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Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases.

Finding Include:

Hospital policy titled, "Patient Flow Process", revealed: " ...Patient Flow Process Within The Hospital ...Patient arriving to Exceptional Community Hospital seeking emergency care will register at the front desk. Follow Check In/Registration, the patient will be escorted to Triage by ER personnel for Initial Medical Screening Examination. Following examination, patients will be prioritized for treatment and, based on room availability and clinical status, will either be placed in a treatment room or returned to the waiting room until called ...."

Hospital policy titled, "Patient Flow Process", revealed: "...Patient Flow Process Within The Hospital ...Patient arriving to Exceptional Community Hospital seeking emergency care will register at the front desk. Follow Check In/Registration, the patient will be escorted to Triage by ER personnel for Initial Medical Screening Examination. Following examination, patients will be prioritized for treatment and, based on room availability and clinical status, will either be placed in a treatment room or returned to the waiting room until called .... "

Hospital policy titled, "LWOT/AMA", revealed: "...Policy: Exceptional Community Hospital and its employee will try to the best of their ability to identify a patient that is choosing to Leave Without Treatment (LWOT) or Against Medical Advice (AMA). In both cases the staff will attempt to determine why the patients are deciding to leave and to seek to reassure them to complete their care. A medical provider will attempt to speak with the patient and provider ever opportunity to educate the patient as necessary .... Procedure: If the patient is found to have let and not informed any of the hospital staff about their departure the staff will: 1. Record the date and time in the patient chart 2. Inform the provider 3. If necessary call the non-emergency police department number to inform them of the patient's departure and perform well check .... "

A request was made for an EMTALA policy. The facility did not provide the requested policy.

Review of the medical record revealed Patient #1 was assigned an ESI of 5. Further review of Patient #1's medical record revealed no evidence of any additional triage documentation including vital signs. Further review of Patient #1's medical record revealed no evidence of a medical provider conducting a medical screening examination or of the medical provider being informed of Patient #1's departure.

Employee #2 confirmed during a medical record review on 05/15/2023 that Patient #1 was given an ESI of 5. Employee #2 further confirmed that no additional triage documentation including vital signs was present in Patient #1's medical record.

Employee #2 confirmed during a medical record review on 05/15/2023 that Patient #1 did not have documentation that medical staff performed a medical screening examination. Employee #2 confirmed that there was no documentation that medical staff were notified that Patient #1 left without being seen or that a medical provider spoke with patient before they left.

Employee #1 confirmed during an interview conducted on 05/15/2023 that a log to record LWOT patients was started in January 2023. Employee #1 further confirmed that in the log the staff records the attempts that were made to locate the patient. Employee #1 confirmed that prior to January 2023 LWOT ' s were not documented according to policy and procedures.

Based on review of policies and procedures, medical records and staff interviews, it was determined that the hospital failed to ensure the medical record was complete with all required documentation for one (1) patient (Patient #1).

Findings Include:

Hospital policy titled, "Medical Record Documentation", revealed: "...A complete medical record contains continuity of care and clinical decision making. A complete medical record contains pertinent facts used for patient care, research, public health, education and services as a legal document ...The medical record will contain sufficient, complete data needed to communicate pertinent patient care to all providers ...The medical record will contain the following elements...Information to identify the patient, patient's communication needs such as preferred language, and the physician/practitioner responsible for patient's care...Pre-hospital care rendered including time and means of arrival, required for emergency care...Reason for admission/treatment, including initial diagnosis, diagnostic impression and/or conditions...."

A review of Patient #1 medical record from [12/09/2022] revealed: name, date of birth, chief concern and insurance information were documented in the facility's EMR system. Further review of Patient #1 medical record revealed a registration time of 1821 was recorded and final disposition was recorded as LWBS (left without being seen) at 1841. Further review of the medical record revealed Patient #1 was assigned an ESI of 5. Further review of Patient #1's medical record revealed no evidence of any additional triage documentation including vital signs. Further review of Patient #1's medical record revealed no evidence of a medical provider conducting a medical screening examination or of the medical provider being informed of Patient #1's departure.

Employee #2 confirmed during a medical record review on 05/15/2023 that Patient #1 did not have documentation that medical staff performed a medical screening examination. Employee #2 confirmed that there was no documentation that medical staff were notified that Patient #1 left without being seen or that a medical provider spoke with patient before they left.

Employee #2 confirmed during a medical record review on 05/15/2023 that Patient #1 was given an ESI of 5. Employee #2 further confirmed that no additional triage documentation including vital signs was present in Patient #1's medical record.

Based on review of policies and procedures, hospital documents, clinical records, and staff interviews, it was determined the hospital failed to provide a Medical Screening Examination to Patient #1 who presented the ED on [12/09/2022] for complaints of behavior concerns.

Findings Include:


Hospital policy titled, "Patient Flow Process", revealed: "...Patient Flow Process Within the Hospital ...Patient arriving to Exceptional Community Hospital seeking emergency care will register at the front desk. Follow Check In/Registration, the patient will be escorted to Triage by ER personnel for Initial Medical Screening Examination. Following examination, patients will be prioritized for treatment and, based on room availability and clinical status, will either be placed in a treatment room or returned to the waiting room until called...."

Hospital policy titled, "LWOT/AMA", revealed: "...Policy: Exceptional Community Hospital and its employee will try to the best of their ability to identify a patient that is choosing to Leave Without Treatment (LWOT) or Against Medical Advice (AMA). In both cases the staff will attempt to determine why the patients are deciding to leave and to seek to reassure them to complete their care. A medical provider will attempt to speak with the patient and provider ever opportunity to educate the patient as necessary....Procedure: If the patient is found to have let and not informed any of the hospital staff about their departure the staff will: 1. Record the date and time in the patient chart 2. Inform the provider 3. If necessary call the non-emergency police department number to inform them of the patient's departure and perform well check...."

A request was made for an EMTALA policy. The facility did not provide the requested policy.

A review of Patient #1 medical record from [12/09/2022] revealed: name, date of birth, chief concern and insurance information was documented in the facility 's EMR system. Further review of Patient #1 medical record revealed a registration time of 1821 was recorded and final disposition was recorded as LWBS (left without being seen) at 1841. Further review of the medical record revealed Patient #1 was assigned an ESI of 5. Further review of Patient #1's medical record revealed no evidence of any additional triage documentation including vital signs. Further review of Patient #1's medical record revealed no evidence of a medical provider conducting a medical screening examination or of the medical provider being informed of Patient #1's departure.

A total of 30 ED medical records were randomly selected for review included patients who were transferred, admitted, or left before Medical Screening Examinations. Two (2) of the thirty (30) patients were documented as LWBS (left without being seen) and there was no documentation on file of provider being informed.

Employee #2 confirmed during a medical record review on 05/15/2023 that Patient #1 did not have documentation that medical staff performed a medical screening examination. Employee #2 confirmed that there was no documentation that medical staff were notified that Patient #1 left without being seen or that a medical provider spoke with patient before they left.

Employee #2 confirmed during a medical record review on 05/15/2023 that Patient #1 was given an ESI of 5. Employee #2 further confirmed that no additional triage documentation including vital signs was present in Patient #1's medical record.

Employee #1 confirmed during an interview conducted on 05/15/2023 that a log to record LWOT patients was started in January 2023. Employee #1 further confirmed that in the log the staff records the attempts that were made to locate the patient. Employee #1 confirmed that prior to January 2023 LWOT 's were not documented according to policy and procedures.