtained by Registered Nurse (RN) BB, the triage (assessment by a nurse to determine medical priority) was noted to begin at 7:59 p.m. RN BB triaged P#13 as a level three acuity. P#13 vital signs were as follows: temperature 99.2 degrees (normal 97.8 to 99.0) Fahrenheit, heart rate- 85 beats per minute (normal 60 to 100 beats per minute), respiratory rate-18 breaths per minute, (normal-12 to 20) blood pressure 121/67 (normal 120/80), pulse oximetry (the amount of oxygen in the blood) 100%.

At 8:00 p.m. RN BB noted that P#13 presented with chest pain, shortness of breath, and left flank pain. P#13 had a past medical history of narcolepsy (excessive daytime sleepiness). At 8:02 p.m. RN BB documented P#13 was waiting for room status. At 8:28 p.m. the laboratory tests (metabolic panels, troponin, lipase) results were within normal limits. At 9:55 p.m. EKG was performed on P#13, the EKG result at 11:16 p.m. was normal findings.

On 12/6/21 at 12:35 am, P#13 was dismissed from the facility, RN BB removed P#13's intravenous (IV) from her right hand and selected P#13's disposition as ED AMA (against medical advice). Further review of P#13's medical record failed to reveal whether P#13 signed or refused to sign an AMA form. A review of the medical record failed to reveal the discussion of the risks of refusing treatment.

Review of the facility's video recording of P#13 dated 12/5/21 revealed the following:

1. The video titled "028 EC Triage Hall" on 12/5/21 at 5:58 p.m. revealed two EMS crew members pushing P#13 on a stretcher across the ED hallway. At 1.33 seconds, the EMS crew member was a female pulling the stretcher wearing a black shirt and pants and a male crew wearing a white shirt. P#13 appeared to be a white female with a purple bag, wearing a blue hospital robe.

2. The video titled "033 EC Lobby" on 12/5/21 at 7:05 p.m. revealed a facility staff pushing P#13 on a blue wheelchair to the waiting room. At 1:19 seconds, the staff dropped P#13's purple bag at the side of the waiting room's door and assisted P#13 to get out of the wheelchair.

3. The video titled "035 EC Waiting Room-Triage -Leaving" on 12/6/21 at 12:24 am revealed P#13 was standing at the ED's receptionist desk. At 1:15 seconds, P#13 was directed to the triage area by the receptionist. P#13 was wearing a green sweater, blue pants and had a gray bag on her shoulder.

4. The video titled "036 EC Waiting- Triage- Leaving" on 12/6/21 at 12:24 am revealed a nurse removing an IV catheter from the back of P#13's hand at 0.03 seconds. At 0.43 seconds, the facility nurse appeared to have completely removed the catheter, and P#13 gave her the hospital rope. P#13 left the triage area and went towards the waiting room.

5. The video titled "037 EC Left Facility" on 12/6/21 at 12:24 a.m. revealed P#13 walking back into the waiting room from the triage area. Further review revealed at 1:10 seconds, P#13 was leaving the waiting room and exiting the facility. P13 left the facility with a purple bag on her left shoulder, a gray bag on her right hand. She was wearing blue pants and a gray sweater. At 12:42 am, P#13 was seen on the video approaching a white SUV. P#13 entered the back seat of the SUV jeep and left the facility.

A review of the video failed to reveal any attempt by the facility staff to encourage P#13 to stay for treatment.

The video failed to reveal that the facility nurse notified a provider, to educate P#13 on the risk and benefits of the offered examination and treatment.

The review of the video failed to show any reasonable steps to secure P#13 refusal for treatment in writing.

A review of the facility's ED log from 12/5/21 at 12:00 p.m. to 12/6/21 at 2:00 p.m. revealed that out of 95 patients in the ED during this time frame, 22 patients had an AMA disposition. P#13 was noted on the log to arrive at the facility on 12/5/21 at 6:01 p.m., P#13 was discharged on 12/6/21 at 12:35 am. P#13 disposition was AMA.


A review of the facility's policy titled "EMTALA", revised 7/16/2019 revealed that the purpose of the policy is to require that acute care or specialty hospital enrolled in Medicare with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to any individual, including every infant who is born alive, at any stage of development, who comes to the Emergency Department (ED) and requests such examination.

Terms & Definitions:

1. Emergency Medical Condition ("EMC"): A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

2. Medical Screening Examination ("MSE"): The process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists. Screening is to be conducted to the extent necessary, by Physicians and/or other QMP (defined below) to determine whether an EMC exists. The extent of the MSE may vary depending on the individual's signs and symptoms. An appropriate MSE can include a wide spectrum of actions ranging from a simple process only involving a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures. The extent of the necessary examination to determine whether an EMC exists is generally within the judgment and discretion of the Physician or other QMP performing the examination consistent with algorithms or protocols established and approved by the Hospital medical staff and governing board.

Responsibilities:

A. General Requirements
Any Hospital with an emergency department will provide to any individual who "comes to the emergency department" an appropriate MSE within the Capability of the Hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an EMC exists, regardless of the individual's ability to pay when a request is made by or on behalf of the individual for medical care, or a prudent layperson would observe that such care is needed, whether the individual is in the Hospital's Dedicated Emergency Department (DED) or elsewhere on the Hospital's Campus. EMTALA requires the Hospital to do the following:
1. Provide an appropriate MSE to the individual within the Capability of the Hospital to determine
whether or not an EMC exists.

B. Medical Screening Examination (MSE).
1. The Hospital will provide an MSE for an individual who comes to an on-campus DED, requesting examination or treatment for a medical condition or has such request made on his/her behalf, or if based on the individual's appearance or behavior, the individual appears to need an examination or treatment for a medical condition.

2. The MSE is an ongoing process. The medical record will reflect an ongoing assessment of the
individual's condition. Monitoring of the individual will continue until the individual.
(i) is Stabilized. (ii) is admitted to the Hospital. (iii) is appropriately transferred, if an EMC exists and the individual requires care and treatment that exceeds the Hospital's capabilities. (iv) is discharged. (v) expires. The MSE process must be documented in the medical record.

C. When the Individual Leaves Before the EMTALA Obligation is Met.

If the Individual Does Not Consent to Examination or Treatment. If the Hospital offers Triage, an MSE, and/or stabilizing treatment and informs the individual of the risks/benefits to the individual of the examination and treatment, but the individual does not consent to the examination and treatment, the Hospital will take all reasonable steps to have the individual sign a "Refusal to Permit Triage, Medical Examination, Treatment or Transfer" form. If such an individual refuses to sign the Refusal to Permit Triage, Medical Examination, Treatment or Transfer form, Hospital staff will document the steps taken to secure the individual's written informed refusal. In the case of the individual who refuses examination and/or treatment following Triage, the Hospital will use its best efforts to complete the individual's registration, open a medical record, the document offers made to the individual that he or she undergo further medical examination and treatment as may be required to identify and stabilize an EMC, log the individual into the Central Log (or EMTALA Log), document discussions with the individual regarding the risks and benefits involved in leaving prior to the medical screening and/or treatment and describe in the medical record the examination and treatment that was refused. If such an individual refuses to sign the Refusal to Permit Triage, Medical Examination, Treatment or Transfer form, Hospital staff will document the steps taken to secure the individual's written informed refusal. Hospital personnel involved with the individual's care and/or other personnel (for example, registrar personnel, triage nurse) who witness or are made aware that an individual has departed from the DED without signing the Refusal to Permit Triage, Medical Examination, Treatment, or Transfer form may complete the forms.


