Mymichigan Medical Center Saginaw

“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: 48030 Based on interview and record review, the facility failed to follow policy and have clinical personnel initiate triage and complete a medical screening examination (MSE) to determine whether the individual had an Emergent Medical Condition for one (P-1) out of 20 patients, resulting in the potential for negative outcomes to P-1. Findings include: Record review revealed on 06/29/2024 at 1626 P-1 arrived to the facility’s emergency department with a chief complaint of a hand laceration. The only documentation in the medical record for P-1 was a facesheet. The patient’s disposition was noted as “left without being seen (LWBS) on 06/29/2024 at 1652. On 8/14/2024 at 1210 an interview with the Patient Registration (Staff P) staff that registered P-1 on 6/29/2024 was conducted. Staff P indicated she has worked at the facility for over 7 years in the Emergency Department (ED) and that she “did not remember anything about this patient”. When queried what the responsibilities of her role are, Staff P revealed she is required to get, “name, date of birth, address, phone number, social security, marital status, race, gender, employment and insurance information”. When queried if a patient presents with a bloody hand and in pain requesting immediate attention, what she would do, Staff P indicated that if she was busy “she would have security help them out” or “she would call the nurse out to see the patient if they were bloody and look like they needed immediate attention”. When queried about the process for a patient that wants to leave before being seen Staff P indicated, “it is a patient’s right to leave” and “I would notify the nurse or the secretary (if one is working) that the patient has left”. Staff P was queried whether she was familiar with the Emergency Medical Treatment and Labor Act (EMTALA) and she indicated she “did not remember what that was”. When queried if she any type of clinical background, Staff P indicated she did not and “we use our judgement” to determine if something needs to be brought clinical personnel’s attention right away or not. On 8/14/2024 at 0921 an interview was conducted with the Medical Director for the Emergency Department (Staff B). Staff B revealed he was not aware of the complaint regarding P-1. When queried what the expectation for the registration process was, Staff B revealed the registration staff should try to confirm identification from the patient or family member, but if a patient is “unstable” and needs immediate attention, a patient can be seen right away. When this situation occurs the registration staff is responsible for letting the charge/triage nurse or physician know a patient needs to be assessed. When queried if it is his expectation that the registration personnel should determine if a patient needs to be seen urgently or emergently, Staff B responded that the nurses and providers are readily available if the registration personnel have questions. Staff B indicated when he is working, he “always watches the board” and he knows when a patient has left without being seen, but staff usually tell him the reason. Staff B revealed if he is notified that a patient is upset or indicating they may want to leave without being seen, he will try to complete a rapid medical exam. When queried if a patient presents to the registration area with a bleeding, in pain and expressing that they feel like they need help immediately what his expectation for registration staff would be, “I would want the triage nurse or myself to be notified, so we can determine he the patient needs to be brought right back”. Review of facility policy titled “ED Provision of Care” last approved 08/2023 revealed under Procedure/Process A. Triage. 1. All patients presenting to the Emergency Department will be triaged by a registered nurse or paramedic for the purpose of establishing patient care priorities prior to obtaining insurance or financial assistance. 2. The Emergency Department nursing staff will provide triage twenty-four (24) hours a day ... Review of policy titled “...Emergency Medical Treatment & Active Labor Act (EMTALA) Policy”, policy #16250182, last approved 3/2024, page 6, under Procedure, Medical Screening and Stabilizing Treatment, #2, a. “Patients who come to a Dedicated Emergency Department requesting services will receive a triage exam ...””

