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Based on EMTALA policy and procedure review, Medical Staff Bylaws, Rules and Regulations Review, Corporate Compliance Meeting documentation review, closed medical record reviews, and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

1. The hospital failed to comply with §489.24 by failing to ensure individual(s) determined qualified and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction to provide appropriate medical screening examinations (MSE) was defined by the hospital's Medical Staff bylaws or rules and regulations for 1 of 1 hospital's Medical Staff bylaws, rules and regulations reviewed ( Carteret General Hospital - Hospital A).

~ Cross refer to §489.24(r) and §489.24(c) Medical Screening Examination, Tag A2406.

2. Based on reviews of medical records and policies and procedures the hospital failed to provide stabilizing treatment to an individual that was within the capabilities of the staff and facilities at the hospital as required to stabilize an emergency medical condition prior to discharge from the ED for 1 (#12) of 20 sampled patients.

~ Cross refer to §489.24 (d) Necessary Stabilizing treatment for Emergency Medical Conditions, Tag A 2407.


The facility was found not to be compliance in with Federal regulations 42 CFR §489.20 and §489.24.

Based on EMTALA policy and procedure review, Medical Staff bylaws, rules and regulations review, corporate compliance meeting documentation review, and staff interviews, the hospital failed to comply with §489.24 by failing to ensure individual(s) determined qualified and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction to provide appropriate medical screening examinations (MSE) was defined by the hospital's Medical Staff bylaws or rules and regulations for 1 of 1 hospital's Medical Staff bylaws, rules and regulations reviewed Carteret General Hospital (Hospital A).


The findings include:
Review of Hospital A's current policy "EMTALA (Emergency Medical Treatment and Labor Act)", revised August 2014, revealed "It is the policy of Carteret General Hospital (Hospital A)....that any individual who comes to the Hospital requesting examination or treatment for a medical condition is entitled to and will receive an Medical Screening Examination as required by the Emergency Medical Treatment and Labor Act (EMTALA) statute ...In compliance with EMTALA's objectives and requirements, it is the Hospital's express policy that, where an individual, regardless of his or her ability to pay, comes to the Hospital requesting examination or treatment for a medical condition, the Hospital, within its Capabilities will provide: · An appropriate Medical Screening Examination (As defined by....Medical Staff Bylaws)...". Further review of the policy failed to reveal any available documentation the policy defined an appropriate MSE or identified the individuals who were Qualified Medical Personnel (QMP) for the purpose of conducting an appropriate MSE to determine the existence of an emergency medical condition (EMC).

Review of Hospital A's current "2015 Medical Staff Bylaws" and "2015 Medical Staff Rules and Regulations" failed to reveal any available documentation of the definition or identification of the individual(s) who were determined qualified by the hospital bylaws or rules and regulations and who met the requirements of §482.55 who could conduct and MSE. Further review failed to reveal the definition of an appropriate medical screening examination as referred to in the hospital's current EMTALA policy.

Review on 05/13/2015 of "Corporate Compliance Meeting" documentation for May 8, 2014 from 1000 to 1035 revealed "...EMTALA: Ms. (Compliance Staff #1) reported that the hospital is conducting an ongoing EMTALA audit. She will present a scorecard at the next quarterly meeting to show the hospitals compliance with EMTALA. Review of an attachment "Corporate Compliance Meeting: revealed ..."EMTALA: This is an audit to determine if (Hospital A) is in compliance with EMTALA requirements. Currently an assessment of the current controls in place are being reviewed. They are as follows: 1. Documented policies, procedures and protocols exist. ...6. Proper documentation of transfers is on file. ...At the next quarterly meeting, a scorecard will be available to show the hospital's compliance with the rules and regulations for EMTALA."