A review of the facility's policy titled "Patient Throughput (Admission through Discharge)", revised 8/23/18 revealed that the purpose of the policy is to define the process for the admission, transfer, and discharge of patients to, from, and within the hospital.

Discharge Against Medical Advice
1. Any patient of sound mind who insists on leaving the hospital without a physician's order will be requested to sign the appropriate form.
2. The medical record for the patient will then be handled as in a routine discharge. The patient's nurse will write a discharge note specifying the patient is of sound mind and insists on leaving "Against Medical Advice".
3. The attending physician must be notified of the patient's intent to leave against medical advice as soon as possible.

A telephone interview was initiated with the complainant on 1/10/22 at 1:10 p.m. She explained that she went to the facility's ED via an ambulance from nearby urgent care. The complaint said that she barely got into the hospital less than 15 minutes when a facility staff asked her for insurance information and thereafter, they left her waiting on a gurney near a back elevator for about 45 minutes before she saw a nurse. The complainant said she saw other patients as well, left on the beds without being attended to by the facility's staff. The complainant said that the nurse came after a while and asked the EMT that brought her what was her complaint. The EMT said chest pain, shortness of breath, and flank pain. The complainant said the nurse did not ask her directly about her complaint. She explained that this was after they had asked her about her insurance and waited for a long time. She said after waiting for 7 hours she told the triage nurse she was leaving; the complainant said the triage nurse was very rude, took the IV off her hand, and told her she can leave. She said she never saw a provider. The complainant explained that she went to the hotel and contacted her family who took her to another facility where she received treatment.


An interview with the facility's ED Manager (MG) (KK) took place on 1/11/22 at 3:35 p.m. MG KK said that when a patient comes in the ED with an ambulance, the ambulance staff will weigh the patient on the scale, register the patient and charge nurse would be notified about patient's arrival. MG KK said the charge nurse will decide if the patient should be taken directly to the room, stay in he hallway, or triage area. MG KK said if the patient was in the hallway the ambulance staff will provide the nurse assigned to the hallway a report, who will assess the patient and wait for the provider's order. MG KK said medical screening examinations start when the provider sees the patient. MG KK further explained that in a scenario where the provider started MSE, and the patient insisted on leaving it will be considered leaving against medical advice (AMA). MG KK stated she expected her nurse would encourage the patient and try to let them stay, but if the patient insisted on leaving the staff would make effort to let the patient sign an AMA form. MG KK stated that if the patient chooses to sign the AMA form the staff would attach the signed AMA form to the patient medical record however based on her experience most times the patient would refuse to sign the form. MG KK further explained that if the patient refuses to sign the form her expectation is for her staff to notify the provider and indicate the patient's disposition as AMA on EPIC (electronic health record). MG KK said the AMA form does not have to be documented and included in the patient's medical record if the patient had refused to sign it. MG KK explained that in her practice she would attempt to ensure the patient sign an AMA form, notify the provider, her charge nurse, and document the encounter in her nurse note. However, her baseline expectation from her staff is for them to choose patient disposition as AMA and notify the provider.


During an interview with AVP (Associate Vice President) AA on 1/11/22 at 4:10 p.m. in the facility's conference room, AVP AA said she did not have any direct contact with patients coming in the ED, she said she was responsible for many departments in the hospitals and that the ED Director (Dir JJ) reports to her. AVP said ultimately, she was responsible for everything that was going on in the ED including ED policies. AVP AA said regarding the AMA form it was not set as an expectation for the ED nurse to print the AMA form, have the patient sign it, and upload it in the patient's chart. AVP AA said that the expectation was for the assigned ED nurse to document the disposition. AVP AA said rapid treatment starts in the front with a triage nurse and a midlevel provider in the triage area, AVP AA said that the facility did not set an expectation for the triage nurse to notify the midlevel provider that a patient left or was leaving AMA at the front end because the midlevel provider works together with the nurse and aware of everything going on. AVP further explained that if the patient was assigned a physician at the back end and the physician accepted the patient then the provider or the nurse must fill out the AMA form regardless of if the patient refused to sign and upload the AMA form in the patient's medical record with notes explaining the patient's decision to leave AMA. AVP said in any case when a patient said the waiting period was too long and indicated he or she was leaving, the expectation was for the nurse to talk to the patient and try to make the patient stay and document it. AVP AA said so frequently, the nurse did not realize the patient was gone until the patient was called because there was so much going on in the ED. AVP AA said they put a person at the ED entrance to try to talk to any patient trying to leave as part of the solution as they were getting a lot of AMA complaints. AVP AA said they have been having discussions about AMA's during huddles and have been actively tracking the AMA trends for the last 7-8 weeks and despite doing things at the waiting room to lower the AMA's it had been a lot of struggles due to the hospital's capacity in the last couple of months. AVP AA explained that most of the AMA's had been associated with waiting time, due to backlog and a lot of patients not leaving the inpatient hold at the ED. AVP AA said due to COVID the facility had been having a very high staff turnover.



An interview with the facility's ED Director (Dir) (JJ) took place on 1/11/22 at 4:49 p.m. Dir JJ had been the facility's director for eight years and his role is to oversee the daily operations of the department along with the leadership team. Dir JJ explained that if a patient with chest pain and shortness of breath is presented to the ED by EMS the patient is identified at the communication desk, weighed and two nurses are assigned to the patient to complete the triage process, the provider is notified to start the medical screening examination. Dir JJ said if a patient decided to leave against medical advice, he expect the nurse to explain the risks and get the provider to talk to the patient. Dir JJ explained that if the patient insisted the staff would ask the patient to sign an AMA form and if the patient refuses to sign, he would expect the nurse to document that patient refuses to sign and choose the patient disposition as AMA. Dir JJ explained that with the new electronic health record used by the facility, the staff may click patients' disposition as AMA and are not mandated to document the encounter in the note. Dir JJ explained that the facility has had an increased number of patients leaving against medical advice due to an increase in wait time and a backlog of patients. Dir JJ further explained that Dir JJ and MD LL had been working on how they would decrease the wait time by getting providers to see more patients at the fast track (a designated area where lower acuity ED patients are rapidly seen). Dir JJ said all the staff had EMTALA training upon hire and annually.

A telephone interview was conducted with the Registered Nurse (RN) II on 1/12/22 at 9:18 a.m. RN II explained that she does triage assessments. RN II said when a patient comes in through EMS complaining of chest pain and shortness of breath, the nurse will assess the patient after getting the report from the EMS crew, take the patient vital signs, EKG and start drawing labs based on the provider's order. RN II explained that if the patient decides to leave during the process of determining whether they have an emergency medical condition, she will talk the patient out of leaving and try to get them to stay. RN II further explain that if the patient insisted on leaving, she would notify the provider and encourage the patient to sign an AMA form. RN II said that if the patient refuses to sign the form she will document the encounter in her note. RN II explained that since the COVID surge it has been common to have so many patients in the ED and it is very common to have a nurse caring for more than 10 patients which hinders them from documenting thoroughly. RN II said the facility is short-staffed and does not always have a tech working at night. RN II said that EMTALA training was included in her orientation packet.


