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Based on observation, interview, review of medical record documentation for 10 of 17 individuals who presented to the hospital for emergency services (Patients 1, 2, 3, 4, 5, 6, 7, 13, 16 and 17), review of central log documentation and review of hospital policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure compliance in the following areas:
* EMTALA policies and procedures, and medical staff bylaws and rules and regulations, were incomplete and unclear and did not ensure EMTALA compliance.
* All individuals who presented to the hospital for emergency services did not receive MSEs by LIPs to determine whether EMCs existed.
* Appropriate transfers were not affected for patients transferred to other hospitals for further examination and stabilizing treatment of an EMC.
* All individuals who presented to the hospital for emergency services were not entered on the central log and the log did not accurately reflect the disposition from the ED.
* EMTALA signage was not posted in all areas where individuals and their representatives waited for exam and treatment.

Findings include:

1. Regarding the posting of signs refer to the findings identified under Tag A2402, CFR 489.20(q).

2. Regarding the central log refer to the findings identified under Tag A2405, CFR 489.20(r)(3).

3. Regarding the provision of MSEs refer to the findings identified under Tag A2406, CFR 489.24(a) & (c).

4. Regarding appropriate transfers refer to the findings identified under Tag A2409, CFR 489.24(e)(1)-(2).

Based on observation, interview and review of policies and procedures it was determined the hospital failed to fully develop and enforce EMTALA policies and procedures that ensured the posting of signage that clearly and accurately specified individuals' EMTALA rights with respect to examination and treatment for emergency medical conditions and women in labor in all areas likely to be noticed and where individuals or their representatives waited for examination and treatment.

Findings include:

1. During tour of the ED on 06/21/2019 at 1115 with the LEDRN one EMTALA sign was observed in the hospital posted immediately adjacent to the locked entrance to the ED from the ED waiting and registration room. Two signs, one in English and one in Spanish, were each on 8 and 1/2 inch by 11 inch paper and were inside a locked bulletin board cabinet with a number of other signs and postings. The bulletin board cabinet was on a wall around the corner from the waiting room chairs so was not visible from those chairs. There were no other signs in any of the following ED areas: main ED entrance from outside the hospital, ED entrance from within the hospital, ambulance entry, ED waiting room, triage room, consult room 411, three exam rooms, two trauma bays, ED corridors, ED nurses station. During interview with the LEDRN at the time of the tour he/she confirmed the findings.

2. During tour of the OB department on 06/21/2019 at 1130 with the LEDRN there were no EMTALA signs posted anywhere in the department including in the following areas: OB locked entrance, OB corridors, three LDRP rooms. During interview with the LEDRN at the time of the tour he/she confirmed there were no signs in the OB department.

3. The review of policies and procedures reflected that they lacked reference to and provisions for EMTALA signs to be posted.

Based on interview, review of medical record and central log documentation for 9 of 17 individuals who presented to the hospital for emergency services (Patients 1, 2, 3, 5, 6, 7, 13, 16 and 17) and review of hospital policies and procedures it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure a central log was maintained to reflect complete and accurate information about all individuals who presented to the hospital for emergency services.
* All individuals who presented to the hospital for emergency services were not entered onto the log.
* The log did not accurately reflect the disposition from the ED.

Findings include:

1 Review of incident documentation reflected that Patients 1 and 2 presented to the hospital for emergency services during the middle of the night at 0330 on 11/29/2018, were sent away from the hospital and did not receive an MSE. Review of the central log for 11/29/2018 revealed no entries to reflect that Patients 1 and 2 presented to the hospital on that date. Refer to the detailed findings for Patients 1 and 2 under Tag C2406.

2. The central log for Patient 3's ED encounter on 01/09/2019 reflected the disposition was "Home." However, the ED record reflected "Disposition/Discharge...Patient referred to the walkin (sic) clinic..." The central log did not accurately reflect the patient's disposition. Refer to the detailed findings for Patient 3 under Tag C2406.

3. The central log for Patient 5's ED encounter on 01/28/2019 reflected the disposition was "Home." However, the ED record reflected "[Physician D] will see pt in clinic" and "Disposition/Discharge: Condition at departure: unchanged. Discharge instructions provided and reviewed. Reviewed referrals." The central log did not accurately reflect the patient's disposition. Refer to the detailed findings for Patient 5 under Tag C2406.

4. The central log for Patient 6's ED encounter on 02/19/2019 reflected the disposition was "Home" and "Good." However, the ED record reflected "Disposition/Discharge...pt is going to walk-in clinic." The central log did not accurately reflect the patient's disposition. Refer to the detailed findings for Patient 6 under Tag C2406.

5. The central log for Patient 7's ED encounter on 02/19/2019 reflected the disposition was "Home." However, the ED record reflected "Disposition/Discharge...[Physician D] going to see pt in clinic." The central log did not accurately reflect the patient's disposition. Refer to the detailed findings for Patient 7 under Tag C2406.

6. The central log for Patient 13's ED encounter on 04/24/2019 reflected the disposition was "Hosp." However, the ED record reflected "Disposition/Discharge...Transported via ambulance by transport team...Patient departed with Flight panda crew)..." and the patient was transferred to LEMC. The central log did not accurately reflect the patient's disposition. Refer to the detailed findings for Patient 13 under Tag C2409.

