Banner Estrella 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: 46598 Based on review of facility records and staff interviews, The Department determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20, responsibilities of Medicare participating hospitals in emergency cases. Findings Include: Hospital policy titled, “ EMTALA-Medical Screening Examination and Stabilization Treatment “ revealed: “ III. Policy: A. Medical Screening Examination ( “ MS”). 1. An appropriate MSER will be offered to individuals on the Campus of Banner Hospitals with a Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested, or in the absence of such a request, whose appearance or behavior would cause a prudent layperson observer to believe that such individuals need emergency examination or treatment. 2 ...Where the individual requires obstetrical or psychiatric services, THE MSER may be rendered in OB triage or the psychiatric crisis center ...4. Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSER ...5. An MSER will be conducted to determine whether the Patient has an EMC. The Hospital will conduct a consistent MSER, in a non-discriminatory matter, for all Patients with similar medical conditions. The MSER is an ongoing process requiring continuing monitoring based upon the Patient need and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred ...12. The MSER includes ancillary services routinely available to the Hospital along with available personnel, which includes on-call Physicians, in determining whether an EMC exists ...13. A Physician or Qualified Medical Personnel (QMP), as determined by the Board will medically screen Patients ...15. An MSER and Stabilizing Treatment will be provided to all individuals with an EMC regardless of managed care/payer requirements .... “ Policy titled “ EMTALA-Medical Screening Examination and Stabilization Treatment “ revealed: “ ...II. Definitions ’ . Emergency Medical condition or EMC: 1. A medical condition manifesting itself by acute symptoms or sufficient severity (including severe pain and/or psychiatric Emergency) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the individual (or with respect to a pregnant woman, the health of the woman, or her unborn child) in serious jeopardy ...B. Stabilizing Care ...5. An MSER will be conducted to determine whether the patient has an EMC. Hospital policy titled “ Emergency Department Patient Care “ revealed: “ ...Medical Screening Exam 1. A medical screening exam (MSER) is completed by an Emergency Physician or QMP ...Triage assessment 1. Completed by a RN- Paramedic or QMP ...2. An Emergency Severity Index (ESI) score is assigned when the triage assessment is completed. ESI 2 = High-risk situation confused/lethargic situation confused/lethargic/disoriented or severe pain distress. ESI 3= Two or more resources may be needed ...Assessment/Reassessment 4. Occurs according to the patient’s clinical presentation or any significant clinical event with the minimum requirements as follows. ESI 2 = documented reassessments every 1 hour until hemodynamically stable, then minimally every 4 hours or per admitting unit guideline of care, ESI 3= Documented reassessments every 4 hours .... “ A review of 20 ED records randomly selected for review included patients who were transferred, admitted, or left before Medical Screening Examinations. Four (4) out of 20 medical records reviewed revealed: Patient # 1 arrived at the ED at 0934, was triaged at 0939, MSER did not receive, Acuity 2 Patient # 4 arrived at the ED at 2338, was triaged at 2342, MSER at 0210, Acuity 3, 3 hours and 25-minute delay. Patient # 5 arrived at the ED at 0116, was triaged at 0234, MSER at 0722, Acuity 3, 5-hour delay. Patient # 15 arrived at the ED at 0330, was triaged at 0335, MSER at 0600, Acuity 2, 2 hours and 30-minute delay. Employee # 8 confirmed the MSER times for Patient # 4, Patient # 5 and Patient # 15 are correct. Patient # 1 did not receive an MSE at all.”

