Norton Hospitals, Inc.

“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: 35627 Based on interviews, review of medical records, EMS Report, video, Policy and Procedure review, and Healthcare System Medical Staff Rules and Regulations” it was determined the facility failed to ensure all individuals presenting to the Emergency Department (ED) received an appropriate medical screening examination within the capability of the hospital’s ED including ancillary services routinely available to the ED to determine whether or not an emergency medical condition existed for one (1) of twenty (20) sampled patients, Patient (P)1, who presented with psychiatric complaints. Refer to findings in Tag A-2406. Based on interviews, review of medical records, Emergency Medical Services (EMS) run sheet review, medical staff regulations and EMTALA policies review, it was determined the facility failed to ensure all individuals transferring from their Emergency Department (ED) to other facilities received appropriate transfers for 1 (one) of twenty (20) sampled patients Patient #1. On 08/01/2025 Patient (P)1 was diverted from Facility #1 by an ED staff member who informed the EMS staff to take the patient to Facility #2. Facility #1 did not seek permission to transfer to the receiving facility #2, and Facility #2 did not accept P1’s care prior to transport and Facility#1 did not transmit any patient documentation to the receiving facility. As these facility failures resulted in an inappropriate transfer of the patient #1. Refer to findings in Tag A-2409.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 35627 Based on interviews, EMS (Emergency Medical Services) report, review of medical records, policy and procedure review, ED Central Log, video review, it was determined the facility failed to ensure all individuals presenting to the ED seeking assistance were entered into the ED Central Log for one (1) of twenty (20) sampled patients, Patient (P)1. The findings include: Review of Facility #1’s policy “EMTALA Emergency Care and Transfers”, dated 11/04/2024 revealed the facility maintained a central log for all patients presenting at the hospital for emergency medical services, including ...individuals in a ground or air ambulance presenting for examination and treatment of a medical condition. Review of Facility #1’s 08/01/2025 recorded video at 9:20 PM revealed an ambulance approaching the Facility #1’s ambulance bay ramp. RN1 jogs toward the ambulance, waving. The ambulance stops, RN1 stands at the passenger side window and appears to speak with the paramedics. At 9:21 PM the ambulance pulls away from the ramp. The EMS report for Patient #1 dated August 1, 2025, was reviewed. The report revealed in part, “Patient transported non-emergent to Norton Hospital downtown (Facility #1). Report called to Norton Hospital with approximately 10 minutes ETA (Estimated time of arrival) ....As ambulance approached the entrance of the hospital ambulance bay, a nurse was standing in the middle of the sidewalk blocking EMS from hospital property and entering ambulance bay, Nurse explained to Medic (EMS personnel) that a “Psyche Nurse” was on the floor and overheard the call in. Said nurse said Norton Downtown could not accept patient due to combativeness. Nurse at ambulance bay relayed that psyche nurse stated patient was to be taken to Facility 2 (Facility #2) as Facility 2 has a psyche unit and security staff.” Review of Facility#1’s ED Central Log for 08/01/2025 revealed no recorded entry for P1. Interview with Director of Compliance and Ethics (DIR) 1 on 09/23/2025 at 8:30 AM revealed after watching the 08/01/2025 video they had contacted CMS via email to report a possible EMTALA violation. DIR1 went on to state that all aspects of EMTALA should be followed when a patient presents on Facility #1’s property seeking medical care. Interview with Nurse Manager (NM)2 on 09/23/2025 at 1:45 PM revealed they were not working the evening P1 was diverted, however ED staff were trained to enter all patients presenting to the ED into Facility #1’s ED Central Log, in the electronic medical record (EMR). Interview with RN3 on 09/30/2025 at 9:46 PM revealed they were the charge nurse on the evening of 08/01/2025 but was tied up a patient when the call from EMS came in. They further stated they had full confidence RN3 would handle whatever “rolled in the door,” as they also served as ED charge and were “more than capable” of ensuring EMTALA guidelines were followed. An interview by telephone with MD1 on 09/23/2025 at 12:47 PM revealed they worked the evening of 08/01/2025 and were present when the EMS call came in for P1. MD1 further explained they were trying to skip the extra stop so P1 could go straight to Facility #2 and nor were there any EMR entries regarding P1. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to maintain a Central log on Patient #1 when she presented to the facility’s property seeking medical assistance for a medical condition.”