7. The central log for Patient 16's ED encounter on 06/10/2019 reflected the disposition was "Home." However, the ED record reflected that the patient did not receive an MSE and left the hospital without being seen because he/she was told the LIP wouldn't perform the procedure the patient indicated he/she needed. Refer to the detailed findings for Patient 16 Tag C2406.

8. The central log for Patient 17's ED encounter on 06/13/2019 reflected the disposition was "Hosp." However, the ED record reflected the "Disposition/Discharge" was "...Transferred to St Charles Medical Center." The ED central log did not accurately reflect the patient's disposition. Refer to the detailed findings for Patient 17 under Tag C2409.

9. The review of policies and procedures reflected that they lacked reference to and provisions for maintenance of the central log.


29708

Based on interview, review of medical record documentation for 8 of 17 individuals who presented to the hospital for emergency services (Patients 1, 2, 3, 4, 5, 6, 7 and 16), review of medical staff bylaws and rules and regulations, and review of policies and procedures it was determined that the hospital failed to fully develop and enforce clear policies and procedures to ensure the provision of complete, accurate, and appropriate MSEs in the ED by LIPs and qualified RNs for all individuals who presented to the hospital for emergency services.
* Individuals who presented to the hospital for emergency services did not always receive an MSE in the ED or OB department and were instead directed to go to a physician's clinic to be seen by a clinic LIP at that time or on another day. The on-call ED provider did not always come to the department to conduct the MSE.
* MSEs for individuals who presented to the hospital for emergency services were not always conducted by LIPs, but rather by RNs determined to be qualified to do so. However, the qualifications were not clearly set forth and some of the RNs who conducted MSEs had not met the qualifications.
* MSEs conducted by RNs were not clearly or distinctly different from triage evaluations.
* There was lack of assurance that staff did or said nothing to dissuade patients from staying at the hospital to be evaluated for an EMC, including minimizing symptoms or inquiring about financial status or payment source.
* Attempts were not made to advise patients of the risks of leaving the hospital before the evaluation for an EMC was completed.

Findings include:

1. Policies and procedures and other documents were reviewed:

a. The policy and procedure titled "Medical Screening Exam Policy & Procedure," dated last approved 02/18/2019 included:
* "Any individual who presents to the Emergency Department, or is on hospital grounds, and requests an examination or treatment for a medical condition, has the right to have a medical screening exam performed. This request may be made by a legal representative for the patient if the patient is on hospital grounds. A medical screening exam may be conducted by a qualified Emergency Department RN or Emergency Medical Care Provider. The medical screening exam shall be done without undue delay in order to determine whether the individual has an emergent condition."
* "The patient will be assessed in the Emergency (ED) or (OB) Department as determined by presenting condition."
* "The ED, or OB RN as appropriate, will respond to the patient location and interview/evaluate the individual as soon as possible after patient arrival."
* "RN performs a quick survey of patient's airway, breathing and circulation and determines a level of acuity...A focused assessment can then be completed based on patient's presenting complaint"
* "The RN notifies the patient's Primary Care Provider or the ED Medical Care Provider...with a report of findings/screening exam."
* "The Medical Care Provider determines the need to respond in person or give telephone orders. If the Medical Care Provider determines that the patient does not have an emergent medical condition, he/she may request that the patient be discharged home or discharged with an appointment to be seen in a medical office or clinic. In the latter situation, RN also completes a 'referral to clinic form' and provides patient with instructions for the follow-up appointment."
* "If the Medical Care Provider determines that the patient has an emergent medical condition, further patient care or testing may be performed according to their orders."
* "Documentation of the complete medical screening exam, Medical Care Provider's orders, and care received, is done within the electronic medical record."

The policy and procedure failed to ensure the following:
* That triage evaluations and processes and MSE evaluations and processes were clearly and distinctly defined.
* That appropriate qualifications for RNs who conducted ED and OB MSEs were clearly set forth and defined.
* Under what circumstances or routine would RNs conduct MSEs versus ED LIPs.
* That criteria were established for on-call ED and OB LIPs to respond in person to the ED and OB to attend to the patient.
* An assurance that no ED and OB patients who had not had an adequate and appropriate MSE to rule out an EMC would be "referred" to a clinic. In other words, an assurance that patients would not be sent to the clinic to have an MSE performed or completed by the LIP.
* That staff would do or say nothing to dissuade patients from staying at the hospital to be evaluated for an EMC, including minimizing symptoms and inquiring about financial status or payment source.

b. The policy and procedure titled "Emergency Patient Care Guidelines," dated last approved 09/18/2018 reflected:
* "An Emergency Department (ED) RN or medical provider may perform a medical screening exam. An RN also performs a focused patient assessment, a Glasgow Coma Score (GCS) and assures vital signs (VS) are obtained as soon as possible after patient's arrival...Record pertinent subjective data, physical assessment, and VS as soon as possible within EMR."
* "Each patient, regardless of whether they are in an exam room or the waiting room should have a triage assessment by an RN, and be rounded on hourly with vital signs recorded."
* "Repeat VS hourly or more frequently as indicated by patient's condition and symptoms, as well as admit and discharge GCS."
* "On weekdays, between the hours of 0600 and 1700, notify the patient's primary Health Care Provider (HCP) first. If HCP is unavailable or patient does not have one, notify on-call HCP. On weekends, holidays and after 1700 during the week notify ED on-call HCP for all ED patients..."
* "Document HCP notification and response times as well as HCPs in and out times, if applicable, in electronic ED documentation system."
* "RN is responsible for entering and completing cardiopulmonary, lab or x-ray electronic orders (if not entered by provider) and notifying appropriate department."
* "Perform visual acuity exam on admission for any patient presenting with an eye problem."
* "Weigh and record weight on admission for all pediatric patients (14 years of age or under)."
* "The Code-Trauma Team should be called in for a Code Blue, Trauma, Stroke, STEMI, Severe Sepsis..."
* "If the HCP requests that the presenting patient is seen in their office during regular business hours, such patients are treated as a discharge from our facility with follow-up appointment in HCP office and should be documented as such..."
* "If patient is discharged home, note date and time of discharge. Provide pre-printed discharge instructions per HCP specifications and document type given, disposition of patient, planned mode of transportation from the hospital, and the condition of the patient upon discharge. Save a copy of saved discharge instructions in patient record."
* "RN's (sic) are to perform patient assessments and discharge teaching for emergency patients..."

