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Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure compliance with CFR 489.24 related to its failure to provide a medical screening exam (MSE) and stabilizing treatment for an emergency medical condition (EMC).

Cross Refer: A2406 The facility failed to provide a medical screening to Patient #1.

Cross Refer: A2407 The facility failed to provide stabilizing treatment for a patient with an emergency medical condition for Patient #1.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure an appropriate medical screening exam (MSE) was provided for one (1) of twenty (20) sampled patients, Patient #1. Patient #1 was discovered, on 07/02/16 at 6:59 AM, on the campus of Facility #1 by that facility's security staff. Patient #1 was found bent over crying and screaming on the floor of an outpatient area. The security officer transported Patient #1 to Facility #2's Emergency Department (ED) without the patient receiving an MSE from Facility #1. It was determined by staff members at Facility #2 that Patient #1 was in active labor with imminent delivery.

The findings include:

Review of the facility's policy titled, "EMTALA Medical Screening Exam", PolicyStat ID:2254983, last reviewed 03/2016, revealed its purpose was to establish guidelines for providing appropriate Medical Screening Exam (MSE's) and, if the individual was determined to have an Emergency Medical Condition (EMC), any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA. The policy further stated an MSE was required when an individual came to an ED, and a request was made on his/her behalf for examination or treatment for a medical condition. Continued review revealed an MSE was required when the individual arrived on facility property, other than the ED, and a request was made on the individual's behalf for examination or treatment for an EMC. Further review revealed a MSE was required if the individual arrived on the facility's property, either in the dedicated emergency department (DED) or property other than the DED. No request was made for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson observer to believe the individual needed such examination or treatment, and the individual would request that examination or treatment if he/she were able to do so.

Review of the facility's policy titled, "Birth/Delivery", last reviewed 02/2015, revealed its purpose was to provide guidelines for treatment and transfer of neonatal and/or obstetric patients in the ED. Further review of the policy revealed the facility did not provide specialized care of the obstetric (OB) patient or neonate. Further review revealed, when delivery was imminent and transport was not an option prior to the delivery, staff members were to prepare an obstetrical pack, and upon delivery, suction nasal and oral airways of the neonate and keep the infant warm in blankets until an isolette arrived. Also, staff members were to generate a medical chart for the infant, with the last name the same as the mother, and initiate a Certificate of Live Birth. Staff members were then to make arrangements for transfer of the mother and infant to the obstetrician requested by the patient.

Review of Patient #1's medical record at Facility #2 revealed the patient arrived at the ED at 7:19 AM with complaints of being in labor. According to the record the ED History was obtained from the "baby's father" because the patient was not answering any questions. The ED history revealed the patient was approximately eight (8) or nine (9) months pregnant, and he did not think the patient had obtained prenatal care. He further reported he thought this was the patient's second pregnancy, and the contractions started around 4:00 AM. Continued review of the ED notes revealed, at 7:19 AM, two (2) Physicians were at the patient's bedside. Their examination determined Patient #1 was "significantly dilated", and labor and delivery (LD) was notified. At 7:27 AM, Patient #1's contractions were one (1) to two (2) minutes apart, and membranes ruptured at 7:29 AM. At 7:34 AM, Patient #1 delivered a viable infant who was handed off to the Neonatal Intensive Care Unit (NICU) nurses at 7:35 AM. Also documented at 7:34 AM, Patient #1's umbilical cord "snapped". Per the ED note, Patient #1 was transported from the ED to LD at Facility #3, the receiving facility and parent facility of Facility #2, at 7:43 AM for delivery of the placenta.

Review of Patient #1's medical record from Facility #3 revealed she was a twenty-three year old who presented to Facility #1 on the morning of 07/02/16 in labor and was inadvertently transported to Facility #2 where she had a precipitous (very rapid) vaginal delivery. Per the medical record, the umbilical cord was avulsed (a tearing of the umbilical cord from its insertion site on the placenta, making delivery of the placenta difficult and possibly requiring a manual extraction). After the precipitous delivery, Patient #1 was transported to LD of Facility #3 where the placenta was spontaneously delivered, grossly intact. Continued review revealed the patient was a gravida (number of pregnancies) two (2), now para (number of deliveries) two (2) who had received no prior prenatal care. Prior medical history revealed Patient #1 was positive for tobacco abuse, drug abuse, and a previous spontaneous vaginal delivery (SVD) at term.

