PRINTED:02/21/2018
FORMAPPROVED
OMB NO 0938-0391

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

~1RE

(Xl) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

X3) DATE SURVEY
COMPLETED

CONSTRUCTION

A R 1rN'

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210038

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01/11/2018

WING
STREET ADDRESS, CITY, STATE, ZIP

NAME OF PROVIDER OR SUPPLIER

CODE

UNIVERSITYOF MDMEDICALCENTERMIDTOWNCAMPUS
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(X4) ID
PREFIX
TAG

A 000

A2402

Based on a media report a complaint
investigation (#MD00121566) of a possible
EMTALA was performed at University of
Maryland Medical center Midtown Campus on
January 11, 2018. The investigation included
review of patients' records and hospital policies,
procedures and other documentation, interviews
with staff, observations of the ED and care being
delivered and review of security videos from the
the hospital ED . Based on the survey the
following deficiencies of EMTALA were cited.
POSTING OF SIGNS
CFR(s): 489.20(q)
[The provider agrees,] in the case of a hospital
as defined in §489.24(b), to post conspicuously
in any emergency department or in a place or
places likely to be noticed by all individuals
entering the emergency department, as well as
those individuals waiting for examination and
treatment in areas other than traditional
emergency departments (that is, entrance,
admitting area, waiting room, treatment area) a
sign (in a form specified by the Secretary)
specifying the rights of individuals under section
1867 of the Act with respect to examination and
treatment for emergency medical conditions and
women in labor; and to post conspicuously (in a
form specifled by the Secretary) information
indicating whether or not the hospital or rural
primary care hospital (e.g., critical access
hospital) participates in the Medicaid program
under a State plan approved under Title XIX.
This STANDARDis not met as evidencedby:
Basedon a detailedreviewof the Emergency
Department(ED) during an EMTALAsurvey,a

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER

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Aooe

INITIAL COMMENTS

_.

REPRESENTATIVE'S

827 LINDEN AVENUE

BALTIMORE,MD21201

~402

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X5)
COMPLETION
DATE

The events that occurred at the University
of Maryland Medical Center, Midtown
Campus on January 9th 2018, clearly
represent an aberration from our
commitment to high quality patient care.
As part of taking full responsibility, we
have conducted an immediate internal
Root Cause Analysis, engaged outside
experts to perform an independent RCA,
and received the feedback from the forcause audit performed by the Joint
Commission. As a result we have taken
actions to address these findings. Our
corrective action plan addresses the
deficiencies cited in this CMS audit
summary. We remain committed to
delivering the highest quality patient care
to our community, and appreciate the
opportunity to provide our responses.

While multiple EMT ALA signs were
already posted in the ED, it was noted
that there was one location in the entry
area to the ED that did not have a sign
posted. EMTALA signage was posted
immediately on January t t", 2018.

1-11-2018

In addition, on February 22nd, 2018,
several additional EMT ALA signs were
placed to ensure that patients will see the
EMT ALA signage from any potential
entrance point.

2-22-2018

EMTALA signage is now checked by the
ED Clinical Manager and reported to
Director of Nursing on a weekly basis.
Any missing signs will be replaced.

SIGNATURE

TITLE

(X6) DATE

Mohan Suntha, MD, MBA, UMMC President and CEO

March 2, 2018

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined at ther safeguards
provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey
whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are
made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation,
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:7NZ5ll

Facility ID: MDHP25

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FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO 0938-0391
CONSTRUCTION

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X3) DATE SURVEY
COMPLETED

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210038

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01/11/2018

WING
STREET ADDRESS, CITY, STATE, ZIP CODE

NAME OF PROVIDER OR SUPPLIER

827 LINDEN AVENUE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS
(X4) ID
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A2402

A2405

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 1
tour of the hospital ED was conducted on January
11, 2018 at approximately9:15 am. The tour
revealed no visible EMTALA signage present in a
place likely to be noticed by individualsentering
the ED at the main pedestrianentrance to the
EmergencyDepartment.
EMERGENCY ROOM LOG
CFR(s): 489.20(r)(3)
[fhe 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 individualwho 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:
Based on a detailed review, interviews and
observations of the Emergency Department
(ED) by surveyors on 1/11/18, the hospital
failed to provide documentation of an accurate
and complete central log for the ED.
Patient#1 was transportedto the hospital ED by
ambulanceat 12:04 PM on a January 2018 day.
The patientwas dischargedat approximately11:
30 PM that night. Pt# 1 retumed a second time to
the hospitalED via ambulanceat approximately
12:20AM the next day. Pt# 1's name, visit and
dispositioninformationappeared only one time in
the hospital'sED log for the initialencounterat

