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Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined that the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, the responsibilities of Medicare participating hospitals in emergency cases.

Findings Include:

Hospital policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)", revealed: " ...This policy applies to persons who come to an HonorHealth Dedicated Emergency Department (DED) seeking examination and treatment for what they believe to be an emergency medical condition or which a layperson might reasonably believe is an emergency medical condition ...All HonorHealth staff must comply with EMTALA and related laws and requirements, including the following: A. Registration and Triage: HonorHealth will not delay providing a medical screening examination or necessary stabilizing treatment for any individual with an emergency medical condition by inquiring about an individual's ability to pay for care ...All persons who present to an HonorHealth hospital campus with what they believe to be a medical emergency, or which a layperson would reasonably believe they are experiencing a medical emergency, must receive a medical screening examination ...Qualified personnel (registered nurse, nurse practitioner, physician assistant, or physician) will conduct a triage examination to determine the order in which persons receive the medical screening examination ...The triage nurse or other qualified personnel will periodically re-triage the person to determine whether he or she should have a higher medical screening priority ...HonorHealth will provide a medical screening examination to all persons who present to an HonorHealth DED requesting emergency services...If the person refuses to sign a refusal of a medical examination and treatment form, HonorHealth personnel will document this fact on the unsigned form and include that form in the person's medical record ...."

Hospital document titled, "Refusal of Screening Examination and Treatment", revealed: " ...I, (the patient or parent/legal representative of the patient listed above) understand that the hospital has a duty to provide care and has offered to perform a medical screening examination and determine if an emergency medical condition exists. The risks associated with refusal have been explained to me by hospital personnel. These risks include, but are not limited to: ...Patient (or patient representative) Acknowledgement of Understanding: I understand that the hospital cannot provide treatment prior to performing a medical screening examination. I understand that by refusing the services offered I am doing so against the advice of the hospital staff. I understand that the availability of medical services, including examination and stabilizing treatment, as well as necessary transfer to another facility is not based on my ability to pay for these services. I have been given the opportunity to ask questions about the above information and my questions have been answered. I completely understand the consequences of my refusal ...Reason for refusal of screening exam and treatment: ________...Reason form not signed: Patient refused to sign; Patient left without notice; patient called, but no answer 1st call time: _______, 2nd call time: ________, 3rd call time: _______...."

The hospital failed to provide a Medical Screening Examination (MSE) to a patient who presented to the ED complaining of chest pain.

The hospital failed to complete a "Refusal of Screening Examination and Treatment" form for Patient #1 documenting that attempts were made three (3) times to call the patient back for the MSE.

Employee #2 confirmed on 03/13/2023 that a Refusal of Screening Examination and Treatment form should be completed and placed in the medical record on every patient that leaves Against Medical Advice or Leaves without being seen.

Employee #6 confirmed on 03/13/2023 that a Medical Screening Examination had not been conducted on Patient #1 before Patient #1 left the ED.

Based on review of policies and procedures, hospital documents, medical records, and staff interviews, it was determined that the hospital failed to ensure a patient who presented to the Emergency Department complaining of chest pain and vomiting was provided a medical screening examination. (Patient #1).

Findings include:

Hospital policy titled, "Against Medical Advice: Informed Refusal/Withdrawal of Treatment or Leaving the Hospital", revealed: " ...Patients with mental capacity to consent to care who express a desire to leave without treatment or to leave the hospital Against Medical Advice (AMA) prior to a planned release are provided an explanation with information related to the medical risks associated with their action, so that they make an informed decision ...The patient/LAR (legally authorized representative) request to leave AMA, Refusal of Treatment/Transfer should be documented in the patient's medical record ...Patients who leave AMA or Refuse Treatment are to be provided with a safe discharge, which includes as applicable, the following: discharge instructions, follow-up care instructions, education, prescriptions ...The patient/LAR will be asked to sign the applicable AMA form ...If the patient/LAR refuses to sign the AMA form the following actions shall be taken: The patient/LAR refusal to sign the AMA form will be documented on the form by the attending physician/provider or nursing. Staff members who were present when the form was offered and refusal by patient/LAR to sign was made will sign as witnesses to the refusal. Circumstances of the refusal are charted in the patient's medical record by the attending physician/provider and nursing with a summary of the facts leading up to the refusal, what occurred at the time of refusal, and notification of the attending physician/provider ...."