“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: 35627 Based on interviews, review of medical records, EMS Report, video, Policy and Procedure review, and Healthcare System Medical Staff Rules and Regulations” it was determined the facility failed to ensure all individuals presenting to the Emergency Department (ED) received an appropriate medical screening examination within the capability of the hospital’s ED including ancillary services routinely available to the ED to determine whether or not an emergency medical condition existed for one (1) of twenty (20) sampled patients, Patient (P)1, who presented with psychiatric complaints. The findings include: Review of Facility #1’s policy “Emergency Medical Treatment and Labor Act (EMTALA) Emergency Care and Transfers”, dated 11/04/2024 indicated the facility “provides without discrimination a Medical Screening Examination by a physician or other Qualified Medical Person to any individual ...who comes to the hospital’s emergency department seeking evaluation and treatment of a medical condition to determine whether the individual has an Emergency Medical Condition, regardless of their ability to pay ...If it is determined that an Emergency Medical Condition exists, Facility #1 provides further examination and medical treatment necessary to Stabilize the Emergency Medical Condition, within the hospital’s Capacity and capabilities, including ancillary services routinely available in the hospital, or arrange for an appropriate Transfer in accordance with the procedures set forth in this policy. Review of Facility#1’s “Healthcare System Medical Staff Rules and Regulations” dated 01/20/2022 revealed “all individuals who come to the hospital’s emergency department seeking examination or treatment shall be provided with a Medical Screening Examination within the capabilities of the hospital and the ancillary services routinely available to the emergency services of the hospital, including examination, testing, treatment, and the services of appropriate on-call physician where necessary.” The EMS report dated August 1, 2025, for Patient #1 was reviewed. The report revealed in part, “Chief complaint Psychiatric episode ... Signs and symptoms: Altered mental status (Primary) Restlessness and agitation ...Dispatched with fire to a residence for reports of unconscious person. On scene, family and fire are surrounding patient who is laying on the ground and is emotional. Other family members assisted with moving the family member to allow EMS to access patient. Patient is yelling and scratching at her face. Patients swings her fist at responders when they get close to her ...Patient exhibiting sever agitation. Patient administered 10 mg Versed (sedative) IM (intramuscular). Approximately 5 minutes after medication administration, patient lifted from sidewalk and placed on stretcher. Patient continued to be agitated and combative. Patient upper extremities restrained using triangle bandages. Patient lower extremities secured with seatbelts. Patient made no attempt to kick responders or get out of seatbelts. No other restraints necessary for lower extremities. Patient secured with all seatbelts and moved to truck. Due to patients’ severe agitation and combative behavior towards responders, 2 firefighters rode in the back of the ambulance to provide support during transport. Patient placed on ...nasal cannula, cardiac monitor, and vital signs obtained. Patient transported non emergent to Norton Hospital Downtown ...report called to Norton Hospital with approximately 10-minute ETA. As ambulance approached the entrance of the hospital ambulance bay, a nurse was standing in the middle of the sidewalk blocking EMS from hospital property and entering ambulance bay, Nurse explained to Medic (EMS personnel) that a “Psyche Nurse” was on the floor and overheard the call in. Said nurse said Norton Downtown could not accept patient due to combativeness. Nurse at ambulance bay relayed that psyche nurse stated patient was to be taken to Facility 2 (Facility #2) as Facility 2 has a psyche unit and security staff. ...EMS crew resumed transport and notified dispatch of the change in destination. Patient transported to Facility #2.” Review of Facility# 1’s recorded video on 08/01/2025 at 9:20 PM revealed an ambulance approaching the Facility #1’s ambulance bay ramp. RN1 jogs toward the ambulance, waving. The ambulance stops, RN1 stands at the passenger side window and appears to speak with the paramedics. At 9:21 PM the ambulance pulls away from the ramp. Review of Facility #2’s “Face Sheet” for Patient #1 was reviewed. The review revealed that P1 was registered in the ED on 08/01/2025 at 9:47 PM for a psychiatric evaluation. Patient #1 was assessed by a provider, treated and discharged on 08/02/2025. Interview with Director of Compliance and Ethics (DIR) 1 on 09/23/2025 at 8:30 AM revealed after watching the 08/01/2025 video they had contacted CMS via email to report a possible EMTALA violation. DIR1 went on to state that all aspects of EMTALA should be followed when a patient presents on Facility #1’s property seeking medical care. Interview with DIR3 on 09/23/2025 at 2:00 PM revealed they identified the 08/01/2025 incident as an EMTALA violation when they were contacted by phone the evening it occurred. They instructed RN3 to begin educating ED staff regarding all components of EMTALA protocol. Interview with RN3 on 09/30/2025 at 9:46 PM, revealed they were the charge nurse on the evening of 08/01/2025 but was tied up a patient when the call from EMS came in. They further stated they had full confidence RN4 would handle whatever “rolled in the door,” as they also served as ED charge and were “more than capable” of ensuring EMTALA guidelines were followed. On 09/26/2025 at 1:30 PM an interview with RN2 was working the evening of 08/01/2025 and overheard the radio call for an extremely agitated patient who had to be sedated with 10 mg of Versed (a sedative) IM for transport. RN2 further stated they then verbalized, to no one in particular, Facility #1 was not admitting agitated, psychotic patients to the Behavioral Health (BH) unit, and wished P1 could go to Facility #2, be seen by a psychiatrist and admitted to an actual BH unit. RN2 shared they would normally wait for medical clearance, assess the patient, then discuss disposition with the attending MD before transferring a patient but since P1 was an agitated BH patient, their assessment would have been minimal prior to transfer. Interview by telephone with MD1 on 09/23/2025 at 12:47 PM revealed they worked for Facility #1 in the ED for 33 years. They worked on 08/01/2025 but “didn’t recall very much” about the incident. MD1 did recall they were in the Doc Box when the EMS call stated they were bringing in a violent patient they’d already sedated. MD1 remembered RN2 stating P1 should go to Facility #2, thought it was a good idea and encouraged diversion to Facility #2. MD1 explained P1 was having a violent episode, BH triage said they could not handle them so, ED would likely end up transferring P1 anyway. MD1 described EMTALA protocol as an initial assessment, comprised of a short interview and an assessment for injuries, to determine if it was life or death. On 08/01/2025, they explained they were trying to skip the extra stop for P1’s sake, so they could go straight to Facility #2. The facility failed to ensure that their Medical Staff Rules and Regulations, and EMTALA policies were followed for Patient #1 when she presented to the hospital’s ED. This was evidenced by the hospital’s failure to provide an appropriate medical screening examination for patient #1 on 08/01/2025 that was within the capabilities of the hospital and the ancillary services routinely available to the emergency services of the hospital, including examination, testing, treatment, and the services of appropriate on-call physician were necessary as stated in the facility’s policy.”