The policy and procedure failed to ensure the following:
* That triage evaluations and processes and MSE evaluations and processes were clearly and distinctly defined.
* That appropriate qualifications for RNs who conducted ED and OB MSEs were clearly set forth and defined.
* Under what circumstances or routine would RNs conduct MSEs versus ED LIPs.
* That criteria were established for on-call ED and OB LIPs to respond in person to the ED and OB to attend to the patient.
* An assurance that no ED and OB patients who had not had an adequate and appropriate MSE to rule out an EMC would be "referred" to a clinic. In other words, an assurance that patients would not be sent to the clinic to have an MSE performed or completed by the LIP.
* That staff would do or say nothing to dissuade patients from staying at the hospital to be evaluated for an EMC, including minimizing symptoms and inquiring about financial status or payment source.

c. The policy and procedure titled "Triage and Communication Policy," dated last approved "07/2018" reflected:
* "The following triage system will be used to help relay patient status of emergency patients...to healthcare providers at Lake District Hospital...Triage Levels...Critical Patient (ESI Level 1)...Urgent Patient (ESI Level 2)...Complex Patient (ESI Level 3)...Non-Urgent Patient (ESI Level 4)...Simple Patient (ESI Level 5)..."

d. The policy and procedure titled "Emergency Department - Nursing Certification Guidelines" dated last approved 11/06/2018 was provided in response to a request for the process the hospital used to qualify RNs to conduct MSEs. The policy reflected:
* "The Goal for full-time and part-time nurses at Lake District Hospital (LDH) is completion of In-house Emergency Department (ED) certification within their first year of employment."
* "The orientation/certification process consists of, but is not limited to the following..." This was followed by a list of approximately 15 items that included professional programs, courses and certifications; an emergency certification proficiency validation check-off list; review of hospital policies and procedures; and training/orientation shifts.
* "When the minimum criteria above is completed, the Lead ED Nurse will review input from the orientee, preceptors, and providers as appropriate and make a recommendation to the CNO to awarded (sic) certification or recommend additional training/orientation."

The policy and procedure failed to ensure the following:
* That triage evaluations and processes and MSE evaluations and processes were clearly and distinctly defined.
* That appropriate qualifications for RNs who conducted ED and OB MSEs were clearly set forth and defined.
* Under what circumstances or routine would RNs conduct MSEs versus ED LIPs.
* That criteria were established for on-call ED and OB LIPs to respond in person to the ED and OB to attend to the patient.
* An assurance that no ED and OB patients who had not had an adequate and appropriate MSE to rule out an EMC would be "referred" to a clinic. In other words, an assurance that patients would not be sent to the clinic to have an MSE performed or completed by the LIP.
* That staff would do or say nothing to dissuade patients from staying at the hospital to be evaluated for an EMC, including minimizing symptoms and inquiring about financial status or payment source.

e. The LDH "Lake District Hospital & Long Term Care Facility Rules and Regulations" dated approved on 12/01/2011 contained the following reference to MSEs:
* "The Hospital and Medical Staff shall treat patients presenting to the Hospital's Emergency Department...in accordance with current state/federal law regarding treatment, stabilization and transfer. All active staff practitioners credentialed by the Hospital and the Hospital employed registered nurses are certified to perform the medical screening examinations."

The rules and regulations failed to ensure the following:
* That appropriate qualifications for RNs who conducted ED and OB MSEs were clearly set forth and defined.
* Under what circumstances or routine would RNs conduct MSEs versus ED LIPs.
* That criteria were established for on-call ED and OB LIPs to respond in person to the ED and OB to attend to the patient.
* An assurance that no ED and OB patients who had not had an adequate and appropriate MSE to rule out an EMC would be "referred" to a clinic. In other words, an assurance that patients would not be sent to the clinic to have an MSE performed or completed by the LIP.

f. The policy and procedure titled "Leaving Without Being Seen Guidelines," dated last approved "07/2018" reflected:
* "A patient presenting for or requesting care in the Emergency Department may leave without being seen if...They appear to be of sound mind to make this decision...They do not appear to be under the influence of alcohol or other intoxicants...They do not appear to be harmful or a threat to themselves or others."
* "Once an inquiry is made by the patient to leave without being seen, the staff member will attempt to discover the reason for this and intervene if possible."
* "The Nurse will make an effort to instruct the patient to follow up with their Health Care Provider or return to the Emergency Department as necessary."
* "The Nurse is to document incident within medical record and on an incident report. If possible, use quotations for statements made by staff and patient; include staffing attempts to prevent patient from leaving and instructions given."

