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A. Based on a review of Emergency Medical Services (EMS) ambulance run sheets, a query of the Emergency Department's (ED) central log, a query of the CAH's computerized medical records, the CAH's Bylaws, Rules/Regulations, and staff interview, it was determined that the CAH failed to ensure all patients presenting to the ED received an appropriate medical screening examination and that the CAH designated those individuals qualified to perform a medical screening examination (MSE). Please refer to C-2406.

B. Based on review of policy and procedure, EMS run sheet, medical record review, and staff interview, it was determined that in 4 of 13 (Pts #1, #16, #17, #18) medical records reviewed in which the patient was transferred from the ED, the CAH failed to ensure documentation of the risks and benefits associated with the transfer, that the patient was aware of the risks and benefits, and failed to meet the transfer requirements of the medical record documentation to the receiving facility. Please refer to C-2409

A. Based on observation and staff interview, it was determined that the CAH failed to ensure the required signage was posted conspicuously in the Emergency Department (ED).

Findings include:

1. During a tour of the ED, conducted on 9/13/11 at 11:00 AM, it was observed that the required signage was only posted in the ambulance entranceway. There were no signs posted in the ambulatory entranceway, at registration, in the waiting room, in treatment areas, or any other areas within the ED.

2. During an interview, conducted with the Critical Care Manager on 9/13/11 at 11:15 AM, the above findings were confirmed. She also verbalized that the ED was recently painted and the signage was not put back in place.

A. Based on a review of the CAH's policy and procedures, Emergency Medical Services (EMS) ambulance run sheets, a review of the Emergency Department (ED) log, and staff interview, it was determined that in 2 of 27 (Pts #1, #2) ED visits reviewed, the CAH failed to ensure all patients presenting to the ED were placed into the central log.

Findings include:

1. The CAH's policy and procedure titled, "Log Book/Patient Register" was reviewed. It indicated under "Policy The ER and SCU will maintain individual log books to identify all persons treated in ER or SCU. The log books will be continuously maintained by the Critical Care nursing staff...." And under "Procedure ER - For each patient treated in the ER, fill out the following information: *All patients that are LWBS (left without being seen), AMA (against medical advice) or dead on arrival, shall be included in ER log book."

2. The EMS ambulance run sheet for Pt #1, dated 5/18/11, indicated that Pt #1 was transported to the CAH with "Bleeding from laceration". The EMS ambulance run sheet for Pt #2, dated 7/21/11, indicated that Pt #2 was transported to the CAH with "...a female who had overdosed and is semi-conscious, slurring words..."

3. The computerized ED central log was reviewed for the months of May and July 2011. There was no documentation that indicated Pt #1 presented to the ED on 5/18/11 or that Pt #2 presented to the ED on 7/21/11.

4. In an interview with the Critical Care Manager, conducted on 9/13/11 at 1:45 PM, it was verbalized that all patient's presenting to the ED are registered in the ED's electoronic central log.

5. During interviews with the Chief Nursing Officer and the Critical Care Manager, conducted on 9/13/11 at 2:45 PM, the above findings were confirmed.

A. Based on a review of EMS ambulance run sheets, a query of the ED's central log, and a query of the CAH's computerized medical records, medical record from the receiving hospital and staff interview it was determined that in 2 of 27 (Pts #1, #2) ED cases reviewed, the CAH failed to ensure all patients presenting to the ED received an appropriate medical screening examination (MSE).

Findings include:

1. The EMS run sheet for Pt #1, dated 5/18/11, was reviewed. It indicated Pt #1 was transported to the CAH with a complaint of "Bleeding from laceration". The EMS run sheet for Pt #2, dated 7/21/11, indicated that Pt #2 was transported to the CAH with "...a female who had overdosed and is semi-conscious, slurring words..."

2. The CAH's computerized ED central log was queried for all patients presenting on 5/18/11 and 7/21/11. There was no documentation that Pt #1 or Pt #2 presented to the ED on the respective dates.

3. The CAH's computerized ED records system was queried for any records of Pt #1 or Pt #2 presenting to the ED on the respective dates and receiving an appropriate MSE. There was no documentation that Pt #1 or Pt #2 received MSE's when they presented to the ED on the respective dates.

4. The Critical Care Manager was interviewed on 9/13/11 in regards to the incident with Pt #1. She verbalized that Pt #1 presented to the ED on 5/17/11 with a self inflicted laceration to the forehead. The wound was closed with a surgical glue. However, she verbalized that Pt #1 became irritated and removed the bonding agent prior to leaving the ED. On 5/18/11 he was transported in the early morning to the CAH by ambulance because the laceration started to bleed again. The ED personnel were aware of Pt #1's pending arrival by radio communication. The staff were informed by the ED physician that all he would due was to reapply the surgical glue. A nurse going out on break met the ambulance and informed Pt #1 of the ED physician's decision. Pt #1 refused to get out of the ambulance and insisted that he be taken to another hospital. At that time the ambulance transported Pt #1 to another facility.

5. EMS ambulance run sheet dated 5/18/11 of Pt #1 was reviewed on 09/13/11. Documentation indicated "Nurse met SQ 21 in ambulance parking and advised pt that doctor was not going to reglue forehead or give stitches, advised all they would is rewrap his head. Pt then stated he wanted to go" (receiving) "hospital."

