Based on document review, video review, and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The Hospital failed to ensure that a patient presenting to the Emergency Department was listed in the centralized log. See deficiency at A-2405. 2. The Hospital failed to ensure that a patient presenting to the Emergency Department received a Medical Screening Examination (MSE). See deficiency at A-2406.

Based on document review, video review, and interview, it was determined that for 1 of 10 patients (Pt. #1) that presented to the Hospital's Free Standing Emergency Center (Facility A), the Hospital failed to ensure that the patient was listed on the Emergency Department (ED) centralized log. Findings include: 1. The Hospital's policy titled, "EMTALA: Emergency Medical Treatment and Labor Act" (effective 3/20/15), was reviewed on 10/31/18 and required, "...A centralized (by reference) log of all individuals presenting to a Dedicated Emergency Department... for emergency medical treatment is maintained, one per dedicated emergency department. The log includes the name of the individual, whether s/he refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, or was discharged ..." 2. Facilty A's ED centralized logs from 10/14/18 to 10/20/18 were reviewed on 10/30/2018, and the logs failed to include the name of Pt #1. 3. The EMS (Emergency Medical Services) run log (received from Pt. #1's record at Facility C), dated 10/19/18 at 7:17 AM, was reviewed on 10/31/18 and included, "...Upon arrival at [Facility A's] ED verbal report given to staff and patient care transferred... After transfer of care Patient relayed to [Facility A's] ED staff and [MD#2] that he [Pt. #1] wanted to kill himself and shoot himself multiple times. [MD#2] stated that patient was drunk and that he [MD#2] was going to send patient back to jail because there is nothing that he can do for patient... Crew left [Facility A] at [6:26 AM]..." 4. The EMS Radio Log (undated, timed at 5:53 AM), identified by Facility A as call log for Pt. #1 on 10/19/18, was reviewed on 10/31/18 and indicated that a [AGE] year old male, arrested for alcohol on board/driving under the influence, was on the way to Facility A with EMS and local police. The log included, "SI [suicide ideation] 6 months ... PMH [Past Medical History]: anxiety, bipolar [disorder]... Orders: continue to treat, transport, and monitor... call back with any problems... ETA [estimated time of arrival]: 7-10 minutes..." 5. Video recordings of Facility A's ambulance bay and ED hallway on 10/19/18, between 5:30 AM and 6:30 AM, were reviewed on 10/31/18, at approximately 9:00 AM, with Security Officer (E#3). The video footage showed the following: - At 6:09:25 AM, a young male (Pt. #1) arrived by EMS, with a police officer present, in the ambulance bay and entered Facility A at 6:09:35 AM. - At approximately 6:10:50 AM, the patient was placed in exam room 3 (designated for Psychiatric patients). - A physician [identified as MD#2 by security officer E#3] and a RN [identified as E#6 by E#3] were standing in the ED hallway during this time. - At approximately 6:17:33 AM, MD#2 entered exam room 3. MD#2 exited the room at approximately 6:20:10 AM and spoke with the police officer. - At approximately 6:25:45 AM, the patient was escorted back towards the ambulance bay entrance/exit. At approximately 6:27:13 AM, the patient was strapped into the transport cart and then loaded back into the ambulance. The ambulance left at approximately 6:28:35 AM. 6. An interview was conducted with the Director of Emergency Services (E#2) on 10/31/18 at 10:07 AM and with the ED Assistant Medical Director (MD#1) on 10/31/18 at approximately 10:38 AM. Both E#2 and MD#1 stated that every patient presenting to the ED should be recorded in the ED (centralized) log even if the patient refused treatment. 7. An interview was conducted with the Charge Nurse (E#4) on 10/31/18 at approximately 12:13 PM. E#4 stated that he did recall this patient coming in the morning of 10/19/18. E#4 stated that he received a radio call from EMS prior to the patient's arrival, and confirmed his (E#4) signature on the (undated) radio log. In regards to this case (a patient with suicide ideation), E#4 stated, "We never divert these kinds of cases... We can take care of this here..." E#4 stated that the patient "wasn't here that long," but there should be a record that he [Pt. #1] was here.

