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Based on the failure of the Hospital to maintain compliance with the requirements in CFR 489.24(a) and 489.24 (c) Medical Screening Exam and 489.24(e)(1-2) Appropriate Transfer, the hospital has failed to maintain its agreement with 489.20.

Based on a review of medical records, hospital documents, and interview, it was determined the hospital failed to provide a medical screening examination to include the provision of stabilizing treatment for Patient #16 who presented to the emergency department with abdominal pain. Furthermore, based on a review of medical records, medical staff rules and regulations, and interview the hospital failed to provide and/or document individuals who presented to the emergency department (ED), the efforts the hospital personnel made to inform patients of the risks and benefits of the examination and treatment, and obtain written informed refusal if the patient continues to refuse the medical screening examination or further examination to determine an emergency medical condition existed for 4 patients ( Patient #4, #5, #10 and #6)

Findings include:

1. Medical staff rules and regulations at 2.5 revealed: "...EMTALA requires a Hospital to provide an appropriate medical screening examination to all patients presenting to the Emergency Room (regardless of age or parental/guardian consent) within the capability of the Hospital's Emergency Department, including ancillary services routinely available to that department, to any person who comes to the Emergency Department and requests...an examination or treatment for a medical conditions...An emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity; sever pain; psychiatric disturbances; and/or symptoms of substance abuse; that absence of immediate medical attention could result in placing person's health in serious jeopardy or serious dysfunction of bodily organ or part...."

The Emergency Department Pain Policy revealed the following: "...Policy...It is the policy of the White Mountain Regional Medical Center Emergency Department to provide adequate pain control of the patient suffering with acute pain, in a safe manner and with appropriate monitoring...Procedure...Acute Pain: Emergency department physicians/providers need to provide adequate pain control for the patient suffering with acute pain, in a safe manner and with appropriate monitoring. This does not mean that the acute pain patient will be pain free, which could be a dangerous practice, but rather, the pain will be much more tolerable...."

Patient #16: This patient was admitted to the hospital on 10/19/09. The patient presented to the emergency department (ED) via ambulance. The emergency medical system (EMS) personnel documented on the pre-hospital form that they found the patient lying supine in bed with a complaint of abdominal pain of 7/10 (on a scale of 0-10, with 10 being the most severe). The pain had started at 0530 on 10/19/09, with sever pressure across the abdomen going to the left back and down to the groin.

The nursing documentation revealed triage at 10/19/09 at 0850, and the patient was identified as urgent. The patient's pain scale was documented by the registered nurse (RN) as 8/10. The pain was described as abdominal pain that radiated to the groin with an acute sudden onset. There was some nausea and cramping. The patient was taken to the room for examination at 0850.

The physician assistant documented the patient was seen, however there was no time of the physician's examination. The physician assistant documented a physical examination that included an abdominal examination. The record revealed an assessment of the abdomen that was tender, abnormal (decreased) bowel sounds.

The computerized tomography (CT) of the abdomen and pelvis with contrast revealed an impression of the following: 1. Obstructive 4-mm left ureterovesical junction calculus with mild hydroureteronephrosis and perinephric stranding; punctate nonobstructive right renal calculus; 2. Cholelithiasis; 3. Colonic diverticulosis; and 4. Moderate prostate enlargement.

The urine culture revealed no growth. The urinalysis revealed the following out of range findings: dark yellow, cloudy appearance with 3+ blood, heavy mucus/HFP and too many to count RBC/HPF.

There was a progress note documented by the physician assistant and revealed the following: "...Pain seems out of proportion to exam. Vital signs and Pt appears at rest. Pt sleeping...."

The physician assistant documented a clinical impression of Ureterolithiasis with mild hydropep. The physician assistant documented the patient was to be discharged home and the condition improved.

The patient was medicated, per physician assistant orders, with Zofran at 0902, Fentanyl 50 milligrams (mg) at 0904, Fentanyl 50 mg at 0930, and Dilaudid 1 mg at 1025. The RN documented the response as no change to the pain. The RN documented the pain scale hourly along with the vital signs. The pain levels were documented as follows: 0950 9/10; 1102 9/10; 1156 5/10; 1257 6/10; and 1359 8/10. The RN documented at the time of discharge, 1445 a pain level of 8/10.

The last physician assistant note and the last note in the medical record, not dated or timed, revealed: "...Pt demanding to be transported to hotel in NM. Demanding shoes/clothes. Refusing to be D.C'd Refusing to sign D/C instructions. Becomes agitated & angry. Reported off to (name of another physician assistant) & Administration advised will see pt in ED to assist.

