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Based on review of facility policy, Emergency Medical Services reports, Emergency Department (ED) central log, medical records, and interviews, the facility failed provide a Medical Screening Exam (MSE) for three (3) patients (Patients #5, #10, and #12), failed to provide stabilizing treatment for one (1) patient prior to transfer (Patient #2), and failed to prevent a delay in a MSE for one (1) patient to inquire about payment (Patient #12), for 31 ED patients reviewed.

The findings include:

Refer to A-2406, A-2407 and A-2408.

Based on review of facility policy, Emergency Medical Services (EMS) reports, Emergency Department (ED) central log, medical records, and interview, the hospital failed to maintain a medical record for each patient that presented to the ED for care. This affected one (1) of 31 reviews, (Patient Identifier #5).

The findings include:

Review of Facility A's policy titled "EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening, Stabilization and Appropriate Transfer of Individuals in Need of Emergency Medical Services" revised 8/2/2012 showed "...If an individual 'Presents' or 'Comes to the ED' or 'Comes to Hospital Property'...with a request for treatment or an apparent emergency medical condition...An individual in an ambulance (or other vehicle) that arrives on Hospital property is considered to have come to the Hospital's emergency department...If an individual attempts to leave the Hospital AMA [Against Medical Advice] or LWBS [Left Without Being Seen], personnel should reasonably attempt to obtain the individual's signature on the AMA form and should attempt to inform the individual of the risk of not waiting to be examined by a physician...Hospital personnel should appropriately document in the medical record that the patient was advised of the risks but left AMA/LWBS...Record-Keeping..."

Review of an EMS report dated 5/29/2020 showed Patient #5 was transported to Facility A's ED on 5/29/2020 from the county jail for a complaint of "sick." Further review showed EMS "...PLACED THE PT. [patient] IN THE ER [emergency room] BED...TURNED THE PT.'S CARE OVER TO THE NURSE IN CHARGE..."

Medical records were not found for Patient #5's ED encounter on 5/29/2020.

Review of an EMS report dated 6/7/2020 showed Patient #5 was transported to Facility A's ED with complaint of injury to the patient's face. Patient #5 was not allowed to enter the ED by nursing staff because the patient refused to have his temperature taken per the Centers for Disease Control and Prevention (CDC) guidelines for Coronavirus screening. The patient was seen by the ED Physician outside of the ED.

Medical records were not found for Patient #5's ED encounter on 6/7/2020.

During a telephone interview on 7/16/2020 at 1:07 PM, Paramedic #1 stated he transported Patient #5 to Facility A's ED twice within the same week. Paramedic #1 stated on 5/29/2020 the ED staff assumed care of the patient. Paramedic #1 stated on 6/7/2020 a male nurse came outside of the facility to the EMS entrance to check Patient #5's temperature and to place a mask on the patient, but the patient refused. The male nurse told the patient he could not enter the ED without a temperature check. Paramedic #1 stated an ED physician then came outside to where the patient was and looked at the patient but did not physically touch the patient.

During an interview on 7/16/2020 at 3:15 PM, Registered Nurse (RN) #1 stated he recalled Patient #5's ED visit on 6/7/2020. RN #1 stated he went out of the EMS entrance to obtain the patient's temperature, but the patient refused to have his temperature taken. RN #1 confirmed Patient #5 was not permitted to enter Facility A's ED because he would not allow the facility to take his temperature.

During a telephone interview on 7/20/2020 at 5:10 PM, Emergency Medical Technician (EMT) #1 stated Patient #5 was transported to Facility A's ED on 5/29/2020 and the ED staff assumed care of the patient. EMT #1 stated on 6/7/2020 the patient was transported to Facility A's ED and upon arrival RN #1 met EMS outside of the ED to check the patient's temperature before entering the ED, but the patient refused. EMT #1 stated RN #1 told the EMS staff Patient #5 could not go inside the facility without a temperature check. EMT #1 stated the ED physician saw Patient #5 outside of the facility and because Patient #5 would not answer the ED physician's questions, the ED physician told Patient #5 if he did not want treatment he would release him back to law enforcement custody.

During a telephone interview on 7/23/2020 at 4:40 PM, the Chief Operating Officer confirmed there were no medical records for Patient #5's ED visits on 5/29/2020 and 6/7/2020.

