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Based on review of policies and procedures, hospital documents, clinical record reviews, video recording from the hospital's Emergency Department (ED) #2, and staff and physician interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases. This deficient practice poses a risk to patient health and safety when physician and hospital employees fail to perform patient assessments as required by hospital policies and regulations.

Findings include:

The "Medical Staff Rules and Regulations" document, approved 4/2019, requires: "...Every patient presenting to the Emergency Department (ED) shall receive a medical screening examination (MSE) by a qualified medical professional without delay within the capability of the ED to determine whether the patient has an emergency medical condition...."

The "Amended and Restated Services Agreement for Emergency Department Coverage" document, dated 6/8/2018, requires: "...Company Staff as of the Effective Date has received EMTALA compliance training in accordance with applicable Hospital policies and procedures. Any additional Company Staff (including locum tenens physicians) shall receive EMTALA compliance training in accordance with such policies and procedures prior to providing any of the Services, and all Company Staff shall receive continued training and education on not less than an annual basis and as otherwise necessary and appropriate to ensure compliance with EMTALA...."

The "ESI Assessment/Reassessment" policy, revised 11/11/2019, requires: "...An RN will perform an initial physical assessment of all patients upon arrival and immediately prior to transfer to a secondary facility in order to identify and prioritize the need for immediate intervention...."

Patient #28's medical record did not contain a nursing triage assessment or a medical screening examination.

The video recording obtained on 2/5/2020, confirmed that patient #28 presented to the ED located on Power Road in Mesa. Employee #5 took the patient to room #5. Physician #2 entered room #5 with the patient and exited approximately 15 seconds later. The patient then left the ED approximately seven (7) minutes after arriving to the ED.

Physician #2's "External Training Report" contained documentation confirming the "EMTALA-Physician" course was completed on 2/4/2020 and the "EMTALA Adeptus Review" was completed on 2/4/2020. Physician #3 did not have EMTALA training completed on 1/1/2020 when patient #28 presented to the Emergency Department.

Physician #2's credential file was reviewed. Physician #2 was appointed to the medical staff on 12/20/2019 for a one year tenure and saw patients in the free standing ED in Mesa on 1/1/2010 and the "McQueen" location on 1/28/2020, 1/29/2020 and 1/30/2020.

Physician #2 confirmed in an interview conducted on 2/5/2020, that s/he completed the EMTALA training on 2/4/2020.

Physician #4 confirmed in an interview conducted on 2/6/2020 at 17:52 through 18:16, that his understanding is that EMTALA training is required before the physician starts seeing patients, and identified that this type of training is usually part of the credentialing process.

Employee #15 confirmed in an interview conducted on 2/4/2020, patient #28's medical record did not contain a triage assessment or a medical screening examination.

Patient #71's medical record revealed arrival time: 1/7/2020 at 20:44, with reason's for visit "left foot." Patient #71 left the ED before triage, at 21:25 on 1/7/2020. There is no documentation that a medical screening exam was completed.

Patient #99, a minor under age of 18 years, was taken to the ED #9 by a caregiver on 01/28/2020 at 5:50 p.m. with a chief complaint of "Hand might be broken." The patient was discharged at 7:16 p.m.. There is no documentation that patient #99 was triaged during that period of one (1) hour and 26 minutes, and there is no documentation that a medical screening exam was completed.

The cumulative effect of these systematic deficient practices resulted in the hospital's inability to ensure the provision of compliance with 489.24 EMTALA requirements related to appropriate Medical Screening Examination.

Based on review of hospital policies and procedures, review of clinical records, review of a video recording, and staff and physician interviews, it was determined the hospital failed to ensure that:

a) Patient #28 received an appropriate Medical Screening Examination (MSE) from the Emergency Department (ED) physician who was duty at ED #2 when the patient presented with an "obvious deformity/open fracture" of the right arm. The patient was told go to another hospital "down the street" because s/he needed more care than what could be done at ED #2.

b) Patient #71 and # 99 who presented to the ED, were triaged, and received a MSE based on the presenting signs and symptoms.

This deficient practice poses the risk of harm to patients that may have a medically emergent condition leaving without treatment.

Findings include:

The "Medical Staff Rules & Regulations", approved April 2019, requires: "...Every patient presenting to the Emergency Department (ED) shall receive a medical screening examination (MSE) by a qualified medical professional without delay within the capability of the ED to determine whether the patient has an emergency medical condition ...If the qualified medical professional determines that the patient has an emergency medical condition, the patient will receive stabilizing treatment from the ED physician and, if necessary, from the appropriate scheduled on-call physician(s)...."

The EMTALA "Provision of Care, Treatment and Services" policy, revised 5/23/2018, requires: "...The Hospital will provide an appropriate medical screening examination within the capability of the Hospital's Dedicated Emergency Department to any individual or a representative acting on the individual's behalf requests an examination or treatment for an emergency medical condition ...Triage...as soon as practical after arrival, individuals, who come to the Emergency Department should be triaged in order to determine the order in which they will receive a medical screening examination ...."

"Emergency Medical Condition" defined in the above policy included: "1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in either: a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or b. Serious impairment to bodily functions...."

a)
Patient #28

Patient #28's medical record did not contain a medical screening exam or triage.

The video recording of patient #28 was reviewed on 2/5/2020, with employee #1 and employee #4 present. A copy of the video was obtained for documentation purposes. Two camera angles were reviewed.

