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

A-2405: Central ED Log: Failure to ensure that the Dedicated Emergency Department Log was completed with all required documentation for each ED patient.

Findings include:

Hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", revealed: "...Emergency medical screening and stabilizing treatment will be provided by a licensed provider and within the capabilities of the hospital's Emergency Department to all persons with an emergency medical condition presenting at the hospital, or on hospital property...without regard to age, race, color, creed, national origin, immigration status, insurance, disability, handicap, diagnosis, or ability to pay...A patient with an emergency medical condition will not be transferred to another facility unless: It is ordered by a physician, the other facility has the capacity to provide the necessary stabilizing care; and the other facility agrees to accept the patient; the transfer and it's risks and benefits have been explained to the patient or their representative; the patient has not refused the transfer; appropriate transportation has been arranged including specialized equipment needed to care for the patient; the attending physician has documented the patient's condition and that the benefits of transfer outweigh the medical risks...Registration: Hospital personnel may not register persons requesting emergency services before the person receives a medical screening examination and necessary stabilizing treatment if the person has an emergency medical condition unless the registration process does not include any inquiry into the person's ability to pay, method of payment or insurance status...Triage: A registered nurse will conduct a triage examination to determine the order in which persons receive the medical screening examination...Logs: Patients with an emergency medical condition must be entered into the electronic health record for the Emergency Department. This process gets the patient into the ED Log. Registration scans the past six (6) months of ED log information into electronic files. The log must be retained in its original form or legally reproduced form for a period of five (5) years from the latest entry...Medical Screening Examination: The hospital will provide a medical screening exam by a physician or credentialed Nurse Practitioner, or Physician's Assistant, within a reasonable time after arrival/triage...The medical screening examination determines whether the person has an emergency medical condition...Stabilizing Treatment: If the medical screening examination demonstrates that the person has an emergency medical condition, qualified medical personnel as defined above will provide stabilizing treatment, within the capabilities of the hospital unless the patient requests transfer to another facility...Once the person is stabilized, the patient bay be provided with additional care, discharge instructions or transferred to another facility, as appropriate for additional or continuing care...Disposition: The qualified medical personnel to the patient's attending physician will determine patient disposition as follows: No emergency medical condition (confirmed by a medical screening examination); Emergency medical condition resolved or stable for discharge...;unstable for transfer- patient who has not been stabilized because the hospital lacks the capability to stabilize the patient and the patient is being transferred to a higher level of care after provision of treatment within the hospital's capabilities to minimize the risk of transfer...Transfer Requirements of Stable/Unstable Patients: The hospital may transfer the patient to another hospital or facility that has the capability to provide additional stabilizing treatment or resolve the patient's emergency medical condition only if the patient requests transfer or the physician certifies that the benefits of the transfer exceed the risks, and the hospital meets the transfer requirements...Record Keeping and Signage Requirements: The following records will be kept related to EMTALA: A central log and medical record for each patient who comes to the hospital seeking emergency medical treatment (see requirements above)...Documentation: ...ED Patient Log: Patient Name, Refusal of Treatment, Refusal by hospital to treat the patient transfer, admission, treatment condition at transfer, Disposition of the patient...."

Hospital policy titled, "Triage Process-Emergency Department", revealed: "...The principle role of the Emergency Department (ED) triage to facilitate prioritization of patients...Acuity is determined by stability of vital functions and potential for life, limb or organ threat utilizing the ESI 1-5 system...To ensure that individuals are treated in a timely manner based on urgency of the patient's condition...a physician will perform the medical screening exam in the ED...A triage assessment is done to determine the priority for receiving medical screening evaluation and the priorities of care based on the physical and psychological needs as well as factors influencing patient flow through the ED including but not limited to patient volume, acuity and available resources...Patients presenting to triage will have a quick triage completed utilizing the Emergency Severity Index (ESI) triage process to determine an acuity ESI 1-5...ESI 1: Impending or actual signs or symptoms that are life or limb threatening and will result in permanent physical impairment or death if not treated immediately...ESI 2: Impending or actual signs or symptoms that are life threatening and /or may result in permanent physical impairment or death if not treated immediately...ESI 3: Demonstrated signs or symptoms of an underlying illness/injury that may result in significant complications for which intervention is necessary, but where the time of treatment is not immediately necessary. The patient may be returned to the waiting area but will require reevaluation at a minimum of every 60 minutes...ESI 4: Demonstrates signs and symptoms of complaints that have the potential or causing complications, but do not have the urgent need of attention or intervention...ESI 5: Demonstrates signs and symptoms of minor complaints sometimes chronic that can be treated on a non-emergent basis...Against Medical Advice/Left Without Being Seen/Elopement: LWBS (left without being seen): Individuals who register and leave prior to being triaged or leave after being triaged but do not stay to see the provider for medical screening exam...AMA (Against Medical Advice): Patient who has had a complete Medical Screening Exam by the provider but determines to leave prior to final disposition or refuses being admitted or transferred. If a patient decides to leave AMA the provider should be informed who revisits with the patient providing risk of AMA and the patient signs AMA form...All patients seeking medical care will be entered on the ED log, even if they leave AMA or LWBS...."