Record review of Patient #2 (viable infant delivered by Patient #1) revealed the patient to be a newborn infant born precipitously in the ED of Facility #2 on 07/02/16 at 7:34 AM. Continued review revealed Patient #2 had Apgar Scores of eight (8) and nine (9). The Apgar Score was used to determine the health status of the infant at one (1) and five (5) minutes after birth, with a range of scores from zero (0, needed resuscitation) to ten (10, no problems identified). Patient #2 was noted to be well-developed, active with a strong cry, and in no obvious distress. Physical examination of Patient #2 revealed the anterior fontanel was flat; mucous membranes were moist; oropharynx was clear; palate was normal with a strong suck; heart rate was regular with strong pulses and no murmur; breath sounds were normal without nasal flaring, respiratory distress, or retractions; and abdomen was soft with positive bowel sounds, no distention, no tenderness and no rebound or guarding. It was noted the umbilical cord was clamped and in place. Neurologically, Patient #2 was noted to be alert with normal strength and suck. Patient #2's skin was noted to be warm, and the capillary refill was less than three (3) seconds. Review of Patient #2's meconium laboratory sample results, revealed he/she was positive for Cannabinoids and Carboxy-THC (substances found in cannibis).

Review of Facility #1's security video, without audio, dated 07/02/2016 and beginning at 6:52 AM, revealed Patient #1 exited the elevators, with a companion and a toddler, on the second floor of the Outpatient Care Center (OCC) building into a lobby/waiting area. Observations revealed she was flailing her arms about, moving from side to side on the couch, and arching her body. She ultimately lowered herself to the floor, and at 6:59 AM, Security Officer (SO) #1 emerged from the elevator and proceeded to make contact with her. At 7:06 AM, SO #2 arrived to the area with a wheelchair, and Patient #1 was assisted off the floor and into the wheelchair by her family. At 7:07 AM, all parties involved left the area by elevator with Patient #1 being pushed in a wheelchair by SO #1.

Review of Facility #1's ED log dated 07/02/16, revealed no documented evidence of Patient #1 or Patient #2's name, date/time of arrival/discharge or disposition.

Review of the other eighteen (18) medical records from Facility #1, revealed there were no problems identified related to EMTALA, such as no MSE, an unstable transfer, discharge, or transfer forms not completed.

Interview with SO #1, on 07/13/16, at 2:53 PM, via telephone, with a Director of Quality present, revealed she had entered the OCC to begin her shift assignments when she heard someone screaming/crying. She stated she ascertained the noise was from the second floor and proceeded there. Upon arrival, she observed Patient #1 lying on the floor, screaming and crying with a companion and a toddler nearby. Further interview revealed SO #1 was unable to elicit any information from the patient, and the companion was mumbling about being headed to Facility #2. Per interview, SO #1 notified Security Dispatch for a wheelchair. She stated her first inclination was to transport Patient #1 to Facility #1's ED because it made sense to go to the nearest ED; however, the companion kept repeating the name of Facility #2. SO #1 stated she thought Patient #1 and her companion wanted to go to Facility #2, so she transported Patient #1 to Facility #2. Continued interview revealed SO #1 was unable to verbalize why she did not call the medical emergency team (MET), Facility #1's rapid response medical team, as per her training. Also, SO #1 revealed she should have taken Patient #1 to Facility #1's ED, per the facility's policy. She stated she had been employed by the facility for fourteen (14) years and had received EMTALA training at least yearly.

Interview with SO #2, on 07/13/16, at 1:35 PM, with a Director of Quality present, revealed his only involvement was to locate and bring a wheelchair to SO #1 at the OCC. Continued interview revealed he heard SO #1 verbalize taking Patient #1 to Facility #1's ED for stabilization/treatment as needed. Further interview revealed it was at that point that SO #2 heard an unknown and unidentified by-stander state to take Patient #1 to Facility #2. Per interview, there were several unidentified by-standers that had gathered around Patient #1. Continued interview revealed he thought SO #1 was coerced into taking Patient #1 to Facility #2's ED by the unknown by-standers. SO #2 stated he had received EMTALA education upon hire approximately two (2) months ago and was aware patients should have a medical screening prior to transfer to another facility. Per interview, he did not assist SO #1 in transporting Patient #1 to seek medical care.