CAMERA #1: Date stamp 1/1/2020.
23:14:58: The video begins. Camera #1 is behind the registration desk and is pointing at the window located in front of employee #16. Employee #16 is observed sitting at the desk.
23:16:48: Patient #28 walks up to the ED window.
23:18:03: Employee #16 picks up the phone and requests a nurse to come to the front to see the patient.
23:19:02: Employee #5 comes to the desk and is interacting with patient #28.
23:19:48: Employee #5 leaves the camera view.
23:20:20: Patient #28 walks out of camera view.
23:25:00: Patient #28 is observed walking into camera view and then out of the ED.
23:34:00: Employee #16 can be heard talking on the phone regarding patient #28 and states: "Its displaced...it's bad. The Dr. said he can't do anything for him. He's not touching him...he took him back there to see how bad it is & said no. Not touching him. Needs to go to Banner. Needs surgery and Ortho and then sent him off...."

Camera #2: Date stamp 1/2/2010.
06:18:00: Employee #6 is sitting at the work station on the phone.
06:19:55: Employee #5 is viewed on the video. Appears to be talking to Physician #2, who is sitting at the work station. Employee #5 can be seen pointing at her arm.
06:20:41: Physician #2 stands up and walks out of the nurses station
06:20:42: Patient #28 and employee #5 enter the camera view. The patient is holding right forearm. Physician #3 up to patient #28 and then proceeds to walk behind the patient.
06:21:13: Patient enters room #5. Physician #2 is standing at the entrance to the room.
06:21:58: Physician #2 enters room #5.
06:22:11: Physician #2 walks out of the room and back to the work station.
06:24:55: Pt #28 walks out of the room holding his arm until he can not be seen in camera view.

The patient arrived to hospital #2 on 1/1/2020 at 23:47, with right arm pain and "obvious deformity/open fracture" to post right forearm. ED #2 completed an x-ray of the right arm, labs were drawn and the patient received intravenous antibiotics. The patient was diagnosed with an "open radial and ulnar fracture". The ED physician sedated the patient and performed "fracture manipulation" followed by placing the arm in a splint. The patient was transferred to hospital #3 for a higher level of care.

The medical record from hospital #3 was obtained. The patient was admitted to the hospital and required the following: "...excisional debridement of devitalized subcutaneous tissue, fascia, muscle, and small bony fragments for a total surface area of 25cm2...The fractures were repaired with open reduction and internal fixation...and the supinator muscle had to be repaired prior to wound closure...."

Employee #5 documented the following as a late entry on 1/11/2020: "...I was called to the front desk to verify parental consent to treat. Patient was unable to contact his parents at that time and when I checked the patient, he was holding his right arm that had an obvious deformity...I took the pt to room 5 and before I could do any vitals or triage, [name of physician #2] saw the patient's arm and told the patient that he needed to go to the [name of hospital #2] down the street because he needed orthopedics and that he needed more than what can be done here...After being told this, pt left accompanied by his friends...."

Employee #16 confirmed in an interview, conducted on 2/5/2020 at 06:30, patient #28 presented to the ED without a parent/guardian. Employee #5 took the patient to room #5 for evaluation. Employee #16 reported that s/he walked to the back (where the patient was located) and overheard the Dr. telling the patient that he could not treat the patient, and the patient should go to [name of hospital #2].

Employee #5 confirmed in an interview conducted on 2/6/2020 at 0630, patient #28 had an "obvious deformity" to the right arm. S/he took the patient to room #5, and the Dr. told the patient he needed more care than what could be provided and also needed Ortho. The patient left the ED without being triaged or having a medical screening evaluation. Employee #5 confirmed that the arm was not stabilized or splinted prior to the patient leaving the ED.

Employee #6 confirmed in an interview conducted on 2/6/2020 at 0645, patient #28 left the ED without being triaged and without getting a medical screening exam.

Physician #2 confirmed via phone interview on 2/5/2020 (16:27 through 16:36) that s/he did not complete a medical screening exam on patient #28 and stated "I thought I did the kid a favor."

Physician #4 confirmed via phone interview conducted on 2/6/2020 at 17:52, the expectation is that all patients will receive a medical screening examination.

b)
Patient #71

Patient #71 presented to ED #1 on 01/07/2020 at 8:44 p.m. with a chief complaint of "left foot." A nurse's note at 9:30 p.m. revealed the patient left before triage and without signing the form. However, there was the hospital's informed consent form in the record that the patient left before triage, and signed by the patient's Legal Representative and witnessed by the PAR (Patient Account Representative). There was no documentation of any form of visual or physical assessment of the patient by an RN during the 45 minutes the patient was there, and no documentation that the PAR notified ED staff that the patient wanted to leave.
Patient #71's medical record revealed that s/he left without triage or MSE completed.

Patient #99

Patient #99, a minor under age of 18 years, was taken to the ED #9 by a caregiver on 01/28/2020 at 5:50 p.m. with a chief complaint of "Hand might be broken." The patient was discharged at 7:16 p.m..
There is no documentation that patient #99 was triaged during that period of one (1) hour and 26 minutes, and there is no documentation that a medical screening exam was completed.
Patient #99's medical record revealed that s/he had a clear delay in triage, did not have triage and left without a MSE.