Based on document review, video review, and interview, it was determined that for 1 of 10 patients (Pt. #1) that presented to the Hospital's Free Standing Emergency Center (Facility A), the Hospital failed to ensure that the patient received a Medical Screening Examination (MSE). Findings include: 1. The Hospital's policy titled, "EMTALA: Emergency Medical Treatment and Labor Act" (effective 3/20/15), was reviewed on 10/31/18 and required, "...All individuals who come to the emergency department... requesting care for emergency medical conditions (or where such requests are made on their behalf) receive an appropriate medical screening prior to admission, discharge or transfer to another facility..." 2. The Hospital's document titled, "The Medical Staff Bylaws" (dated 10/30/17) was reviewed on 10/30/18 and included, "...Individuals who present to the hospital for emergency care will receive an appropriate medical screening examination by qualified medical personnel to determine if the individual has an emergency medical condition ..." 3. Pt. #1's ED (Emergency Department) record was requested on 10/30/18 at approximately 10:00 AM. At approximately 11:30 AM, the Accreditation Manager (E#1) stated that there was no record for Pt. #1. 4. The clinical record from the recipient Hospital (Facility C) of Pt. #1 was reviewed on 10/31/2018, at 8:30 AM. Pt. #1 was [AGE] year old male, who presented to Facility C's ED on 10/19/18 at 6:42 AM, with a diagnosis of suicidal ideation (SI). A physician's note, dated 10/19/18 at 6:47 AM, included, "22 y/o [year old] male presents to the ED via EMS [Emergency Medical Services] for a psychiatric evaluation secondary to a SI [suicide ideation]... Per police, pt [patient] was pulled over for a traffic stop and while at booking began stating that he was suicidal and has been thinking about killing himself for the past six months. Pt states, "I am going to shoot myself." Per EMS, Pt was taken to a free standing emergency department [Facility A] and ED physician refused to see pt. History is limited due to uncooperative pt." 5. The EMS (Emergency Medical Services) run log (received from Pt. #1's record at Facility C), dated 10/19/18 at 7:17 AM, was reviewed on 10/31/18 and included, "...Upon arrival at [Facility A's] ED verbal report given to staff and patient care transferred... After transfer of care Patient relayed to [Facility A's] ED staff and [MD#2] that he [Pt. #1] wanted to kill himself and shoot himself multiple times. [MD#2] stated that patient was drunk and that he [MD#2] was going to send patient back to jail because there is nothing that he can do for patient... Crew left [Facility A] at [6:26 AM]..." 6. Video recordings of Facility A's ambulance bay and ED hallway on 10/19/18, between 5:30 AM and 6:30 AM, were reviewed on 10/31/18, at approximately 9:00 AM, with Security Officer (E#3). The video footage showed the following: - At 6:09:25 AM, a young male (Pt. #1) arrived by EMS, with a police officer present, in the ambulance bay and entered Facility A at 6:09:35 AM. - At approximately 6:10:50 AM, the patient was placed in exam room 3 (designated for Psychiatric patients). - A physician [identified as MD#2 by security officer E#3] and a RN [identified as E#6 by E#3] were standing in the ED hallway during this time. - At approximately 6:17:33 AM, MD#2 entered exam room 3. MD#2 exited the room at approximately 6:20:10 AM and spoke with the police officer. - At approximately 6:25:45 AM, the patient was escorted back towards the ambulance bay entrance/exit. At approximately 6:27:13 AM, the patient was strapped into the transport cart and then loaded back into the ambulance. The ambulance left at approximately 6:28:35 AM. 7. An interview was conducted with the Security Officer (E#3) on 10/31/18 at approximately 9:00 AM, during the review of the ED video recordings. E#3 stated that the patient [Pt. #1] was not cooperative. E#3 stated that MD#2 spoke with the police officer after seeing the patient, and decided to send the patient back to jail. 8. An interview was conducted with the Director of Emergency Services (E#2) on 10/31/18 at 10:07 AM and with the ED Medical Director (MD#1) on 10/31/18 at approximately 10:38 AM. Both E#2 and MD#1 agreed that every patient presenting to the ED should receive a MSE; however, if the patient refused treatment, documentation should be made to show that a MSE was attempted. 9. An interview was conducted with the ED physician (MD#2) on 10/31/18 at 1:40 PM. MD#2 stated that the patient [Pt. #1] refused to be seen by ED staff on 10/19/18 and refused to give any information. MD#2 stated that he [MD#2] discussed the situation with the police officer and told the officer that ED staff could not touch the patient since he [Pt. #1] was refusing care. MD#2 stated that Pt. #1 was "not in my custody because he [Pt. #1] had cuffs on." When asked about documentation of the encounter, MD#2 stated that during the incident on 10/19/18 he [MD#2] asked whether a chart needed to be made. MD#2 stated that someone (did not recall who) told him that since the patient was going back to jail, a chart would not be created for this patient [Pt. #1].

