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Based on review of hospital policies and procedures, tours of the dedicated emergency departments (DED's), review of medical records, and interviews with staff, it was determined the hospital failed to comply with 489.24, as evidenced by failing to:

489.24(r) and 489.24(c)
conduct appropriate medical screening examinations (MSE) for Pt #14; and

489.24(d)(4) and (5)
ensure the hospital's practices would not unduly discourage patients from remaining for further examinations for Pt #'s 18 and 19.

The cumulative effect of these system processes resulted in non compliance with the Special responsibilities of Medicare hospitals in emergency cases.

Based on observation during a tour of the Obstetrical (OB) Department triage area, hospital policies and procedures and interview with staff, it was determined the hospital failed to post EMTALA rights signs in the OB dedicated emergency department area.

Findings include:

The hospital policy titled EMTALA Signage, required: "...Purpose: To require that all individuals are made aware of their rights to medical screening examination and stabilization for an emergency medical condition...All dedicated emergency departments and any other place likely to be noticed by individuals entering the dedicated emergency departments, and other areas of the the hospital...must post appropriate signage notifying patients of their right to a medical screening examination...and whether the hospital participates in the Medicaid program...."

The Obstetrical (OB) Department did not have any Emergency Medical Transfer and Active Labor Act (EMTALA) rights signs posted for patients entering the OB area for a medical screening examination (MSE).

The Director of OB, Employee #4, confirmed on 07/20/10 at 0900 hours, that the OB department did not have the required EMTALA rights signs posted for patients.

Based on review of medical staff bylaws, rules, regulations, medical records, policies and procedures, and interviews with staff, it was determined that the hospital failed to: conduct an appropriate medical screening examination (MSE) for Pt #14.

Findings include:

ED Director, (Employee #3), explained on 07/20/10, the nurses triage every patient and assign an Emergency Severity Index (ESI) level. The ESI acuity rating is defined as: Level I = Resuscitation; Level II = Emergent; Level III = Urgent; Level IV = Non-Urgent; and Level V = Referred.

The physicians decide if they will be conducting a medical screening examination only (MSO). If the physician decides the patient does not have an emergency medical condition the patients are discharged. A patient without insurance will decide if they want to pay the $250.00 deposit and get prescriptions and/or treatment for the non-emergent condition or not. Patients with insurance will have their copay collected at the time the physician determines the patient does not have an emergency medical condition (EMC). If the patients don't want to pay they are discharged with a community healthcare resources list provided by the registration clerk with the names and locations of facilities that will provide care and are cheaper. Patients choosing not to pay don't recieve prescriptions and they are referred to less expensive places to get their prescriptions filled or get care for their non emergent condition.

The Director of Admitting explained that the hospital utilizes a MSO form (titled Emergency Department Patients with non-Urgent or Non-Emergent Conditions) for patients who have seen a physician, and the physician enters into the computer that the patient does not have an EMC. This signifies that the registration clerk may inquire about insurance and collect copays and deposits.

The hospital's MSO form reads: "...You have been seen by a qualified medical professional. Your medical screening assessment indicates that your present condition is not an emergency. Considering the high cost of Emergency Department services, it would be most appropriate for you to seek care at a physician's office or outpatient clinic, rather than using an Emergency Department. If you choose to be treated in our Emergency Department, and do not have insurance coverage, you will need to pay a $250.00 deposit before service will be given. You will be billed for the balance of any charges you incur while in the Emergency Department, consistent with the Hospital's self-pay discount policies. If you have health insurance coverage for these services, you will not be required to pay a $ 250.00 deposit but may be required to pay an additional copayment under your insurance coverage. We will obtain the necessary health insurance information from you and submit the bill for payment. If you choose not to be treated in out Emergency Department, you may seek non-emergent/non-urgent care from a physician or dentist of your choice, or from one of the facilities listed on the Community Health Care Resources sheet given to you by us...." The form contains 3 boxes for the patient to check indicating their choice. The boxes include: "...Yes, I would like to pay the $250.00 deposit for service and to be treated in the Emergency Department at this time...(next box) Yes, I have insurance coverage and will provide the information necessary to bill the insurance company for services rendered...(next box) No, I do not desire to be treated in the Emergency Department and will seek care from my Physician or one of the facilities listed on the Community Health Care Resource sheet...Community Health Care Resource sheet provided by: (line left for initials)...."

On 07/21/10, the ED Director Employee #3 confirmed the above practice is the process the hospital is using and has used since opening.

Patient # 14 arrived in the ED on 06/06/10 at 0450 hours. Nursing documented the chief complaint as "abdominal pain for 3 weeks/pain got worse tonight with nausea." Nursing documented the level of pain as 10, on a scale from 0-10, with 10 as the worst pain ever. Vital signs were: BP 134/72, P 86, R 16, T 98, O2 sat 98% on RA. Past medical history included: "...Bi-Polar...HTN (hypertension)...High Cholesterol...." The patient was assigned an ESI level of III.

The ED physician documented "...Pt reports 3 week HX (history) of intermittent abd pain. Came in tonite (sic) because 'he can't take it anymore.' Has not taken any pain meds but using Pepto and OTC (over the counter) Prilosec. Pt is smoker. Has not seen PCP (primary care physician). No vom/diarrhea/melena. Pt is eating daily and has no fever. No back pain...." The pain scale indicates the patient's pain level is a 10. The appearance is documented as "Pt smiling and laughing with GF (girl friend)."

ED physician # 6 indicated "I have performed a Medical Screening Evaluation...No Emergency Medical Condition Exists." The clinical diagnosis is abdominal pain. The discharge instructions indicate: "...Follow up with urgent care or your primary care doctor or clinic. Discontinue smoking. Return to ER sooner if symptoms worsen...." The patient did not sign for the discharge instructions.

