St. Vincent’s East

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 41623 Based on review of the hospital’s Medical Staff Rules & Regulations, hospital Policy and Procedure, video recordings, Freestanding Emergency Department (FED) Census Report, FED Central Log, and interviews with staff, it was determined that individuals who comes to the emergency department, the hospital must provide an appropriate an Medical Screening Examination (MSE) within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. This affected nine (9) of 28 patients who presented to the FED for emergent care on 7/12/24 between 12:01 AM and 11:59 PM and had the potential to negatively affect all patients who presented to the hospital requesting emergency care. Findings include: Refer to findings in Tag A- 2406.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 41623 Based on hospital policy, Freestanding Emergency Department (FED) Central Logs, video recordings, and interviews with staff, it was determined the hospital failed to ensure every patient who presented to the FED for emergent care was entered into the FED Central Log. This affected nine (9) of (twenty-eight) 28 patients who presented to the FED for emergent care on 7/12/24 and had the potential to negatively affect all patients who presented to this hospital requesting emergency care. Findings include: Hospital Policy: Emergency Medical Treatment and Active Labor Act (EMTALA) Policy Number: 12492090 Revised: 10/6/22 ...Definitions: ...”Central Log” is a log the Hospital is required to maintain on each individual who comes to a Dedicated Emergency Department seeking care for an emergency medical condition... 1. Review of the FED Central Log dated 7/12/24 revealed a total of 29 patients were registered in the FED Central Log from 12:01 AM to 11:59 PM. Review of the 7/12/24 FED Census Report revealed at 4:00 PM the FED had one patient and 11 beds available, at 5:00 PM the FED had three patients and nine available beds, at 6:00 PM the FED had two patients and 10 available beds, at 7:00 PM the FED had one patient and 11 available beds, and at 8:00 PM the FED had one patient and 11 available beds. A review of the video recordings was conducted on 7/24/24 at 10:00 AM with Employee Identifier (EI) # 14, Security Manager. The following is a summary of the recordings. The review of the video surveillance on 7/12/24 from 12:01 AM to 11:59 PM revealed 9 instances where people were observed arriving at the FED and leaving the hospital’s property after an interaction with the security guard. The following is a summary of the video review. a. On 7/12/24 at 4:02 PM an adult male entered the FED and approached the security officer at the desk, identified by EI # 14 as EI # 11, Armed Security Officer. At 4:03 PM the unidentified adult male exited the FED. b. On 7/12/24 at 5:53 PM, two adult females entered the FED and approached EI # 11 at the security desk. At 5:54 PM the two females exited the FED. c. On 7/12/24 at 6:03 PM an adult female and an adult male entered the FED and approached EI # 11 at the security desk. At 6:04 PM the two individuals exited the FED. d. On 7/12/24 at 6:09 PM an adult female entered the FED and approached EI # 11 at the security desk. At 6:09 PM the adult female exited the FED. e. On 7/12/24 at 6:13 PM two adult females and one adult male entered the FED and approached EI # 11 at the security desk. At 6:13 PM the three individuals exited the FED. f. On 7/12/24 at 6:19 PM one adult female entered the FED and approached EI # 11 at the security desk. At 6:19 PM the female exited the FED. g. On 7/12/24 at 7:00 PM a silver car stopped at the ED entrance. An adult male exited the drivers side and walked around to the passenger and was assisting a female out of the car. At 7:01 PM, EI # 11 walked outside and addressed the driver. At 7:02 PM the silver car drove away and neither driver or passenger entered the FED. h. On 7/12/24 at 7:19 PM a black car stopped at the FED entrance. EI # 11 went outside and addressed the passengers in the car. At 7:19 PM the black car drove away and neither the passenger or driver from the car entered the FED. i. On 7/12/24 at 7:24 PM an adult male and adult female entered the FED and approached EI # 11 at the security desk. At 7:25 PM both adults exited the FED. Review of the video recordings and FED Central Log dated 7/12/24 revealed the hospital failed to ensure nine patients who presented to the FED on 7/12/24 and left between 4:02 PM to 7:24 PM were entered into the FED Central Log. An interview was conducted on 7/24/24 9:30 AM with EI # 1, President, Chief Operating Officer, who stated the FED had a brief period on 7/12/24 when they had a power glitch and the security officer had turned some patients away at the door. An interview was conducted on 7/24/24 at 3:20 PM with EI # 10, Unit Secretary, who stated when the ambulatory patients arrive at the FED, they come through the security area and then come to the registration desk where their information is obtained and entered into the electronic log. An interview was conducted on 7/24/24 at 3:47 PM with EI # 11 who stated when patients walk into the FED they are seen first by the security officer and security asks them if they need to be seen or if they are a visitor. EI # 11 further stated the FED had a power outage on 7/12/24 that affected the wi-fi and some of the critical systems, including Computerized Tomography (CT) and computers which hampered their ability to handle an influx of patients. EI # 11 stated he/she told the “six to twelve” patients that came in that they could be seen but they did not have the capability to do CTs or x-rays and the wait time would be long. An interview was conducted on 7/25/24 at 8:00 AM with EI # 12, Registered Nurse (RN) Charge Nurse, who stated he/she came to work on 7/12/24 at 7:00 PM and was informed by the registration clerk that patients were leaving the security area and not being registered. EI # 12 stated he/she notified EI # 2, Clinical Manager, of the patients not being seen and notified the staff to tell the patients arriving that it would be an extended wait for CTs and x-rays but they were still seeing patients and the doctor was still there. An interview was conducted on 7/25/24 at 2:41 PM with EI # 2, who confirmed a total of nine patients who arrived at the FED on 7/12/24 between 4:02 PM and 7:24 PM were not entered into the FED Central Log. EI # 2 further confirmed the FED had beds available and sufficient staff to treat all the patients who arrived for emergent care.