A telephone interview took place with RN BB on 1/12/22 at 9:45 am in the conference room. RN BB explained that she had been working at the facility's ED for the last ten months. RN BB explained that if a patient present to the ED by ambulance complaining of chest pain and dyspnea (shortness of breath) she would check patient vitals, put on order for EKG, take labs and notify the provider to start the medical screening exam. RN BB explained that during the process if the patients decided to leave, she would encourage them to stay and if the patient insisted, she would call the midlevel providers or physicians and they would try to advise the patient to stay and present an AMA form to the patient. RN BB explained that if the patient signed the form, she would scan it into the patient's medical record but if the patient refuses to sign she would make a note in the chart that the patient refuses to sign. RN BB explained that the staff is not obligated to scan the AMA form into patients' charts if they refuse to sign it and that she would only document in the nurse note that the patient refuses to sign.

A telephone interview with RN CC took place on 1/12/22 at 10:05 am. RN CC said he had been working for 2 years at the facility. RN CC explained that if a patient presents via EMS with a complaint of dyspnea and chest pain the process is to get the patient registered, triage by the nurse who will order an EKG, and seen by a midlevel provider. RN CC said if the patient wants to leave, he will notify the mid-level, who will explain the risk of leaving against medical advice to the patient. RN CC explained that if the patient was competent in making a decision and verbalize understanding the risks, he would encourage them to sign the AMA form and include the form in the patient's medical record. RN CC said if the patient refuses to sign he would document the encounter in the nurse note and disposition of the patient as AMA. RN CC said EMTALA training was done annually and during orientation.

During an interview with the ED (emergency department) Medical Director (MD), MD LL on 1/12/22 at 11:05 a.m., MD LL stated he was a medical director for the ED for about five years. He said when a patient came to the ED with chest pain there were no established and specific steps to approach the patient, it was all dependent on the clinical presentation. MD LL said chest pain may indicate more than one thing if the patient had chest pain associated with other pain like flank pain or the patient had chest pain and sweating; he said in either presentation the patient was to get some basic works done such as an EKG ( electrocardiogram that indicated how the heart was working), radiology study, order some basic lab/blood works all these would step to take after intake. MD LL said some of these may not be immediately necessary in the case of a patient coming from another facility and if for instance the EKG had already been done. MD LL said if a patient in the ED decided to leave due to waiting time, he expected the nurse assigned to this patient to notify the provider and that the provider was to deescalate the situation by trying to explain the process to the patient including the risk of leaving without getting a full evaluation and document in the notes that the patient was advised of the risk and that the patient decided to leave. MD LL said there should be some verbiage in the notes regarding the patient's leaving. That was his expectation. However, MD LL said he recognized this can be difficult to get the patient to even stay to talk to the provider. MD LL said there was a standard AMA form for the patient to sign and document that patient refused to sign. MD LL said there should be some notes indicating the patient was made aware of the risk of leaving AMA.

An interview with the Accreditation Manager (AM) (QQ) took place on 1/12/22 at 3:44 p.m. AM QQ said that discussions about AMA and LWOT occur during morning huddles, but the data are not rolled up to committee meetings. AM QQ explained that before COVID the ED quality committee meets physically but recently they have been doing it virtually and there are no minutes of the meetings.

A review of 13 additional medical records (#5,9,11,15,20,22,23,24,25,26,27,28,29) revealed the following:

P#5 arrived in the facility's ED on 8/7/21 at 5:09 p.m., NS NN created an encounter and did a quick registration at 5:09:04 p.m.. P#5 signed the facility's request for treatment and authorization form at 5: 10 p.m., NS NN completed P#5 registration at 5:14 p.m.. P#5 was triaged at 5:26 p.m. and evaluated by a provider at 5:28 p.m.. Complete registration was done before the medical screening exam (MSE). ED disposition was AMA, review of record failed to reveal a signed AMA form.

P#9 arrived in the facility's ED on 12/5/21 at 4:31 p.m., NS MM created an encounter and did a quick registration at 4:31 p.m.. NS MM completed P#9 registration at 4:57 p.m., P#9 signed the facility's request for treatment and authorization form at 5:33 p.m. P# 9 was called to triage at 6:01 p.m.. P#9 was dismissed, and ED disposition was set as AMA on 12/6/21 at 12:21 am. RN noted P#9 was called twice. NS MM completed P#9 registration before triage and MSE. P#9 didn't encounter a provider on this visit.

P#11 arrived in the facility's ED on 12/5/21 at 5:32 p.m., NS MM created an emergency encounter at 5:32 p.m. and P#11 signed the facility's request for treatment form at 5:33 p.m.. NS MM completed P# 11 registration including insurance verification at 5:36 p.m., P#11 first encounter with the provider (NP DD) was at 5:41 p.m.. NP DD noted that P#11 was referred to the ED by a physician for direct admission secondary to vaginal bleeding. NP DD documented she explained to P#11 that the hospital was full, and P#11 had to wait. P#11 said she would wait at home and come back the next day. NP DD noted she explained to P#11 it would be better for her to stay today if that is what her doctor wants. P#11 was dismissed, and ED disposition was set as AMA on 12/5/21 at 6:40 p.m. Further review of P#11's record failed to reveal a sign AMA form by the patient.

P#15 arrived in the facility's ED on 12/6/21 at 4:59 am, emergency encounter was created at 4:59 am. First provider encounter at 5:20 am. P#15 was dismissed at 5:57 am, ED disposition set as AMA. No documentation showing where the patient signed an AMA form, nor any conversation between the provider and the patient regarding the risk of the decision to leave against medical advice.

P#20 arrived at the facility on 9/22/21 at 6:48 am with a complaint of abdominal pain, emergency encounter with the navigation specialist was created at 6:47 am. P#20 complete registration including insurance verification was done at 6:49 am. At 6:56 am triage started, P#20 encounter with a provider was at 7:02 am. P#20 was discharged at 2:50 p.m., ED disposition set as both eloped and AMA. Further review of P#20's medical record revealed P#20 left AMA. RN documented that P#20 was agitated, pulled out intermittent needle therapy (INT), threw a catheter on the bed, and stormed out of the room. P#20 was found at the nurse's desk with blood dripping down his arm, gauze applied to where INT was taken out and P#20 was shown the way to the ED waiting room. RN noted P#20 left AMA. There was no evidence P#20 was asked to sign an AMA form or was notified of the risk of leaving the facility against medical advice.

P#22 arrived at the facility on 12/14/21 at 3:54 p.m., emergency encounter with NS MM was created at 3:54 p.m.. NS MM completed P#22's registration including insurance verification at 3:55 p.m.. P#22 first encounter with a provider was at 4:05 p.m., triage started at 4:17 p.m.. On 12/15/21 at 4:21 am RN CC documented that P#22 was called in the ED waiting room and no response was received, provider and charge nurse was notified, no AMA form was signed by the patient. ED disposition set as AMA at 4:21 am.

