Honor Health John C. Lincoln Medical Center

“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: 52392 Based on review of hospital policies and procedures, hospital documents, medical records, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, the responsibilities of Medicare participating hospitals in emergency cases. Findings Include: Patient #1 presented to the Emergency Department (ED) on 09/14/2025 at 1402 complaining of 4 (four) days of Nausea and Vomiting, feeling weak. The allegations are that the hospital did not provide a proper medical screening examination or provide stabilizing treatment before discharging home. Review of Patient #1 medical Record revealed Patient #1 received a medical screening examination and was provided stabilizing treatment prior to discharge. Review of twenty (20) additional medical records randomly selected from the hospital ED log revealed the following: Hospital Policy titled, “Emergency Medical Treatment and Labor Act (EMTALA) Policy”, revealed: “ ...All persons who present to an HonorHealth hospital campus with what they believe to be a medical emergency, or which a layperson would reasonably believe they are experiencing a medical emergency, must receive a medical screening examination ...If the medical screening examination demonstrates that the person has an emergency medical condition, HonorHealth will provide stabilizing treatment ... A person is stabilized when the person has received such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the emergency medical condition is likely to result from or occur during the transfer of the individual from a facility ... The qualified medical personnel who provided the stabilizing treatment will document in the medical record the stabilizing treatment provided and that the person’s emergency medical condition has been stabilized. Once the person is stabilized, HonorHealth may provide additional or continuing care, discharge the person, or transfer him or her to another facility as appropriate for additional or continuing care ....” Hospital Policy titled, “Network Emergency Department Operating Policy,” revealed: “ ...III. Goals: The Emergency Department will: a. Deliver quality care to each individual presenting to the Emergency Department requesting treatment or in need of treatment. b. Provide triage, assessment, and treatment ...V. Unit/Department/Service Operations: a. Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity...Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, planning, implementing and evaluating all nursing care performed for that patient...Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity. The method of patient care delivery is consistent with unit and nursing structure standards and Patient Centered Care. Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, reassessing, planning, implementing and evaluating all nursing care performed for that patient ... Stable patients are discharged by emergency department nurses in accordance with physician recommendation and follow up based on diagnosis ....” Hospital Policy titled, “HonorHealth Emergency Department Adult and Pediatric Reassessment Guidelines,” revealed: “ ... Reassessment frequency, including vital signs, should be determined by the patient ’ s initial presentation and status. Once medically cleared, patients should be reassessed at a minimum of every eight hours ... Reassessment, including vital signs, to be done within 30minutes of discharge ...In the event that a patient ’ s status changes during the course of their stay in the department, reassessment guidelines should change to reflect the patients ’ current condition or admission status ....” Hospital Policy titled, “Against Medical Advice (AMA): Informed Refusal/Withdrawal of Treatment or Leaving the Hospital”, revealed: “ ...The purpose of this policy is to: Respect and honor the right of a competent adult ...to make informed decisions that are Against Medical Advice (AMA) and to assist providers and staff by instituting a structured AMA process consistent with best possible care and Arizona Law ...Patients with mental capacity to consent to or refuse care (or LAR when appropriate) who express an intent to leave without treatment or leave AMA prior to a planned release will be provided with the information necessary to facilitate an understanding of the risks, complications, and consequences of the decision and the potential benefits of agreeing to continued care. Patients with a mental disorder may require a No AMA order if a danger to self or others or if in immediate danger of serious physical harm or illness ...Against Medical Advice (AMA): refers to patients who request to be discharged from the facility before completion of treatment or contrary to the advice of the attending physician/provider ...Capacity: A medical determination about the patient ’ s medical decision-making capability. Capacity is decision specific. A determination concerning capacity must focus only on that decision ...A patient has medical decision-making capacity if he/she is perceived to have all three of the following: Ability to comprehend or understand the information about the medical problem ...Appreciate the impact of the disease/medical issue. Consequences of various options for treatment, including forgoing options...Ability to evaluate the options. Compare risks and benefits of each option ...Deliberate in accord with the patient ’ s own values ...Ability to communicate and demonstrate understanding of his or her choice in any manner ...Elopement/Missing Patient: Elopement refers to the patient ’ s departure from the facility without notifying staff or being discharged which may place the patient at risk of injury or death ...AGAINST MEDICAL ADVICE (AMA) ...Complete the following steps if a patient or unemancipated minor’s LAR expresses the desire to be discharged Against Medical Advice (AMA) or Refuses Treatment/Transfer ...1. Initiate appropriate verbal interventions to dissuade the patient from leaving AMA and explain the need to notify the attending Physician/Provider Designee before the patient leaves ...Immediately notify the patient ’ s attending Physician/Provider or his/her Provider Designee ...Notify the Supervisor/Director/Admin. Rep ...2. Decision-Making Capacity: ...Attending Physician /Provider Designee to assess the patient ’ s decision-making capacity and document in the medical record ...Nurse to assess the patient ’ s mental status and level of consciousness assessment and document it in the medical record ...Attending Physician/Provider Designee and Nursing will document the discussion with the patient regarding the severity of the patient ’ s illness, the potential consequences/risks of leaving AMA, and potential benefits of treatment ...If patient is perceived to lack decision-making capacity, may have a mental disorder, and an LAR cannot be located, go to NO AMA PATIENTS procedures ...3. Explain the risk(s) of leaving before treatment is completed, refusal of treatment/transfer, and attempt to convince the patient to stay for completion of treatment by explaining the potential benefits of care ...4. If it appears that the attending Physician/Provider Designee may not have an opportunity to assess the patient before the patient leaves AMA, nursing will attempt to have patient assessed by an available Physician/Provider and inform the patient that they are welcome back to the facility for evaluation and treatment in the Emergency Department if the patient changes their mind ...5. Request assistance from Case Management regarding arrangements for any follow-up care needed or referrals for the patient and document specifics and urgency of needed care and efforts made to schedule ...6. Request the patient sign the AMA form (attached) prior to leaving. If the patient or LAR refuses to sign the AMA form, the attending Physician/Provider Designee or nurse will attempt to read the form to the patient/LAR and document the refusal on the AMA form indicating date and time. In addition, a note that “patient refuses to sign” will be entered on the signature line. Obtain witness signatures from all people present at the time the release was offered and refused. Ensure the form is scanned into the medical record ...8. Provide the patient with discharge instructions. Document in the medical record that instructions, both verbal and written, were provided, prescriptions if applicable, and suggestions for follow-up or further care by physicians and/or appropriate agencies ...9. Patients who leave AMA or refuse treatment will be provided a safe discharge ...10. Documentation in the medical record to include: The patient ’ s reason(s) for wanting to go AMA ...Any circumstances surrounding the incident, including the patient ’ s perceived emotional state ...Patient behavior and any pertinent conversations ...Physician notification...Information discussed with the patient regarding risks, benefits, attempts to resolve care concerns, etc. ...Include patient ’ s perceived understanding of information discussed ...11. Complete event report for all patients leaving AMA ...ELOPEMENT ...Notify attending Physician/Provider Designee ...Notify Admin. Rep ...Notify Security ...Conduct an on-site search of areas ...Attempt to contact the patient on cell phone ...should document the date and time patient identified as missing, last time seen, actions taken to locate, and all information surrounding the event ...Complete event report ....” Review of 20 ED patient medical records randomly selected from the ED logs for months August, September and October of 2025, revealed 5 out of 20 patients (Patient #4, Patient #12, Patient # 16, Patient # 17 and Patient #20) left without being seen (LWBS) or left Against Medical Advice (AMA) and no event report was completed. Further review of the 20 records revealed 2 patients (Patient #4 and #16) did not have completed AMA forms in the EMR. Review of Patient # 4 ’ s Electronic Medical record (EMR) revealed: “ ...RN attempted to start an IV on the patient ....Upon threading the IV the patient became verbally aggressive, cussing and yelling it hurts to take it out ...patient refused ...Upon removing it the patient demanded to speak to the doctor ...didn ’ t want blood work or anything ...MD explained to the patient that s/he would need to leave AMA if s/he was refusing the testing ordered ...Pt verbalized understanding and signed the AMA paperwork ....” Patient #4 left AMA before MSE was completed. Review of Patient #12 ’ s Electronic Medical record (EMR) revealed: “ ...Patient had left [his/her] ED room and was now in the triage area speaking with security ...patient was seen exiting the hospital ...MD notified patient eloped ....” Patient # 12 did not complete her MSE and a request for patient #12 ’ s discharge instructions or an AMA form were not provided to the surveyor and no records of an Event report were filed or provided. Review of Patient #16 ’ s Electronic Medical record (EMR) revealed: “ ...who presents with headache, wrist pain and penile pain ... no obvious traumatic findings noted ...ordered CT head, right wrist x-ray, urine, drug screen, gonorrhea and chlamydia ...s/he was given Valium and Tylenol...Patient eloped from ER ....” Further review of Patient #16 EMR revealed: “ ...Security still waiting outside pt room at this time ...Pt became aggressive and violent with x-ray staff. Security entered and pt continued to escalate, swinging fists, using profanity, making threats towards staff ...Pt warned by security to stop these behaviors ...Behaviors continued and security escorted pt out of the building. Pt refused vital signs prior to discharge ...No IV in place ...Dr. Notified ....” A hospital document titled “Midas report,” revealed: “ ...10/14/2025 ...RN was inside pt ’ s [#16] room having just finished medicating pt. Security was already outside room after returning from CT. XR tech entered pt ’ s room and began to provide instructions when patient became verbally aggressive and violent towards staff. Pt made threats towards staff, used profanity, and swung fist multiple times at equipment in the room. Security entered pts room from the hallway, attempted to set boundaries with pt who was not receptive. Security verified with RN pt was not being medically held or on a psych hold. RN verified and security escorted patient out ....” Request for patient #16 ’ s discharge instructions or an AMA form were not provided to the surveyor and no records of an Event report were filed or provided. Review of Patient #17 ’ s Electronic Medical record (EMR) revealed: “ ...Pt brought back to split