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Based on observation, interview, and record review, the hospital failed to comply with the regulatory requirements for EMTALA for two of 21 patients, Patient (Pt) 1 and Pt 2 when:

1. Pt 1 was transported to Hospital A Emergency Department (ED) on 1/22/24 at 1:31 p.m. by ambulance with a chief complaint of seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). There was no documented evidence Pt 1 was triaged (the sorting of patients according to the urgency of their need for care) or physically assessed and per the paramedic (PMC), Pt 1 continued to have seizures while in the ED. The PMC informed Registered Nurse (RN) 1 about Pt 1's change in condition and was told by RN 1 to treat his patient. By this time Pt 1 had been in the ED for close to an hour with no interventions to prevent further seizures and the PMC made the decision to transport Pt 1 to Hospital B. (Refer to A2406, Finding 1)

2. Pt 2 came into the ED at Hospital A on 12/27/23 at 6:19 p.m. with abdominal cramping, stating she was pregnant. Pt 2 was triaged by an RN, then sent to wait in the waiting room. She did not receive an MSE and left the hospital without being seen to determine if she had an EMC. (Refer to A2406, Finding 2)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner.

Based on observation, interview, and record review, Hospital A failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [EMC] exists) within the capability of the hospital's emergency department (ED) for two of 21 patients (Patient (Pt) 1 and Pt 2) when:

1. Pt 1 was transported to Hospital A Emergency Department (ED) on 1/22/24 at 1:31 p.m. by ambulance with a chief complaint of seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). There was no documented evidence Pt 1 was triaged (the sorting of patients according to the urgency of their need for care) or physically assessed and per the paramedic (PMC), Pt 1 continued to have seizures while in the ED. The PMC informed Registered Nurse (RN) 1 about Pt 1's change in condition and was told by RN 1 to treat his patient (Pt 1). By this time Pt 1 had been in the ED for close to an hour with no interventions to prevent further seizures and the PMC made the decision to transport Pt 1 to Hospital B.

This failure resulted in Pt 1 not having the hospital address a recognized emergency condition (seizures), a delay in providing an appropriate MSE and providing stabilizing measures and prompted a decision to be transported to Hospital B where Pt 1 was admitted as an inpatient for three days.

2. Pt 2 came into the ED at Hospital A on 12/27/23 at 6:19 p.m. with abdominal pain, stating she was pregnant. Pt 2 was triaged by an RN, then sent to wait in the waiting room. She did not receive an MSE and left the hospital without being seen by a medical provider.

This failure resulted in not providing Pt 2 the benefit of being examined by a qualified medical professional in order to determine if an EMC existed and could possibly lead to harm to Pt 2 and Pt 2's unborn baby.

Findings:

1. During a review of Pt 1's "[name of ambulance service] Record", dated 1/22/24, the Record indicated a call was received at 12:48 p.m. and at 1:05 p.m., the emergency medical services (EMS) crew made contact with Pt 1. The Record indicated, " ...arrived on scene, [patient] found postictal [a period that begins when a seizure subsides and ends when the patient returns to baseline] in his bed. Per wife, [patient] had about 9 seizures before we arrived on scene that lasted about 15 seconds each, which started 2 hours ago. [Patient] has a history of seizures and was unable to take his seizure medications because he was vomiting last night ..." The Record indicated, at 1:19 p.m., Pt 1's pulse (the number of times the heart beats in a minute) was 80, blood pressure (BP-the pressure the heart exerts to push blood out of the heart and into the body) was 233/140 (normal BP is less than 120/80), 100% oxygen saturation (a measurement of how much oxygen blood is carrying as a percentage of the maximum it could carry), respirations (the number of breaths a person takes per minute) were 20, Glasgow Coma Scale (GCS-assesses patients according to responsiveness of eye-opening, motor, and verbal responses) of 13 (normal is 15), and blood sugar was 81. The Record indicated, a peripheral intravenous line (IV-a tube inserted into the vein to administer fluids or medications) was initiated with three failed attempts due to "poor veins".

During a tour of the ED on 3/6/24 at 11:51 a.m. with the ED Director (DED) and Quality Review Nurse (QRN) 1, the DED stated, "Until actual handoff to a medical provider, the paramedics are responsible for the patient."

During a concurrent interview and record review on 3/7/24 at 11:15 a.m. with the DED, Pt 1's "Electronic Medical Record (EMR-an electronic collection of medical information about a person)," dated 1/22/24 was reviewed. The EMR indicated Pt 1 was a 39-year-old male brought in by ambulance at 1:31 p.m. to Hospital A. The DED stated Pt 1 was not triaged and did not have vital signs assessed while in the ED. The DED stated Pt 1 was assigned to the hallway, waiting for a room.

