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Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases.

Findings Include:

Patient #1 presented to the hospital with complaints of severe abdominal pain, sweating, chills, diarrhea, and nausea, on 09/22/2023 at 2040. Patient #1 was triaged at 2106 and given an acuity score of 3. Patient #1 left the Emergency Department (ED) at 2351 without being seen.

Policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", revealed: "...All patients who present to the Hospital's DED or on Hospital Property and request examination or treatment of a potential EMC, shall receive an appropriate MSE...A physician or QMP must perform the MSE to determine if an EMC exists. The MSE must be appropriate to the patient's presenting complaint and symptoms, and the medical history of the patient...indicates his/her intention to leave the Hospital prior to receiving a MSE, ED staff should whenever practicable, inform the patient of the risks and benefits of the examination and, if the patient continues to refuse examination, request that the patient sign the "Refusal of a Medical Screening Exam" form reflecting the refusal and indicating that the patient has been informed of the risks and benefits of medical screening examination

Policy titled "Patient Assessment, Reassessment and Documentation of Care in the Emergency Department," revealed: "...After initial ESI level assigned and focused assessment completed, all patients will have reassessments completed based on condition and established ESI level. Reassessments include, but are not limited to, response to treatments, pain reassessment, repeat vital signs (repeat temperature to be documented if initial abnormal or patient treated for fever)...ESI Level 2 - Reassessments to be completed as needed based on condition and no less frequently than every 1 hour until hemodynamically stable. Once condition has stabilized, reassessments to be completed every 2 hours until disposition determined...ESI Level 3 - Reassessments to be completed no less than every 2 hours if vital signs are abnormal. If vital signs are within normal limits, reassessments to be completed every 4 hours or as needed based on condition...."

A review of Patient #1 medical record revealed the patient did not receive a MSE prior to leaving the facility and there was no documentation regarding the "Refusal of a Medical Screening Exam" form in the patient's medical record.

A review of ten (10) medical records revealed three (3) patients who did not have reassessments per policy:
Patient #6: ESI 2; Vital signs at 12:57, with BP of 214/108, next at 18:16; 5 hours and 19 minutes between vital signs
Patient #8: ESI 3; Vital signs at 18:23, next at 01:50; 7 hours and 27 minutes between vital signs
Patient #9: ESI 2; Vital signs at 22:13, next at 03:55; 5 hours and 42 minutes between vital signs

Employee #1 confirmed in an interview on 10/23/2023, that these patients did not have vital signs taken per policy.

Employee #5 confirmed in an interview on 10/23/2023 that Patient #1 was triaged but had no MSE performed before the patient left the hospital stating s/he wanted to go home to sleep.

Based on review of policies and procedures, hospital documents, observations, and interviews, it was determined that the hospital failed to provide a Medical Screening Examination to a patient who presented to the ED for examination and treatment (Patient #1).

Findings include:

Patient #1 presented to the hospital with complaints of severe abdominal pain, sweating, chills, diarrhea, and nausea, on 09/22/2023 at 2040. Patient #1 was triaged at 2106 and given an acuity score of 3. Patient #1 left the Emergency Department (ED) at 2351 without being seen.

Hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", revealed: "...All patients who present to the Hospital's DED or on Hospital Property and request examination or treatment of a potential EMC, shall receive an appropriate MSE...A physician or QMP must perform the MSE to determine if an EMC exists. The MSE must be appropriate to the patient's presenting complaint and symptoms, and the medical history of the patient...indicates his/her intention to leave the Hospital prior to receiving a MSE, ED staff should whenever practicable, inform the patient of the risks and benefits of the examination and, if the patient continues to refuse examination, request that the patient sign the "Refusal of a Medical Screening Exam" form reflecting the refusal and indicating that the patient has been informed of the risks and benefits of medical screening examination 2. If the patient refuses to sign the form, staff shall document on the ED Sign-In Sheet that the patient refused to sign the "Refusal of a Medical Screening Exam " form...The medical record must contain a description of the attempt to inform the patients of the risks and benefits of the medical screening examination...."

A review of Patient #1's medical record dated 09/22/2023, revealed Patient #1 checked in at 2040, and was triaged with an ESI of 3, BP 147/90, HR 80, and a pain score of 9, at 2106. A CBC and CMP were drawn at 2110, as well as a urine specimen sent. Results were within reference range with three values slightly out of reference range. On 09/22/2023 at 2351 it was documented "...Pt advs [she] would rather go to sleep at home...."

A review of 20 ED records randomly selected for review included patients who were transferred, admitted, or left before Medical Screening Examinations. There was no documentation that there were any delays in assessments and/or treatments based on patient ability to pay for medical services.

Employee #5 confirmed in an interview conducted on 10/23/2023, that Patient #1 was seen by a nurse, triaged as an acuity of 3, had labs drawn and left after 2 hours and 45 minutes saying s/he wanted to go sleep at home. Employee #5 confirmed there was no other documentation in Patient #1's medical record about leaving the hospital before the MSE.