Based on review of facility policy, Emergency Medical Services (EMS) reports, Emergency Department (ED) central log, and interview, the hospital failed to document each patient that presented to the ED for care on the central log. This affected two (2) of 31 patients, (Patient Identifiers #5, #10).

The findings include:

Review of Facility A's policy titled "EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening, Stabilization and Appropriate Transfer of Individuals in Need of Emergency Medical Services" revised 8/2/2012 showed "...An individual in an ambulance (or other vehicle) that arrives on Hospital property is considered to have come to the Hospital's emergency department...The Hospital should maintain a Central Log on each individual who comes to the emergency department...seeking assistance and whether the individual refused treatment, was refused treatment, or whether the individual was transferred, admitted and treated, stabilized and transferred, or discharged..."

Review of an EMS report dated 5/29/2020 showed Patient #5 was transported to Facility A's ED on 5/29/2020 for a complaint of "sick." Further review showed EMS "...PLACED THE PT. [patient] IN THE ER [emergency room] BED...TURNED THE PT.'S CARE OVER TO THE NURSE IN CHARGE..."

Review of Facility A's ED Central Log dated 5/29/2020 showed Patient #5 was not listed.

During a telephone interview on 7/16/2020 at 1:07 PM, Paramedic #1 confirmed Patient #5 was transported to Facility A's ED on 5/29/2020 and the patient's care was assumed by the ED staff.

During a telephone interview on 7/23/2020 at 4:40 PM, the Chief Operating Officer confirmed Patient #5 was not listed on the ED Central Log dated 5/29/2020.

Review of an EMS report dated 7/10/2020 showed EMS transported Patient #10 to Facility A on 7/10/2020 for a complaint of weakness, fatigue, difficulty walking, and a blood sugar reading of 437 (normal range 79-110). Further review showed EMS attempted to call Facility A's ED three times with no answer each time. Upon arrival to Facility A's ED an Emergency Medical Technician (EMT) entered the facility and found no staff present. The EMT called out for staff "a few times" but no one responded. EMS left Facility A and transported Patient #10 to another acute care hospital (Facility B).

Review of an audio EMS radio communication dated 7/10/20 at 2:18 AM from the EMS crew to dispatch showed "...non-emergency [Facility A]...[2:22 AM]...we [EMS crew] have tried to contact [Facility A] via phone no answer either time...we're also gonna be on scene up here at the hospital...[2:25 AM]...got to [Facility A] knocked on ER [emergency room] door 3 times before making entry to the ER door no nurse found in ER...diversion to [Facility B] with patient..."

Review of Facility A's Central ED Log dated 7/10/2020 showed Patient #10 was not listed.

During a telephone interview on 7/16/2020 at 1:07 PM, Paramedic #1 stated Patient #10 was transported to Facility A on 7/10/2020. Paramedic #1 stated he attempted to contact Facility A's ED by phone 3 times while in route to the hospital without success. Paramedic #1 stated his partner entered Facility A's ED, but no staff was present in the ED and no one responded when his partner called out.

During a telephone interview on 7/20/2020 at 5:10 PM, Emergency Medical Technician (EMT) #1 stated Patient #10 was transported to Facility A on 7/10/2020. EMT #1 stated Paramedic #1 attempted to contact Facility A's ED while in route to the hospital but no one answered. EMT #1 stated upon arrival to Facility A's ED he knocked on the locked ED door, but got no response. EMT#1 stated he was able to enter the ED by entering a pin number on the door keypad, but found no staff present in the ED and no one responded when he yelled out.

During a telephone interview on 7/23/2020 at 4:40 PM, the Chief Operating Officer confirmed Patient 5 and Patient #10 were not listed on the ED Central Log.

Based on review of facility policy, Emergency Medical Services (EMS) reports, Emergency Department (ED) Admission forms, medical records, and interviews, the facility failed to ensure a medical screening exam (MSE) was completed for patients that presented to the hospital ED for treatment. This affected (Patients #5, #10, and #12) three (3) of 31 ED patients sampled.

