Based on a review of facility policies and procedures, medical records (MR), and staff interviews (EMP), it was determined the facility failed to enforce a policy to ensure compliance with the requirements of 489.24 for three of four medical records reviewed (MR1, MR14 and MR15). Findings include: Review of facility policy and procedure "Emergency Medical Screening, Treatment & Transfer Policy (EMTALA)" last revised July 26, 2018, revealed "II. No Delay In Screening Or Examination ... A. There shall be no delay in providing a medical screening examination or follow-up treatment for an emergency medical condition in order to inquire about the patient's method of payment or insurance status. ... C. Patients who inquire about financial responsibility for emergency care will be encouraged to delay such discussions until after the completion of the medical screening examination and the initiation of stabilizing treatment, if necessary. These patients will also be told that the health System will provide a medical screening examination and stabilizing treatment, regardless of their ability to pay. Health System personnel may not respond to questions form patients about whether or not their insurance plan will pay for hospital services. Patients are to be directed to call their insurance provider for assistance." Review of facility policy and procedure "Discharge Against Medical Advice (AMA)" last revised April 25, 2018, revealed "It is the goal of Washington Health System Green to provide an atmosphere and therapeutic approach which dissuade patients from leaving treatment against medical advice (AMA). It is acknowledged, however, that situations will occur when a patient makes the decision to leave AMA. When this intent is made known to the staff, attempts should be made to discuss the situation with the patient. The patient's reasons for desiring to leave should be explored and alternatives suggested for the patient to deal with the stress or crisis that he/she perceives as the reason for leaving. it it becomes apparent that the patient is unable to be dissuaded from leaving, the following procedure applies: 1. Contact family/significant other, if not present." Review of facility documentation revealed MR1 presented to the Emergency Department (ED) on January 9, 2019. Further review revealed EMP1 informed the patient that the patient did not have current insurance. Continued review of MR1 revealed that the patient left the facility after learning about not having insurance and before receiving a medical screening exam. Interview with EMP1 on January 16, 2019, at 11:20 AM confirmed the above findings and revealed "I looked it up [insurance information] and [MR1] had two types of insurance, one was inactive and the other was in patient Medicare only. He said something like 'if the insurance isn't going to pay for it, I will just go buy some' ... ." Interview with EMP5 on January 17, 2019, at 12:45 PM confirmed the above findings and revealed, "I heard [MR1] say something like 'I can't afford that if my insurance isn't paying, I'm leaving'." Review of MR14 on January 17, 2019, revealed the patient presented on July 4, 2018, at 09:32 PM with complaints of left foot pain and chest pain. Further review of MR14 revealed the patient signed a form and left the emergency room against medical advice. Continued review revealed no documentation the family or significant other were contacted, as per above policy. Review of MR15 on January 17, 2019, revealed the patient came into the emergency department on July 9, 2019, at 11:26 AM with complaints of abdominal pain. Further review of MR15 revealed the patient signed a form and left the emergency room against medical advice. Continued review revealed no documentation the family or significant other were contacted, as per above policy. Interview with EMP2 on January 17, 2019, at 2:00 PM confirmed the above findings.

Based on a review of facility policy and staff interview (EMP), it was determined that the facility's Bylaws or Rules and Regulations failed to determine which individual(s) may conduct a medical screening examination. Findings include: Review of facility policy, Emergency Medical Screening, Treatment & Transfer Policy (EMTALA), last Revised July 26, 2018, revealed, "... 1. PRESENTING FOR CARE AND MEDICAL SCREENING EXAMINATION ... I. A list of the categories of qualified medical personnel who have been approved by the Board to perform medical screening examinations is attached as Appendix B. ... APPENDIX B CATEGORIES OF QUALIFIED MEDICAL PERSONNEL TO PERFORM MEDICAL SCREENING EXAMINATIONS 1. Physicians (MD or DO) 2. Certified Registered Nurse Practitioner (CRNP) 3. Physician's Assistant (PA). ..." A review of facility documents on January 16, 2019 revealed no documentation in the facility's Medical Staff Bylaws and Rules and Regulations dated December 21, 2015, of individuals determined to be Qualified Medical Personnel to perform Medical Screening Examinations. Interview with EMP13, on January 16, 2019, at approximately 12:00 pm, confirmed the above findings.