“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: 35627 Based on interviews, review of medical records, Emergency Medical Services (EMS) run sheet review, medical staff regulations and EMTALA policies review, it was determined the facility failed to ensure all individuals transferring from their Emergency Department (ED) to other facilities received appropriate transfers for 1 (one) of twenty (20) sampled patients Patient #1. On 08/01/2025 Patient (P)1 was diverted from Facility #1 by an ED staff member who informed the EMS staff to take the patient to Facility #2. Facility #1 did not seek permission to transfer to the receiving facility #2, and Facility #2 did not accept P1’s care prior to transport and Facility#1 did not transmit any patient documentation to the receiving facility. As these facility failures resulted in an inappropriate transfer of the patient #1. The findings include. Review of Facility #1’s policy “Emergency Medical Treatment and Labor Act (EMTALA) Emergency Care and Transfers”, dated 11/04/2024 revealed “an Emergency Medical Condition specifically[sic] includes undiagnosed acute pain, psychiatric disturbances and symptoms of substance abuse (including intoxication).” “If it is determined that an Emergency Medical Condition exists, Norton Healthcare provides further examination and medical treatment necessary to Stabilize the Emergency Medical Condition, within the hospital’s Capacity and capabilities, including ancillary services routinely available in the hospital, or arrange for an appropriate Transfer in accordance with the procedures set forth in this policy.” “If the attending physician or Qualified Medical Person determines the individual does not have an Emergency Medical Condition, then the provider may discharge or transfer the individual as appropriate. If the individual has an un-stabilized Emergency Medical Condition, the individual may be transferred or discharged only under the following circumstances: Individual Initiated Transfers: An individual-initiated Transfer is appropriate if: (1) the individual, without suggestion or prompting by hospital staff, requests to be transferred to another health care facility; (2) the treating physician has recorded the risks and benefits of Transfer, and the individual or authorized representative has been informed of the risks associated with such a Transfer and of the hospitals’ obligations under this policy; and, (3) the patient or an authorized representative sign the Transfer Request form available in EPIC ( a comprehensive Electronic Health Record platform) . “Individual-initiated transfers comply with the Transfer requirements outlined below. Physician Certified Transfers: A physician may authorize a Transfer of an individual if: (1) the treating physician has examined the individual and determined that he or she is in need of services or procedures not within the hospital’s capabilities; (2) the treating physician signs a certification, stating that the benefits of the proposed Transfer outweigh the associated risks of Transfer; (3) the risks and benefits of the Transfer are clearly documented on the Transfer Record and have been explained to the individual; and (4) the individual or an authorized representative has signed an informed consent agreeing to the Transfer based upon the risks and benefits disclosed in the Transfer Record.” “If no one is able to sign the consent, staff document this fact in the medical record and on the Transfer Record. All physician-certified Transfers comply with the Transfer requirements outlined below. The hospital will not penalize or take adverse action against a physician or another Qualified Medical Person because such person refused to authorize a Transfer of an individual with an Emergency Medical Condition that has not been stabilized. If a Transfer meets the above-stated conditions, an appropriate Transfer is made. Any Transfer of an un-stabilized individual with an Emergency Medical Condition also requires compliance with all of the following actions: 1. Providing medical treatment to the individual until the Transfer has been completed; 2. Obtaining acceptance of the individual by a physician at the receiving facility; 3. Obtaining consent to the Transfer from the receiving health care facility; 4. Obtaining consent to the Transfer from the individual and/or authorized representative, when possible; 5. Sending all available pertinent medical records to the receiving health care facility; 6. Completing the Transfer through qualified personnel and transportation equipment, including life support measures; 7. Written documentation of the foregoing requirements. Transfer Record and Transfer Consent forms are maintained in Epic under the consents icon under Transfer and Transfer-Peds.” Review of Facility #1’s “Healthcare System Medical Staff Rules and Regulations” dated 01/20/2022 revealed “all patient transfers shall be conducted in accordance with the requirements of the Emergency Patient Care and Patient Transfer policy. When patients are transferred, appropriate information related to the care provided shall be exchanged with other service providers.” Review of the 08/01/2025 EMS run sheet, “as the ambulance approached the entrance to the facility’s ambulance bay, a nurse was standing in the middle of the sidewalk blocking them from hospital property.” The report stated the nurse explained, “a psych nurse had overheard the call and said Facility #1 could not accept P1 due to combativeness. Registered Nurse 2 had recommended P1 go to Facility #2, where they have security, a psychiatrist to assess patients and potential admission to a psychiatric unit”. The EMS crew resumed transport and notified dispatch of the change in destination. Interview with Paramedic (PMD)1 on 09/30/2025 at 12:53 PM revealed they were dispatched to assist P1 on 08/01/2025. When they arrived P1 was screaming and hollering, the Fire department was already on scene and family was holding P1 down. De-escalation of P1 didn’t