The policy and procedure failed to ensure the following:
* An assurance that no ED and OB patients who had not had an adequate and appropriate MSE to rule out an EMC would be "referred" to a clinic. In other words, an assurance that patients would not be sent to the clinic to have an MSE performed or completed by the LIP.
* That staff would do or say nothing to dissuade patients from staying at the hospital to be evaluated for an EMC, including minimizing symptoms and inquiring about financial status or payment source.

g. Review of email correspondence provided dated 04/09/2019 at 5:00 pm revealed an email from the CNO to staff that included the following: "Apparently there have been an increasing number of patients that present to our ED but aren't seen, due to a variety of reasons...This is the law we are required to follow...We are also posting a 'script' for you to use during clinic hours to ask if a patient wants to be seen in the walk in clinic or the emergency department. Once they ask to be seen in the ED, there are NO options, the patient must receive a medical screening exam for an emergency condition. If they have an emergency condition, they (sic) we are required to treat them...When a patient presents to ER, per EMTALA regulations, they MUST receive a Medical Screening Exam. Nursing or Unit Secretaries cannot make the decision of whether or not to enter a patient into the system. If they come to our ER with a medical complaint, we have to perform a MSE - it's the law. If it is determined they don't have an emergency condition, they can be offered to be seen at the walk in clinic. If a patient is not seen by a provider THEY ARE NOT CHARGED. So don't try to take them out of the system to save them money, that's a nonissue."

This communication failed to ensure the following:
* Where it stated that when a patient presented to the ED they be asked if they wanted to be seen in the walk in clinic or the ED it failed to ensure that all patients who presented for emergency services receive an MSE in the ED and were not dissuaded in any way from that process.
* Further, where it stated that when a patient presented to the ED they be asked if they wanted to be seen in the walk in clinic or the ED was contradicted later in the email where it stated that if the patient had a medical complaint an MSE must be performed.
* That patients who presented with other than "medical" complaints, such as psychiatric and obstetrical complaints, would receive an appropriate MSE.

2. Regarding Patients 1 and 2:

a. Review of incident documentation reflected that on 11/29/2018 at 1000 the hospital received a complaint that alleged two patients who presented to the hospital for emergency services during the middle of the night at 0330 on 11/29/2018 were sent away from the hospital and did not receive an MSE. The documentation reflected that an investigation was initiated and staff present at the time the patients presented were interviewed. The findings of the investigation included "[family members] arrived with two young children...It was reported to a unit secretary and to the ED nurse that the children had been vomiting for about an hour...[family member] did request that a provider look at the children when first presenting to the ED...Information from the nurse also included the possibility of the illness being viral or something they ate and that the walk-in clinic could provide appropriate care - that the situation was not really for the ED. At that time, the family left, after approximately ten minutes in the ED. The nurse is versed in the requirement to contact a provider when requested...Lake Health District requires that any patient presenting to the ED requesting a provider will be treated by a provider and we are addressing the staff involved in this encounter."

b. Review of the central log for 11/29/2018 revealed no entries for Patients 1 and 2 on that date. Review of medical records revealed no ED records for Patients 1 and 2 on that date.

c. During interview with the LEDRN on 06/21/2019 at 1035 he/she confirmed that there were no entries on the central log for Patients 1 and 2 who were brought to the ED by a family member on 11/29/2018 at 0330. The LEDRN stated that they should have been entered. The LEDRN indicated that he/she spoke with the RN on duty on 11/29/2019 who confirmed that Patients 1 and 2 presented to the after-hours ED entrance where the RN spoke with the patients' representative. The RN indicated that the patients, young children, were "drinking water" and were "alert and oriented." The LEDRN stated that the RN on duty confirmed that the patients were not taken into the ED, did not receive a MSE, the patients' family representative did not refuse an MSE, left the hospital and no records were generated for the encounter.

3. Regarding Patient 3:

a. The ED record of Patient 3 was reviewed and reflected the patient presented to the ED on 01/09/2019 at 1135 with a chief complaint of dizziness.
* At 1135 the RN notes reflected the patient's blood pressure was 194/82 and heart rate was "109."
* At 1141 the RN triage notes reflected "...eye hurt, nothing makes it better or worse...took xanax at 8 and another half a xanax at 1030, stating that [he/she] thought it was anxiety. The medication did not help...States that [his/her] neck hurts and [his/her] head as well.)..." and "Pain level now 1/10."
* RN documentation at 1143 and 1144 reflected "Medications" was "Thyroid Medication" and "Seroquel Oral. Xanax Oral" respectively.
* At 1145 the RN documented "Interventions Identification band on patient" and "Glasgow Coma Score: (15)...eyes open-spontaneous...best verbal response-oriented...best motor response-obeys commands..."
* At 1147 the RN notes reflected the patient's blood pressure was 150/89 and heart rate was "102."
* The "Physical Assessment" documented by the RN at 1147 consisted of the following:
- "Ambulatory to room."
- "General/Neuro/Psych: Alert. Oriented X 4. Appears in no acute distress."
- "HEENT: Pupils equal, round and reactive to light. No facial asymmetry noted."
- "CVS: Capillary refill less than 2 seconds."
- "Skin: Skin is warm and dry."
* The RN notes at 1200 reflected "...[Physician C] notified about patient and what has been going (sic). [Physician C] stated that [he/she] does not have time to see a patient in the ER fro (sic) a clinic issue and that [he/she] can be seen in the walk-in clinic..."
* At 1217 the RN documented "Departure time: 12:15...Disposition/Discharge...Condition at departure unchanged. (Patient referred to the walkin (sic) clinic.)."
* There was no documentation by a physician or other LIP.
* There were no physician or other LIP orders.
* There was no documentation of lab testing, x-ray or other diagnostic tests or procedures.