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:7NZ511

BALTIMORE, MD 21201
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
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(X5)

COMPLETION
DATE

A2402

In the past, when a patient returned to the ED
within 2 hours of a prior visit, the original
A2405
encounter was re-opened in the Electronic Health
Record using the "un-discharge" function. As a
result, no new encounter was created. The
physicians believed that this expedited clinical
care. During the survey, it was identified that the
practice of the informal 2 hour rule inadvertently
resulted in the returning patient not being captured
on the EMTALA log.
On February 8,2018, this practice was
2-8-2018
discontinued. The ED registration staff was
educated that they must cease the practice of
using the "un-discharge" function.
Additionally, on February 28, 2018 the "un2-28-2018
discharge" functionality was disabled in the EHR
by the IT team. This ensures that each patient visit
now appears in the EMTALA log. We have
validated the effectiveness of these changes by
examining the month of February 2018. We note
that 41 patients returned to the ED within 24
hours, 2 of whom were found to have been
registered within 2 hours of their prior visit. We
will continue auditing on a monthly basis.
The EMTALA log will be reviewed monthly by the
Quality Improvement Coordinator assigned to the
ED to ensure that all patients are re-registered
upon revisit to the ED. If the log shows evidence 0
patients having more than one encounter within
two hours, the process will be deemed compliant.
Historically, ED leadership reports that
approximately 3 patients per month retum within 2
hours. If the audit shows that no patients are found
to have more than one encounter within two hours
for a period of 30 days, 70 records will be audited
to check for any evidence of notes entered after
the first discharge time which may indicate a
revisit.
Facility ID: MDHP25

If continuation sheet Page 2 of 8

 PRINTED: 02/21/2018
FORM APPROVED
OMB NO 0938-0391

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

210038

~1Rf
A

EilDI[:

B

WING

NAME OF PROVIDER OR SUPPLIER

A2405

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 2
1:30 PM . There were no entries in the log when
the patient retumed to the ED by ambulance
about 40 minutes after the first discharge.
In addition, because the hospital ED maintained
an informal policy of not re-registering patients
who re-presented to the ED within 2 hours of
discharge, it was impossible to determine how
accurate the ED log might be.

A2406

X3) DATE SURVEY
COMPLETED

C
01/11/2018
STREET ADDRESS, CITY, STATE, ZIP
CODE 827 LINDEN AVENUE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS
(X4) ID
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CONSTRUCTION

See Tag A0406 of the Condition of
Participation complaint survey of the same
date. MEDICAL SCREENING EXAM CFR(s):
489.24(a) & 489.24(c)
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) ofthis
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 conceming emergency
services personnel and direction; and

BALTIMORE, MD 21201
ID
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PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X5)
COMPLETION

DATE

Given that we monitor all patients who are deemed
A2405 high utilizers (meaning that they have more than 6
visits in the past 6 months) to address population
health needs, we will use this population to perform
these audits.
The results of this audit will be presented to the ED
Department Comprehensive Unit-based Safety
Program, any results that require follow up will be
reported to the Patient Safety & HRO Committee for
resolution, and ultimately to the Quality and Safety
Committee of the University of Maryland Medical
Center Board of the Directors. The Director of
Quality will be responsible for ongoing monitoring.

A2406

During the survey, it was identified that the use of an
informal 2 hour rule (see A2405 for details) allowed
staff to bypass the creation of a new encounter. This
resulted in the continuation of the prior medical
record, and as such no new MSE was performed.
Physicians and all ED staff have been re-educated
that an MSE must occur with every encounter.
On February 8,2018, the practice of using the "un2-8-2018
discharged" function of the EHR was discontinued.
The ED registration staff was educated that they
must cease the practice of using the "un-discharge"
function.
Additionally, on February 28, 2018 the "un2-28-2018
discharge' functionality was disabled in the EHR by
the IT team.
Disabling this function results in ensuring that each
arrival generates a new encounter number and
patients will appear on the ED Tracker board which
will trigger the MSE.
The EMT ALA log will be reviewed monthly by the
Quality Improvement Coordinator assigned to the
ED to ensure that all patients are reregistered upon
revisit to the ED and receive a new MSE.
For additional monitoring plan details, see A2405.