Based on document review and interview, it was determined the Hospital failed to ensure compliance with 42 CFR 489.20, and 42 CFR 489.24. Findings include: 1. The Hospital failed to capture the patients' information in the ED (Emergency Department) log. Refer to A-2405 2. The Hospital failed to include in their Medical Bylaws the responsible person to provide medical screening. Refer to A-2406 A 3. The Hospital failed to provide medical screening examinations. Refer to A-2406 B. 4. The Hospital failed to provide appropriate transfer to the patients that were transferred to other Hospitals. Refer to A-2409.

Based on document review and interview, it was determined that for 8 of 16 (Pts. #5, #10, #13, #14, #15, #16, #19 and #20) patients transferred to another Facility, the Hospital failed to ensure all patients were appropriately transferred. Findings include: 1. Hospital policy entitled, "Emergency Medical Treatment and Labor Act," (effective 3/20/15) required, "Procedure...B. Transfer to Another Facility...4. For all cases of transfer subject to this policy, the following steps must occur: i. Staff provides medical treatment ...to minimize the risks to the patient's health...ii Staff determines that the receiving facility has available space and qualified personnel for the treatment of the individual, and agrees to accept transfer of the patient and provide appropriate medical treatment. iii Staff documents in the medical record, and on the log, the above information including any discussion of risks and benefits of the transfer, The Patient Transfer Form and Physician Certificate for Transfer are completed...v. Staff arranges for transportation via qualified personnel and equipment, including the use of necessary and medically appropriate measures, as determined by the responsible physician..." 2. The clinical record of Pt #5 was reviewed on 7/17/17 at approximately 10:00AM. Pt #5 was a [AGE] year old female that (MDS) dated [DATE] with complaints of dizziness, headache, and abdominal discomfort. Physician documentation included, "Advised patient that further evaluation in a functioning emergency department is advised. Nearby options for care were reviewed with the patient and she expressed understanding. She agrees to go directly for care." Pt #5's clinical record lacked a copy of The Patient Transfer Form and Physician Certificate for Transfer and documentation that Pt #5 had been transferred by appropriate personnel, as required. 3. The clinical record of Pt #10 was reviewed on 7/17/17 at approximately 10:15 AM. Pt #10 was a [AGE] year old male that (MDS) dated [DATE] at approximately 4:12 PM with complaints of chest pain, shortness of breath, and left arm tingling. Vital signs included, "heart rate 87, respirations 16, blood pressure of 142/108, and oxygen saturation of 98%. Physician documentation included, "The following assessment was performed purely for safety to help facilitate getting the patient to seek the medical services they desire. Pt was advised that patients symptoms require timely evaluation in an emergency department setting and given the nature of the complaint and inability to exclude cardiac etiology without additional testing, ambulance transfer recommended. Patient agreeable to this. On site ambulance notified, they performed an EKG which I reviewed which showed NSR (normal sinus rhythm)...Patient taken to closest nearby hospital (H #1). I called the ED..." Pt #1's clinical record failed to include a copy of The Patient Transfer Form and Physician Certificate for Transfer, as required. 4. The clinical record of Pt #13 was reviewed on 7/17/17 at approximately 10:20 AM. Pt #13 was a [AGE] year old female that (MDS) dated [DATE] with complaints of right back pain. Physician documentation included, "Her friend dropped her off and she has no ride...we cannot provide any clinical evaluation or care what so ever. Patient placed in an ambulance to be transported to another hospital." Pt #13's clinical record lacked a copy of The Patient Transfer Form and Physician Certificate for Transfer, documentation that the receiving Hospital accepted the patient, and that the patient had been transferred by appropriate personnel, as required. 