Hospital policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)", revealed: " ...This policy applies to persons who come to an HonorHealth Dedicated Emergency Department (DED) seeking examination and treatment for what they believe to be an emergency medical condition or which a layperson might reasonably believe is an emergency medical condition ...All HonorHealth staff must comply with EMTALA and related laws and requirements, including the following: A. Registration and Triage: HonorHealth will not delay providing a medical screening examination or necessary stabilizing treatment for any individual with an emergency medical condition by inquiring about an individual's ability to pay for care ...All persons who present to an HonorHealth hospital campus with what they believe to be a medical emergency, or which a layperson would reasonably believe they are experiencing a medical emergency, must receive a medical screening examination ...Qualified personnel (registered nurse, nurse practitioner, physician assistant, or physician) will conduct a triage examination to determine the order in which persons receive the medical screening examination ...The triage nurse or other qualified personnel will periodically re-triage the person to determine whether he or she should have a higher medical screening priority ...HonorHealth will provide a medical screening examination to all persons who present to an HonorHealth DED requesting emergency services ...."

Hospital policy titled, "Network Emergency Department Operating Policy", revealed: " ...The Emergency Departments (ED) are located on the first floor of each HonorHealth campus, are DNV accredited and provide care 24 hours/day, 7 days/week ...Deer Valley Medical Center: It is a 34-bed comprehensive care department and functions as a Level 1 Trauma Center and Primary Stroke Center, Chest Pain Receiving Center, and a base station-communication room ...The Emergency Department will: a. Deliver quality care to each individual presenting to the Emergency Department requesting treatment or in need of treatment, b. Provide triage, assessment and treatment ...Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity ...Reassessment Guidelines: ESI Level 1: Reassess every 5-15 minutes dependent upon clinical presentation and no less frequently, then every hour for the first four hours, then every two hours if clinically stable ...ESI 2: Reassess no less frequently than every hour for the first four hours, then every two hours if clinically stable ...ESI 3: No less frequently than every four hours if vital signs are within normal limits and no less frequently than every two hours for the first four hours if vital signs are abnormal then every four hours if clinically stable ...ESI 4: No less frequently than every four hours ...ESI 5: Upon triage and within 30 minutes prior to discharge ...Situations requiring Special Considerations: ...Patients remaining in the waiting room for an extended period: Reassessment frequency, including vital signs, should occur at a minimum of every two hours until brought into the department ...."

A request was made for an ED Triage/Emergency Severity Index (ESI) policy. The facility did not provide the requested policy.

Hospital document titled, "Refusal of Screening Examination and Treatment", revealed: " ...I, (the patient or parent/legal representative of the patient listed above) understand that the hospital has a duty to provide care and has offered to perform a medical screening examination and determine if an emergency medical condition exists. The risks associated with refusal have been explained to me by hospital personnel. These risks include, but are not limited to: ...Patient (or patient representative) Acknowledgement of Understanding: I understand that the hospital cannot provide treatment prior to performing a medical screening examination. I understand that by refusing the services offered I am doing so against the advice of the hospital staff. I understand that the availability of medical services, including examination and stabilizing treatment, as well as necessary transfer to another facility is not based on my ability to pay for these services. I have been given the opportunity to ask questions about the above information and my questions have been answered. I completely understand the consequences of my refusal ...Reason for refusal of screening exam and treatment: ________...Reason form not signed: Patient refused to sign; Patient left without notice; patient called, but no answer 1st call time: _______, 2nd call time: ________, 3rd call time: _______...."

Hospital document titled, "Patient Relations Worksheet", dated 03/01/2023 revealed a grievance was filed on behalf of Patient #1. Review of the grievance investigation document revealed: "...Comments: 03/02/2023 12:28 pm by Employee #3; patient arrived at 12:51 with CC {sic} (chief complaint) of N&V (nausea and vomiting) and assigned an ESI of 3. Then the patient was triaged at 12:55 and vital signs taken with hypertension 163/11 repeated 139/105 with increased HR at 116 and chief complaint changed to LUQ pain X4 days with N&V. Patient left without being seen by a provider between 12:56 and 13:41 less than an hour. PMH (past medical history) HTN (hypertension) and Bundle branch block. Our protocol is to obtain an ECG with this presentation, waiting to hear back from Triage RN to find out why it was not completed...03/09/2023 02:14 pm by Employee #3: patient left before being seen, presented with abdominal pain is why an EKG was not performed...."

