Uf Health Shands Hospital

“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: 46523 Based on medical records reviews, Medical Staff Bylaws review, Policy review, and staff interviews, it was determined the facility failed to ensure all individuals presenting to the hospital’s emergency department with presenting signs and symptoms (abdominal pain/shortness of breath, abnormal Ultrasound, Seizures, Elevated Blood Pressure readings, severe Back pain, syncope episodes/Chest pain, status /post falls and complaint of weakness) received and appropriate medical screening examination (MSE)within the capability of the hospital’s Emergency Department (ED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 10 (ten) Patient (Pt) #1, Pt #3, Pt#4, Pt #5, Pt #8 Pt #10, Pt #11, Pt #13, Pt #15, Pt #16 of 24 (twenty-four) sampled patients medical records reviewed. Additionally, the facility failed to have an effective system in place to ensure that patients in the hospital’s ED lobby received an appropriate medical screening examination by Qualified Physicians or Other Qualified Medical Professionals. Refer to finding sin Tag A-2406.”

“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: 46523 Based on medical records reviews, Medical Staff Bylaws review, Policy review, and staff interviews, it was determined the facility failed to ensure all individuals presenting to the hospital’s emergency department with presenting signs and symptoms (abdominal pain/shortness of breath, abnormal Ultrasound, Seizures, Elevated Blood Pressure readings, severe Back pain, syncope episodes/Chest pain, status /post falls and complaint of weakness) received and appropriate medical screening examination (MSE) within the capability of the hospital’s Emergency Department (ED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 10 (ten) Patient (Pt) #1, Pt #3, Pt#4, Pt #5, Pt #8 Pt #10, Pt #11, Pt #13, Pt #15, Pt #16 of 24 (twenty-four) sampled patients medical records reviewed. Additionally, the facility failed to have an effective system in place to ensure that patients in the hospital’s ED lobby received an appropriate medical screening examination by Qualified Physicians or Other Qualified Medical Professionals. Findings include: Review of the policy and procedures titled, “Emergency Medical Screening Exams” Policy Number: CP02.019, last approval date of 01/17/2024 read, “Policy: All Patients Presenting to a UF Health Shands Hospital or Emergency Department (ED) seeking an emergency examination or treatment shall receive an appropriate Medical Screening Examination by a Qualified Physician or other qualified medical personnel ... Purpose: To ensure all patient presenting to a UF Health Shands Hospital or Emergency Department requesting treatment are medically screened to determine whether or not an emergency medical condition exists, and treated, admitted, stabilized, discharged and/or transferred, as appropriate. .. DEFINITIONS: ... B. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances or symptoms of substance abuse) of immediate medical attention could reasonably be expected to result in: a. Serious Jeopardy to a patient’s physical or mental health ...b. serious impairment of bodily functions; or Serious dysfunction of any bodily organ or part ...C. Medical Screening Exam (MSE) - A medical examination conducted by a Qualified Physician or Other Qualified Medical Professional that is within the capability of the hospital both as to ancillary services and available personnel and is sufficient to determine whether or not an individual has an Emergency Medical Condition.” The facility’s UH Health Shands Hospital Medical Staff Bylaws, Re-Adopted by Board of Directors, Effective, adopted: July 1, 1998, revised: September 10, 2025, was reviewed. The section of Medical Staff Bylaws, 14.1.1.6 titled, “Emergency Medical Screening Exams, was reviewed. The review revealed in part, “All Patients presenting to the Hospital ED seeking an emergency examination or treatment shall receive an appropriate Medical Screening Examination by a Qualified Physician or Other Qualified Medical Professional to determine whether or not an Emergency Medical Condition exists, and treated , admitted, stabilized, discharged, and/or transferred as appropriate ...Qualified Physician is defined as credentialed physicians, Residents, and Fellows. Other Qualified Medical Professional is defined as Licensed Registered Nurses and include APRNs (Advanced Practice Registered Nurses), Physician Assistants, and Psychiatric and Substance Abuse Evaluation Counselors qualified to perform Medical Screening Examinations, provided that they have been approved by the Service Chief, or when not applicable, the Medical Director of the Emergency