5. The clinical record of Pt #14 was reviewed on 7/17/17 at approximately 10:30 AM. Pt #14 was a 3 year old male that (MDS) dated [DATE] with complaints of fever with vomiting. Pt #14's vital signs on admission to the ED included temperature of 102.4, heart rate of 132, and blood pressure of 123/81. Physician documentation included," Northwestern Lake Forest Hospital is unable to render any emergency care at this time. The patient was provided information on nearby locations to seek medical attention. Referred to immediate care centers..." Pt #14's clinical record lacked documentation of appropriate transportation being provided. 6. The clinical record of Pt #15 was reviewed on 7/17/17 at approximately 10:40 AM. Pt #15 was a [AGE] year old male that (MDS) dated [DATE] with complaints of crushed injury to left great toe with laceration. Physician documentation included," Northwestern Lake Forest Hospital is unable to render any emergency care at this time. The patient was provided information on nearby locations to seek medical attention. Wound needs repair, referred to another ED; they will likely go to H #1. Pt #15's clinical record lacked documentation that the receiving Hospital accepted the patient, a copy of The Patient Transfer Form and Physician Certificate for Transfer, documentation that the receiving Hospital accepted the patient, and that the patient had been transferred by appropriate personnel, as required. 7. The clinical record of Pt #16 was reviewed on 7/17/17 at approximately 10:50 AM. Pt #16 was a [AGE] year old female that (MDS) dated [DATE] with a complaint of occipital headache and vomiting. Physician documentation included, "Patient/husband informed that this ED is closed due to flooding/recovery and we are unable to provide the advanced CT imaging, labs and BP monitoring she needs now and should seek emergent care from an acute care Hospital ED such as...and not wait till Monday to see her PCP (primary care physician). Her Husband stated that he wants to drive her to H #2 instead..." Pt #16's clinical record lacked documentation that the receiving Hospital accepted the patient, a copy of The Patient Transfer Form and Physician Certificate for Transfer, documentation that the receiving Hospital accepted the patient, and that the patient had been transferred by appropriate personnel, as required. 8. The clinical record of Pt #19 was reviewed on 7/17/17 at approximately 11:00 AM. Pt #19 was a [AGE] year old female that (MDS) dated [DATE] with complaints that someone put glue in both ears. Documentation included, "...we have no diagnostic or ancillary services at this time. They were told to go to...facility for further care." Pt #19's clinical record lacked documentation that the receiving Hospital accepted the patient, a copy of The Patient Transfer Form and Physician Certificate for Transfer, documentation that the receiving Hospital accepted the patient, and that the patient had been transferred by appropriate personnel, as required. 9. The clinical record of Pt #20 was reviewed on 7/17/17 at approximately 11:10 AM. Pt #20 was a [AGE] year old female that (MDS) dated [DATE] with complaints of itching following exposure to a cat. Physician documentation included, "Pt informed that Northwestern Lake Forest is closed due to flooding. No diagnostic or ancillary services are available. Pt states she is going to H #3." Pt #20's clinical record lacked a copy of The Patient Transfer Form and Physician Certificate for Transfer, documentation that the receiving Hospital accepted the patient, and that the patient had been transferred by appropriate personnel, as required. 10. The Vice President of Quality (E #1) stated during an interview on 7/17/17 at approximately 2:30 PM, that the Hospital was closed and there was no service given and for the ones that needed a treatment, it was provided by the ambulance company not the Hospital.