Post-survey interview with LD #10, a nurse, on 07/22/16 at 10:01 AM, revealed she responded from Facility #3 (parent facility) to Facility #2's ED for a patient in active labor. Per interview, Patient #1 was actively pushing. Continued interview revealed, very shortly after her arrival and prior to the Obstetrical Hospitalist's (OH) arrival, Patient #1 delivered a viable infant. LD #10 stated she "caught the baby" as she was entering Patient #1's ED room to assess the patient. Per interview, ED Physician #2 was also at the bedside, and the OH arrived prior to assessing the one (1) minute Apgar score. LD #10 stated Patient #1's umbilical cord was avulsed, resulting in a complete separation of the cord between mother and baby. She stated she immediately clamped the infant end of the umbilical cord and another staff member clamped Patient #1's end of the cord. LD #10 reported she "handed" the infant to the NICU nursing staff.

Post-survey interview with ED Physician #2, on 07/21/16 at 3:00 PM, revealed she was on duty in Facility #2's ED on 07/02/16 at the time of the incident. Continued interview revealed Patient #1 arrived at the facility in possible active labor. An examination was performed, and Patient #1 was assessed to be in active labor with birth imminent. The LD Unit of Facility #3 (parent facility) was notified, and an LD nurse; NICU nurses; and an OH responded, coming to Facility #2's ED. Per interview, LD #10 delivered the infant because she had more experience with the delivery process; however ED Physician #2 was actively involved and at Patient #1's bedside during delivery. Further interview revealed, the OH arrived right after the delivery and assumed care for Patient #1 and Patient #2.

Post-survey interview with Facility #3's OH, on 07/21/16 at 3:43 PM, revealed she was notified of a potential precipitious birth in Facility's #2 ED and responded to that ED. Further interview revealed she arrived in the ED after the birth; however, prior to the one (1) minute infant Apgar scoring. Per interview, care of the infant (Patient #2) was being given by the nursery staff. The OH assumed care of Patient #1 and Patient #2 after her arrival. Continued interview revealed she was informed the umbilical cord was avulsed, without clear cause. She noted there had been moderate to large bleeding. She assessed Patient #1 and determined she was stable for transport from Facility #2's ED to Facility #3's LD Unit for delivery of the placenta.

Interviews with involved staff and others revealed they were all aware of the components of EMTALA and received annual EMTALA education.

Interview with Facility #1's Acting Security Supervisor, on 07/02/16, revealed SO #1 notified him only that she needed a wheelchair to transport someone to Facility #2; and, if more information had been relayed, he would have instructed her to transport Patient #1 to Facility #1's ED. Also, the Acting Security Supervisor revealed he would have notified the MET.

Interview with the Director of Compliance for Facility #3, on 07/14/16 at 10:22 AM, revealed she was made aware of Patient #1 delivering a baby in Facility #2's ED on 07/05/16. Continued interview with the Director revealed she immediately began an investigation into a possible EMTALA violation; educated ED staff on EMTALA; and began formulating an EMTALA education program for all facility staff, not just ED staff.

Interview with Registered Nurse (RN) #1, on 07/14/16, at 11:16 AM, revealed she was working as a "greeter" (triage trained ED RN that registered and pre-triaged patients, giving patients a first visual assessment) on 07/02/16 when Patient #1 entered the ED waiting area from the outpatient side, in a wheelchair, accompanied by a security officer from Facility #1, a toddler, and a male companion. RN #1 stated she attempted to enter demographics and pre-triage Patient #1, but the patient was non-verbal, just screaming. RN #1 stated as she picked up the phone to notify the ED, a respiratory therapist exited the ED, observed the situation, and stated he/she would take Patient #1 back to the ED. Continued interview revealed she was aware of EMTALA components, and she received yearly EMTALA training.

Interviews on 07/15/16, at 3:04 PM, with the Chief Nursing Officer and the President of Facility #1 revealed they agreed the EMTALA process had not been adhered to by the facility. However, they revealed there was not a negative outcome and would hope the immediacy with which measures were taken to ensure EMTALA educational needs of staff members were met and that there was available response assistance, such as with MET, would be viewed as a step in the right direction to ensure a situation like this did not occur again.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to provide stabilizing treatment for a patient with an emergency medical condition (EMC) for one (1) of twenty (20) sampled patients, Patient #1. Patient #1 was discovered, on 07/02/16 at 6:59 AM, on the campus of Facility #1 by their security staff. Patient #1 was found bent over crying and screaming on the floor of an outpatient area. Facility #1's security officer transported Patient #1 from Facility #1 to Facility #2's Emergency Department (ED) without the patient receiving stabilizing treatment from Facility #1. It was later determined Patient #1 was in active labor with imminent delivery, and therefore had an EMC.

