Based on interviews, medical record review, facility document review and policy review, the facility failed to ensure a log was maintained of all patients who presented to the emergency department (A2405) and failed to ensure patients who presented to the emergency department seeking a medical screening exam were not discouraged from seeking a medical screening exam. (A2408) The cumulative effect of these systemic practices resulted in the facility's inability to ensure that all patients presenting to the Emergency Department would receive a medical screening exam. The average monthly census of the Emergency Department is 4,350 patients.

Based on review of the facility's emergency department log, policy review and interview, the facility failed to ensure a log of all patients who presented to the emergency department was maintained for one (Patient #9) of 20 medical records reviewed. The average monthly census of the Emergency Department is 4,350 patients. Findings include: The facility's emergency department log was reviewed. The log did not reveal Patient #9 arrived to the emergency department two times on 01/08/17. The log only contained Patient #9's second visit to the emergency department on 01/08/17. On 03/08/17 at 7:42 AM, Staff B was interviewed. Staff B confirmed that Patient #9 was not on the emergency department log during the first visit of two visits to the emergency department on 01/08/17. On 03/08/17 at 7:25 AM, the findings regarding Patient #9 not being listed on the emergency department log during his/her first presentation at the emergency department were shared with Staff D and Staff E and confirmed. The facility's EMTALA policy (LD-39) was reviewed. The policy stated the facility will keep a central log revealing each individual who came to the emergency department seeking care and whether the patient refused treatment, was treated and admitted , was transferred, or was discharged .

Based on interviews, facility document review, medical record review and policy review, the facility failed to ensure patients who presented to the emergency department seeking a medical screening exam were not discouraged from seeking a medical screening exam. This affected one patient (Patient #9) of 20 medical records reviewed. The average monthly census of the Emergency Department is 4,350 patients. Findings include: Staff A was interviewed on 03/08/17 at 7:16 AM with Staff B present. Staff A reported remembering Patient #9's visit at the facility from 01/08/17. Staff A talked to Patient #9's wife about presenting complaints regarding Patient #9's arrest. The wife reported she was driving Patient #9 to the hospital when Patient #9 quit breathing. They had called their insurance company and someone from the insurance had told them to go to Hospital S or Hospital N. Staff A reported the facility's administration had brought it to his attention that Patient #9 had presented to the facility prior to the EMS bringing Patient #9 to the facility. Immediately following Patient #9's death, Staff A was conducting bereavement counseling with Patient #9's wife. During the counseling, the wife informed Staff A about Patient #9's insurance issues. Staff A reported Patient #9 and his wife were at registration here prior to the EMS bringing Patient #9 to the facility. They stopped out front (quick registration desk) and Staff A doesn't know why they left. Staff A did not know about Patient #9's prior visit to the emergency department until after Patient #9 had expired. On 03/08/17 at 7:35 AM, Staff B was interviewed. Staff B reported Staff A became aware of Patient #9's previous visit on 01/08/17 after Patient #9 had expired. Staff A brought Patient #9's previous visit on 01/08/17 to the facility's attention. An investigation was completed at that time by Staff F, Staff B and risk management. Staff B reported Patient #9's wife came to desk, stated he is parking the car and will be in in a minute, and stated she thinks he has pneumonia. Patient #9 came in and gave the registrar his insurance card. The registrar informed him of the insurance not covering an emergency department visit. Patient #9 said he would go somewhere else. The registrar asked him if he wanted the registrar to get him a nurse and he said "no, I'll go somewhere else". The registrar informed him there was an Urgent care H and he insisted he was going. Staff C was interviewed via telephone on 03/08/17 at 8:05 AM. Staff C recalled Patient #9's visit from 01/08/17. Staff C reported Patient #9's wife came to the emergency department and stated Patient #9 needed to be seen. Staff C typed in Patient #9's name in the computer system and went to quick register Patient #9. Staff C hit the wrong number then decided to go through a full registration. Staff C reported it was a slow period and no one else was around so he/she decided to go through a full registration for Patient #9. Patient #9's wife stated he was presenting with pneumonia. The wife didn't have Patient #9's identification card or insurance card when the wife came in and