work, so we sedated P1 but still had to restrain P1. The patient was hitting their head against something and scratching their own face. Once on the truck, PMD2 made the call to Facility #1. As they approached a nurse was standing at top of the ramp waving at me. We pulled the ambulance over and they asked us if this was the patient we’d called about. We affirmed and they told us to go to Facility #2 because P1 was a sedated psychiatric patient and Facility #2 has psychiatrists and security. I questioned this, as Facility #1 has psychiatrists and security, and the nurse said their psychiatric nurse had said they needed to go to Facility #2. Further interview revealed, once they got to Facility #2 they talked with a triage nurse, telling them what happened at Facility #1. Review of Facility #2’s “Face Sheet” reveals P1 was registered in the ED on 08/01/2025 at 9:47 PM in for a psychiatric evaluation. Review of an “ED Physician Note” dated 08/02/2025 at 3:20 AM the from P1’s 08/01/2025 visit revealed P1 began having diffuse abdominal pain, nausea and vomiting and was transferred from psychiatric services to the main MD for medical clearance. P1 was given Zofran for nausea, slept for some time and upon awakening began hitting themselves in the head. P1 was given IV droperidol (treats nausea and vomiting) and restrained. Once calm and medically cleared, P1 was transferred back to Facility #2’s Emergency Psychiatric Service (EPS). Continued record review of an “EPS Evaluation Note” dated 08/02/2025 at 5:44 AM revealed P1 denied suicidal and homicidal ideation, nor did they disclose any audiovisual hallucination. P1 remained calm and had no memory of hitting themselves in the ED. Etiology “likely panic disorder that is associated with menstruation and recommended follow up with Primary Care Physician or appropriate referrals.” Further review of the medical record revealed that there was no indication in Facility #2’s medical record for P1 of any correspondence with Facility #1, contacted facility #2, prior to or after the visit regarding their transfer. During an interview with MD1 on 09/23/2025 at 12:47 PM they described EMTALA protocol as an initial assessment, comprised of a short interview and an assessment for injuries, to determine if it was life or death. On 08/01/2025, they explained they were trying to skip the extra stop for P1’s sake, so they could go straight to Facility #2. MD1 stated after she spoke with RN4 she “thought it had been taken care of”. MD1 further stated they had not, nor had any ED staff contacted Facility #2 regarding P1. The facility failed to ensure that their EMTALA transfer policy and procedures were followed as evidenced by failing to provide an appropriate transfer of patient #1 on 08/01/2025.”

“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: 29137 Based on interview, record review, review of Facility #1’s policies, review of Facility #1’s Investigation Report, review of videos (from the facility and the police body camera), and review of Patient #1’s medical record from Facility #2, it was determined the facility failed to comply with 42 CFR 489.24 related to not providing an appropriate medical screening examination (MSE) and stabilizing treatment to a patient with an Emergency Medical Condition (EMC), for one (1) of twenty (20) sampled patients, Patient #1. Refer to the findings in 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: 29137 Based on interview, record review, review of Facility #1’s policies, review of Facility #1’s Investigation Report, review of videos (from the facility and the police body camera), and review of Patient #1’s medical record from Facility #2, it was determined the facility failed to comply with 42 CFR 489.24 related to not providing an appropriate medical screening examination (MSE) to a patient with an Emergency Medical Condition (EMC), for one (1) of twenty (20) sampled patients, Patient #1. Review of the distance between the Facility #1 and #2, using www.mapquest.com, revealed a distance of nine (9) miles and a drive time of sixteen (16) minutes. The findings included: Review of Facility #1’s policy #3771.9, titled “EMTALA Emergency Care and Transfers”, dated July 31, 2020, revealed an Emergency Medical Condition (EMC) specifically included psychiatric disturbances. The policy also defined Medical Screening Examination (MSE) as the process required to determine with reasonable clinical confidence whether an Emergency Medical Condition existed. Per the policy “comes to the hospital’s emergency department” meant an individual was considered to have “come to the hospital’s emergency department” where the individual presented to the emergency department and a request was made on his or her behalf for an examination or treatment for any medical condition, or a person observing the individual’s appearance or behavior would reasonably believe the individual needed examination or treatment for a medical condition. Per the policy, all individuals who “come to the hospital’s emergency department” seeking examination or treatment were provided a Medical Screening Examination (MSE) within the capabilities of the hospital and the ancillary services routinely available to the emergency services of the hospital, including examination, testing, treatment, and the services of an appropriate on-call physician where necessary. The policy stated all individuals would be treated similarly to other individuals who came to the hospital’s emergency department seeking treatment and/or examination and would be offered an appropriate MSE in line with hospital policies, rules, and regulations. Review of Facility #1’s policy #3770.6, titled “Care of Prisoners, (Forensic Patients)”, dated April 18, 2023, revealed the policy was designed to ensure that patients who were in custody of law enforcement officials remained in a secure environment while at Facility #1 and that appropriate measures were taken to ensure the safety of employees, patients, and visitors. Continued review revealed