During a concurrent interview and record review on 3/7/24 at 11:20 a.m. with the DED, Pt 1's "Nursing Note (NN)," dated 1/22/24 was reviewed. The DED stated at 2:30 p.m., the NN indicated, "Paramedic was with [patient] on the wall waiting for a bed to become available. Shortly after his arrival paramedic informed me [patient] was having another seizure. I informed him I had no nursing staff to care for [patient] at this time and asked him to [continue] to care for his [patient] and treat the [patient] per his protocol and asked him to start an IV on the [patient]. [RN 5] spoke with medic and informed him we were moving [patients] around to get [patient] bedded. When I went to find medic in the hallway to tell him what room to go to, he had left the building with the [patient]." The DED stated the paramedic should have communicated to the Charge Nurse he was taking Pt 1 to another hospital.

During a concurrent interview and record review on 3/7/24 at 11:35 a.m. with the DED, Pt 1's EMR, dated 1/22/24 was reviewed. The DED stated, "In this case, there was no formal process for triaging Pt 1 on the wall (indicating patient and paramedic were waiting in the hallway for room placement) and the ED healthcare staff lacked documentation of triage." The DED stated the ED's process for when a patient came through by ambulance, the patient was not triaged until the patient was roomed and hand off was given between the medic and RN. The DED stated once hand off was completed, the RN triaged the patient.

During a concurrent interview and record review on 3/7/24 at 11:45 a.m. with the DED, Pt 1's "ED Discharge Form (Form)," dated 1/22/24 was reviewed. The DED stated the Form indicated at 3:36 p.m., Pt 1 was discharged from [name of Hospital A], with no actual or suspected pain, ED disposition was left without being seen, mode of transportation was ambulance, ED Condition was unknown, and Discharge comments were "See Ad Hoc Note".

During an interview on 3/8/24 at 4:30 p.m. with the PMC, the PMC stated on 1/22/24 he and his partner were called to Pt 1's home due to Pt 1 having seizures. The PMC stated Pt 1 had a seizure while they were about to buckle Pt 1 onto the gurney and another seizure enroute to Hospital A. The PMC stated while enroute to Hospital A, he called the med net radio (system in place to inform the ED, EMS was enroute and the condition of the patient, so as to give ED healthcare staff prior knowledge and preparation for the patient's arrival) to inform the healthcare staff, he was transporting Pt 1 to the ED, but no one answered the radio. The PMC stated once he arrived at Hospital A, he informed RN 1 about Pt 1's seizures and RN 1 told him to hold the wall (wait for a room in the hallway) with a few other EMS crews who were there with their patients. The PMC stated while they were holding the wall, Pt 1 had another seizure and he informed RN 1 of Pt 1's change in condition. The PMC stated RN 1 told him, "I don't have the staff to help, treat your patient." The PMC stated he walked back to Pt 1 and Pt 1 had another seizure which lasted 30 seconds, then 15 minutes later another seizure, followed by another seizure where Pt 1 did not come out of the postictal phase. The PMC stated other nurses in the ED witnessed Pt 1 have seizures while they were in the ED, and nothing was done. The PMC stated after Pt 1 had his last seizure, the PMC took Pt 1 back to the ambulance and administered midazolam (a drug used to treat anxiety and to relax muscles) intramuscular (IM-injected into the muscle). The PMC stated after being in the ED for close to an hour with no medical interventions provided to Pt 1, for the safety of Pt 1 he made the decision to take Pt 1 to Hospital B.

During an interview on 3/11/24 at 10:46 a.m. with RN 1, RN 1 stated when Pt 1 came into the ED by ambulance, there were no rooms available, so she told the PMC and Pt 1 to hold the wall along with three to four other EMS crews. RN 1 stated based on Pt 1's acuity, she would have roomed Pt 1 first. RN 1 stated an actively seizing patient was considered an emergency and required an IV, medication, oxygen, and protection of the patient's airway. RN 1 stated Pt 1 was in the postictal phase on arrival to the ED and did not require immediate medical attention. RN 1 stated when a patient came to the ED, they treated what they saw, and the physician entered the orders. RN 1 stated the importance of the physician assessing the patient was to assess the patient's signs and symptoms and place orders. RN 1 stated the medic should have the patient attached to monitoring equipment while in the ED so she could see Pt 1's vitals when checking on patients while they are holding the wall.

