University of Louisville 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: 28734 Based on interview,document review, and policy review, the allegation Facility 1 failed to provide an appropriate medical screening exam (MSE) to one (1) of 20 sampled patients who came to the emergency department (ED) was substantiated. The findings include: Patient 5 presented to the hospital Emergency Department with a request for a medical screening exam. Staff refused to see Patient 5 and he was transported back to jail without an appropriate examination to rule out an emergency medical condition. Cross Refer to 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: 28734 Based on interview, policy review, and document review, the facility failed to provide an appropriate medical screening exam (MSE) within the capability of the hospital’s emergency department for one (1) of 20 sampled patients. Patient (P) 5, an inmate at Facility (F)2 presented to the emergency department (ED) and the Emergency Psychiatric Service (EPS) area accompanied by a Correctional Officer (CO), however, the patient was turned away without an appropriate medical screening examination (MSE). The findings include: A review of the policy titled, “EMTALA: Treatment and Transfer of Individuals in Need of Emergency” dated 03/28/2025 revealed UofL Health (Facility 1) must ensure any individual, including those with behavioral health needs, who seek emergency care received an appropriate MSE by a physician or a qualified medical person (QMP) within the capability of the hospital to determine whether an emergency medical condition (EMC) exists. The policy continued to reveal that UofL Health was required to complete an MSE and provide necessary stabilizing treatment to the individual. If the facility was unable to provide the necessary stabilizing treatment, or the patient requested a transfer, the ED must obtain, or attempt to obtain, in writing, an informed refusal of an examination, treatment, or an appropriate transfer. Review of the Office Inspector General (OIG) intake, dated 02/23/2026, and transmitted by the Vice-President (VP) of Quality Management (QM) of UofL Health stated Patient (P)5 had presented to the UofL Hospital’s EPS on 02/21/2026 around 1:28 AM escorted by a F2 correctional officer (CO). When P5 presented to the EPS, staff stated they could not treat them while in the custody of F2. P5 was then escorted out of the facility by F2’s CO without an MSE being conducted. The intake revealed the immediate actions taken included notifications of the House Manager, Risk Management, Compliance, Quality, and senior leadership of a potential EMTALA violation shortly after P5’s departure and an internal investigation was currently in progress. Review of the ED Log dated 02/21/2026 from 00:00 to 02/21/2026 at 11:59 PM revealed P5 presented to the ED on 02/21/2026 at 1:28 AM and had been checked out on 02/21/2026 at 3:43 AM without being assigned a physician or an ED room number. Further review of the log revealed P5 left the EPS without being seen (LWBS) on 02/21/2026 at 3:43 AM. Review of the facility medical records revealed no medical record pertaining to P5’s visit of 02/21/2026. Review of the “Uniform Citation” issued by the Metro Correctional Service Department, dated 02/20/2026 at 9:46 PM revealed “Post Arrest Complaint- Charge 1: 60/360 days involuntary hospitalization of mentally ill, serving involuntary hospitalization order from Jefferson County District Court MIW [mental inquest warrant].” Documentation indicated P5, “...has been stating that the voices in his head have been instructing him to kill his mother. He strangled and assaulted her.” Interview on 03/06/2026 at 11:00 AM with the Medical Director of EPS revealed P5 had already been placed in custody at the jail prior to their arrival at the EPS. She stated once P5 presented to the ED/EPS, no decision was made on where they should be evaluated, and P5 left without having received an MSE. The Medical Director further stated the correct process would have been to bring the patient to the assigned area, which is the holding area for prisoners, and was a more monitored area. She revealed P5 had been registered, but never given an MSE by the ED. She revealed after an MSE had been completed in the ED, then the ED would have called the EPS, and P5 would probably have been sent back to the jail. She revealed she had completed additional training with the staff and physicians regarding EMTALA. Interview on 03/06/2026 at 11:37 AM with the Licensed Clinical Social Worker (LCSW) revealed she had been on-site when P5 arrived at the ED/EPS and the nurses had informed her a prisoner had arrived on a 202A, and could she speak with the guards. She stated she had conferred with the Program Assistant to ensure the EPS had not received an email from the court in regard to the 202A, however, there had not been an e-mail. She stated she reviewed the paperwork sent with the prisoner and the presented 202A did not reveal the prisoner was out of