* A "Medical Screening Exam - Referral to Clinic" form reflected the same preprinted language as above. The space after "An appointment has been made for me to be at:" reflected "Walk in clinic, no appointment made." The form was signed by the patient and the RN and dated 01/09/2019 at 1215. There were no other discharge instructions. The documentation on the form unclearly reflected both "An appointment has been made..." and "no appointment made." There were no other discharge instructions.

* The record was unclear and inconsistent, and lacked documentation that reflected an MSE was conducted within the capabilities of the hospital and in accordance with hospital policies and procedures. For example, the record reflected:
- The RN documentation lacked a focused assessment of the patient's complaints of dizziness. For example, the RN notes at 1147 reflected "Ambulatory to room" but no further assessment of the patient's ambulation (e.g. gait, balance, dizziness upon standing or walking, etc.). The record reflected the patient's blood pressure and pulse rate were elevated at 1135 and 1147. However, there was no further assessment of the elevated blood pressure, pulse rate or other vital signs prior to discharge.
- The RN documented "Medications" were "Thyroid Medication" and "Seroquel Oral. Xanax Oral." However, it was unclear if these were home medications, medications taken prior to arrival, or other.
- At 1141 the RN documented the patient had neck and head pain and "Pain level now 1/10" but there was no further assessment of the patient's head and neck pain (e.g. location, quality, onset, duration), and no physical assessment of the patient's head and neck.
- There was no documentation of a GCS on discharge.
- The RN documented "...[Physician C] stated that [he/she] does not have time to see a patient in the ER fro (sic) a clinic issue..." However, there was no documentation that the physician or other LIP determined the need to respond in person or give telephone orders.
- There was no documentation that the physician or other LIP determined whether the patient had an EMC.

b. The central log for Patient 3's ED encounter on 01/09/2019 reflected the disposition was "Home." However, the ED record reflected "Disposition/Discharge...Patient referred to the walkin (sic) clinic..." The central log did not clearly reflect the patient's disposition.

c. During an interview with the ISRN on 06/21/2019 at 1300 he/she stated Physician D was on call for the ED on 01/09/2019. The ISRN confirmed there was no documentation that reflected Physician C, Physician D, or any other LIP came to the ED and evaluated the patient.

4. Regarding Patient 4:

a. The ED record of Patient 4 reflected he/she presented to the ED on 01/27/2019 at 2250 with a chief complaint of shortness of breath and asthma attack.
* At 2303 the "Physical Assessment" documented by the RN reflected "...Respiratory: Moderate respiratory distress. The patient can speak a few words at a time. Expiratory and inspiratory bilateral wheezes diffusely...Capillary refill less than 2 seconds..."
* At 2303 the RN notes reflected "Patient ready for evaluation-ED physician notified. (Orders received.)"
* At 2314 the RN notes reflected "Dexamethasone...given..."
* At 2325 the RN notes reflected "Reassessment...Still having some difficulty getting a full breath...wheezy with inspirations and expiration...HR: 110. RR: 27. O2 saturation 92%."
* At 2332 the RN notes reflected "...[Physician D] updated to patient status. New orders received..."
* On 01/28/2019 at 0019 the RN notes reflected "...patient became SOB and reports beginning to feel 'tight' again..."
* At 0046 the RN notes reflected "...patient status improved...feels better...Able to auscultate airflow...resting...on room air..."
* At 0113 the "Disposition/Discharge" documented by the RN reflected "...[Patient] was discharged home..."
* There was no documentation of lab testing, x-ray or other diagnostic tests or procedures.
* There was no documentation by a physician or other LIP.

* The record lacked documentation that reflected an MSE was conducted within the capabilities of the hospital and in accordance with hospital policies and procedures. For example:
- Although the RN documented "Patient ready for evaluation-ED physician notified," there was no documentation that the physician, or other LIP determined the need to respond in person or give telephone orders.
- There was no documentation that the physician, or other LIP determined whether the patient had an EMC.

b. During an interview with the ISRN on 06/21/2019 at 1100, he/she confirmed there was no documentation that reflected Physician D, or any other LIP came to the ED and evaluated the patient. The ISRN stated "I'm not seeing a provider note. [Physician D] was on call." My guess is [he/she] didn't come in."

5. Regarding Patient 5:

a. The ED record of Patient 5 reflected the patient presented to the ED on 01/28/2019 at 1517 with a chief complaint of left finger laceration.
* At 1519 RN F's notes reflected "Pain level now deferred."
* The "Physical Assessment" documented by the RN reflected "15:26...Extremities: Left hand: (laceration lt hand)...Skin intact. Skin is warm and dry."
* At 1527 the RN notes reflected "[Physician D's] office called, [Physician D] will see pt in clinic. Pt verbalized understanding..."
* At 1825 the RN documented "Medications None" and "Problems: Dental Pain."
* The "Disposition/Discharge" documented by the RN at 1827 reflected "Condition at departure: unchanged. Discharge instructions provided and reviewed. Reviewed referrals."
* There was no documentation of lab testing, imaging or other diagnostic tests/procedures.

