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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:

A2406: Medical Screening Examinations.

The hospital failed to ensure for 16 of 18 patients who presented to Carondelet Marana Hospital ED and for 2 of 9 patients who presented to the ED at St. Mary's Hospital, the patients did not receive Medical Screening Examinations (MSE). Refer to Tag A2406 for specific details on each patient.

The hospital's Emergency Medical Treatment and Labor Act of 1986" included: "...All employees whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy. Failure to comply with this policy will be subject to appropriate performance management pursuant to all applicable policies and procedures, up to and including termination. Such performance management may also include modification of compensation, including any merit or discretionary compensation awards, as allowed by applicable law...."

Based on review of hospital policies and procedures, clinical record reviews, and staff interviews, it was determined for 16 of 18 patients who presented to the Emergency Department (ED) of Carondelet Marana Hospital (Patients: #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #13, #14, #15, #16, #17, and #18, and for 2 of 9 patients (Patients #21 and #24) who presented to St. Mary's Hospital's ED did not receive Medical Screening Examinations (MSE).

Findings include:

The hospitals' policy and procedure titled "Emergency Medical Treatment and Labor Act of 1986 (EMTALA)" included: "...[Carondelet Hospitals] will provide an appropriate MSE within the capability of Carondelet Hospital to any individual coming to the Dedicated Emergency Department, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists...."

The policy and procedure titled "Triage, Assessment and Re-Assessment" included: "...Patients presenting to the Emergency Department are rapidly screened to determine the appropriate medical and nursing care based on the chief complaint and acuity level. Patients are assigned an acuity level according to the guidelines set force through AHRQ Emergency Severity Index, Version 4....Every patient will be sorted and classified according to urgency of condition or complaint. Triage is the first decision point in the care of the emergency patient. Quick-Look Triage: refers to a rapid assessment that assures ABCs are intact and the patient does not have a life-threatening or potentially life-threatening illness or injury. Comprehensive Triage: refers to a focused assessment based on chief complaint and presenting signs and symptoms and urgency of care needed...Emergency Severity Index, Version 4 (ESI): Triage tool used for triage acuity assessment, shown to be reproductive, utilizing five category levels for patient acuity being (1) immediate life-saving intervention required-resuscitation, (2) High risk situation-emergent, (3) Urgent, acknowledging needed resources or danger zone vital signs, (4) Semi-urgent needing one resource, (5) Non-urgent needing no resources/referable...."

The following ED patients were randomly selected from Carondelet Marana Hospital's ED Logs:

-Patient #1 presented to the ED on 07/10/2023 at 8:09 p.m. a chief complaint of "High Blood Pressure Sent from [name] Urgent Care." The patient was checked out of the electronic medical record at 9:37 p.m., a period of 1.5 hours after arrival without being triaged or receiving an MSE.

An interview was conducted with Patient #1 on 07/12/2023 who reported s/he had a serious migraine that was getting worse. The patient went to an Urgent Care (UC) facility who directed her/him to go to the closest hospital because his/her blood pressure continued to rise in spite of medication administered at the UC. When the patient arrived at Carondelet Marana Hospital, the patient gave the person at the front the urgent care visit summary. The person at the registration desk told the patient they would receive a text with a link to a form to complete registration. The website had an admissions questionnaire and in addition to requiring the patient to photograph both sides of insurance cards. After waiting for a while without being triaged and without anyone at the registration desk, a security staff member came out of the double doors of the ED. The security staff member was asked if someone could at least take the patient's blood pressure and s/he responded yes, however, no one came out of the ED. After waiting a period of time with no response, the patient left the ED.

-Patient #2 presented to the ED on 02/06/2023 at 5:33 p.m. with a chief complaint of sharp abdominal pain. The patient was checked out at 7:38 p.m., over two hours later without documentation of being triaged or receiving an MSE.

-Patient #3 was a pediatric patient who arrived at the ED on 02/06/2023 at 6:40 p.m. with a sore throat, cough,, and runny nose. The patient was not triaged or provided with an MSE before leaving at 8:22 p.m., a period of almost 1.5 hours.

-Patient #4 went to the ED on 02/14/2023 at 2:24 p.m. after being involved in car accident. The patient was checked out at 3:35 p.m., over one hour later without being triaged or receiving an MSE.

-Patient #5 presented to the ED on 02/14/2023 at 3:27 p.m. with a chief complaint of migraine. The adolescent patient was checked out at 5:17 p.m., almost two hours later, without documentation of being triaged or receiving an MSE.

-Patient #6 went to the ED on 02/14/2023 at 3:52 p.m. with "abscess on both legs." The patient left at 6:13 p.m., over two hours after arrival with no documentation of being triaged and/or receiving an MSE.

-Patient #7 presented to the ED on 02/14/2023 at 4:01 p.m. The chief complaint for the pediatric patient was a possible broken foot. The patient was checked out at 6:37 p.m., a period of over 2.5 hours with no documentation of a triage and/or MSE performed during that time.

-Patient #8 presented to the ED on 2/14/2023 at 4:36 p.m. with a chief complaint of possible deep vein thrombosis per referral from a Chiropractor. The patient was checked out at 6:31 p.m., a period of almost two hours later after arrival and no documentation that the patient was triaged MSE performed.