Based on document review and interview, it was determined that for 3 (Pts. #1, #2 & 21) of approximately 27 patients that (MDS) dated [DATE], the Hospital failed to ensure the patients required information who presented to the Emergency Department (ED) was captured in the ED log as required. Findings include: 1. On 7/14/17, the policy entitled "EMTALA: Emergency Medical Treatment and Labor Act" (effective 3/20/15) was reviewed and indicated, "...C. Centralized Log: A Centralized (by reference) log of all individuals presenting to a Dedicated Emergency Department within (the Hospital) for emergency medical treatment is maintained, one per dedicated emergency department. The log includes the name of the individual, whether s/he refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, or was discharged ..." 2. On the "Disaster Triage log" reviewed on 7/14/17 at approximately 10:55 AM and indicated the following patients presented to the ED. - At 7:30 AM, Pt. #1, was an 8 year old female, accompanied by the mother, and presented to the ED with a complaint of hand pain. This log did not contain the name of Pt. #1. - At 8:00 AM, Pt. #2, was a female, who presented to the ED "bent over did not give complaint drove over an hour" to arrive to the ED. The log failed to contain Pt. #2's name. 3. On 7/14/17 at approximately 10:50 AM the "ED Activity Log" (centralized log) was reviewed. Pt#1, #2, and #3 were not documented on this log. 4.On 7/13/17 at approximately 11:30 AM, the Registered Nurse (RN) E #3, was interviewed and stated the electronic system was not in service at the time these patients arrived to the ED and they were manually entering the information of the patients "disaster triage log". This was the document in use at that time to log the patients that arrived to the ED. It did not include Pts. #1 & 2's names. These patients were not entered in the electronic system when it became available. 5. On 7/17/17 at approximately 2:30 PM, the ED physician (MD #2) was interviewed. MD #2 stated he saw 2 patients on 7/13/17. MD #2 stated one patient (Pt. #21) was not entered in the log. Pt. #21 was not identified on any ED documentation.

A. Based on document review and interview, it was determined that the Hospital failed to ensure that the Hospital's Bylaws of the Medical Staff of Northwestern Lake Forest Hospital included the person responsible to perform a medical screening exam. This potentially affected all the patients that present to the Emergency Department seeking medical attention. Findings include: 1. The Hospital's Bylaws of the Medical Staff of Northwestern Lake Forest Hospital (approved October 28, 2013) were reviewed on 7/17/17 at approximately 9:00 AM. The Hospital's Bylaws of the Medical Staff of Northwestern Lake Forest Hospital failed to include the requirement of the person deemed qualified to perform a medical screening exam. 2. On 7/17/17 at approximately 9:00 AM the Vice President of Quality (E #1) stated that, "The Hospital has Medical Staff Bylaws and the Rules and Regulations are included in the Bylaws. The Medical Staff functions with policies." 3. On 7/17/17 at approximately 2:00 PM, E #1 stated that, "The policy is followed for who can do a medical screening and it is not in the Bylaws." B. Based on observational tour, document review, and interview, it was determined that for 7 (Pts. #1, #2, #3, #4, #6, #13 and #19) of 20 clinical records reviewed of patients who presented in the Emergency Department (ED), the Hospital failed to provide a medical screening examination (MSE). Findings include: 1. On 7/13/17 at 12:15 PM, an observational tour was conducted in the Emergency Department (ED) with the Manager of Emergency Services (E #1). The Registered Nurse (E #3) provided an ED "initial triage" list of 4 patients (Pts. #1 - 4) who had entered the ED since 7/13/17 at 7:00 AM. 2, According to the initial triage list, on 7/13/17 at 7:30 AM, Pt. #1 arrived. Pt. #1 was an 8 year old female with left hand pain. 3. In an interview, E #3 stated Pt. #1's vital signs were not taken, she was not seen by the physician, and the mother was told to take Pt. #1 to Vernon Hills Acute Care for treatment. E #3 stated Pt. #1 was in the triage area about 1 minute before leaving the Hospital. 