Review on 05/13/2015 of "Corporate Compliance Meeting" documentation for August 14, 2014 from 1000 to 1050, revealed "Present: ...(Division Director #1 name)...". Further review revealed "I did do a hospital policy EMTALA audit and I will share the findings. See attached (handwritten)." Review of "Corporate Compliance EMTALA Policy Audit" (not dated), revealed "OBJECTIVE: The purpose of this audit is to determine if (Hospital A name) is in compliance with the guidelines set forth in the Emergency Medical Treatment and Active Labor Act. EMTALA requires a hospital to have set policies in place. SCOPE: The Scope of this audit included the review of all pertinent policies, procedures, and protocols to determine if they meet EMTALA guidelines. ...A random audit of medical records of patients who are transferred to other facilities from the Emergency Department was conducted to ensure that adequate documentation is present to support the transfer of a patient to another facility. ...FINDINGS: 1. EMTALA requires that the hospital have an EMTALA policy in place. The hospital does have a set policy to ensure compliance with EMTALA that is inclusive of several different EMTALA requirements. 2. EMTALA requires that the hospital have policy setting forth which medical personnel are qualified to perform a Medical Screening Exam (MSE). Currently the policy does not name which medical personnel are qualified to perform and MSE. ...RECOMMENDATIONS: A revised compliance policy is recommended. (Hospital A) EMTALA policy needs to be reviewed and revised to better address the responsibility of the hospital as to what treatment and services must be provided by the hospital to ensure compliance with the Emergency Medical Treatment and Active Labor Act. ...Audited by (Compliance Staff #1 name) 05/28/2014. Audit completed on above date."


The facility ' s PATIENT CARE SERVICES POLICY MANUAL ... SUBJECT: Plan of care, Review dates;1/2010 was reviewed. The policy specified in part, The Emergency Department is staffed by Emergency Physicians twenty-four (24) hours a day. The emergency Medicine Provider ensures that patients with an emergency medical condition (EMC) receive a medical screening examination.

Interview on 05/13/2015 at 1524 with Division Director #1, revealed the hospital's current EMTALA policy is an administrative policy. Interview revealed the EMTALA policy does not define an appropriate medical screening examination or the individual(s) determined Qualified Medical Personnel for the purpose of conducting an appropriate MSE to determine the existence of an emergency medical condition (EMC). Interview revealed the EMTALA policy refers back to the hospital's Medical Staff Bylaws, Rules and Regulations. Interview revealed the hospital's current 2015 Medical Staff Bylaws, Rules and Regulations did not contain requirements for conducting an appropriate MSE and did not define who was approved as a QMP. Interview revealed the EMTALA audit was conducted by Compliance Staff #1 in May 2014 and the findings were presented at the Corporate Compliance Committee meeting in August 2014. Interview revealed the EMTALA audit determined that the current EMTALA policy did not define or determine which medical personnel could perform a MSE. Interview revealed there have been no changes to the hospital's EMTALA policy or Medical Staff Bylaws, Rules and Regulations as a result of the EMTALA audit's findings and recommendations in August 2014. Interview confirmed the hospital's current 2015 Medical Staff Bylaws, Rules and Regulations, failed to define the identification of the individual(s) who were determined qualified (QMP) by the hospital bylaws or rules and regulations and who met the requirements of §482.55 who could conduct an MSE.

Concurrent interview on 05/13/2015 at 1524 with Physician B revealed she was the DED Medical Director for Hospital A. Interview revealed MSE are performed in the DED by physicians, nurse practitioners (NP) and physician assistants (PA). Interview revealed the providers are employees of a contracted emergency physician group. Interview revealed providers are credentialed through the hospital and granted privileges by the governing body. Interview revealed she is the supervising physician for the NPs and PAs and gives them permission to see patients along with company policy. Interview revealed the contracted emergency physician's group policy allows NPs and PAs to see patients triaged as ESI (emergency severity index) level 4 and 5 independently. ESI levels 1-3 must be seen in conjunction with a physician. Interview revealed the purpose of the MSE is to determine if an EMC exists when a patient presents to the DED. Interview revealed she was unaware of the EMTALA audit findings presented at the Corporate Compliance meeting in August 2014. Interview confirmed the hospital's current 2015 Medical Staff Bylaws, Rules and Regulations, failed to define the identification of the individual(s) who were determined qualified (QMP) by the hospital bylaws or rules and regulations and who met the requirements of §482.55 who could conduct an MSE.

Based on reviews of medical records and policies and procedures the hospital failed to provide stabilizing treatment to an individual that was within the capabilities of the staff and facilities at the hospital as required to stabilize an emergency medical condition prior to discharge from the ED for 1 (#12) of 20 sampled patients.