Law Enforcement Responsibilities at Facility #1 included that prior to arrival, the Law Enforcement Officer (LEO) was to contact the facility to inform them of their estimated arrival time. Further review revealed that upon arrival at the emergency room or designated location, the LEO was not to unload the patient (prisoner) at that time. The LEO was to call the hospital security dispatch to request escort assistance and designated parking location. Continued review of the policy revealed that upon arrival at the emergency room or designated location, the patient was to be logged into the security dispatch log and receive a forensic patient general information handout. Additional review revealed Facility Security was to transport the forensic patient via wheelchair to the designated location, and the LEO needed to walk alongside the wheelchair with their weapon located on the opposite side of the patient. Review of an email notification, dated 11/28/2023 at 3:21 PM, revealed Facility #2 notified Facility #1 they had received notification that Patient #1 had initially been brought to Facility #1 on 11/27/2023 by local law enforcement officer (LEO) #1 for suicidal ideation (SI). It was reported LEO #1 stated Patient #1 was refused treatment at Facility #1 because they did not take voluntary SI patients and therefore, Patient #1 was transported to Facility #2 for treatment. Continued review revealed Facility #2 requested Facility #1 to review the situation to determine the reason Patient #1 was was not provided medical stabilizing treatment prior to transport to Facility #2. Review of Facility #1’s Review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, dated 11/30/2023, revealed Facility #1 might have failed to provide a Medical Screening Exam (MSE) to an individual brought in by a local law enforcement officer (LEO), with a potentially unstable medical condition. Further review revealed Triage Registered Nurse (RN) #1 interpreted LEO #1’s question of “could you do this”, as meaning could the Emergency Department (ED) do a blood draw to check the blood alcohol content level of Patient #1. Further review of the document revealed Facility #1 had contacted LEO #1 for a statement, and LEO #1 stated he had relayed to RN #1 that Patient #1 was requesting voluntary mental health assistance. Additional review of the document revealed Facility #1 had stated that they did review the video (no audio) of the interaction between RN #1 and LEO #1. The document stated that the interaction between RN #1 and LEO #1 lasted for no more than twenty-two (22) seconds and that LEO #1 and Patient #1 were in the ED waiting room less than a minute. Continued review of the document revealed Patient #1 was not wearing handcuffs and did not appear in any distress. Further review of Facility #1’s self-report document indicated Facility #1 felt that there might have been some miscommunication between RN #1 and LEO #1. Review of Facility #1’s Central Log, dated 11/01/2023 through 12/18/2023, revealed Patient #1 was not documented as having presented to Facility #1’s Emergency Department (ED) on 11/27/2023. In addition, there was no documented evidence Patient #1 had a medical record generated at Facility #1 on 11/27/2023. Review of the video provided by Facility #1 revealed that on 11/27/2023, at 10:53:11 PM, Law Enforcement Officer (LEO) #1 and Patient #1 entered camera view. LEO #1 was casually entering the waiting room, with his hands in his pockets and Patient #1 was several steps behind, with a backpack, almost as if he/she was a separate individual, waiting to be checked in. Patient #1 was not in handcuffs. There were no observations of Patient #1 exhibiting any untoward behaviors. At 10:53:24 PM, LEO #1 and Patient #1 walked to the desk as Registered Nurse (RN) #1 was seating another patient for Triage. Review at 10:53:34 PM, showed RN #1 observed LEO #1 and Patient #1. There was no audio, but body language suggested there was a short conversation between RN #1 and LEO #1. At 10:53:39 PM, both the Triage Patient and Significant Other were watching the exchange between RN #1 and LEO #1. Between 10:53:47 PM and 10:53:56 PM, RN #1 retrieved a blood pressure cuff and applied it to the Triage Patient. Further review of the video revealed that at 10:53:59 PM, RN #1 continued with the Triage Patient, and LEO #1 and Patient #1 were observed turned toward the exit. Additional review revealed at 22:54:05 PM, Patient #1 turned back to the waiting room to retrieve his/her backpack. Between 22:54:18 PM and 22:54:23 PM, LEO #1 and Patient #1 were observed to walk toward the exit and disappear from camera view. Review of the Body Camera (Cam) footage from LEO #1 revealed LEO #1 and Patient #1 entered the ED at 9:48 minutes into the video, or time of 22:52:59 (10:52 PM). Continued review revealed they walked to the desk at 10:18 minutes into the video, or time of 22:53:29 (10:53 PM), and it sounded like LEO #1 told the nurse “voluntary consumer, do you need paperwork from me?” Additional review revealed RN #1 could be heard telling LEO #1 “we don’t deal in” then inaudible, at 10:25 minutes into the video, or time of 22:53:36 (10:53 PM). After this, there was some discussion of where the patient wanted to go between Patient #1 and LEO #1, and both left the ED. Review of Facility #1’s Investigation Report, dated 11/28/2023, revealed on 11/29/2023, facility video footage was reviewed, and RN #1 was identified as the Triage Nurse on 11/27/2023. RN #1 was interviewed and reported that she did not remember Law Enforcement Officer (LEO) #1 telling her that Patient #1 was having suicidal ideation (SI). It was further documented in the investigation that all she remembered was LEO #1 asking if they “do this”, as meaning could the Emergency Department (ED) do a blood draw to check the blood alcohol content level of Patient #1. RN #1 was reported to have said that at no time did LEO #1 express to her that Patient #1 was having SI. Continued review of Facility #1’s