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Based on staff interviews and review of medical records, policies/procedures and Medical Staff Bylaws, the facility failed to comply with the Medicare provider agreement as defined in 489.20 and 489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

The facility failed to meet the following requirements under the EMTALA regulations:

Tag A2405 Emergency Room Log
The facility failed to maintain a complete central log on each individual who came to the emergency department, as defined in ?489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. Specifically, the facility failed to record Sample Patient #1 into the emergency department's log and failed to ensure that the logs for the emergency department and obstetrics department were complete.

Tag A2406 Medical Screening Examination
The facility failed to ensure that all individuals that "comes to the emergency department", as defined in paragraph (b) of this section, were provided an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. Specifically, the facility failed to ensure that Sample Patient #1 was provided a medical screening examination when the patient was brought into the facility's emergency department by ambulance.

Based on review of the facility's policies/procedures, facility document review, staff interview, and medical record review the facility failed to maintain a complete central log on each individual who came to the emergency department, as defined in ?489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. Specifically, the facility failed to record Sample Patient #1 into the emergency department's log and failed to ensure that the logs for the emergency department and obstetrics department were complete.

The findings were:

A review of the facility's policy titled, "EMTALA Guidelines for Emergency Department Services" last revised 3/2008 stated the following, in pertinent parts:
"...Medical Screening Exams:
Medical Screening Exams should include at a minimum the following:
?Emergency Department Log entry including disposition of patient
?Patient's triage record
?Vital signs
?History
?Physical exam of affected systems and potentially affected systems
?Exam of known chronic conditions
?Necessary testing to rule out emergency medical conditions
?Notification and use of on-call personnel to complete previously mentioned guidelines
?Notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary
?Vital signs upon discharge or transfer
?Complete documentation of the medical screening exam ..."

A review of the facility's Emergency Department and Obstetrical Department's logs that were used to satisfy the requirements at 489.20 revealed that Sample patient #1 was not included in the log. Also the logs for both departments were noted to have incomplete entries which included the absence of dispositions of some of the patients.

A review of the facility's Emergency Department's log revealed that the following entries were incomplete:
Sample patient #8's entry from 1/29/2012 did not have a discharge date/time or disposition. The log also did not include information about the patient's presenting complaint.
Sample patient #9's entry from 1/29/2012 did not have a discharge date/time or disposition.
Sample patient #10's entry from 1/29/2012 did not have a discharge date/time or disposition. The log also did not include information about the patient's presenting complaint.
Sample patient #11's entry from 1/30/2012 did not have a discharge date/time or disposition. The log also did not include information about the patient's presenting complaint.
Sample patient #12's entry from 1/31/2012 did not have a discharge disposition. The log also did not include information about the patient's presenting complaint.
Sample patient #13's entry from 2/1/2012 did not have a discharge date/time or disposition. The log also did not include information about the patient's presenting complaint.
Sample patient #14's entry from 2/1/2012 did not have information about the patient's presenting complaint.
Sample patient #15's entry from 2/1/2012 did not have a discharge date/time. The log also did not include information about the patient's presenting complaint.

An interview with the facility's Director of the Emergency Department on 4/12/2012 at approximately 2:45 PM revealed that the logs provided to the surveyors were the logs that the facility used to satisfy the requirements of this section. S/he confirmed that the log was incomplete and that it did not include Sample patient #1.

An interview with the facility's Director of Obstetrics on 4/12/2012 at approximately 2:00 PM revealed that there was one log used to capture all patients presenting to the obstetrics department. S/he reviewed the log titled "OB Log" and stated that all admissions, transfers, and discharges for the department would be documented on this log. The Director of Obstetrics stated that the logs are typically completed by technicians and are not audited by staff. S/he confirmed that the log had missing information as to discharge of patients from the department.

Based on medical record review, staff interview, review of facility documents and policies/procedures the facility failed to ensure that all individuals that "comes to the emergency department", as defined in paragraph (b) of this section, were provided an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. Specifically, the facility failed to ensure that Sample Patient #1 was provided a medical screening examination when the patient was brought into the facility's emergency department by ambulance.