Services, Labor & Delivery, or Psychiatry as appropriate.” Review of the Emergency Department medical record documentation for Patient #1 revealed the patient arrived -in the emergency department on 01/18/2025 at 12:40 PM. Review of the ED note revealed the ED triage nurse documented, “Patient arrives as walk in c/o [complaint of] 6/10 (pain scale 0-10 measures intensity of pain ;6- moderate to strong pain) lower right abdominal pain x 3 days worsen with movement, also reports sob [shortness of breath] developing cough today, states she is concerned for a blood clot as she is on birth control or appendicitis (serious medical condition in which the appendix becomes inflamed and painful). Denies n/v/d nausea/vomiting/diarrhea]/fever, no known sick contacts. States she had pneumonia (an infection that inflames the air sacs in one or both lungs) and mono (mononucleosis-a common, contagious viral infection) in October. No other medical hx [history].” Further review revealed that at 12:49 PM a Peripheral intravenous line was inserted into the patient’s right anterior forearm. Vital signs were completed at 12:51 PM: Blood pressure 125/73; Temperature: 98.4 Fahrenheit; Pulse:116 (normal pulse rate: 60-100); At 1254 PM: Pain Scale: 6, Pain Type: Acute Pain, Pain location: abdomen, Pain orientation: Right Lower. Pain description: Sharp, Pain Frequency: Continuous, Pain Onset: Ongoing, Clinical Progression: Gradually Worsening. At 12:55 PM Primary assessment at 12:55 PM revealed, “Airway: patent, Breathing: No use of accessory muscles. Normal chest expansion, Breathing: Not impaired, Chest rises and falls spontaneously. Circulation: Normotensive. Neurological: Responds readily to normal speaking voice, Patient is awake and alert. Glasgow Coma Scale (a neurological assessment tool used to measure a person’s level of consciousness): Open eyes spontaneously, oriented, obeys commands, Glasgow Coma Scale score: 15.” Further review revealed the patient was triaged (medical and nursing process of rapidly assessing, sorting, and prioritizing patients based on the severity of the of their condition) , as “Patient Acuity Emergent (2)”. Review of the medical record also revealed that an attending physician electronically ordered and signed for the following diagnostic testing: an EKG (Electrocardiogram-test that records the heart’s electrical activity) documented as completed on 01/18/2025 at 12:42 PM; EKG Interpretation: No STEMI (ST - segment elevation myocardial infarction- a severe heart attack). Labs/Diagnostics are documented as completed on 01/18/2025 at 12:43 PM. Troponins I (heart skeletal muscles that control contraction, testing HS (high sensitivity),12:48 PM for a complete blood count with differential. On 01/18/2025 at 12:48 basic metabolic panel, magnesium, and phosphorus. At 1:13 PM chest x-ray 1 View; Impression: Normal cardiomediastinal silhouette (the outline of heart as seen on frontal and lateral chest radiographs). Lungs are clear. No pleural effusion or pneumothorax. Unremarkable upper abdomen. No acute osseous (composed of bone) abnormalities. On 01/18/2025 at 3:48 PM a Troponin 1 HS 2 hour was completed. Vital signs were documented as completed on 01/18/2025 at 2:10 PM, 3:04 PM, 4:16 PM, 5:30 PM, and 6:30 PM. Further review revealed documentation under, “ED Disposition” read, LWBS [left without being seen] after Triage. Date/Time: Sat Jan 18, 2025, 10:02 PM. Comment: Pt. [patient] left without notifying this RN [registered nurse]. Review of Patient #1’s Emergency Department medical record did not contain documentation of a physical examination and no MSE was performed for Patient #1 by a Qualified Physician or Other Qualified Medical Professional to determine whether or not an EMC existed. During an interview on 10/06/2025 at 11:47 AM the Emergency Department Manager stated, “We cannot divert the patients there is no one to divert to. If it is a true emergency we have the trauma area and keep it open, this is used for example if they [the patient] is non-responsive. Someone who we can maintain in the lobby they have stable vitals that is what we will do as best we can. We can go to a provider in core 3, if needed, they go to the lobby and do a quick look and they give an order. It happens all the time for provider coverage and routine telehealth intermittently. Her [Patient #1’s] care was appropriate. Vitals signs were done every 2 hours. The nurse is assigning the ESI [Emergency Severity Index]- emergency Severity Index- tool used in the ED to classify patients by acuity (severity) and resource need] at triage. There is no provider at all, not for the lobby. The patient just gets reassessed and if the nurse feels they need another reassessment. If they [the nurse] feels