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Based on document review and interview, it was determined the Hospital failed to ensure compliance with 42 CFR 482.24.

Findings include:

1. The Hospital failed to ensure that a timely assessment was performed to determine whether or not an emergency medical condition existed to ensure that patients transported to the ED by ambulance were not delayed from a medical screening examination. A 2406 A.

2. The Hospital failed to ensure the Medical Staff Bylaws/Rules and Regulations included the persons permitted to perform medical screening examinations in the Emergency Department (ED). A 2406 B.

A. Based on document review and interview, it was determined that for 7 of 24 patient records (Pt. #12, Pt. #14, Pt. #17, Pt. #18, Pt. #19, Pt. #21, and Pt. #22) reviewed for medical screening examination, the Hospital failed to ensure that a timely assessment was performed to determine whether or not an emergency medical condition existed to ensure that patients transported to the ED by ambulance were not delayed from receiving a medical screening examination.

Findings include:

1. On 7/28/2021, the Hospital's policy titled, "...1. Individuals who come to the ED [Emergency Department] receive a MSE [Medical Screening Examination] performed by a QMP [Qualified Medical Person] to determine if an EMC [Emergency Medical Condition] exists, even if the individual arrives when the hospital is on diversionary status...Medical Screening Examination (MSE) 1. The MSE is provided to any individual who comes to the ED...2. Continue to monitor and document the individual's health status until stabilized, admitted, or transferred to another facility."

2. On 7/28/2021, Pt. #12, Pt #14, Pt #17, Pt #18, Pt #19, Pt #21, and Pt #22's clinical records were reviewed and included:

-Pt. #12's ambulance run sheet, dated 7/7/2021, included documentation that Pt #12 arrived by ambulance to the Hospital's ED at 3:26 PM and was held in the ambulance bay until 4:15 PM (49 minutes) before being assessed by Hospital personnel. Pt. #12's initial complaint was vomiting. Pt. #12 had a MSE at 4:17 PM, and was triaged at 4:22 PM, as emergent. Pt. #12's hospital admitting diagnosis was sepsis.

-Pt. #14's ambulance run sheet, dated 7/9/2021, included documentation that Pt. #14 arrived by ambulance to the Hospital's ED at 4:30 PM and was held in the ambulance bay until 5:17 PM (47 minutes) before being assessed by Hospital personnel. Pt. #14's initial complaint was possible pneumonia. Pt. #14 had a medical screening exam at 5:23 PM, and was triaged at 6:12 PM, as emergent. Pt. #14's hospital admitting diagnosis was congestive heart failure exacerbation.

-Pt. #17's ambulance run sheet, dated 7/18/2021, included documentation that Pt. #17 arrived by ambulance to the Hospital's ED at 3:06 PM and was held in the ambulance bay until 3:43 PM (37 minutes) before being assessed by Hospital personnel. Pt. #17's initial complaint was dizziness. Pt. #17 was triaged at 3:47 PM, as urgent, and had a MSE at 3:49 PM.

-Pt. #18's ambulance run sheet, dated 7/18/2021, included documentation that Pt. #18 arrived by ambulance to the Hospital's ED at 5:20 PM and was held in the ambulance bay until 6:23 PM (1 hour and 3 minutes) before being seen by Hospital personnel. Pt. #18's initial complaint was behavior/psychiatric. The run sheet included, "Pt. [Pt. #18] found conscious alert and oriented X 3. Ambulatory on scene. Pt. is agitated and belligerent on scene, handcuffed in company of CPD [police department]. Pt. was verbally aggressive to crew ...On arrival at the hospital crew was advised by hospital charge nurse to remain in the ambulance until they can prepare a bed ...crew remained in the ambulance bay with [police department] ...until Pt. [Pt. #18] was accepted by the hospital ..." Pt. #18's initial complaint was behavior/psychiatric. Pt. #18 had a MSE at 6:19 PM, and was triaged at 6:36 PM as emergent.

-Pt. #19's ambulance run sheet, dated 7/18/2021, included documentation that Pt. #19 arrived by ambulance to the Hospital's ED at 5:48 PM and was held in the ambulance bay until 7:30 PM (1 hour and 42 minutes) before being assessed by Hospital personnel. Pt. #19's initial complaint was chest pressure. Pt. #19 had a MSE at 7:37 PM, and was triaged at 7:51 PM as urgent.

