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Based on record review and interview the facility failed to ensure patients were informed of the risks and benefits of leaving the hospital prior to medical evaluation and did not make attempts to obtain written informed refusal of medical evaluation for 3 (P [patient]1, P6, and P12) of 9 (P1, P2, P4, P5, P6, P12, P13, P14, and P15) patients reviewed for leaving the hospital without being seen and/or against medical advice.

The findings are:

A. Record review of facility policy titled, "EMTALA [Emergency Medical Treatment and Active Labor Act]" dated 05/2014 on page 5 under, "Right to Refuse MSE [Medical Screening Exam], stabilizing treatment and/or transfer" it is stated, "5.1 A patient retains the right to refuse a MSE, necessary stabilizing treatment and further medical examination, as well as transfer to another facility. [Hospital name] will not transfer a patient with an unstabilized EMC [Emergency Medical Condition] (includes a pregnant patient having contractions, a patient in severe pain, a psychiatric disturbance or symptoms of substance abuse) unless the patient so requests and [Hospital name] staff does all of the following: 5.1 .I Offers the patient further medical examination and treatment within the staff and facilities available to [Hospital name] as may be required to identify and stabilized [sic] an EMC; 5. I .2 Informs the patient of the risks and benefits of such examination and treatment, and of the risks and benefits of withdrawal prior to receiving such examination and treatment; 5.1.3 Takes all reasonable steps to secure the patient's written informed refusal for such examination and treatment; and 5.1.4 Documents the above actions in the Central Log and medical record along with a description of the examination, treatment, or both, if applicable, that was refused. 5.2 Patients who leave [name of facility] without notifying hospital clinical staff shall be appropriately noted in the medical record, if any, and the Central Log. The documentation must reflect that the patient had been at the hospital and the time the patient was discovered to have left the premises."

B. Record review of facility document titled, "Patient Departure/Discharge Against Medical Advice" undated it is stated, "I, [space for patient name], hereby acknowledge that on [space for date] my physician or other health care professional involved in my examination and treatment fully explained my condition, the risks and benefits of treatment, and the potential risks and/or complications (including serious injury or even death) that could arise from my refusal to follow medical advice regarding continued hospitalization for examination and treatment. I also understand that other unknown risks and/or complications (including serious injury or even death) are possible if I refuse continued hospitalization for further medical examination and treatment. I have been fully informed about and understand my medical condition, the benefits of medical treatment, and the potential risks and/or complications (including serious injury or even death) involved in leaving the hospital against the advice of my physician and/or other healthcare professional. I have been given adequate opportunity to ask questions and all of my questions have been answered to my satisfaction. . ." The rest of the document contains signature lines for the patient and healthcare professional to sign, it also contains a box that can be marked that stated, "Patient Refused to Sign."

C. Record review of P1's electronic medical record for admission date 11/27/2023 revealed the following:

1. Document titled for date 11/27/2023 at 8:05 PM, "[Hospital name] FirstNet Tracking and Triage Form" stated patients presented for, "BIBPD [brought in by police department] for intoxication while walking down 550 [road in city] trying to get home. Pt [patient] was almost hit a few times by drivers so OD [police department] brought in patient for wellness check not in custody. Pt [sic] lives alone." It is also documented, "Is the patient presenting suicidal/self-harm/harm of others ideation OR presenting for behavioral conditions as the primary reason for this visit?: [sic] No".

2. Document titled, "ED (Emergency Department) Nursing Discharge Summary Form" for date 11/27/2023 at 10:05 PM it was documented, "Reason Patient Not Seen: Left Without Being Seen (LWBS) (Comment: PT not able to be located in ED . . .)"

3. P1's electronic medical record did not contain evidence that the risks and benefits of leaving the hospital nor did it contain a written informed refusal.

D. Record review of video footage from the night of 11/27/2023 revealed P1 was brought in by police at 7:44 PM in hand cuffs. Patient is seen exiting ambulance bay doors at 8:09 PM, patient re-enters the emergency department by catching a door and sat in a chair in the hallway at 8:12 PM. Staff was seen interacting with patient from 8:13 PM to 8:46 PM. Patient's audio cannot be heard but staff was heard stating, "your ride is on the way." At 8:53 PM patient got up from chair and walked out ambulance bay doors.

E. Record review of P6's electronic medical record for admission date 11/27/2023 revealed the following:

1. Document titled, "Status Change Notification Form" for date 11/27/2023 at 5:12 PM it was documented, "Status Change Observed: Patient requested to leave. IV [intravenous catheter] removed and patient LWBS."