the patient is worsening, they can escalate and give a call to a Core 1 physician to provide care for the patient. Typically, we are slammed in the waiting room. I have 30 people in the lobby. Given your acuity, the hope is to get you back to the ED [emergency department] beds but we are not able to tell them a time frame. We don’t know what will be coming through the door.” During an interview on 10/6/2025 at 12:51 PM the Director of Emergency Services stated, “Core 3 attending and resident staff. That is the escalation pathway that staff needs to let them know that there are patients that need to be addressed before going back to the chair [waiting room]. I think we address chief complaints; chest x-ray for shortness of breath complaint, vitals not escalating to correlate with pain score. They probably relied on physical pain assessment on patient then rely on a number. The vitals were stable at the time she left [Patient #1]. They [the nurse] will put an NA [no answer] and try to contact [the patient], and if they don’t answer they will document. I think staffing is fine unless we get overrun with 10 patients from the lobby and then from EMS [emergency medical services]. The concern is the influx of patients when not expected can exceed our capacity to process them. We have been busy throughout the week holding patients that we should be putting our ED patients in, but they are being used for boarding, and this becomes a capacity issue. We have three attendings on 24/7 and a resident if there is an urgent need. There are chest pain evals (evaluations), car accidents, and patients with pain as well. We have a lot of boarders, 700 hours, about 40-50 patients boarding and we only have 61 licensed beds. These patients are waiting for an open bed in the hospital. On call we have at least one provider and administrator.” During an interview on 10/06/2025 at 1:58 PM the ED Director stated, Monday through Friday are usually our worst times. The weekends we don’t get as many patients coming in. This was a very busy weekend with an unexpected influx of patients. There was enough staff to take care of the emergencies and when available they would see the patients in the lobby who are stable. Staffing was not a concern it was more the occupancy of boarder patients. During an interview on 10/6/2025 at 3:17 PM Staff A, Nurse Specialist stated, “For the boarders it is a mixture of both med surg [medical surgical] nurses and ED nurses taking care of the patients while they are boarders.” During an interview on 10/06/2025 at 3:25 PM the ED Medical Director stated, “It is never appropriate for a patient to leave the ED without being seen. Filled with boarders and not with emergency patients in an enormously small ED traditionally would result in zero capacity. It’s not the ESI, it is more being deprived of the space. Then there are always external factors which are out of our control. Standing chronic wait times are an issue associated with the lack of space. The standing orders are in place to conduct a workup to either close out the case or identify the patient who might be sicker than what they might think and not wasting the time waiting to be seen by a provider. During an interview on 10/7/2025 at 8:19 AM the Director of Quality and Regulations stated, “[Patient #1’s name] has no MSE and no education.” During an interview on 10/7/2025 at 9:25 AM the ED Director stated, “On January 18, I did not have an assigned APP [Advanced Practice Provider] dedicated to the lobby. We had an APP working in Core 3 which would cover along with the resident and between the team in Core 3 to answer all questions and meet the needs for the lobby patient. That started Monday, Tuesday, and Wednesday from 11:00 AM to 11:00 PM, the peak admit time. Thursday is covered. It was initiated for 12 hours of peak times. Our peak volume is on Tuesday through Friday. The volume settles out on the weekend. So, we did not find the need for dedicated coverage of the lobby due to the volume settling out. The nurses have not verbalized a concern about not having a dedicated provider on the weekends. It all depends on the volume and Core 3 is approachable. Core 3 is close to the lobby about 25 feet. Residents, APP, and Attending are the ones who can do an MSE. RNs are not able to do the MSE, only the initial triage and standing orders for the complaint presented. The ESI score is labor intensive. It provides an understanding of how many resources are needed. [Patient #1’s name] came in with abdominal pain so we have to do labs such as troponins and an EKG within a certain time frame. Once the results come back it can be downgraded but nurses are not allowed to downgrade, that would only be a provider. Until they see