custody. The social worker stated she informed the guard the EPS could not see the prisoner as long as he was still in custody and shackled. She revealed she had received prior and recent education on EMTALA after the incident with P5. Interview on 03/11/2026 at 9:44 AM with Registered Nurse (RN)3 revealed she had been the ED Charge Nurse when the incident had occurred. She stated the Triage Nurse had spoken with her, and F2 had brought in a prisoner on a 202A, but the EPS had refused to see them. She stated once she got to the area where the prisoner and the CO were, there were three (3) others from EPS there which included two (2) nurses, and a social worker (SW). She stated the SW had aggressively “jumped right in” and told the CO the prisoner could not be seen while they were in custody, and that the P5 had to be on furlough from F2. She continued to state that inmates could be housed in the ED because the CO could go in as well. She revealed P5 could have received an MSE in the ED. She stated she had been trying to speak in regard to this; however, it had been very hard to get a word in the conversation because of the SW yelling at the correctional officer. She stated she heard the CO state that if the prisoner could not be cleared of the 202A, they would take them back to the jail. The RN revealed after the CO left with the inmate, she had immediately called the House Manager. She stated she had explained the entire situation to the House Manager and informed the manager what she had witnessed just “felt wrong” and she had been concerned it may have been an EMTALA violation. Telephonic interview, on 03/11/2026 at 10:10 AM with RN2 revealed the EPS cannot evaluate prisoners if they have an armed officer with them. She revealed she had observed P5 shackled, and in an orange jumpsuit with a CO in the ambulance bay. She stated the CO had stated something about the prisoner being on a furlough, so she told the CO to “hold on” and she went back to the EPS, told the providers what she knew about the inmate. She revealed at that point, she and the social worker spoke with the CO together, and the social worker reviewed the paperwork, but a furlough had not been indicated for P5. She revealed he could have received a medical screening in the ED, but the EPS could still not evaluate an inmate in custody. She revealed she had received education on EMTALA prior to the incident, and after the incident. Telephonic interview with the Chief Nursing Officer (CNO) on 03/11/2026 at 11:00 AM revealed she had been made aware of the situation in the ED/EPS from the ED director, and from there, notifications had been cascaded to the Risk and Compliance team for review. She revealed P5 should have received an MSE in the ED. She stated the situation got the team a little confused, and out of their normal processes because this type of situation was rare. She revealed staff had received EMTALA training prior to the incident and also post incident. Review of the “EMTALA Action Plan 2026” revealed a UofL ED Staff Meeting had been held on 02/26/2026 with the plans to discuss EMTALA concerns with the ED Department, and to educate all patients, including inmates brought to EPS on a MIW (Mental Inquest Warrant) did require a screening. This plan was completed on 02/26/2026. To continue quarterly EMTALA training for those on or near an ED campus, update training quiz to incorporate inmates. The annual training was completed on 01/31/2026, and the quarterly assignment projected to be completed by 04/01/2026. Chief Medical Officer (CMO) to speak with the Medical Director of the EPS to confirm understanding that all individuals must be screened, completed 02/23/2026. The Medical Director of the EPS to communicate with EPS and behavioral health staff, completed 02/24/2026, and a review of the state guidelines for MIW processes in Louisville, KY with legal, projected completion date of 03/13/2026. Review of the ED “Staff Meeting” minutes, dated 02/24/2026 and 02/26/2026 revealed, “ ...Anyone that comes through our doors and signs in must have a medical screening exam. We had an inmate come in Friday night that was on a 202A and requesting EPS. Long story short, EPS does not typically evaluate inmates that are in custody, so this caused some confusion. The patient was sent away by EPS staff back to jail. Please make sure we are educating and reminding our staff that everyone gets seen.””

“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 video footage reviews, staff interviews, medical record reviews, Policy and Procedure review, it was determined the facility failed ensure all individuals who present to the ED seeking care received a medical screening examination (MSE) within the capability of the hospital’s emergency department including ancillary services routinely available to the emergency department to determine whether or not and emergency medical condition exists for one (1) of twenty (20) sampled patients, Patient (P)1 on 09/05/2025. The findings include: Cross Reference to A2406.”