investigation revealed LEO #1 was interviewed on 11/29/2023. It was documented that he asked RN #1 if they (Facility #1) handled voluntary patients that were having suicidal thoughts, and RN #1 told him no, so he transported Patient #1 to Facility #2. Review of Patient #1’s medical record from Facility #2 revealed, on 11/27/2023 at 11:50 PM, Patient #1 was admitted to the ED, with the Chief Complaint (CC) of suicidal ideation (SI). Continued review revealed that an appropriate medical screening exam (MSE) was completed, and Patient #1 also received a Psychiatric evaluation. The Psychiatric evaluation eventually recommended an in-patient stay, and a bed was obtained at Facility #3, a Psychiatric hospital. Request for records from Facility #3 revealed Patient #1 did not have an admission on 11/27/2023 or 11/28/2023. On 12/19/2023 at 9:29 AM, and 12/21/2023 at 11:22 AM, voicemails were left for law enforcement officer (LEO) #1, but no return phone call was received. While interviewing Registered Nurse (RN) #1 on 12/20/2023 at 12:47 PM, she stated she had been an employee of Facility #1 for a total of three and one-half (3.5) years, two and one-half (2.5) years as a facility employee and one (1) year as Agency. She stated she had been caring for another patient at the Triage desk when LEO #1 walked in with Patient #1. She stated Patient #1 was not in acute distress, and he/she did not display any outward signs or symptoms of anxiety, such as crying, trembling, or a flat affect. She stated Patient #1 was calm and without disruptive behaviors. She stated Patient #1 was standing several steps behind LEO #1, smiling, without handcuffs and with a casual behavior. RN #1 stated that if she had observed any signs or symptoms of abnormal behaviors, she would have inquired further into the needs of Patient #1. RN #1 stated that all she remembered LEO #1 asking was how she was doing, and there was no indication of what Patient #1’s needs were. Additionally, RN #1 stated that she assumed LEO #1 brought Patient #1 in for a “chain of custody” blood draw to check for the amount of alcohol in Patient #1’s systems. She stated she remembered telling LEO #1 they did not do chain of custody blood draws at the facility if law enforcement did not bring the kit, but thought another local facility did do them. During an interview with the ED Educator (EDE) on 12/21/2023 at 9:15 AM, she stated that the Triage area in the waiting room was called First Watch, that was because the staff were the eyes of the waiting room. In addition to triaging patients, they would keep watch on the waiting room to assess if there was a change in an individual’s condition that might require emergent attention. The EDE stated clinical staff had replaced non-clinical staff as registrars for constant visualization of the waiting room for any change in individuals’ conditions, whether they had already been checked or were waiting to be checked in. She stated First Watch education was presented annually and was ongoing. During interviews with Registered Nurse (RN) #2 and RN #3 on 12/22/2023 at 10:49 AM, they both stated part of the responsibility of the First Watch (Triage) nurse was to complete across the room assessments of the individuals in the waiting room, both the ones waiting to be seen and the ones waiting on a bed if applicable. RN #1 and RN #2 stated they would observe for any changes in individuals in the waiting room and respond accordingly. While continuing the interviews with RN #2 and RN #3, both stated that the usual process any time a law enforcement officer (LEO) brought an individual into the emergency department (ED) for evaluation and treatment, was they usually came in through the ambulance bays and not the front door. RN #3 stated she could not remember the last time a LEO brought someone in the front door, and most of the LEOs were aware of the process. While interviewing the Director of the Emergency Department (DED) on 12/22/2023 at 1:09 PM, she stated she had been notified by the Director of Care Coordination (DCC) on 11/28/2023 of the possible EMTALA event. The DED stated she had reviewed the video to ascertain who the RN was working First Watch at that time, and she was able to identify RN #1. Continuing the interview, the DED stated she had RN #1 share her recollection of the encounter. The DED stated that RN #1 was adamant that law enforcement officer (LEO) #1 never stated the purpose of the visit. RN #1 stated all she remembered of the conversation with LEO #1 was him asking, “do you do this?” The DED stated RN #1 told her that RN #1 had not been able to ascertain that Patient #1 was even with LEO #1 until she observed Patient #1 following LEO #1 toward the exit. The DED stated RN #1 told her she had looked toward the door when LEO #1 was casually entering the waiting room, with his hands in his pockets, and Patient #1 was several steps behind, with a backpack. Patient #1 was not in handcuffs. While further interviewing the DED, she stated RN #1 expressed to her that even as LEO #1 was walking toward the desk, Patient #1 remained several steps behind him, almost as if he/she was a separate individual, waiting to be checked in. The DED stated RN #1 told her about the conversation, RN #1 assumed LEO #1 was talking about chain of custody blood draws, and RN #1 told LEO #1 the facility did not do those (Facility #1 did not have a Forensics Lab for chain of custody). The DED stated RN #1 told her as LEO #1 turned to exit, still with his hands in his pockets, Patient #1 followed him out, still several steps behind. The DED stated RN #1 told her, in hind sight, RN #1 should have asked more questions. The DED stated she had provided RN #1 with verbal real time education that included do not assume: ask every patient the purpose of the visit, all patients were screened, and regarding chain of custody blood draws, the facility could still do the blood draw for alcohol blood level. However, she stated the results would not hold up in court, and the LEO and