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Based on interview, record reviews, and review of facility documents, the facility failed to comply with the conditions of participation outlined in §489.20 and related requirements at 489.24: (refer to Appendix V). The facility failed to provide a medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine if an emergency medical condition existed for two patients (#'s 11 and 24) of 24 sampled patients.

Findings include:

Review of facility policy, "Admission to Emergency Department," with a revision date of 4/2015, showed:
" In compliance with EMTALA regulations, Hospital will provide for appropriate medical screening examinations, provide necessary stabilizing treatment for emergency medical conditions and labor, provide for an appropriate transfer of the individual if the hospital does not have the capability or capacity to provide the treatment necessary to remove the emergency medical condition, not delay examination and/or treatment in order to inquire about insurance or payment status, accept appropriate transfers of individuals with medical emergencies if the hospital has the specialized capabilities not available at the transferring hospital and has the capacity to treat those individuals, and obtain or attempt to obtain informed written consent or refusal for examination, treatment or appropriate transfer. The facility will not take adverse action against a physician or qualified medical personnel who refuses to transfer an individual with an emergency medical condition or against an employee who reports a violation of the EMTALA requirements."

-Patient #11 did not receive a MSE (Medical Screening Examination) after seeking care in the emergency department. (Refer to C-2406)

-Patient #24 did not receive an appropriate MSE in the emergency department after seeking care and before being discharged. (Refer to C-2406).

Based on interview, record review, and review of facility documents, the facility failed to provide a MSE for 1 (#11), and the facility failed to provide an appropriate MSE for 1 (#24) of 24 sampled patients.

Findings include:

1. Emergency visit #1:

Patient #11 was seen in the emergency department on 5/22/23 at 9:14 p.m. for a complaint of a sore throat. Patient #11 had experienced the sore throat for 4 hours and was concerned he may have had strep throat due to his history of strep throat. Patient #11 was assessed in triage at 9:19 p.m. by staff member H. Vital signs were temperature 97.7F, Pulse 85, Blood Pressure 130/76, and Oxygen saturation 98% on room air. Patient #11's throat appeared irritated, but without white patches. Patient #11's condition was assessed as non-urgent. Staff member H performed a POC strep test, results were documented as negative. Staff member H discharged patient #11 at 9:21 p.m. with instructions to increase fluids, quit smoking, take Tylenol for discomfort, and return to the clinic the following day if signs and symptoms worsen. Staff member H did not notify staff member I of patient #11's admission to the emergency department, or the patient's need for evaluation.

Emergency visit #2:

Patient #11 was seen a second time in the emergency department on 5/23/23 at 7:51 a.m. for complaint of continued sore throat with fever, chills, and worsening symptoms. Patient #11 was assessed in triage at 7:54 a.m. by staff member C. Vital signs for the patient included a temperature 99.1F, Pulse 91, Blood Pressure 136/77, and oxygen saturation of 97% on room air. The patient's throat appeared reddened and irritated without noticeable white patches. Patient #11's condition was assessed as non-urgent. Patient #11 reported he had been seen in the ED the previous night and "had not had the opportunity to see the physician." Staff member K evaluated patient #11 and dictated a history and physical at 8:30 a.m. Patient #11 was diagnosed with strep pharyngitis and administered amoxicillin 500 mg and dexamethasone 10 mg in the ED. He was sent home with a prescription for amoxicillin 500 mg twice daily for 10 days. Patient #11 was discharged at 8:35 a.m. with instructions to follow-up with his primary physician in 7 to 10 days and return to the ED if symptoms worsen.

During a phone interview on 3/27/24 at 10:20 a.m., staff member H stated she was currently working as a travel RN and worked at the facility a few shifts a month. Staff member H said she did not remember the incident with patient #11. Staff member H said when working as an ED nurse, she would sometimes see a patient and do a throat swab or other POC testing and give the patient the results. If the result was negative and the patient did not want to see the provider, or no interventions were required; she would discharge the patient with instructions. Staff member H said she would consider this a nurse visit, and document the patient was not seen by the physician. If the patient wanted to see the provider, she would notify the provider. Staff member H said, in her experience, she had seen facilities provide nurse visits and was told a nurse visit was allowed in this facility. Staff member H said she had no formal training or classes on EMTALA, but it was her understanding that patients requesting care had to be evaluated and treated. Staff member H stated she was not aware of an MSE being required for all patients presenting to the ED for care. Staff member H said she did not recall being informed about the incident or being provided further training following the incident.