“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 staff interviews, Emergency Department Central Log Review, and Policy review it was determined F1 (University of Louisville Hospital) failed to ensure all individuals who present to the hospital’s ED seeking care were entered into the ED (Emergency Department) log for one (1) of twenty (20) sampled patients, Patient (P)1. The findings include: University of Louisville Hospital policy, “EMTALA: Treatment and Transfer of Individuals in Need of Emergency Medical Services”, reference number 840-004, dated 09/01/2022 and revised 03/28/2025 was reviewed. The section of the policy titled “Central Log” revealed in part, “UofL Hospitals are required to maintain a Central Log on each individual presenting with an EMC including those individuals who present to the non-ED department of the hospital with an EMC, including all additional logs incorporated into the Central Log by reference, is maintained in the same manner and with the same central core of information. The logs must contain a minimum, patient visit to the emergency room in chronological order including: The log must contain at a minimum, patient visits to the emergency room in chronological order, including patient identification, means of arrival, time of arrival, whether the patient refused treatment, was refused treatment, transferred, admitted and treated, stabilized and transferred or stabilized and discharged.” Review of F1’s 09/05/2025 ED’s Central Log revealed no entry for P1. An interview with Patient Access Registrar (Reg1) on 12/03/2025 at 1:08 PM stated their role as a registrar was to take down each patient’s reason for wanting to be seen (chief complaint), determine if they had been seen prior, to copy their ID and get a consent to treat form signed. These items were completed in registration before triage. Reg1 stated they’d worked dayshift on 09/05/2025 and had recognized P1 when they entered the ED. Reg1 was working the desk and stated P1 was a regular patient and was often loud and obnoxious. Reg1 stated P1 called them a “bitch” while waiting in line. Reg1 had worked with agitated patients at F1 on the inpatient psychiatric unit, so they were unbothered and ignored P1. Reg1 stated P1 cussed them the whole time Reg1 was asking registration questions. When Reg1 asked for ID, P1 “threw it at me.” Reg1 stated they had trouble completing the registration because P1 didn’t want to report their chief complaint. Reg1 went on to state, “patients register and leave without being seen because they go outside to smoke or whatever and then don’t come back. I always ask the nurse if patients want to know how long, because they have a better idea of timeframes and I can share this with patients, so they don’t leave. It’s usually less than an hour. We all want the patients to get the care they need. All the patients are equal. We want to follow the laws.” Reg1 recalled completing annual EMTALA education in KNOW (F1’s electronic education software). Reg1 also stated they received individual EMTALA education on 09/05/2025 and the department had an EMTALA refresher the following week. Reg1 stated they fully understood, “every single patient who comes in the door must be fully registered, included on the Central Log and seen.” An interview with RN5 on 12/05/2025 at 3:31 PM revealed they were ED Charge Nurse on 09/05/025. RN5 stated, “I reported to House what had happened, I knew it was an EMTALA violation, and I was concerned about the physical aspect of the interaction. ED leadership spoke about the incident in our daily huddles and in the monthly staff meeting. ED Staff all have EMTALA training in our KNOW module quarterly. EMTALA means that when a patient comes onto our property they must be treated, no matter what.” Interview with RN1 on 12/04/2025 at 3:14 PM revealed they worked on 09/05/2025 as House Manager and RN5 reported a possible EMTALA violation to them. After watching the video. RN1 determined since P1 had signed in, F1 was in violation of EMTALA. The ED DON set up a conference call to discuss next steps and I did an incident report. P1 was hard to find because their registration was incomplete, and they weren’t listed on the Central Log. RN1 was finally able to find P1 and saw they were registered in F2’s (facility where P1 went to) ED. RN1 wanted to ensure P1 was OK. An interview with DON during the 12/01/2025 ED tour and observation at 3:40 PM revealed they were in the ED on 09/05/2025 when the incident occurred. The DON recalled P1 was “well known to ED staff and was needlessly escorted out of the waiting room. The DON stated P1 should have been seen that day, and all aspects of EMTALA would have been followed, which includes Central Log documentation.” Interview with Dir2 on 12/03/2025 at 10:39 AM revealed they were involved in the investigation and follow up education for the 09/05/2025 incident. Dir2 stated staff should always deescalate, and assume our patients are going through stuff. If a patient is too loud in the lobby, take them to a private area and have a provider do the screening as quickly as possible to stabilize them and our surroundings. If P1 had been treated more gently, they would have signed in, made it onto the Central Log and been screened. An interview with F1’s Chief Executive Officer (CEO), and prior Medical Officer on 12/04/2025 at 3:00 PM. The CEO explained registration should sign patients in, so they are on the Central Log. The facility failed to ensure that their policy was followed as evidenced by failing to maintain a Central Log on P1 when he/she presented to the hospital’s ED on 09/05/2025.”