flow, assessment and triage complete ...Pt insists on my girl and kids to be back with him/her repeatedly. Pt informed this is not allowed in this area ...Pt chose to leave without being seen ... ED Disposition set to LWBS After Triage ...This note is being completed for administrative purposes only. Patient left emergency department before I was able to evaluate patient. Nursing staff tried to get patient to stay for evaluation ....” Request for patient #17 ’ s discharge instructions or an AMA form were not provided to the surveyor and no records of an Event report were filed or provided. Review of Patient # 20 ’ s Electronic Medical record (EMR) revealed: “ ...RN in triage stated s/he saw patient to walk out the front door ...ED Disposition set to LWBS After Triage ....” Requested patient #20 ’ s records of an Event report and none were filed or provided to the surveyor. Employee #8 and Employee # 9 confirmed Patient #1 was given a medical screening exam by Provider and stabilized with appropriate treatments before discharge home. Employee #9 confirmed patient signed discharge instructions and a summary was provided to patient #1. Employee # 8 confirmed the facility failed to follow Against Medical Advice (AMA): Informed Refusal/Withdrawal of Treatment or Leaving the Hospital policy and procedures.”

“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: 52392 Based on review of policies and procedures, hospital documents, medical records, and staff interviews, it was determined that the hospital failed to ensure four (4) patients who presented to the Emergency Department were provided a medical screening examination. (Patient #12,#16, #17, #20). Findings include: Hospital Policy titled, “Emergency Medical Treatment and Labor Act (EMTALA) Policy”, revealed: “ ...All persons who present to an HonorHealth hospital campus with what they believe to be a medical emergency, or which a layperson would reasonably believe they are experiencing a medical emergency, must receive a medical screening examination ...If the medical screening examination demonstrates that the person has an emergency medical condition, HonorHealth will provide stabilizing treatment ... A person is stabilized when the person has received such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the emergency medical condition is likely to result from or occur during the transfer of the individual from a facility ... The qualified medical personnel who provided the stabilizing treatment will document in the medical record the stabilizing treatment provided and that the person’s emergency medical condition has been stabilized. Once the person is stabilized, HonorHealth may provide additional or continuing care, discharge the person, or transfer him or her to another facility as appropriate for additional or continuing care ....” Hospital Policy titled, “Network Emergency Department Operating Policy,” revealed: “ ...III. Goals: The Emergency Department will: a. Deliver quality care to each individual presenting to the Emergency Department requesting treatment or in need of treatment. b. Provide triage, assessment, and treatment ...V. Unit/Department/Service Operations: a. Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity...Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, planning, implementing and evaluating all nursing care performed for that patient...Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity. The method of patient care delivery is consistent with unit and nursing structure standards and Patient Centered Care. Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, reassessing, planning, implementing and evaluating all nursing care performed for that patient ...Stable patients are discharged by emergency department nurses in accordance with physician recommendation and follow up based on diagnosis ....” Patient #1 presented to the Emergency Department (ED) on 09/14/2025 at 1402 complaining of 4 (four) days of Nausea and Vomiting, feeling weak. The allegations are that the hospital did not provide a proper medical screening examination or provide stabilizing treatment before discharging home. Review of Patient #1 Electronic Medical Record revealed Patient #1 received a medical screening examination and was provided stabilizing treatment prior to being discharged from the facility. Review of 20 ED patient medical records randomly selected from the ED logs for months August, September and October of 2025, revealed four (4) out of twenty (20) patients (Patient #12, Patient # 16, Patient # 17 and Patient #20) left before a medical screening could be completed. Review of Patient #12 ’ s Electronic Medical record (EMR) revealed: “ ...Patient had left [his/her] ED room and was now in the triage area speaking with security ...patient was seen exiting the hospital ...MD notified patient eloped ....” Patient # 12 did not complete her MSE and a request for patient #12 ’ s discharge instructions or an AMA form were not provided to the surveyor and no records of an Event report were filed or provided. Review of Patient #16 ’ s Electronic Medical record (EMR) revealed: “ ...who presents with headache, wrist pain and penile pain ... no obvious traumatic findings noted ...ordered CT head, right wrist x-ray, urine, drug screen, gonorrhea and chlamydia ...s/he was given Valium and Tylenol...Patient eloped from ER ....” Further review of Patient #16 EMR revealed: “ ...Security still waiting outside pt room at this time ...Pt became aggressive and violent with x-ray staff. Security entered and pt continued to escalate, swinging fists, using profanity, making threats towards staff ...Pt warned by security to stop these behaviors ...Behaviors continued and security escorted pt out of the building. Pt refused vital signs prior to discharge ...No IV in place ...Dr. Notified ....” Patient #16 eloped before the MSE was completed. Review of Patient #17 ’ s Electronic Medical record (EMR) revealed: “ ...Pt brought back to split flow, assessment and triage complete ...Pt insists on my girl and kids to be back with him/her repeatedly. Pt informed this is not allowed in this area ...Pt chose to leave without being seen ... ED Disposition set to LWBS After Triage ...This note is being completed for administrative purposes only. Patient left emergency department before I was able to evaluate patient. Nursing staff tried to get patient to stay for evaluation ....” Request for patient #17 ’ s discharge instructions or an AMA form were not provided to the surveyor and no records of an Event report were filed or provided. Review of Patient # 20 ’ s Electronic Medical record (EMR) revealed: “ ...RN in triage stated s/he saw patient to walk out the front door ...ED Disposition set to LWBS After Triage ....” Requested patient #20 ’ s records of an Event report and none were filed or provided to the surveyor. Employee # 8 and Employee #9 confirmed that patients # 12, #16, and #17, and #20 did not have screening exams completed.