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The hospital, having a dedicated Emergency Department (ED), did not comply with the requirements for the Emergency Medical Treatment and Labor Act (EMTALA, 42 CFR 489.20 and 489.24) regulations.

Findings include:

1) The hospital failed for one patient in a sample of thirty patients to ensure they maintain their ED Registration Log on each individual who comes to the hospital's ED (as defined in 489.24(b)), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or was discharged, in accordance with §489.20(r)(3) Logs.

See tag 2405.

2) The hospital failed, for one patient in a sample of thirty patients, to provide an appropriate Medical Screening Examination, in accordance with §489.24(a); §489.24(c) Appropriate Medical Screening Examination.

See tag 2406.

Based on interviews, the hospital failed for one patient in a sample of thirty patients to ensure they maintain their ED Registration Log on each individual who comes to the hospital's ED (as defined in 489.24(b)), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or was discharged, in accordance with §489.20(r)(3) Logs.

Findings include:

The surveyor interviewed the ED Director on 01/10/2023 at 9:50 A.M. The ED Director acknowledged that there was an EMTALA violation and that Patient #1 was never registered, (patient registration is a method of how the hospital identifies patients that present to the ED seeking emergency care).

Based on interviews and document review the hospital failed, for one patient of a sample of thirty patients, to provide an appropriate Medical Screening Examination, in accordance with §489.24(a); §489.24(c) Appropriate Medical Screening Examination.

Findings include:

The hospital reported an incident to the Department of Public Health (DPH) on 01/03/2023. The hospital reported that on 12/27/2022 between the hours of approximately 2:00 A.M. and 3:00 A.M., Patient #1 arrived to the ED ambulance bay of the hospital. Patient #1 was not unloaded and the Emergency Medical Services (EMS) paramedic was met by Physician #1 who reviewed Patient #1's EKG (electrocardiogram, which is a recording of the heart's electrical activity). After review, Physician #1 agreed with the EMS paramedic's findings that Patient #1 was having a possible ST elevated myocardial infarction, (STEMI, also known as a type of heart attack) and it was decided to continue their transport to a tertiary medical facility for STEMI treatment. Patient #1 was not unloaded and assessed by ED personnel.

The surveyor interviewed the ED Director on 01/10/2023 at 9:50 A.M. The ED Director acknowledged that there was an EMTALA violation, that it did not appear that Physician #1 assessed and/or saw Patient #1 and that Patient #1 was never registered, (patient registration is a method of how the hospital identifies patients that present to the ED seeking emergency care).

The surveyor interviewed Physician #1 on 1/11/2023 at 4:06 P.M. Physician #1 stated that he did not visibly see Patient #1 nor did Physician #1 ever provide a medical examination to Patient #1.

The surveyor interviewed the Director of Risk Management (DRM) on 01/13/2023 at 9:00 A.M. The DRM had reviewed new video footage (as requested by the surveyor who identified a camera during the survey's ED tour, that is located in the ED vestibule. The ED vestibule area is located between the outdoor ambulance bay and the main ED). The video footage identified and confirmed that the EMS paramedic for Patient #1 had a conversation with Physician #1 for approximately 1 minute in the ED vestibule area. The DRM stated that the video footage identified that there was also an ED staff nurse (Nurse #1) present during this conversation between the EMS paramedic and Physician #1 in the ED vestibule. Additionally, a second nurse (nurse #2) had entered the ED vestibule as the EMS paramedic was departing and acknowledged the departure with a waive goodbye. The DRM stated that the leadership/investigation team had not spoken to either Nurse #1 nor Nurse #2 regarding this EMTALA violation as of 01/13/2023.

The surveyor interviewed the ED Director on 01/10/2023 at 9:50 A.M. The Director was made aware of this EMTALA violation by two external non-hospital staff: 1) E-mail correspondence from an EMS Director employed by a completely different hospital system, a tertiary medical facility (hospital B) where Patient #1 was eventually transported to. 2) The EMS paramedic who initially transported Patient #1 to this hospital (hospital A), and after a 1 minute in-person discussion with Physician #1, brought Patient #1 to a tertiary medical facility (hospital B).

The policy titled "Incident Reporting" last reviewed 06/2020, states under the procedure section for physician/employee responsibility, "The physician/employee is required to complete the first page of an Incident Report upon witnessing or being involved in an incident, injury, a failure of equipment or utilities, or observing what the physician/employee believes to be misconduct of a healthcare provider." Physician #1, Nurse #1 and Nurse #2 failed to report this EMTALA incident in accordance with the aforementioned policy.

The surveyor interviewed the DRM on 01/17/2023 at 1:20 P.M. The DRM confirmed that the 12/27/2022 EMTALA incident was not reported through the hospital's internal incident reporting system.

The Senior Director of Quality/Risk (SDQR) was interviewed on 01/10/2023 at 11:15 A.M. The SDQR confirmed that although Physician #1 received re-education from the ED Director, the hospital failed to ensure all other practicing ED providers (physicians, physician assistants and nurse practitioners) were re-educated and re-trained on EMTALA regulations. As of 01/10/2023 only 1/18 or roughly 6% of the ED providers had received some form of re-education on EMTALA regulations.

The surveyor interviewed the SDQR on 1/10/2023 at 2:45 P.M. The SDQR said that EMTALA training should be completed by applicable hospital staff on an annual basis.

A document given to the surveyor on 01/10/2023 titled, "EMTALA Test Completion" is a compiled list of EMTALA training completed by the providers (physicians, physician assistants and nurse practitioners) employed in the ED. This EMTALA training indicated that all 18 providers were overdue for their annual EMTALA training. The most recent EMTALA training was completed in November of 2021.

The hospital failed to demonstrate evidence that ED staff are properly trained in EMTALA regulations as indicated by the EMTALA violation that occurred on 12/27/2022, the lack of internal reporting by ED staff who directly witnessed the EMTALA violation in accordance with hospital policy, and the lack of a thorough hospital investigation and corrective action plan to ensure that all current ED staff have up to date EMTALA training completed. As a result, the hospital remains at risk for the potential of future EMTALA violations.