a provider, we will normally not downgrade. For the ESI we will just change the frequency of the monitoring assessments. They [nursing] look at the patient and the longer she sat in the ER her clinical presentation did not change. If the patient leaves without us knowing it is really hard to have that conversation and for education be provided. We did all things based on our standing orders. That is why we have standing orders to use. If we think that the patient will not be seen timely, so the provider has a better clinical picture, and triggers for the nurse to communicate with the provider. The ED follows the hospital escalation pathway, first the APP and resident, then they go to the attending, and they have a coordinator; if not they call me or the manager, and if not they escalate to the director. During an interview on 10/7/2025 at 10:15 AM the Chief of Service of Emergency Medicine stated, “Generally nurses triage and give an ESI. The medical screening is done as soon as possible as capacity allows. I am not aware of the capacity that particular day. Many days we are very full. A lot of time if we have a surge, we will call for a physician to come in and see patients in the waiting room in order to get orders in place. The potential busiest days are Tuesday through Friday. A lot of the time weekend patients are discharged. In terms of concerns, resources would be used Monday through Friday for 8 hours for screening. It is driven by capacity and staff available. The influx in the ED is large. Normally if the patient makes it known that they are going and do not disappear we educate and let them know they will be seen by the provider.” During an interview on 10/7/2025 at 11:09 AM the ED Medical Director stated, “Ideally absolutely [Patient #1’s name] should have been screened to determine no emergency condition was present. The ED is well sized, we are just working with one half or a third of the ED. There can be 12-15 patients at one time. There are efforts on our part to make it safe. Patients deserve to be in a room; care needs need to be placed where they need to be. We need a solution for the hospital boarding such as early discharges and boarding on the hospital floor. Boarding is twice as long to admit and twice as long to leave. That day [01/18/2025] they had 700 hours,10%. Admission holds averaged a hold of 27-29 hours that is expected to be seen in four hours.” During an interview on 10/7/2025 at 10:27 AM the Physician Director of Quality of emergency Medicine stated, “Unfortunately the situation that the patient [Patient #1] left without being seen. The process was followed. The patient was issued an ESI appropriately, monitored, and she had hemodynamically stable vitals. Appropriate standing orders were provided, and she had no abnormal labs or EKG. If she would have had abnormal labs or EKG that would have been escalated and she would have been given a room sooner. Due to her diagnostic normal labs, BMP [basic metabolic panel] and CBC [complete blood count] and an unremarkable chest x-ray and EKG it was appropriate waiting six 6 hours in the ED. The patient was not evaluated by a physician but left after workup in triage indicated good stability. It is hard to say, but it is possible she could have been an ESI of 3 after her vitals and initial work up. She was hemodynamically stable and no sign of acute distress. I don’t want to downplay her pain but with abdominal pain sometimes medication is more harmful than good. I do expect that the patient is educated and the staff usually do. Most of the time nurses will document. In this case they called out twice in one hour and no answer it was not like she came and gave that opportunity [for MSE and/or education]. This particular patient was monitored and six sets of vitals that validate she was hemodynamically stable while she waited.” During an interview on 10/07/2025 at 11:15 AM the Senior Associate Dean Profession College of Medicine Department of Anesthesiology stated, “It is terrible that that is the facts we bare. It is a terrible thing to have happen and not the standards that we want for our patients. Our left without being seen is way too high and we have known about this for the past two years and thinking about what we have been doing to alleviate it. Over the last year we opened a 9000 square foot facility in east Gainesville with an idea they [patients] will show up to the ER [Emergency Room] Urgent Care. It is staffed seven days a week and closes at 8:00 PM. Last year we opened an ED in Marion, a pharmacy kiosk in the south tower for common medications and out the door, and this is open for 24 hours a day for the community pharmacy so they [patients] can come get their meds. We opened a staffed