Review of Patient #1 medical record dated 02/26/2023 revealed a scanned copy of the ED Intake Sign-in Sheet from Hospital #1 which revealed: " ...Reason for visit: Unable to hold a meal, Chest Pain ...."

Review of Patient #1 medical record dated 02/26/2023 from Hospital #1 revealed: " ...ED Note: Reason for Visit: Chief Complaint: Emesis (vomiting) X4 days, Abdominal Pain (LUQ left upper quadrant) ...Arrival date and time: 02/26/2023 12:51 ...Means of arrival: Privately Owned Vehicle (POV) ...ED Disposition: LWBS (left without being screened) after Triage 02/26/2023 13:41 ...ED Timeline: 12:51 Patient arrived ED
12:52 Arrival Complaint: Nausea, emesis ...12:55 Acuity: Patient Acuity 3 ...12:55 Destination Care Area: Main ...12:55 Vitals Reassessment Temp 97.2, Heart rate 109* (elevated), Respirations 18, BP (blood Pressure) 163/111* (elevated), SpO2( oxygen saturation) 97%...12:55 Chief Complaint updated: Emesis X4 days ...12:55 Triage started ...12:55 Chief complaint updated: Abdominal pain (LUQ)m Emesis X 4days ...12:56 Vitals Reassessment: BP 139/105 * (elevated) ...13:41 Patient dismissed, ED LWBS: ED disposition set to LWBS after Triage ...Admission Diagnoses: procedure and treatment not carried out due to patient leaving prior to being seen by health care provider ...."

Further review of Patient #1 medical record for Hospital #1 revealed no other documentation present for 02/26/2023. Further review of Patient #1 medical record from Hospital #1 revealed no evidence of the Refusal of Screening Examination and Treatment form being completed.

Review of Patient #1 medical record dated 02/26/2023 from Hospital #2 revealed an ED Triage note at 14:08 which revealed: " ...patient presents to ED c/o vomiting for 5 days, mid chest pain for 4 days, and L arm pain that started today at private residence ...BP 181/99, Heart rated 94, ESI 3 ...."

Further review of Patient #1 medical record dated 02/26/2023 from Hospital #2 revealed an ED Note-Physician which revealed: " ...Chief complaint: Patient presents to ED c/o vomiting for 5 days, mid chest pain for 4 days and left arm pain that started today at private residence ...presents today with a chief complaint of having chest pain X4 days. Patient states that [she] also has been experiencing some shortness of breath, pain to [her] left upper extremity. [She] also has some nausea ...Patient states that [she] does not have any known cardiac history but states that [she] was told years ago that [she] had a LBBB (left bundle branch block) ...[She] is supposed to be taking metoprolol but states that [she] has been out of that medication for approximately 2 weeks. Blood pressure at time of arrival was 181/99. At time of my evaluation, the patient blood pressure was 189/104 ...[She] rates [her] pain as 6/10 ...Labs revealed an elevated troponin of 1.24 but EKG showed LBBB which is apparently chronic for [her] ...Impression/Plan: NSTEMIT (non-ST elevated myocardial infarction/heart attack) ...Admit to Inpatient per ED ... [Dr. Maholtra] (cardiology) was consulted and provided clinical history and findings for this patient. [He] recommended starting the patient on a heparin drip ...."

Further review of Patient #1 medical record from Hospital #2 discharge summary dated 02/28/2023 revealed: " ...during [her] hospitalization cardiology was consulted and the patient underwent cardiac cath ...Cardiac Cath ...Angioplasty ...."

Employee #6 confirmed on 03/13/2023 that Patient #1 presented to the ED on 02/26/2023 complaining of vomiting. Employee #6 confirmed that the chief complaint was updated to include abdominal pain when the patient was overheard telling the registration clerk that [she] was having abdominal pain. Employee #6 stated that the patient intake form was blank where patients are supposed to state reason for visit. Employee #6 confirmed that Patient #1 had an elevated blood pressure and it remained elevated when re-checked one minute later. Employee #6 confirmed that Patient #1 left the ED before being screened by a medical provider. Employee #6 confirmed that patients are not considered leaving AMA if they have not been seen by a medical provider. Employee #6 confirmed that if a patient presents to the ED complaining of chest pain, an EKG is done immediately.