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Based on document review and interview, the facility failed to ensure compliance with 489.24 in that the facility failed to admit a patient they accepted for admission and which the facility had the capabilities of treating for 1 of 20 medical records reviewed. (Patient [P]15)


Findings Include:

See findings cited at 42 CFR 489.24, A2411.

Based on document review, observation, and interview, the facility failed to provide a medical screening examination for 1 of 20 patient medical records (MR) reviewed. (Patient [P]15)

Findings include:

1. Facility policy titled, Emergency EMTALA/Assessment Process, PolicyStatID: 13792158, last revised 3/2012, indicated Under POLICY: 2. When a person presents for evaluation, or when a potential patient is seen at an offsite location by the mobile assessment team, an appropriate assessment will be completed. The assessment as described in the assessment policy will include: personal demographics, medical history/screening information psychiatric history/mental status exam, initial diagnostic impression.

2. P15 MR indicated the following:
a. Facility consent for treatment forms completed and signed by FM1 (Guardian of P15).
b. MR lacked documentation of a medical screening examination.
c. MR indicated FM1 signed facility Refusal to Permit Medical Treatment or Transfer form on 5/1/24 at approximately 11:10, did not distinguish am or pm.

3. Facility document, untitled, dated 5/6/24 at 6:03 pm, indicated P15 was under the care of the Emergency Medical Services (EMS) while physically present at the facility, then at an undocumented time was signed in and under the care of the facility.

4. Observation of facility video surveillance completed 6/3/24 at approximately 3:30 pm, indicated on 5/1/24 at approximately 8:15 pm, P15 arrived to facility via Emergency Medical Services (EMS). On 5/1/24 at approximately 9:53 pm facility staff were observed signing an item held by EMS, then EMS exited building. On 5/1/25 at approximately 11:20 pm P15 left facility with family.

5. In interview, on 6/3/24 at approximately 4:10 pm, N2 (Intake Clinician) verified part of the intake process was a transfer of care from EMS to facility. When patients arrive at the facility via EMS there was a patient transfer of care from EMS to the facility and it would be documented by EMS, and signed by facility staff. This documentation was typically done on an electronic tablet. EMS does not give the facility a copy of the documentation. N2 verified once EMS exits the facility, the facility has accepted care of the patient.

6. In interview, on 6/3/24 at approximately 2:36 pm, A3 (Director of Risk Management, Performance Improvement, and Medical Records [DRM]) verified FM1 signed the facility Refusal to Permit Medical Treatment or Transfer form at 11:10 pm.

7. In interview, on 6/3/24 at approximately 4:20 pm, A2 (Interim Director of Intake) verified the nurse in the video surveillance signed EMS transportation document and EMS exited the facility at approximately 9:53 pm on 5/1/24.

8. In interview, on 6/4/24 at approximately 10:20 am, FM1 verified he/she signed the Refusal to Permit Medical Treatment or Transfer after suggestion by facility staff to come get P15.

Based on document review and interview, the facility failed to admit a patient they accepted for admission and which the facility had the capabilities of treating for 1 of 20 medical records (MR) reviewed. (Patient [P]15)

Findings include:

1. Facility procedure titled, Facility - Red/Yellow/Green Admission Criteria, no approval date listed, indicated under Red Zone: EXCLUSIONARY/CANNOT BE TREATED AT OUR FACILITY: 1. suctioning/trach, 2. wounds requiring complicated dressings, 3. severe neurological deficits, 4. continuous oxygen, 5. difficulty swallowing, 6. indwelling catheters, 7. intravenous tubing, 8. uncontrolled seizure disorder, 9. infections disease requiring isolation, 10. unstable vital signs, 11. need for heparin, 12. total nursing care, 13. currently medically unstable, 14. enrolled in hospice or end of life care, 15. IQ less than 70, 16. PICC line.

2. Facility document, untitled, dated 5/6/24 at 6:03 pm, indicated P15 was under the care of the Emergency Medical Services (EMS) while physically present at the facility, then at an undocumented time was signed in and under the care of the facility. The document indicated F1 was unable to meet the care needs of P15.

3. P15 MR indicated the following:
a. Facility consent for treatment forms completed and signed by FM1 (Guardian of P15).
b. MR indicated FM1 signed facility Refusal to Permit Medical Treatment or Transfer form on 5/1/24 at approximately 11:10, did not distinguish am or pm.
c. MR lacked documented attempts for placement or transfer to another facility.
d. MR lacked documented phone calls between facility staff and FM1.

4. Observation of facility video surveillance completed 6/3/24 at approximately 3:30 pm, observed date 5/1/24 at approximately 8:15 pm to approximately 11:20 pm, indicated on 5/1/24 at approximately 8:15 pm P15 arrived to facility via Emergency Medical Services (EMS). On 5/1/24 at approximately 9:53 pm facility staff seen signing an item held by EMS, then EMS exited building. On 5/1/25 at approximately 11:20 pm P15 left facility with family.

5. In interview, on 6/3/24 at approximately 2:36 pm, A3 (Director of Risk Management, Performance Improvement, and Medical Records [DRM]) verified FM1 signed the facility Refusal to Permit Medical Treatment or Transfer form at 11:10 pm.

6. In interview, on 6/3/24 at approximately 2:37 pm, A2 (Interim Director of Intake) verified there were no facility policies related to insulin pumps and insulin pumps were not listed as exclusionary criteria.

7. In interview, on 6/3/24 at approximately 2:50 pm, MD1 (facility provider) verified he/she agreed to accept P15 as a patient at the facility and was aware of the existing insulin pump prior to acceptance of patient.

8. In interview, on 6/3/24 at approximately 4:10 pm, N2 (Intake Clinician) verified part of the intake process is to check with nursing units to verify adequate staff before accepting a patient.

9. In interview, on 6/4/24 at approximately 10:20 am, FM1 verified he/she signed the Refusal to Permit Medical Treatment or Transfer after suggestion by facility staff to come get P15.