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Based on interview, record review, and review of the facility's policies, it was determined the facility failed to comply with 42 CFR 489.24(a)(1) regarding not performing an appropriate medical screening examination (MSE) for one (1) of twenty-two (22) sampled patients, Patient #1, on 07/24/2020.


Refer to findings in Tag A-2406

Based on Central log review, facility policy review, and review of the facility's Occupational Safety and Health Administration's (OSHA) Form 300, Log of Work-Related Injuries and Illnesses, it was determined failed to maintain a central log on each individual who came to the emergency department seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for one (1) of twenty-two (22) sampled patients, Patient #1. This incident occurred on 07/24/2020.

The findings include:

Review of the Occupational Safety and Health Administration's (OSHA) Form 300, Log of Work-Related Injuries and Illnesses, verified that on 07/24/2020, Patient #1, while in the pharmacy, experienced a reaction to a cleaner and started coughing, requiring time off work. Patient #1, a facility employee at the time of the incident, experienced respiratory distress as a result of exposure to cleaning chemicals used by housekeeping staff. Patient #1 contacted the Employee Health Nurse (EHN) and was escorted by the EHN outside for fresh air. Patient #1 refused to re-enter the facility to be seen in the Emergency Department (ED) for fear of re-exposure to chemicals that had caused his/her reaction; although he/she did not make it clear to staff the reason for not wanting to re-enter the facility.

Review of the ED Log for 07/24/2020 revealed no record of Patient #1 being logged in and treated.

Review of the facility's policy titled, "EMTALA", effective date 06/27/2018, defined a Central Log as a log the hospital is required to maintain on each individual who "comes to the emergency department" seeking assistance, that documents whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted, treated, stabilized, and treated or discharged. The purpose of the Central Log is to track the care provided to each individual where EMTALA is triggered. The definition continued stating the Central Log included logs from other areas of the hospital that might be considered a dedicated emergency department; as well as individuals who seek care for an emergency medical condition in other areas located on the hospital property other than a dedicated emergency department. Further review of the policy revealed in part, "2. Leaving the hospital in Non-ED prior to an MSE ...Individual refuses to have the MSE performed prior to getting to the DED, the department personnel must obtain or attempt to obtain information and signature on the informed consent to Refusal Form. Once the form is completed, it is to be taken to the DED at that site ...This information should then be placed on the DED's Central Log."

The facility failed to ensure that their policies and procedures were followed as evidenced failing to maintain a central log for Patient #1 who located on the hospital property other than a dedicated emergency department.

Based on review the facility's Occupational Safety and Health Administration's (OSHA) Form 300, Log of Work-Related Injuries and Illnesses, Safety Data Sheet review, Central Log review, policy and procedure review, and staff interviews, it was determined the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists for 1 (Patient #1) of 22 sampled patients who was on the facility's property other that the hospital's dedicated emergency department.


The findings include:

Review of the facility's Occupational Safety and Health Administration's (OSHA) Form 300, Log of Work-Related Injuries and Illnesses, dated year 2020, and Patient #1 was listed as case #250 on 7/24/2020. Patient #1, a facility employee at the time of the incident, experienced respiratory distress as result of exposure to cleaning chemicals used by housekeeping staff. Patient #1 contacted the Employee Health Nurse (EHN) and was escorted by the EHN outside for fresh air. Patient #1 refused to re-enter the facility to be seen in the Emergency Department (ED) for fear of re-exposure to chemicals that had caused his/her reaction; although he/she did not make it clear to staff the reason for not wanting to re-enter the facility. The facility's failure to ensure that staff notified the ED physician that Patient #1's was located on the hospital's property other than the DED resulted in Patient #1 not receiving an appropriate medical screening examination (MSE) from the ED Physician, and staff prior to leaving the premises with her spouse, (A Medical Doctor) approximately one (1) hour later.


Review of the facility's policy titled, "EMTALA", defined "Comes to ED" to include an individual who presented to on-campus hospital property other than the dedicated ED, and, in the absence of a request for examination or treatment, such a request would be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needed emergency examination and treatment. The policy also stated (page 10 of 36) specified in part, "The EMTALA obligations are triggered when there has been a request for medical care by an individual within the DED or when an individual request care on hospital property other than in the DED."

