Based on a detailed review of the Emergency Department (ED) during an EMTALA survey, a tour of the hospital ED was conducted on January 11, 2018 at approximately 9:15 am. The tour revealed no visible EMTALA signage present in a place likely to be noticed by individuals entering the ED at the main pedestrian entrance to the Emergency Department.

Based on a detailed review, interviews and observations of the Emergency Department (ED) by surveyors on 1/11/18, the hospital failed to provide documentation of an accurate and complete central log for the ED. Patient #1 was transported to the hospital ED by ambulance at 12:04 PM on a January 2018 day. The patient was discharged at approximately 11: 30 PM that night. Pt# 1 returned a second time to the hospital ED via ambulance at approximately 12:20 AM the next day. Pt# 1's name, visit and disposition information appeared only one time in the hospital's ED log for the initial encounter at 1:30 PM . There were no entries in the log when the patient returned to the ED by ambulance about 40 minutes after the first discharge. In addition, because the hospital ED maintained an informal policy of not re-registering patients who re-presented to the ED within 2 hours of discharge, it was impossible to determine how accurate the ED log might be. See Tag A0406 of the Condition of Participation complaint survey of the same date.

Based on a tour of the Emergency Department (ED) on 1/11/2018, review of ED processes related to medical screening examinations (MSE), staff interviews, policy and procedure and other documentation, it was revealed that in multiple ways, the hospital failed to ensure that every presenting patient receives an MSE, when it, 1) established an unwritten policy to reopen an initial ED record for patients presenting within 2 hours of ED discharge in order to utilize the initial MSE for the second visit; 2) failed to conduct a MSE for patient #1 who presented a second time within two hours; 3) failed to give unencumbered access to the emergency department for every walk-in patient; and 4) failed to designate who can conduct an emergency medical screening examination. 1) On 1/11/2018 at approximately 0930, a request to a Quality staff member for patient #1's two same-day ED presentations revealed in part, that patient #1 had only one record due to an unwritten hospital policy that instructed patient access staff to reopen the initial ED record for patients who return to the ED within 2 hours of discharge. Interview at 0930 revealed that "The prior record (initial presentation) is reopened for continuity of care." Further inquiry revealed that the second presenting chief complaint would determine if a new MSE was to be done on the second presentation. Based on this information, there was no guarantee that a new MSE would be conducted for a patient presenting within 2 hours of discharge from the ED. This process failed to meet regulatory requirements for the provision of a MSE for individuals coming to an ED regardless of timeline. Interview at approximately 9:45 am with the Director of Patient Access revealed knowledge of the 2-hour rule, but identified that there was no written policy. Further, that when it was noted at the registrar that a patient had been seen 2-hours prior, the ED RN was to be notified. Interview at approximately 1030 with the Regional Medical Director for contracted ED providers revealed knowledge of the 2-hour rule and the statement that upon the second presentation, the expectation is that a provider enter an addendum progress note into the re-opened record. 2) Patient #1 was a young adult who presented to the ED in January 2018 at 1304 via ambulance following a fall from a motorized bike, which resulted in striking a curb and an apparent minor head injury. On arrival, an MSE was conducted inclusive of Computed Tomography (CT) of the head. Following the MSE, patient #1 was found to be free of an emergency medical condition and was cleared for discharge. Patient #1 was resistant to discharge and would not dress. Patient #1 was subsequently escorted from the hospital by security staff while still in a hospital gown on or about 2340. The patient was brought back via ambulance at 0013. Ambulance documentation revealed patient #1's chief complaint was, "I do not feel normal, and do not know what normal is." Upon arrival to the ED the second time, the initial ED record was reopened. Other than the ambulance documentation and a note by the ED case manager at 0048, no other documentation revealed that patient #1 had a second presentation to the ED. The case manager note stated in part, " ...Patient escorted out earlier. Came back ...," and "Per multiple staff, (patient #1) ambulated well in the ER and was discharged via cab to the shelter." Patient #1 received no vitals, and no triage. While the earlier interviewed Quality staff had indicated that a chief complaint would determine if a new MSE was conducted, there was no documentation that hospital staff asked for a chief complaint from patient #1 when she returned by ambulance nor did they document the chief complaint given by the ambulance crew. Patient #1 was not seen by a provider, who according to other documentation, told staff not to re-register patient #1. There was no evidence that a new MSE was conducted. for the second presentation. 3) A survey tour of the Emergency Department walk-in entrance revealed a large ante-area from the street which contained a security booth housing two security guards. Adjacent to the security booth was the locked entrance door to the ED waiting room and registration area. In order to register to be seen in the ED, the doors must be unlocked to allow the patient passage to the registration desk. The locked door could only be opened by security. During an interview with security guard #1 at approximately 1000 on 1/11, the surveyor questioned what the guard would do if someone who presented to the ED as a walk-in, acted unruly. Security guard #1 stated he would "Escort the person from the premises, or call the police if the patient did not leave." An unruly patient could be symptomatic of multiple somatic conditions such as an individual with low blood sugar. Therefore non-clinical personnel could determine which presenting patients could enter the ED for evaluation of an emergency medical condition. Both security guard #1 and security guard #2 were asked if they had training related to the Emergency Treatment and Labor Act (EMTALA). Both guards were unable to say what EMTALA was, and did not remember hearing the term, or having any training in EMTALA. However, a review of their personnel records revealed that they had received EMTALA training. Based on the responses of the security guards, it was apparent that the security guards did not understand EMTALA despite having the requisite training. Additionally, interviews revealed no relevant reason as to why non-clinical staff such as security guards would be placed in a position to determine who could and could not enter the locked door to the ED. 4) Based on review of the hospital's bylaws and other policies, it was determined that the hospital failed to designate those clinicians who Medical Staff allow to conduct an MSE. The Quality staff stated such a document, "Does not exist." Based on this, it could not be determined who the Medical Staff deemed as qualified to conduct a MSE. In summary, and demonstrated in practice,the hospital has an unwritten policy that allows for any clinician to determine if a patient who presents to the ED a second time within two hours will receive a MSE. Further, locked doors to the ED, and non-clinical security staff to whom the hospital gave decision-making rights regarding who could enter the ED, can act as a barrier to patients seeking evaluation of a potential emergency medical condition. Finally, there was no Medical Staff delineation of who could conduct an MSE which failed to meet the requirements of EMTALA. Therefore, the hospital failed to meet regulatory requirements for MSE.

Based on review of 2 open medical records, 28 closed medical records and other pertinent documents, including policies and procedures, and review of video footage from the Emergency Department revealed that patient #1 left the hospital being followed out by security prior to obtaining a medical screening examination as evidenced by: Patient #1 presented to the Emergency Department (ED) on 3/1/2016 for a complaint of an abscess. The patient was triaged at 0143. Security footage revealed that while Patient #1 was in the triage area, hospital security was summoned. Security did not place hands on the patient, but when patient left the room they walked with him out of the ED. Patient #1 had not been seen by a physician. Documentation noted that patient was loud and verbally abusive to staff. Per a nursing note the patient was escorted out by security. There was no documentation indicating why Patient #1 left the ED in his medical record or Against Medical Advice form. Failure to document the patient's justification for leaving the ED or whether security requested the patient to leave makes it difficult to determine if the patient left Against Medical Advice.