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Based on document review and staff interviews, the facility failed to ensure a central log was accurately maintained to include all patients seeking emergency care at the facility. Specifically, patients who presented to the emergency department had been removed from the log by registration staff. Furthermore, facility staff instructed patients who presented to the emergency department to return to the patient ' s car to get a face mask prior to seeking treatment.

Findings include:

Facility policy:

According to the EMTALA (Emergency Medical Treatment & Active Labor Act) policy, reasonable registration processes may not unduly discourage an individual from remaining for further evaluation. A central log must list each individual seeking or in need of emergency services who comes to the hospital, the dedicated emergency department anywhere else on the hospital campus, or to off campus departments that qualify as a dedicated emergency department of the hospital designated with CMS provider-based status. The log must include an indication whether the individual did not consent to treatment or transfer, or was transferred, admitted and treated, stabilized and transferred, or discharged. Logs that are maintained in departments that qualify as dedicated emergency departments that perform a medical screening examination (MSE) (e.g., labor and delivery, psychiatry, outpatient) will be deemed a part of the central log and are subject to the same requirements as the central log. A central log must include the name of the individual who comes to the hospital and makes it clear (or if it is unclear) that the medical condition is not an emergency nature, and a MSE is performed to determine that the individual does not have an emergency medical condition.

1. The facility failed to maintain a complete and accurate central log of patients who presented to the facility.

a. Review of the electronic Central EMTALA Log from 4/1/20 to 9/10/20 revealed no entry for patients who had left the facility against medical advice (AMA), discharged home, or left without being seen (LWBS).

Upon request of the missing entries, the facility was able to provide an additional electronic Central EMTALA log from 4/1/20 to 9/10/20 with patients who had left the facility against medical advice (AMA), discharged home, or left without being seen (LWBS).

b. Observations conducted on 9/10/20 at 9:19 a.m., revealed registration staff (Registrar #1) at the entrance to the emergency department (ED). Patients who entered the ED seeking emergency care were screened by security first for temperature and absence of COVID-19 symptoms, then went to the registrar's desk to fill out a form with their chief complaint or reason for seeking treatment.

An interview was conducted with Registrar #1 during the observation, who stated if a patient left the facility prior to being assessed by clinical personnel (LWBS) she deleted the patient's chart and canceled the visit from the Electronic Medical Record (EMR).

A further interview was conducted on 9/10/20 at 2:37 p.m., with Registrar #1. Registar #1 stated her job in the ED was to register patients who presented to the emergency department seeking treatment. Registar #1 stated if a patient LWBS she canceled and deleted the patient's chart. She stated sometimes she entered a note to explain why the patient left. Registar #1 stated she did not remember who taught her this process. She stated she canceled the visit so the patient was not billed for an ED visit if they LWBS.

Registrar #1 stated she told patients who arrived at the ED seeking care without a mask to go to their car to retrieve a mask prior to checking them in with their chief complaint. She stated she did this because it was a state mandate for everyone who entered the building to wear a mask and the facility did not have enough masks to give one to every patient. She stated sometimes when people went to their car to get their mask, they did not return. Registrar #1 stated she was not clinical and was unable to determine if the patients had a medical emergency prior to sending them to their car to retrieve their own masks.

c. On 9/10/20 at 2:37 p.m., the Patient Access Coordinator (Coordinator #2) was interviewed at the same time as Registrar #1. Coordinator #2 stated he had patients leave the ED because they didn't want to wear a mask while he was registering them. He stated if a patient didn't have a mask, they were instructed to go to their car to retrieve their own mask rather than providing them a mask from the facility. Coordinator stated sometimes a patient would not come back into the facility for treatment because they didn't want to wear a mask anyway. He stated the time the patient arrived was documented as the time they arrived back into the facility with their masks on since this was the time they were registered. Coordinator #2 stated if the patient did not return from their car, they were not entered into the ED log because their encounter technically hadn't started yet.

d. A list of all patients who had deleted or canceled charts from the ED from 4/1/20 to 9/10/20 was provided with comments. The list revealed 145 patient encounters had been deleted. 60 of the deleted patient encounters had the comment "canceled" with 13 of those with the additional comment which read LWBS (left without being seen). 23 patient deleted encounters had no comments at all.

An example of one additional comment included: patient refused to wear a mask. Seven patients were selected from the list and information to include a medical record and chief complaint was requested.

Patient #15 had the comment "patient refused to wear a mask" on the list. The information the facility provided regarding Patient #15's encounter in the ED did not include a medical record, chief complaint, determination if Patient #15 had a medical emergency or if Patient #15 was refused care.

The additional six patient encounters revealed the same as Patient #15. There was no evidence of a medical record which would indicate the encounter was canceled due to a clerical error, no chief complaint, determination if they had a medical emergency or if they were refused care.

e. 9/11/20 at 8:21 a.m., an interview with Patient Access Supervisor (Supervisor #4) was conducted. She stated she was the supervisor of patient registration. Supervisor #4 stated she was aware staff canceled visits if they made a clerical error. She stated she was not aware staff canceled and deleted patient visits if they LWBS. Supervisor #4 stated deleting LWBS visits was not the facility process because they were supposed to have a document of all patients who entered the ED to receive emergency care.

Supervisor #4 stated without notes as to the reason why the visit was canceled, she was unable to determine the reason. She was unable to determine if Patient #15 LWBS or refused care. Additionally, she was unable to determine if Patient #15 was having a medical emergency. Supervisor #4 stated refusal to wear a mask was not the same as refusal of services. Supervisor #4 stated if a patient refused to wear a mask, the hospital policy was to notify a clinical staff member and have the patient wait for services isolated from other patients.

Supervisor #4 stated the facility had masks at the desk and staff should provide the patient with a mask if they did not have one of their own. She stated staff should not send a patient to their car to retrieve their own mask because it was unknown what could be medically occurring with the patient while they were not in the facility. She stated she did not want the patient to get more critical while attempting to retrieve their own mask.

Supervisor #4 stated the time the patient arrived at the ED was entered into the system when the patient was registered. She stated if the patient was not registered and not documented as entered the facility until they returned from their car, then the log was not accurate. She stated the time the patient entered the facility the first time seeking care was when the patient should be documented on the EMTALA log.

Supervisor #4 stated she had quickly reviewed the list of deleted charts and stated the majority were deleted due to a clerical error. However, Supervisor #4 stated she had not gone through the list to investigate or see if the patient had a medical record or verified if it had indeed been entered in error.

Supervisor stated she was concerned about the deleted patient visits which were not entered in error because they violated the facility EMTALA policy and federal EMTALA regulations.

f. On 9/11/20 at 9:04 a.m., the ED Manager (Manager #3) was interviewed. Manager #3 stated when a patient arrived at the ED they should be screened by a medical provider to determine if they were medically stable. She stated even if a person decided to leave the facility to seek treatment elsewhere, they should be screened by clinical personnel prior to leaving to prevent an EMTALA violation.

Manager #3 stated the facility process for all patients to be registered, then if they LWBS, there would be a notation in their medical record to document the reason.

Manager #3 stated it was important to keep an accurate log for all patients who arrived at the ED seeking emergency care for tracking purposes and performance improvement.

Manager #3 stated if a patient arrived at the ED without a mask, they should be provided a mask from the facility. She stated a patient should not be instructed to retrieve a mask from their car because they could have a medical emergency and not have told the registration person yet. She stated if a patient refused to wear a mask, they should be taken to a room and evaluated.