6. The medical record of Pt #1 from the receiving hospital was reviewed on 9/13/11. It indicated that Pt #1 arrived via ambulance on 5/18/11 at 0237 with a laceration to the forehead. The documentation indicated that after obtaining consent, Pt #1 was treated by being prepped and draped in sterile fashion. The wound area was infiltrated with 1% Lidocaine without epinephrine....A simple repair of the laceration, about 5.0 centimeters long, was closed with 5.0 Nylon...The wound was well approximated. There were no complications...". The wound was treated with a topical antibiotic ointment and dressed with a 4x4 guaze pad and Coban. Pt #1 was placed on an oral antibiotic and discharged with instructions.

7. During a follow up interview with the Critical Care Manager, conducted on 9/14/11 at 3:00 PM, it was verbalized that she had investigated the incident regarding Pt #2. Her findings revealed that Pt #2 was brought to the ED by EMS ambulance. Pt #2 was taken to triage where Pt #2 verbalized to Employee #1that Pt #2 had not overdosed and that her family had called the ambulance. Pt #2 also verbalized to E #1that Pt #2 did not know if she could refuse the transport/care provided by EMS. Pt #2 continued that Pt #2 did not feel she needed to be seen by the physician. At that time the E #1 released Pt #2 to her home without any registration or medical screening examination.

8. During an interview with the Critical Care Manager, conducted on 9/13/11 at 1:50 PM, the above finding was confirmed.

B. Based on a review of the CAH's Bylaws, Rules/Regulations, and staff interview, it was determined that the CAH failed to ensure it's Bylaws or Rules/Regulations determined those individuals qualified to conduct the MSE.

Findings include:

1. The Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO) were asked to identify in the CAH's Bylaws or Rules/Regulations that language that determined those individuals qualified to conduct the MSE for those patient's presenting to the ED. No documentation was presented that indicated the above.

2. During interviews with the CEO and the CNO, conducted on 9/13/11 at 2:30 PM, the above findings were confirmed.

A. Based on a review of policy and procedure, EMS run sheet, medical record review, and staff interview, it was determined in 3 of 13 (Pts #1, #16, #18) medical records reviewed in which the patient was transferred from the ED, the CAH failed to ensure documentation of the risks and benefits associated with the transfer, and that the patient was aware of these.

Findings include:

1. The CAH's policy titled, "Transfer of Patients" was reviewed. It indicated under, "Policy 3. Inter-Agency (To another facility/hospital)...The physician will complete information required on the COBRA Form. The nurse will then complete all appropriate transfer forms and obtain needed copies of the patient's medical record....."

2. The EMS run sheet for Pt #1, dated 5/18/11, was reviewed on 09/13/11. Documentation indicated "Nurse met SQ 21 in ambulance parking and advised pt that doctor was not going to reglue forehead or give stitiches, advised all they would is rewrap his head. Pt then stated he wanted to go" (receiving) "hospital."

3. The Critical Care Manager was interviewed on 9/13/11 in regards to the incident with Pt #1. She verbalized that Pt #1 presented to the ED on 8/17/11 with a self inflicted laceration to the forehead. The wound was closed with a surgical glue. However, she verbalized that Pt #1 became irritated and removed the bonding agent prior to leaving the ED. On 8/18/11 he was transported in the early morning to the CAH by ambulance because the laceration started to bleed again. The ED personnel were aware of Pt #1's pending arrival by radio communication. The staff were informed by the ED physician that all he would due was to reapply the surgical glue. A nurse going out on break met the ambulance and informed Pt #1 of the ED physician's decision. Pt #1 refused to get out of the ambulance and insisted that he be taken to another hospital. At that time the ambulance transported Pt #1 to another facility.

4. The medical record of Pt #1 from the receiving hospital was reviewed on 9/13/11. It indicated that Pt #1 arrived via ambulance on 5/18/11 at 0237 with a laceration to the forehead. There was no documetation of a transfer request or a physician certification from the transferring hospital The documentation indicated that after obtaining consent, Pt #1 was treated by being prepped and draped in sterile fashion. The wound area was infiltrated with 1% Lidocaine without epinephrine....A simple repair of the laceration, about 5.0 centimeters long, was closed with 5.0 Nylon...The wound was well approximated. There were no complications...". The wound was treated with a topical antibiotic ointment and dressed with a 4x4 guaze pad and Coban. Pt #1 was placed on an oral antibiotic and discharged with instructions.

5. The medical record of Pt #16 was reviewed on 9/13/11. It indicated Pt #16 presented to the ED on 5/2/11 with a diagnosis of suicidal ideation. Documentation indicated that Pt #16 was transferred with an involuntary admission. There was no documentation of a physicians certification that indicated risks or benefits of transfer and that the patient was aware of these.

6. The medical record of Pt #18 was reviewed on 9/13/11. It indicated Pt #18 presented to the ED with chief complaints of chest pain and headache. Documentation indicated Pt #18 was transferred. The certification failed to indicate the risks involved with transferring the patient to another facility and that the patient was aware of these.

7. During interviews with the CNO and Critical Care Manager, conducted on 9/13/11 at 2:15 PM, the above findings were confirmed

B. Based on medical record review, and staff interview, it was determined in 1 of 13 (Pt #17) medical records reviewed in which the patient was transferred from the ED, the CAH failed to meet the transfer requirements of the medical record documentation to the receiving hospital.

1. The medical record of Pt #17 was reviewed on 9/13/11. It indicated Pt #17 presented to the ED on 5/11/11 with diagnoses of Sepsis, Urosepsis, Diabetes Mellitus II, Acute Renal Failure, Hyponatremia, and Hypokalemia. Documentation indicated that Pt #17 was transferred. The certification in the medical record failed to indicate what documents were sent with the patient to the receiving hospital.

2. During interviews with the CNO and Critical Care Manager, conducted on 9/13/11 at 2:15 PM, the above findings were confirmed.