* The documentation on the "Medical Screening Exam - Referral to Clinic" form reflected the same preprinted language as above. The space after "An appointment has been made for me to be at:" reflected the name of Physician D. There was no date or time of the appointment. There were no other discharge instructions.

* The record was unclear and inconsistent, and lacked documentation that reflected an MSE was conducted within the capabilities of the hospital and in accordance with hospital policies and procedures. For example, the record reflected:
- The RN documentation lacked a physical assessment of the patient's finger/hand injury. For example, the record unclearly reflected "lt finger laceration," "laceration lt hand" and "Skin intact. Skin warm and dry." There was no further assessment of the laceration including but not limited to definitive site/location, depth, approximation, drainage, swelling, etc.
- The RN documented "Pain level was deferred." There was no pain assessment and no explanation for why the pain level was deferred.
- There was no documentation of a GCS on admit or discharge.
- The RN documented "Medications None." It was unclear what medications this referred to (e.g. home medications, medications taken prior to arrival, etc.)
- The RN documented "Problems: Dental Pain." It was unclear if this was a current problem. There was no assessment, or any other information related to dental pain.
- The RN notes reflected "[Physician D's] office called, [Physician D] will see pt in clinic." However, there was no documentation that reflected who at the office was spoken to, what was reported, and who determined the patient would be seen in a clinic instead of the ED. There was no documentation that reflected the RN notified the physician or other LIP with a report of the findings of a screening exam.
- There was no documentation that the physician or other LIP determined the need to respond in person or give telephone orders.
- There was no documentation that the physician or other LIP determined whether the patient had an EMC.

b. The central log for Patient 5's ED encounter on 01/28/2019 reflected the disposition was "Home." However, the ED record reflected "[Physician D] will see pt in clinic" and "Disposition/Discharge: Condition at departure: unchanged. Discharge instructions provided and reviewed. Reviewed referrals." The central log documentation did not clearly reflect the patient's disposition.

c. During an interview with the ISRN on 06/21/2019 at 1215 he/she stated Physician C was on call for the ED on 01/28/2019. The ISRN stated there was no documentation that reflected Physician C or any other LIP came to the ED and evaluated the patient.

d. A document titled "Employees Licenses & Certifications" dated "2019" was provided in response to a request for a list of all RNs "certified" (qualified) to conduct MSEs in the ED. The document had a column with ED staff names and a column with the heading "ED." The ED column had spaces for recording an "X" next to the names of staff who were certified to conduct MSEs. The "ED" (certified) column for RN F was blank. There was no documentation that reflected RN F was certified to conduct an MSE. No other RNs were documented in Patient 5's ED record.

6. Regarding Patient 6:

a. The ED record of Patient 6 reflected the patient presented to the ED for emergency services on 02/19/2019 at 0701 with a chief complaint of skin rash.
* At 0701 RN G documented the patient's height/length, weight and BMI. This was the only documentation by RN G.
* At 0722 the triage notes documented by RN F reflected "...pt has red blotches skin, eye swelling, denies difficulty breathing...Reported as generalized in location. It is described as itchy. [He/she] has recently taken medication. [He/she] has had itching...Treatment PTA: Took Benadryl."
* The "History" documented by RN F at 0724 reflected "SOCIAL HX: (provided education on walk-in clinic. Pt and [family] verbalized wanting to go to the clinic. Referred to walk in clinic.)."
* At 0725 the RN documented "Disposition/Discharge...Condition at departure: unchanged...pt is going to walk-in clinic..."
* At 0726 the RN documented:
- "Medications None."
- "Allergies None."
- "Problems: Allergic Reaction. Pneumonia."
* There was no documentation by a physician or other LIP.
* There were no physician or other LIP orders.
* There was no documentation of lab testing, x-ray or other diagnostic tests or procedures.

* The "Medical Screening Exam - Referral to Clinic" form dated "2/19/19" reflected the same preprinted language as above. The space after "An appointment has been made for me to be at:" reflected "Walk-in clinic." The form was signed by the RN but not dated or timed when it was signed. The space for the patient signature reflected "...pt didn't sign but agreed to go to clinic [at] 0727." There were no further discharge instructions.

* The record was unclear and inconsistent, and lacked documentation that reflected an MSE was conducted within the capabilities of the hospital and in accordance with hospital policies and procedures. For example, the record reflected:
- The RN notes lacked a focused assessment of the patient's presenting complaint of skin rash. The RN notes reflected the patient had "pt has red blotches skin, eye swelling...Reported as generalized in location...described as itchy." However, there was no further physical assessment of the patient's reported skin rash and eye swelling (e.g. anatomic location and distribution over the body, size, open areas, drainage, odor, texture, severity of eye swelling, etc.).
- The RN notes reflected "...has recently taken medication...," "Treatment PTA: Took Benadryl," and "Medications None." It was unclear what medications were or were not taken, if any, and when.
- The RN notes reflected "Allergies None." However, the notes also reflected "Problems: Allergic Reaction. Pneumonia." It was unclear if the patient had allergies, an allergic reaction or both. It was unclear if the patient had a current or past problem of pneumonia.
- There was no documentation of a GCS on admit or discharge.
- The RN notes reflected the patient's social history was "...provided education on walk-in clinic. Pt and [family] verbalized wanting to go to the clinic. Referred to walk in clinic." It was unclear how this information was relevant to the patient's social history.
- There was no documentation of lab testing, imaging or other diagnostic tests or procedures.
- There was no documentation that reflected the RN notified the physician or other LIP with a report of the findings of a screening exam.
- No documentation that a physician or other LIP determined the need to respond in person or give telephone orders.
- No documentation that a physician or other LIP determined whether the patient had an EMC.