During a phone interview on 3/27/24 at 10:10 a.m., staff member I said he was not made aware of the incident with patient #11. Staff member I said the usual practice in the ED was to notify the physician once the patient had been brought back to an examination room in the ED. Staff member I said if he was in the ED at the time the patient was brought back to an examination room, he would immediately go to examine the patient, if he was available. Staff member I said if there were no patients in the ED, he would be in the physician call room. Nursing staff would usually contact him in the call room, and he would go and evaluate the patients. Staff member I said if the ED was not busy, he would have been in the call room at the time patient #11 was in the ED. He said if he was not contacted by nursing staff, he would have no idea what had occurred with patient #11.

During an interview on 3/27/24 at 9:18 a.m., staff member C said patients that report to the ED, after convenient care hours, will be taken back to an examination room to be seen. Staff member I typically would come to the examination room with the nurse and start his evaluation at the same time the nurse was performing the triage evaluation. Staff member C said staff member I was in the call room at the time patient #11 arrived at the ED on 5/22/23. Staff member C said staff member H never notified staff member I of the arrival of patient #11. Staff member C said she was the nurse that cared for patient #11 on his second visit to the ED on 5/23/23. She stated she became aware of patient #11 not seeing a provider when she checked him in for his triage evaluation. Staff member C included the information as part of a patient complaint that included multiple issues with the care provided by staff member H. Staff member C then filed a "Risk Qual" document with the facilities incident reporting system and filled out a written complaint document with the patient information. Staff member C stated she contacted staff member H and provided her with verbal coaching which included appropriate customer service for patients seeking care at the facility and in-depth education on EMTALA. Staff member C said staff member H was newer to the facility and was only scheduled to work a few shifts a month. Staff member C said the incident was treated as a patient complaint and had not been identified as an EMTALA violation by the facility. Staff member C said the facility was made aware of the EMTALA violation in February during the facility recertification survey. Staff member C said during the investigation for the EMTALA violation, it was identified that new staff had not been receiving education on EMTALA requirements upon hire and only received education during the annual staff training in November of each year. Staff member C then started a QAPI project, in February, to include EMTALA training as part of the new hire orientation and added it to the skills checklist for new staff. Staff member C stated current ER nursing staff are scheduled to receive EMTALA training at the upcoming April ED staff meeting. Staff member C said it was a not regular practice for staff to swab a patient's throat for testing without a physician order. Staff member C stated the only time a patient had a swab without a formal order was during COVID 19 testing at a testing area outside of the ED.

During an interview on 3/27/24 at 3:00 p.m., staff member K said he was the provider that cared for patient #11 during his ED visit on 5/23/23. Staff member K said he did not remember patient #11 but had reviewed the charting for the visit. Staff member K said the occurrence for patient #11's visit on 5/22/23 was not a typical occurrence. Staff member K stated a patient is seen by the ED nursing staff and triaged based on the vital signs and patient's report. The nurse would give report to the physician, and a verbal order for any testing may be given at that time. Staff member K stated the only time a nurse would do swab testing without a patient being evaluated was during COVID 19, a standing order was in place. Staff member K said he diagnosed patient #11 with strep pharyngitis and treated him with amoxicillin and dexamethasone. Staff member K said patient #11 should have been evaluated by a physician on his 5/22/23 visit to the ER.

During an interview on 3/27/24 at 1:38 p.m., staff member A said patient #11's visit on 5/22/23 was documented and investigated by staff member C as a patient complaint. Staff member A stated a "Risk Qual" report was filed but was not found in the reporting system until the facility's recertification survey, which occurred in February 2024. Staff member A stated the incident had been investigated and reported through the QAPI committee as a complaint and was also presented to the medical staff and the governing board as a complaint. The incident was presented at the last medical staff meeting in February, and the physicians were provided education on EMTALA during the meeting. Staff member A stated the governing board was presented with a report on all facility complaints during the last scheduled meeting and the board was given an opportunity to ask questions about the specific complaints. Staff member A said the new QAPI project was still in progress and the facility was currently orienting two new nurses to the ED using the new orientation checklist that had been developed.