2. P6's electronic medical record did not contain evidence that the risks and benefits of leaving the hospital nor did it contain a written informed refusal.

F. During an interview with S2, ED Manager on 12/06/2023 at 4:30 PM it was asked if the charting found in P6's medical record was complete, since it did not include documentation that the patient was counseled on risks nor did it include documentation that the provider was notified of the patients desire to leave. S2 confirmed that it was not complete documentation and stated, "it [that type of documentation] happens often."

G. Record review of P12's electronic medical record for admission date 07/01/2023 revealed the following:

1. Patient visit list revealed documentation that patient's "Discharge Disposition" was "Left Against Medical Advice-7"

2. P12's electronic medical record did not contain evidence that the risks and benefits of leaving the hospital nor did it contain a written informed refusal.

H. During an interview with S6, Quality Consultant on 12/05/2023at 11:20 AM it was confirmed that P12 did not have a written informed refusal in their record for leave against medical advice.

I. During an interview with S2, ED Manager on 12/06/2023 at 4:30 PM it was asked if the facilities document titled, "Patient Departure/Discharge Against Medical Advice" is utilized in cases where the patient leaves prior to being seen by the provider. S2 explained that they do not get a written refusal to be seen in those cases as they consider them a patient who leaves without being seen rather than a patient who is leaving against medical advice.

Based on record review and interview the facility failed to incorporate the Emergency Department (ED) services as it relates to EMTALA (Emergency Medical Treatment and Labor Act) into the hospital wide quality assessment and performance improvement program. This deficient practice effects all patients that receive care from the hospital and can lead to issues in service delivery not being addressed and lead to poor patient outcomes.

The findings are:

A. Refer to Tag A-0273.

Based on record review and interview the facility failed to incorporate the Emergency Department (ED) services as it relates to EMTALA (Emergency Medical Treatment and Labor Act) into the hospital wide quality assessment and performance improvement program. This deficient practice effects all patients that receive care from the hospital and can lead to issues in service delivery not being addressed and lead to poor patient outcomes.

The findings are:

A. During record review of facility's "Quality Assessment and Performance Improvement [QAPI] Program" dated July 2023 - June 2024 on page 3 under, "Scope" it is stated, "[Hospital name] maintains a coordinated quality assurance program that integrates the review activities of all hospital services to enhance the quality and safety of patient care. [Hospital name] leadership and staff are committed to providing quality healthcare and services and achieve customer satisfaction by meeting or exceeding requirements, expectations, and perceptions, and conducting performance improvement initiatives. Organizational Framework The organizational framework for clinical quality and safety activities is diagrammed in Figure 1 and serves as a foundation for achievement of the QAPI and communication about all quality and safety improvement initiatives. It facilitates a unified, collaborative, consistent, organization-wide program for interdisciplinary improvement efforts and promotes close collaboration and communication among and between the [Hospital name] strategic areas, service lines, departments, administration, medical staff, and Board of Directors." On page 4 it is stated, "Mission - The mission of the QAPI is to foster communication and oversight of all quality and safety improvement activities that support [Hospital name] as a center of excellence that consistently delivers high-quality, safe healthcare. Vision - By deepening our understanding of our care structures, processes, and outcomes, we focus our continuous quality improvement efforts where they will most effectively be translated into better care quality and safety for our patients, families, and the community."

B. Record review of facility's meeting minutes from "ED team meetings" dated December 2022 through November 2023 revealed no evidence of discussions related to EMTALA data or quality measures.

C. Record review of facility's meeting minutes from "[Hospital name] Medical Staff and Hospital Quality Committee Minutes" dated May 2023 through October 2023 revealed no evidence of discussions related to EMTALA data or quality measures.

D. Record review of facility's meeting minutes from, "[Hospital name] Medical Executive Committee Meeting Minutes" dated November 14, 2023 revealed no evidence of discussions related to EMTALA data or quality measures.

E. During an interview on 12/04/2023 at 4:30 PM with S8, COO (Chief Operating Officer) it was asked if the facility had anything QAPI related to EMTALA data. S8 confirmed there was nothing specifically related to EMTALA in their quality meetings.

F. During an interview on 12/06/2023 at 4:20 PM with S8, COO it was confirmed the facility does not routinely collect data regarding EMTALA such as; patients that leave against medical advice, transfers, and patients who leave without being seen.

Based on record review, observation, and interview the hospital failed to ensure sources of infection were maintained in a manner that prevented the spread of infection for all patients that entered the emergency department. This deficient practice can lead to patients developing hospital acquired infections and lead to poor outcomes.