The findings include:

Review of Facility A's policy titled "EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening, Stabilization and Appropriate Transfer of Individuals in Need of Emergency Medical Services" revised 8/2/2012 showed "...If an individual 'Presents' or 'Comes to the ED' or 'Comes to Hospital Property'...with a request for treatment or an apparent emergency medical condition...then the patient must be screened by Qualified Medical Person [QMP] and stabilized or appropriately transferred...Hospital personnel should not delay providing an appropriate MSE or further medical examination and treatment in order to inquire about the individual's method of payment, insurance/financial status, or to obtain prior authorization from the individual's insurance company...Reasonable registration processes also should not unduly discourage an individual from remaining for further evaluation...If an individual attempts to leave the Hospital AMA [Against Medical Advice] or LWBS [Left Without Being Seen], personnel should reasonably attempt to obtain the individual's signature on the AMA form and should attempt to inform the individual of the risk of not waiting to be examined by a physician..."

Review of Facility A's titled "Private Pay Policy" dated 4/16/2020 showed "...For individuals who present themselves with no known insurance provider available, they may pay in full at the time services are rendered for services at the then established Medicare Allowable Rate in effect at the time of services, and the hospital shall render said services. Regarding individuals who are uninsured, and refuse to pay in full at the time of services rendered, the hospital will render services, and said individuals will be assessed charges according to the then published hospital rate for said services..."

Review of an EMS report dated 5/29/2020 showed Patient #5 was transported to Facility A's ED on 5/29/2020 for a complaint of "sick." Further review showed EMS "...PLACED THE PT. [patient] IN THE ER [emergency room] BED...TURNED THE PT.'S CARE OVER TO THE NURSE IN CHARGE..."

Medical records were not found for Patient #5's ED encounter on 5/29/2020.

During a telephone interview on 7/16/2020 at 1:07 PM, Paramedic #1 confirmed Patient #5 was transported to Facility A's ED on 5/29/2020 and the patient's care was assumed by the ED staff.

Review of an EMS report dated 6/7/2020 showed Patient #5 was transported to Facility A's ED on 6/7/2020 with a complaint of injury to the patient's face. Patient #5 was not allowed to enter the ED by nursing staff because he refused to have his temperature taken as part of the screening recommended by the Centers for Disease Control for Coronavirus. Patient #5 was seen outside by the ED physician.

Medical records were not found for Patient #5's ED encounter on 6/7/2020.

During a telephone interview on 7/20/2020 at 5:10 PM, Emergency Medical Technician (EMT) #1 confirmed Patient #5 was transported to Facility A's ED on 6/7/2020. EMT #1 stated Registered Nurse (RN) #1 met EMS at the door to check the patient's temperature before the patient could enter the ED, but the patient refused. EMT #1 stated RN #1 told EMS patient could not enter the facility without a temperature check, so they remained outside of the ED. EMT #1 stated the ED Physician came outside of the hospital and attempted to talk to the patient. EMT #1 stated the ED Physician "eye viewed" Patient #5 and did not touch or examine the patient.

Review of an EMS report dated 7/10/2020 at 2:18 AM showed EMS transported Patient #10 to Facility A on 7/10/2020 for a complaint of weakness, fatigue, difficulty walking, and a blood sugar reading of 437 (normal range 79-110). Further review showed EMS attempted to call Facility A's ED three times while in route, with no answer each time, and upon arrival to Facility A's ED EMS found no staff was present in the ED. EMS left Facility A and transported Patient #10 to another acute care hospital (Facility B).

Medical record review showed there was no documentation Patient #10 received a MSE by a QMP on 7/10/2020.

During a telephone interview on 7/16/2020 at 1:07 PM, Paramedic #1 stated he attempted to contact Facility A's ED without success by phone 3 times while in route to the hospital with Patient #10. Paramedic #1 stated his partner entered Facility A's ED, but no staff was present in the ED.

During a telephone interview on 7/20/2020 at 5:10 PM, Emergency Medical Technician (EMT) #1 stated upon arrival to Facility A's ED with Patient #10 he knocked on the locked ED door, but got no response. EMT#1 stated he was able to enter the ED by entering a number on the door keypad. EMT #1 stated he found no staff present in the ED and no one responded when he yelled out.