During a concurrent interview and record review on 3/11/24 at 11 a.m. with RN 1, Pt 1's "NN," dated 1/22/24 was reviewed. The NN indicated, "Paramedic was with [patient] on the wall waiting for a bed to become available. Shortly after his arrival paramedic informed me [patient] was having another seizure. I informed him I had no nursing staff to care for [patient] at this time and asked him to [continue] to care for his [patient] and treat the [patient] per his protocol and asked him to start an IV on the [patient] ...When I went to find medic in the hallway to tell him what room to go to he had left the building with the [patient]." The NN indicated there was no indication a physician was informed about Pt 1's condition. RN 1 stated she did not see Pt 1 have a seizure in the ED. RN 1 stated the medic did not inform her they were leaving the ED.

During a concurrent interview and record review on 3/11/24 at 11:15 a.m. with RN 1, Pt 1's "EMR," dated 1/22/24 was reviewed. RN 1 stated the EMR indicated Pt 1 was registered at 1:31 p.m. and at 2:30 p.m. she made her note but "it was probably a good 15 minutes after medic and Pt 1 had left the ED, so they were in the ED for about 45 minutes prior to leaving the ED."

During an interview on 3/11/24 at 11:28 a.m. with RN 5, RN 5 stated she remembered Pt 1 and this particular day in the ED she was called to help a nurse stabilize a patient. RN 5 stated there were EMS crews waiting and she was working with RN 1 to move patients around so Pt 1 could be roomed. RN 5 stated she informed Pt 1 and the medic they were moving patients in the ED to provide a room for Pt 1. RN 5 stated when she gave the medic an update on getting Pt 1 a room, Pt 1 did not have seizure activity and he looked fine. RN 5 stated Pt 1 required a room and if he was actively seizing, she would have put him in a room but there were no rooms available. RN 5 stated a seizing patient required oxygen and suction as well as any medications the physician ordered for the seizures. RN 5 stated the importance of getting the patient assessed by a physician was to obtain orders for treatment of the patient and if she witnessed the patient actively seizing, she would have gotten an order from a physician to treat the patient.

During a telephone interview on 3/11/24 at 1:50 p.m. with RN 2, RN 2 stated she remembered on 1/22/24, the ED was busy, and several EMS crews were holding the wall. RN 2 stated she received a phone call from the EMS liaison from Hospital B informing her, Pt 1 was enroute to Hospital B due to Hospital A's inability to care for Pt 1. RN 2 stated she spoke to RN 1 to find out what was going on and they both went to look for Pt 1, but Pt 1 was no longer there.

During an interview on 3/11/24 at 2:21 p.m. with the Chief Nursing Officer (CNO), the CNO stated her expectations for patients who came to the ED were greeted by healthcare staff, registered immediately, obtained the patients chief complaint and vitals, and triaged as quickly as possible. The CNO stated the MSE should be initiated within 20 minutes and if the patient required a bed, the patient was immediately roomed if they had an open room. The CNO stated vital signs should be taken with ESI assignment during triage. The CNO stated her expectations of care for a seizing patient were to room the pt, maintain the patient's airway and a physician should have assessed Pt 1 and initiated the MSE immediately to obtain medication orders and administer medications. The CNO stated for Pt 1, once Pt 1 was in the ED, Pt 1 was the hospital's responsibility and they needed to collaborate with the EMS crew.

During an interview on 3/11/24 at 2:37 p.m. with the ED Medical Director (EMD), the EMD stated once a patient was within 250 yards of the ED, the patient was their patient. The EMD stated they made it a goal to see patients right away, especially patients who arrived by ambulance because they were generally more acute (signs and symptoms that begin and worsen quickly). The EMD stated the ED physicians took turns initiating MSEs on patients and often times he did not wait for the patient to be roomed, often he would see the patients on the gurney and placed orders. The EMD stated the patients who were holding the wall should be treated like any other patient who walked into the ED to request medical care. The EMD stated it was his preference to obtain the patient's medical history and chief complaint from the medic and if the patient had a medical emergency, the Charge Nurse (CN) should inform one of the physicians to assess the patient right away, even if the patient was still on the gurney.