Record review of a verbal coaching report by staff member C, dated 5/24/23, showed:
"Spoke with [staff member H] about patient situation that she treated as a nurse visit. Pt returned next day with c/o not being allowed to see MD. Informed her that we don't do nurse visits in the ER, and potential for EMTALA violation. ...Stated understanding of need to contact MD with all pt arrivals."

Review of a facility document, "Patient/Visitor Feedback Form," dated 5/23/24, showed patient #11 was seen the previous night by staff member H and was treated disrespectfully and "talked down to". Patient #11 complained he was not given an option to see a doctor and was told to return to the clinic if he had worsening symptoms.

Review of facility policy, "Admission to Emergency Department," with a revision date of 4/2015, showed:
" In compliance with EMTALA regulations, Hospital will provide for appropriate medical screening examinations ...
Policy:
1. A medical screening exam must be provided to any individual who presents on hospital property requesting care for an emergency medical condition regardless of diagnosis, financial status, race, color, national origin, or handicap.
2. Medial screening exams may be performed by non-physician medical professionals such as nursing personnel. The determination of the existence of an emergency medical condition is made by the physician based on the results of the screening exam..."

Review of facility policy, "Physician Notification," with a revision date of 4/2015, showed:
" ...1. All patients admitted to the Emergency Department will be assessed by an appropriate nursing staff member. An RN will assess all patients who present with an emergent or urgent condition.
2. The physician or qualified extender shall be notified by the RN regarding the admission of an Emergency Department patient..."

Review of facility policy, "Medical Staff Obligations- Emergency Department," with a revision date of 4/2015, showed:
" ...3. No treatments or tests will be completed, or medications administered without an order from the physician..."

Review of a facility document, "ED/Trauma Committee Meeting Minutes," dated 2/23/24, showed:
" ...EMTALA education was presented by [staff member C]..."

Review of a facility document, "Board of Directors Meeting," dated 2/26/24, showed:
" ...Risk Qual: A summary report was given to the Board of Directors on the facility incidents..."

Review of a facility document, "Bylaws, Rules and Regulations of the Combined Medical-Dental staffs of St. Luke Community Hospital and Nursing Home," with a revision date of 2/2023, showed:
" ... Section 14. Emergency Room ...
3. In addition to physician staff, emergency room screening examinations may be performed by a Nurse Practitioner, Physician Assistant or RN. RN's performing screening examinations must consult the physician prior to determining that no emergency medical condition exists..."

2. Patient #24 presented to the ED on 3/31/23 for right side pain that she had been experiencing for the previous four days. Patient #24 had an elevated heart rate of 114 bpm (normal less than 100), and she had a past medical history significant for recent pregnancy (delivered one month prior), anemia, poor nutrition, and weight loss. Record review of patient #24's medical chart showed she was not treated or provided discharge instructions related to her tachycardia, and no labs or radiology tests were ordered to determine the cause of the patient's abdominal pain. Patient #24 did not receive an appropriate MSE to determine if an emergency medical condition existed prior to her discharge from the ED.

Review of patient #24's EMR, dated 3/31/24 showed patient #24 presented to the ED at 5:34 a.m. for rib pain. At 5:38 a.m., patient #24's triage assessment was completed. Her vital signs were BP 101/64, P 114, R 18, and Spo2 of 98%. Patient #24 received a 20g Peripheral IV at 5:56 a.m. At 6:24 a.m., Staff member K reviewed patient #24's medical history. Her medical chart did not identify the time she was seen by staff member K. At 6:40 a.m., patient #24 was documented as ready to discharge.