ten bed observation unit. It is next to the main ED. This allows us to move a lot of patients to the observation unit. We have 21 protocols in place for abdominal pain, migraines, and we add one protocol per month. We have an ED bypass where the patient would go to the operating unit. We have a pilot program for the ED right next to radiology. It is a five patient bed that they use for recovery and fast track for ESI of 4-5. Staff that go to get the patient and the patient doesn’t get moved backed to the ED after results. It works as a treat and street. Next to the lobby are clinical administration suites and what we are thinking of doing is convert that to a fast-track area. It is under building and facility planning currently. A lot of these patients would need to get seen by doctors and we are working to free up the space. It’s a problem and we are sorry that it happens. The issue is capacity, I think if we could have transferred patients upstairs, we would have seen the patient earlier.” Review of the Emergency Department medical record documentation for Patient #3 read, “Arrival Date/Time: 01/18/2025 1031 [10:31 AM]. Means of Arrival: Wheelchair. Review of the ED Notes revealed the patient’s Chief Complaints were listed as: Abdominal Pain, dizziness, Nausea. Visit Diagnoses: Dizziness. Review of the ED Triage Notes documentation by the EMT-P (Emergency Medical Technician Paramedic) revealed that on: 01/18/25 at 1101 [11:01 AM], “A conscious 77 y/o female, to ED via wheelchair w/ [with] a c/c [chief complaint] of ABD [abdominal pain], dizziness, and nausea. Pt. [Patient] reported ABD pain began last night around dinner time followed by dyspnea (difficulty breathing). Pt. was seen at hospital in Palatka last night and diagnosed w/ ‘large hiatal hernia (occurs when a part of the stomach bulges into the chest).’ Pt. Reporting constant left-sided ABD pain rated “6” on a scale to 10.” The patient was triaged as “Patient Acuity Urgent (3)”. Review of the medical record also revealed the attending physician assigned to this patient electronically ordered and signed for the following diagnostic testing: Labs: CBC and Differential on 01/28/2025 at 10:45 AM STAT, Troponin 1 HS on 01/18/2025 at 10:45 AM, BMP on 01/18/2205 at 11:33 AM. Troponin I HS, 2 Hour on 01/18/2025 at 12:45 PM. XR [x-ray] Chest 1 view - Impression: Redemonstrated large hiatal hernia. Mild bibasilar subsegmental atelectasis (when there is a collapse in the bottom part of both lungs). EKG 01/18/2025 at 10:37 AM No STEMI. Vitals completed on 01/18/2025 at 10:35 AM: Blood Pressure: 141/80 (normal blood pressure for most adults defined as systolic pressure number (top number) of less than 120 mmHg and a diastolic pressure (bottom number) of less than 80mmHg (<120/80); Pulse: 69; SP02 (oxygen saturation): 92% (normal oxygen saturation 95% to 100%), Vital signs were also obtained at 2:00 PM, and 4:14 PM. Further review revealed in part, “ED Disposition: LWBS after Triage. Date/Time Sat. Jan 18, 2025, 10:00 PM. Comment: Pt. left without notifying this RN.” Review of Patient #3’s Emergency Department medical record did not contain documentation that a physical examination was performed by a qualified medical provider for patient #3 on 1/18/2025. During an interview on 10/07/2025 at 8:31 AM the Director of Quality and Regulations stated, “No MSE and no education was provided for [Patient #3’s name]. Review of the Emergency Department medical record for Patient #4 read, “Admission Information: Arrival Date/Time: 01/18/2025 1459 [2:59 PM]. Means of Arrival: Walk In. Chief Complaint: Suture/Staple Removal. 1501 [3:01 PM]. Review also revealed the patient was assigned an attending physician. Review of the ED Notes dated 1/18/2025 at 1503 [3:03 PM] the ED triage nurse documented, “Patient arrived ambulatory into ED for complaint of needing sutures removed from right eye. He reports he was just released from prison. He notes having sutures to his right eye placed in GA [Georgia] in [name of facility] post global rupture (severe eye injury where the eyeball wall (sclera or cornea) tears or punctures) 12/30. He reports irritation to his right eye, 7/10 (Pain score (Strong/Severe Pain). Denies any other changes or complaints at this time. Patient A&Ox4 [Awake, Alert and Oriented to person, place, time, and event].” Patient #4 was triaged as “Patient Acuity Urgent (3).” Vitals signs completed on 01/18/2025 at 1504 [3:04 PM] were listed as Blood Pressure 143/91!; Pulse: 91; Resp: 18; Spo2: 96% and at 1819 [6:19 PM]: Blood Pressure 143/88!; Pulse 106 (normal pulse 60-100). Review of the ED Disposition read, “LWBS after Triage. Date/Time: Sat Jan 18, 2025, 10:41 PM. Comment: Pt. left without notifying this RN. There was no