There was no documented evidence the physician assistant discussed with the patient the alternatives and the rationale as to why the physician assistant determined the patient was safe for discharge.

The ED provider call schedule revealed that the physician assistant who documented the evaluation of the patient in the medical record had been scheduled to work from 0001 - 1400 and the second physician assistant was scheduled to work 1400 to 2400.

There was no further documentation. There was no further documented assessment by a physician assistant or a physician. There was a physician's signature on the ED physician notes, however it is not dated or timed. There was no documentation by either physician assistant that a physician was consulted in this case.

There was no documentation of evidence the patient's pain was re-evaluated by the provider with a pain scale of 8/10.

The discharge instructions were signed by the RN, and there is a scribble in the area for the patient to sign, however it is not legible. There is also the signature of a physician. This physician signature is not dated or timed.

The Chief Nursing Officer was interviewed on 02/12/2010. The Chief Nursing Officer stated in the interview that she was aware of the patient and recalled that the patient wanted a ride to the hotel. The patient was transported to a local hotel by a member of the hospital staff. The Chief Nursing Officer was asked if there was a review of this case by the medical staff. The Chief Nursing Officer was not aware of a review by the medical staff. The Chief Nursing Officer was not able to provide any peer review documentation during the onsite survey.

The patient presented to another acute care facility on 10/20/09. The record revealed the patient presented to the emergency room on 10/20/09 at 1000, with a chief complaint of diffuse abdominal pain to the left flank and a pain scale rating of 9/10. The RN documented the pain as sharp and located mid abdomen and left flank area. The ED physician documented the following: pain started at 6 AM yesterday; hiccups now with the pain, aching pain that was sharp with hiccups, vomiting "last night black." The physician documented the pain as severe with a 10/10 on the pain scale, and relieved by being supine. The patient was medicated with Dilaudid, Toradol, Ativan, and Reglan throughout the ED examination and treatment time. The ED physician recommended admission to the hospital with diagnosis of chronic back pain, high blood pressure, and renal cyst.

The admission plan was to admit for observation on the medical surgical floor for left ureteral stone with hydronephrosis and pyelonephritis and continue intravenous fluids initiated in the ED. The patient was started on antibiotics, continued on pain medications and medication for vomiting with the addition of Flomax. The plan was to strain all urine and obtain a urological consult. The physician progress notes revealed the patient passed the stone and the stone was sent to the lab for analysis. The patient was discharged home on 10/21/09.

2. Interview with the Chief Nursing Officer on 02/11/2010, revealed the hospital required a form called Leaving Provider Facility Against Advice would be completed for all patient's who present to the hospital ED and then leave. The Chief Nursing Office also confirmed that if the patient is not capable of signing or is not available to sign the form should be completed by the hospital personnel with the reason the patient could not sign or was not available to sign.

The medical staff rules and regulations at 3.7 Patient Leaving Against Medical Advice process included: "...Patients refusing treatment or hospitalization may be discharged against medical advice after the Hospital attempts to secure their signature on a release relieving the Hospital and the attending Practitioner of any further responsibility for their medical condition...."

Patient #4 presented to the ED on 10/09/09 at 1830, with a chief complaint of lower back pain for the past three weeks. The RN documented in the chief complaint at the time of triage that the patient had a possible urinary tract infection due to bright colored urine.

There was no documentation of a medical screening examination by the provider. There was no documentation by the RN after the triage documentation. The ED log revealed under the disposition that the patient was considered "LWBS (left without being seen)." There was no documented evidence of the patient being explained the risks of not receiving a medical screening examination or documentation by the facility of a refusal of treatment form completed by the hospital if the patient was not available to sign.

Patient #5 presented to the hospital on October 15, 2009 at 1044, with a chief complaint of a spider bite. The RN documented triage at 1055 with a note of a right foot spider bite 30 minutes ago. The patient had brought the spider into the hospital with him.

The RN documented the patient made the decision to leave after "reading" the spider was not a wolf spider and was not poisonous. The RN documented: "if its not poisonous he doesn't have the money to be seen." The provider was notified. There was no evidence of a LWBS form on the medical record.

There was no documented evidence the provider or the RN explained the benefits to having a medical screening examination or the risks to the patient if not seen. There was no documented evidence the hospital personnel attempted to obtain the refusal by the patient in writing. There was no documentation as to who identified the spider type or what type of spider it was. The patient's record indicated the patient left the ED at 1105.

Patient #10 was identified in the ED log as having presented to the ED on 11/23/09. The surveyor requested the patient's medical record. Interview with the Director of Medical Records on 02/11/2010, revealed there was no medical record initiated for this patient. There was no documented evidence of the patient's chief complaint or the events that had occurred when the patient presented. There was no documentation as to the patient's refusal of services or if the hospital personnel had informed the patient of the hospital's responsibility to provide a medical screening examination.