The findings include:

Review of the facility's policy titled, "EMTALA Medical Screening Exam", PolicyStat ID:2254983, last reviewed 03/2016, revealed its purpose was to establish guidelines for providing appropriate medical screening exams (MSE) and, if the individual was determined to have an EMC, any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA.

Review of the facility's policy titled, "EMTALA: Treatment and Transfer of Individuals in Need of Emergency Medical Services", PolicyStat ID: 2032903, last reviewed 12/2015, revealed its purpose was to require, in conjunction with state laws and regulations, that Facility #1, with an ED, would provide an appropriate MSE to any individual and would provide stabilizing treatment for any EMC discovered from an MSE by either admitting the patient, discharging the patient, or providing an appropriate transfer of the patient as required by EMTALA.

Review of the facility's policy titled, "Birth/Delivery", last reviewed 02/2015, revealed its purpose was to provide guidelines for treatment and transfer of neonatal and/or obstetric patients in the ED. Further review of the policy revealed the facility did not provide specialized care of the obstetric (OB) patient or neonate. Further review revealed, when delivery was imminent and transport was not an option prior to delivery, staff members were to prepare an obstetrical pack, and upon delivery, suction nasal and oral airways of the neonate and keep the infant warm in blankets until an isolette arrived. Also, staff members were to generate a medical chart for the infant, with the last name the same as the mother, and initiate a Certificate of Live Birth. Staff members were then to make arrangements for transfer of the mother and infant to the obstetrician requested by the patient.

Review of the facility policy, titled "Medical Emergency Team" (MET), PolicyStat ID 1689287, last reviewed 07/2015, revealed a MET call was initiated if a patient met certain criteria, including concerns about a patient's status. Additional review revealed guidelines for initiating a MET call included staff members calling the facility operator to advise where the MET was needed and the operator initiating a group page to individuals that included the Hospitalist, who would attend the MET call and the House Supervisor. Further review revealed the actions and responsibility of the MET responders included deploying to the MET call within five (5) minutes, completing a patient assessment, and evaluating the need to transfer the patient to a higher level of care.

Review of the facility policy titled, "Medical Emergency Response for Non-Inpatients", PolicyStat ID: 1552479, last reviewed 05/2015, revealed the scope encompassed the Outpatient Care Center (OCC) clinical area and delineated the process by which emergencies were to be handled outside of inpatient clinical areas. The process, as related to non-inpatients that included outpatients, team members, visitors and/or medical staff, was for the person identifying the medical emergency to contact the operator to call for the MET; if the MET determined back-up was needed, they would notify the operator to call the ED and security. The ED would send a trained nurse to the location and security would respond with the emergency response bag/lift to assist with patient transport, if necessary. Continued review revealed the patient would be transferred to the facility's ED, as appropriate, after stabilization.

Review of Patient #1's medical record at Facility #2 revealed the patient arrived at the ED at 7:19 AM with complaints of being in labor. According to the record, the ED History was obtained from the "baby's father" because the patient was not answering any questions. The ED history revealed the patient was approximately eight (8) or nine (9) months pregnant, and he did not think the patient had obtained prenatal care. He further reported he thought this was the patient's second pregnancy, and the contractions started around 4:00 AM. Continued review of the ED notes revealed, at 7:19 AM, two (2) Physicians were at the patient's bedside. Their examination determined Patient #1 was "significantly dilated", and labor and delivery (LD) was notified. At 7:27 AM, Patient #1's contractions were one (1) to two (2) minutes apart, and membranes ruptured at 7:29 AM. At 7:34 AM, Patient #1 delivered a viable infant who was handed off to the Neonatal Intensive Care Unit (NICU) nurses at 7:35 AM. Also documented at 7:34 AM, Patient #1's umbilical cord "snapped". Per the ED note, Patient #1 was transported from the the ED to LD at Facility #3, the receiving facility and parent facility of Facility #2, at 7:43 AM for delivery of the placenta.

Review of Patient #1's medical record from Facility #3 revealed she was a twenty-three year old who presented to Facility #1 on the morning of 07/02/16 in labor and was inadvertently transported to Facility #2 where she had a precipitous (rapid) vaginal delivery. Per the medical record, the umbilical cord was avulsed (a tearing of the umbilical cord from its insertion site on the placenta, making delivery of the placenta difficult and possibly requiring a manual extraction). After the precipitous delivery, Patient #1 was transported to LD of Facility #3 where the placenta was spontaneously delivered, grossly intact. Continued review revealed the patient was a gravida (number of pregnancies two (2), now para (number of deliveries) two (2) who had received no prenatal care. Prior medical history revealed Patient #1 was positive for tobacco abuse, drug abuse, and a previous spontaneous vaginal delivery (SVD) at term.