The patient was not reassessed by nursing upon discharge. The vital signs upon discharge were all entered as zeros and no reassessment of pain was documented.

The ED Director reviewed the medical record with the Surveyor on 07/19/10 at 1200 hours. She verified the patient did not have his pain and vital signs reassessed. She could not verify the patient received discharge instructions. She also verified the physician did not do any tests on the patient.

The patient signed the MSO form, but did not check a box to indicate his choice. The boxes are blank. There are initials indicating the Community Health Resource List with names and addresses of facilities available for providing care was provided by the registration clerk.

Based on review of policies and procedures, medical records, and interview with staff, it was determined the hospital's practice could unduly discourage patients from remaining for further examinations as evidenced by, Pt's #18 and 19 signed the Medical Screning Only (MSO) forms prior to seeing an ED provider to rule out an EMC.

Findings include:

The Director of Admitting explained in an interview on 07/20/10, that the hospital utilizes a MSO form for patients who have seen a physician and the physician enters into the computer that the patient does not have an EMC. This signifies that the registration clerk may inquire about insurance and collect copays and deposits. She was asked if the hospital has a policy regarding MSO and she explained it is a process and there is no policy.

The hospital's MSO form reads: "...You have been seen by a qualified medical professional. Your medical screening assessment indicates that your present condition is not an emergency. Considering the high cost of Emergency Department services, it would be most appropriate for you to seek care at a physician's office or outpatient clinic, rather than using an Emergency Department. If you choose to be treated in our Emergency Department, and do not have insurance coverage, you will need to pay a $250.00 deposit before service will be given. You will be billed for the balance of any charges you incur while in the Emergency Department, consistent with the Hospital's self-pay discount policies. If you have health insurance coverage for these services, you will not be required to pay a $ 250.00 deposit it may be required to pay an additional copayment under your insurance coverage. We will obtain the necessary health insurance information from you and submit the bill for payment. If you choose not to be treated in our Emergency Department, you may seek non-emergent/non-urgent care from a physician or dentist of your choice, or from one of the facilities listed on the Community Health Care Resources sheet given to you by us...." The form contains 3 boxes for the patient to check indicating their choice. The boxes include: "...Yes, I would like to pay the $250.00 deposit for service and to be treated in the Emergency Department at this time...(next box) Yes, I have insurance coverage and will provide the information necessary to bill the insurance company for services rendered...(next box) No, I do not desire to be treated in the Emergency Department and will seek care from my Physician or one of the facilities listed on the Community Health Care Resource sheet...Community Health Care Resource sheet provided by: (line left for initials)...."

Patient's #18's Legal Representative (mother) signed the MSO form at 1256 hours, indicating, "No, I do not desire to be treated in the Emergency Department and will seek care form my Physician or one of the facilities listed on the Community Health Care Resource sheet." The time on the form indicates the patient's representative signed the form prior to the nursing triage documentation at 1308 hours and prior to the physician's documentation time at 1440 hours.

The hospital's provided the Emergency Department Visit Audit log, which revealed the physician determined the patient was non emergent at 13:17:38. The patient signed the MSO form at 1256 hours, which was prior to the medical screening examination.

Patient #18, a teenager, arrived in the ED on 06/06/10, at 1308 hours. Nursing documented the chief complaint as, "Pt c/o having diarrhea for a yr. (year). Pt states recently found out is lactose intolerant. Pt states saw worm in toilet after BM (bowel movement), 'just chilling'." The vital signs were: BP 130/93, P 70, R 16, T 97.3, O2 sat 98% on RA. The patient was assigned an ESI level of IV.

The ED physician (Personnel #6) wrote: "...presents to ER complaining of recurrent diarrhea for about one year and few (sic) days ago saw some worms in his stool. No melena or hematochezia...."

The ED physician indicated, "No Emergency Medical Condition Exists."

Patient # 19 arrived in the ED on 06/28/10, at 1700 hours. Nursing documented the chief complaint as: "...pt has left wrist splint placed this morning, came back because the ace wrap was loose, pt has no other complaints, no increased swelling, pain tolerable per pt...." The vital signs were: BP 151/76, P 71, R 16, O2 sat 100% on RA. The patient was assigned an ESI level of V.

ED physician 14, wrote the following: "...female who was seen at this ED on 05/27/10 after an assault she had a splint placed on her left forearm at that time. pt (sic) states the wrap is coming undone at the end. pain (sic) is tolerable...." The physician indicated, "I have performed a Medical Screening Evaluation...No Emergency Medical Condition Exists."

Patient # 19 signed the MSO form at 1637 hours, which was prior to the nursing triage documentation time of 1700 hours and physician documentation of "ready for discharge...1717 (hours)." The patient filled out the Emergency Department Sign In Sheet at "4:30 pm" (1630 hours) and signed the MSO form at 1637 hours indicating, "No, I do not desire to be treated in the Emergency Department and will seek care from my Physician or one of the facilities listed on the Community Health Care Resource sheet" prior to seeing a physician.

The Emergency Department Visit Record indicated that the patient was registered on 06/28/10 at 1637 hours. The Emergency Department Visit Audit log indicates the Provider (Nurse Practitioner) entered into the computer that the patient was determined non urgent at 17:09:03.

The Director of Admitting offered an explanation as to why the forms were signed prior to the patient being evaluated by a physician. She reported after talking to the registration clerk, the clerk put the time on the form when she registered the patient and then had the patients sign the forms after the physician determined the patients did not have an emergency medical condition.