Maple Grove 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: 33925 Based on interview and document review, the hospital failed to ensure the emergency department (ED) central log and corresponding patient medical record was maintained with required data including treatment course and disposition for 1 of 20 patients (P1) reviewed. P1 presented to the ED seeking care and was not fully registered into the system causing multiple data fields and nearly the entire medical record and central log itself to be left blank or without required information when retrieved for review. See A-2405 for additional information. Based on observation, interview, and document review, the hospital failed to ensure a medical screening examination (MSE) was completed for 1 of 20 patients (P1) reviewed who presented to the emergency department (ED) seeking care. P1 presented to the ED on 3/7/26 intoxicated and wanting to get care, but he then became verbally belligerent with staff causing them to notify local law enforcement who then arrested P1 without a MSE being completed. The hospital self-reported this violation of EMTALA to the State Agency (SA) and implemented multiple corrective actions prior to the onsite investigation. See A-2406 for additional information.”

“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: 33925 Based on interview and document review, the hospital failed to ensure the emergency department (ED) central log and corresponding patient medical record was maintained with required data including treatment course and disposition for 1 of 20 patients (P1) reviewed. P1 presented to the ED seeking care and was not fully registered into the system causing multiple data fields and nearly the entire medical record and central log itself to be left blank or without required information when retrieved for review. Findings include: P1’s electronic medical record identified he presented to the ED on 3/7/26 at 18:37 and was entered into the system with a chief complaint recorded, “Alcohol problem.” P1’s Patient Event Tracking identified this encounter as an ED visit. The medical record lacked any recorded vital signs, nursing notes, physician notes, timeline for care, or other rationale explaining what, if any, services, or MSE was completed on the patient. The ED central log(s), dated 3/6/26 to 3/7/26 and 4/19/26, were requested and provided. The log included seven columns which were labeled as MRN (medical record number), arrival date, unit location, primary diagnosis, admit confirmation, discharge destination and one added to demonstrate disposition labeled, “MDH Column.” However, the log had space under the diagnosis and discharged destination columns amongst multiple patients which just had, “NULL,” being recorded. For P1, their MRN was identified along with a date of arrival as 3/7/26 at 00:00 along with, “NULL,” being recorded for their primary diagnosis and discharge destination. The added column for MDH screening identified a status, “Canceled.” When interviewed on 4/20/26 at 11:29 a.m., registered nurse (RN)-B stated they were working when P1 presented to the ED on 3/7/26 in the evening hours. P1 started to pound on the triage door at one point and wanted his blood pressure checked. RN-B explained to P1 they would help him as soon as they finished with their current patient and P1 returned to sitting in the lobby in the corner. There was some confusion amongst the staff on if P1 had been “checked in” or not yet, so RN-B went up to the patient and asked him why he presented to the ED. P1 then started to verbally curse at them and reported wanting to go to detox. RN-B stated to P1 that he needed to finish getting registered and then they could help him further. P1 stated the staff had his information which another staff member standing there verified. RN-B stated another nurse watching this got concerned and stated they were going to notify law enforcement who subsequently arrested P1 without a MSE being done. On 4/20/26 at 1:17 p.m., a group interview was held with nurse manager (RN)-A, the director of risk management (DRM), risk management specialist (RMS), and director of emergency services (DES). RN-A explained P1 had been initially entered into the record system by registration staff who checked on him but never was “arrived” into the tracking system as normally was done. DES stated they recalled P1 presented with some various papers and an old after-visit summary (AVS), but not all the papers needed to formally complete the check-in process. The group was unsure why P1’s details were not recorded on the central log despite his medical record having a chief complaint listed, but there was belief it may have been due to how IT was pulling the information. During interview on 4/20/26 at 3:15 p.m., system quality director (SQD)-A explained they worked with IT on pulling the requested ED logs when they were requested earlier that day by the surveyor. The information on the logs is pulled from the EPIC medical record system, and the columns could be adjusted or screened based on information needed or wanted. SQD-A stated the column labeled for MDH was an attempt to try to further pull information into the report to show the whole ED log. However, SQD-A was unsure why various fields were pulling with, “NULL,” included instead of actual data. SQD-A stated the missing data presented an opportunity to review the workflow for that information and how it pulls into the log adding they had involved people from the ED and IT teams to review that to ensure the data is captured accurately. The hospital Emergency Medical Treatment & Active Labor Act (EMTALA) policy, dated 10/2024, identified the hospital would provide emergency medical services in accordance with EMTALA and the applicable requirements. The policy stated an EMTALA log would be maintained with sufficient detail to include the patient’s name, date and time, diagnosis, and disposition of persons requesting examination or treatment of a medical condition. This log would be maintained for a minimum of seven (7) years.”