During a telephone interview on 7/20/2020 at 6:55 PM, RN #2 stated she was the nurse on duty 7/10/2020 and she was not aware EMS brought Patient #10 to the ED.

Medical record review of an ED Nursing Record at Facility A showed Patient #12 presented to Facility A's ED on 5/30/2020 at 5:15 PM with complaint of right upper quadrant abdominal pain. The patient was assessed as in moderate distress, was anxious, and had abdominal guarding. Continued review showed "...[Patient #12] was advised of non-insurance policy. Became agitated & [and] left without being seen..." at 5:50 PM.

Review of an ED Admission Form at Facility A dated 5/30/2020 showed Patient #12 did not have health insurance.

Medical record review showed no documentation Patient #12 received a MSE by a QMP on 5/30/2020.

During a telephone interview on 7/20/2020 at 10:35 AM, Patient #12 stated he presented to Facility A's ED on 5/30/2020. Patient #12 stated "...The nurse asked me if I had insurance. I told her 'no'...she said 'well, do you have $150.00'..." Patient #12 stated he had not been seen by a physician prior to the conversation with the nurse regarding insurance. The patient stated he left Facility A's ED and went to Facility B's ED for treatment.

During a telephone interview on 7/23/2020 at 5:50 PM, Registered Nurse (RN) #2 confirmed she told Patient #12 he would have to pay $150.00 before he received a MSE by the physician. RN #2 stated the patient became agitated and left without being seen by the physician.

During a telephone interview on 7/23/2020 at 4:40 PM, the Chief Operating Officer confirmed there was no documentation Patient #5, Patient #10, or Patient #12 received a MSE by a QMP.

During a telephone interview on 7/23/2020 at 5:40 PM, the Chief Executive Officer confirmed the facility has a fee of $150.00 for ED patients without insurance and "...the expectation is the patients would be notified of the fee after a MSE was completed..."

Based on review of facility policy, medical record, and interview, the facility failed to provide interventions for pain prior to a transfer after a fall with injuries for one (1) of 31 patients reviewed, (Patient #2).

The findings include:

Review of Facility A's policy titled "EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening, Stabilization and Appropriate Transfer of Individuals in Need of Emergency Medical Services" revised 8/2/2012 showed "...If an individual 'Presents' or 'Comes to the ED' or 'Comes to Hospital Property'...with a request for treatment or an apparent emergency medical condition...then the patient must be screened by Qualified Medical Person and stabilized or appropriately transferred...When it is determined that the individual has an EMC [Emergency Medical Condition]...The Hospital, within its capability, should provide medical treatment which minimizes the risks to the individual's health..."

Medical record review of an ED Nursing Record showed Patient #2 presented to Facility A's ED on 4/21/2020 at 9:40 PM after the patient passed out and fell down a flight of stairs at home. The patient was noted to have abrasions to the right shoulder, mid back, and back of head; had increased pain with movement of his head; and his neck was tender to touch. The patient's pain level was described as a 9 (on a scale of 1-10, with 10 being the worst possible pain). There was no documentation in the medical record that Patient #2 received any interventions for pain.

Medical record review of an ED Physician's Record dated 4/21/2020 showed Patient #2 complained of pain in the upper back, neck, and head, which increased with movement. Further review revealed the patient was in moderate distress and was mildly anxious. The ED Physician initiated a transfer of the patient to Facility C at 10:55 PM and Emergency Medical Services (EMS) was contacted for transport. Continued review showed "...Clinical Impression...Syncope c [with] Fall...cervical pain...thoracic pain...hyperglycemia..." The physician documented the patient's pain scale remained a 9 at time of discharge.

Medical record review of a Transfer form for Patient #2 showed the patient was transferred to Facility C on 4/21/2020 at 11:30 PM for trauma and imaging not available at Facility A.

Medical record review of an ED Admission document from Facility C dated 5/17/2020 1:12 AM showed Patient #2 arrived to the ED via EMS and level of service was "high severity."

