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Based on staff interviews and review of medical records, policies/procedures and Medical Staff Bylaws, the facility failed to comply with the Medicare provider agreement as defined in 489.20 and 489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

The facility failed to meet the following requirements under the EMTALA regulations:

Tag A2407 Stabilizing Treatment
The facility failed to perform complete vital signs on admission and vital signs after the administration of medications and at discharge.

Based on staff interview and review of medical records and the facility's policies/procedures, the facility failed to perform the following:
1. Initial vital signs in two (#10 and #12) of 20 medical records reviewed.
2. Vital signs after the administration of medications in five (#7, #8, #10, #12 and #14) of 20 medical records reviewed.
3. Discharge vital signs in six (#7, #8, #10, #12, #14 and #18) of 20 medical records reviewed.
The failure to perform complete initial vital signs and vital signs after the administration of medications and at discharge, created the potential for not having the criteria available that identified whether the patient had a stable or an unstable medical condition and safe to be discharged.

The findings were:

The facility's emergency department policy and procedure entitled, "Fundamental Standards of Care," stated the following in pertinent part: "Fundamental Emergency Department nursing interventions include, but are not limited to the following:
Vital signs every 5-15 minutes on Level I, II, III patients, unless ordered more frequently.
Vital signs every one to two (1-2) hours on Level IV patients, unless ordered more frequently.
Vital signs on admission and PRN (as occasion requires) on Level V patients, unless ordered more frequently.
All patients in the Emergency Department (ED) greater than one hour will have vital signs taken and recorded upon admission and discharge.
Vital signs will be repeated after administration of medications with potential side effects."

Sample patient #7 presented to the ED on 6/26/11 at 8:15 p.m. with complaints of body and head aches. Triage was performed at 8:15 p.m. with a complete set of vital signs taken and designated as a Level IV. The patient was administered Penicillin V (antiinfective) at 10:05 p.m. and discharged at 10:05 p.m. There were no vital signs performed after the administration of the antiinfective or at the time of discharge.

Sample patient #8 presented to the ED on 6/30/11 at 2:52 p.m. with complaints of back pain from a motor vehicle accident that occurred three days prior to presentation. Vital signs were performed in triage at 2:52 p.m. and the patient was designated as a Level IV. The patient was administered Percocet (opiate analgesic) at 4:25 p.m. and discharged at 4:30 p.m. There were no vital signs performed after the administration of the opiate analgesic or at the time of discharge.

Sample patient #10 presented to the ED on 7/7/11 at 4:20 p.m. with complaints of right wrist pain. A temperature, pulse, respiratory rate and oxygen saturation level were performed on the patient in triage at 4:20 p.m.; however, there was no blood pressure taken. The patient was designated a Level IV and given Percocet (opiate analgesic) at 5:16 p.m. and discharged at 5:30 p.m. There was no blood pressure performed in triage or vital signs performed after the administration of the opiate analgesic or at the time of discharge.

Sample patient #12 presented to the ED on 8/1/11 at 8:50 p.m. with complaints of a foot injury. A temperature, pulse, respiratory rate and oxygen saturation level were performed on the patient in triage at 8:50 p.m.; however, there was no blood pressure taken. The patient was designated a Level IV and given Toradol (analgesic), Vicodin (analgesic) and Zofran (antiemetic) at 10:00 p.m. and discharged at 10:10 p.m. There was no blood pressure performed in triage or vital signs performed after the administration of two analgesics and one antiemetic or at the time of discharge.

Sample patient #14 presented to the ED on 8/14/11 at 3:21 p.m. with complaints of "bad neuropathy." Vital signs were performed in triage at 3:21 p.m. and designated a Level V. The patient was discharged at 5:35 p.m. without any discharge vital signs being taken.

Sample patient #18 presented to the ED on 9/2/11 at 8:34 p.m. with complaints of a headache and sore throat. Vital signs were performed in triage at 8:34 p.m. and the patient was designated a Level IV. At 9:55 p.m., medications Azithromycin (anti-infective) and Prednisone (corticosteroid) were administered at 10:05 p.m. and discharged at 10:05 p.m. There were no vital signs performed after the administration of an anti-infective and a corticosteroid or at the time of discharge.

An interview was conducted with the Director of Emergency/Trauma Services on 10/18/11 at approximately 11:35 a.m. The Director stated that vital signs are needed to determine improvement. There is a check box on the ED form that stated "see VS (vital sign) printout." The Director further stated that sometimes when vital signs are not recorded on the ED form that box will be checked and there should be an attachment with recorded vital signs. This surveyor informed the Director that there were no "VS printout" boxes checked on the above referenced medical records and no additional attached vital sign sheet.

In summary, the facility failed to follow their policies and procedures to determine if the patients had an unstable or a stabilized medical condition by the performance of the required vital signs.