(b) 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
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:7NZ511

Facility ID: MDHP25

If continuation

sheet Page 3 of 8

 PRINTED: 02/21/2018
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(Xl) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO 0938-0391
~1RE

CONSTRUCTION

A

BlO""

B

WING

X3) DATE SURVEY
COMPLETED

C
210038

01/11/2018
STREET ADDRESS, CITY, STATE, ZIP

NAME OF PROVIDER OR SUPPLIER

CODE 827 LINDEN AVENUE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS
(X4) 10
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A2406

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 3
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) Non-applicability of provisions of this section.
Sanctions under this section for inappropriate
transfer during a national emergency 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 located in an emergency area, as
specified in section 1135(g)(1) of the Act. 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 for by 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.

BALTIMORE, MD 21201
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PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X5)
COMPLETION
DATE

Registrars were educated on February 8,2018 2-8-2018
that the process of reopening an account was
A2406 discontinued (See attachment A). All patients
that present to the ED receive a new
encounter each and every time they present.
With the implementation of the system
2-28-2018
changes in the electronic medical record on
February 28, 2018, the clinical staff can no
longer open a discharged encounter. This
new process ensures that all patients are reregistered with a new encounter number.
The EMTALA log will be reviewed monthly by
the Quality Improvement Coordinator assigned
to the ED to ensure that all patients are
reregistered upon revisit to the ED. If the log
shows evidence of patients having more than
one encounter within two hours, the process
will be deemed compliant.
If no patients are found to have more than one
encounter within two hours for a period of 30
days, 70 records will be audited per month to
check for any evidence of notes entered after
the first discharge time which may indicate a
revisit. Given that we historically monitor all
patients who are deemed high utilizers,
(meaning that they have more than 6 visits in
the past 6 months) we will use this population
to perform audits. We have performed this
validation for the month of February 2018 and
note that 41 patients returned to the ED within
24 hours, 2 of which were found to have been
registered within 2 hours on February 22,
2018. We will continue this audit on a monthly
basis.
The results of this audit will be presented to
the ED Department Comprehensive Unitbased Safety Program, any results that require
follow up will be reported to the Patient Safety
& HRO Committee for resolution, and
ultimately to the Quality and Safety Committee
of the University of Maryland Medical Center
Board of the Directors. The Director of Quality
will be responsible for ongoing monitoring.

This STANDARD is not met as evidenced by:
Based on a tour of the Emergency Department
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:7NZ5ll

Facility 10: MDHP25

If continuation sheet Page 4 of 8

 PRINTED: 02/21/2018
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

210038

OMB NO 0938-0391
~lR.E
A

RI["N':

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WING

CONSTRUCTION

X3) DATE SURVEY
COMPLETED

C
01/11/2018
STREET ADDRESS, CITY, STATE, ZIP

NAME OF PROVIDER OR SUPPLIER

CODE 827 LINDEN AVENUE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS
(X4) 10
PREFIX
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A2406

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 4
(ED) on 1/11/2018, review of ED processes
related to medical screening examinations
(MSE), staff interviews, policy and procedure
and other documentation, it was revealed that in
multiple ways, the hospital failed to ensure that
every presenting patient receives an MSE, when
it, 1) established an unwritten policy to reopen
an initial ED record for patients presenting within
2 hours of ED discharge in order to utilize the
initial MSE for the second visit; 2) failed to
conduct a MSE for patient #1 who presented a
second time within two hours; 3) failed to give
unencumbered access to the emergency
department for every walk-in patient; and 4)
failed to designate who can conduct an
emergency medical screening examination.