“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: 33925 Based on observation, interview, and document review, the hospital failed to ensure a medical screening examination (MSE) was completed for 1 of 20 patients (P1) reviewed who presented to the emergency department (ED) seeking care. P1 presented to the ED on 3/7/26 intoxicated and wanting to get care, but he then became verbally belligerent with staff causing them to notify local law enforcement who then arrested P1 without a MSE being completed. The hospital self-reported this violation of EMTALA to the State Agency (SA) and implemented multiple corrective actions prior to the onsite investigation. Findings include: On 4/20/26 at 9:30 a.m. the hospital ED was toured with registered nurse manager (RN)-A present. The ED was advertised to the local public as an ED with red-colored “EMERGENCY” signage posted outside of the building, and EMTALA signage was posted inside the lobby area which identified all persons presenting to the ED had the right to a MSE to determine if an emergency condition existed. P1’s electronic medical record was reviewed. P1 presented to the ED on 3/7/26 at 18:37 and was entered into the system with a chief complaint recorded, “Alcohol problem.” P1’s Patient Event Tracking identified this encounter as an ED visit. However, the medical record lacked any recorded vital signs, nursing notes, physician notes, timeline for care, or other rationale explaining what, if any, services, or MSE was completed on the patient. When interviewed on 4/20/26 at 10:28 a.m., RN-A stated they recalled this case and explained P1 presented to the ED intoxicated and started to get upset with the staff. He pounded on the triage room door at one point and wanted his vitals checked and help getting to “detox.” The nurses attempted multiple times to get P1 to comply with the registration and triage process, but he would not do so and remained in the general ED lobby area. P1’s behavior ended up causing one of the nurses to feel unsafe, so they called the local police department who responded and arrested P1 without an MSE being completed. RN-A stated they helped investigate this incident and the hospital self-reported it to the State Agency. When investigated, the hospital determined that none of the staff had alerted the medical providers of the situation to come do a MSE on P1 despite him sitting in the lobby area. RN-A stated the hospital sent re-education following this incident to the ED staff members to address the scenario and remind them to get a provider involved to help resolve the situation and do the MSE. When interviewed on 4/20/26 at 11:29 a.m., RN-B stated they were working when P1 presented to the ED on 3/7/26. P1 started to pound on the triage door at one point and wanted his blood pressure checked. RN-B explained to P1 they would help him as soon as they finished with their current patient and P1 returned to sitting in the lobby in the corner. There was some confusion amongst the staff on if P1 had been “checked in” or not yet, so RN-B went up to the patient and asked him why he presented to the ED. P1 then started to verbally curse at them and reported wanting to go to detox. RN-B stated to P1 that he needed to finish getting registered and then they could help him further. P1 stated the staff had his information which another staff member standing there verified. P1 continued to be upset and at one point seemed to stand up and “come at” RN-B who then extended their hand with a stop-like motion. P1 ran into the hand and became upset, but never physically threatened to strike anyone. RN-B stated another nurse watching this got concerned and stated they were going to notify law enforcement. RN-B stated at one point they recalled telling the other nurse P1 needed a MSE still. RN-B stated another nurse, RN-C, then started their shift and came out to the lobby to interact with P1, so they then left the area and reported the situation to the charge nurse. RN-B stated they never notified the medical providers working on the situation or to do an MSE, adding such would have been the “most appropriate” thing to do in hindsight. RN-B stated the hospital did address the situation and incident with them afterward and provided re-education on EMTALA obligations and how to address a scenario like this was “moving forward.” RN-B stated any patient presenting to the ED needed to have a MSE completed regardless of their behavior and staff would notify the provider immediately moving forward. When interviewed on 4/20/26 at 12:05 p.m., RN-C recalled starting their shift on 3/7/26 and hearing a male patient yelling aloud in the lobby. RN-C responded and found multiple staff members with P1 explaining they needed him to finish the registration process. P1 was responding with mostly curse words and “send me to detox.” RN-C stated another nurse had contacted the local police who responded and when P1 saw them, he stood up and walked outside to meet them when he was taken away. RN-C stated someone presenting to the ED could be checked in as “anonymous” if needed, but recalled there was not a room to immediately take him to, either. RN-C stated when they interacted with P1 on 3/7/26, they were not sure whether he had been seen or not by a medical provider for an MSE but added he should have been. RN-C stated they recalled RN-A discussing the incident with them afterward and everyone in the ED was re-assigned some EMTALA education to ensure the provider sees all patients who come to the ED for an MSE. When interviewed on 4/20/26 at 12:21 p.m., the ED medical director (MD)-A stated they were now aware of the incident with P1 which happened on 3/7/26 but had not been when it occurred. MD-A stated that a patient coming to the ED for care goes through a registration then triage process and placed into a room for the medical provider to evaluate them. MD-A stated if there were ever questions or issues, the nurses could always get one of the physicians involved to screen someone or do an MSE, including in the lobby, if needed. MD-A stated in the scenario with P1, the provider could have been contacted and involved with the situation. MD-A stated since the incident, they had sent some EMTALA reminders to the medical team about having to do screenings in non-traditional places like the lobby and reiterated any patient presenting to the ED needs a MSE to be completed in accordance with EMTALA. On 4/20/26 at 1:17 p.m., a group interview was held with RN-A, the director of risk management (DRM), risk management specialist (RMS), and director of emergency services (DES). RN-A reviewed the details of their investigation into the incident with P1 on 3/7/26 and stated P1 had been initially entered into the record system but never got “arrived” into the system as normally is done. DES stated it would be rare to admit someone under anonymous, but it could be done. The group all acknowledged the medical record being nearly entirely blank and that an MSE was not completed on P1 despite him presenting to ED seeking care. When asked, nobody believed P1’s situation would constitute an example of leaving against medical advice (AMA) or leaving without being seen (LWBS). RN-A stated they could “see both sides” of the issue with this case as nurses wanted to remain safe but also patients, even if behavioral, needed to be evaluated under EMTALA. DRM stated the incident was self-reported to the SA as it constituted an allegation of potential neglect of care. Following the incident, the hospital decided to immediately send EMTALA education to the ED staff members and communicate the need for a MSE to be completed in “shift huddles” which was done with the assigned online education being nearly completed by all ED staff members. The provided Assignment Completion Report, dated 4/20/26, identified the current completion rate of the ED staff education with each staff member listed. The completion rate was recorded as, “96.05%.” The hospital Emergency Medical Treatment & Active Labor Act (EMTALA) policy, dated 10/2024, identified the hospital would provide emergency medical services in accordance with EMTALA and the applicable requirements. This included, “[Hospital] shall provide a medical screening exam performed by qualified medical personnel to any individual who comes to the hospital campus property to determine if the patient has an emergency medical condition.””