Umass Memorial Healthalliance Hospitals

“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: 41143 The Hospital failed to ensure compliance with EMTALA regulations as one Patient (#1) out of a total sample of 30 patients, did not receive a medical screening evaluation (MSE) to determine whether an emergency medical condition existed. Patient #1 presented to the Hospital’s second campus Emergency Department (ED) and was diverted to the Hospital’s main campus without a MSE by a physician.(see tag A2406).”

“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: 41143 Based on record review and interviews, the Hospital failed to ensure one Patient (#1) out of a total sample of 30 patients, received a medical screening evaluation (MSE) to determine whether an emergency medical condition existed. Patient #1 presented to the Hospital’s second campus Emergency Department (ED) and was diverted to the Hospital’s main campus without a MSE by a physician. Findings include: Review of the Hospital’s policy titled “EMTALA Compliance - Medical Screening, Transfers and Refusal of Care”, dated 1/13/25, indicated the following: -All Patients presenting to the Hospital requesting examination or treatment for what may be an emergency medical condition shall receive an appropriate medical screening examination, stabilizing treatment for an emergency medical condition, and if necessary, transfer in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). -The Hospital will not engage in activities that discourage individuals from seeking emergency medical care. -Medical Screening Examination: The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition does or does not exist. The MSE must be provided by a physician or other qualified individuals who have been approved by the Hospital’s Board of Trustees to perform such examinations. -Presents to Hospital: When an individual is on the Hospital campus where and Emergency Department is located or on property adjacent to these campuses, including any sidewalk, parking lot, or driveway within 250 yards of the campus. -Provision of MSE: If an individual presents to the Hospital and either a request is made by the individual or on the individual’s behalf for examination or treatment of an emergency medical condition, the Hospital will provide an appropriate MSE within the capability of the Hospital. Review of the Hospital’s policy titled “Medical Clearance of Behavioral Health Patients”, dated 11/12/24, indicated the following: -All patients presenting to the Emergency Department as a behavioral health patient will have a MSE by an emergency department provider to determine clearance from emergency medical conditions that would preclude or delay a behavioral health evaluation. Review of Patient #1’s medical record indicated the Patient presented to the Hospital’s ED on 3/31/25 at 10:04 P.M. with an arrival complaint for a mental health evaluation. A Registered Nurse (RN) documented Patient #1 was sent to the Hospital ED for a behavioral health hold until an inpatient bed search for psychiatric placement could be completed by the community health organization. Patient #1 was documented to have had feelings of wanting to hurt her/himself and had a self-inflicted superficial scratch on his/her forehead. Patient #1 presented to the Hospital’s second campus, was met outside by Hospital staff, and told to come to the main Hospital campus due to a lack of rooms at the other campus. Patient #1 was evaluated to be a moderate risk for suicide, placed on a behavioral health hold with constant observation, and was transferred to a psychiatric hospital for inpatient care. Review of the security footage from the Hospital’s second campus ED ambulance bay from 3/31/25 indicated Patient #1 arrived at 9:44 P.M. to the ED via car. Patient #1 was met by RN #6 and a patient care technician. RN #6 could be observed talking into the passenger window of the vehicle. At 9:46 P.M., the vehicle left the bay area in front of the ED without anyone exiting the vehicle. During an interview with RN #1 on 4/9/25 at 10:56 A.M., she said she was working the evening of 3/31/25 at the Hospital. She said the ED was full that evening and a patient care technician had called out for the night shift and a sitter had left sick. She said a call had come in from the community health organization, in which the ED staff were told Patient #1 was being sent to the Hospital ED for behavioral health issues. She said the nursing staff in the ED were overwhelmed at that point and did not have a supervisor on site at that time. She said she called the nursing supervisor working on the Hospital’s main campus, who was unable to send any staff to the Hospital’s second campus to help with the patient load. She said she asked