“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 video footage reviews, staff interviews, medical record reviews, Policy and Procedure review, it was determined the facility failed ensure all individuals who present to the ED seeking care received a medical screening examination (MSE) within the capability of the hospital’s emergency department including ancillary services routinely available to the emergency department to determine whether or not and emergency medical condition exists for one (1) of twenty (20) sampled patients, Patient (P)1 on 09/05/2025. The findings included: Review of the F1’s ((University of Louisville Hospital ) ER (Emergency Room)2 video footage dated 09/05/2025, no audio, shows the ED (Emergency Department) waiting room with a patient at the registration desk engaged with Patient Access Registrar (Reg1), four individuals seated in the waiting room and one individual standing near the back hallway at the door to the ambulatory care clinic. Reg2 was seen multiple times behind the registration desk. P1 enters the pivot triage waiting area at 11:13 AM from the external entrance and stands in queue at the registration desk. P1 waits for six minutes. Reg1 began registration with P1 at 11:19 AM. At 11:22:15 AM P1 sat down in the waiting area opposite the registration desk. P1 returned to the desk at 11:22:49 AM and appeared to interact with Reg1 briefly, then turned and walked toward Security Officer (Sec1). At 11:22:54 AM, Sec1 approached P1, their verbal interaction appeared both animated and simultaneous, Sec1 stepped forward and as the distance between them closed, P1 backed up. Sec1 gestured toward the waiting area then toward the exit. P1 leaned in toward Sec1 and pointed a finger near Sec1’s face. Sec1 grasped P1’s right wrist with their right hand, turned P1’s upper body away from them toward the exit. P1 went to the ground, and Sec2 entered the frame from the external entrance. As P1 regained footing Sec1 and Sec2 assisted them toward the exit. P1 exited the building at 11:23:07 AM. Further review revealed that F1 provided no documented evidence indicating P1 had a medical record generated at F1 on 09/05/2025. The facility failed to ensure that an appropriate medical screening examination was provided for P1, who became disruptive with an ED staff member in the hospital’s ED lobby on 9/5/2025. The patient was escorted out of the hospital’s ED lobby by a hospital security guard and was not in custody as stated in the facility’s policy. As this resulted in an inappropriate MSE for P1 on 9/5/2025. The State Survey Agency (SSA) was unable to reach Sec1 for interview. Sec1 did not return to duty following 09/05/2025 and is no longer employed by F1. Sec1 did not return SSA calls nor texts, on 12/03/2025 at 9:00 AM and on 12/04/2025 at 11:30 AM. F2’s (another ER Pt.#1 went to) “face sheet” for P1’s 09/05/2025 ED visit revealed they were registered at 11:41 AM and their reason for visit was “ear infection and kidney stone.” The “physician note” stated P1 was 33 years old with a history of bipolar disorder and presented with multiple medical complaints. Physical examination of P1, an abdominal Computed Tomography (CT) scan, labs and urinalysis ruled out both kidney stones and ear infection. The CT did reveal a large stool burden, for which P1 was treated with Miralax and psyllium fiber (medications for constipation). P1’s “discharge instructions” show they were discharged on 09/05/2025 at 1:46 PM to home and the care of their primary care provider. Review of F1 policy, “EMTALA: Treatment and Transfer of Individuals in Need of Emergency Medical Services”, reference number 840-004, dated 09/01/2022 and revised 03/28/2025, states “F1 would comply with EMTALA and any applicable state, or local regulations related to emergency medicine. F1 must ensure any individual in or on the campus, including infants, minors, and those with behavioral health needs, regardless of the ability to pay, who seek emergency care receives an appropriate Medical Screening Exam (MSE) by a physician or qualified medical person (QMP) within the capability of the hospital’s ED to determine whether an emergency medical condition (EMC) exists; to include labor, minors and behavioral health needs.” Additionally, “EMTALA: Treatment and Transfer of Individuals in Need of Emergency Medical Services” explains, if an individual presents to the ED for care and then becomes disruptive to the point security and local law enforcement must intervene, a MSE or refusal of MSE must still be completed and documented in the Central Log and medical record. An MSE must be completed unless the disruptive patient is taken into custody. An interview with DON on 12/01/2025 at 3:40 PM revealed they were present in the ED on 09/05/2025 when the incident occurred. The DON stated they viewed the video footage of the incident with the Assistant Chief Nursing Officer (ACNO), VP1 and Coord, P1 “was escorted out of the waiting room before triage and a medical screening exam. An incident report was sent to Senior Vice President of Compliance, Risk & Audit Services (VP2), Senior VP Patient Services and Chief Nursing Officer (CNO), Chief Executive Officer (CEO) and our in-house Counsel, everyone who needed to be involved in determining EMTALA status. Once they made the call, the department heads got together to start on