EMTALA compliance is greatly complicated in communities with significant homeless populations, says Candy Campbell, DNP, RN, CNL, CEP, FNAP, assistant professor, MSN-CNL maternity lead, at the School of Nursing and Health Professions at the University of San Francisco.

Campbell has worked with nurses at San Francisco hospitals who tell of frequently encountering homeless people who present to the ED with vague complaints that must be investigated, even though the clinicians understand that the person is really there to escape the weather and get a meal. Though the nurses and physicians are sympathetic, catering to those patients for the sake of EMTALA compliance takes up valuable resources and delays care to other patients, she explains.

Campbell recently heard a nurse relate her experience with a man who presented to the ED during flu season, complaining of symptoms consistent with diabetic complications, prompting the need for tests. While the patient waited, the nurse gave him a box lunch and a bed bath. When she reported that his tests indicated no diabetic issues, the man pulled his pants down and urinated on her, saying that must mean he had a urinary tract infection.

“So she was duty bound to ask about it, and he knew what to say, complaining about the itching and how he couldn’t help himself when he urinated on her. For the sake of EMTALA, he got to stay again while he was worked up for a urinary tract infection that he did not have. It’s a misuse of generosity, and it’s sad.”

Clinicians do their best to be compassionate in such instances, she says, but they also are pressured to free up resources for more needy patients.

“She knew what was going on, right from the start. He wasn’t fooling her,” Campbell says. “But if she had told him she was sorry, she didn’t have time for this and he had to leave, that would have been called an EMTALA violation.”