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Based on reviews of medical records, policies and procedures, Emergency Diagnostic Protocols, and interviews, the hospital failed to ensure that a medical screening examination was provided that was 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 existed, when the request for medical attention was made on the individual's behalf for 1 (Patient #11) for 20 patients reviewed. Refer to findings in Tag A-2406.

Based on reviews of medical records, Emergency Medical Services ambulance run sheet, policies and procedures, and family member interview, the hospital failed to maintain medical records and other related records for individuals presenting to the emergency department for 1 (Patient #11) of 20 patients reviewed.

Findings include:

The facility's policy titled "Admission to the Emergency Department" effective March 6, 2001, last revised 1/14 specified in part, "I. An Emergency Department record is completed on every patient, including an initial assessment and nursing record." The Policy titled "Enter Emergency Patient " Effective March 1, 2001, last revision 2/6, revealed in part, "Policy: The patient is entered into the Medhost System (computerized system) with minimal demographic information to begin the visit to the emergency room ... Purpose to provide guidelines for the Registrar in entering an emergency patient ...PROCEDURES AND GUIDELINES. A Upon arrival either through the front entrance ... the patient is entered directly in to the Medhost system ... if through the front then the registrar that is at the presentation (Triage) desk will enter into Medhost."

During a telephone interview on 10/22/14 at 4:55 p.m., Patient #11's family member said he and the patient presented at the reception desk in hospital's emergency department (ED) in the middle of the night between 10/19 and 10/20/14.

The facility failed to ensure that their policies and procedures were followed as evidenced by failing to create a medical record for Patient #11 when he presented to the Emergency Department on October 19, 2014. The facility also failed to ensure that Patient #11 was entered into the hospital's computerized system (other related records) on 10/19/14, as per hospital policy and procedure.

Based on interviews and review of records and policy/procedures, the hospital failed to log 1 (Patient #11) of 20 patients reviewed coming to the hospital for emergency services as required by the Emergency Medical Treatment and Labor Act (EMTALA).

The findings included:

1. During a telephone interview on 10/22/14 at 4:55 p.m., Patient #11's family member said he and the patient presented at the reception desk in the hospital's emergency department (ED) in the middle of the night between 10/19/14 and 10/20/14. Patient #11's family member said he told the hospital register person Patient #11 needed medical attention, but had (name)'s insurance and wanted to know if the hospital accepts this insurance before the patient was seen by a physician. Patient #11's family member said the receptionist said this hospital does not accept this insurance. He told the receptionist he needed to stay within the insurance perimeters. The receptionist suggested he call an ambulance and another hospital in the area would probably take his insurance. They left the reception's desk and he called 911. The ambulance picked him up in about 15 minutes. He said if Patient #11 was passed out he would have obtained medical services at the hospital. Since the patient was not passed out and only in pain, he probably would not have accepted medical services. Patient #11's family member said he brought up the insurance first, not the hospital staff.


2. On 10/23/14, a review of the facility's emergency room log revealed Patient #11's name was not on the log for the dates of 10/19/14 and 10/20/14.


3. During an interview on 10/23/14 at 3:11 p.m., the risk manager said she was told about the possible EMTALA by the receiving hospital and reviewed the EM system run report. It showed Patient #11's name was not on the report. She interviewed the registry person at the front desk of the emergency department and the risk manager was told by the registry person she did not put Patient #11 on the ED log.


4. A review on 10/23/14 of the hospital's policy title: EMTALA Central Log Policy, original effective date 3/1/2006, revision date 9/1/2013 included:
"Policy: Each Hospital that provides emergency services will maintain a Central Log to include information on each individual who comes to the Hospital requesting emergency medical treatment, including those patients presenting to labor and delivery, the Dedicated Emergency Department, and other areas where Emergency Medical Conditions are treated.
Procedure: Please refer to the EMTALA - Medical Screening/Stabilization Policy G2 for a complete list of definitions pertaining to this policy.
1. Each Hospital must maintain a Central Log to track the care provided to each individual who comes to the Hospital seeking care for an Emergency Medical Condition.
2. The Central Log must include patients presenting to the Dedicated Emergency Room regardless of whether they received treatment. ...
4. The Central Log must contain:
The name of the individual seeking assistance; and
The disposition. Permitted dispositions include: 1) Left without Treatment; 2) patient refused treatment...
6. If the patient informs the ED registration staff that he/she is leaving the Hospital without receiving a Medical Screening Examination, document the date, time and disposition in the emergency department information system. ...
8. If the patient has not provided registration information before he/she leaves, the Hospital should register that patient as John Doe/Jane Doe: ..."

The hospital did not follow their policy for people who present in the emergency department to be entered on the emergency room log and whether they did or did not accept medical services.

Based on reviews of medical records, policies and procedures, Emergency Diagnostic Protocols, and interviews the hospital failed to ensure that a medical screening examination was provided that was with in 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 existed, when the request was made on the individual's behalf that the individual needed medical attention for 1 (Patient #11) for 20 patients reviewed.

