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Based on record review, policy review, and interview, the facility failed to comply with the Conditions of Participation outlined in §489.24: the facility failed to complete an MSE for one patient (#10) who refused to have a COVID-19 test and failed to provide an MSE by a qualified medical provider for 2 patients (#s 5 and 18) triaged to the urgent care clinic. These failures could cause unintended adverse medical consequences for all emergency department patients seeking emergency medical care. Findings include:

1. Patient #10 presented to the facility's emergency department complaining of chest pain. When the provider asked for a COVID-19 test to be performed, the patient refused. The provider would not continue the evaluation without the patient consenting to a COVID-19 test. Patient #10 left the facility without signing an AMA form. The patient went to another facility, where he was diagnosed with acute coronary syndrome and required two stents. See C-2406.

2. Patients #s 5 and 18 presented to the facility's emergency room seeking emergency medical care and did not have an MSE by a qualified medical provider. Both patients went to the urgent care clinic after seeing a triage nurse. See C-2406.

Based on record review, policy review, and interview, the facility failed to complete a MSE for one patient (#10) who refused to allow a COVID-19 test and failed to provide an MSE by a qualified medical provider for 2 patients (#s 5 and 18) triaged to the urgent care clinic. These failures could cause unintended adverse medical consequences for all emergency department patients seeking emergency medical care. Findings include:

1. During a telephone interview on 4/26/23 at 1:19 p.m., patient #10 stated he came to the facility on 1/29/23 seeking emergency medical care for chest pain. Upon arrival, he was taken back to the emergency department by a nurse (staff member C). Patient #10 stated the nurse did an EKG and was in the process of starting an IV. There was a lab person (staff member H) in the room and a few other people. As the nurse was about to start the IV, the provider, a PA (staff member D) came into the room. Staff member D told patient #10 he would need a COVID-19 test to be transferred to another facility. Patient #10 stated he did not outright refuse to do the COVID-19 test, but he did question the provider about the necessity for the test at that time. Patient #10 said he asked the provider if he would just run the blood work to see if he was having a heart attack and staff member D told him he needed to do the COVID-19 test. Patient #10 said the provider kept going over the COVID-19 test and refused to move on, stating if he didn't have the test done, he could not be transferred, and it would waste time. Patient #10 said he thought he could just be having heartburn and wasn't convinced he needed to be transferred at all. He could not understand why the provider would not at least make sure he was not having a heart attack without doing the COVID-19 test. Patient #10 stated staff member D told him, "We are done," when he said he did not want to do the COVID-19 test. Staff member D left the room and came back with AMA paperwork. Patient #10 said he refused to sign the paperwork because he still wanted to do the lab work and find out if he was having a heart attack. Patient #10 stated staff member D would not go forward with lab testing without the COVID-19 test. NF1 stated, "We felt like our hands were tied so we just left and went home." Patient #10 stated he went home and continued to have chest pain throughout the night. Around 4:00 a.m., he decided he could not wait and drove himself to another hospital in a snow and ice storm. Patient #10 stated the other hospital found he was having a heart attack and they took him to the cardiac cath lab, where he received two stents in his heart.

During a telephone interview on 4/26/23 at 2:13 p.m., staff member H stated she was present on 1/29/23 when patient #10 came to the emergency department for chest pain. Staff member H said she was part of the team that goes to the emergency department to collect blood when a patient presents with chest pain. Staff member H stated there were ten things that needed to be completed within the first ten minutes of a patient complaining of chest pain and blood work was one of the ten things. Staff member H said the patient did not want to do a COVID-19 test and the provider (staff member D) tried to talk patient #10 into allowing the test, so he could be transported to another hospital. Staff member H stated staff member D did not offer to continue to treat patient #10 without performing the COVID-19 test.

