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Based on staff interviews, ED Physician/Non-Physician Practitioner On Call Schedule review, Emergency Department Daily Log, Emergency Department Staff Meeting Minutes and policy review the hospital failed to maintain a central log on each individual who "comes to the emergency department," seeking treatment as defined in §489.24(b): four (4) of four (4) shifts reviewed, June 10, 2022 - 7:00 a.m. - 7:00 p.m. (a.m. shift) and 7:00 p.m. to 7:00 a.m. (p.m. shift); June 11, 2022 - a.m. shift; June 12, 2022 - a.m. shift.

Findings Include:

An interview, on 06/15/2022 at 1:05 p.m. with the Register Nurse (RN) #1 working in the facility and Emergency Department (ED) on 6/11/2022 from 7:00 a.m. to 7:00 p.m., confirmed the facility was on "Diversionary Status", (A hospital diverts individuals to another ED when it does not have staff or facilities to accept additional emergency patients.), due to the unavailability of the scheduled ED Physician, ED MD #1, for personal reasons. RN #1 reported the facility could not find another physician/non-physician practitioner to cover the shifts. RN #1 confirmed when the facility goes on Diversion and a patient (individual) presents to the ED requesting treatment, she will do a visual inspection of a patient (individual) and if the patient (individual) is in distress, she will call the ED Physician at their partner facility to obtain a verbal order or call an ambulance to transfer them to another facility. The RN confirmed she does not record the patients in the ED log that she does not bring into the ED or recommends they go to another facility, when on Diversion. RN #1 reports there were three (3) individuals who walked up to the ED door during her shift on 06/11/2022 from 7:00 a.m. to 7:00 p.m. RN #1 confirmed she did not have a patient (individual) present to the ED on this date with serious injuries or in distress.

An interview on 06/15/2022 at 1:20 p.m. with the Chief Administrative Officer (CAO) confirmed the facility's ED was on diversion June 10, 2022 - 7:00 a.m. - 7:00 p.m. (a.m. shift) and 7:00 p.m. to 7:00 a.m. (p.m. shift); June 11, 2022 - a.m. shift; June 12, 2022 - a.m. shift. The CAO reported the scheduled ED Physician, ED MD #1, called in unable to work due to childcare issues. The CAO confirmed the facility was unable to find coverage for the ED. The CAO reported the facility notified Emergency Medical (Ambulance) Services (EMS #1) of the need to go on Diversion. The CAO confirmed she was aware EMTALA regulations require all individuals who come to the ED for care, must be recorded in the ED log and have a Medical Screening.

An interview on 06/15/2022 at 2:10 p.m. with Security Guard # 1 for the day of the alleged incident, 06/11/2022, confirmed while on Diversion he had three (3) people come to the ED door and none were in distress or had a serious injury.

Review of the facility's "ED Physician/Non-Physician Practitioner On Call Schedule" for June 20, 2022, revealed the facility did not have an ED Physician or Non-Physician Practitioner working June 10, 2022 - 7:00 a.m. - 7:00 p.m. (a.m. shift) and 7:00 p.m. to 7:00 a.m. (p.m. shift); June 11, 2022 - a.m. shift; June 12, 2022 - a.m. shift.

Review of Emergency Department daily logs dated March 1, 2022 - June 15, 2022, revealed no documented evidence of any patients (individuals) who presented to the ED for care and were turned away or sent to another facility, recorded in the ED log on the reported dates of Diversion June 10, 2022 - 7:00 a.m. - 7:00 p.m. (a.m. shift) and 7:00 p.m. to 7:00 a.m. (p.m. shift); June 11, 2022 - a.m. shift; June 12, 2022 - a.m. shift.

Review of the facility's "EMTALA Transfer Process," not dated, the facility used for education on 4/22/22 revealed that patients are not to be turned away and must be seen and logged with an accurate time of arrival. The process also states that " ...Three Distinct Requirements: 1. Provide a Medical Screening Exam ...2. Stabilizing Treatment ...3. Appropriate Transfer ..." .

Review of facility's "ED Staff Meeting Minutes," dated 5/26/2022 revealed staff were made aware of the EMTALA rules and " ...it applies to all patients who present to the emergency department and request treatment ..." ,

Review of the facility's "EMTALA Policy," effective dated 12/28/21, revealed " ...The Hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE ...".

During Exit Conference on 06/16/2022 at 4:30 p.m. survey findings were discussed, and no further documentation was submitted for review.