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 52392 Based on review of hospital records, and interviews, it was determined that the Hospital failed to provide treatment for five (5) patient that presented to the Emergency Department for treatment for an emergency medical condition (Patient #4, #12, #16, #17, #20). Findings Include: Hospital Policy titled, “Emergency Medical Treatment and Labor Act (EMTALA) Policy”, revealed: “ ...All persons who present to an HonorHealth hospital campus with what they believe to be a medical emergency, or which a layperson would reasonably believe they are experiencing a medical emergency, must receive a medical screening examination ...If the medical screening examination demonstrates that the person has an emergency medical condition, HonorHealth will provide stabilizing treatment ... A person is stabilized when the person has received such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the emergency medical condition is likely to result from or occur during the transfer of the individual from a facility ... The qualified medical personnel who provided the stabilizing treatment will document in the medical record the stabilizing treatment provided and that the person’s emergency medical condition has been stabilized. Once the person is stabilized, HonorHealth may provide additional or continuing care, discharge the person, or transfer him or her to another facility as appropriate for additional or continuing care ....” Hospital Policy titled, “Network Emergency Department Operating Policy,” revealed: “ ...III. Goals: The Emergency Department will: a. Deliver quality care to each individual presenting to the Emergency Department requesting treatment or in need of treatment. b. Provide triage, assessment, and treatment ...V. Unit/Department/Service Operations: a. Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity...Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, planning, implementing and evaluating all nursing care performed for that patient...Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity. The method of patient care delivery is consistent with unit and nursing structure standards and Patient Centered Care. Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, reassessing, planning, implementing and evaluating all nursing care performed for that patient ... Stable patients are discharged by emergency department nurses in accordance with physician recommendation and follow up based on diagnosis ....” Patient #1 presented to the Emergency Department (ED) on 09/14/2025 at 1402 complaining of 4 (four) days of Nausea and Vomiting, feeling weak. Review of Patient #1 medical Record revealed Patient #1 received stabilizing treatment. These treatments included: COVID-19/FLU/RSV PCR, Blood Culture, CT Abdomen Pelvis W Contrast, CBC/PLT with Differential, Comprehensive Metabolic Panel, Lipase, D-Dimer, Quantitative, Troponin I High Sensitivity, B-Type Natriuretic Peptide, Urine, Culture Urine, Manual Differential, Lactic Acid, Magnesium, Beta Hydroxybutyrate, ECG 12 lead, Monitoring vitals signs, Peripheral IV, Normal Saline 2 liters, Lorazepam 2mg/ml IVP, and Ceftriaxone 1 gram IV. Patient #1 was prescribed three (3) prescriptions, Ondansetron 4mg ODT, Cefdinir 300 mg, and Potassium Chloride 10 mEq at discharge. Review of 20 ED patient medical records randomly selected from the ED logs for months August, September and October of 2025, revealed 5 out of 20 patients (Patient #4, Patient #12, Patient # 16, Patient # 17 and Patient #20) left before stabilizing treatment could be started or completed. Review of Patient # 4 ’ s Electronic Medical record (EMR) revealed: “ ...RN attempted to start an IV on the patient ....Upon threading the IV the patient became verbally aggressive, cussing and yelling it hurts to take it out ...patient refused ...Upon removing it the patient demanded to speak to the doctor ...didn ’ t want blood work or anything ...MD explained to the patient that s/he would need to leave AMA if s/he was refusing the testing ordered ...Pt verbalized understanding and signed the AMA paperwork ....” No stabilizing treatment was started or completed as patient #4 left AMA. Review of Patient #12 ’ s Electronic Medical record (EMR) revealed: “ ...Patient had left [his/her] ED room and was now in the triage area speaking with security ...patient was seen exiting the hospital ...MD notified patient eloped ....” Patient #12 had no stabilizing treatment started or completed at the facility. Review of Patient #16 ’ s Electronic Medical record (EMR) revealed: “ ...who presents with headache, wrist pain and penile pain ... no obvious traumatic findings noted ...ordered CT head, right wrist x-ray, urine, drug screen, gonorrhea and chlamydia ...s/he was given Valium and Tylenol...Patient eloped from ER ....” Patient #16 had multiple tests ordered, however, patient #16 was escorted off the facility property before tests were resulted and completed. Review of Patient #17 ’ s Electronic Medical record (EMR) revealed: “ ...Pt brought back to split flow, assessment and triage complete ...Pt insists on my girl and kids to be back with him/her repeatedly. Pt informed this is not allowed in this area ...Pt chose to leave without being seen ... ED Disposition set to LWBS After Triage ...This note is being completed for administrative purposes only. Patient left emergency department before I was able to evaluate patient. Nursing staff tried to get patient to stay for evaluation ....” Patient #17 had no stabilizing treatment started or completed at the facility. Review of Patient # 20 ’ s Electronic Medical record (EMR) revealed: “ ...RN in triage stated s/he saw patient to walk out the front door ...ED Disposition set to LWBS After Triage ....” Patient #20 had no stabilizing treatment started or completed at the facility. Employee #8 and Employee #9 confirmed Patient #4, Patient # 12, Patient #16, Patient #17, and Patient #20 did not have treatment started or completed at the facility.