the supervisor if the Hospital’s second campus could go on behavioral health diversion, and she said she was told by the supervisor if Patient #1 could be diverted safely, send the Patient to the main campus. She said later in the shift, while she was in triage, another RN made contact with Patient #1 outside the second campus ED, and the Patient went to the Hospital’s main campus without an evaluation. She said following this event, the Hospital will be holding mandatory in-person trainings to review EMTALA with Hospital staff. During an interview with RN #2 on 4/9/25 at 11:19 A.M., she was unaware of any communication following the diversion of Patient #1 to another Hospital campus on 3/31/25. During an interview with RN #3 on 4/9/25 at 11:40 A.M., she said following the diversion of Patient #1 to another Hospital campus on 3/31/25 she had received a notification for in-person, mandatory training for EMTALA, which was scheduled for future dates. She said during the day shift the ED Nurse Manager is on-site at the Hospital’s second campus for support. She said when the ED Nurse Manager is gone, the staff rely on an off-site supervisor at the Hospital’s main campus for support. During an interview with the Nurse Supervisor on 4/9/25 at 1:25 P.M., he said he received a call from RN #1 on 3/31/25 regarding Patient #1. He said he told RN #1 that Patient #1 could be transferred to the Hospital’s main campus after he/she received a MSE and a physician on the Hospital’s second campus arranged a transfer with a physician on the Hospital’s main campus. He said after the call with RN #1, he was later informed by the ED charge RN at the Hospital’s main campus that Patient #1 had arrived there and was told by a RN at the Hospital’s second campus he/she could not be evaluated there. He said a patient should always triaged and evaluated by a provider before being discharged or transfered from an Emergency Department. During an interview with RN #4 on 4/10/25 at 7:55 A.M., she said she worked the evening of 3/31/25 at the Hospital’s second campus ED. She said another RN there had contacted the Nursing Supervisor at the Hospital’s main campus and was told to just send Patient #1 to the main campus ED. She said the Hospital was planning to have mandatory, in-person trainings regarding EMTALA following the event. She believed she received a form from the Hospital explaining what EMTALA was via a messaging application. During an interview with RN#5 on 4/10/25 at 8:20 A.M., she said she was not sure about what occurred with Patient #1 on 3/31/25. She said she was the charge RN at the Hospital’s second campus ED on the evening of 3/31/25. She said it was a busy shift, difficult with staffing, and she had a six-patient assignment and was away from the nursing station due to the location of her patients. She said she was unaware Patient #1 had been diverted from the Hospital’s second campus to the Hospital’s main campus ED until the ED Nursing Manager contacted her the next day. She said following the event, the Hospital has scheduled future mandatory, in-person trainings on EMTALA. During an interview with RN #6 on 4/10/25 1:10 P.M., she said she worked the evening of 3/31/25 at the Hospital’s second campus ED. She said the patient volume was high that shift. She said all the behavioral health beds were filled at that time, along with the ED overflow beds. She said a phone call came into the ED from the community health organization informing the ED staff a behavioral health patient (Patient #1) would be arriving at the Hospital’s second campus ED. She said another RN called the supervisor at the Hospital’s main campus to ask for support as the second campus ED did not have a patient care technician available to assist with behavioral health needs. She said the other RN said the supervisor said he didn’t have anything to help the staff at the Hospital’s second campus. Following the call with the supervisor, another patient sitter called out for the night shift, and most of the ED staff were leaving at 11:00 P.M. She said the supervisor was called again and she was told if Patient #1 does not exit the vehicle, he/she can be redirected to the Hospital’s main campus for evaluation. She said she met Patient #1 at the car he/she was arriving to the ED in and told the Patient to go to the Hospital’s main campus as the second campus ED had no beds available for him/her. She said it is difficult at times at the Hospital’s second campus ED with staffing as the charge is often pulled away on an assignment and there is no supervisor on site to assist with problems the staff experience. She said since the diversion of Patient #1 on 3/31/25, the Hospital has scheduled mandatory education for EMTALA, which will be coming up.”