Continued review of the facility's policy titled, "EMTALA", defined Medical Screening Exam (MSE) as the process required to reach with reasonable clinical confidence the determination whether or not an emergency medical condition (EMC) existed. The policy stated screening was to be conducted by Physicians and/or other qualified medical personnel, to include Physician Assistants and Advanced Registered Nurse Practitioners.


Review of the facility's policy titled, "Reportable Events", dated 07/23/2018, revealed it was facility's policy to document, investigate, and evaluate each event or occurrence which resulted in an injury to or which might have a detrimental effect on the health and safety of a patient, visitor, or employee. It stated each employee was responsible for safety and event reporting, and employees and volunteers would report to employee health. The policy stated the employee and supervisor were responsible for initiating the Reportable Event file, determining where the reportable event occurred, what medical attention the injured person needed, with the supervisor responsible for checking the Reportable Event file for completeness. There was no Reportable Event form, for 07/24/2020 available for review for patient #1.

Review of the Safety Data Sheet (SDS) for Oxycide Daily Disinfectant Cleaner revealed the product at dilution required medical attention if symptoms occurred after inhalation; however, no respiratory protection was required normally for exposure at diluted strength. In addition, the SDS stated no health injuries were expected through inhalation under normal use.

Review of the ED Log for 07/24/2020 revealed no record of Patient #1 refusing treatment, treated or stabilized, nor treated and discharged.

Interview with the EHN, on 10/04/2022 at 1:34 PM, revealed Patient #1 called her, she believed around mid-day on 07/24/2020, to let her know he/she was having a reaction to a cleaning product. The EHN revealed Patient #1 was coughing when on the phone. The EHN stated Patient #1 had on a special mask provided to him/her [R95 with a charcoal filter], had a cough, and stated he/she had a tickle in his/her throat. The EHN stated they stepped outside, removed their masks, and within a couple of minutes Patient #1 started feeling better, stating the fresh air helped. The EHN stated Patient #1's cough lessened, and she asked Patient #1 if he/she wanted to be seen in the ED, and Patient #1 said he/she did not. The EHN stated she made a phone call to Patient #1's division supervisor, the OSD (Outpatient Services Director), to let her know what was going on. The EHN stated the OSD came down, asked again if Patient #1 wanted to be seen in the ED, and the patient refused. The EHN stated the OSD went into the ED, and RN #3 came out of the ED, spoke with Patient #1 and Physician #1 (Patient #1's spouse, (is a Medical Doctor) who had arrived from a nearby location by that time). The EHN stated Patient #1 again said he/she did not want to go inside to be seen. The EHN stated Patient #1 did not appear to be in respiratory distress, and he/she was able to converse with him/her. She stated Patient #1 verbalized he/she did feel better, and his/her cough had lessened. She stated, when Physician #1 (Patient #1 spouse) arrived, he/she did a quick assessment (listened to Patient #1's lungs with a stethoscope and spoke with Patient #1) and stated he/she would take Patient #1 home. When asked about the Reportable Event form for 07/24/2020, the EHN stated usually employees completed the form. She stated, if the employee was unable, she usually made some quick notes until the employee was able to complete the form (AR6). She stated she did not think Patient #1 completed a report and was not sure if there would be documentation, as Patient #1 left the premises ill.

Interview with the Executive Vice President of Patient Care Services (EVP PCS), formerly the OSD and a respiratory therapist, on 10/04/2022 at 2:20 PM, revealed, on 07/24/2020, the EHN called her and said she was outside of the outpatient pharmacy with Patient #1. The EVP PCS stated she went out, and Patient #1 was sitting with his/her back against a brick wall. The EVP PCS revealed she started trying to talk to Patient #1 about relaxing and breathing through his/her nose. She stated once Patient #1's mask was off, his/her breathing slowed down, he/she was able to talk, he/she was able to answer questions, and the EVP PCS was feeling better that Patient #1 was outside and had gotten out of that mask. The EVP PCS described the mask as a "special N95 combat zone looking thing". The EVP PCS revealed Patient #1 did not say anything about the ED or being seen by anybody. The EVP PCS revealed somebody had a pulse oximeter (measured blood oxygen saturation); Patient #1's blood oxygen saturation level was really good; and his/her breathing had calmed down. The EVP PCS stated Patient #1 was firm in that he/she did not want to go into the ED. The EVP PCS revealed once Patient #1 was calm and could stand up, he/she left with Physician #1. The EVP PCS stated if she could not get a patient to where he/she was moving air and could speak, she would feel the need to get him/her to the ED. She stated she did not feel that way, or she would have argued with Physician #1. The EVP PCS stated when she initially saw him/her, Patient #1 was still breathing a little faster, so she encouraged the patient to take slow, deep breaths. She stated Patient #1 understood and was slowing his/her breathing down, his/her chest was expanding, his/her color was good, and there was no discoloration to the lips.