A request was made for the Dedicated ED Logs for October 2022 through January 2023. The facility provided a spreadsheet that was dated from October 1, 2022 through January 31, 2023. This spreadsheet contained columns that were labeled: Patient Number; Patient Name; Age; MR Number; Admit Date; Admit Time; Discharge Date; Discharge Time; Triage Level; triage Description; Disposition; ER Complaint. Review of the spreadsheet revealed the discharge date, discharge time and disposition were incomplete on the majority of the patients. When the surveyor asked for clarification, the spreadsheet was identified as not being the Dedicated ED Log.

A second request was made for the Dedicated ED Logs for October 2022 through January 2023. The facility provided binders with documents titled "Patient Log with Milestones" which contained the following columns: Patient Name, Medical Record Number, Account Number, Age, Sex, Mode of Arrival, Arrival Time, Chief Complaint, Triage Time, Providers, Departure Time, Disposition, Length of Stay and Diagnosis Description. Review of the logs revealed of the 3100 patients listed 88 patients did not have a final disposition documented. Further review revealed that only one (1) patient had mode of arrival documented for the entire 4 months reviewed.

A document was provided titled " Emergency Department EMTALA Log" with an explanation that this was a log the registration desk logged in patients who came in but did not register for treatment. The dates on the log ranged from December 2020 through January 2023. Review of the log revealed documentation of persons inquiring as to the length of stay and type of services the ED provided. Further review revealed documentation these people left without registering for treatment.

A review of a newly created Dedicated ED Log was provided on 02/02/2023 which revealed all required areas of documentation were included and completed for each patient coming to the ED.

Review of 25 ED patient medical records randomly selected from the ED logs revealed triage procedures, medical screening examinations, and discharge/transfers were done in accordance with the hospital's policies and procedures.

Employee #1 confirmed during an interview conducted on 02/01/2023 that the ED logs provided were incomplete and required documentation was missing. Employee #1 confirmed during an interview conducted on 02/02/2023 that the ED log had been updated and the required documentation was included and had been programmed into the computer electronic record as of 02/02/2023.

Based on review of policies and procedures, hospital documents and staff interviews, it was determined that the Hospital failed to ensure that the Dedicated Emergency Department Log was completed with all required documentation for each ED patient.

Findings include:

Hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", revealed: "...Logs: Patients with an emergency medical condition must be entered into the electronic healthe record for the Emergency Department. This process gets the patient into the ED Log. Registration scans the past six (6) months of ED log information into electronic files. The log must be retained in its origianl form or legally reproduced form for a period of five (5) years from the latest entry...Record Keeping and Signage Requirements: The following records will be kept related to EMTALA: A central log and medical record for each patient who comes to the hospital seeking emergency medical treatment (see requirements above)...Documentation: ...ED Patient Log: Patient Name, Refusal of Treatment, Refusal by hospital to treat the patient transfer, admission, treatment condition at transfer, Disposition of the patient...."

Hospital policy titled, "Triage Process-Emergency Department", revealed: "...All patients seeking medical care will be entered on the ED log, even if they leave AMA or LWBS...."

A request was made for the Dedicated ED Logs for October 2022 through January 2023. The facility provided a spreadsheet that was dated from October 1, 2022 through January 31, 2023. This spreadsheet contained columns that were labeled: Patient Number; Patient Name; Age; MR Number; Admit Date; Admit Time; Discharge Date; Discharge Time; Triage Level; triage Description; Disposition; ER Complaint. Review of the spreadsheet revealed the discharge date, discharge time and disposition were incomplete on the majority of the patients. When the surveyor asked for clarification, the spreadsheet was identified as not being the Dedicated ED Log.

A second request was made for the Dedicated ED Logs for October 2022 through January 2023. The facility provided binders with documents titled "Patient Log with Milestones" which contained the following columns: Patient Name, Medical Record Number, Account Number, Age, Sex, Mode of Arrival, Arrival Time, Chief Complaint, Triage Time, Providers, Departure Time, Disposition, Length of Stay and Diagnosis Description. Review of the logs revealed of the 3100 patients listed 88 patients did not have a final disposition documented. Further review revealed that only one (1) patient had mode of arrival documented for the entire 4 months reviewed.

A document was provided titled " Emergency Department EMTALA Log" with an explanation that this was a log the registration desk logged in patients who came in but did not register for treatment. The dates on the log ranged from December 2020 through January 2023. Review of the log revealed documentation of persons inquiring as to the length of stay and type of services the ED provided. Further review revealed documentation these people left without registering for treatment.

A review of a newly created Dedicated ED Log was provided on 02/02/2023 which revealed all required areas of documentation were included and completed for each patient coming to the ED.

Employee #1 confirmed during an interview conducted on 02/01/2023 that the ED logs provided were incomplete and required documentation was missing. Employee #1 confirmed during an interview conducted on 02/02/2023 that the ED log had been updated and the required documentation was included and had been programmed into the computer electronic record as of 02/02/2023.