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Based on medical record review, patient and staff interview, and review of facility policies and procedures, it was determined the hospital failed to comply with the requirements at 489.20 and 489.24. Specifically, the hospital failed to ensure 1 of 26 closed sample patients (#26) was provided with an appropriate medical screening exam. In addition, the facility failed to ensure 1 of 26 closed sample patients (#3) was provided with an appropriate medical screening exam without unnecessary delay. Refer to C2406 and C2408.

Based on medical record review, staff and patient interview, and review of facility policies and procedures, the facility failed to provide a medical screening exam (MSE) for 1 of 26 sample patients (#26) who requested that exam. The findings were:

Review of the medical record for patient #26 showed s/he came to the emergency department (ED) on 11/27/12 at 1:42 PM with abdominal pain. Review of the patient's emergency record showed the patient was triaged at 4:51 PM as non-emergent. Further review showed the patient was to have an abdominal ultrasound. The following concerns were noted:
a. The review showed the patient did not have identification (ID) at that time, and was not given an MSE or any other treatment. The patient was told by the critical care registered nurse (RN) in charge of the ED to come back the next morning with an ID. Interview with patient #26 on 2/25/13 at 2:45 PM revealed that out of frustration with the process, s/he did not return to the facility.
b. During an interview with the chief nursing officer (CNO) on 2/11/13 at 3:10 PM, she stated there were no mid-level practitioners practicing at the facility. She further confirmed that only physicians could complete an MSE in the ED, and that the triage completed by the RNs and EMTs in the ED did not constitute an MSE. She stated no RNs or EMTs at the facility were checked off for competencies related to completing an MSE.
c. During an interview with the medical director of the ED on 2/12/13 at 11:45 AM, he stated the facility policy concerning admissions was changed by the administrator several months prior (unsure exactly when). He stated the policy in the emergency department was for an RN or emergency medical technician (EMT) to triage a patient. He further stated that if the patient was triaged as non-emergent, and did not have an ID, the patient was told to leave the facility and come back with an ID. The medical director knew of no incidents when anyone was turned away due to this policy. During interviews on 2/12/13 with the following ED staff members, the policy was confirmed concerning non-emergent patients without ID being turned away from treatment before an MSE was performed: RN #1 at 9:50 AM, EMT #1 at 8:30 AM, admission clerk #1 at 9 AM, and EMT #2 at 8:50 AM. During these interviews it was revealed that one patient had been turned away due to the inability to produce an ID, patient #26. The interviewees agreed this practice was in effect and infrequently a patient could not produce an ID. During an interview on 2/12/13 at 12:05 PM with the critical care RN in charge of the ED (with the CNO present), she confirmed the policy was currently enforced. She was aware of one incident of a patient being sent away from the facility to obtain an ID, and the patient did not return. However, she was unable to provide the name of the patient or the date.
d. During an interview with the administrator (with the CNO present) on 2/12/13 at 12:15 PM, he confirmed that he placed a policy in effect (several months prior, unsure of time) hospital wide, which included the ED, that required patient ID. He further stated that patients in the ED were triaged by RNs and EMTs first; and he felt that met their obligation for an MSE. He further stated that a patient would be asked to leave the facility to obtain an ID before treatment, but not if it caused undue hardship such as a patient living a long distance from the facility.
e. Review of the facility policy #200-13 titled, "Patient Identification and Insurance/Payment Information" revealed the following:

"Strict guidelines shall be followed when admitting any patient to Memorial Hospital of Carbon County to help promote the safety and ensure the identification of all patients of Memorial Hospital of Carbon County, through accurate patient information collection.
I. REQUEST OF PROPER AND NECESSARY FORMS OF PATIENT IDENTIFICATION
? Photo Identification (Driver's License, Military I.D., Student I.D., Passport, or any other form of picture identification)
? Current Medical Insurance Information/Card(s) (If the patient is insured)

II. REQUESTING PATIENT INFORMATION
? Upon every patient presenting him or her self for any hospital service, they must be asked for the above current information. The exception being emergencies and traumas.
? Those patients who do not have one or both of the above forms of identification will be asked to retrieve or obtain such information at that time, before proceeding with their non-emergent hospital service(s). If such information is not available the patient will be asked to reschedule their services for another time when they have the information needed.
? All Emergency Room patients must be triaged prior to requesting any payment or insurance information."