During a telephone interview on 4/26/23 at 3:26 p.m., staff member C said she brought patient #10 back into the emergency department when the patient presented with chest pain. Staff member C said patient #10 was being difficult and did not want his chest shaved for the EKG but she was able to talk him into the procedure. She obtained the EKG, and it went to the provider (staff member D). She began to start an IV and draw blood for testing when staff member D entered the room and began explaining what would need to be done. When he told patient #10 a COVID-19 test was required, the patient made everyone stop. She did not get the IV in or the blood drawn prior to the patient questioning the need for the COVID-19 test. Staff member C said patient #10 was adamant he did not want the COVID-19 test. Staff member C stated staff member D explained to patient #10 the importance of getting the test to expedite transfer to another hospital. Staff member C stated staff member D never offered to do any other testing without first doing the COVID-19 test.

During a telephone interview on 4/26/23 at 3:56 p.m., staff member D stated, "No, I did not offer to treat him without doing the COVID test because that is not part of the standard of care." Staff member D stated, "I hope that this patient getting in the way of his own care by refusing an ordered test doesn't constitute an EMTALA violation. If it does, we have gone too far."

During an interview on 4/27/23 at 10:39 a.m., staff member G stated the emergency department had a protocol for a patient presenting with chest pain. The protocol was called, "Ten things in ten minutes." The ten things included: scribe, chart, vital signs, telemetry, allergies, time frame, aspirin, start IV, EKG, and labs. Staff member G stated based on the chest pain pathway the nurse would follow the providers lead from there. She stated the nurse would monitor the patient, prepare a nitro drip, and monitor the chest pain until the Troponin levels were back from the lab.

Review of patient #10's EMR on 4/26/23 showed, patient #10 arrived in the emergency department at 8:25 p.m., vital signs were recorded at 8:25 p.m., provider was assigned at 8:24 p.m., and patient discharged at 8:41 p.m. A document titled HPI, authored by staff member D, showed, "He (patient #10) allows ECG to be obtained. Then he declares that if we are going to do a COVID test that he would not participate in this evaluation. I shared with him that the COVID test is done at this point in all of the testing so that it does not delay eminent transport if he in fact has an acute coronary syndrome. He is adamant that he will not participate in a COVID test unless done orally. I shared with him that our protocol is a nasal COVID swab and that it would not be appropriate for me to deviate from our policy and procedure." A document titled Leaving Hospital Against Advice was included in the EMR, it showed, "Refuses to sign," under the patient signature line.

Review of a facility policy and procedure dated 11/2022, titled Chest Pain Standing Protocol, showed:

"Standing Orders:
A. Notify ED provider immediately.
B. Call lab tech and radiology tech. Call EKG tech or respiratory therapist if available in-house.
C. Place patient in gown.
D. Room air saturation. If <94%, place on O2 via NC at 4L/min.
E. Cardiac monitor
F. 12-lead EKG
G. Obtain vitals.
H. Obtain IV access. 18 ga or larger preferred.
I. Draw "rainbow" labs (with IV start if possible)
J. Aspirin 324m chew and swallow if not allergic (use 4 chewable 81mg aspirin tabs)
K. Semi-Fowler position
L. Nitro 0.4mg sublingual if having ongoing chest pain if SBP > 110 and known cardiac history ...
M. Present EKG to provider for interpretation.
N. Labs: CBC, BMP, troponin. Draw rainbow.
O. Portable chest Xray.
P. Document ... [sic]"
The policy and procedure failed to show COVID-19 testing as part of the procedure.

Review of a facility policy and procedure dated 11/2022, titled EMTALA-Emergency Transfer, failed to show COVID-19 testing as part of the procedure.

Review of a facility policy and procedure dated 3/2023, titled COVID-19 testing-NAAT, failed to show COVID-19 testing as a requirement for transfer to another facility.

Review of a facility document dated 11/28/2001, titled Patient Transfer Agreement, failed to show COVID-19 testing as a requirement for transfer to another facility.