4. The initial triage list included that, on 7/13/17 at 8:00 AM, Pt. #2 arrived. Pt. #2 was a female, age not provided, who was "bent over" and "stated [she] drove over an hour to get here". 5. E #3 stated Pt. #2 was informed the Hospital was closed, no vital signs were taken, she was not seen by the physician, and was informed of Acute Care and other local Hospital ERs. E #3 stated Pt. #1 was in the triage area about 1 minute before leaving the Hospital. 6.The initial triage list included that, on 7/13/17 at 10:15 AM, Pt. #3 arrived. Pt. #3 was a male, birth date not legible, who complained of "leg ulcers" and was in "no distress, ambulatory without difficulty". 7. E #3 stated Pt. #3 was informed the Hospital was closed; no vital signs were taken; he was not seen by the physician, and was informed of Hospital #4 (acute care hospital) to go for treatment. E #2 stated Pt. #4 was in the triage area less than 5 minutes before leaving the Hospital. 8.The clinical record of Pt. #4 was reviewed on 7/14/17. Pt #4 was a [AGE] year old male that (MDS) dated [DATE] with a chief compliant of left foot pain and swelling. The ED physician (MD #2) documented in his note dated 7/13/17 at 2:07 PM "Due to local disaster ...we are unable to provide clinical care or treatment at this time aside from emergent treatment...Reviewed local options where patient can seek medical care..." No medical screening was performed. 9. The clinical record of Pt. #6 was reviewed on 7/17/17. Pt. #6 was a [AGE] year old female that (MDS) dated [DATE] with a chief complaint of "right hand injury". MD #3 documented in his note dated 7/14/17 at 10:14 PM "She (Pt. #6) was informed that the "(Hospital) is closed due to flooding and we do not have any diagnostic or ancillary services available. Pt (Pt. #6) will be driven to Hospital #1 (acute care hospital). No medical screening was provided. 10. The clinical record of Pt. #13 was reviewed on 7/17/17. Pt. #13 was a [AGE] year old female that presented to the ED with a chief compliant of "right back pain". The ED physician (MD #4) documented on 7/14/17 at 8:11 AM " the emergency department and the hospital are both closed ...we cannot provide any clinical evaluation or care whatsoever...: 11. The clinical record of Pt. #19 was reviewed on 7/16/17. Pt. #19 was a [AGE] year old female that (MDS) dated [DATE] with a chief compliant of "alleged assault". The ED physician MD #3 documented on 7/15/15 at 2:07 PM "Pt (Pt. #19) and her friend were told the (Hospital) is closed and we have no diagnostic or ancillary services at this time. They were told to go to Hospital #1 (acute care hospital)...for further care." No medical screening exam was provided. 12. On 7/17/17 at approximately at 11:33 AM, the Manager of ED (E #6) was interviewed. E #6 stated "the ED closed Friday (7/14/17) in the morning. The staff was moved to the main entrance and the doors were completely closed. 13. On 7/17/17 at approximately 1:35 PM, the ED physician (MD #1) was interviewed via telephone. MD #1 was on duty 7/13/17 from 3:00 PM to 9:00 PM. MD #1 stated "the ED was closed, we remained onsite in the event someone would arrive to provide them with guidance or advise. MD #1 stated "they were not treated as my patient or received full evaluation." 14. On 7/17/17 at approximately 2:30 PM, the ED physician MD #2) was interviewed. MD #2 was on duty on 7/13/17 during the morning. MD #2 stated that he would direct patients to go to another ED. MD #2 stated the Hospital Administration wanted a physician onsite in the event an individual would arrive and needed emergent care. MD #2 stated "I saw two patients on my shift and told these patients that we were not able to provide services and offered options to other locations." 15. On 7/17/17 at approximately 2:45 PM, the Vice President of Quality (E #1) was interviewed. E #1 stated the ED was closed and that the ED was not required to provide medical screenings at that time.