patient needed to be educated about that because Facility #1 did not have a Forensics Lab. Additionally, the DED shared these concerns with the State Survey Agency (SSA) Surveyor via an email, dated 12/27/2023, which stated: “I wanted to share some concerns I have after watching the 11/27/23 video of a LMPD [Louisville Metro Police Department] officer walking a person in and then leaving with the person. My first concern was that the officer brought a SI person in the front ED lobby. Most of these type of patients are brought in the EMS bay. This keeps our lobby safe with patients and families waiting. When police brings in a SI patient through the EMS doors this also is near our behavioral health rooms. The officer was also walking in front of the person with his arms in his coat almost the entire time he was in the lobby. The person had two personal bags, which he placed in waiting chairs prior to approaching the nurse’s station. We do not know if the bags had been searched; their contents could pose danger to the officer, the person with the officer, and everyone in the lobby. From watching the interaction with the officer and the nurse, he spoke a very brief time with the nurse who was with another patient the majority of their interaction. He did not sign the person in or wait for his turn. Their interaction of speaking was less than 15 seconds which is a very short time to give a report of why you were called and why the person is here. If he would have signed the person in and waited, this could have been done with no interruptions and a clear and concise report would have be given. There would also have been no possibility of breaking [Health Insurance Portability and Accountability Act] HIPAA as he was talking about the person he brought in right in front of a patient waiting to be checked in. After the officer spoke to the nurse, the officer did not seem concerned about what was said by the nurse or that he questioned the validity. His expression did not change and he appeared to speak briefly to the person without facing the person again with his hands in his coat. The officer walked out toward the exit with the person behind him and did not see initially that the person went back in to get his belongings that he left in a chair. Officer then turned around to see where person went and walked back to the person. Next they both walked out of the emergency department with the officer in front with his back to the person. Again not the usual close observation of someone who is suicidal. I can see how my nurse would have thought this person was not here for behavioral health concerns but an alcohol screening.” Facility #1 alleged the following actions were completed prior to the survey entrance date: 1. A. Facility #1 alleged they had self-reported the possible Emergency Medical Treatment and Labor Act (EMTALA) event on 11/27/2023 to the State Survey Agency (SSA) and the Centers for Medicare and Medicaid (CMS). B. Review of Facility #1’s Review of the Report of Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation, dated 11/30/2023, revealed Facility #1 self reported a Potential Emergency Medical Treatment and Labor Act (EMTALA) Violation to the Centers for Medicare and Medicaid (CMS), Region IV office in Atlanta, Georgia. 2. A. Facility #1 alleged Leadership met via a ZOOM meeting, discussed the event, and devised a corrective Action Plan prior to the State Survey Agency (SSA) Surveyor’s entry on 12/18/2023. Facility #1 alleged the ZOOM Leadership meeting discussed the investigation, devising a corrective Action Plan, and proposed training with Emergency Department staff at the facility. Facility #1 alleged the Action Plan had components added to the annual EMTALA education that would address that staff must observe for signs and symptoms of mental illness and ask clarifying questions as to the purpose of an individual’s visit to the Emergency Department (ED). B. Review of Facility #1’s Investigation Report, dated 11/28/2023 revealed a ZOOM Leadership meeting took place on 12/01/2023, at 12:30 PM. Participants were the Chief Nursing Officer, Director of Emergency Department/Patient Care, Risk Director, Compliance Director, Quality Director, Emergency Department Educator and the Emergency Department Manager. The meeting detailed the investigation and response of review of completed training records as well as proposed training with Emergency Department staff at Facility #1. Review of the Action Plan revealed components were added to the annual EMTALA education that would address staff observing for signs and symptoms of mental illness and asking clarifying questions as to purpose of an individual’s visit to the emergency department (ED) in slides #25 and #53. Review of training records for the revised EMTALA education revealed an employee roster was utilized to ensure all staff were educated in the emergency department (ED). Additional review revealed the training was completed by 12/08/2023, with disciplinary action for staff who did the complete the education timely. Review of RN #1’s employee file did not reveal any disciplinary actions, she was up-to-date on competencies, including EMTALA, and she had completed the Pilot Education on 12/05/2023. Review of an email, dated 12/08/2023 at 7:07 AM, sent from the Emergency Department Educator, to the 12/01/2023 ZOOM meeting participants, outlined the remediation education that had been presented to Facility #1 ED staff, that included Traveling Nurses. During an interview with Patient #2, on 12/18/2023 at 4:47 PM, the patient stated he/she had presented to the Emergency Department (ED) for suicidal ideation (SI). Patient #2 stated that during this time, he/she did not have any concerns and felt care was being delivered in a professional manner. During continued interview with the ED Educator (EDE) on 12/21/2023 at 9:15 AM, she stated she had been present at the ZOOM meeting on 12/01/2023. She stated that during the meeting, the investigation into the event of 11/27/2023 