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 52392 Based on review of hospital policies and procedures, hospital documents, medical records, and staff interviews, it was determined the hospital failed to ensure four (4) patients were discharged per policy from the Emergency Department after seeking treatment for an emergency medical condition (Patient #12, #16, #17, #20). Findings include: Hospital Policy titled, “Emergency Medical Treatment and Labor Act (EMTALA) Policy”, revealed: “ ...All persons who present to an HonorHealth hospital campus with what they believe to be a medical emergency, or which a layperson would reasonably believe they are experiencing a medical emergency, must receive a medical screening examination ...If the medical screening examination demonstrates that the person has an emergency medical condition, HonorHealth will provide stabilizing treatment ... A person is stabilized when the person has received such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the emergency medical condition is likely to result from or occur during the transfer of the individual from a facility ... The qualified medical personnel who provided the stabilizing treatment will document in the medical record the stabilizing treatment provided and that the person’s emergency medical condition has been stabilized. Once the person is stabilized, HonorHealth may provide additional or continuing care, discharge the person, or transfer him or her to another facility as appropriate for additional or continuing care ....” Hospital Policy titled, “Network Emergency Department Operating Policy,” revealed: “ ...III. Goals: The Emergency Department will: a. Deliver quality care to each individual presenting to the Emergency Department requesting treatment or in need of treatment. b. Provide triage, assessment, and treatment ...V. Unit/Department/Service Operations: a. Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity...Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, planning, implementing and evaluating all nursing care performed for that patient...Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity. The method of patient care delivery is consistent with unit and nursing structure standards and Patient Centered Care. Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, reassessing, planning, implementing and evaluating all nursing care performed for that patient ... Stable patients are discharged by emergency department nurses in accordance with physician recommendation and follow up based on diagnosis ....” Hospital Policy titled, “Against Medical Advice (AMA): Informed Refusal/Withdrawal of Treatment or Leaving the Hospital”, revealed: “ ...The purpose of this policy is to: Respect and honor the right of a competent adult ...to make informed decisions that are Against Medical Advice (AMA) and to assist providers and staff by instituting a structured AMA process consistent with best possible care and Arizona Law ...Patients with mental capacity to consent to or refuse care (or LAR when appropriate) who express an intent to leave without treatment or leave AMA prior to a planned release will be provided with the information necessary to facilitate an understanding of the risks, complications, and consequences of the decision and the potential benefits of agreeing to continued care. Patients with a mental disorder may require a No AMA order if a danger to self or others or if in immediate danger of serious physical harm or illness ...Against Medical Advice (AMA): refers to patients who request to be discharged from the facility before completion of treatment or contrary to the advice of the attending physician/provider ...Capacity: A medical determination about the patient ’ s medical decision-making capability. Capacity is decision specific. A determination concerning capacity must focus only on that decision ...A patient has medical decision-making capacity if he/she is perceived to have all three of the following: Ability to comprehend or understand the information about the medical problem ...Appreciate the impact of the disease/medical issue. Consequences of various options for treatment, including forgoing options...Ability to evaluate the options. Compare risks and benefits of each option ...Deliberate in accord with the patient ’ s own values ...Ability to communicate and demonstrate understanding of his or her choice in any manner ...Elopement/Missing Patient: Elopement refers to the patient ’ s departure from the facility without notifying staff or being discharged which may place the patient at risk of injury or death ...AGAINST MEDICAL ADVICE (AMA) ...Complete the following steps if a patient or unemancipated minor’s LAR expresses the desire to be discharged Against Medical Advice (AMA) or Refuses Treatment/Transfer ...1. Initiate appropriate verbal interventions to dissuade the patient from leaving AMA and explain the need to notify the attending Physician/Provider Designee before the patient leaves ...Immediately notify the patient ’ s attending Physician/Provider or his/her Provider Designee ...Notify the Supervisor/Director/Admin. Rep ...2. Decision-Making Capacity: ...Attending Physician /Provider Designee to assess the patient ’ s decision-making capacity and document in the medical record ...Nurse to assess the patient ’ s mental status and level of consciousness assessment and document it in the medical record ...Attending Physician/Provider Designee and Nursing will document the discussion with the patient regarding the severity of the patient ’ s illness, the potential consequences/risks of leaving AMA, and potential benefits of treatment ...If patient is perceived to lack decision-making capacity, may have a mental disorder, and an LAR cannot be located, go to NO AMA PATIENTS procedures ...3. Explain the risk(s) of leaving before treatment is completed, refusal of treatment/transfer, and attempt to convince the patient to stay for completion of treatment by