1) On 1/1112018 at approximately0930, a request
to a Qualitystaff memberfor patient#1's two
same-dayED presentationsrevealedin part,that
patient#1 had only one record due to an unwritten
hospitalpolicythat instructedpatientaccess staff
to reopenthe initialED recordfor patientswho
retum to the ED within 2 hours of discharge.
Interviewat 0930 revealedthat "The prior record
(initialpresentation)is reopenedfor continuityof
care." Furtherinquiryrevealedthat the second
presentingchief complaintwould determineif a
new MSEwas to be done on the second
presentation.Basedon this information,there was
no guaranteethat a new MSE would be conducted
for a patientpresentingwithin 2 hours of discharge
from the ED. This processfailed to meet regulatory
requirementsfor the provisionof a MSE for
individualscoming to an ED regardlessof timeline.
Interviewat approximately9:45 am with the
Directorof PatientAccess revealedknowledgeof
the 2-hour rule, but identifiedthat
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:7NZ511

BALTIMORE, MD 21201
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A2406

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCy)

(X5)

COMPLETION
DATE

Patients who present to the ED for care can
only receive a nursing triage and assessment if 2-28-2018
they appear on the ED Tracking Board to allow
clinicians to document care. During the survey,
it was identified that the use of an informal 2
hour rule (see A2405 for details) allowed staff to
bypass the creation of a new encounter, which
resulted in a continuation of the prior record
with no new triage being performed.
The elimination of the informal 2 hour rule on
2-8-2018
February 8, 2018 ensures that each patient
arrival is documented as a new encounter, and
as such, will trigger a nursing triage and
assessment. A review of the records in the
month of February 2018 demonstrate that the
two patients who were registered within two
hours of their original discharge, each had new
nursing triage and assessments.
Documentation audits will be conducted
monthly on a random sample of all patients
seen in the ED to ensure that this triage
assessment is being performed. The ED
Clinical manager will perform these audits.
The source of this problem was the informal 2
hour rule (see A2405 for details). When the
chart was re-opened, the patient was not reregistered, and without the registration, the
patient never appeared on the ED tracker
Board which is what prompts the Medical
Screening Exam.
The process of discontinuing the 2 hour rule will
ensure that each arrival generates a new
encounter number to place the patient on the
ED Tracker Board to trigger a new MSE.
Physicians and all ED staff have been reeducated that a MSE must occur with every
encounter, regardless of the time elapsed
between discharge and re-presentation.
The EMTALA log will be reviewed monthly by
the Quality Improvement Coordinator assigned
to the ED to ensure that all patients are reregistered upon revisit to the ED. If the log
shows evidence of patients having more than
one encounter within two hours, the process will
be deemed comoliant.
Facility 10: MDHP25

If continuationsheet Page 5 of 8

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FORM APPROVED
OMB NO 0938-0391

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(Xl) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

CONSTRUCTION

QQfvUlR.E

X3) DATE SURVEY
COMPLETED

A

C
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210038

01/11/2018

WING
STREET ADDRESS, CITY, STATE, ZIP

NAME OF PROVIDER OR SUPPLIER

CODE 827 LINDEN AVENUE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS
(X4) 10
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A2406

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCy)

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A240€

Continued From page 5
there was no written policy, Further, that when it
was noted at the registrar that a patient had been
seen 2-hours prior, the ED RN was to be notified.
Interview at approximately 1030 with the Regional
Medical Director for contracted ED providers
revealed knowledge of the 2-hour rule and the
statement that upon the second presentation, the
expectation is that a provider enter an addendum
progress note into the re-opened record.
2) Patient #1 was a young adult who presented to
the ED in January 2018 at 1304 via ambulance
following a fall from a motorized bike, which
resulted in striking a curb and an apparent minor
head injury. On arrival, an MSE was conducted
inclusive of Computed Tomography (CT) of the
head. Following the MSE, patient #1 was found
to be free of an emergency medical condition
and was cleared for discharge.
Patient #1 was resistant to discharge and would
not dress. Patient #1 was subsequently escorted
from the hospital by security staff while still in a
hospital gown on or about 2340. The patient was
brought back via ambulance at 0013. Ambulance
documentation revealed patient #1's chief
complaint was, "I do not feel normal, and do not
know what normal is." Upon arrival to the ED the
second time, the initial ED record was reopened.
Other than the ambulance documentation and a
note by the ED case manager at 0048, no other
documentation revealed that patient #1 had a
second presentation to the ED. The case
manager note stated in part, " ...Patient escorted
out earlier. Came back ...," and "Per multiple staff,
(patient #1) ambulated well in the ER and was
discharged via cab to the shelter."
Patient #1 received no vitals, and no triage. While

