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Based on observation, interview and policy review, the facility failed to follow their internal policies regarding the registration, triage (initial nursing assessment and prioritization process), and the medical screening exam (MSE) for one (Patient #21), of 20 records reviewed, four of which were minors, that presented to the emergency department (ED) requesting treatment. The facility had an average daily census of ten. The facility census was five.

Findings included:

Review of the facility's policy titled, "EMTALA [Emergency Medical Treatment and Active Labor Act] Guidelines for Emergency Department Services," reviewed 01/14, showed the hospital will provide an MSE and treatment within the scope of its capabilities to all patients presenting for treatment. This MSE includes all necessary testing and on call services within the capability of the hospital to reach a diagnosis. The MSE included:
a. Emergency Department Log entry, including disposition of the patient;
b. Patient's triage record;
c. Vital signs;
d. History;
e. Physical Exam;
f. Necessary testing; and
g. Complete documentation of the MSE.

Review of the facility's policy titled, "Triage," reviewed 01/14, showed the following:
- The RN will evaluate and categorize each patient upon arrival to the ED.
- The initial evaluation shall include the patient's name, medications, medical history, chief complaint, and objective nursing observations.
- Sprains, strains;
- Lacerations, pain, and headaches.

Review of the facility's policy titled, "Consents for Treatment for Minor and Incompetent Patients," reviewed 01/14, showed prior to treatment being rendered to a minor, a signed consent for treatment will be completed, except in a life threatening emergency.

Observation and concurrent interview, on 03/11/14 at 9:05 AM, showed the ED had four rooms, capable of treating five patients. Typically, the walk-in ED patient would present at a sliding registration window (ED lobby-just inside the ED entrance) where the ED registration clerk would request the patient's name, date of birth, and chief complaint (all this information was entered into the computerized log). When the registration was complete, the ED clerk would notify the ED Registered Nurse (RN) to do the triage.

During an interview on 03/11/14 at 12:15 PM, Staff G, ED registration clerk, stated the following:
- Patient #21 presented to the ED on 03/06/14 sometime between 5:00 and 6:00 PM. Staff G estimated the patient was 14 years old (a minor).
- Patient #21 had a visible knot on her forehead, and had her hair pulled out from a fight on the school bus that day.
- The patient's grandmother accompanied the patient to the ED window and requested Patient #21 be evaluated in the ED.
- Staff D, Charge Nurse, walked around the ED window to the ED lobby and and asked the patient's grandmother if she was the patient's guardian.
- The grandmother was not the patient's guardian, so Staff D told them they could not treat underage patients without parental consent. Staff D told them they would only treat a minor if there was a life/death emergency.
- The typical registration forms were not completed.
- The patient and grandmother left the ED without triage or MSE.
(Staff failed to get the patient's name, age, and complaint per policy).

During interviews on 03/11/14 at 12:58 PM and 4:50 PM, Staff D, RN charge nurse, stated that Patient #21 presented to the ED at about 5:00 to 6:00 PM. Staff D stated that the hospital can't treat a minor patient until parental/guardian consent was obtained. Staff D stated that she could have done vital signs and a nursing assessment, but did not because the patient did not have any visible injuries, and the grandmother did not have custody of the patient. Patient #21 was not registered in the ED log or triaged (which would trigger the MSE). Staff failed to register the patient into the ED log, and failed to conduct the nursing triage and MSE per policy.

During an interview on 03/11/14 at 1:25 PM, Staff C, nurse manager confirmed that Patient #21 and her grandmother left the ED on 03/06/14 without being entered into the ED log, without triage and MSE, because it was not deemed an emergency by nursing staff. Staff C was not aware of the requirements included in the hospital policy on consents for treatment of minors.

During an interview on 03/11/14 at 1:35 PM, Staff J, ED physician on duty on 03/06/14, stated that all patients presenting to the ED were to be seen.

During an interview on 03/12/14 at 9:00 AM, Staff A, Chief Executive Officer stated that to "treat" and to "log-in and/or triage" were different things. Staff A stated that a minor patient could be logged-in, triaged and screened (MSE) without consent. Then, if deemed an emergency, treatment continued. If not an emergency, the patient's treatment could wait for consent by a parent/guardian. Staff A stated that he had really concentrated on the facility's policies in the past two years. He stated all staff had reviewed them, and had been trained on EMTALA annually. He stated that he was upset with his staff for not knowing to register, triage and perform a MSE on any patient.

During an interview on 03/13/14 at 12:17 PM, the patient's grandmother stated that the patient presented to the ED on 03/06/14 at about 5:00-6:00 PM, had a visible "goose egg" on her forehead, lots of hair that was pulled out, and the patient also had a headache. She stated that they (the patient and grandmother) did not get past the ED lobby when they arrived. "Someone came from behind the desk and told us they could not see my granddaughter unless I had written consent or was her parent/guardian. No vital signs or other exam was conducted. Nothing was written down (log). They just sent us away."