explaining the potential benefits of care ...4. If it appears that the attending Physician/Provider Designee may not have an opportunity to assess the patient before the patient leaves AMA, nursing will attempt to have patient assessed by an available Physician/Provider and inform the patient that they are welcome back to the facility for evaluation and treatment in the Emergency Department if the patient changes their mind ...5. Request assistance from Case Management regarding arrangements for any follow-up care needed or referrals for the patient and document specifics and urgency of needed care and efforts made to schedule ...6. Request the patient sign the AMA form (attached) prior to leaving. If the patient or LAR refuses to sign the AMA form, the attending Physician/Provider Designee or nurse will attempt to read the form to the patient/LAR and document the refusal on the AMA form indicating date and time. In addition, a note that “patient refuses to sign” will be entered on the signature line. Obtain witness signatures from all people present at the time the release was offered and refused. Ensure the form is scanned into the medical record ...8. Provide the patient with discharge instructions. Document in the medical record that instructions, both verbal and written, were provided, prescriptions if applicable, and suggestions for follow-up or further care by physicians and/or appropriate agencies ...9. Patients who leave AMA or refuse treatment will be provided a safe discharge ...10. Documentation in the medical record to include: The patient ’ s reason(s) for wanting to go AMA ...Any circumstances surrounding the incident, including the patient ’ s perceived emotional state ...Patient behavior and any pertinent conversations ...Physician notification...Information discussed with the patient regarding risks, benefits, attempts to resolve care concerns, etc. ...Include patient ’ s perceived understanding of information discussed ...11. Complete event report for all patients leaving AMA ...ELOPEMENT ...Notify attending Physician/Provider Designee ...Notify Admin. Rep ...Notify Security ...Conduct an on-site search of areas ...Attempt to contact the patient on cell phone ...should document the date and time patient identified as missing, last time seen, actions taken to locate, and all information surrounding the event ...Complete event report ....” Patient #1 presented to the Emergency Department (ED) on 09/14/2025 at 1402 complaining of 4 (four) days of Nausea and Vomiting, feeling weak. The allegations are that the hospital did not provide a proper medical screening examination or provide stabilizing treatment before discharging home. Review of Patient #1 ’ s Medical Record revealed Patient #1 did receive Discharge prescriptions and instructions. Review of 20 ED patient medical records randomly selected from the ED logs for months August, September and October of 2025, revealed 4 out of 20 patients (Patient #12, Patient # 16, Patient # 17 and Patient #20) left without any discharge instructions. Review of Patient #12 ’ s Electronic Medical record (EMR) revealed: “ ...Patient had left [his/her] ED room and was now in the triage area speaking with security ...patient was seen exiting the hospital ...MD notified patient eloped ....” Patient #12 had no discharge instructions given. Review of Patient #16 ’ s Electronic Medical record (EMR) revealed: “ ...who presents with headache, wrist pain and penile pain ... no obvious traumatic findings noted ...ordered CT head, right wrist x-ray, urine, drug screen, gonorrhea and chlamydia ...s/he was given Valium and Tylenol...Patient eloped from ER ....” Patient #16 did not have discharge instructions from the facility. Review of Patient #17 ’ s Electronic Medical record (EMR) revealed: “ ...Pt brought back to split flow, assessment and triage complete ...Pt insists on my girl and kids to be back with him/her repeatedly. Pt informed this is not allowed in this area ...Pt chose to leave without being seen ...ED Disposition set to LWBS After Triage ...This note is being completed for administrative purposes only. Patient left emergency department before I was able to evaluate patient. Nursing staff tried to get patient to stay for evaluation ....” Patient #17 did not have discharge instructions from the facility. Review of Patient # 20 ’ s Electronic Medical record (EMR) revealed: “ ...RN in triage stated s/he saw patient to walk out the front door ...ED Disposition set to LWBS After Triage ....” Patient #20 did not have discharge instructions from the facility. Employee #8 and Employee #9 confirmed Patient # 12, Patient #16, Patient #17, and Patient #20 did not have discharge instructions from the facility.”

“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: 48110 Based on record reviews and staff interviews, it was determined the hospital did not reassess two (2) out of 20 patients (Patient #1 and #14) who presented to the ED per the hospital’s policies and procedures, that comply with the requirements of 42 CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases. This deficient practice poses a risk to the health and safety of patients if the patient’s condition starts to deteriorate and goes unnoticed while waiting for care in the ED. Findings include: Hospital policy titled, “Emergency Medical Treatment and Labor Act (EMTALA)”, revealed: “ ...Procedure ...A. Registration and Triage ...HonorHealth will not delay providing a medical screening examination or necessary stabilizing treatment for any individual with an emergency medical condition by inquiring about an individual’s ability to pay for care. All persons who present to an HonorHealth hospital campus with what they believe to be a medical emergency, or which a layperson would reasonably believe they are experiencing an medical emergency, must receive a medical screening examination ....Qualified personnel (registered nurse, nurse practitioner, physician assistant, or physician) will conduct a triage examination to determine the order in which persons receive the medical screening examination described in (B), below ....Triage does not satisfy the requirements for a medical screening examination as defined below in Section (B). B. Medical Screening Examination. HonorHealth will provide a medical screening examination