P#23 arrived at the facility on 01/04/22 at 9:16 p.m. with a complaint of abdominal pain, emergency encounter was created at 9:16 p.m.. P#23 was evaluated by a provider at 9:16 p.m.. Triage started at 9:29 p.m.. Registration was completed at 10:58 p.m. and P#23 was dismissed from the hospital on 1/5/22 at 2:39 am. ED disposition was set as AMA by RN II. Further review failed to reveal that P#23 signed the AMA form, no evidence that P#23 was notified of the risk of leaving the facility. There was no documented evidence that P#23 was called and no response was received. There was no evidence that RN II notify the provider that P#23 left the facility against medical advice.

P#24 arrived in the facility's ED on 1/4/22 at 10:48 p.m., emergency encounter was created at 10:48 p.m.. First provider encounter at 11:50 p.m.. Triage started at 11:53 p.m.. Registration was completed on 1/5/22 at 12:28 am, P#24 was dismissed at 2:27 am, ED disposition was set as AMA. Further review failed to reveal a sign of refusal to sign the AMA form, no evidence that P#24 was notified of the risk of leaving the facility. There was no documented evidence that P#24 was called, and no response was received. No evidence that the provider was notified that P#24 left the facility against medical advice.

P#25 arrived in the facility's ED on 1/4/22 at 10: 31 p.m., emergency encounter was created at 10:31 p.m. by NS HH. provider encounter at 11:36 p.m.. Triage started at 11:36 p.m.. Registration was completed at 11:58 p.m.. P#25 was dismissed on 1/5/22 at 2:55 am, ED disposition set as AMA. Further review failed to reveal a sign of refusal to sign AMA form, no evidence that P#25 was notified of the risk of leaving the facility. There was no documented evidence that P#25 was called, and no response was received. No evidence that the provider was notified that P#25 left the facility against medical advice.

P#26 arrived at the facility on 11/25/21 at 5:53 p.m. with the complaint of a motor vehicle crash, the emergency encounter with NS MM was created at 5:53 p.m.. Triage started at 6:12 p.m., provider encountered P#26 at 6:20 p.m.. NS MM completed P#26's registration at 6:26 p.m.. RN CC documented that P#26 was called in the ED waiting room and no response was received, provider and charge nurse was notified, no AMA form was signed by the patient. ED disposition set as AMA at 8:01 p.m..

P#27 arrived in the facility's ED on 12/25/21 at 12:48 p.m., emergency encounter was created at 12:48 p.m. by NS MM. provider encounter at 12:55 p.m.. Triage started at 12:58 p.m.. P#27 was dismissed at 4:36 p.m., ED disposition set as AMA. Further review failed to reveal that P#27 refused to sign the AMA form, no evidence that P#27 was notified of the risk of leaving the facility.

P#28 arrived in the facility's ED on 11/13/21 at 1:06 p.m. complaining of shortness of breath and headache, emergency encounter was created at 1:06 p.m.. First provider encounter at 1:34 p.m.. Triage started at 1:36 p.m.. P#28 was dismissed on 11/14/21 at 2:14 am, ED disposition set as AMA. Further review failed to reveal a sign of refusal to sign the AMA form, no evidence that P#28 was notified of the risk of leaving the facility. There was no documented evidence that P#28 was called, and no response was received. No evidence that the provider was notified that P#28 left the facility against medical advice.

P#29 arrived at the facility on 11/7/21 at 12:43 p.m. due to a motor vehicle crash, emergency encounter was created at 12:43 p.m.. P#29 registration was completed at 12:50 p.m.. P#29 first encounter with a provider was at 2:48 p.m., triage started at 3:37 p.m.. RN CC docume

Based on a review of the medical record, video recordings, Emergency Department (ED) log, policies and procedures, Emergency Medical Services (EMS) trip report, staff interviews, it was determined that the facility failed provide 14 patients P (#5,9,11,13,15,20,22,23,24,25,26,27,28,29) out of 30 sampled patients with an explanation of risks verses benefits of leaving the ED prior to stabilization of their emergency medical condition.

Findings were:

Review of the EMS trip report dated 12/5/21 revealed that the EMS crew received a call from a health care provider's office regarding a 50-year-old patient who needed to be transported to an emergency room. The report indicated that the crew arrived at the patient's side at 5:34 p.m. Patient (P) #13 was in a room on a hospital-type bed on the arrival of the EMS crew. The report noted that P#13 had been driving when she started having chest pain and shortness of breath, P#13 went to the health care provider's office (urgent care center) for evaluation and treatment. The urgent care center treated P#13 and ordered her to be transported to the ED for further assessment and treatment. Documentation revealed the ambulance arrived at the hospital at 5:56 p.m. P#13 was turned over to paramedic pair in the ED hallway due to no room's availability.

A review of Patient #13' s ED medical record revealed P#13 arrived in the ED on 12/5/21 at 6:01 p.m. At 6:01:19 p.m. P#13 was registered using quick check-in features by Navigation Specialist (NS) HH, P#13 complaint was chest pain and shortness of breath. At 6:29 p.m. NS HH completed P#13's registration. P#13 signed the facility's request for treatment and authorization form at 6:31 p.m.. P#13's registration was completed before triage and MSE.

At 7:00 p.m. The Nurse practitioner (NP) (DD) evaluated P#13, NP DD orders at 7:46 p.m. Included laboratory tests, X-rays, electrocardiogram (EKG) (measures electrical signals in your heart).

On 12/6/21 at 12:35 am, P#13 was dismissed from the facility, RN BB removed P#13's IV from her right hand and selected P#13's disposition as ED AMA (against medical advice). Further review of P#13's medical record failed to reveal whether P#13 signed or refused to sign an AMA form. A review of the medical record failed to reveal the discussion of the risks of refusing treatment.

Review of the facility's video recording of P#13 dated 12/5/21 revealed the following:

1. The video titled "028 EC Triage Hall" on 12/5/21 at 5:58 p.m. revealed two EMS crew members pushing P#13 on a stretcher across the ED hallway. At 1.33 seconds, the EMS crew member was a female pulling the stretcher wearing a black shirt and pants and a male crew wearing a white shirt. P#13 appeared to be a white lady with a purple bag, wearing a blue hospital rope.

2. The video titled "033 EC Lobby" on 12/5/21 at 7:05 p.m. revealed a facility staff pushing P#13 on a blue wheelchair to the waiting room. At 1:19 seconds, the staff dropped P#13's purple bag at the side of the waiting room's door and assisted P#13 to get out of the wheelchair.

3. The video titled "035 EC Waiting Room-Triage -Leaving" on 12/6/21 at 12:24 am revealed P#13 was standing at the ED's receptionist desk. At 1:15 seconds, P#13 was directed to the triage area by the receptionist. P#13 was wearing a green sweater, blue pants and had a gray bag on her shoulder.

4. The video titled "036 EC Waiting- Triage- Leaving" on 12/6/21 at 12:24 am revealed a nurse removing an IV catheter from the back of P#13's hand at 0.03 seconds. At 0.43 seconds, the facility nurse appeared to have completely removed the catheter, and P#13 gave her the hospital rope. P#13 left the triage area and went towards the waiting room.