Review of a facility policy and procedure dated 12/2022, titled Emergency Medical Screening and Stabilization, showed:

"Section 5. How to Provide the Medical Screening Examination ...
h. A Medical Screening Examination is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation prior to discharge or transfer. ..."

2. During an interview on 4/25/23 at 9:30 a.m., staff member E stated a patient would see the HUC first, then wait in the waiting room. The ED nurse would triage the patient in the waiting room. Staff member E stated, "If the patient presents to the ED and states, they want to be seen in the ED then we have to see them in the ED. If the patient could be seen in the clinic the doctor or PA will quickly assess the patient to do the MSE and then they can go to the clinic if the physician deems it is appropriate. MSE's are provided by ED physician or PA. Our OB nurses can provide an MSE for OB patients that are already in our system. If they are not one of our patients, they go to the ED and get their MSE from the ED provider."

During an interview on 4/26/23 at 12:26 p.m., staff member A stated, "We knew we had a problem when we opened the urgent care clinic and we started triaging to the clinic. The providers were not documenting their MSE's, and some providers would not sign them. We started a PI project to work on changing policy and procedures, MSE's, and triage to the clinic."

During an interview on 4/26/23 at 2:44 p.m., staff member I stated, "Our gals in the front have a scripted thing where you offer the ED or offer the clinic. If they choose to go to the clinic, then they are directed there. If I have already triaged them and they decide they want to go to the clinic, then I chart them as 'left without being seen.' It is just a charting difference at that point. If I see them, it is 'left without being seen after triage,' if it is before I have seen them, we then chart 'left without being seen before triage.' The provider doesn't have to see them if they choose to go the clinic, but if they say they want to come into the ER they are seen in the ER."

Review of patient #5's EMR showed, patient #5 presented to the emergency department with complaints of pain. Patient #5 was supposed to have an appointment for a back injection, but the appointment got cancelled. He came to the emergency department seeking pain medication to get him through until he could have the back injection. Patient #5 was admitted to the emergency department at 8:20 a.m., on 10/15/22. Patient #5 was discharged from the emergency department at 8:25 a.m., on 10/15/22. Patient #5's disposition showed, "Patient presented because he ran out of pain medication. He was supposed to have steroid injections of his low back yesterday, but the doctor cancelled due to being ill. He only had medication to get him to the time of that appointment. After talking, the patient decided he would prefer to go to the clinic." Patient #5's EMR for the visit on 10/15/22, failed to show a MSE from a qualified provider.

Review of patient #18's EMR showed, patient #18 presented to the emergency department with complaints of a wound under her breast. Patient #18 was admitted to the emergency department on 12/13/22 at 12:54 p.m. The patient was roomed in the ED at 12:59 p.m., and was discharged at 1:00 p.m. Nursing notes showed, "This patient reports that she has an open lesion under her breast, and she is concerned and wants it to be looked at. I informed patient that there was urgent care available at the clinic and recommended that she be seen there, as the wait time in the ER could be several hours. Pt agreeable and is heading to the clinic." Patient #18's EMR failed to show a MSE from a qualified medical provider for the 12/13/22 visit.

Review of a facility policy and procedure dated 12/2022, titled Emergency Medical Screening and Stabilization showed:

"...Section 1 Medical Screening
A. Statement: Any individual who comes to [facility name] requesting emergency services is entitled to and will receive a Medical Screening Examination (MSE) performed by individuals qualified to perform such examination to determine whether an emergency medical condition exists
... s. Qualified Medical Personnel refers to those non-physician individuals defined by [facility name] staff by-laws rules and regulations manual and approved by the Hospital's Governing Board to perform the initial medical screening examinations for those individuals who come to the emergency department and request examination or treatment.

Review of a facility document dated 12/2022, titled Medical Staff and Allied Professional Staff Bylaws, failed to show an ED triage nurse is a Qualified Medical Personnel as described in the Medical Screening policy for the facility.