The findings were:

A review of the facility's policy titled, "EMTALA Guidelines for Emergency Department Services" last revised 3/2008 stated the following, in pertinent parts:
"All patients presenting to SLVRMC Emergency or Labor and Delivery Departments and seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay.
?In the absence of an actual request for services, if a "prudent layperson" observer would believe, based on the individual's appearance or behavior, that the individual needs an examination or treatment for a medical condition, EMTALA still applies and the person must be accepted and evaluated for treatment.
?All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis ...
SLVRMC may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of their medical condition, they are legally unstable as per EMTALA ...
Medical Screening Exams:
Medical Screening Exams should include at a minimum the following:
? Emergency Department Log entry including disposition of patient
? Patient's triage record
?Vital signs
?History
?Physical exam of affected systems and potentially affected systems
?Exam of known chronic conditions
?Necessary testing to rule out emergency medical conditions
?Notification and use of on-call personnel to complete previously mentioned guidelines
?Notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary
?Vital signs upon discharge or transfer
?Complete documentation of the medical screening exam ..."

A review of the facility's medical staff rules and regulations which were last revised 9/29/2010 revealed the following, in pertinent parts:
" ...B. Emergency
1. An appropriate medical record shall be kept for every patient receiving emergency services. The medical record for patients receiving emergency services shall include the following:
a. Identification data including name, address, date of birth, and next of kin.
b. Information concerning the time of the patient's arrival, means of arrival, and by whom transported.
c. Pertinent history of the injury or illness including details relative to first aid or emergency care given to the patient prior to his/her arrival at the Hospital.
d. Description of significant clinical laboratory and x-ray findings.
e. Diagnosis
f. Treatment given
g. Condition of the patient on discharge or transfer
h. Final disposition, including the instructions given for follow-up care.
2. The medical record shall be signed by the Practitioner in attendance.
C. The completed outpatient service medical record should include applicable data from the following list:
1. Vital data, including patient identification, name of nearest relative or other responsible agent, social security and/or outpatient service registration number, identification of other sources of medical care, and dates and times of visits.
2. Clinical data, including working diagnosis or patient's clinical problem, operative report on outpatient surgery including pre-anesthesia evaluation and type of anesthesia, techniques and dosage used, discharge summary
d. Progress notes as are pertinent to the oral condition.
e. Clinical resume (or summary statement)
2. The physician's responsibilities include:
a. An admission history and physical
b. Supervision of the patient's general health status while hospitalized.
c. The admitting physician or qualified alternate shall be available for emergencies when general anesthetic is administered to dental patients ...
ARTICLE VIII. EMERGENCY SERVICES
A. The MEC shall have overall responsibility for emergency medical care.
B. The MEC shall adopt a plan for providing medical coverage in the emergency service area. Such plan shall include the following:
1. Each Practitioner shall be available to the emergency care area through the medical call roster in their specialty.
2. Practitioner on-call response time (The following times are guidelines and any deviations shall be monitored and/or reviewed as needed by the MEC.):
a. To voice/digital pages - 20 minutes by phone.
b. Critical/unstable - 40 minutes from phone contact to arrival In person.
3. Consultation shall be available at the request of the attending Medical Staff member.
C. The Emergency Department Committee shall develop a procedure manual which sets forth the duties and responsibilities of all personnel serving patient within the emergency area.
D. The disaster plan shall include the following:
1. Availability of adequate basic utilities and supplies, including gas, food, water, and essential medical and supportive materials.
2. An efficient system for notifying and assigning personnel.
3. A unified medical commend under the direction of a designated Practitioner (the chairman of the committee or the designated substitute).
4. Conversion of all usable space into clearly defined areas for efficient triage, for patient observation, and for immediate care.
5. Prompt transfer, when necessary, and after preliminary medical or surgical services have been rendered, to the facility most appropriate or administering definitive care.
6. A special disaster medical record, such as an appropriate designed tag, which accompanies the casualty as he/she is moved.
7. Procedures for the prompt discharge or transfer of patients in the Hospital who can be moved without jeopardy.
8. Maintaining security in order to keep relatives and curious persons out of the triage area.
9. Pre-establishment of a public information center and assignment of public relations liaison duties to a qualified individual. Advance arrangements with communications media will help to provide organized dissemination of information ..."