-Pt. #21's ambulance run sheet dated 7/19/2021, included documentation that Pt. #21 arrived by ambulance to the Hospital's ED at 5:02 PM and was held in the ambulance bay until 6:00 PM (58 minutes) before being assessed by Hospital personnel. Pt. #21's initial complaint was weakness. Pt. #21 had a MSE at 5:50 PM, and was triaged at 6:00 PM, as emergent.

-Pt. #22's ambulance run sheet, dated 7/20/2021, included documentation that Pt. #22 arrived by ambulance to the Hospital's ED at 4:21 PM and was held in the ambulance bay until 5:42 PM (1 hour and 21 minutes) before being assessed by Hospital personnel. Pt. #22's initial complaint was hypotension (low blood pressure). Pt. #22 had a MSE at 5:42 PM and was triaged at 5:58 PM, as urgent.

Pt. #12, Pt. #14, Pt. #17, Pt. #18, Pt. #19, Pt. #21, and Pt. #22's clinical records lacked documentation of an assessment by Hospital staff to determine if an Emergency Medical Condition existed while waiting in the ambulances to be seen in the ED.

3. On 7/28/2021 at 12:40 PM, an interview was conducted with the ED Manager (E#3). E #3 stated that ambulances are asked to hold patients when the ED is at maximum capacity. E #3 stated that ambulance holds have not been more than 1 hour. E#3 stated that the patients being held in the ambulance are not assessed but are "eyeballed" to make sure they are not in distress. E #3 stated that not every patient being held in the ambulance is checked by Hospital personnel while being held. E #3 stated that staff do not document on the patients that are checked while waiting in the ambulance to come into the ED. E #3 stated that the state's Emergency Resource system has to grant permission for the Hospital to divert or go on bypass. E #3 stated that the ambulance is directed by their resource Hospital (not always the receiving Hospital) where to transport the patient.

4. On 7/28/2021 at 2:06 PM, an interview was conducted with the Chief Medical Officer (MD #1). MD #1 stated that he is an Emergency Department Physician. MD #1 stated that once a patient is on hospital property seeking care from the Emergency Department, they must be assessed, and there must be documentation of the assessment.

B. Based on document review and interview, it was determined that the Hospital failed to follow the "Professional Staff Rules and Regulations" by failing to ensure that only Qualified Medical Persons (QMP) perform the Medical Screening Examination (MSE).

Findings Include:

1. On 7/28/2021, the By-laws and Rules and Regulations, dated January 28, 2020, was reviewed. The rules and regulations required, "Patients who come to the Emergency department shall receive a screening by a physician in the emergency room and specialty on-call physicians as needed in the judgement of the on-site physician. Screening may also be performed by a patient's attending physician or a specialist/consultant who has accepted a referral to see the patient so long as the physician meets and sees the patient in the emergency room."

2. On 7/28/2021, the Hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)" approved by the Hospital 6/1/2021, was reviewed. The policy included, "Definitions ...10. Qualified Medical Person (QMP): A physician is a QMP qualified to provide an appropriate MSE [Medical Screening Exam]. In addition, a non-physician practitioner can be designated a QMP, as long as this determination is set forth in the hospital by-laws or in the rules and regulations governing the medical staff following governing body approval ..."

3. On 7/29/2021, Pt. #23 and Pt. #24's clinical records were reviewed.

-Pt. #23 was seen in the Emergency Department (ED) on 7/11/2021, with a chief complaint of right wrist pain. Pt. #23's MSE was completed on 7/11/2021 at 10:16 PM by a Physician Assistant (E #4).

-Pt. #24 was in the ED on 6/29/2021, for an overall physical and complaint of mass to the left breast. Pt. #24's MSE was completed on 6/29/2021 at 12:35 PM by a Physician Assistant (E #5).

4. On 7/28/2021 at 2:06 PM, an interview was conducted with the Chief Medical Officer (MD #1). MD #1 stated that he is an Emergency Department Physician. MD #1 stated that Advanced Practice Nurses (APN) and Physician Assistants (PA) perform Medical Screening Examinations on patients in the Emergency Department. MD #1 stated that the bylaws and rules and regulations do not include APN's and PA's as Qualified Medical Person able to perform MSE's.