Based on medical record review, staff interview, and review of facility policies and procedures, the facility failed to provide a medical screening exam without unnecessary delay for 1 of 26 sample patients (#3) who requested that exam. The findings were:

Review of the medical record for patient #3 showed s/he came to the emergency department (ED) on 1/22/13 at 7:13 PM with right leg calf pain and was promptly triaged as non-emergent. Review of the emergency nursing record showed the patient was taken to a room at 7:24 PM and an MSE was started at that time. The following concerns were noted:
a. During an interview with the patient on 12/11/13 at 6:30 PM, s/he stated that after being triaged at the facility on 1/22/13, s/he was asked to provide an ID and insurance information. When the patient did not have that information, s/he was told that information would need to be provided in order to receive any further treatment (unsure of name of female staff member). The patient then asked, "What if someone shot me in the chest?" The patient was then told, "You would need an ID." The patient's spouse was able to find a picture ID within minutes after leaving the ED, and the patient's treatment then proceeded.
b. During an interview with the medical director of the ED on 2/12/13 at 11:45 AM, he stated the facility policy concerning admissions was changed by the administrator several months prior (unsure exactly when). He stated the policy in the emergency department was for an RN or emergency medical technician (EMT) to triage a patient. He further stated that if the patient was triaged as non-emergent, and did not have an ID, the patient was told to leave the facility and come back with an ID. The medical director knew of no incidents when anyone was turned away due to this policy. During interviews on 2/12/13 with the following ED staff members, the policy was confirmed concerning non-emergent patients without ID being turned away from treatment before an MSE was performed: RN #1 at 9:50 AM, EMT #1 at 8:30 AM, admission clerk #1 at 9 AM, and EMT #2 at 8:50 AM. Also, the interviewees agreed this practice was in effect and infrequently a patient could not produce an ID. During an interview on 2/12/13 at 12:05 PM with the critical care RN in charge of the ED (with the CNO present), she confirmed the policy was currently being enforced. She was aware of one incident of a patient being sent away from the facility to obtain an ID, and the patient did not return. However, she was unable to provide the name of the patient or the date.
c. During an interview with the administrator (with the CNO present) on 2/12/13 at 12:15 PM, he confirmed that he placed a policy in effect (several months prior, unsure of time) hospital wide, which included the ED, that required patient ID. He further stated that patients in the ED were triaged by RNs and EMTs first; and he felt that met their obligation for an MSE. He further stated that a patient would be asked to leave the facility to obtain an ID before treatment, but not if it caused undue hardship such as a patient living a long distance from the facility.
d. Review of the facility policy #200-13 titled, "Patient Identification and Insurance/Payment Information" revealed the following:

"Strict guidelines shall be followed when admitting any patient to Memorial Hospital of Carbon County to help promote the safety and ensure the identification of all patients of Memorial Hospital of Carbon County, through accurate patient information collection.
I. REQUEST OF PROPER AND NECESSARY FORMS OF PATIENT IDENTIFICATION
? Photo Identification (Driver's License, Military I.D., Student I.D., Passport, or any other form of picture identification)
? Current Medical Insurance Information/Card(s) (If the patient is insured)

II. REQUESTING PATIENT INFORMATION
? Upon every patient presenting him or her self for any hospital service, they must be asked for the above current information. The exception being emergencies and traumas.
? Those patients who do not have one or both of the above forms of identification will be asked to retrieve or obtain such information at that time, before proceeding with their non-emergent hospital service(s). If such information is not available the patient will be asked to reschedule their services for another time when they have the information needed.
? All Emergency Room patients must be triaged prior to requesting any payment or insurance information."