5. The video titled "037 EC Left Facility" on 12/6/21 at 12:24 a.m. revealed P#13 walking back into the waiting room from the triage area. Further review revealed at 1:10 seconds, P#13 was leaving the waiting room and exiting the facility. P13 left the facility with a purple bag on her left shoulder, a gray bag on her right hand. She was wearing blue pants and a gray sweater. At 12:42 am, P#13 was seen on the video approaching a white SUV. P#13 entered the back seat of the SUV jeep and left the facility.

A review of the video failed to reveal any attempt by the facility staff to encourage P#13 to stay for treatment.

The video failed to reveal that the facility nurse notified a provider, to educate P#13 on the risk and benefits of the offered examination and treatment.

The review of the video failed to show any reasonable steps to secure P#13 refusal for treatment in writing.

A review of the facility's ED log from 12/5/21 at 12:00 p.m. to 12/6/21 at 2:00 p.m. revealed that out of 95 patients in the ED during this time frame, 22 patients had an AMA disposition. P#13 was noted on the log to arrive at the facility on 12/5/21 at 6:01 p.m., P#13 was discharged on 12/6/21 at 12:35 am. P#13 disposition was AMA.

A review of the facility's policy titled "EMTALA", revised 7/16/2019 revealed that the purpose of the policy is to require that acute care or specialty hospital enrolled in Medicare with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to any individual, including every infant who is born alive, at any stage of development, who comes to the Emergency Department (ED) and requests such examination.

Terms & Definitions:

1. Emergency Medical Condition ("EMC"): A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

Responsibilities:

2. The MSE is an ongoing process. The medical record will reflect an ongoing assessment of the
individual's condition. Monitoring of the individual will continue until the individual.
(i) is Stabilized. (ii) is admitted to the Hospital. (iii) is appropriately transferred, if an EMC exists and the individual requires care and treatment that exceeds the Hospital's capabilities. (iv) is discharged. (v) expires. The MSE process must be documented in the medical record.

C. When the Individual Leaves Before the EMTALA Obligation is Met.

If the Individual Does Not Consent to Examination or Treatment. If the Hospital offers Triage, an MSE, and/or stabilizing treatment and informs the individual of the risks/benefits to the individual of the examination and treatment, but the individual does not consent to the examination and treatment, the Hospital will take all reasonable steps to have the individual sign a "Refusal to Permit Triage, Medical Examination, Treatment or Transfer" form. If such an individual refuses to sign the Refusal to Permit Triage, Medical Examination, Treatment or Transfer form, Hospital staff will document the steps taken to secure the individual's written informed refusal. In the case of the individual who refuses examination and/or treatment following Triage, the Hospital will use its best efforts to complete the individual's registration, open a medical record, the document offers made to the individual that he or she undergo further medical examination and treatment as may be required to identify and stabilize an EMC, log the individual into the Central Log (or EMTALA Log), document discussions with the individual regarding the risks and benefits involved in leaving prior to the medical screening and/or treatment and describe in the medical record the examination and treatment that was refused. If such an individual refuses to sign the Refusal to Permit Triage, Medical Examination, Treatment or Transfer form, Hospital staff will document the steps taken to secure the individual's written informed refusal. Hospital personnel involved with the individual's care and/or other personnel (for example, registrar personnel, triage nurse) who witness or are made aware that an individual has departed from the DED without signing the Refusal to Permit Triage, Medical Examination, Treatment, or Transfer form may complete the forms.

A review of the facility's policy titled "Patient Throughput (Admission through Discharge)", revised 8/23/18 revealed that the purpose of the policy is to define the process for the admission, transfer, and discharge of patients to, from, and within the hospital.

Discharge Against Medical Advice
1. Any patient of sound mind who insists on leaving the hospital without a physician's order will be requested to sign the appropriate form.
2. The medical record for the patient will then be handled as in a routine discharge. The patient's nurse will write a discharge note specifying the patient is of sound mind and insists on leaving "Against Medical Advice".
3. The attending physician must be notified of the patient's intent to leave against medical advice as soon as possible.

A telephone interview was initiated with the complainant on 1/10/22 at 1:10 p.m. She explained that she went to the facility's ED via an ambulance from nearby urgent care. She said after waiting for 7 hours she told the triage nurse she was leaving; the complainant said the triage nurse was very rude, took the IV off her hand, and told her she can leave. She said she never saw a provider. The complainant explained that she went to the hotel and contacted her family who took her to another facility where she received treatment.

An interview with the facility's ED Manager (MG) (KK) took place on 1/11/22 at 3:35 p.m. MG KK said medical screening examinations start when the provider sees the patient. MG KK further explained that in a scenario where the provider started MSE, and the patient insisted on leaving it will be considered leaving against medical advice (AMA). MG KK stated she expected her nurse would encourage the patient and try to let them stay, but if the patient insisted on leaving the staff would make effort to let the patient sign an AMA form. MG KK stated that if the patient chooses to sign the AMA form the staff would attach the signed AMA form to the patient medical record however based on her experience most times the patient would refuse to sign the form. MG KK further explained that if the patient refuses to sign the form her expectation is for her staff to notify the provider and indicate the patient's disposition as AMA on EPIC (electronic health record). MG KK said the AMA form does not have to be documented and included in the patient's medical record if the patient had refused to sign it. MG KK explained that in her practice she would attempt to ensure the patient sign an AMA form, notify the provider, her charge nurse, and document the encounter in her nurse note. However, her baseline expectation from her staff is for them to choose patient disposition as AMA and notify the provider.

During an interview with AVP (Associate Vice President) AA on 1/11/22 at 4:10 p.m. in the facility's conference room, AVP AA said she did not have any direct contact with patients coming in the ED, she said she was responsible for many departments in the hospitals and that the ED Director (Dir JJ) reports to her. AVP said ultimately, she was responsible for everything that was going on in the ED including ED policies. AVP AA said regarding the AMA form it was not set as an expectation for the ED nurse to print the AMA form, have the patient sign it, and upload it in the patient's chart. AVP AA said that the expectation was for the assigned ED nurse to document the disposition. AVP AA said rapid treatment starts in the front with a triage nurse and a midlevel provider in the triage area, AVP AA said that the facility did not set an expectation for the triage nurse to notify the midlevel provider that a patient left or was leaving AMA at the front end because the midlevel provider works together with the nurse and aware of everything going on. AVP further explained that if the patient was assigned a physician at the back end and the physician accepted the patient then the provider or the nurse must fill out the AMA form regardless of if the patient refused to sign and upload the AMA form in the patient's medical record with notes explaining the patient's decision to leave AMA. AVP said in any case when a patient said the waiting period was too long and indicated he or she was leaving, the expectation was for the nurse to talk to the patient and try to make the patient stay and document it. AVP AA said so frequently, the nurse did not realize the patient was gone until the patient was called because there was so much going on in the ED. AVP AA said they put a person at the ED entrance to try to talk to any patient trying to leave as part of the solution as they were getting a lot of AMA complaints. AVP AA said they have been having discussions about AMA's during huddles and have been actively tracking the AMA trends for the last 7-8 weeks and despite doing things at the waiting room to lower the AMA's it had been a lot of struggles due to the hospital's capacity in the last couple of months. AVP AA explained that most of the AMA's had been associated with waiting time, due to backlog and a lot of patients not leaving the inpatient hold at the ED. AVP AA said due to COVID the facility had been having a very high staff turnover.