to all persons who present to an HonorHealth DED requesting emergency services (or when such a request is made on their behalf), regardless of their ability to pay. The purpose of the medical screening examination is to determine whether the person has an emergency medical condition ....If the Person is determined not to have an emergency medical condition, the qualified medical personnel who performed the medical screening examination will document this fact in the person’s medical record. C. Stabilizing Treatment. If the medical screening examination demonstrates that the person has an emergency medical condition, HonorHealth will provide stabilizing treatment within its capabilities, unless the person requests transfer to another facility ....The qualified medical personnel who provided the stabilizing treatment will document in the medical record the stabilizing treatment provided and that the person’s emergency medical condition has been stabilized ....” Hospital policy titled, “Network Emergency Department Operating Policy”, revealed: “ ...III. Goals: The Emergency Department will: a. Deliver quality care to each individual presenting to the Emergency Department requesting treatment or in need of treatment. b. Provide triage, assessment, and treatment ....V. Unit/Department/Service Operations: a. Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity ....Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, planning, implementing and evaluating all nursing care performed for that patient ....” Hospital document titled, “HonorHealth Emergency Department Reassessment Guidelines”, revealed: “ ...Purpose: Reassessment guidelines promote rapid identification of changes or deterioration in patient’s conditions and are determined by evidence-based practice and clinical expertise ....Guideline/Parameters ...ESI Level ...Should be reassessed (after initial assessment) ...2 ...No less frequently than every hour for the first four hours, then every two hours if clinically stable ...3 No less frequently than every four hours if vital signs are within normal limits and no less frequently than every two hours for the first four hours if vital signs are abnormal then every four hours if clinically stable ....Situations Requiring Special Considerations ...Patients remaining in the waiting room for an extended period. Reassessment frequency, including vital signs, should occur at a minimum of every two hours until brought into the department ....” Patient #1’s medical record dated 07/26/2024 identified an ED care timeline, and it revealed: “ ...7/26/2024 ...23:54 ...Patient arrived in ED ...23:55 ...Arrival Complaint ...Asthma ...23:57 ...Vital Signs ...Heart Rate: 140 ...Resp: 22 ...BP: 148/87 ...7/27/2024 ...00:00 ...Patient Acuity: 2 ...00:00 ...Chief Complaints Updated ...Asthma (Pt reports increased SOB and cough x15 mins, Pt reports HX asthma, Pt reports rescue inhaler not working) ...01:26 ...ED Prolonged Wait Patient Message ...02:54 ...Vital Reassessment ...04:14 ...Patient roomed in ED ...to room 17 ...04:14 ...Assign Physician ...04:26 ...Patient Care Initiated ....04:48 ...Medication Given ...ipratropium-albuterol (DUONEB) 0.5 mg-2.5 mg/3mL nebulizer solution 3mL ...04:48 ...RT Therapies ...RT Assessment ...Respiratory Pattern: Dyspnea at rest (SOB), Right Upper Lobe Auscultation: Crackles, Right Middle Lobe Auscultation: Crackles, Right Lower Lobe Auscultation: Crackles, Left Upper Lobe Auscultation: Crackles, Left Lower Lobe Auscultation: Crackles ....” Patient #14’s medical record dated 07/26/2024 identified an ED care timeline, and it revealed: “ ...23:58 ...Patient arrived in ED ...00:00 ...Vital Signs ...Heart Rate: 125 ...BP: 160/104 ...00:01 ...Chief Complaints Updated ...Leg Swelling (Pt reports L leg swelling x3 days with warmth and throbbing pain. Pt reports L hip replacement 7/15/24) ...00:02 ...Patient Acuity: 2 ...01:28 ...ED Prolonged Wait Patient Message ....02:30 ...Patient dismissed ....” Review of Patient #14’s medical record revealed a document titled, “Refusal of Screening Examination and Treatment”, and Patient #14 was called with no answer at 04:33, 04:48, and 05:03. Further review of Patient #14’s medical record revealed no reassessment between triage at 00:01 ESI of 2 and Patient #14’s LWBS at 04:33, with four hours and 32 minutes elapsed. Employee #4 and Employee #6 confirmed during an interview conducted on 10/22/2024 that Patient #1 and Patient #14 did not have documented reassessment or vital signs retaken for changes of condition per the facility’s policies and procedures and guidelines.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the Hospital delayed examination and treatment for three (3) out of 20 patients (Patients #1, #10, and #14), who presented to the ED seeking medical treatment. Failure to provide timely medical screening examination and treatment poses a potential risk that the patient’s condition deteriorates and they do not receive life saving medical treatment Findings include: Hospital policy titled, “Emergency Medical Treatment and Labor Act (EMTALA)”, revealed: “ ...Procedure ...A. Registration and Triage ...HonorHealth will not delay providing a medical screening examination or necessary stabilizing treatment for any individual with an emergency medical condition by inquiring about an individual’s ability to pay for care. All persons who present to an HonorHealth hospital campus with what they believe to be a medical emergency, or which a layperson would reasonably believe they are experiencing an medical emergency, must receive a medical screening examination ....Qualified personnel (registered nurse, nurse practitioner, physician assistant, or physician) will conduct a triage examination to determine the order in which persons receive the medical screening examination described in (B), below ....Triage does not satisfy the requirements for a medical screening examination as defined below in Section (B). B. Medical Screening Examination. HonorHealth will provide a medical screening examination to all persons who present to an HonorHealth DED requesting emergency services (or when such a request is made on their behalf), regardless of their ability to pay. The purpose of the medical screening examination is to determine whether the person has an emergency medical condition ....If the Person is determined not to have an emergency medical condition, the qualified medical personnel who performed the medical screening examination will document this fact in the person’s medical record. C. Stabilizing Treatment. If the medical screening examination demonstrates that the person has an emergency medical condition, HonorHealth will provide stabilizing treatment within its capabilities, unless the person requests transfer to another facility ....The qualified medical personnel who provided the stabilizing treatment will document in the medical record the stabilizing treatment provided and that the person’s emergency medical condition has been stabilized ....” Hospital policy titled, “Network Emergency Department Operating Policy”, revealed: “ ...III. Goals: The Emergency Department will: a. Deliver quality care to each individual presenting to the Emergency Department requesting treatment or in need of treatment. b. Provide triage, assessment, and treatment ....V. Unit/Department/Service Operations: a. Staff Responsibilities: All patients entering the Emergency Department will receive a triage assessment by a RN and on-going evaluation based on patient acuity ....Nursing staff will provide patient care to patients while the patient remains in the ED. The nurse assigned to that patient is responsible for assessing, planning, implementing and evaluating all nursing care performed for that patient ....VI. Staffing: ...The Emergency Department is staffed with professional and non-professional staff members to provide the required hours of nursing care for its daily census ...Staffing will be flexed and managed by Nursing Supervisors to account for changes in acuity ....” Hospital document titled, “End of Shift Report 07/26/2024”, revealed: “ ...Time: 1800-0600 ...Volume: 56 ...Barriers & Safety: ...Closed main assignment 17-20 at midnight due to staffing ...5 in the lobby at 0220 ...CN covering assignment while nurse took patient to MRI and take patients left in assignment 3-6 allowing the 3am nurse to leave on time. CN unable to go into the count, helping RNs with task trying to get everyone caught up. CN called reports, discharged patients, and landed patients from triage and ambulances. Short staffed with high acuity patients. Patient on split flow need a consult from plastics due to a dog bite to the face, (Provider #3) refused to come see the patient. NP treated the patient. (Patient #21) ....” The end of shift report for the morning shift of 07/26/2024 was requested. None was provided. Review of hospital ED log for July 2024 revealed from 07/26/2024 18:00 through 07/27/2024 06:00 there were 12 patients that left without being seen (LWBS). Review of Patient #1’s medical record dated 07/26/2024 identified an ED care timeline, and it revealed: “ ...7/26/2024 ...23:54 ...Patient arrived in ED ...23:55 ...Arrival Complaint ...Asthma ...23:57 ...Vital Signs ...Heart Rate: 140 ...Resp: 22 ...BP: 148/87 ...7/27/2024 ...00:00 ...Patient Acuity: 2 ...00:00 ...Chief Complaints Updated ...Asthma (Pt reports increased SOB and cough x15 mins, Pt reports HX asthma, Pt reports rescue inhaler not working) ...01:26 ...ED Prolonged Wait Patient Message ...02:54 ...Vital Reassessment ...04:14 ...Patient roomed in ED ...to room 17 ...04:14 ...Assign Physician ...04:26 ...Patient Care Initiated ....04:48 ...Medication Given ...ipratropium-albuterol (DUONEB) 0.5 mg-2.5 mg/3mL nebulizer solution 3mL ...04:48 ...RT Therapies ...RT Assessment ...Respiratory Pattern: Dyspnea at rest (SOB), Right Upper Lobe Auscultation: Crackles, Right Middle Lobe Auscultation: Crackles, Right Lower Lobe Auscultation: Crackles, Left Upper Lobe Auscultation: Crackles, Left Lower Lobe Auscultation: Crackles ....” Review of Patient #1’s medical record dated 07/27/2024 identified an ED provider note, and it revealed: “ ...Time Seen: 4:26 AM ...Chief Complaint ...Asthma Pt reports increased SOB and coughing x15 mins, Pt reports HX asthma, Pt reports rescue inhaler not working ...presents to the emergency department for evaluation of cough an {sic}(and) asthma exacerbation. Patient reports history of asthma, and recent diagnosis of bronchitis that (Patient #1) reports triggered (Patient #1) asthma ....reports both a dry and productive cough of clear mucus. (Patient #1) reports that (Patient #1) was cough so hard (Patient #1) experienced post-tussive emesis and shortness of breath earlier ...Radiology Studies: XR Chest ...Impression: No acute findings ....Patient will be given Solu-Medro, IV fluids, DuoNeb, promethazine with codeine ...Patient reassessed at bedside, resting comfortably, still with cough, however has improved from prior. Discussed the patient is on all appropriate therapies ....instructed to follow up with pulmonology, to use a humidifier while at home, and to continue compliance with all...medications. Updated on results. Discussed plan for discharge including indications to return to ER. Instructed to follow up with PCP/other specialist. Patient agrees with plan ....” Review of Patient #1’s medical record revealed they remained in the waiting area after triage at 00:00, and no laboratory or diagnostic imaging were ordered, and no interventions and treatment were initiated until after medical screening examination at 04:26. Review of additional 19 randomly selected ED medical records revealed two (2) patients had a delay in examination or treatment: 1. Patient #10, arrived 07/14/2024 21:55 for chest pain, triaged 22:00 with ESI 3, EKG 22:07 with no documentation reviewed by a qualified medical provider, no MSE, LWBS 23:46, time elapsed from arrival: one hour and 51 minutes; 2. Patient #14, arrived 07/26/2024 23:58 for leg swelling, triaged 07/27/2024 00:01 with ESI 2, no MSE, patient called but no answer 04:33, 04:48, and 05:03, time elapsed from arrival: four hours and 35 minutes Employee #4 and Employee #6 confirmed during an interview conducted on 10/22/2024 that Patient #1 presented to the ED with asthma exacerbation, and was triaged an acuity of two. Employee #4 and Employee #6 also confirmed Patient #1 did not receive a medical screening examination until four hours and 32 minutes after arrival. Employee #4 confirmed Patient #1 did not receive breathing treatment for their asthma exacerbation until four hours and 51 minutes after arrival.”