During a review of Pt 1's "EMR" from Hospital B, dated 1/22/24, the EMR from Hospital B indicated Pt 1 was brought in by ambulance (BIBA) with EMS personnel and triaged at 2:39 p.m. with an acuity of 1. The EMR from Hospital B indicated Pt 1's chief complaint was seizure, "BIBA from home then [Hospital A] for seizures; per medic family stated [patient] has been vomiting and unable to take seizure meds." The EMR indicated Pt 1's prehospital blood sugar was 87, EMS medication given was midazolam 5 milligrams (mg-unit of measure), pulse 71, blood pressure 239/170, and oxygen saturation was 97% on 2 liters (L-the flow of oxygen) via nasal cannula (NC-a thin, flexible tube with two prongs that go inside your nostrils to deliver oxygen). Pt 1 was admitted to Hospital B where he stayed for 3 days.

During a review of the hospital's policy and procedure (P&P) titled, "MOD COMP-RCC 5.16 EMTALA POLICY," dated 9/28/22, the P&P indicated, " ...The purpose of this policy is to set forth policies and procedures for Hospital's use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA) ...If an individual comes to the Emergency Department ...The Hospital will provide as appropriate medical screening examination within the capability of the Hospital's Dedicated Emergency Department, including ancillary services routinely available, to determine whether or not an emergency medical condition exists ...The Hospital will ...provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition ...Triage ...As soon as practical after arrival, individuals who come to the Emergency Department should be triaged in order to determine the order in which they will receive a medical screening examination ...Triage is not a medical screening examination, as it does not determine the presence or absence of an emergency medical condition, but rather ...order in which individuals will receive a medical screening examination ...The Hospitals' Chief Nursing Officer and Chief Medical Officer are responsible for assuring that this policy is implemented and followed, and that instances of noncompliance with this policy are reported immediately to the Compliance Officer ...All Hospital staff and Medical staff 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 ..."

During a review of the hospital's P&P titled, "ED.1.06 Triage Nurse Policy," dated 9/28/22, the P&P indicated, " ...To outline the responsibilities and function of the Triage Nurse in the Emergency Department ...The triage nurse is utilized in most high-volume emergency departments to provide safety for ambulatory patients presenting unaccompanied, requesting care. Upon arrival an initial assessment is performed to determine the need for immediate treatment, or close observation based upon presenting clinical assessment by the primary triage nurse ...Greet all patients entering the ambulatory entrance of the Emergency Department and obtain brief initial assessment ...Chief complaint ...Brief history of problem ...Make a determination based on initial assessment as to the need for immediate intervention ...All patient conditions will be classified and prioritized as follows ...ESI Level 1: the patient requires immediate medical care ...ESI Level 2: the patient is assessed as high risk ...ESI Level 3: the patient is assessed as stable. The patient's vital signs are within the accepted normal parameters for age and not within the danger zone ...ESI 4: the patient is assessed as stable. These patients are predicted to use one (1) resource to reach disposition ...ESI Level 5: the patient is assessed as stable. The patient is predicted to use no resources ...If determined that the patient is in need of immediate interventions or observation, transport the patient immediately to a designated treatment area ...Notify the charge nurse ...If determined that the patient does not need immediate interventions or observation, complete an initial nursing history, allergies, vital signs, and initiate appropriate order per protocol ... The patient's triage category may be updated based on this reassessment ...Documentation of the triage classification, assessment, and all interventions performed are entered into the Emergency Department electronic documentation system ..."

During a professional reference review from the Morbidity and Mortality Weekly Report an article titled, "Seizure- or Epilepsy-Related Emergency Department Visits Before and During the Covid-19 Pandemic-United States, 2019-2021," dated 5/27/22, the article indicated, " ...Seizures generally account for approximately 1% of all emergency department visits. Persons of any age can experience seizures, and outcomes might range from no complications for those with a single seizure to increased risk for injury, comorbidity [when a person has more than one disease or condition at the same time], impaired quality of life, and early mortality [death] for those with epilepsy [seizure disorder] ..."

During a professional reference review from the National Library of Medicine, the article titled, "Seizure," dated Jan 2024, the article indicated, " ...For the patient with generalized convulsive status epilepticus [a seizure that lasts longer than five minutes or having more than one seizure within a five-minute period], immediate treatment of the seizures should begin while stabilization and other diagnostic procedures commence. Supportive care with attention to airway, breathing, and circulation issues are vital. Benzodiazepines [drug used to relax muscles and prevent seizures] ... are acceptable as the first-line medications for continuing seizures ...Respiratory depression [when breathing too slowly, preventing proper gas exchange in the lungs] is a common side effect, and patients will need careful monitoring ..."