The findings are:

A. Refer to Tag A-0750.

Based on record review, observation, and interview the hospital failed to ensure hazardous waste (waste that can be dangerous or have a harmful effect on human health) was maintained in a manner that prevented the spread of infection for all patients that entered the emergency department and did not ensure staff was washing hands and equipment. This deficient practice can lead to patients developing hospital acquired infections and lead to poor outcomes.

The findings are:

Not handling biohazards per policy:

A. Record review of facility policy titled, "Infectious Waste [hazardous waste] Disposal" dated 12/28/2021 on page 2 it stated, "4.2 Containment of infectious waste must be in a manner and location which affords protection from animal intrusion, does not provide a breeding place or a food source for insects and rodents, and minimizes exposures to the public. 4.3 To provide the maximum amount of protection to patients and personnel, all infectious waste will be contained at the point of generation and segregated from all other solid waste. 4.4 All infectious waste must be sealed and tied in red, infectious waste plastic bags (to prevent expulsion of liquid) and placed in a red, Lined rigid container with a secure fitting lid. . . 4.6 Solid infectious waste must be contained in plastic bags inside rigid containers. 4.7 Infectious waste, once removed from the collection receptacle must be stored in the Soiled Utility room located on the unit."

B. During an observation in the Emergency Department (ED) on 12/06/2023 at 7:15 AM S (staff) 11, housekeeper was removing red biohazard bags from emergency rooms 12, 13, and 14, dropped them on the floor in the hallway and then put them in the regular trash.

C. During an interview on 12/06/2023 at 7:18 AM with S11, housekeeper it was asked if it was policy to put biohazard bags on the floor in the hallway. S11 stated, "I'm picking them up right now."

D. During an interview on 12/06/2023 at 7:22 AM with S9, ED Charge Nurse it was asked if it was standard practice for the housekeepers to throw the biohazard bags on the floor, S9 explained it was normal practice as they are cleaning the rooms. It was then asked if it was normal for them to put the biohazard bags in the regular trash, S9 stated, "Oh, no [they] shouldn't have done that."

E. During an interview on 12/06/2023 at 4:30 PM with S2, ED Manager it was asked where the biohazard bags should go once removed from the patient rooms, S2 explained that they should always go into a hard bin and not on the floor.

F. During an observation of the ED waiting room on 12/06/2023 at 11:45 AM a basin with the word "urine" written on it was seen on the floor, there was a biohazard bag with a specimen cup of yellow liquid in it. Waiting room was observed until 12:06 PM and no staff member checked basin.

G. During an interview on 12/06/2023 at 11:57 AM with S10, Patient Access (registration clerk) it was asked how often that basin is checked for patient samples. S10 explained that it is usually checked often or sometimes patients bring her samples directly.

H. During an interview on 12/06/2023 at 4:30 PM with S2, ED Manager and S16, ED Medical Director it was asked what the process was for a patient to give a urine specimen. S2, ED Manager explained that it is preferably handed to staff. S2, ED Manager confirmed that the basin on the floor of the ED waiting room was not effective infection control.

Not washing hands or equipment:

I. Record review of facility policy titled, "Standard Precautions" dated 08/16/2021 on page 1 under, "Implementation Procedures" it is stated, "1. Standard Precautions 1.1. Standard Precautions are the primary strategy for preventing transmission of pathogens [any organism or agent that can produce disease] from one person to another. 1.2. Standard Precautions apply to all patients receiving care regardless of their diagnosis or presumed infection. If there are questions about precautions, contact the Infection Prevention and Control Department (IPCD). 1.3. Staff shall be familiar with and comply with standard precautions and related infection control practices detailed in this manual as well as the Bloodborne Pathogens [any organism or agent that can produce disease originating from a blood source] Exposure Control Plan. Individuals who are consistently non-compliant shall be subject to disciplinary action. 1.4. Standard Precautions combines the major features of Universal Precautions and Body Substance Isolation [refers to the practice of contacting with patients bodily fluids by wearing nonporous articles such as gowns and gloves] and is based on the principal that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. 1.5. Standard precautions include: 1.5.1. Hand hygiene 1.5.2. Use of personal protective equipment (PPE) when indicated to prevent exposure to blood, bodily fluids, and other potentially infectious material (OPIM) 1.5.3. Safe injection practices 1.5.4. Safe handling of potentially contaminated equipment or surfaces in the patient environment 1.5.5. Respiratory hygiene/cough etiquette. 2.HAND HYGIENE (HH) 2.1. Hand hygiene is an essential element of Standard Precautions. 2.2. Hand hygiene includes both handwashing with either soap and water or use of alcohol-based products (gels, rinses, foams). Please see Hand Hygiene Procedure in the Infection Control Manual for more details."