An interview with the facility's ED Director (Dir) (JJ) took place on 1/11/22 at 4:49 p.m. Dir JJ had been the facility's director for eight years and his role is to oversee the daily operations of the department along with the leadership team. Dir JJ said if a patient decided to leave against medical advice, he expect the nurse to explain the risks and get the provider to talk to the patient. Dir JJ explained that if the patient insisted the staff would ask the patient to sign an AMA form and if the patient refuses to sign, he would expect the nurse to document that patient refuses to sign and choose the patient disposition as AMA. Dir JJ explained that with the new electronic health record used by the facility, the staff may click patients' disposition as AMA and are not mandated to document the encounter in the note. Dir JJ explained that the facility has had an increased number of patients leaving against medical advice due to an increase in wait time and a backlog of patients. Dir JJ further explained that Dir JJ and MD LL had been working on how they would decrease the wait time by getting providers to see more patients at the fast track (a designated area where lower acuity ED patients are rapidly seen). Dir JJ said all the staff had EMTALA training upon hire and annually.

A telephone interview was conducted with the Registered Nurse (RN) II on 1/12/22 at 9:18 a.m. RN II explained that she does triage assessments. RN II explained that if the patient decides to leave during the process of determining whether they have an emergency medical condition, she will talk the patient out of leaving and try to get them to stay. RN II further explain that if the patient insisted on leaving, she would notify the provider and encourage the patient to sign an AMA form. RN II said that if the patient refuses to sign the form she will document the encounter in her note. RN II explained that since the COVID surge it has been common to have so many patients in the ED and it is very common to have a nurse caring for more than 10 patients which hinders them from documenting thoroughly. RN II said the facility is short-staffed and does not always have a tech working at night. RN II said that EMTALA training was included in her orientation packet.

A telephone interview took place with RN BB on 1/12/22 at 9:45 am in the conference room. RN BB explained that she had been working at the facility's ED for the last ten months. RN BB explained that if a patient present to the ED by ambulance complaining of chest pain and dyspnea (shortness of breath) she would check patient vitals, put on order for EKG, take labs and notify the provider to start the medical screening exam. RN BB explained that during the process if the patients decided to leave, she would encourage them to stay and if the patient insisted, she would call the midlevel providers or physicians and they would try to advise the patient to stay and present an AMA form to the patient. RN BB explained that if the patient signed the form, she would scan it into the patient's medical record but if the patient refuses to sign she would make a note in the chart that the patient refuses to sign. RN BB explained that the staff is not obligated to scan the AMA form into patients' charts if they refuse to sign it and that she would only document in the nurse note that the patient refuses to sign.

A telephone interview with RN CC took place on 1/12/22 at 10:05 am. RN CC said he had been working for 2 years at the facility. RN CC said if the patient wants to leave, he will notify the mid-level, who will explain the risk of leaving against medical advice to the patient. RN CC explained that if the patient was competent in making a decision and verbalize understanding the risks, he would encourage them to sign the AMA form and include the form in the patient's medical record. RN CC said if the patient refuses to sign he would document the encounter in the nurse note and disposition of the patient as AMA. RN CC said EMTALA training was done annually and during orientation.

During an interview with the ED (emergency department) Medical Director (MD), MD LL on 1/12/22 at 11:05 a.m., MD LL stated he was a medical director for the ED for about five years. He said when a patient came to the ED with chest pain there were no established and specific steps to approach the patient, it was all dependent on the clinical presentation. MD LL said if a patient in the ED decided to leave due to waiting time, he expected the nurse assigned to this patient to notify the provider and that the provider was to deescalate the situation by trying to explain the process to the patient including the risk of leaving without getting a full evaluation and document in the notes that the patient was advised of the risk and that the patient decided to leave. MD LL said there should be some verbiage in the notes regarding the patient's leaving. That was his expectation. However, MD LL said he recognized this can be difficult to get the patient to even stay to talk to the provider. MD LL said there was a standard AMA form for the patient to sign and document that patient refused to sign. MD LL said there should be some notes indicating the patient was made aware of the risk of leaving AMA.

An interview with the Accreditation Manager (AM) (QQ) took place on 1/12/22 at 3:44 p.m. AM QQ said that discussions about AMA and LWOT occur during morning huddles, but the data are not rolled up to committee meetings. AM QQ explained that before COVID the ED quality committee meets physically but recently they have been doing it virtually and there are no minutes of the meetings.

A review of 13 additional medical records (#5,9,11,15,20,22,23,24,25,26,27,28,29) revealed the following:

P#5 arrived in the facility's ED on 8/7/21 at 5:09 p.m., NS NN created an encounter and did a quick registration at 5:09:04 p.m.. P#5 signed the facility's request for treatment and authorization form at 5: 10 p.m., NS NN completed P#5 registration at 5:14 p.m.. P#5 was triaged at 5:26 p.m. and evaluated by a provider at 5:28 p.m.. Complete registration was done before the medical screening exam (MSE). ED disposition was AMA, review of record failed to reveal a signed AMA form.

P#9 arrived in the facility's ED on 12/5/21 at 4:31 p.m., NS MM created an encounter and did a quick registration at 4:31 p.m.. NS MM completed P#9 registration at 4:57 p.m., P#9 signed the facility's request for treatment and authorization form at 5:33 p.m. P# 9 was called to triage at 6:01 p.m.. P#9 was dismissed, and ED disposition was set as AMA on 12/6/21 at 12:21 am. RN noted P#9 was called twice. NS MM completed P#9 registration before triage and MSE. P#9 didn't encounter a provider on this visit.

P#11 arrived in the facility's ED on 12/5/21 at 5:32 p.m., NS MM created an emergency encounter at 5:32 p.m. and P#11 signed the facility's request for treatment form at 5:33 p.m.. NS MM completed P# 11 registration including insurance verification at 5:36 p.m., P#11 first encounter with the provider (NP DD) was at 5:41 p.m.. NP DD noted that P#11 was referred to the ED by a physician for direct admission secondary to vaginal bleeding. NP DD documented she explained to P#11 that the hospital was full, and P#11 had to wait. P#11 said she would wait at home and come back the next day. NP DD noted she explained to P#11 it would be better for her to stay today if that is what her doctor wants. P#11 was dismissed, and ED disposition was set as AMA on 12/5/21 at 6:40 p.m. Further review of P#11's record failed to reveal a sign AMA form by the patient.

P#15 arrived in the facility's ED on 12/6/21 at 4:59 am, emergency encounter was created at 4:59 am. First provider encounter at 5:20 am. P#15 was dismissed at 5:57 am, ED disposition set as AMA. No documentation showing where the patient signed an AMA form, nor any conversation between the provider and the patient regarding the risk of the decision to leave against medical advice.