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 48030 Based on interview and record review, the facility failed to identify delays in treatment due to the registration process for one (P-1) out of 20 patients, resulting in P-1 leaving without being seen (LWBS), delayed treatment and the potential for negative outcomes to P-1. Findings include: Record review revealed on 06/29/2024 at 1626 P-1 arrived to the facility’s emergency department with a chief complaint of a hand laceration. The only documentation in the medical record for P-1 was a facesheet. The patient’s disposition was noted as “left without being seen (LWBS) on 06/29/2024 at 1652. On 8/13/2024 at 1600 an interview was conducted with the ED Security Officer (Staff M) who was assigned to work in the ED when P-1 came to the facility seeking care. Staff M indicated he was not sure if he could recall interacting with P-1 but did recall an incident with a patient that was very upset, and he overheard him speaking with their family on the phone in the triage area saying, “nobody cares about me here” and was requesting they come get him to go somewhere else. Staff M indicated he remembers Staff P walking out into the lobby to address P-1 about his statements on the phone and overheard her say, “we know you are here, but we have other patients”. Staff M indicated he did not believe P-1 was ever evaluated by a nurse or physician and that he waited for about 20 minutes for a ride to another ED and during that time he witnessed P-1 holding his arm and looked like he was in pain. Staff M added he did not recall the patient bleeding. Staff M revealed he had witnessed another incident in which he witnessed Staff P interacting with a patient’s boyfriend who was worried and requesting help and Staff P was very “abrasive” with them and they left. When queried if he had ever reported any of his concerns about Staff P, Staff M indicated he had not, and added “I probably should have, it has been going on for quite a while”. On 8/14/2024 at 0921 an interview was conducted with the Medical Director for the Emergency Department (Staff B). Staff B revealed he was not aware of the complaint regarding P-1. When queried what the expectation for the registration process was, Staff B revealed the registration staff should try to confirm identification from the patient or family member, but if a patient is “unstable” and needs immediate attention, a patient can be seen right away. When this situation occurs the registration staff is responsible for letting the charge/triage nurse or physician know a patient needs to be assessed. When queried if it is his expectation that the registration personnel should determine if a patient needs to be seen urgently or emergently, Staff B responded that the nurses and providers are readily available if the registration personnel have questions. Staff B indicated when he is working, he “always watches the board” and he knows when a patient has left without being seen, but staff usually tell him the reason. Staff B revealed if he is notified that a patient is upset or indicating they may want to leave without being seen, he will try to complete a rapid medical exam. When queried if a patient presents to the registration area with bleeding, in pain and expressing that they feel like they need help immediately what his expectation for registration staff would be, “I would want the triage nurse or myself to be notified, so we can determine he the patient needs to be brought right back”. On 8/14/2024 at 1030 an interview with the Emergency Department Charge Nurse (Staff Q) that was working the day P-1 came in seeking treatment. Staff Q indicated P-1 “did not ring a bell” with her and she does not recall being notified about the patient from registration. When queried what the standard process for a patient that arrives that is bleeding and in pain, Staff Q indicated, “patients that are bleeding, having chest pain, shortness of breath, symptoms of a stroke are usually brought right back”. Staff Q added that the registration staff will notify them that a patient has arrived that needs immediate attention, and the triage nurse will come out to evaluate the patient. When queried what she would do if she was notified that a patient was upset and indicating they were going to leave, Staff Q indicated “this doesn’t happen super frequently” but if it did, I would go out to the lobby to speak with them and usually it is a communication issue and I can convince them to stay. Staff Q added that she has observed Staff P interact with patients or families in the past and “sometimes she can be a little adversarial with the process”. On 8/14/2024 at 1210 an interview with the Patient Registration (Staff P) staff that registered P-1 on 6/29/2024 was conducted. Staff P indicated she has worked at the facility for over 7 years in the Emergency Department (ED) and that she “did not remember anything about this patient”. When queried what the responsibilities of her role are, Staff P revealed she is required to get, “name, date of birth, address, phone number, social security, marital status, race, gender, employment and insurance information”. When queried if a patient presents with a bloody hand and in pain requesting immediate attention, what she would do, Staff P indicated she if she was busy “she would have security help them out” or “she would call the nurse out to see the patient if they were bloody and look like they needed immediate attention”. When queried about the process for a patient that wants to leave before being seen Staff P indicated, “it is a patient ’ s right to leave” and “I would notify the nurse or the secretary (if one is working) that the patient has left”. Staff P was queried whether she was familiar with EMTALA and she indicated she “did not remember what that was”. When queried if she any type of clinical background, Staff P indicated she did not and “we use our judgement” to determine if something needs to be brought to clinical personnel ’ s attention right away or not. On 8/14/2024 at 1300 review of policy titled “...Emergency Medical Treatment & Active Labor Act (EMTALA) Policy”, policy #16250182, last approved 3/2024, page 6, under Procedure, Medical Screening and Stabilizing Treatment, #2, a. “Patients who come to a Dedicated Emergency Department requesting services will receive a triage exam. If the triage exam detects a possible Emergency Medical Condition that needs immediate attention, the patient will be immediately brought to the examining area where the Medical Screening Examination will continue by a physician or a Qualified Medical Person.””