3. The medical staff rules and regulations at 3.8 Refusal Of A Patient To Accept Treatment revealed: "...The medical record should contain a description of the treatment offered and the reason for refusal. Facility staff will attempt to obtain the refusal in writing...When a competent patient refuses treatment, the Practitioner should make an additional effort to explain the treatment and the medical consequences of continued refusal. If the patient continues to refuse treatment, the patient should be asked to sign a statement that summarizes the risks and alternative to the proposed treatment...."

Patient #6: The patient was admitted to the hospital's ED on 11/01/09 at 1815, with a complaint of abdominal pain. The triage was completed at 1815.

The patient was seen and evaluated by the physician assistant.

The physician assistant documentation revealed the patient was seen at 1817. The physician assistant documented "Pt with ongoing constipation X 6...They can't get me into clinic tomorrow...." The severity was documented as mild and moderate. The PA documented the patient was treated by the primary care provider (PCP) for constipation without significant relief.

The PA documentation revealed "Pt leaves UA the leaves ER (elopes) (without) notifying RN nor Provider. Had been advised of pending DX & plan/FU." The clinical impression was "obstipation."

The RN documented at 1920 the patient left AMA/LWBS. There was no documented evidence of a leaving against medical advice form.

Based on a review of medical records, medical staff bylaws rules and regulations, and interview, it was determined the hospital failed to require:

1. the physician assistant complete the required certification that documented the benefits and risks of the transfer, received consent from the patient, provided the risks and benefits to the patient, notification to the receiving facility confirming the receiving facility agreed to accept the transfer and confirm in the documentation the receiving facility had space and qualified personnel to treat the patient upon arrival (Patient #19); and

2. the physician assistant consult and document the consultation with the physician prior to the transfer of patients, and the physician failed to date his signature on the transfer form when signing the certification for the transfer (Patients #1, 2, 3, 8, 9, and 19).

Findings include:

1. The medical staff bylaws rules and regulations at 2.6 Transfer and Transport of Patient revealed: "...(2) When a patient is transferred from the Medical Center to another facility, the patient's Practitioner will obtain a written informed consent for the transfer, except in an emergency and then the Practitioner will document in the medical record why informed consent could not be obtained...."

The Chief Nursing Officer confirmed that the Patient Transfer Transport Record was required for all transfers from the emergency department to another healthcare facility. The form included the risks and benefits of the transfer, acknowledgment of the transfer by the receiving facility, report provided to the receiving facility and the acceptance of the receiving facility, patient consent, and the certification by the physician.

Patient #19's medical record was reviewed on 02/12/2010. The patient was seen by a physician assistant in the ED. The patient was admitted to the ED after a self inflicted left wrist laceration. The patient had been drinking alcohol most of the day, "six bottles of vodka." The physician assistant's dictated report revealed: ".. Usually when he drinks, he gets very depressed and wants to hurt himself, so he cut himself with a four-inch blade in his left wrist area so he could die...." The patient has a history of drug and alcohol abuse. The laceration was described as approximately 3.5 cm and full thickness in nature.

The patient was seen by a counselor for psychological assessment. The crisis center evaluation revealed the patient was considered to have severe mental incapacitation with multiple inpatient placements in the past. The patient was not willing to contract for safety. The counselor documented the patient was to be admitted to a Level 1 acute care psychiatric hospital.

The physician assistant's dictated report included the patient would be admitted as an inpatient to a psychiatric facility. The assessment included a full thickness vertical lacerations of the wrist with repair, depression, alcohol abuse, and suicidal ideation.

There was no documentation that the inpatient psychiatric facility was notified prior to the transfer, and/or that the facility accepted the patient in transfer.

There was no documentation the medical record information went with the patient to the receiving facility.

There was no documentation of the patient consent for transfer to another facility or the reason for why this consent was not obtained.

There was no documented certification of transfer on the record. The physician assistant documentation was co-signed by a physician, however there was no date or time of the co-signature.

There was no order for the discharge to a Level 1 Psychiatric hospital. The physician assistant dictation revealed the patient was going to be transported to the Level 1 Psychiatric facility by the private car of the counselor.

The physician, who identified himself as the lead of the emergency department medical staff, was conducted on 02/12/2010. The physician was informed that Patient #19 was transferred to a psychiatric facility without a transfer certification form. At this time without him having a chance to review the record, he stated that any patient who was transferred from the ED for continued medical care would require the certification form to be completed.