P#20 arrived at the facility on 9/22/21 at 6:48 am with a complaint of abdominal pain, emergency encounter with the navigation specialist was created at 6:47 am. P#20 complete registration including insurance verification was done at 6:49 am. At 6:56 am triage started, P#20 encounter with a provider was at 7:02 am. P#20 was discharged at 2:50 p.m., ED disposition set as both eloped and AMA. Further review of P#20's medical record revealed P#20 left AMA. RN documented that P#20 was agitated, pulled out intermittent needle therapy (INT), threw a catheter on the bed, and stormed out of the room. P#20 was found at the nurse's desk with blood dripping down his arm, gauze applied to where INT was taken out and P#20 was shown the way to the ED waiting room. RN noted P#20 left AMA. There was no evidence P#20 was asked to sign an AMA form or was notified of the risk of leaving the facility against medical advice.

P#22 arrived at the facility on 12/14/21 at 3:54 p.m., emergency encounter with NS MM was created at 3:54 p.m.. NS MM completed P#22's registration including insurance verification at 3:55 p.m.. P#22 first encounter with a provider was at 4:05 p.m., triage started at 4:17 p.m.. On 12/15/21 at 4:21 am RN CC documented that P#22 was called in the ED waiting room and no response was received, provider and charge nurse was notified, no AMA form was signed by the patient. ED disposition set as AMA at 4:21 am.

P#23 arrived at the facility on 01/04/22 at 9:16 p.m. with a complaint of abdominal pain, emergency encounter was created at 9:16 p.m.. P#23 was evaluated by a provider at 9:16 p.m.. Triage started at 9:29 p.m.. Registration was completed at 10:58 p.m. and P#23 was dismissed from the hospital on 1/5/22 at 2:39 am. ED disposition was set as AMA by RN II. Further review failed to reveal that P#23 signed the AMA form, no evidence that P#23 was notified of the risk of leaving the facility. There was no documented evidence that P#23 was called and no response was received. There was no evidence that RN II notify the provider that P#23 left the facility against medical advice.

P#24 arrived in the facility's ED on 1/4/22 at 10:48 p.m., emergency encounter was created at 10:48 p.m.. First provider encounter at 11:50 p.m.. Triage started at 11:53 p.m.. Registration was completed on 1/5/22 at 12:28 am, P#24 was dismissed at 2:27 am, ED disposition was set as AMA. Further review failed to reveal a sign of refusal to sign the AMA form, no evidence that P#24 was notified of the risk of leaving the facility. There was no documented evidence that P#24 was called, and no response was received. No evidence that the provider was notified that P#24 left the facility against medical advice.

P#25 arrived in the facility's ED on 1/4/22 at 10: 31 p.m., emergency encounter was created at 10:31 p.m. by NS HH. provider encounter at 11:36 p.m.. Triage started at 11:36 p.m.. Registration was completed at 11:58 p.m.. P#25 was dismissed on 1/5/22 at 2:55 am, ED disposition set as AMA. Further review failed to reveal a sign of refusal to sign AMA form, no evidence that P#25 was notified of the risk of leaving the facility. There was no documented evidence that P#25 was called, and no response was received. No evidence that the provider was notified that P#25 left the facility against medical advice.

P#26 arrived at the facility on 11/25/21 at 5:53 p.m. with the complaint of a motor vehicle crash, the emergency encounter with NS MM was created at 5:53 p.m.. Triage started at 6:12 p.m., provider encountered P#26 at 6:20 p.m.. NS MM completed P#26's registration at 6:26 p.m.. RN CC documented that P#26 was called in the ED waiting room and no response was received, provider and charge nurse was notified, no AMA form was signed by the patient. ED disposition set as AMA at 8:01 p.m..

P#27 arrived in the facility's ED on 12/25/21 at 12:48 p.m., emergency encounter was created at 12:48 p.m. by NS MM. provider encounter at 12:55 p.m.. Triage started at 12:58 p.m.. P#27 was dismissed at 4:36 p.m., ED disposition set as AMA. Further review failed to reveal that P#27 refused to sign the AMA form, no evidence that P#27 was notified of the risk of leaving the facility.

P#28 arrived in the facility's ED on 11/13/21 at 1:06 p.m. complaining of shortness of breath and headache, emergency encounter was created at 1:06 p.m.. First provider encounter at 1:34 p.m.. Triage started at 1:36 p.m.. P#28 was dismissed on 11/14/21 at 2:14 am, ED disposition set as AMA. Further review failed to reveal a sign of refusal to sign the AMA form, no evidence that P#28 was notified of the risk of leaving the facility. There was no documented evidence that P#28 was called, and no response was received. No evidence that the provider was notified that P#28 left the facility against medical advice.

P#29 arrived at the facility on 11/7/21 at 12:43 p.m. due to a motor vehicle crash, emergency encounter was created at 12:43 p.m.. P#29 registration was completed at 12:50 p.m.. P#29 first encounter with a provider was at 2:48 p.m., triage started at 3:37 p.m.. RN CC documented at 8:38 p.m. that P#29 was called in the ED waiting room and no response was received, provider and charge nurse was notified, no AMA form was signed by the patient. ED disposition set as AMA at 8:39 p.m..

Based on a review of the medical record, video recordings, facility's work instruction, and staff interviews, it was determined that the facility failed to follow work instructions for providing an appropriate Medical Screening Exam (MSE) prior to inquiries about an individual's insurance or payment status from 7 patients P (#5,9,11,13,20,22,29) out of 30 sampled patients.

Findings were:

A review of Patient #13's ED medical record revealed P#13 arrived in the ED on 12/5/21 at 6:01 p.m. At 6:01:19 p.m. P#13 was registered using quick check-in features by Navigation Specialist (NS) HH, P#13 complaint was chest pain and shortness of breath. At 6:29 p.m. NS HH completed P#13's registration. P#13 signed the facility's request for treatment and authorization form at 6:31 p.m.. P#13's registration was completed before triage and MSE.

A review of the facility's document titled "Work instruction" last revised 5/25/21 revealed that the work instruction is to establish a consistent method for assessing for, educating on, and implementing emergency center documentation in the facility's health system. Further review revealed that to meet EMTALA requirements all patients will be registered using the quick check-in feature, gathering limited information from the patient. Once the patient had been medically screened by a provider, the navigation specialist will use the revised encounter details and access HDX to verify benefits and determine co-pays, co-insurance, and deductibles.

During the tour of the facility's Emergency Department (ED) on 1/11/22 at 2:36 p.m., an interview with the Registration clerk (RC) MM took place. RC MM explained that when a patient comes in through the door to the registration desk at the ED, she would do a quick registration which entails asking for an identity card and/or inputting the patient's date of birth, last name, complaint and address into the system. RC MM said she would not ask for insurance during a quick registration, RC MM further explained that she would wait until at least 45 minutes or after the patient had seen a provider before completing the final registration and that is when insurance inquiries will be asked. RC MM said if the patient had to wait longer than 45 minutes before seeing a provider, she would wait for the patient to see a provider before completing the process of registration. RC MM said she would always ensure that the patient had seen a provider before asking for insurance and completing full registration.