“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: 46598 Based on review of facility records, and staff interviews, the Department determined the Administrator failed to ensure that an appropriate medical screening examination was performed on a patient who presented to the Emergency Department. This deficient practice poses a potential risk to the health and safety of the patient(s) when emergency medical conditions are not identified, addressed, and treated immediately at the time of incident. Findings Include: Patient # 1 arrived at Banner Estrella Medical Center on April 30th, 2023 with a complaint of headache and left-hand tingling. The patient arrived at 0934, was triaged at 0939 and had an EKG which was read by the physician that showed normal sinus rhythm, and sent back to the lobby to wait. The patient stated that [she] waited 3 hours and then decided to leave and go to another hospital where [she] was treated. Hospital policy titled, “ EMTALA-Medical Screening Examination and Stabilization Treatment “ , revealed: “ III. Policy: A. Medical Screening Examination ( “ MSER “ ). 1. An appropriate MSER will be offered to individuals on the Campus of Banner Hospitals with a Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested, or in the absence of such a request, whose appearance or behavior would cause a prudent layperson observer to believe that such individuals need emergency examination or treatment. 2 ...Where the individual requires obstetrical or psychiatric services, THE MSER may be rendered in OB triage or the psychiatric crisis center ...4. Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSER ...5. An MSER will be conducted to determine whether the Patient has an EMC. The Hospital will conduct a consistent MSER, in a non-discriminatory matter, for all Patients with similar medical conditions. The MSER is an ongoing process requiring continuing monitoring based upon the Patient need and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred ...12. The MSER includes ancillary services routinely available to the Hospital along with available personnel, which includes on-call Physicians, in determining whether an EMC exists ...13. A Physician or Qualified Medical Personnel (QMP), as determined by the Board will medically screen Patients ...15. An MSER and Stabilizing Treatment will be provided to all individuals with an EMC regardless of managed care/payer requirements .... “ Hospital document titled, “ Emergency Department Log dated 03/01/2023 through 05/30/2023 revealed that Patient # 1 arrived at the ED on April 30th at 0934. A review of Patient # 1 ’ s medical record dated 04/30/2023, revealed: ED Triage Chief Complaint: Pt presents w/HA since Thursday, tingling in left hand. FAST NEG pmg HTN ...Discussed patient medical risk of leaving prior to medical screen exam and inform staff: English ...Tracking Acuity: 2 .... “ A review of Patient # 1 ’ s medical record dated 04/30/2023, revealed a Flow sheet. vitals signs were taken upon arrival, BP 215/105, HR 112, Respirations 18, Temperature 36.5. EKG performed, signed off by the physician. A review of Patient # 1 ’ s medical record dated 04/30/2023, Refusal of Examination, revealed: “ ...Elopement..., The patient left without informing the staff of his/her withdrawal of request for an examination and/or prior to completion of care at 1256 ...1315 ...1400 a.m./p.m. an attempt was made to locate the patient without success ...Comments: Called and looked for put x# ...ER premises .... “ signed and dated by RN. Tour/Observation: A tour of the ED was conducted on 04/08/2024, with Employee # 8. Observation of the ED waiting area revealed no patients waiting. Employee # 8 revealed the updated area, Ace Program (Accelerated Care Experience) of the ED that now allows the patients to be seen and treated upon entering the ED. The area is comprised of 52 patient bed/chair zone, 8 Intake Bay, 2 Procedure waiting areas, 3 Procedure areas, 4 Results waiting areas, and 3 discharge bays in order to enhance the patient experience and avoid patients leaving without being seen. Employee # 8 confirmed in an interview that patient # 1 did not receive an MSER before leaving the facility. Medical Screening”

“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: 46598 Based on review facility records and staff interviews, it was determined the hospital the hospital delayed screening and treatment of 4 out of 20 patients who presented to the Emergency Department. Findings Include: Policy titled “ Emergency Department Patient Care “ revealed: “ ...Medical Screening Exam 1. A medical screening exam (MSER) is completed by an Emergency Physician or QMP ...Triage assessment 1. Completed by a RN- Paramedic or QMP ...2. An Emergency Severity Index (ESI) score is assigned when the triage assessment is completed. ESI 2 = High-risk situation confused/lethargic situation confused/lethargic/disoriented or severe pain distress. ESI 3= Two or more resources may be needed ...Assessment/Reassessment 4. Occurs according to the patient’s clinical presentation or any significant clinical event with the minimum requirements as follows. ESI 2 = documented reassessments every 1 hour until hemodynamically stable, then minimally every 4 hours or per admitting unit guideline of care, ESI 3= Documented reassessments every 4 hours .... “ Policy titled “ EMTALA-Medical Screening Examination and Stabilization Treatment “ revealed: “ ...II. Definitions ’ . Emergency Medical condition or EMC: 1. A medical condition manifesting itself by acute symptoms or sufficient severity (including severe pain and/or psychiatric Emergency) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the individual (or with respect to a pregnant woman, the health of the woman, or her unborn child) in serious jeopardy ...B. Stabilizing Care ...5. An MSER will be conducted to determine whether the patient has an EMC. A review of 20 ED records randomly selected for review included patients who were transferred, admitted, or left before Medical Screening Examinations. Three (3) out of 20 medical records reviewed revealed: Patient # 4 arrived at the ED at 2338, was triaged at 2342, MSER at 0210, Acuity 3, 3 hours and 25-minute delay. Patient # 5 arrived at the ED at 0116, was triaged at 0234, MSER at 0722, Acuity 3, 5-hour delay. Patient # 15 arrived at the ED at 0330, was triaged at 0335, MSER at 0600, Acuity 2, 2 hours and 30-minute delay. Employee # 8 confirmed the MSER times for Patient # 4, Patient # 5 and Patient # 15 are correct.”