our education.” Interview with the Accreditation Performance Improvement and Peer Review Coordinator (Coord) on 12/03/2025 at 8:25 AM revealed, on 09/05/2025, upon hearing of the ED incident with P1, they looked the patient up in the System (S)1 and discovered P1 had gone to F2 and was treated in the ED there. An interview with Reg1 on 12/03/2025 at 1:08 PM revealed they had trouble completing P1’s registration on 09/05/2026 because P1 was agitated and didn’t want to report their chief complaint. Reg1 had completed annual EMTALA education in Knowledge Hub, F1’s electronic education software prior to the incident, individualized training on 09/05/2025 and the department had an EMTALA refresher the following week. Reg1 stated they fully understood, “every single patient who comes in the door must be fully registered and seen.” During an interview with Sec2 on 12/03/2025 at 2:30 PM they stated they assisted Sec1 escort P1 from the ED on 09/05/2025. Sec1 also stated, “when a patient comes to the ED, they have a legal right to a medical exam regardless of ability to pay or how they present, emotionally.” During an interview with the System Director of Security (DIR)1 on 12/03/2025 at 3:40 PM they reported on 09/05/2025 they saw P1 escorted off property by Sec1 and Sec2. Following the incident, a charge nurse reported F1 had a possible EMTALA violation. Dir1 recalled the video, “P1 had signed in, argued with Sec1 and P1 was escorted out before they were screened.” Dir1 reported they called compliance immediately after viewing video. Continued interview with Dir1stated “Sec1 reacted to P1s aggression. Sec1 could have paused after they were able to get away from P1 and asked for other staff to help.” Dir1 further explained Security knows if patients are in the waiting room, then they haven’t been screened. If one of those patients is so disruptive we think they’ll be escorted out, we must ask for help including nursing and a provider, when possible, sometimes nursing staff can talk the patients into staying if they are just reacting to Security, sometimes just their uniforms. Security will always document an incident report in these cases. During an interview with Dir2 on 12/04/2025 at 10:39 AM they recalled the 09/05/2025 incident and stated they knew it was a reportable EMTALA violation, as soon as they viewed the video. The report for the 09/05/2025 was sent to quality by 4:00 PM that same day. They stated, “our staff should always deescalate, assume our patients are going through stuff. If a patient is too loud in the lobby, take them to a private area and have a provider do the screening as quickly as possible to stabilize them.” Interview with CEO and prior Chief Medical Officer on 12/04/2025 at 3:00 PM revealed they took part in the conference call on 09/05/2025. The CEO recalled “P1 did not have the appropriate medical evaluation before they were escorted out of the ED. CEO explained the triage nurse must complete the triage to help determine if they have a serious medical condition, then with a provider’s stabilize before discharge. Interview with RN1 on 12/04/2025 at 3:14 PM revealed they worked on 09/05/2025 as House Manager and they determined P1 had signed in and was not screened, so it was an EMTALA violation. They reviewed the incident with the Director of Nursing (DON), registration and then called it in to Vice President of Quality and Patient Safety (VP). They had a quick conference call with leadership and filed an incident report before they left on 09/05/2025. Sec3 stated in an interview on 12/05/2025 at 2:10 PM “We can’t refuse anyone to be seen at the facility once they arrive. We cannot refuse anyone even if they are irate and/or making a scene. We need to get the MD and get Nursing involved to ensure they are seen.” During an interview on 12/05/2025 at 2:26 PM, RN4 stated, “EMTALA, generally, involves emergency care. If a patient comes on hospital property and needs emergency care, they have the right to be seen, have a medical screening and any care required.” Reg3 shared in an interview on 12/05/2025 at 3:00 PM they worked in registration on 09/05/2025. They checked on Reg1 when they heard P1 yelling at Sec1 and saw P1’s agitation from the live video feed in bed control at the main desk. They stated P1 was a regular and always comes in agitated, no matter how nice they are. Reg3 also stated “all patients who come in (to the ED) must be seen even if they were just seen, left and came back, if not it is EMTALA. Even when patients are supposed be at F2 for a procedure or whatever, they still register them and make sure they have a medical screen before they go.” Sec5 stated in an interview on 12/05/2025 at 3:08 PM, “EMTALA is if somebody presents themselves in the ED asking for emergency treatment, if they’re on property they must be seen no matter what the circumstances.” An interview with RN5 on 12/05/2025 at 3:31 PM revealed they were ED Charge Nurse on 09/05/025. RN5 stated, “I reported to House what had happened, I knew it was an EMTALA violation, and I was concerned about the physical aspect of the interaction. ED leadership spoke about the incident in our daily huddles and in the monthly staff meeting. ED Staff all have EMTALA training in our KNOW module quarterly. EMTALA means that when a patient comes onto our property they must be treated, no matter what.””