Review of patient #24's ED electronic medical record, dated 3/31/23, showed: "Medical Decision Making Narrative: Patient is a 16-year-old female presenting with right upper quadrant pain. She was dropped off by her aunt and uncle who then left the hospital. Patient is a unaccompanied minor at this time. Her boyfriend tried to contact and get her mother to consent to treat and we currently we are waiting for mom to arrive. Objectively patient appeared nontoxic and in no acute distress. Vital signs were significant for tachycardia heart rate of 114 bpm. She is sitting comfortably in bed at this time waiting her mother's arrival. Mother did not want to come to the hospital. We did not obtain permission to treat. The patient was discharged with her boyfriend who took her home. I advised the patient that she may take ibuprofen and Tylenol as needed at home and to drink plenty of water. Discussed when she returns home to encourage her mother to take her back to the hospital if she continues to have discomfort or worse symptoms. Patient understood and agreed with this plan."

Review of patient #24's ED discharge instructions, dated 3/31/23, showed: "Unfortunately we are unable to treat you this morning without parental permission. If symptoms persist please return to the ED with your mother for permission. You may take ibuprofen and Tylenol as needed to help with discomfort. Please drink plenty of water, 1 to 2 L daily. Try to eat small, bland, frequent meals."

During an interview on 4/30/24 at 2:46 p.m., patient #24 stated she went to the ED on 3/31/23, as she had been having stomach pain for two to three days. Patient #24 stated she was seen by the ED physician, but she could not recall what the physician told her, other than the facility had to have parental consent before she could be treated. Patient #24 stated she had recently delivered a baby prior to going to the ED, and the facility was aware of this information. Patient #24 stated the facility tried to reach out to her mother to get consent for her to be treated, but her mother denied coming to the facility to provide consent. Patient #24 stated the facility did not perform any labs, X-rays, or ultrasounds while she was at the ED to determine the cause of her abdominal pain.

During an interview on 4/30/24 at 9:10 a.m., staff member C stated she was the manager for the ED. Staff member C stated staff member K saw patient #24 on 3/31/23 and did not provide treatment to the patient because she was a minor and he did not receive parental consent to treat her. Staff member C said patient #24 delivered a viable male on 2/26/24. Staff member C stated someone from the medical records department contacted her when it was discovered during patient #24's record review that the patient did not need a parent to consent for treatment, as the patient was an emancipated minor. Staff member C stated an email was sent out to all providers on 4/12/23 with a link to education and the state law regarding emancipated minors. Staff member C stated the education was also discussed with the providers during a trauma meeting, which occurred on 4/28/23.

During an interview on 5/1/24 at 7:43 a.m., staff member K stated he was the ED physician who saw patient #24 on 3/31/23. Staff member K stated patient #24 was provided a medical screening upon her arrival to the ED. Staff member K stated, "The patient did not have anything life threatening." Staff member K stated patient #24 did not present with any acute findings and did not appear to be in distress. Staff member K stated he would not have done any further testing or labs for the patient, as the patient had been experiencing her symptoms for several days. Staff member K stated if a minor patient presented to the ED with an emergent condition, he would treat the patient without parental consent. He stated patient #24 did not have an emergent condition or appear to be in distress, and she was discharged and given instructions for return precautions, with instructions to return to the ED if her symptoms changed or worsened. Staff member K said patient #24's ED visit was discussed in a trauma meeting following the incident, and the medical staff were educated on the conditions required to meet the status of emancipated minors for the state. Staff member K said the medical staff and the emergency department staff were provided further training on the rules and the intent of EMTALA regulations.

Review of a facility policy, "Admission to Emergency Department," with a revision date of 4/2015, showed:
" In compliance with EMTALA regulations, Hospital will provide for appropriate medical screening examinations....
Policy:
1. A medical screening exam must be provided to any individual who presents on hospital property requesting care for an emergency medical condition regardless of diagnosis, financial status, race, color, national origin, or handicap.

Record review of facility policy, "Medical Staff Obligations- Emergency Department", revised 4/2015, showed:
" ...2. Physicians responsible for Emergency Department coverage are required to provide an appropriate medical screening exam for patients presenting with complaint of an emergency medical condition...

Record review of a facility provided email, sent by staff member L, dated 4/12/23, showed:
"Subject: Consent for minor for Health Services: I have attached the link for [State] Code for the Validity of Consent for Minor for Health Services for you to review. There has been some questions about minors who have had a child and being able to consent for services. Please see 41-1-402 (2)(a) attached..."