J. Record review of ED video recording of 11/27/2023 at 7:51 PM an unidentified staff member was seen providing patient care, removing IV (intravenous) catheter, giving an injection, and going in and out of patient rooms without washing their hands and without wearing gloves. The video revealed that equipment, chairs and stretchers were not cleaned between patients.

K. During an interview on 12/07/2023 at 3:56 PM with S2, ED Manager it was asked if staff should be washing their hands and wearing gloves during patient care and if equipment should be cleaned between patients. It was confirmed that staff should be washing hands, wearing gloves and cleaning equipment between patients.

Based on interview and record review the facility was found not in compliance with the Emergency Medical Treatment and Labor Act (EMTALA). This effects all patients that present to the emergency department and can lead to patients not being aware of the risks during emergency care.

The findings are:

A. The facility failed to ensure patients were made aware of risks of refusing a medical screening exam. Refer to tag A-2407.

B. The facility failed to obtain a consent for patients being transferred to another facility. Refer to tag A-2409

Based on record review and interview the facility failed to obtain a consent to transfer to another facility for 2 (P(patient)17 and P20) of 5 (P7, P8, P10, P17, P20) patients reviewed for being transferred from the Emergency Department (ED) to another facility. This deficient practice could lead to patients not being properly informed of the reason and risks of being transferred.

The findings are:

A. Record review of facility policy titled, "EMTALA [Emergency Medical Treatment and Active Labor Act]" dated 05/2014 on page 4 under "Transfers from [Hospital name] to a second hospital outside of [Hospital name]" it is stated "3.2 Complete the transfer paperwork. . . . 3.5 The treating provider who is ordering the transfer must certify in writing that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual and, in the case of a woman in labor, to the unborn child, from effecting the transfer. The certification, which shall be documented on the "Transfer Summary Form," includes a summary of the risks and benefits upon which the certification is based and the reason(s) for the transfer. If the treating provider is not physically present at the time of transfer, another provider can sign the certification as long as that provider is in agreement with the certification and the treating provider subsequently, countersigns the certification."

B. Record review of P17's electronic medical record for admission dated 11/29/2023 revealed the following:

1. Document titled, "ED Note - Provider" dated 11/29/2023 at 2:17 PM did not reveal evidence that patient was being transferred to another facility.

2. Document titled, "Text-Admit/Discharge/Transfer Forms" dated 11/30/2023 at 3:43 AM stated, "Patient has received a medical screening, patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary appropriate life support measures. Receiving facility has agreed to accept transfer and to provide appropriate medical treatments. Receiving facility has available space and qualified personnel for the treatment of the patient. Risks and benefits of transfer explained to patient. Risks and benefits of transfer explained to legal representative." This note was entered by a registered nurse. There was no evidence the patient or legal representative signed a consent form for the transfer, no evidence of prior acceptance by the receiving hospital and no signed physician certification.

C. Record review of P20's electronic medical record for admission date 10/09/2023 revealed the following:

1. Document titled, "Text-Admit/Discharge/Transfer Forms" dated 10/09/2023 at 10:48 PM stated, "Patient has received a medical screening, patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary appropriate life support measures. Receiving facility has agreed to accept transfer and to provide appropriate medical treatments. Receiving facility has available space and qualified personnel for the treatment of the patient. Risks and benefits of transfer explained to patient." This note was entered by a registered nurse.

2. Document titled "Transfer Consent" dated 10/09/2023 under "Transfer Requirements" it is stated "Note: The patient may not be transferred unless each of the following requirements are met:" There is one box checked that stated, "The receiving facility has available space and qualified personnel for treatment of the patient." There are three boxes that were not checked that stated, "The receiving facility has agreed to accept transfer to provide appropriate medical treatment. . . . The receiving facility will be provided with appropriate medical records at the examination and treatment of the patient. The patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures." On the second page of this consent form there was a line for the patient to sign and was blank. The record did not contain any documentation of why the patient did not sign the consent form.

D. During an interview on 12/06/2023 at 9:49 AM with S (staff) 6, Quality Coordinator confirmed the consent form for P20 was not filled out in its entirety and confirmed there was no other documentation in the chart.

E. During an interview on 12/07/2023 at 3:48 PM with S8, Chief Operating Officer it was confirmed that a consent form could not be found for P17.