The findings include:

Review of Hospital A's current policy "EMTALA (Emergency Medical Treatment and Labor Act)", revised August 2014, revealed "It is the policy of Carteret General Hospital (Hospital A)....that any individual who comes to the Hospital requesting examination or treatment for a medical condition is entitled to and will receive an Medical Screening Examination as required by the Emergency Medical Treatment and Labor Act (EMTALA) statute ...In compliance with EMTALA's objectives and requirements, it is the Hospital's express policy that, where an individual, regardless of his or her ability to pay, comes to the Hospital requesting examination or treatment for a medical condition, the Hospital, within its Capabilities will provide: Necessary Stabilizing treatment for an Emergency Medical Condition."

Patient #12's medical record from Carteret General Hospital was reviewed on 5/13/2015. Review of the medical record revealed that Patient #12 was a 54 year old male who presented ambulatory via private transportation to the DED (Dedicated Emergency Department) on 02/03/2015 at 1150. Review revealed the patient was triaged by an RN (Registered Nurse) at 1153. Review revealed the a chief complaint of wound and a stated complaint of lip bleed. Review also revealed, "PT AMBULATORY TO TRIAGE WITH C/O (COMPLAINT/OF) LIP BLEEDING. HAS 'PIMPLE' LOWER LIP STARTED BLEEDING X 2 HRS (HOURS) AGO. Review revealed VS (vital signs) were assessed as T (temperature) 98.4 degrees F (Fahrenheit); P (Pulse) 77; R (respirations) 16; BP (Blood Pressure) 161/60 (Normal BP-120 during heart relaxation; 80 during heart relaxation); and Sp02 on RA (room air); Pain level was assessed as a 0 (zero) using a 0-10 pain scale. The patient was assigned as ESI (Emergency Severity Index) Priority 4 (on a scale of 1 to 5 with 1 being the most urgent ). Review at 1153, revealed treatment prior to arrival "HOLDING PRESSURE TO AREA." Review revealed a past medical history of end stage liver disease (final stage of liver failure), asthma, esophageal varices, and hepatitis C (liver disease). At 1225, Topical Silver Nitrate (Topical antimicrobial cream) was applied to the wound by the provider. At 1509, revealed Disposition Type- discharge; discharge to home; discharged with parent: mode of discharge ambulatory; education topics discharge instructions; patient specific instructions given improved. Disposition assessment- level of consciousness: alert, awake, and appropriate. VS were assessed as P-81; R-18; BP 161/79; Sp02 100% on RA; and Pain 7/10. (on a scale of 1-10 with 10 being the greatest). Review revealed departure date/time: 02/03/2015 at 1511-home.
Review of dictated MSE documentation by Nurse Practitioner #1, revealed the patient was seen at 1155. Review revealed "Chief Complaint: LIP BLEED." Review revealed, "I confirm that the attending physician has examined the patient, reviewed my documentation on the patient's chart, and discussed the evaluation, plan of care and disposition of the patient with me. I saw this patient with an Attending Physician." . . .History of Present illness (HPI): Patient presents with a complaint of bleeding from his lower lip that will not stop the past 3 hours. He has had this one other time in the past. And in fact has been told that the area needs to be biopsied however he does not have any medical insurance at this time and has not had a [sic] it taking care of Incidentally he has chronic cirrhosis (long term liver disease) and states that he is under the care of (name) Clinic for this however... he and his mother do not feel that he is getting adequate treatment for his cirrhosis at this time in the [sic] (and they) feel that he has been sicker recently and request lab work be obtained. He does have significant ascites (excess fluid in the abdomen) however he is able to lay down flat without any difficulty breathing. Review of Systems (ROS). Total of ten systems reviewed and negative, except as indicated in the HPI and ROS... Physical Examination: General: Alert. HEENT (Head, Ear, Eye, Nose, Throat): Normal ENT inspection. Eyes: Lids Normal. Oropharynx/Throat: Normal Pharynx, Moist mucus membranes. Neck: No Lymphadenopathy, No Meningismus and Supple. Respiratory: No Resp (respiratory distress) Distress and Normal Breath Sounds. Cardio-Vascular: No murmur, No rub and RRR. Abdomen: Nontender and soft: Back: Achilles DTR's (deep tendon reflexes) nl (normal) and equal. No CVA (costovertebral angle) tenderness, No Midline Tenderness, Non-Tender and Patella DTR's nl and equal. Extremity: No edema. Neurological: Alert, Oriented X 3. No Gross Weakness and Speech Normal. Skin: No rash, No Petechiae, Warm and Dry. Psychological: Mood Affect/Normal and Normal Memory/Judgement. Review revealed a complete blood count, basic metabolic count, lactate, Ammonia, Partial Thromboplastin Time, Prothrombin Time with INR, urinalysis, and acute abdominal series with chest x-ray were ordered and obtained. Review of a radiology report dated 02/03/2015 at 1331 for an acute abdominal series revealed, "Impression::nonacute abdomen and chest." A review of a chemistry laboratory report dated 02/03/2015 at 1304 for Patient #12 revealed in part the following: Platelet (parts of the blood that helps the blood to clot) count low 83(Hospital normal reference range 165-353); Total Bilirubin (test for diagnosing liver dysfunction) 8 High (Hospital normal reference range 0.1- 1.3); and Albumin (found in liver to maintain fluid balance) 3.0 Low (Hospital reference range 3.5 to 5.0). Review of "Medical Decision Making" revealed "The studies were reviewed with the Patient. The patient understands that at this time there is no indication for admission; however, if symptoms worsen or donot improve they must return for repeat evaluation. Patient is instructed to follow-up with their physician as directed in the discharge instructions. Patient was also seen by (Physician C). Surgeons feel [sic] (Surgicel-blood clotting inducing material) applied to bleeding site. Also cauterized with silver nitrate stick and pressure dressing applied the bleeding did stop. Lipitor [sic] (liver) studies were obtained and actually look better that his previous studies last September. He is not in any acute distress at this time. He is able to lie flat without any difficulty breathing. And Although he does have end stage liver failure and significant ascites there is no emergency medical condition at this time. This was explained to the patient he may follow-up with (name) Clinic and possibly have an out patient paracentesis (procedure to remove fluid that has accumulated in the abdominal cavity). Return for any worsening symptoms such as shortness of breath." The clinical Impression for Patient #12 was listed as: 1. Skin Lesion; 2. Bleeding; 3. Liver Failure.