reported Patient #9 would give it to the registrar. When he came in, he went and sat on the double bench next to the registration desk. The wife walked over to him and stated she needed his identification card and insurance card. The wife handed them to Staff C. "At that time, I thought insurance C was not covered at all" (for emergency department visits). "I found out after, that it (insurance C) covered emergency department visits". "I (Staff C) told them (Patient #9 and his wife) their emergency department visit would not be covered". Staff C instructed Patient #9 and his wife on financial aid. "I (Staff C) saw he (Patient #9) was short of breath". Staff C told him that he should let Staff C get a nurse for him as he was visibly short of breath. Patient #9 said he "wasn't going to stay if insurance doesn't cover it. I can't afford this". Staff C tried to convince him to stay. Patient #9's wife asked if there was an urgent care near. Staff C told them Urgent Care H was nearby. Patient #9's wife said she would take him to Hospital N. Patient #9's wife said he didn't want to stay (at the facility's emergency department) if his insurance didn't cover it. They left the facility. At about 3:10 PM, Patient #9 came back to the facility. Patient #9's wife came through the same door and said I'm pretty sure he is dead. The wife reported an ambulance was bringing Patient #9 to the facility. "I (Staff C) found out later that we were covered for emergency department visits (through insurance C). Patient #9 "never said he was short of breath or having chest pain". Patient #9 was "taking short, shallow, frequent" respirations. "I did not call the nurse to come see him". Staff C was reaching for the phone to call the nurse and he "kept saying no, no, no I'm going to go somewhere else". There was a meeting after this incident and facility staff told me (Staff C) we have to call the nurse if a situation like this occurs. Patient #9 was trying to leave, "he was bound". The facility's EMTALA policy (LD-39) was reviewed. The policy stated the facility will examine and provide stabilizing treatment or facilitate an appropriate transfer for individuals seeking emergency care in accordance with this Policy and Procedure, regardless of the person's ability to pay, race, color, national origin, or otherwise. The hospital will keep a central log revealing each individual who came to the emergency department seeking care and whether the patient refused treatment, was treated and admitted , was transferred, or was discharged . The facility's quick registration desk was observed with a posting of conditions to immediately notify the triage nurse for. The posting stated to notify the triage nurse immediately for any patients presenting with difficulty breathing for any reason. Staff C stated in interview on 03/08/17 at 8:05 AM she did not contact the nurse to see Patient #9. An EMS (emergency medical services) Run Sheet for Patient #9 from 01/08/17 was reviewed. The run sheet stated the EMS received a call at 2:57 PM and arrived at Patient #9's location at 3:05 PM . The run sheet stated Patient #9 was seated in the front passenger seat of a vehicle. Patient #9 was pulseless and apneic. Cardiopulmonary resuscitation (CPR) was started. Patient #9's family stated Patient #9 was enroute to Hospital N's Emergency Department for treatment of possible pneumonia. The fire department on scene stated they found Patient #9 in cardiac arrest. The fire department stated they initiated cardiopulmonary resuscitation with chest compressions and bag valve mask ventilations and applied an automated external defibrillator to Patient #9 with shock advised. The fire department stated one shock was delivered without incident and stated CPR continued without delay. The EMS arrived at the facility with Patient #9 at 3:21 PM. The facility's investigation report involving Patient #9's emergency department visit on 01/08/17 was reviewed. The report stated: On 01/09/17 received call from Staff B, Director Emergency Department, and Risk Manager concerning possible EMTALA violation. Patient #9 arrived at the facility on 01/08/17 and upon hearing that the facility was not a provider listed on his/her insurance, Patient #9 refused to be treated. Patient #9 left the emergency department and returned approximately 30 minutes later and expired. On 01/11/17 the Chief Risk Officer (CRO) and Risk Director, spoke with the registrar. The registrar said that she told Patient #9 that his insurance would not cover the visit and Patient #9 said he was leaving. The registrar asked him to stay and see a nurse. Patient #9 refused. The registrar said she asked Patient #9 to see the nurse twice. Patient #9 left. An Ambulance brought Patient #9 back and he expired. On 01/18/17 a root cause analysis (RCA) was done to review case. RCA: All insurances cover emergency department visits. Patient #9 was asked to see a nurse a couple times and refused. Patient #9's treatment was not delayed. Patient #9 was not refused treatment, Patient #9 refused to be treated.