Record review of Patient #2 (viable infant delivered by Patient #1) revealed the patient to be a newborn infant born precipitously in the ED of Facility #2 on 07/02/16 at 7:34 AM. Continued review revealed Patient #2 had Apgar Scores of eight (8) and nine (9). The Apgar Score was used to determine the health status of the infant at one (1) and five (5) minutes after birth, with a range of scores from zero (0, needed resuscitation) to ten (10, no problems identified). Patient #2 was noted to be well-developed, active with a strong cry, and in no obvious distress. Physical examination of Patient #2 revealed the anterior fontanel was flat; mucous membranes were moist; oropharynx was clear; palate was normal with a strong suck; heart rate was regular with strong pulses and no murmur; breath sounds were normal without nasal flaring, respiratory distress, or retractions; and abdomen was soft with positive bowel sounds, no distention, no tenderness and no rebound or guarding. It was noted the umbilical cord was clamped and in place. Neurologically, Patient #2 was noted to be alert with normal strength and suck. Patient #2's skin was noted to be warm, and the capillary refill was less than three (3) seconds. Review of Patient #2's meconium laboratory sample results, revealed he/she was positive for Cannabinoids and Carboxy-THC (substances found in cannibis).

Review of Facility #1's security video, without audio, dated 07/02/2016 and beginning at 6:52 AM, revealed Patient #1 exited the elevators, with a companion and a toddler, on the second floor of the Outpatient Care Center (OCC) building into a lobby/waiting area. Observations revealed she was flailing her arms about, moving from side to side on the couch, and arching her body. She ultimately lowered herself to the floor, and at 6:59 AM, Security Officer (SO) #1 emerged from the elevator and proceeded to make contact with her. At 7:06 AM, SO #2 arrived to the area with a wheelchair, and Patient #1 was assisted off the floor and into the wheelchair by her family. At 7:07 AM, all parties involved left the area by elevator with Patient #1 being pushed in a wheelchair by SO #1.

Review of Facility #1's ED log dated 07/02/16, revealed no documented evidence of Patient #1 or Patient #2's name, date/time of arrival/discharge or disposition.

Review of the other eighteen (18) medical records from Facility #1, revealed there were no problems identified related to EMTALA, such as no MSE, an unstable transfer, discharge, or transfer forms not completed.

Interview with SO #1, on 07/13/16, at 2:53 PM, via telephone, with a Director of Quality present, revealed she had entered the OCC to begin her shift assignments when she heard someone screaming/crying. She stated she ascertained the noise was from the second floor and proceeded there. Upon arrival, she observed Patient #1 lying on the floor, screaming and crying with a companion and a toddler nearby. Further interview revealed SO #1 was unable to elicit any information from the patient, and the companion was mumbling about being headed to Facility #2. Per interview, SO #1 notified Security Dispatch for a wheelchair. She stated her first inclination was to transport Patient #1 to Facility #1's ED because it made sense to go to the nearest ED; however, the companion kept repeating the name of Facility #2. SO #1 stated she thought Patient #1 and the companion wanted to go to Facility #2, so she transported Patient #1 to Facility #2. Continued interview revealed SO #1 was unable to verbalize why she did not call the medical emergency team (MET), Facility #1's rapid response medical team, as per her training. Also, SO #1 revealed she should have taken Patient #1 to Facility #1's ED, per the facility's policy. She stated she had been employed by the facility for fourteen (14) years and had received EMTALA training at least yearly.

Interview with SO #2, on 07/13/16, at 1:35 PM, with a Director of Quality present, revealed his only involvement was to locate and bring a wheelchair to SO #1 at the OCC. Continued interview revealed he heard SO #1 verbalize taking Patient #1 to Facility #1's ED for stabilization/treatment as needed. Further interview revealed it was at that point that SO #2 heard an unknown and unidentified by-stander state to take Patient #1 to Facility #3. Per interview, there were several unidentified by-standers that had gathered around Patient #1. Continued interview revealed he thought SO #1 was coerced into taking Patient #1 to Facility #2's ED by the unknown by-standers. SO #2 stated he had received EMTALA education upon hire approximately two (2) months ago and was aware patients should have a medical screening prior to transfer to another facility. Per interview, he did not assist SO #1 in transporting Patient #1 to seek medical care.