Review on 5/02/2015 of the DED central log for February 2015 revealed no subsequent log entries for Patient #12 on 2/3/2015 after his discharge at 1511.

Review of a "Visit by Date" report for patient #12 revealed the patient was directly admitted to an in-patient observation bed on 2/3/2015 for ascites and was discharged on 02/04/2015. Hospital A, closed in-patient record review revealed Patient #12 was admitted to observation status on 02/03/2015 at 1827 (3 hours after discharge from the emergency room) to an in-patient unit. Review of an admission history and physical dictated by Physician D on 02/04/2015 at 0831, revealed the patient was seen at 1915 (02/03/2015) with chief complaint of abdominal distention. Review of HPI, revealed "This is a 54-year old gentlemen with a history of Chronic hepatitis C who was seen in the emergency department earlier today for a facial cut from shaving that he could not stop the bleeding on. Apparently he was seen and treated, and released. He went to the (name) clinic and was seen by Dr.(name). She called me and told me that this gentleman had massive ascites from his cirrhosis, is quite uncomfortable, and requires observation admission and paracentesis with albumin infusion. So he is being admitted for this. .. He does have some mild dyspnea but usually when he is lying down flat due to his ascites....OBJECTIVE: GENERAL: He is a pleasant gentleman who is no distress. He is jaundiced....HEENT: Sclera are jaundiced...LUNGS: Clear to auscultation. CARDIAC: Regular without murmur, rub, or gallop. ABDOMEN: Tense and distended with ascites, but he is not tender. No guarding or rebound. The belly is soft with positive bowel sounds. NEUROLOGICAL SURVEY:...Normal mental status. He is oriented X3... ASSESSMENT AND PLAN: Ascites in a gentlemen with end stage liver disease. He is being admitted for observation. He will have a therapeutic paracentesis in the morning followed by albumin infusion and likely discharge after lunch. A review of the Ultra Sound Abdominal Paracentesis revealed that 4.32 liters (1 gallon) of fluid was removed form the right lower quadrant of patient #12's abdomen. The patient was discharged on 02/04/2015.

The facility failed to provide stabilizing treatment for patient #12 on 2/3/2015 that was within the capability and capacity of the Hospital as evidenced by failing to treat the abnormal lab values, significant ascites, pain level on presentation was 0 and on discharge pain level of 7, which the staff were well aware of prior to discharge. As this resulted in Patietn #12 returning to the hospital as a direct admit within 3 hours after discharge from the ED with massive ascites and requiring appropriate treatment for his medical condition.