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BAYSTATE MEDICAL CENTER
COMPLIANCE WITH 489.24
Tag No.: A2400
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-one 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 of a sample of thirty-one patients, to provide an appropriate Medical Screening Examination, in accordance with §489.24(a); §489.24(c) Appropriate Medical Screening Examination.
See tag 2406.
EMERGENCY ROOM LOG
Tag No.: A2405
Based on interviews, the hospital failed for one patient in a sample of thirty-one 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 hospital Senior Director of Patient Safety on 12/10/2021 at 10:35 A.M. The Senior Director of Patient Safety stated that there was no history or record of Pt #1 ever being registered or recorded as a patient in the hospital ED.
MEDICAL SCREENING EXAM
Tag No.: A2406
Based on interviews and document review the hospital failed, for one patient of a sample of thirty-one patients, to provide an appropriate Medical Screening Examination, in accordance with §489.24(a); §489.24(c) Appropriate Medical Screening Examination.
Findings include:
On 12/10/2021 at 2:30 P.M., video observation regarding Pt #1 was reviewed, in the presence of the Department of Public Health (DPH) surveyor, the Security Investigator, and the Senior Director of Security. The video observation indicated the following timeline of events, regarding Patient #1:
On 12/06/2021 at 9:09 P.M. and 14 seconds, an Emergency Medical Service (EMS) brought Pt #1 through the ambulance bay entrance and arrived to an area located just inside the ambulance bay area known as the FlowBox area.
EMS staff remains with Pt #1 during the entire time of video footage observed between 12/06/2021 9:09 P.M. and 14 seconds and 11:07 P.M. and 58 seconds in the FlowBox area. During this entire time period, Pt #1 was never observed to be registered/evaluated by any of the hospital's staff.
At 11:07 P.M. and 58 seconds Pt #1 and an EMT member walk away from the FlowBox area of the Emergency Department (ED). The EMT member is observed returning to the FlowBox area of the ED without Pt #1 at 11:08 P.M. and 59 seconds.
At 11:11 P.M. and 52 seconds, Pt #1 is observed walking out of the ED.
The surveyor interviewed EMT #1 on 12/14/2021 at 3:00 P.M. EMT #1 stated that at approximately 11:04 P.M. on 12/06/2021, Pt #1 stated that Pt #1 wanted to leave, and although EMT #1 made attempts to encourage Pt #1 to stay and warned Pt #1 of the risks of leaving, Pt #1 signed an EMT Against Medical Advice (AMA) form at 11:04 P.M. EMT #1 said that her co-worker (an EMT member working with EMT #1) escorted Pt #1 to the ED waiting room.
The surveyor interviewed the hospital Senior Director of Patient Safety on 12/10/2021 at 10:35 A.M. The Senior Director of Patient Safety stated that there was no history or record of Pt #1 ever being registered or recorded as a patient in the hospital ED.