b. The central log for Patient 6's ED encounter on 02/19/2019 reflected the disposition was "Home" and "Good." However, the ED record reflected "Disposition/Discharge...pt is going to walk-in clinic." The central log did not clearly reflect the patient's disposition.

c. During an interview with the ISRN on 06/21/2019 at 1230 he/she stated LIP B was on call for the ED on 02/19/2019. The ISRN stated there was no documentation that reflected LIP B, or any other LIP came to the ED and evaluated the patient.

d. A document titled "Employees Licenses & Certifications" dated "2019" was provided in response to a request for a list of all RNs "certified" (qualified) to conduct MSEs in the ED. The document had a column

29708

Based on interview, review of documentation in 2 of 2 medical records and ED logs of patients who were transferred from LDH to another hospital for specialty services not available at LDH (Patients 13 and 17), and review of policies and procedures, it was determined that the hospital failed to fully develop and enforce EMTALA policies and procedures to ensure that it affected appropriate transfers for patients for whom an EMC had not been ruled out, removed or resolved. The following required appropriate transfer elements were not carried out:
* Transfers were not affected using appropriate transportation with qualified personnel and necessary and medically appropriate life support measures during transfer.
* Physician certification of transfers lacked patient specific and individualized medical benefits vs patient specific risks of transfer.

Findings include:

1. Policies and Procedures were reviewed:

a. The LDH "Emergency Patient Care Guidelines" dated last approved 09/18/2018 reflected "...If the patient is being transferred to another facility, initiate and complete Transfer (COBRA) documents and follow all transfer guidelines..."

b. The policy and procedure titled "Transfer of Patient Policy and Procedure," dated approved "07/2018" reflected:
* "Lake District Hospital (LDH) follows the regulations outlined in the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)..."
* "The LDH Medical Provider documents the reason for transfer, the name of the accepting physician, and medical necessity on Lake District (LDH) 'Patient Transfer to Outside Facility' (COBRA) form, see sample, Attachment A." The "Attachments" section on page 3 of the policy reflected "No attachments" and there were no attachments to the policy.
* "LDH Medical Provider is also responsible to complete the 'Medical Necessity of Transport' portion of the Transfer (COBRA) form. Provider may consider patient medical and flight insurance coverage...Ground transportation, if available, can be used for a more stable patient. Air transport is indicated for transporting less stable patients or when time is of the essence...Transport of an obstetric, neonatal, or pediatric patient, requiring a special transport team can be done by Perinatal Transport Teams...The transferring Provider ultimately determines which transport agency to contact for transfer..." The policy and procedure was unclear where it reflected "Provider may consider patient medical and flight insurance coverage..." There was no documentation in the policy that ensured inquiries related to patient insurance coverage would not delay the implementation of MSEs and stabilizing treatment.

2. Regarding Patient 13:

a. The ED medical record of 4-month old Patient 13 reflected that he/she presented to the hospital for emergency services on 04/24/2019 at 0016 with a chief complaint of respiratory distress. The record reflected the following:
* At 0031 the triage notes reflected "...Symptoms are constant...[he/she] has had moderate fever of 100 F...[He/she] has had chest congestion and cough...HR: 172. RR: 80. O2 saturation: 92%. Temp: 101.6 F."
* At 0035 the RN documented "Albuterol Nebulizer Treatment Inhalation 1 unit dose given..."
* At 0130 the RN documented "Rocephin...via IV site #1...amount infused: 7 mL..."
* At 0220 the RN documented "Tylenol PR Supp...97.5 mg given."
* At 0455 the RN documented "...infant sleeping. Eyes rolled back, respiratory rate dropped to 30, infant became dusky and sats to the low 80's...RT in to adjust hi flow O2 and give Albuterol treatment..."
* At 0614 the RN documented "HR: 149. RR: 67. O2 saturation: 95%. Temp: 100.5 (rectal)...[high flow O2] 10 lpm..."
* At 0715 the RN documented "Disposition/Discharge...Transported via ambulance by transport team. (Patient departed with Flight panda crew)."
* The FNP "Addenda Lake District Hospital Emergency Department" notes electronically signed by the FNP and dated 05/21/2019 at 1744 reflected "...Severe respiratory distress. Severe retractions...Peripheral cyanosis (mottles to all extremities). Poor skin turgor (anterior fontanel sucken (sic)...Prominent pallor (to face and trunk)..." The "Clinical Impression" reflected "Acute bronchiolitis...with respiratory distress and hypoxemia. Bacterial pneumonia. Respiratory failure."
* The record reflected the patient was transferred to LEMC by fixed wing air transport with Panda team on 04/24/2019 at 0715.

* The "Patient Transfer to Outside Facility" form reflected:
- "This patient requires the following specific clinical services that our facility is unable to provide: Pediatric Critical Care...requires Air Transport due to...Critical condition..."
- The physician certification and risks of transfer section was signed by the FNP and dated 04/24/2019. The following preprinted generic risks were checked "Deterioration of Condition," "Disability," and "Death."

