HospitalInspections.org

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:

A good Samaritan called 911 after finding Patient #1 lying on the sidewalk across the street from Hospital #1 on 08/20/2023 at 07:30. Upon arrival to the scene on 08/20/2023 at 07:41, Phoenix Fire found the patient awake, alert but slow to respond to questions. While evaluating Patient #1 a hospital employee from Hospital #1 approached the EMS crew and stated that Patient #1 had been at the facility twice on 08/19/2023 and the facility did not find anything wrong with Patient #1. The hospital employee stated the Hospital #1 would not take Patient #1 for evaluation. EMS then transported Patient #1 via ambulance to Hospital #2 for evaluation and treatment.

Hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy-Arizona", revealed: " ...Policy ...2. The EMTALA obligation applies regardless of an individual's ability to pay, his/her payer source, or his/her age, race, religion, national origin, disability, or diagnosis. 3. A Mayo Clinic (MC) physician or other qualified medical personnel must provide a medical screening examination to any individual who comes to the Emergency Department (ED) requesting medical services (or when such a request is made on his/her behalf), or whose appearance or behavior would cause a prudent layperson observer to believe that the individual needs examination or treatment for a medical condition ....4. MC personnel must not engage in any activity that discourages an individual from seeking emergency medical care such as by demanding that ED patient's pay before receiving treatment for emergency medical conditions or by permitting debt collection activities that interfere with the provision of emergency medical care. 5. A MC physician or other qualified medical personnel provides a medical screening examination to any individual who is on the MCH property requesting examination or treatment or what may be an emergency medical condition (or when such a request is made on his/her behalf), or whose appearance or behavior would cause a prudent layperson observer to believe that the individual needs emergency medical examination or treatment ...Definitions ...b. Any individual who comes to other MCH department or is on MCH property (including parking lots, driveways, and sidewalks) and request examination or treatment for what may be an emergency medical condition, or has such a request made on his/her behalf, or whose appearance or behavior would cause a prudent layperson observer to believe that the individual needs emergency examination or treatment. ...."

Hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Procedure-Arizona", revealed: " ...Procedure ...14. Records: Keep the following records related to EMTALA: ...b. A central log containing identifying information on each individual who comes to MCH seeking emergency medical treatment and whether he/she voluntarily left without receiving a medical screening examination and/or treatment, refused treatment, was denied treatment, and whether the individual was treated, admitted and treatment, stabilized and/or transferred or was discharged ...."


The hospital failed to provided a Medical Screening Examination (MSE) to a patient who was within 0.4 miles of hospital property.

The hospital failed to provide documentation of Patient #1 on the emergency department central log on [08/20/2023].

Review of 19 additional ED patients' medical records randomly selected from the ED logs revealed all required documentation was present in each patient's medical record.


Employee #13 confirmed on 10/30/2023 that there is no documentation of Patient #1 on the emergency department log. Employee #13 further confirmed on 10/30/2023 that Patient #1 did not receive a MSE.

Based on review of policy and procedure, hospital documents and staff interview, it was determined the facility failed to document a patient presenting to the ED for examination and treatment on the dedicated ED log. (Patient #1)

Findings Include:

A good Samaritan called 911 after finding Patient #1 lying on the sidewalk across the street from Hospital #1 on 08/20/2023 at 07:30. Upon arrival to the scene on 08/20/2023 at 07:41, Phoenix Fire found the patient awake, alert but slow to respond to questions. While evaluating Patient #1 a hospital employee from Hospital #1 approached the EMS crew and stated that Patient #1 had been at the facility twice on 08/19/2023 and the facility did not find anything wrong with Patient #1. The hospital employee stated the Hospital #1 would not take Patient #1 for evaluation. EMS then transported Patient #1 via ambulance to Hospital #2 for evaluation and treatment.

Hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Procedure-Arizona", revealed: " ...Procedure ...14. Records: Keep the following records related to EMTALA: ...b. A central log containing identifying information on each individual who comes to MCH seeking emergency medical treatment and whether he/she voluntarily left without receiving a medical screening examination and/or treatment, refused treatment, was denied treatment, and whether the individual was treated, admitted and treatment, stabilized and/or transferred or was discharged ...."

A request was made for the dedicated ED log for August, September and October 2023 was made on 10/30/2023. Review of the ED log on 10/30/2023 revealed documentation of Patient #1 on the ED log for [08/19/2023 07:18] and [08/19/2023 17:06]. Further review of the ED log on 10/30/2023 revealed no documentation of Patient #1 on the ED log for 08/20/2023.

Employee #13 confirmed on 10/30/2023 that Patient #1 had presented to the facility twice on 08/19/2023. The first time on 08/19/2023 was 07:18 and the second time at 17:06. Employee #13 further confirmed that there was no documentation of Patient #1 on the ED log for 08/20/2023.