Based on observation, interview, record review, and policy review the facility failed to register one patient requesting treatment (Patient #21) into the emergency department (ED) log, of 20 ED records reviewed. The facility had an average daily ED census of ten. The facility census was five.

Findings included:

Review of the facility's policy titled, "EMTALA [Emergency Medical Treatment and Active Labor Act] Guidelines for Emergency Department Services," reviewed 01/14, showed all patients presenting, seeking care, must be accepted and evaluated. To include, ED log entry, including disposition of the patient.

Observation and concurrent interview in the ED, on 03/11/14, showed the ED had four rooms, capable of treating five patients. A patient started at the registration window where the patient's name, date of birth, and chief complaint were requested. When the registration in the ED log was complete, the ED clerk would notify the ED Registered Nurse (RN) to do the triage (initial nursing assessment and prioritization process).

Record review of the facility's ED logs from 10/01/13 through 03/11/14 showed no entry for Patient #21 on 03/06/14.

During an interview on 03/11/14 at 12:15 PM, Staff G, ED registration clerk, stated the following:
- Patient #21 (13 years old) presented to the ED on 03/06/14 sometime between 5:00 and 6:00 PM.
- Patient #21 had a visible knot on her forehead, and had her hair pulled out from a fight on the school bus that day.
- The patient's grandmother accompanied the patient to the ED and requested Patient #21 be evaluated in the ED. Staff D, RN, charge nurse, told the grandmother the patient could not be seen in the ED without parental consent.
- The typical registration forms and log were not completed. (Staff failed to get the patient's name, age, complaint, etc.)
- The patient and grandmother left the ED without nursing triage or a MSE.

During interviews on 03/11/14 at 12:58 PM and 4:50 PM, Staff D stated that Patient #21 presented to the ED lobby at about 5:00 to 6:00 PM on 03/06/14. Staff D stated that the patient did not have any visible injuries, such as disorientation, lack of speech, bleeding, cuts, and bumps or bruises, and the grandmother did not have custody of the patient. Staff D determined the patient did not have an emergency condition (from just viewing the patient) and told them the hospital did not treat minors without consent. Staff D confirmed the patient was not registered into the log. This failure lead to the failure to conduct the initial nursing assessment (triage) and completing the MSE of Patient #21.

During an interview on 03/11/14 at 1:25 PM, Staff C, nurse manager stated that they (the ED) did not treat a minor without parental consent, unless it was a life/limb emergency. Staff C confirmed Patient #21 left the ED without being registered into the log.

During an interview on 03/12/14 at 9:13 AM, Staff E, physician credentialer (Staff E's title), stated that a patient presenting to the ED should be registered into the log as soon as the patient comes to the ED.

During an interview on 03/12/14 at approximately 9:00 AM, Staff A, Chief Executive Officer (CEO) stated that to "treat" and to "log-in and/or triage" are different things. Staff A stated that all patients presenting to the ED window should be registered on the log.

During an interview on 03/13/14 at 12:17 PM, the patient's grandmother stated that Patient #21 presented to the ED on 03/06/14 at about 5:00-6:00 PM, had a visible "goose egg" on her forehead, lots of hair that was pulled out, and the patient also had a headache. She stated that they (the patient and grandmother) did not get past the ED lobby when they arrived. "Someone came from behind the desk and told us they could not see my granddaughter unless I had written consent or was her parent/guardian. Nothing was written down (log). They just sent us away."

Based on observation, interview, record review, and policy review the facility failed to perform a medical screening examination (MSE), on one (Patient #21) of twenty patients reviewed that presented to the ED for treatment.

This failure had the potential to affect all minor patients (under age 18 without a parent/guardian) presenting to the ED for treatment. The facility failed to conduct an MSE to determine if an emergency medical condition (EMC) was present. The facility had an average daily ED census of ten. The facility census was five.

Findings included:

Review of the facility's policy titled, "EMTALA [Emergency Medical Treatment and Active Labor Act] Guidelines for Emergency Department Services," reviewed 01/14, showed the hospital will provide an MSE and treatment within the scope of its capabilities to all patients presenting for treatment. This MSE includes all necessary testing and on call services within the capability of the hospital to reach a diagnosis. The ED physician is designated as the qualified medical professional (QMP) to do the MSE. The MSE included:
a. Emergency Department Log entry including disposition of the patient;
b. Patient's triage (initial nursing assessment and prioritization process) record;
c. Vital signs;
d. History;
e. Physical Exam;
f. Necessary testing; and
g. Complete documentation of the MSE.

Review of the facility's policy titled, "Triage," reviewed 01/14, showed the following:
- The RN will evaluate and categorize each patient upon arrival to the ED.
- The initial evaluation shall include the patient's name, medications, medical history, chief complaint, and objective nursing observations.
- Sprains, strains;
- Lacerations, pain, and headaches.

Review of the facility's policy titled, "Consents for Treatment for Minor and Incompetent Patients, reviewed 01/14, showed prior to treatment being rendered to a minor, a signed consent for treatment will be completed, except in a life threatening emergency. (The policy failed to define parameters of what is included in "treatment").