documentation in the medical record to indicate the assigned attending physician was notified of the patient’s complaint of the affected eye pain (7/10), nor of his request to have sutures removed where he had surgery for a globe rupture 19 days prior. Review of Patient #4’s Emergency Department medical record failed to reveal that a physical examination was documented, and no evaluation was performed by a qualified medical provider for patient #4 on 1/18/2025. During an interview on 10/7/2025 at 8:43 AM the Director of Quality and Regulations stated, “No MSE or education was provided to [Patient #4’s name]. Review of the Emergency Department medical record for Patient #5 documentation revealed, “Admission Information: Arrival Date/Time: 01/18/2025 1051 [10:51 AM] Means of Arrival: Walk In’, and the patient was assigned an attending provider. The patient’s reason for visit was listed as, “Chief Complaint: Back Pain (R [right] side).” Review of the ED Triage Notes dated 01/18/2025 1103 [11:03 AM] the RN documented, “Pt arrives into ED via WC Wheelchair) w (with) CC (Chief complaint) of 9/10 (Pain score Severe/Very severe: Pain is overwhelming), and back pain (Sciatica- pain affecting the back, caused by compression of a nerve root in lower back), Pt. states she sees a chiropractor for her sciatica and the NSAIDS [nonsteroidal anti-inflammatory drugs] have not been working. Recommended by chiropractor to be seen for steroids. PT A&OX4, GCS 15, RA [alert and oriented to person, place, time, event. Glasgow Coma Scale score of 15 - Room Air]”. Patient #5 was triaged at 10:52 AM., as “Patient Acuity Urgent (3).” Vital signs were completed on 01/18/2025 at 1052 [1052 AM] and 1404 [2:04 PM]. Further review of the ED Disposition read, “LWBS after Triage. Date/Time: Sat Jan. 18, 2025, 7:13 PM. Comment: Pt. left without notifying this RN. Review of Patient #5’s Emergency Department medical record did not contain documentation that Patient #5 was evaluated by a qualified medical provider, and no physical examination was conducted. screening. Review of the Emergency Department medical record for Patient #8 read, “Admission Information: Arrival Date/Time: 01/18/2205 0856 [8:56 AM]. Means of Arrival: Walk In. Chief Complaint: Eye Problem. Review revealed that an attending physician was assigned to this patient. Review of the ED Notes dated 01/18/2025 0903 [9:03 AM] the triage Nurse documented, “Patient arrives ambulatory into ED for complaint of flashing white light in right eye X (time)10 hours. She denies any other vision changes, denies pain. Wears glasses at baseline. Upon arrival, Noted, A&OX4, GSC 15. Patient admits hx [history of] HTN [hypertension] and took her BP [blood pressure] meds this AM but reports her BP has been remaining elevated. Patient denies chest pain, SOB [shortness of breath] or any other symptoms at this time”. The patient was triaged as “Patient Acuity Emergent (2)”. Blood Pressures were re-assessed and completed on 01/18/2025 at 0900 [9:00 AM]: Blood Pressure (B/P) : 173/95; B/P at 1013 [10:13 AM] 170/99; B/P at 1128 [11:28 AM] 156/73; B/P at 1241 [12:41 PM 168/87; B/P at 1349 [1:49 PM]175/98; B/P at 1459 [2:49 PM]169/91 and B/P at 1610 [4:10 PM] 170/95. There was no documentation in the medical record to indicate the attending physician was notified of the patient’s elevated blood pressures. Review of the ED Disposition read, “LWBS after Triage. Date/Time: Sat. Jan. 18, 2025, 5:05 PM.” Review of the Discharge Information read, “Discharge Date/Time 01/18/2025 1706 [5:06 PM] Left Without Being Seen.” Review of the Discharge Information read, “Discharge Date/Time 01/18/2025 1706 [5:06 PM] Left Without Being Seen.” Review of the ED Notes read, “01/18/2025 1703 [5:03 PM] CCT [Clinical Care Technician] informed this RN patient left.” Review of Patient #8’s Emergency Department medical record revealed that a medical screening examination was not provided and by a qualified medical provider, and no documentation that a physical examination was performed. During an interview on 10/07/2025 at 8:34 AM the Director of Quality and Regulations stated, “No MSE or education was completed for Patient #8.” Review of the Emergency Department medical record for Patient #10 read, “Admission information: Arrival Date/Time: 01/17/2025 2216 [10:16 PM] Means of Arrival: Walk In. The “Reason for Visit was listed as “Chief Complaint: Fall (Pt. states that she fell twice today. Pt. states she just lost her balance, denies dizziness or loss of consciousness. Pt. state that the last time she fell she fell backward and did hit her head. Pt. complains of pain to the back of the head that radiates down the neck and shoulders and down the back)”. Review revealed that an attending physician was