Review of an ED Physician's Provider Note from Facility C dated 4/22/2020 at 1:51 AM revealed "...s/p [status post] prior low back surgeries and cervical spine fusion...transfer from [Facility A]...syncopal episode [dizziness] this evening...brief loss of consciousness...small contusion on the back of his head...reports pain to the back of the head, posterior neck and upper thoracic spine along the midline...alert and oriented...appears a little uncomfortable..." Further review of an Assessment and Plan revealed "...upon arrival was evaluated by the trauma team and the ED staff...once stabilized, the patient was taken immediately to the CT scanner..."

Review of a CT report from Facility C dated 4/22/2020 at 3:57 AM revealed "...no findings of acute intracranial abnormality...no cervical spine fracture...T2 [the second thoracic vertebrae] superior endplate deformity may be acute..."

Review of a Magnetic Resonance Imaging (MRI) of the Cervical and Thoracic Spine report from Facility C dated 4/22/2020 at 8:50 AM revealed "...Impression: Acute compression fractures of T1-T3 [the first thoracic vertebrae through the third thoracic vertebrae]..."

Review of a Physician's note from Facility C dated 4/22/2020 at 4:52 PM revealed "...closed fracture of third thoracic vertebra..." Continued review revealed Patient #2 was admitted to the facility for observation.

During an interview on 7/16/2020 at 5:30 PM, ED Physician #1 confirmed Patient #2 was not treated for pain prior to transfer to Facility C (108 miles away from Facility A).

Based on review of facility policy, medical record, and interview, the facility failed to ensure there was not a delay in treatment to inquire about method of payment and insurance status. This affected one (1) of 31 patients reviewed, (Patient #12).

The findings include:

Review of Facility A's policy titled "EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening, Stabilization and Appropriate Transfer of Individuals in Need of Emergency Medical Services" revised 8/2/2012 showed "...If an individual 'Presents' or 'Comes to the ED' or 'Comes to Hospital Property'...with a request for treatment or an apparent emergency medical condition...then the patient must be screened by Qualified Medical Person [QMP] and stabilized or appropriately transferred...Hospital personnel should not delay providing an appropriate MSE or further medical examination and treatment in order to inquire about the individual's method of payment, insurance/financial status, or to obtain prior authorization from the individual's insurance company...The Hospital, within its capability, should provide medical treatment which minimizes the risks to the individual's health..."

Review of Facility A's titled "Private Pay Policy" dated 4/16/2020 showed "...For individuals who present themselves with no known insurance provider available, they may pay in full at the time services are rendered for services at the then established Medicare Allowable Rate in effect at the time of services, and the hospital shall render said services. Regarding individuals who are uninsured, and refuse to pay in full at the time of services rendered, the hospital will render services, and said individuals will be assessed charges according to the then published hospital rate for said services..."

Medical record review of an ED Nursing Record at Facility A showed Patient #12 presented to Facility A's ED on 5/30/2020 at 5:15 PM with a complaint of right upper quadrant abdominal pain. Further review of the nurse's initial physical assessment of Patient #12 at 5:25 PM showed the patient was in moderate distress, was anxious, and had abdominal guarding (tightening of the abdominal muscles in response to pain). Continued review of a nurse's note showed "...[Patient #12] was advised of non-insurance policy. [Patient #12] Became agitated & [and] left without being seen..." at 5:50 PM.

Medical record review of an ED Admission Form at Facility A dated 5/30/2020 showed Patient #12 did not have health insurance.

Medical record review at Facility A showed no documentation Patient #12 had a MSE by a QMP on 5/30/2020.

During a telephone interview on 7/20/2020 at 10:35 AM, Patient #12 stated he presented to Facility A's ED on 5/30/2020. Patient #12 stated "...The nurse asked me if I had insurance. I told her 'no'...she said 'well do you have $150.00'..." Patient #12 stated he had not been seen by a physician prior the conversation with the nurse. The patient stated he left Facility A's ED and went to Facility B's ED (located 7 miles away from Facility A).

During a telephone interview on 7/23/2020 at 5:50 PM, Registered Nurse (RN) #2 confirmed she told Patient #12 he would have to pay $150.00 before he received a MSE by the physician. RN #2 stated the patient became agitated and left without being seen by the physician.

During a telephone interview on 7/23/2020 at 5:40 PM, the Chief Executive Officer stated the facility charges a $150.00 fee for ED patients without insurance and "...the expectation is the patients would be notified of the fee after a MSE was completed..."