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Based on observation, record review and interview, facility staff failed to perform a medical screening exam and maintain a comprehensive log for 1 of 21 patients presenting to the Emergency Department (Patient #1).

Findings include:

Facility staff failed to maintain a log of all patients presenting to the Emergency Department. See tag C2405.

Facility staff failed to perform a medical screening exam for all patients presenting to the Emergency Department. See tag C2406.

Based on record review and interview, facility staff failed to maintain a record of patients presenting to the Emergency Department on a centralized log for 1 of 21 patients reviewed, in a sample of 21 patients (Patient #1).

Findings include:

Review of facility policy "EMTALA" dated 3/2018 revealed "II. Definitions: A. Dedicated Emergency Department: A provider-based Department or facility of the Hospital Property... C. Hospital Property: The physical area immediately adjacent to the Hospital's main buildings and other areas and structures that are not strictly contiguous to the main buildings, but are located within 250 yards of the main buildings, including the parking lot, sidewalk and driveway... IV. D. Records and Records Retention: A centralized log of all patients presenting with a request for emergency care to the Dedicated Emergency Departments and Hospital Property shall be maintained and shall include the name of the patient, outcome, any refusal of care and whether the patient was admitted, stabilized and transferred, or discharged. The log, patient records, physicians' on-call lists and any non-appearance of on-call physicians shall be maintained for at least five years."

During an interview on 5/28/2019 at 11:30 AM, Director of Nursing A stated Patient #1 presented to the Emergency Department via ambulance in the evening of 5/17/2019.

Review of the facility's Emergency Department log did not include Patient #1.

During an interview on 5/29/2019 at 11:05 AM, when asked Registered Nurse E stated patients are usually entered in the log when they are registered. When asked about Patient #1, who presented to the Emergency Department but was not registered, E stated "I'm not sure." Regarding E's understanding of presenting the Emergency Department, Registered Nurse E stated "when they come in and ask for help" or if in the parking lot, "then we'd bring them in."

Based on observation, record review and interview, facility staff failed to perform a medical screening exam for patients presenting the Emergency Department in 1 of 21 patients reviewed, in a sample of 21 patients (Patient #1).

Findings include:

Review of facility policy "EMTALA" dated 3/2018 revealed "II. Definitions: A. Dedicated Emergency Department: A provider-based Department or facility of the Hospital Property... C. Hospital Property: The physical area immediately adjacent to the Hospital's main buildings and other areas and structures that are not strictly contiguous to the main buildings, but are located within 250 yards of the main buildings, including the parking lot, sidewalk and driveway... D. Medical Screening: Medical examination, within the capability of the Hospital, including ancillary services routinely as available, as required to determine whether an Emergency Medical Condition exists for a particular patient, including diagnostic testing and ongoing monitoring, according to patient needs and condition. The Medical Screening must be performed by a Qualified Medical Person. E. Qualified Medical Person: An emergency physician... with appropriate clinical privileges, or another person qualified by experience and training and to perform Medical Screenings... III. Applicability of EMTALA to Hospital Location: A. 1. If an individual: a. Presents at the 'Dedicated Emergency Department;' and c. Has a request for examination or treatment for a medical condition made on his or her behalf... 2. Then the Dedicated Emergency Department will provide a Medical Screening to determine if the individual has an emergency medical condition, and provide any necessary Stabilizing Treatment... E. Ambulances: The obligations in Section III.A above apply to individuals in an ambulance on Hospital Property."

Review of facility policy "Use of Emergency Garage" dated 3/2016 revealed "1. Garage entrance door will be kept unlocked from 6 AM to 9 PM daily. 2. The night shift will unlock the door by throwing the switch at Nurses Station at 6 AM, and evening Charge Nurse will lock door at 9 PM daily. 3. While unlocked, door will automatically open when vehicle passes over magnetic loop, allowing ambulances or private vehicles to enter garage. ...7. Between 9 PM and 6 AM vehicles desiring admission to the garage will gain staff attention by using the outside emergency bell. Staff will then respond and open the door."

Review of Patient #1's Ambulance Transport report, dated 5/17/2019, revealed "Upon arrival outside ambulance door had been made inoperable and nurse came to rig to report that family wanted patient to go to [Facility BB], better for patient. Nurse had visual of patient who had fallen asleep. Ambulance then left with transfer to [Facility BB]."

During an interview on 5/28/2019 at 11:30 AM, Director of Nursing A stated "there was a misunderstanding." Per A, the ambulance had been called to the skilled nursing facility to bring Patient #1 to the hospital due to confusion and combative behavior. Per A, the ambulance staff were told by Patient #1's family that the family preferred for Patient #1 to be transported to Facility BB. Director A stated "the ambulance called here and then stopped here, our nurse met the ambulance outside and they [ambulance staff] said they would take him directly to [Facility BB]."

During an interview on 5/28/2019 at 12:35 PM, Emergency Medical Technician F stated "the family asked 'can you take [Patient #1] to [Facility BB]?' and we told them we typically go to the nearest [ED] and they agreed to that." Per F, "when we left [Skilled Nursing Facility CC] our destination was [Facility AA], [EMT K] called when we were about 5 minutes out and when we got there the door wouldn't work, it's supposed to open when we pull up." EMT F stated "the nurse on the phone was insistent that we take the patient to [Facility BB], then a nurse came out of the building and said we should go to [Facility BB]. We got tired of explaining it so we just gave up, they just really didn't want [Patient #1]." Per F, "we were right at the door, right there" and "I wasn't sure what to do."

During an interview on 5/28/2019 at 12:25 PM, Registered Nurse D stated "I met the ambulance outside, the driver came in the door into the hallway and said 'the family wants the patient to go to [Facility BB] but we can't take the ambulance out of service that long.' I saw the patient, [he/she] looked calm and stable and I said 'why don't you just take [him/her] there [to Facility BB].'" Registered Nurse D stated D did not contact the Physician Assistant covering the Emergency Department to report that Patient #1 had presented to the ED. Per D, "we usually do that after we triage them."

During observation of the ambulance bay on 5/29/2019 at 8:05 AM, Registered Nurse E stated "the door gets locked at night for security reasons, usually between 9 and 11 PM." Per E, the door is locked by a switch at the nurses station and when the door is not locked the ambulance door opens automatically. On 5/29/2019 at 8:15 AM, the ambulance bay door opened automatically when a car drove up to test the door. Registered Nurse E stated E was sitting at the nurses station when the ambulance presented to the ED with Patient #1 on 5/17/2019 at approximately 6:50 PM and "I believe the switch was on, I don't know why the door didn't open. I don't know where the ambulance was parked."

Observation of surveillance footage on 5/29/2019 at 8:45 AM revealed the following: on 5/17/2019 at 6:56 PM: ambulance pulled up to the ED entrance in front of the ambulance bay; the bay doors did not open and the ambulance did not enter the ambulance bay; the driver entered the hospital ED doors and spoke with a nurse, the nurse went outside to the ambulance at 6:57 PM; the ambulance left by backing out of the area at 7:00 PM.

During an interview on 5/29/2019 at 11:10 AM, Director of Nursing A stated "once they came here we should have just seen the patient. Once they are here they are our responsibility."