An interview with the Navigation Specialist (NS) (FF) took place on 1/12/22 at 10:30 a.m. in the conference room. NS FF explain that her job included registering patients that present to the ED for treatment. NS FF said there is two registration area at the ED, the upfront for the ambulatory patient and the back for patient coming by EMS. NS FF explained that at the back the EMS crew will bring the patient information to the navigation specialist sitting at the registration area and the patient information will be put in the ED log, she will give a label to EMS and talk to the patient to verify name and date of birth. NS FF explained that she will wait until the patient had seen a provider before asking for insurance. NS FF said after the provider had seen the patient, she will complete the registration process. NS FF explained that registration including insurance verification is not completed until a provider had seen the patient. NS FF acknowledged that asking for insurance before an MSE is an EMTALA violation, she further stated that they are trained on EMTALA annually and during orientation.

During an interview with the Navigation Specialist (NS) HH on 1/12/2022 at 11:50 a.m. NS HH stated she was in the role for about four months ago. Staff HH described the registration process as follows: when a patient arrived, she greeted the patient by asking simple questions such as "how can I help you?". She then asked for ID then put the patient on the system. She said she then got the sticker and wrist band, placed it on the patient; she then asked the patient to wait in the waiting room for the triage nurse to call his or her name. NS HH said the process for a patient who presented with chest pain was different. She stated if a patient presented in the ED with chest pain, she would register the patient the same way she did for other patients but would go in the back to tell the triage nurse to come to get the patient. NS HH said it would take less than five minutes (average 2 minutes) for the nurse to come and bring the patient into the triage room. NS HH said they will not ask for insurance until after forty-five minutes post-arrival or until after a provider had seen the patient.

An interview with the Patient Access Manager (PAM) (OO) took place on 1/12/22 at 12:56 p.m. in the conference room. PAM OO explained that she had been the ED patient access manager for 5 years and left the position 3 days ago. PAM OO acknowledged her role included supervising the navigation specialist. PAM OO explained that when a patient is presented to the ED her navigation specialist would get an ID from the patient if available and verify the patient name, date of birth (DOB), social security, and address. PAM OO said they try to get at least four identifiers for the quick registration which is on EPIC (electronic health record) called arrival. PAM OO explained that after the patient had been seen by a provider then the navigation specialist would complete the registration and inquiry about insurance. PAM OO said the hospital policy was to inquire for insurance and complete the registration only after the patient had seen a provider. PAM OO said previously they either ask for insurance 45 minutes post-arrival or when a provider had seen the patient, however, they don't use the 45 minutes timeline anymore. The patient had to see a provider before insurance information is verified and registration is completed. When presented with P#20's medical record to confirm what "registration completed" meant, PAM OO acknowledged that registration completed included insurance verification and should only be done after the patient had already seen a provider for a medical screening exam. When asked for a hospital policy that clearly states that patients had to see a provider for MSE before insurance verifications, PAM OO provided a hospital work instruction.

An interview with the Patient Access Manager (PAM) (PP) took place on 1/12/22 at 1:05 p.m. in the conference room. PAM PP said she had been the pediatric ED patient access manager for a year and took over as the ED patient access manager three days ago. PAM PP explained that when a patient arrives in the ED the navigation specialist would complete a quick registration and ask for the patient's name, DOB, complaint, and address. PAM PP said the navigation specialist would not ask for insurance. PAM PP said they would document the information in the system, give the patient an armband and wait for the patient to be triaged and seen by a provider. PAM PP explained that after the patient had been seen, the navigation specialist will go to the patient room or where the patient is held to complete the registration. PAM PP said that the registration is completed when patients' insurance had been signed and uploaded on the electronic medical record.

P#5 arrived in the facility's ED on 8/7/21 at 5:09 p.m., NS NN created an encounter and did a quick registration at 5:09:04 p.m.. P#5 signed the facility's request for treatment and authorization form at 5: 10 p.m., NS NN completed P#5 registration at 5:14 p.m.. P#5 was triaged at 5:26 p.m. and evaluated by a provider at 5:28 p.m.. Complete registration was done before the medical screening exam (MSE). ED disposition was AMA, review of record failed to reveal a signed AMA form.

P#9 arrived in the facility's ED on 12/5/21 at 4:31 p.m., NS MM created an encounter and did a quick registration at 4:31 p.m.. NS MM completed P#9 registration at 4:57 p.m., P#9 signed the facility's request for treatment and authorization form at 5:33 p.m. P# 9 was called to triage at 6:01 p.m.. P#9 was dismissed, and ED disposition was set as AMA on 12/6/21 at 12:21 am. RN noted P#9 was called twice. NS MM completed P#9 registration before triage and MSE. P#9 didn't encounter a provider on this visit.

P#11 arrived in the facility's ED on 12/5/21 at 5:32 p.m., NS MM created an emergency encounter at 5:32 p.m. and P#11 signed the facility's request for treatment form at 5:33 p.m.. NS MM completed P# 11 registration including insurance verification at 5:36 p.m., P#11 first encounter with the provider (NP DD) was at 5:41 p.m.. NP DD noted that P#11 was referred to the ED by a physician for direct admission secondary to vaginal bleeding. NP DD documented she explained to P#11 that the hospital was full, and P#11 had to wait. P#11 said she would wait at home and come back the next day. NP DD noted she explained to P#11 it would be better for her to stay today if that is what her doctor wants. P#11 was dismissed, and ED disposition was set as AMA on 12/5/21 at 6:40 p.m. Further review of P#11's record failed to reveal a sign AMA form by the patient.

P#20 arrived at the facility on 9/22/21 at 6:48 am with a complaint of abdominal pain, emergency encounter with the navigation specialist was created at 6:47 am. P#20 complete registration including insurance verification was done at 6:49 am. At 6:56 am triage started, P#20 encounter with a provider was at 7:02 am. P#20 was discharged at 2:50 p.m., ED disposition set as both eloped and AMA. Further review of P#20's medical record revealed P#20 left AMA. RN documented that P#20 was agitated, pulled out intermittent needle therapy (INT), threw a catheter on the bed, and stormed out of the room. P#20 was found at the nurse's desk with blood dripping down his arm, gauze applied to where INT was taken out and P#20 was shown the way to the ED waiting room. RN noted P#20 left AMA. There was no evidence P#20 was asked to sign an AMA form or was notified of the risk of leaving the facility against medical advice.

P#22 arrived at the facility on 12/14/21 at 3:54 p.m., emergency encounter with NS MM was created at 3:54 p.m.. NS MM completed P#22's registration including insurance verification at 3:55 p.m.. P#22 first encounter with a provider was at 4:05 p.m., triage started at 4:17 p.m.. On 12/15/21 at 4:21 am RN CC documented that P#22 was called in the ED waiting room and no response was received, provider and charge nurse was notified, no AMA form was signed by the patient. ED disposition set as AMA at 4:21 am.

P#29 arrived at the facility on 11/7/21 at 12:43 p.m. due to a motor vehicle crash, emergency encounter was created at 12:43 p.m.. P#29 registration was completed at 12:50 p.m.. P#29 first encounter with a provider was at 2:48 p.m., triage started at 3:37 p.m.. RN CC documented at 8:38 p.m. that P#29 was called in the ED waiting room and no response was received, provider and charge nurse was notified, no AMA form was signed by the patient. ED disposition set as AMA at 8:39 p.m..