There was no documentation on the transfer form or elsewhere in the medical record that reflected patient specific, individualized risks of transfer had been identified for this 4-month old infant who was in respiratory failure.

b. The central log for Patient 13's ED encounter on 04/24/2019 reflected the disposition was "Hosp." However, the ED record reflected "Disposition/Discharge...Transported via ambulance by transport team...Patient departed with Flight panda crew)..." and the patient was transferred to LEMC. The central log did not clearly reflect the patient's disposition.

c. During an interview with the ISRN on 06/21/2019 beginning at 1330, the ISRN confirmed the record contained no documentation that reflected patient specific, individualized risks of transfer had been identified.

d. An on-line distance calculator reflected that the flight distance between LEMC is approximately 260 air miles and 52 minutes flight time from LDH.

3. Regarding Patient 17:

a. The ED medical record of 9-year old Patient 17 reflected that he/she presented to the hospital for emergency services on 06/13/2019 at 1446 with a chief complaint of stomach pain and possible appendicitis. The record reflected the following:
* Triage notes at 1503 reflected "[Patient] has had decreased oral intake...Temp: 97.9...pain scale: 8/10."

* RN documentation at 1528 reflected "...IV in the right hand...Saline lock flushed..." The record reflected labs were drawn and the patient was administered IV fluids and antibiotics.

* The CBC with differential lab test "Final Results" at 1536 reflected "WBC 15.16 [High]..."

* Physician notes electronically signed by the physician and dated 06/13/2019 at 1810 reflected "...Abdominal pain...described as located in the right lower quadrant. This started today and is still present...At its maximum, severity described as severe...Not relieved by anything. The patient has had nausea and diarrhea...Abdomen...Tenderness in the right lower quadrant..." The notes reflected a CT of the abdomen and pelvis with contrast was completed and the "Clinical Impression" was "Acute appendicitis..."

* RN documentation at 1900 reflected "Disposition/Discharge...Discharge instructions provided and reviewed with [family]. [Family] verbalized understanding...patient was accompanied by [family] and discharged (SCMC). [He/she] left...via private vehicle. [Family] driving. Transferred to St Charles Medical Center...Transported via (POV)."
* RN documentation at 1903 reflected the patient's temperature had increased to 98.3 F.
* RN documentation at 1905 reflected "Site #1 in place upon transfer...IV site checked...flushed..."

* The undated "Nursing Transfer Summary and Final Notes" form signed by the RN reflected "Transfer to...SCMC...going POV...22 [gauge] R hand left in place - instructions provided to leave it alone. Discharged in care of [family]."

* The patient "General Instructions with ExitWriter" form signed by the family member and the RN at 1913 reflected:
- "...You have been evaluated today...for the following conditions(s): Acute appendicitis..."
- The "Instructions" section reflected "(Nothing by mouth)." There were no other patient/family instructions on the form.

* Documentation on the 7-page "Patient Transfer to Outside Facility" form included:
- Page 1 reflected "Agency requested" with "private vehicle" handwritten next to it.
"Accepting Hospital/Facility" reflected "SCMC"
- Page 3 reflected "The following seven air transport companies serve the Lakeview area, 24 hours per day. My choice would be:" This was followed by a list of emergency transport services with boxes next to each. None of the boxes were checked. "Private vehical (sic)" was handwritten next to the list. There was no documentation that reflected who wrote the handwritten entry. The page was signed by the family member and dated 06/13/2019.
- Page 4 reflected "Confirm transferring agency has been contacted by the Unit Secretary..." with a checked box next to it. There was a handwritten entry above this that reflected "going POV." There was no documentation that reflected a "transferring agency" was contacted.
- Page 5 reflected "This patient requires the following specific clinical services that our facility is unable to provide: Surgical Services..."
- Page 7 was signed by the physician and dated 06/13/2019. It reflected "Patient diagnosis: Appendicitis"
"Reason for Transfer: No surgeon at [illegible] hospital"
"Potential risks...Deterioration of Condition"
"Mode of transport...Private vehicle"

There was no documentation of an appropriate transfer on the transfer form or elsewhere in the medical record that reflected:
* Patient specific, individualized risks of transfer had been identified for the patient.
* The transfer was effected through appropriate transportation and qualified personnel, including the use of any necessary and medically appropriate measures for transfer of this pediatric patient with acute appendicitis, increasing temperature, high WBC count, and IV access. The record reflected the patient was transported by private vehicle with a family member.
* That the patient/responsible person refused appropriate transportation with qualified personnel.
Further, the record reflected the patient was offered choices rather than hospital arranged transportation where it reflected "My choice would be" followed by "Private vehical (sic)." This documentation did not clearly reflect that the ED physician made arrangements for appropriate transportation with qualified personnel, and that the patient/responsible person subsequently refused that transportation, and was informed of the risks of refusal.

b. The central log for Patient 17's ED encounter on 06/13/2019 reflected the disposition was "Hosp." However, the ED record reflected the "Disposition/Discharge" was "...Transferred to St Charles Medical Center." The ED central log did not clearly reflect the patient's disposition.

c. During an interview with the ISRN on 06/21/2019 at 1400, the ISRN confirmed the record reflected the patient was transported to SCMC by private vehicle with a family member and an IV line in place. The ISRN confirmed the record contained no documentation that reflected patient specific, individualized risks of transfer had been identified.

d. Online driving directions reflected SCMC is 178 miles and 3 hours and 6 minutes driving time from LDH.