2. The medical staff bylaws revealed at 6.6 Active Allied Health Profession Medical Staff the following: "...C. (3) Supervision/Collaboration. a. Physician Assistants shall perform patient care services, autonomously, that are within the Physician Assistant's scope of training and experience; and, under the supervision of a Physician and have been properly delegated by the Supervising Physician. The Supervising Physician shall demonstrate his supervision by co-signing every entry made by the Physician Assistant in the patient's medical record within thirty (30) days of the entry and the Supervising Physician shall be available for consultations...."

The medical staff rules and regulations revealed at 2.6 A. (4) revealed: "...If a Physician is not physically present in the Emergency Department when a patient is transferred, A Qualified Medical Person ('QMP') must sign a certification after consulting with a Physician. The certifications must be countersigned by the physician."

The medical staff rules and regulations revealed at 3.3 the following: "...Completion of Medical Records...The medical record shall be considered delinquent if the...medical record is not completed within thirty (30) days of discharge of the patient...."

Medical record documentation completed by the Physician Assistant for Patients #1, 2, 3, 8, and 9 revealed the physician assistant completed the medical screening exam, determined the need to transfer the patient to a higher level of care or for specialty care not available at the hospital, completed the transfer form and signed the Certification for the transfer.

The form that is signed revealed the following pre-printed statement as a part of the form: "...If the certifying physician is not physically present at the time of transfer, I have discussed the transfer with the physician name below who certified the transfer an I concur with the certification...."

In each of the five records reviewed there was no documentation by the physician assistant of consultation with the physician who signed the certification form. There was no date or time of the signature on the medical record as to when the physician signed the certification.

Interview with the Physician Assistants was not possible due to the hospital having discontinued the Physician Assistants involved contract due to a reorganization of the emergency department's provider coverage.

The Chief Nursing Officer, during an interview on 02/12/2010, revealed the consultations, when occurred would be documented in the medical record in addition to the pre-printed statement on the consent form.

Patient #1 was seen in the emergency department (ED) on 01/01/09, after an assault that resulted in face trauma. The x-rays revealed fracture of the right orbital floor that extended from the anterior maxillary wall through the lateral maxillary wall and a right nasal bone fracture. The patient was transferred for the availability of a surgeon to care for the fractures. There was no documented evidence of consultation with the physician from White Mountain Regional Medical Center. The physician signed the transfer certification form, however there was no date or time of the signature.

Patient #2 arrived to the ED on 01/01/09, after a single car accident. During the ED triage and physician assistant examination, the patient complained of an onset of shoulder pain that was evaluated for cardiac in addition to the patient being evaluated for the car accident. The physician assistant documented consultation with the receiving hospital trauma surgeon, however there was no documentation of consultation with the physician at White Mountain Regional Medical Center. The physician signed the transfer certification form, however there was no date or time of the signature.

Patient #3 presented to the ED on 01/01/09, with a chief complaint of abdominal pain. The physician assistant's documented clinical impression of the patient after examination and diagnostics were completed was appendicitis. There was no documentation of consultation with the physician at White Mountain Regional Medical Center. The physician signed the transfer certification form, however there was no date or time of the signature.

Patient #8 was a pediatric patient who presented to the ED on 10/30/09, with difficulty breathing and fever. The patient had been receiving breathing treatments every 1 and 1/2 hours. The physician assistant documented the clinical impression as reactive airway disease and hypoxemia with respiratory distress. The physician assistant completed the transfer certification. There was documentation of consultation with the receiving facility, however there was no documented evidence of consultation with the physician at White Mountain Regional Medical Center prior to the transfer. The certification form was signed by the physician, however there was no date or time of the signature.

Patient #9 presented to the ED on 11/05/09, with a chief complaint of dizziness for the past 3-4 days. The physician assistant documented the clinical impression as hypercalcemia, hyponatremia, gastrointestinal bleed and renal insufficiency. The patient was transferred to another acute care facility. The certification was signed by the physician assistant, and there was no documented evidence of consultation with the physician prior to the patient being transferred. There was a signature by the White Mountain Regional Medical Center's physician, however there was no date or time for the signature.

Patient #19's medical record was reviewed on 02/12/2010. The patient was seen by a physician assistant in the ED. The patient was admitted to the ED after a self inflicted left wrist laceration. The patient had been drinking alcohol most of the day, "six bottles of vodka." The physician assistant transferred the patient to a Level 1 Psychiatric Hospital. There was no documented evidence the physician assistant consulted with a physician who was credentialed at White Mountain Regional Medical Center prior to releasing the patient by private car of the counselor to an inpatient setting for continued medical care for his suicidal ideation, and alcohol abuse.