Peacehealth United General Medical Center

“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: 42740 . Based on interview, record review, and review of hospital policies and procedures, the hospital failed to provide an appropriate medical screening examination for all patients presenting to the emergency department for care, in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). Failure to comply with EMTALA regulations risks poor patient outcomes, injury and death. Findings included: The hospital failed to provide a medical screening examination for two patients who presented to the hospital requesting emergency medical care. Cross-Reference: A 2406 .”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 42740 . Based on interview, document review, and review of hospital policies and procedures, the hospital failed to provide an appropriate medical screening exam (MSE) for 2 of 20 patients (Patient #1, Patient #4) seeking treatment in the emergency department (ED). Failure to provide an appropriate MSE by a qualified medical professional risks poor health outcomes, injury, and death. Findings included: 1. Review of the hospital’s policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance,” PolicyStat ID #14920715, approved 02/19/24, showed that the medical center provides an appropriate medical screening exam (MSE) whenever an individual comes to the dedicated ED and requests examination or treatment. 2. Review of the document titled “Medical Staff Rules and Regulations,” approved 05/22, showed that Qualified Medical Personnel (QMP) who can perform medical screening exams within applicable hospital policies and procedures are defined as: a. Members of the Medical Staff with clinical privileges in Emergency Medicine b. Other active members of the Medical Staff c. Appropriately credentialed Advance Practice Professionals Patient #1 3. The investigators reviewed the medical record for Patient #1, a 33-year-old male. The record showed: a. Patient #1 arrived at the hospital emergency department (ED) on 04/27/24 at 3:40 PM complaining of groin pain and nausea. b. The patient was discharged at 3:44 PM by the registered nurse (RN) assigned to triage (Staff #8). c. Staff #8 updated Patient #1’s disposition to “registered in error”. d. Documentation of a medical screening exam (MSE) before discharge could not be found. 4. Hospital system electronic medical record (EMR) review showed that Patient #1 registered at another hospital ED with a complaint of groin pain on the same day, 1 hour and 54 minutes after “registered in error” was entered in the EMR. Patient #4 5. The investigators reviewed the medical record for Patient #4, an 8-year-old male. The record showed: a. Patient #4 arrived in the hospital ED on 04/27/24 at 12:40 PM complaining of groin pain. b. The patient was discharged at 12:45 PM by the RN assigned to triage (Staff #8). c. Staff #8 updated Patient #4’s disposition to “registered in error”. d. Documentation of a medical screening exam (MSE) before discharge could not be found. Interviews 6. On 06/11/24, from 12:00 PM to 1:00 PM, the investigators reviewed the medical records of Patient #1 and Patient #4 with the ED Assistant Manager (Staff #2) and the ED Manager (Staff #3). Staff #2 and Staff #3 verbally confirmed that Patient #1 and Patient #2 were registered for ED services and then their dispositions were changed to “registered in error” within a few minutes of arrival to the ED. Staff #2 confirmed that Patient #1 and Patient #4 did not have a medical screening exam from 04/27/24 documented in their medical record. 7. On 06/11/24 at 12:45 PM, the investigators interviewed the registration staff member (Staff #4) who registered Patient #1 and Patient #4 on 04/27/24. Staff #4 stated that after she registered Patient #1, she observed the triage nurse (Staff #8) enter the waiting area and speak with Patient #1. Patient #1 then left the hospital. Patient #4 was also registered for ED services. Staff #4 stated that she observed Staff #8 entering the waiting area and speaking to the family of Patient #4. Patient #4 and his family then left the hospital. Staff #4 expressed concern for patients being turned away, so she notified the house supervisor. 8. On 06/11/21 at 3:30 PM, the investigators interviewed the ED RN (Staff #8) who spoke with Patient #1 and the family of Patient #4 in the waiting area on 04/27/24. Staff #8 stated the following: a. She could not specifically recall Patient #1 and Patient #4 but admitted to notifying patients waiting for care when certain services or testing were not available, and afterwards, some patients would choose to go elsewhere. b. Patients with groin or testicular pain typically require an ultrasound to rule out testicular torsion. c. There were times at the hospital when an ultrasound technician was not available, and she would notify patients who would potentially need an ultrasound. d. Staff #8 would change the patient’s disposition to “registered in error” so that they wouldn’t be charged for care. e. Staff #8 also stated that she only informed patients of services not available when they appeared stable. f. Staff #8 confirmed that the patients who chose to leave were not evaluated by a medical provider before leaving the hospital. g. Staff #8 discussed the waiting area conversations with hospital leadership and stated that she had learned a hard lesson but had not yet received additional formal EMTALA education. 9. On 06/11/24 at 1:00 PM, the investigators interviewed the Director of Clinical Risk Management (Staff #12). Staff #12 stated that on 04/27/24, hospital leadership was alerted to 2 patients leaving the ED. Staff #12 confirmed that their investigation showed that Patient #1 left the hospital and received care at another hospital ED on the same day for the same concerns. Staff #12 stated that an immediate internal investigation was completed and a corrective action plan was in progress. 10. On 6/12/24 at 10:30 AM, Investigator #2 conducted a second interview with the Director of Clinical Risk Management (Staff #12). Staff #12 stated that the hospital interviewed Staff #8 who confirmed that she had spoken with Patient #1 and Patient #4, decided that they were stable, and advised both patients to go to another hospital because ultrasound in the ED was not available at the time. .”