During a professional reference review from the Institute of Medicine Committee on the Public Health Dimensions of the Epilepsies, the article titled, "Epilepsy Across the Spectrum: Promoting Health and Understanding," dated 2012, the article indicated, " ...In seeking treatment for epilepsy and its comorbidities, patients and families interact with primary care, emergency, and specialist physicians, as well as a range of other health professionals ...Teams should comprise professionals assembled and prepared to meet the diverse needs of individual patients ...Negative perceptions of people with epilepsy among health professionals contribute to stigma and can affect quality of care ..."

2. During a concurrent interview and record review on 3/8/24 at 9:08 a.m. with the Director of Women and Children's Services (DWC), Pt 2's "EMR," dated 12/27/23 was reviewed. The document titled "ED Triage Form" dated 12/27/23 at 6:19 p.m. by RN 1 indicated Pt 2 was a 27-year-old woman who came to the ED complaining of abdominal cramping for the last 3 days. Pt 2 described her pain level as 8 out of 10, with 1 being the least pain and 10 being the most pain. The document titled, "Depart Summary (verified) indicated Pt 2's "ED Discharge Time: 12/27/23 [9:34 p.m.]. The DWC stated she was unable to find any documentation to indicate a physician treated the patient during her ED stay or that any care was provided.

During a concurrent interview and record review on 3/8/24 at 9:35 a.m. with RN 5, Pt 2's "EMR," dated 12/27/23 was reviewed. RN 5 opened the EMR for Pt 2 and attempted to find evidence that Pt 2 had a MSE within the capability of the hospital's ED by a QMP. RN 5 stated she was unable to locate any note in the EMR to indicate Pt 2 was medically screened.

During a concurrent interview and record review on 3/11/24 at 11:08 a.m. with RN 4, Pt 2's "EMR," dated 12/27/23 and the hospital's "Emergency Department - Daily Staffing Schedule (Staffing Schedule)," dated 2/27/24 were reviewed. RN 4 stated the EMR indicated she did the triage for Pt 2. RN 4 reviewed the Staffing Schedule and stated there were 17 nurses working at the time Pt 2 came to the ED, not including trauma nurse. RN 4 reviewed the "ED launch point" document and stated the document indicated the attempts to call (by calling the patient's name in the waiting room) Pt 2 to be seen by the physician. The document indicated Pt 2 checked in to the ED at 6:12 p.m. with abdominal cramping, abdominal pain - Pregnancy, and was sent to the waiting room wait to be seen by a physician. The document indicated attempts to call Pt 2 to be seen at 7:13 p.m., 8:59 p.m., and 9:24 p.m. and indicated, "NA" (no answer when called.) The Discharge Disposition indicated Pt 2 went "Home/self-care" and her length of stay in the ED was recorded as 3 hours and 22 minutes. RN 4 stated the expectation was a patient should be seen by a provider within 30 minutes of arrival. RN 4 stated her concern for this patient was that she, "would wonder if she was miscarrying."

During an interview on 3/11/24 at 2:07 p.m. with the CNO, the CNO stated her expectation of the triage nurse was to "greet, register, get the chief complaint, get vitals, and get MSE done within 20 minutes." She stated they "have a lot of work to do in the triage area."

During an interview on 3/11/24 at 2:36 p.m. with the EMD, the EMD stated " ...The patients are all our (the hospital) responsibility even before they come through the door. It's important to do the MSE right away ..."

During a phone interview on 3/11/24 at 11:30 a.m. with Pt 2, Pt 2 stated she was not examined by anyone while in the ED. She left the waiting room after "a long time." Pt 2 stated she was having abdominal cramping and she was 6 weeks pregnant at that time. Pt 2 stated she had experienced "a little bleeding" but decided it would be better to go to her own doctor the next day, because it was taking so long to see the doctor in the ED.

During a review of the hospital's P&P titled, "ED.1.03 Medical Screening Examination," dated 9/28/22, the P&P indicated, " ...III. PROCEDURE ...B. 3. The scope of the examination is tailored to the patient's presenting symptoms and the medical history of the patient. The MSE is an ongoing monitoring process, which continues until a medical emergency condition is found not to exist or until appropriate steps to stabilize the presenting emergency medical condition begin ..."

During a professional reference review from the Emergency Nurses Association titled, "A Triage Tool For Emergency Care," dated 2020, the document indicated, " ...Females with abdominal pain or vaginal bleeding should be carefully assessed and vital signs obtained if there is no obvious life threat. Pregnancy history and last menstrual period should always be ascertained from all females of childbearing age ... in early pregnancy, the triage nurse should assess for signs and symptoms of ectopic pregnancy and spontaneous abortion ..."