Observation and concurrent interview, on 03/11/14 at 9:05 AM, showed the ED had four rooms, capable of treating five patients. Typically, the walk-in ED patient presented at the sliding registration window (ED lobby-just inside the ED entrance) where the ED registration clerk would request the patient's name, date of birth, and chief complaint (all this information was entered into the computerized log). When the registration was complete, the ED clerk would notify the ED Registered Nurse (RN) to do the triage.

During an interview on 03/11/14 at 12:15 PM, Staff G, ED registration clerk, stated the following:
- She remembered Patient #21 (13 years old) presented to the ED on 03/06/14 sometime between 5:00 and 6:00 PM. Staff G estimated the patient was 14 years old (a minor).
- Patient #21 had a visible knot on her forehead, and had her hair pulled out from a fight on the school bus that day.
- The patient's grandmother accompanied the patient to the ED and requested Patient #21 be evaluated in the ED.
- Staff D, charge nurse, interjected and asked the patient's grandmother if she was the patient's guardian.
- The grandmother was not the patient's guardian, so Staff D told them they could not treat underage patients without parental consent. Staff D told them they would only treat a minor if there was a life/death emergency.
- The typical registration forms were not completed.
- The patient and grandmother left the ED without triage or MSE.
(Staff failed to get the patient's name, age, and complaint. The staff also failed to conduct the MSE).

During an interview on 03/11/14 at 12:39 PM, Staff H, ED registration clerk, stated that the RN in the ED was responsible for the triage, and made decisions regarding treatment to a minor patient. Staff H confirmed the hospital philosophy was that a minor could not be seen, unless a dire emergency, without parental/guardian consent.

During an interview on 03/11/14 at 12:50 PM, Staff I, ED registration clerk, stated that the ED typically attempted to reach a parent/guardian by phone if not physically available. Staff I stated that she relied on the RN to make decisions related to a minor patient regarding treatment.

During interviews on 03/11/14 at 12:58 PM and 4:50 PM, Staff D, RN charge nurse, stated that Patient #21 presented to the ED at about 5:00 to 6:00 PM. Staff D stated that "we" can't treat a minor patient until "we" get parental/guardian consent. Staff D stated that she could have done vital signs and a nursing assessment, but did not because the patient did not have any visible injuries, and the grandmother did not have custody of the patient. Patient #21 was not registered or triaged. Staff D called her supervisor, Staff C, nurse manager, and she directed Staff D not to treat Patient #21. Staff D estimated approximately four minor patients had presented to the ED without parental consent, and not received treatment, since her employment eight years prior. (Staff failed to conduct the initial nursing assessment [triage] or perform a MSE).

During an interview on 03/11/14 at 1:25 PM, Staff C, nurse manager stated that they (the ED) did not treat a minor without parental consent, unless it was a life/limb emergency. Staff C stated Patient #21 and her grandmother left the ED without being registered, triaged or given a MSE because it was not deemed an emergency.

During an interview on 03/11/14 at 1:35 PM, Staff J, ED physician on duty on 03/06 (but did not see Patient #21), stated that all patients presenting to the ED were to receive an MSE. Staff J stated that treatment of a minor depends on the seriousness of a patient's complaints, per the triage nurse's assessment. Staff J stated that he spoke with the triage nurse (Staff D) in this case (after the incident), and according to what Staff D told him he did not feel Patient #21's complaints were serious enough to warrant a MSE without consent.

During an interview on 03/12/14 at 9:00 AM, Staff A, Chief Executive Officer stated that to "treat" and to "log-in and/or triage" are different things. Staff A stated that any patient should be logged-in, triaged and screened (MSE) without consent. Then, if deemed an emergency, treatment (medications, diagnostic testing, etc.) continued. If not an emergency, the patient's treatment could wait for consent by a parent/guardian. Staff A stated that all staff had been required to review policies, and had been trained on EMTALA annually. He stated that he was upset with his staff for not knowing to register, triage and do the MSE on any patient.

During an interview on 03/12/14 at 9:13 AM, Staff E, physician credentialer (Staff E's title), stated that a patient presenting to the ED should be registered into the log as soon as the patient comes to the ED lobby.

During an interview on 03/13/14 at 12:17 PM, the patient's grandmother stated that the patient presented to the ED at about 5:00-6:00 PM, had a visible "goose egg" on her forehead, lots of hair that was pulled out and the patient also had a headache. She stated that they (the patient and grandmother) did not get past the ED lobby when they arrived. "Someone came from behind the desk and told us they could not see my granddaughter unless I had written consent or was her parent/guardian. No vital signs or other exam was conducted. Nothing was written down (log). They just sent us away. We went to another hospital (hospital B) and were seen immediately, without question."

Record review of hospital B's ED record showed the following:
- Patient #21 presented on 03/06/14 at 11:29 PM.
- The patient was registered, triaged and examined by the ED physician.
- The patient was discharged with closed head injury instructions.