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 41623 Based on review of the hospital’s Medical Staff Rules & Regulations, hospital Policy and Procedure, video recordings, Freestanding Emergency Department (FED) Census Report, FED Central Log, and interviews with staff, it was determined that individuals who comes to the emergency department, the hospital must provide an appropriate an Medical Screening Examination (MSE) within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. This affected nine (9) of 28 patients who presented to the FED for emergent care on 7/12/24 between 12:01 AM and 11:59 PM and had the potential to negatively affect all patients who presented to the hospital requesting emergency care. Findings include: St. Vincent’s East Medical Staff Rules & Regulations Date: July 2023 (St. VIncent’s East An Affiliate of Health System). “...E. Emergency Medical Services: ...1. All individuals presenting to the emergency department ... for treatment or examination, or arriving on hospital grounds requesting emergency care, will receive an appropriate Medical Screening Examiantion.” Hospital Policy: Emergency Medial Treatment and Active Labor Act (EMTALA) Policy Number: 12492090 Revised: 10/6/22 “...Standards for (MSE): 1. Patients who come to a Dedicated Emergency Department requesting examination and treatment will be Triaged and receive a Medical Screening Examination by a QMP (Qualified Medical Personnel).” 1. Review of the FED Central Log dated 7/12/24 revealed a total of 29 patients were registered in the FED Central Log from 12:01 AM to 11:59 PM. Review of the 7/12/24 FED Census Report revealed at 4:00 PM the FED had one patient and 11 beds available, at 5:00 PM the FED had three patients and nine available beds, at 6:00 PM the FED had two patients and 10 available beds, at 7:00 PM the FED had one patient and 11 available beds, and at 8:00 PM the FED had one patient and 11 available beds. A review of the video recordings was conducted on 7/24/24 at 10:00 AM with Employee Identifier (EI) # 14, Security Manager. The review of the video surveillance on 7/12/24 from 12:01 AM to 11:59 PM revealed 9 instances of individuals arriving at the FED and leaving the hospital’s property after an interaction with the security guard. The following is a summary of the video review: a. On 7/12/24 at 4:02 PM an adult male entered the FED and approached the security officer at the desk, identified by EI # 14 as EI # 11, Armed Security Officer. At 4:03 PM the unidentified adult male exited the FED. b. On 7/12/24 at 5:53 PM, two adult females entered the FED and approached EI # 11 at the security desk. At 5:54 PM the two unidentified females exited the FED. c. On 7/12/24 at 6:03 PM an adult female and an adult male entered the FED and approached EI # 11 at the security desk. At 6:04 PM the two unidentified individuals exited the FED. d. On 7/12/24 at 6:09 PM an adult female entered the FED and approached EI # 11 at the security desk. At 6:09 PM the unidentified adult female exited the FED. e. On 7/12/24 at 6:13 PM two adult females and one adult male entered the FED and approached EI # 11 at the security desk. At 6:13 PM the three unidentified individuals exited the FED. f. On 7/12/24 at 6:19 PM one adult female entered the FED and approached EI # 11 at the security desk. At 6:19 PM the unidentified female exited the FED. g. On 7/12/24 at 7:00 PM a silver car stopped at the ED entrance. An adult male exited the drivers side and walked around to the passenger side door and was assisting a female out of the car. At 7:01 PM, EI # 11 walked outside and addressed the driver. At 7:02 PM the silver car drove away and neither the unidentified driver or passenger entered the FED. h. On 7/12/24 at 7:19 PM a black car stopped at the FED entrance. EI # 11 went outside and addressed the unidentified passengers in the car. At 7:19 PM the black car drove away and no one from the car entered the FED. i. On 7/12/24 at 7:24 PM an adult male and adult female entered the FED and approached EI # 11 at the security desk. At 7:25 PM both unidentified adults exited the FED. There was no evidence the facility offered or provided a MSE for the nine unidentified patients who arrived on 7/12/24 between 4:02 PM and 7:24 PM. An interview was conducted on 7/24/24 9:30 AM with EI # 1, President, Chief Operating Officer, who stated the FED had a brief period on 7/12/24 when they had a power glitch and the security officer had turned some patients away at the door. An interview was conducted on 7/24/24 at 3:47 PM with EI # 11 who stated the FED had a power outage on 7/12/24 that affected the wifi and some of the critical systems, including Computerized Tomography (CT) and computers which hampered their ability to handle an influx of patients. EI # 11 stated he/she told the “six to twelve” patients that came in that they could be seen but they did not have the capability to do CTs or x-rays and the wait time would be long. An interview was conducted on 7/25/24 at 8:00 AM with EI # 12, Registered Nurse (RN) Charge Nurse, who stated he/she came to work at 7:00 PM and was informed by the registration clerk that patients were leaving the security area and not being registered. EI # 12 stated he/she notified EI # 2, Clinical Manager, of the patients not being seen and notified the staff to tell the patients arriving that it would be an extended wait for CTs and x-rays but they were still seeing patients and the doctor was still there. An interview was conducted on 7/25/24 at 2:41 PM with EI # 2, who confirmed a total of nine patients who arrived at the FED on 7/12/24 did not receive a MSE. EI # 2 further confirmed the FED had beds available and sufficient staff to treat all the patients who arrived for emergent care. The hospital failed to ensure that their Policy and Procedure, and Medical Staff Bylaws were followed as evidenced by failing to ensure that 9 of 28 patients who presented to the hospital’s emergency department requesting an evaluation received a medical screening examination by a Qualified Medical Personnel.”