FORM CMS-2567(02-99) Previous Versions Obsolete

BALTIMORE, MD 21201

Event ID:7NZ5ll

(X5)
COMPLETION
DATE

If no patients are found to have more than one
encounter within two hours for a period of 30
days, 70 records will be audited per month to
check for any evidence of notes entered after
the first discharge time which may indicate a
revisit. Given that we historically monitor all
patients who are deemed high utilizers,
(meaning that they have more than 6 visits in
the past 6 months) we will use this population
to perform audits. We have performed this
validation for the month of February 2018 and
note that 41 patients returned to the ED within
24 hours, 2 of which were found to have been
registered within 2 hours on February 22,
2018. We will continue this audit on a monthly
basis.
The results of this audit will be presented to
the ED Department Comprehensive Unitbased Safety Program, any results that require
follow up will be reported to the Patient Safety
& HRO Committee for resolution, and
ultimately to the Quality and Safety Committee
of the University of Maryland Medical Center
Board of the Directors. The Director of Quality
will be responsible for ongoing monitoring.
The Medical Staff Bylaws did not define who
2-22-2018
could perform an MSE. A change was made to
the Medical Staff Bylaws to identify who can
conduct a Medical Screening Exam (MSE).
The governing Board approved proposed
changes on February 22, 2018. (See
attachment B). Bylaws are reviewed annually
and will be updated as needed to reflect any
changes in practice or regulatory
requirements. The Medical Executive
Committee is responsible for this review. The
current practice of who is performing the MSE
did not change. Therefore, no education is
required. The EMTALA log will be reviewed
monthly by the Quality Improvement
Coordinator assigned to the ED to ensure that
all patients are reregistered upon revisit to the
ED and receive a new MSE and that it was
performed by an appropriate provider. For
additional monitorina Dian details see A2405.

Facility 10: MDHP25

If continuation sheet Page 6 of 8

 PRINTED: 02/21/2018
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

210038

OMB NO 0938-0391
~1Rf
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RH1Ir.

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CONSTRUCTION

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01/11/2018
STREET ADDRESS, CITY, STATE, ZIP

NAME OF PROVIDER OR SUPPLIER

CODE 827 LINDEN AVENUE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS
(X4) ID
PREFIX
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A2406

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 6

ID
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A2406

the earlier interviewed Quality staff had indicated
that a chief complaint would determine if a new
MSE was conducted, there was no
documentation that hospital staff asked for a
chief complaint from patient #1 when she
returned by ambulance nor did they document
the chief complaint given by the ambulance
crew. Patient #1 was not seen by a provider,
who according to other documentation, told staff
not to re-register patient #1. There was no
evidence that a new MSE was conducted. for the
second presentation.
3) A survey tour of the Emergency Department
walk-in entrance revealed a large ante-area from
the street which contained a security booth
housing two security guards. Adjacent to the
security booth was the locked entrance door to
the ED waiting room and registration area. In
order to register to be seen in the ED, the doors
must be unlocked to allow the patient passage to
the registration desk. The locked door could only
be opened by security.
During an interview with security guard #1 at
approximately 1000 on 1/11, the surveyor
questioned what the guard would do if someone
who presented to the ED as a walk-in, acted
unruly. Security guard #1 stated he would "Escort
the person from the premises, or call the police if
the patient did not leave." An unruly patient could
be symptomatic of multiple somatic conditions
such as an individual with low blood sugar.
Therefore non-clinical personnel could determine
which presenting patients could enter the ED for
evaluation of an emergency medical condition.
Both security guard #1 and security guard #2
were asked if they had training related to the
FORM CMS-2567(D2-99) Previous Versions Obsolete