was discussed and a remediation Action Plan was formulated. The Action Plan included “Pilot Education”, which was additional education added to the Emergency Medical Treatment and Active Labor Act (EMTALA) education that was already in place. The added education dealt with making sure staff asked enough questions to ascertain an individual’s concern for presenting to the ED. She continued the interview by stating that notification to staff was across multiple communications media, notifying them of the education and test and the deadline date of 12/08/2023. She stated that a Master Grid for the ED was utilized to ensure all staff completed the education and post-test. She stated she ran a report on 12/08/2023 and sent to Leadership for review. Compliance was 100%. While interviewing the Compliance Director on 12/21/2023 at 2:24 PM, he stated the Pilot Education for ED staff was a direct result of the identified miscommunication between RN #1 and law enforcement officer (LEO) #1, on 11/27/2023. The Compliance Director further stated the Pilot Education was part of the Action Plan instituted by Facility #1. During an interview on 12/21/2023 at 2:28 PM with the Quality Director, she verified she had been a participant in the ZOOM meeting on 12/01/2023. The topic of discussion was the possible EMTALA event on 11/27/2023. She stated an Action Plan was devised to present the Pilot Education to all Emergency Department (ED) staff with a 12/08/2023 compliance date. During an interview on 12/21/2023 at 3:48 PM with the Emergency Department (ED) Manager, she stated she was present at the ZOOM meeting on 12/01/2023. She stated the purpose of the meeting was to review the possible EMTALA event of 11/27/2023. The ED Manager stated it was determined what education (Pilot Education) was needed, and a deadline date was decided to be 12/08/2023. She stated the Pilot Education contained slides (#25 and #53) that went over recognizing mental health issues and to ask clarifying questions and not just going by perceptions. She also stated that the education sparked additional discussion in the ED. While interviewing Emergency Room Technician (ERT) #1 and ERT #2 on 12/22/2023 at 10:18 AM, both stated they had received the new EMTALA education and had passed the post-test. In an interview with the Director of Care Coordination (DCC) on 12/22/2023 at 12:57 PM, she stated she had attended the ZOOM meeting on 12/01/2023. She stated the meeting included going over the possible EMTALA event of 11/27/2023 and devising an Action Plan that included the Pilot Education. During an additional interview with the Compliance Director on 12/27/2023 at 1:48 PM, he stated that the Pilot Education was slated to be rolled out system-wide on 01/08/2024. However, he stated, given the possible EMTALA event on 11/27/2023, the education was piloted at Facility #1 as part of the remediation process. He continued the interview by stating that the plan would be to monitor the new education, system-wide, on an on-going basis. While interviewing the Director of Accreditation and Medical Staff Services on 12/27/2023 at 2:02 PM, she stated she had shared, in general conversation last week (12/18/2023 to 12/22/2023) with the State Survey Agency (SSA) Surveyor, about Facility #1’s Quality Management System (QMS) escalation process. The Director of Accreditation continued by stating, that in the case of the possible EMTALA event of 11/27/2023, the Chief Nursing Officer (CNO) had pulled the Leadership team (ZOOM participants of 12/01/2023) together to identify the root cause analysis (RCA) (miscommunication), and develop a corrective Action Plan. She stated the Action Plan included the Pilot Education, so named because of the on-going assessment of the test results and adjusting the remediation process as part of the process of improving the efficacy of the education. She stated QMS supported management of concerns at the local level and would escalate up the ladder to the CNO or Executive sponsor. She stated QMS provided the opportunity to solve concerns and replicate solutions across the System. In an interview with the Director of Risk Management (DRM) on 12/27/2023 at 2:30 PM, she verified she was present at the ZOOM meeting on 12/01/2023. The DRM stated that in addition to the discussion about the Pilot Education program and process for presenting the education and monitoring efficacy of the education, there was also discussion of the two (2) different perceptions of RN #1 and LEO #1. Continuing the interview, the DRM stated she sent a weekly Standards publication (Zero-gram) via email to Department Leaders for pertinent discussion of content with their staff. Review of the weekly Zero-gram, dated 12/07/2023 at 11:00 AM, revealed a discussion of clear, concise communication regarding patient safety strategies to prevent errors and miscommunication. Per interview on 12/27/2023 at 2:57 PM with the Quality Director, the Director stated the Root Cause Analysis (RCA) was determined to be miscommunication of the involved parties. While interviewing Registered Nurse (RN) #1, #2, #3, #4, #5, #6, and Emergency Room Technician (ERT) #1 on 12/27/2023 at 3:02 PM, they verified they had received the updated EMTALA education and passed a post-test. While continuing the interviews with RN #7, #8, #9, #10, #11, #12, and ERT #2 on 12/27/2023 at 3:11 PM, they stated they had received the new EMTALA education with a post-test. During interviews on 12/27/2023 at 3:21 PM with RN #13, #14, #15, #16, and ERT #3, they verified they had received the updated EMTALA education and passed a post-test. On 12/27/2023 at 3:37 PM during interviews with Physician #1 and Physician #2, they both stated they were employees of Facility #1 and had received the updated EMTALA training. In additional interviews on 12/27/2023 at 3:52 PM with Advanced Practice Registered Nurse (APRN)#1, Physician’s Assistant (PA) #1, and PA #2, they stated they were employees of Facility #1 and had received the updated EMTALA training.”