Continued interview with the EVP PCS, on 10/04/2022 at 2:20 PM, revealed there had been another incident very similar in the same outpatient pharmacy, maybe a month or two (2) before this one. She stated the mask became an issue once the facility got an accommodation for Patient #1, and he/she came back to work. She stated there was also another incident where he/she ended up going with Physician #1 to the clinic; a very similar panic level. The EVP PCS revealed when a person could not breathe, there was always a certain level of panic. The EVP PCS stated Physician #1 was there in a very short time. She stated the EHN called her, as the facility needed to get coverage or close that pharmacy. She stated the EHN called Physician #1 to let him know. She stated Physician #1 was a provider and saw patients every day. The EVS PCS stated Physician #1 did an assessment, but she was not sure what that included. She stated she was not sure if Physician #1 listed to the patient's lungs; or, if he/she had the pulse oximeter.

Telephone interview with Patient #1, on 10/04/2022 at 3:41 PM, revealed Patient #1 was overheard to have difficulty responding to the State Survey Agency (SSA) Surveyor's questions, with frequent pausing to catch breath in response to questions. The patient was overheard to have obvious labored breathing and a raspy voice.
Patient #1 stated the hospital switched to bleach cleaner after the reaction to PeridoxRTU in January 2020. However, the patient stated the Pharmacy Manager changed to another brand of paracetic acid disinfectant in March 2020 and instructed Patient #1 to wear a gas mask to work, which caused skin breakdown and which Patient #1 could not tolerate for extended use. After multiple discussions with management, Patient #1 stated pharmacy did switch to a bleach-based cleaner, and Patient #1 stated he/she had no reactions to that cleaner. Patient #1 stated that on 07/24/2020, a fill-in housekeeper used Oxycide on Patient #1's keyboard and all over his/her workstation. Patient #1 stated he/she experienced chest pain and his/her spouse (Physician #1) told Patient #1 to call the EHN, which he/she did. He/she stated the EHN came down and took Patient #1 outside, though Patient #1 stated he/she could hardly walk or stand up. Patient #1 stated he/she sat on the ground because there was not a bench, and he/she was too weak to stand. Patient #1 stated the EHN was on her phone, not looking at Patient #1, but Patient #1 believed the EHN was trying to get a doctor to come treat him/her. Patient #1 stated Physician #1 arrived, after approximately an hour, and asked if anyone had listened to Patient #1's lungs. The EHN said she could not get anyone to come out. Patient #1 stated he/she had always been told his/her spouse could not act as his/her doctor, but he/she was so sick, he/she felt there was not a choice. Patient #1 stated when Physician #1 examined him/her, his/her extremities were tingling, and he/she still felt he/she could not breathe. Patient #1 stated Physician #1 heard Patient #1 wheezing and went to the pharmacy to get him/her steroids. Patient #1 stated the Outpatient Services Director (OSD) came out while Physician #1 was in the pharmacy. Patient #1 stated the OSD could not believe no ED staff was out there to assess Patient #1. Patient #1 stated he/she felt he/she could not go back into the building and get re-exposed to the chemical for fear he/she would die. Patient #1 stated the OSD offered a wheelchair so Patient #1 would have somewhere to sit other than the ground. Patient #1 stated an ED nurse (Registered Nurse (RN) #3) came out with a wheelchair. Patient #1 stated they asked the nurse if the ED physician was going to come out, but RN #3 said that he was not. Patient #1 stated the EHN offered to contact another doctor, but Patient #1 and Physician #1 wanted to get Patient #1 out of the heat (it was over ninety (90) degrees Fahrenheit that day), rather than wait on another doctor to arrive. Patient #1 stated he/she had to be helped in the car because he/she could not walk.