BALTIMORE, MD 21201

Event ID:7NZ511

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

In efforts to provide a safe care environment for
staff and patients, there was a longstanding
practice of keeping the interior ED entrance doors
locked, requiring Security (stationed at this
entrance 24 hours a day! 7 days a week) to buzz
people in upon arrival. The surveyors noted that
this practice resulted in a potential issue of limiting
access to patients arriving at the ED for
emergency care.
On January 12,2018, a communication occurred
to security staff to require them to allow access to
anyone arriving in the ED lobby seeking medical
care. EMTALA education was provided to all ED
security and was completed by February 28,2018
with a special emphasis on patient rights to
unencumbered access to emergency department.
While security staff is still present at the entrance
to maintain a safe environment, the automatic
closing mechanism on the doors was disabled
and doors were placed in the open position on
February 22,2018. In addition, on February 22
the automatic locking function was disabled by
facilities and modified as to not allow the doors to
be relocked if they do close.
Facilities installed functional door handles on
February 24,2018 to allow entry to the ED
registrar and triage area.
Due to the fact that these are smoke barrier
doors, security implemented a protocol on
February 23, 2018 to close these doors during a
fire alarm event.
Leadership rounding will be completed by
Security Director and Security Manager at least
weekly to reinforce security staff knowledge and
understanding of EMTALA and Patient Rights.
Daily rounding will be conducted by security
supervisors to ensure that the ED entrance doors
remain open. The Director of Security will be
responsible for ongoing monitoring.

(X5)
COMPLETION
DATE

1-12-2018

2-28-2018

2-22-2018

2-24-2018

2-23-2018

EMTALA education is provided upon new hire
orientation and annually to reinforce important
principles.
All staff working within the emergency department 2-28-2018
Facility ID: MDHP25

If continuation sheet Page 7 of 8

 PRINTED: 02/21/2018
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO 0938-0391
~1RE

CONSTRUCTION

A

RIIN-

B

WING

X3) DATE SURVEY
COMPLETED

C
210038

01/11/2018
STREET ADDRESS, CITY, STATE, ZIP

NAME OF PROVIDER OR SUPPLIER

CODE 827 LINDEN AVENUE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS
(X4)ID
PREFIX
TAG

A2406

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 7
Emergency Treatment and Labor Act (EMTALA),
Both guards were unable to say what EMTALA
was, and did not remember hearing the term, or
having any training in EMTALA. However, a
review of their personnel records revealed that
they had received EMTALA training. Based on
the responses of the security guards, it was
apparent that the security guards did not
understand EMTALA despite having the requisite
training. Additionally, interviews revealed no
relevant reason as to why non-clinical staff such
as security guards would be placed in a position
to determine who could and could not enter the
locked door to the ED.
4) Based on review of the hospital's bylaws and
other policies, it was determined that the hospital
failed to designate those clinicians who Medical
Staff allow to conduct an MSE. The Quality staff
stated such a document, "Does not exist." Based
on this, it could not be determined who the
Medical Staff deemed as qualified to conduct a
MSE.

BALTIMORE, MD 21201
ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCy)

(X5)

COMPLETION
OATE

were provided additional EMTALA education in
A2406 response to this event which was completed by
February 28,2018 (See attachment C- content
and attendance records).
In-person education was provided to staff
through nurse educators, Clinical Nurse
Manager, Director of Nursing, Security
Supervisor, Registration Supervisor, Director of
Quality, Director/Manager of Case
Management, and SBIRT Supervisors. For
staff unavailable to attend in-person training, a
self-learning packet was provided with an
attestation statement documenting completion.
Nursing, security, registration and providers
teams have designated a person to perform
rounding and on-going education.
Monitoring will include ongoing rounding with
ED team members to ascertain their
comprehension and practice related to
EMTALA. In addition, the ED Clinical Nurse
Manager and Director of Nursing will complete
spot audits weekly. Audit results will be
communicated at the ED CUSP. The Director
of Nursing will be responsible for ongoing
monitoring.

In summary, and demonstrated in practice, the
hospital has an unwritten policy that allows for
any clinician to determine if a patient who
presents to the ED a second time within two
hours will receive a MSE. Further, locked doors to
the ED, and non-clinical security staff to whom the
hospital gave decision-making rights regarding
who could enter the ED, can act as a barrier to
patients seeking evaluation of a potential
emergency medical condition. Finally, there was
no Medical Staff delineation of who could conduct
an MSE which failed to meet the requirements of
EMTALA.Therefore, the hospital failed to meet
regulatory requirementsfor MSE.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:7NZ511

Facility ID: MDHP25

If continuation sheet Page 8 of 8