Based on a review of facility documentation and medical record (MR), and staff interview (EMP), it was determined the facility failed to ensure screening or stabilization services were furnished by a hospital, physician, or nonphysician practitioner to an individual before reviewing the individual's insurance information for one of one medical record reviewed (MR1). Findings include: Review of facility policy and procedure "Emergency Medical Screening, Treatment & Transfer Policy (EMTALA)" last revised July 26, 2018, revealed "II. No Delay in Screening Or Examination ... A. There shall be no delay in providing a medical screening examination or follow-up treatment for an emergency medical condition in order to inquire about the patient's method of payment or insurance status. ... C. Patients who inquire about financial responsibility for emergency care will be encouraged to delay such discussions until after the completion of the medical screening examination and the initiation of stabilizing treatment, if necessary. These patients will also be told that the health System will provide a medical screening examination and stabilizing treatment, regardless of their ability to pay. Health System personnel may not respond to questions form patients about whether or not their insurance plan will pay for hospital services. Patients are to be directed to call their insurance provider for assistance." Review of facility documentation revealed MR1 presented to the Emergency Department (ED) on January 9, 2019. Further review revealed EMP1 informed the patient that the patient did not have current insurance. Continued review of MR1 revealed that the patient left the facility after learning about not having insurance and before receiving a medical screening exam. Interview with EMP1 on January 16, 2019, at 11:20 AM confirmed the above findings and revealed "I looked it up [insurance information] and [MR1] had two types of insurance, one was inactive and the other was in patient Medicare only. He said something like 'if the insurance isn't going to pay for it, I will just go buy some' ... ." Interview with EMP5 on January 17, 2019, at 12:45 PM confirmed the above findings.

Based on a review of facility policy and documents, and staff interviews (EMP), it was determined the facility failed to provide an appropriate medical screening examination within the capability of the hospital's Emergency Department. Findings include: Review of Southwest Regional Medical Center ' s Rules and Regulations. ... " 6.1(a) Screening: (1) Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition." Review of the facility's policy "EMTALA - Definitions and General Requirements" dated April 1, 2011, revealed "The Facility with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development who ' comes to the emergency department ' an appropriate Medical Screening Examination (MSE) within the capability of the facility's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) exists regardless of the individual's ability to pay." A review of a facility document dated February 5, 2015, indicated a patient presented to ED and triaged with a complaint of eye pain. Patient verbalized being seen at a nearby hospital ED and was told to follow up with the eye clinic. Patient did not follow up with the eye clinic due to cost. As a result, patient presented to ED and requested to be seen. Nursing staff discussed patient ' s situation with the ED physician. Nursing staff " did not want to bring any more burden on the patient, financially " therefore called a local eye doctor and scheduled an appointment for the patient. Patient then signed LWOT (left without treatment) paperwork and went to the eye clinic. The document also indicated that the ED physician believed it would have been unethical to complete a medical screening examination in an attempt to collect an emergency department fee when the patient had no insurance and did not have the money to pay, which patient made facility aware. During an interview on February 13, 2015, at approximately 8:45 AM, EMP11 confirmed the above findings. When asked if there was a medical record for the patient, EMP11 stated, " No there is not, he never came into the back." During an interview on February 13, 2015, at approximately 9:15 AM, EMP2 stated, " There is not a medical record, there was a quick reg. (registration) and the nursing documentation that they left before treatment." Review of a " Complaint Statement and Statement Summary " dated February 2, 2015, indicated that a female and child presented to the ED registration window. The female requested that the child be seen for a cough. It was explained that the female was not the child ' s parent, but the appointed caregiver assigned by Children and Youth Services (CYS). The female had no records or information regarding the child. The ED staff called Children and Youth Services who suggested that the female and child be seen at another local hospital ED for treatment as that hospital had the child ' s records. The female and child left the ED without being seen. During an interview on February 12, 2015, at approximately 9:15 AM, EMP1 stated, " A foster mother came in with a child to be checked. ... CYS was called and stated the child was from [another county] and to take the child to [nearby hospital]. The nurse relayed the message and the foster mother left with the child to take the child to [nearby hospital]. They were never seen by a physician." During an interview on February 13, 2015, at approximately 9:00 AM, EMP2 stated, "There is no medical record for that incident. They were never seen."