assigned to the patient. Review of the ED notes revealed “Date of Service: 01/17/2025 2224 [10:24 PM].” The ED triage nurse documented in part, “Pt. states that she fell today, hitting the back of her head. Pt. complains of pain of the back of the head down through the neck and back”. The patient was triaged as “Patient Acuity Urgent (3).” Continued review revealed the patient’s admission and final diagnosis were coded as “Headache, Unspecified.” Review of ED Notes dated 01/18/2205 0033 [12:33 AM] the Technician documented in part, “Pt. stated ...that she was leaving and will come back in the morning. Pt. did not have an IV and was notified that if anything worsens to come back in.” Review of ED Disposition read, “LWBS after Triage. Date/Time: Sat. Jan. 18, 2025, 12:35 AM [12:35 AM].” Review of Patient #10’s Emergency Department medical record revealed that no physical examination was conducted, and the patient was not seen by a qualified medical provider. During an interview on 10/07/2025 at 9:00 AM the Director of Quality and Regulations stated, “No MSE or education was completed for Patient #10.” Review of the Emergency Department medical record for Patient #11 read, “Arrival Date/Time: 01/18/2025 1320 [1:20 PM]. Means of Arrival: Walk In”. The patient’s Chief Complain was listed as “Evaluation of Abnormal Diagnostic Test (Abnormal ultrasound[ultrasound- shows structures inside the body, and used to examine an unborn fetus in pregnant women])”. Review revealed that an attending provider was assigned to this patient. Review of the ED Notes revealed “Date of Service:0118/25 1323 [1:23 PM], the ED triage nurse documented, “Pt. coming in with c/o [complaint of] abnormal ultrasound screening. Pt. went to a self checked ultrasound, and the worker wasn’t able to see much on the scan. The pt. was able to have the sack measured to be 8-9 weeks. Pt. is concerned because there was no fetus coming up on their ultrasound. Pt. denies any other symptoms right now other than regular pregnancy symptoms. “Pt. is A&Ox4 ...” On 01/18/2025 at 1329 [1:29] the patient was triaged as Patient Acuity “Less Urgent (4) and at 1455 [2:45 PM] the triage status was increased to patient Acuity “Urgent (3)”. There was no documentation in the medical record to indicate why the triage status was increased and/or why the ED physician was not notified of the change in triage status. The patient’s final diagnosis was coded as “Abnormal findings and diagnostic imaging of other abdominal regions, including retroperitoneum (The lining that of the abdominal cavity).” The ED Disposition read, “LWBS after Triage. Date/Time: Sat. Jan. 18, 2025, 6:07 PM.” Review of Patient #11’s Emergency Department medical record revealed that no physical examination was conducted, and the patient was not seen by a qualified medical provider. During an interview on 11/19/2025 at 11:04 AM the Risk Manager Quality and Safety stated, the patient [Patient #11] did not see a provider prior to leaving.” Review of the Emergency Department medical chart for Patient #13, the section titled “Admission Information” revealed, “Arrival Date/time: 01/18/2025 1709 [5:09 PM]. Means of Arrival: [Name of local ambulance company”]. The Chief Compliant was listed as “Syncope (fainting or passing out) [witnessed]. Visit Diagnosis: Other Chest pain (primary).” Review also revealed that an attending provider was assigned to this patient. Further review of the ED Note revealed “Date of Service: 01/18/25 1725 [5:25 PM], the ED Triage Nurse documented, “Pt. brought in by [name of local ambulance company], pt. smoked “weed” or what he thought was “weed” after smoking he had a witnessed syncopal episode. Pt. supposedly hit his head per witnessed no obvious signs of injury. Pt. is alert and orient no signs of distress”. The patient was triaged as Patient Acuity “Urgent (3). Continuous review revealed that the attending physician ordered the following diagnostic testing which were completed: Labs: CBC and Differential, Troponin HS 0hr, Basic Metabolic Panel, EKG: Cardiology Test: Rate 84, Sinus Rhythm. LAE [left atrial enlargement] consider biatrial [involving both atria] enlargement left ventricular hypertrophy (the thickening of the heart main pumping chamber (Left ventricle) forces the heart to work harder). Further review of the ED Disposition read, “LWBS after Triage. Date/Time: Sat. Jan. 18, 2025, 6:46 PM.” Review of Patient #13’s Emergency Department medical record revealed no documentation that the patient was evaluated by a by a qualified medical provider and no documentation that a physical examination was provided. During an interview on 11/19/2025 at 11:21 AM the Director of Quality and Regulations stated, “This Patient [Patient #13] was not seen