Post-survey interview with LD #10, a nurse, on 07/22/16 at 10:01 AM, revealed she responded from Facility #3 (parent facility) to Facility #2's emergency department for a patient in active labor. Per interview, Patient #1 was actively pushing. Continued interview revealed, very shortly after her arrival and prior to the Obstetrical Hospitalist's (OH) arrival, Patient #1 delivered a viable infant. LD #10 stated she "caught the baby" as she was entering Patient #1's ED room to assess the patient. Per interview, ED Physician #2 was also at the bedside, and the OH arrived prior to assessing the one (1) minute Apgar score. LD #10 stated Patient #1's umbilical cord was avulsed, resulting in a complete separation of the cord between mother and baby. She stated she immediately clamped the infant end of the umbilical cord and another staff member clamped Patient #1's end of the cord. LD #10 reported she "handed" the infant to the NICU nursing staff.

Post-survey interview with ED Physician #2, on 07/21/16 at 3:00 PM, revealed she was on duty in the ED of Facility #2 on 07/02/16 at the time of the incident. Continued interview revealed Patient #1 arrived to the facility in possible active labor. An examination was performed and Patient #1 was assessed to be in active labor with birth imminent. The LD Unit of Facility #3 (parent facility) was notified, and an LD nurse; NICU nurses; and an OH responded, coming to Facility #2's ED. Per interview, LD #10 delivered the infant because she had more experience with the delivery process; however ED Physician #2 was actively involved and at Patient #1's bedside during delivery. Further interview revealed the OH arrived right after the delivery and assumed care for Patient #1 and Patient #2.

Post-survey interview with Facility #3's OH, on 07/21/16 at 3:43 PM, revealed she was notified of a potential emergent precipitious birth in Facility's #2 ED and responded to the ED. Further interview revealed she arrived in the ED after the birth but prior to the one (1) minute infant Apgar scoring. Per interview, care of the infant (Patient #2) was being given by the nursery staff. The OH assumed care of Patient #1 and Patient #2 after her arrival. Continued interview revealed she was informed the umbilical cord was avulsed without clear cause. She noted there had been moderate to large bleeding. She assessed Patient #1 and determined her to be stable to be transported from Facility #2's ED to Facility #3's LD Unit for delivery of the placenta.

Interviews with involved staff members and others revealed they were all aware of the components of EMTALA and received annual EMTALA education.

Interview with Facility #1's Acting Security Supervisor, on 07/02/16, revealed SO #1 notified him only that she needed a wheelchair to transport someone to Facility #2. He also revealed if more information had been relayed, he would have instructed SO #1 to transport Patient #1 to Facility #1's ED. Also, the Acting Security Supervisor revealed he would have notified the MET.

Interview with the Director of Compliance for Facility #3, on 07/14/16 at 10:22 AM, revealed she was made aware of Patient #1 delivering a baby in Facility #2's ED on 07/05/16. Continued interview with the Director revealed she immediately began an investigation into a possible EMTALA violation; educated ED staff on EMTALA; and started formulating an EMTALA education program for all facility staff, not just ED staff.

Interview with Registered Nurse (RN) #1, on 07/14/16, at 11:16 AM, revealed she was working as a "greeter" (triage trained ED RN that registered and pre-triaged patients, giving patients their first visual assessment) on 07/02/16 when Patient #1 entered the ED waiting area from the outpatient side, in a wheelchair, accompanied by a security officer from Facility #1, a toddler, and a male companion. RN #1 stated she attempted to enter demographics and pre-triage Patient #1, but the patient was non-verbal, just screaming. RN #1 stated as she picked up the phone to notify the ED, a respiratory therapist exited the ED, observed the situation, and stated he/she would take Patient #1 back to the ED. Continued interview revealed she was aware of EMTALA components and yearly EMTALA education was provided to her.

Interviews with the Chief Nursing Officer and the President of Facility #1, on 07/15/16 at 3:04 PM, revealed they agreed the EMTALA process had not been adhered to by the facility. However, they revealed there was not a negative outcome and hoped the immediacy with which measures were taken to ensure EMTALA educational needs of the staff were met and that there was available response assistance, such as with MET, would be viewed as a step in the right direction to ensure a situation like this did not occur again.