Continued interview with Patient #1, on 10/04/2022 at 3:41 PM, revealed he/she made an appointment with a doctor in Bowling Green (approximately thirty-six (36) miles from the hospital), on 08/04/2020, who referred Patient #1 to Pulmonology and a Ears, Nose, and Throat (ENT) provider. Patient #1 stated the ENT instructed him/her not to go into an emergency room due to chemical exposure and possible unnecessary intubation. Patient #1 stated Worker's Compensation required him/her to go to a university hospital for a full workup, but this assessment was unable to be completed because Patient #1 lost consciousness for a little bit. Patient #1 stated that Physician #1 had evaluated him/her during previous episodes and that part of the EHN's role was to make follow-up appointments for employees who have had a health issue at work. Patient #1 stated the 07/24/2020 reaction was a lot worse than the ones he/she had experienced previously. Patient #1 stated he/she started steroids (medication to reduce inflammation) on 07/24/2020 until being evaluated by another provider on 08/04/2020. Patient #1 stated he/she did not recall filing a grievance with the hospital and never heard back from them after the 07/24/2020 incident. Patient #1 stated he/she did not want his/her spouse to lose his/her job due to this complaint, which was partially why he/she waited to file the complaint.

Telephone Interview with Physician #1, on 10/04/2022 at 5:37 PM, revealed he/she recalled working in the office when he/she was notified that the spouse, Patient #1, was having breathing issues at work. He/she stated he/she was not able to leave immediately and assumed the ED doctors would treat Patient #1, and the patient would be in the ED when he/she got there. The physician stated, when he/she did get there, the spouse was dyspneic and leaning against the wall. Physician #1 stated he/she used a stethoscope to listen to Patient #1's lungs, and he/she was working hard to breathe, with wheezing and a prolonged expiratory phase. Physician #1 stated the OSD and the EHN were there with Patient #1, so the physician went to the pharmacy to order some steroids for Patient #1, while they waited for further treatment from an ED physician. Physician #1 stated when he/she returned, RN #3 was out there with a vitals cart, including a blood pressure cuff. Physician #1 stated RN #3 said the physician staff in the ED was aware Patient #1 was outside but was not going to come out. Physician #1 stated he/she felt Patient #1 needed immediate treatment, so he/she provided it because the hospital was not doing it. Nobody was coming out. Physician #1 stated that EMTALA was enacted because of a pregnant woman in the parking lot where no one came out to see her; and, here you have a person in the parking lot in distress, and no one came out to treat him/her.

Interview with the ED Coordinator (RN #3, staff nurse at time of incident), on 10/05/2022 at 8:03 AM, revealed she remembered Patient #1 being outside with Physician #1. She remembered there were chemicals involved and that somebody came to the ED, but she did not remember the specifics. RN #3 revealed she was sure she tried to get Patient #1 to come into the ED but did not think he/she went into the ED. RN #3 stated she was sure that she brought something out to check Patient #1, as that was the first thing she would do, i.e. check the patient's blood oxygen saturation level with the pulse oximeter, if the patient was short of breath. RN #3 revealed she would not have anywhere to document that if he/she was not an ED patient. RN #3 stated it was an employee incident that somebody had asked her for a quick assessment to see if Patient #1 needed to be seen in the ED and encourage the patient to do so. RN #3 did not recall whether or not she brought a wheelchair out and did not remember whether Patient #1 was sitting or standing, although she stated she would have encouraged a patient to sit if standing and short of breath. RN #3 stated she did not recall Patient #1 saying why he/she did not want to come into the ED. RN #3 stated if there was a situation where someone did not want to come in but needed to, she could strongly advise, and stated she had begged people before to come to the ED. Ultimately, RN #3 stated, if they were in their right minds and could make their own decisions, they could not be forced to come to the ED. She also stated there was only so much staff could do outside of the building, such as to check vital signs and to do a very quick assessment. There was no documentation the facility took vital signs for Patient #1, to include blood oxygen saturation, on 07/24/2020.

Telephone interview with Physician #2, on 10/06/2022 at 10:02 AM, revealed he was working in the ED, on 07/24/2020, and stated he did not remember any situation with someone in distress outside of the ED. MD #2 stated if someone were in distress, he would go out if that was what was necessary to help them.


The facility failed to ensure that their policy was followed as evidenced by failing to ensure that an appropriate medical screening examination was provided for Patient #1 on 7/24/2020, who was located on the hospital property other than the DED.