by a provider.” Review of the Emergency Department medical record for Patient #15 documented, “Arrival Date/Time: 01/17/2025 1310 [1:10 PM]. Means of Arrival: [Name of local ambulance company].” The patient’s Chief Complaint was listed as “Seizures” (is a sudden, temporary burst of uncontrolled, abnormal electrical activity in the brain that disrupt normal function) [pt denies].” Review of the medical record revealed an attending physician was assigned to this patient. Review of the ED Notes dated 1/17/25 at 1325 [1:25 PM], the triage ED Nurse documented, “Pt. arrived ED via [name of local ambulance company] in reference to possible seizure. Pt. denies any seizure, but her brother advised he found her by her bed on the ground. Pt. advised that she rolled out of bed. Pt. is GCS15 A&OX4, and able to ambulate at this time. Pt. does not present postictal (recovery phase following a seizure, characterized by confusion) and EMS [Emergency Management Services] denies any postictal phase from the pt. Pt. denies any complaints. Pt. has a hx of seizure and is prescribed keppra (medication used to treat seizures). The patient was triaged as Patient Acuity “Emergent (2). Vital signs were taken 01/17/2025 at 1325 [1:25 PM]. Blood Pressure: 166/93 and Pulse: 110. The section of the medical record titled “ED Disposition” documentation by an RN revealed “ED Disposition: “LWBS after Triage ...Date/Time: Fri. Jan 17, 2025, 8:53 PM. Comment: Pt. left without notifying this RN.” Review of Patient #15’s Emergency Department medical record did not contain documentation of a physical examination, and the patient was not evaluated by a qualified medical provider. During an interview on 11/19/2025 at 12:12 PM the Risk Manager Quality and Safety stated, “The patient [Patient #15] did not have a Medical Screening Examination and did not see a provider prior to leaving.” Review of the Emergency Department medical chart for Patient #16 the section of the medical record titled “Admission Information” revealed, “Arrival Date/Time: 01/17/2025 1059 [10:59 AM]. Means of Arrival: Car/Private Transportation.” Review revealed that an attending physician was assigned to the patient. Review also revealed “Chief Complaint: Weakness” The ED notes dated 01/17/25 1103 [11:03 AM], the triage nurse documented, “Pt. arrived from home with concern of weakness that has been going on for the past 2 weeks, pt was seen by her PCP [primary care physician] today and they told her to come be seen. Pt. states that after a week she began to have trouble walking. Pt. states that when the weakness began she was recently sick or had any other symptoms {sic}. Alert X 4, abcs [airway, breathing, circulation] intact.” The patient was triaged as Patient Acuity “Emergent (2). Continued review revealed on 1/17/2025 1105 [11:05 AM] revealed the following diagnostic testing was ordered by the attending physician. The following diagnostic testing were completed: Labs: CBC and Differential 01/17/2025 1105 [11:05 AM], Basic Metabolic Panel 01/17/2025 1105, and Hepatic Function Panel 01/17/2025 1105. Radiology: 11/17/2025 1146 [11:46 AM] XR Chest 1 View: Impression: No acute cardiopulmonary abnormality. Cardiology Testing: 01/17/2025 1115 [11:15 AM]. Rate 97. Sinus rhythm. Right atrial enlargement. Borderline Right Axis Deviation. Anteroseptal infarct, old. Repol abnrm [repolarization abnormality] suggest ischemia, diffuse leads.” Vital signs were completed 11/17/2025 at 1100 [11:00 AM], 1159 [11:59 AM], 1310 [1:10 PM], 1425 [2:25 PM], and 1602 [4:02 PM].” Review of the ED Disposition read, “LWBS after Triage. Date/Time: Fri. Jan. 17, 2025, 9:13 PM. Review of the ED Notes read, “Date of Service 01/17/2025. Patient’s chart accessed for LWBS call back ... Patient was contacted via phone call ... Patient said she waited 7 hours and left.” Review of Patient #16’s Emergency Department medical record did not contain documentation of a physical examination, and the patient was not evaluated by a qualified medical provider. During an interview on 11/9/2025 at 12:19 PM the Director of Quality and Regulations stated, “No education, no Medical Screening Examination, and the patient [Patient #16] was not seen by a provider.” The facility failed to ensure that the Medical Staff Bylaws and Policy (EMTALA Medical Screening Exams) were followed as evidenced by failing to ensure that on 1/17/25-1/18/25 Pt #1, Pt #3, Pt#4, Pt #5, Pt #8, Pt #10, Pt #11, Pt #13, Pt #15, and Pt #16, presented to the hospital ED requesting treatment were medical screened by a Qualified Physician or Other Qualified Medical Personnel to determine whether or not an Emergency Medical Condition existed, and treated, admitted, stabilized, discharged and/or transferred, as appropriate.”