A review of an ambulance trip report for 2/2/2012 from the hospital's ambulance service revealed that Sample Patient #1 was treated by the hospital's ambulance service. The report was dated 2/2/2012 and stated that the type of patient was "Difficulty Breathing/Respiratory Distress." The EMTs listed on the report included: EMT 1, EMT 2, and EMT 3.
The narrative stated the following:
"Alamosa Ambulance was dispatched to [Dialysis treatment clinic] for a 61 year old [patient] with difficulty breathing.
Upon arriving on scene, the patient was encountered awake and alert sitting on a reclined treatment chair. Staff members informed EMS that the patient was brought to the dialysis center from [Hospital B] for dialysis treatment. Patient was admitted to [Hospital B] for left side fractured ribs. While receiving treatment, the patient's oxygen saturation was reported to have decreased to 70% while 3 lpm nasal cannula O2 was being consumed. The patient was also reported to have become hypotensive with a systolic pressure in the 80's. The patient was administered fluid which elevated his systolic pressure to the 120's. Patient's current SpO2 was reported to EMS by staff as 88% on 6 lpm nasal cannula O2.
The patient presented AAO x 3 as s/he sat reclined on the chair. The patient reported experiencing "some" SOB. Patient's respiratory rate was observed to be 18 bpm and non-labored. Patient's skin appearance was warm, pink and dry. The patient was placed onto portable with a flow rate of 6 lpm. Patient was transported out of the facility and placed into Med 102.
Vital signs were obtained from the patient and were found as: BP 130/88, HR 104 and irregular, RR 18 and a Sp02 of 96% after placing him/her onto a NRB mask with a flow rate of 15 lpm. After the patient was placed onto the NRB mask, s/he reported improvement. Patient stated" I'm feeling good." Patient's lung sounds were found clear but diminished bilaterally. The patient was placed onto the cardiac monitor which displayed a rhythm of atrial fibrillation along with artifact. The patient was questioned and found to have a h[istory] consisting of atrial fibrillation along with diabetes. IV access was not attempted by EMS as the patient had IV access in his right AC which was reported to have been established by [Hospital B] nursing staff. Patient report was relayed to the ED. After learning of the patient's current status and improvement, medical control ordered the patient to be returned to [Hospital B] since s/he was still an admitted patient at the facility. Patient report was relayed to the ED of [Hospital B], which is where s/he was transported.
Upon arriving at [Hospital B], the patient was removed from Med 102 and transported through the ED and into his/her current hospital room as directed by nursing staff. The patient was removed from the stretcher and transferred onto a hospital bed. Patient report as well as patient care was given to the receiving nursing staff. Med 102 departed the hospital and cleared the call."
The report stated that the unit arrived at the scene at 9:52 and to the patient at 9:54. Assessment, vital signs, and interventions were documented to be performed from 9:57 through 10:03. The report stated that the ambulance departed the scene at 10:04 and arrived at the destination (later identified as SLVRMC) at 10:09. The report had assessments and vital signs documented at 10:15, 10:30, and 10:45. The report did not state when the ambulance departed SLVRMC or arrive at [Hospital B].

A total of twenty one medical records were reviewed as a part of the investigation of this complaint. The hospital was unable to provide a record for Sample patient #1 when requested to do so. The facility had no documentation to support that a medical screening examination was performed on Sample patient #1. There was no documentation of any assessment by hospital staff or physician available for review for Sample patient #1.