-Patient #9 presented to the ED on 02/14/2023 at 5:50 p.m. with a chief complaint of vomiting and abdominal pain and a history of gastroparesis. The patient was triaged at 6:41 p.m. and assigned an ESI Severity of "3" Urgent. The patient's vital signs at the time of triage were: 189/85 Blood Pressure; Respirations 24; Pulse 76; Temperature 99.3 degrees Fahrenheit; and Pain Score 10. The patient was checked out on 02/15/2023 at 1:01 a.m., a period of over seven hours after arrival. There was no documentation the patient received an MSE or was reassessed during that period of time.

-Patient #11 presented to the ED on 02/20/2023 at 6:06 p.m. with a chief complaint of "Headache." The nursing documentation at 7:53 p.m., almost two hours later included: "Patient told registration that they were leaving. No longer in lobby. LWOT...." There was no documentation that the registration staff notified clinical staff that the patient wanted to leave.

-Patient #13 presented to the ED on 02/21/2023 at 2:47 p.m. with a chief complaint of "Severe left sided rib pain, high heart rate." The patient was documented to have left without being seen at 3:13 p.m., a period of 1.5 hours. There was no documentation the patient was triaged or received an MSE.

-Patient #14 presented to the ED on 03/04/2023 at 5:17 p.m. with a chief complaint of chest pain, shortness of breath, and vomiting. The patient left the ED at 6:57 p.m., a period of over 1.5 hours later without being triaged or receiving an MSE.

-Patient #15 presented to the ED on 05/15/2023 at 11:22 p.m. with a chief diagnosis of "Pacemaker vibrating." The patient was triaged by a Registered Nurse (RN) at 12:44 a.m. on 05/16/2023. Documentation in the clinical record revealed an EKG ("Abnormal ECG Rhythm") was performed, blood was drawn for lab work, a chest x-ray was obtained. The patient left the lobby of the ED at 2:34 a.m. The RN documented registration staff observed the patient leaving the lobby. There was no documentation the patient received an MSE prior to leaving.

-Patient #16 presented to the ED on 07/07/2023 at 8:15 p.m. with a chief complaint of dizziness after a motor vehicle accident. The patient was checked out of the electronic
medical record at 10:30 p.m., a period of over two hours later without being triaged or receiving an MSE.

-Patient #17 presented to the ED on 07/07/2023 at 8:16 p.m. with a chief complaint of wrist and chest pain after a motor vehicle accident. The patient was checked out of the electronic medical record at 10:29 p.m., a period of 2 hours without being triaged by an RN or receiving an MSE.

-Patient #18 presented to the ED on 02/06/2023 at 4:18 p.m. with a chief complaint of "High Blood Pressure and Headache. The patient left the ED at 5:44 p.m., a period of 1.5 hours later without being triaged or receiving an MSE.

-Patient #21 presented to St. Mary's Hospital Emergency Department on 07/17/2023 at 12:20 p.m. for a chief complaint of "Radiator blew up on him-skin is burning." The patient was triaged by the RN who documented: "Pt here after reporting that his radiator blew up in his face & burned him over his arm, body, and face...." The RN further documented there were no visible burns or blisters on the patient. The patient's blood pressure was elevated at 117/102 and the patient reported a pain level of 9. The patient was assigned an ESI score of 4, The patient was checked out of the electronic medical system at 5:09 p.m., almost five hours after arrival. There was no documentation the patient received an MSE.

-Patient #24 presented to St. Mary's Hospital Emergency Department on 07/13/2023 at 1:31 p.m. with a chief complaint of tingling on the left side of his/her face and left shoulder with a history of stroke. The patient was triaged at 2:02 p.m. and assigned an ESI Severity Index of 2 (Emergent). Documentation in the clinical record revealed a Nurse Practitioner ordered lab work and an EKG, however, there was not documentation the Nurse Practitioner saw the patient and initiated the MSE. A physician's note at 10:25 p.m., nine hours after the patient's arrival included: "I signed up for this patient. However, when I went to look for [patient] in the waiting room, I could not find [patient]. I was notified by registration staff that [patient] had actually left the emergency department a long time ago. I did not evaluate or speak to [patient]." There was no documentation the patient was reassessed while in the ED.

The above clinical records were reviewed with hospital staff who acknowledged the documentation and/or lack of documentation.

Observations of the Emergency Department at Carondelet Marana Hospital on 08/07/2023 at 9 a.m. revealed a Patient Access Representative (PAR) (Staff #4) at the reception area. Staff #4 reported there is a PAR at the desk 24 hours a day, seven days a week.

The Director of Patient Access, Staff #5, reported during an interview on 08/07/2023 that the PAR's are provided by a contracted agency. Staff #5 confirmed the only time a PAR would not be at the reception desk is during breaks, meal times, and when they were in an ED room to complete registration of the patient. Staff #5 reported the contracted agency requested Carondelet Marana Hospital to assign a clinical staff person to be assigned to the reception area and be available to monitor patients, however, the hospital chose to assign a security staff member to take over the function of the PAR during their absence from the front.

The Market Chief Nursing Officer, Staff #1 reported during an interview on 08/07/2023 that Carondelet Marana Hospital did not have a Triage nurse assigned specifically to that role. She explained that the volume of patients presenting to the ED was anticipated to be such that the RN's in the ED would be able to immediately triage and room the patients at the same time.

The Director of Emergency Services, Staff #3, reported that patient's are initially registered by the PAR with basic information such as name, address, age, and presenting complaint. Staff #3 reported the patient's name and presenting symptoms are immediately posted to a "bed board" in the ED and monitored by both physician and nursing staff. The surveyor asked if the bed board included patients waiting in the lobby as well as patients in rooms, Staff #3, responded, yes.