Findings include:

A review of the hospital's EMTALA Medical Screening Stabilization Policy (effective 11/1/2006, revised 9/1/2013) included:
"General requirements: In general, when an individual comes, by himself or herself, with another person, or by EMS to the Dedicated Emergency Department of the Hospital and a request is made on the individual's behalf for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of Hospital (including ancillary services routinely available in the Dedicated Emergency Department ...to determine whether an Emergency Medical Condition exists... These same requirements apply if a prudent layperson would believe the individual is in need of an emergency examination or treatment.
The Location in Which the Medical Screening Examination Should Be Preformed
... If an individual arrives at a facility and is not technically in the Dedicated Emergency Department, but is on the premises of the Hospital and requests emergency care, he or she is entitled to a Medical Screening Examination...
Medical Screening Examination Requirements: 1. Hospitals are obligated to perform the Medical Screening Examination to determine if an Emergency Medical Condition exists. 2. Medicare participating Hospitals that provide emergency services must provide a Medical Screening examination to any individual regardless of diagnosis financial status, race, color, national origin, handicap, ability to pay, or other protected category... 5. A Hospital, regardless of size or patient mix, must provide screening and stabilizing treatment within the scope of it capabilities, as needed, to the individuals who come to the Hospital for examination and treatment."

The hospital's policy: Triage of Patients, effective Date March 6, 2001, revised 1/14 was reviewed. The policy indicated in part ... "G. in the event that there is a delay in the patient seeing an ED provider then the Diagnostic Protocols will be initiated."
ED Diagnostic Protocols were reviewed. The ED Diagnostics Protocols specified in part, "... Abdominal Pain - Upper protocol CBC with Diff, CMP, Lipase, Urinalysis with C&S (culture and sensitivity) if indicated, EKG IF > (greater than) 50 years of age."

During a telephone interview on 10/22/14 at 4:55 p.m., Patient #11's family member said he and the patient presented at the reception desk in hospital's emergency department (ED) in the middle of the night between 10/19 and 10/20/14. Patient #11's family member said he told the hospital register person Patient #11 needed medical attention. The receptionist suggested he call an ambulance and another hospital in the area would probably take his insurance.

The Emergency Medical Services (EMS) ambulance run sheet dated 10/20/2014 at 00:26 was reviewed. The EMS ambulance run sheet revealed in part, "Resp. Mode: Lights and sirens... Incident: 6101 Pine Road (Physicians Regional Medical Center- Pine Ridge) Naples, Florida... Disposition: treated and transported by EMS... Destination: (name of acute care hospital) Downtown Naples, Florida Dest. (destination) Detrem (determination): Closest facility... Primary impression: Abdominal Pain/Acute Abdomen... Upon arrival, patient sitting on bench outside of pr (Physicians Regional) conscious/alert... he c/o (complains of) right lower quad (quadrant). Abd (abdominal) with n/v (nausea/vomiting) for the past 4 hours. He denies diarrhea or bloody vomit. he denies bile type vomit... patient states pr (Physicians Regional) will not accept his insurance so he request transport to another hospital. Moved to unit."

The medical record from the acute care hospital where the family member took Patient #11 on 10/19/2014 was reviewed. The medical record specified in part, "Emergency or Urgent Care Reports... Basic Information: Time Seen: Date and time: 10/20/2014 1:12:00 A.M. Arrival Mode: Ambulance... History of Present Illness: This is a 63 year old male presenting to the ED via EMS complaining of RLQ (right lower quadrant) abdominal pain... the pain starts in his right flank ad radiates through his RLQ into his right testicle. However, the pain is worst in the RLQ region. He describes the pain as constant, sharp sensation. The pain worsened with movement, and is severe just laying supine. He has never had this pain before. Before coming to the ED, he visited Physician's Regional, but was turned away because of insurance purposes, at which time his wife called 911 from the parking lot (at Physicians Regional Medical Center) to get medical attention for her husband ...Physical Examination Blood Pressure 163/92 (high)... General:... Gastrointestinal: ... Tenderness: Severe, right flank, right lower quadrant. Guarding: Voluntary... Medical Decision making: Orders: Lactated Ringers injection, 1000 ml IV (intravenously) Bolus Zofran (medication for nausea) 4 mg IV slow Dilaudid (medication for pain) 1 mg IV push ... Pipperacillin/Tazobactam (antibiotic medication) 4.5 g (IVPB)... Study: CT ABDOMEN AND PELVIS WITH CONTRAST ... FINDINGS ... There are multiple gallstones (small, hard crystalline mass found abnormally in the gallbladder or bile ducts from bile pigments, cholesterol, and calcium salts. Gallstones can cause severe pain.) ... Impression: .. Cholelthiasis (production of gallstones).... Plan: Disposition: Admit. "

During an interview on 10/23/14 at 3:11 p.m., the risk manager said she had asked for the EM system run report and Patient #11's name was not on the report. The risk manager reported on 10/20/14 she had a telephone conservation with employees, and the register person recalled a person, (alleged family member, not the patient) coming in and asked if they accept international insurance. The register person said they told them no but told the person if they need assistance they will see the patient. The family member said he did not want cost and asked for other hospitals. The register person said the patient would have to come in from outside so the hospital can treat. The register person told the family member all hospitals will treat the patient. Patient #11's family member declined medical treatment from the hospital. The register person advised the patient to call 911. The patient and wife came to the register person's desk. The patient called the insurance company and was told their insurance was not accepted at this hospital. The register person said the patient asked about their insurance and not medical emergency. Patient #11 and family member left the hospital. The hospital failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that a medical screening examination was provided that was within the capabilities of the hospital when the request was made for medical care/attention regardless of the patient's (#11) his ability to pay (international insurance), including ancillary services as per the hospital's ED Diagnostic Protocols (Abdominal Pain-Upper Protocol) to determine whether or not an emergency medical condition existed for patient #11 on 10/19/14.