Based on review of policies and procedures, hospital documents and staff interviews, it was determined that the hospital failed to provide a Medical Screening Examination to Patient #1.


Findings Include:

A good Samaritan called 911 after finding Patient #1 lying on the sidewalk across the street from Hospital #1 on 08/20/2023 at 07:30. Upon arrival to the scene on 08/20/2023 at 07:41, Phoenix Fire found the patient awake, alert but slow to respond to questions. While evaluating Patient #1 a hospital employee from Hospital #1 approached the EMS crew and stated that Patient #1 had been at the facility twice on 08/19/2023 and the facility did not find anything wrong with Patient #1. The hospital employee stated the Hospital #1 would not take Patient #1 for evaluation. EMS then transported Patient #1 via ambulance to Hospital #2 for evaluation and treatment.

Hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy-Arizona", revealed: " ...Policy ...2. The EMTALA obligation applies regardless of an individual's ability to pay, his/her payer source, or his/her age, race, religion, national origin, disability, or diagnosis. 3. A Mayo Clinic (MC) physician or other qualified medical personnel must provide a medical screening examination to any individual who comes to the Emergency Department (ED) requesting medical services (or when such a request is made on his/her behalf), or whose appearance or behavior would cause a prudent layperson observer to believe that the individual needs examination or treatment for a medical condition ....4. MC personnel must not engage in any activity that discourages an individual from seeking emergency medical care such as by demanding that ED patient's pay before receiving treatment for emergency medical conditions or by permitting debt collection activities that interfere with the provision of emergency medical care. 5. A MC physician or other qualified medical personnel provides a medical screening examination to any individual who is on the MCH property requesting examination or treatment or what may be an emergency medical condition (or when such a request is made on his/her behalf), or whose appearance or behavior would cause a prudent layperson observer to believe that the individual needs emergency medical examination or treatment ...Definitions ...b. Any individual who comes to other MCH department or is on MCH property (including parking lots, driveways, and sidewalks) and request examination or treatment for what may be an emergency medical condition, or has such a request made on his/her behalf, or whose appearance or behavior would cause a prudent layperson observer to believe that the individual needs emergency examination or treatment. ...."

Review of Hospital ED Log for August, 2023 revealed Patient #1 was on the Log for [08/19/2023] after further review Patient #1 was not on the log for [08/20/2023].


A review of Patient #1 Emergency Department medical record from Hospital #1 revealed: " ....ED Nursing Documentation ...[08/19/2023 07:18] Patient arrived in ED ...07:22 Triage started ...07:22 Chief Complaints Updated: back pain ...dehydration ...shoulder pain ...07:24 Acuity ESI 4 ...07:44 Provider Assigned ...08:55 XR Ordered Dx Lumbar Spine 2-3 views, Dx Shoulder left 2+ views ...08:55 ED Lab Ordered: Comprehensive Metabolic Panel, Creatine Kinase (CK), CBC with Differential, ...1300 Free Text: Patient has ordered multiple meals. I discussed some of the results with [him]. [His] white count is elevated but I do not feel[he] has any findings concerning for infection at this time. I feel [he] is mainly here because of [his] homeless status. [He] does have a local primary care provider. I stated [he] needs to contact [him] or orthopedic referral for [his] back, knee, and shoulder issue. Recommend also cutting back on [his] alcohol intake. Patient discharged in stable condition ...13:46 ED Quick Update ...Free Text Pt refused to leave, yelled at this RN, "Do not rush me." Security called, pt escorted out ....13:49 Patient Discharged ...."

A review of Patient #1 Emergency Department medical record from Hospital #1 revealed: " ...ED Arrival Information: Arrival [08/19/2023 17:06] ... Acuity 5 ... Means of Arrival Personal Vehicle ...Chief Complaint: Complaint Illness Comment: Patient requested Phoenix PD to be brought to Mayo Clinic ER. When asked what medical emergency is, patient states "I'm here for surgery" ....Triage: 17:15 ...17:19 ED Quick Update Provider at bedside ...Free Text: [Dr. Heller] in triage with [Ben] RN, and Security ...17:25 ED Quick Updated Free Text: Patient medically cleared by [Dr. Heller]. Patient refused Motrin; patient escorted out by security ...."

A review of Global Security report from Hospital #1 revealed: " ...Reported Date/Time: 2023-08-19 17:14 ...Location Name PX MH 01 Mayo Clinic Hospital ...Activity Note: Patient arrived this morning at approximately 0630 by a good samaritan. Patient looks to be homeless. Patient was admitted ...Patient was discharged at approximately 1410 hours. Patient left without incident with bus pass and scrubs. Patient was brought back via [Phoenix Police Department] at approximately 1700 hours. Patient checked into ED and seen by doctor and discharged again. Security provided water and a sandwich to patient. Patient left property at 1534 hours. Patient not aggressive and no further incident occurred ...."