An interview with the facility's Director of Emergency Services was conducted on 4/12/2012 at approximately 12:15 PM during observations of the facility's emergency department. S/he stated that the facility's physicians are the only providers that are able to perform a medical screening examination. S/he stated that s/he vaguely remembered 2/2/2012 and when s/he had spoken with Physician #1, s/he stated to him/her that s/he vaguely recalled the date and sample patient #1. S/he stated that if the patient had checked into the department, than the hospital would have a record of the patient. S/he stated that two of the EMTs that were on the call were present in the ED (EMT#1 and EMT#3) and were available to interview. S/he then stated that the EMTs told her that the patient was brought into the ED at SLVRMC.

An interview with EMT #1 was conducted on 4/12/2012 at approximately 12:45 PM with EMT #3 present. He stated that both of the EMTs were present on the call and that s/he recalled the call. S/he stated they were called to the dialysis clinic for a patient that had low blood pressure and that prior to their arrival the facility had given the patient fluid and that the patient's oxygen saturations were in the 80's and the patient was short of breath. They placed the patient on a non-rebreather mask and the patient improved. S/he stated that they brought the patient to SLVRMC's ED and that Physician #1 had evaluated the patient on the stretcher inside the doors of the ED. S/he stated that they were told that since the patient was an inpatient at Hospital B, that it was best to take the patient back to Hospital B. When asked to interpret the ambulance trip report, s/he stated that s/he thought that the arrival time on the report was when they arrived at SLVRMC rather than Hospital B. When asked for clarification, s/he stated that the ambulance's stretcher with the patient was brought into the doors of the hospital's ED and that Physician #1 had met the stretcher at that point. S/he stated that there was no direction given to the ambulance when they had first contacted the facility via the radio and that they were not aware that the patient was an inpatient at Hospital B when they brought the patient into the ED. S/he stated that they were informed by the staff at SLVRMC that the patient was an inpatient at Hospital B. S/he stated that Physician #1 performed a "brief assessment" and that patient was able to talk to the physician. S/he stated that s/he was not given any documentation of this "brief assessment" or any documentation from SLVRMC upon transfer of the patient. S/he stated that the patient remained on a non-rebreather the entire trip. S/he stated that after being given direction to take the patient to Hospital B by Physician #1, they took the patient to Hospital B. They then took the patient to his assigned room at Hospital B and gave report to the facility's staff upon arrival. S/he stated that there was no paperwork from SLVRMC for a transfer and there was no paperwork from the dialysis clinic. He stated that this was the first time s/he had ever been redirected from SLVRMC. S/he also stated that this was the first time that this call had been brought up/questioned.
EMT #3 stated that s/he was the driver that day and that EMT #1's recall of the events matched his/her recollection of the day in question. S/he stated that s/he had accompanied the patient into SLVRMC's ED as well.

A telephone interview was conducted with Physician #1 on 4/12/2012 at approximately 1:15 PM. S/he stated that s/he was the hospital's ED Medical Director. S/he stated that he did not recall the patient coming into the ED. S/he stated that s/he had spoken to staff. S/he stated that SLVRMC had been contacted by Hospital B regarding the sample patient #1 and that the patient was needing a VQ scan later that day and that the patient had become hypoxic/hypotensive at dialysis and that EMS was called. S/he stated that after the interventions of the dialysis clinic and EMS, the patient was stabilized in the opinion of the Paramedic and that SLVRMC had communicated with Hospital B who stated they were comfortable receiving the patient back. S/he stated that s/he "definitely never performed a medical screening examination on the patient myself" and that the patient was "definitely not in the emergency department". S/he stated that the above was coordinated by telephone and not the EMS radio. S/he stated that the patient was not registered and that there was not a medical record and that there could not be any documentation if there was no medical record or registration. When confronted with the previous interviews that had been conducted that stated that Physician #1 had seen the patient in the ED, s/he stated that it was "not how I remember it - could be possible." S/he stated that EMS personnel were not able to perform medical screening examinations.