A review of Patient #1's EMS Run Sheet revealed: " ...Incident Summary ...Date of Service: 08/20/2023 07:34:38 ...Destination Name : [[DV] ABRAZO SCT CAMPUS] Distance: 3.2 miles ...Incident Information ...Incident Location Type: Street-Freeway-Bus Stop Address: [18850 N 50th ST] ...Call Times By Unit ...Call Received: [08/20/2023 07:30:03] ...On Scene: [08/20/2023 07:43:30] ...Unit Clear: [08/20/2023 08:24:56] ...Narrative ...On Scene Narrative: Upon arrival {the} fire department, patient was found laying (sic) on left side on sidewalk with above complaint. People driving by saw patient and called 911. Upon arrival at (sic) fire department patient is awake, alert and answers most questions appropriately, but is occasionally slow to respond. Patient present in no obvious distress. Patient states that [he] has psych history, but is not specific in the details of what it is. Unknown patient baseline. Patient was kicked out of [Mayo Hospital] yesterday afternoon {according to} security that showed up on scene during evaluation. Hospital stated that patient was taken in twice and neither times hospital {was} able to find anything wrong with [him]. [He] just didn't want to leave. Patient currently denies any pain or complaints, but occasionally alerted and occasionally slow to respond. After evaluation, patient offered ambulance and transportation to hospital his choosing for further evaluation. Security on scene stated that [Mayo Hospital] would not take the patient back. Patient transported via ambulance to [Paradise Valley Hospital] for further evaluation. Pt (patient) refused IV (intravenous) from Fd (fire department) personnel ...."


A review of Patient #1 Emergency Department medical record from hospital #2 revealed: " ...Arrival Time: [08/20/2023 08:18] ...ED Discharge Time: [08/20/2023 12:14] ...Chief Complaint Knee Pain-Swelling ...Triage: [08/20/2023 08:24]...ESI 3 ...MSE [08/20/2023 08:32]...Medications Given: cephalexin monohydrate 250mg cap ...potassium chloride 20 mEq tab ER ...Major tests and Procedures: Calcium ...CMP ...Complete Blood Count with Auto Differential ...Ethanol Level ...Lipase Level ...Magnesium Level ...Prothrombin Time ...Troponin I ...UA with Microscopic ...Urinalysis Microscopic Exam ...Urine Culture ...CT Head or Brain W/O Contrast ...CXR 1 View ...XR Knee 4 View Minimum Left ...Patient Diagnosis: Acute urinary tract infection; Hypokalemia; Knee Pain, left ...."

Distance between where Patient #1 was found to Hospital #1 is 0.4 miles.

Distance between where Patient #1 was found to Hospital #2 is 3.2 miles.

A conference call on 11/01/2023 was attended by Employee #8, Employee #47, Employee #39, Employee #40 and Employee #41. Employee #37 confirmed that Hospital #1 did not have any interaction with Patient #1 on 08/20/2023. Employee #37 further confirmed that Hospital #1 has not internal documentation confirming an interaction with the EMS facility on 08/20/2023. Employee #37 confirmed that the security guards from Hospital #1 do not leave the facility property. Employee #40 further confirmed that the facility has no evidence to substantiate the claim that Patient #1 was denied admittance to the facility. Employee #41 further confirmed that the facility's security guard receive adequate training in EMTALA. Employee #37 confirmed that Hospital #1 is the closest hospital to were Patient #1 was found.

Employee #37 confirmed on 11/01/2023 during an employee filed review the security guards at Hospital #1 do not received the same EMTALA training as the medical staff and physicians. Employee #37 further confirmed that during orientation there is section called
"General Orders and Standard Procedures in Field Training" that includes EMTALA information. A copy of the training was requested. Employee #38 was unable to provide a copy of the training.

An interview was conducted on 11/01/2023 with EMS Paramedic #1 who confirmed that it is normal practice for EMS to transport the patient to the nearest appropriate hospital based on the patient's condition.

An interview was conducted on 11/02/2023 with EMS Paramedic #2 who confirmed Patient #1 was found on the sidewalk by a passerby across the street from Hospital #1. EMS Paramedic #2 further confirmed Hospital #1 security guard crossed the street and stated that Patient #1 was a patient at Hospital #1 on 08/19/2023. EMS Paramedic #2 confirmed that Hospital #1 security guard stated to not bring the patient to Hospital #1. EMS Paramedic #2 confirmed that the security guard was able to provided medical information about Patient #1.