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Based on interview and record review, the facility failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) as evidenced by:

1. The facility failed to provide a medical screening exam for Patient 1. (Refer to C 2406)

2. The facility failed to keep an accurate emergency room log. (Refer to C 2405)

Based on interview and document review, the facility failed to maintain an accurate and complete Emergency Department (ED) log when one of 21 sampled patients' (Patient 1) names who presented to the ED for treatment was not included in the log. Four of 15 other patients whose names appeared on the ED log did not include whether they were transferred, admitted and treated, stabilized and transferred, or discharged. This resulted in a lack of information regarding Patient 1's reasons for presenting to the ED and disposition and had the potential to result in miscommunication regarding the treatment and dispositions of the other four patients.

Findings:

A review of the ED log did not include Patient 1's name.

During an interview on 4/27/16 at 11:25 am, the Medical Records Director confirmed they had no records showing Patient 1 had been treated at the facility.

During an interview on 4/18/16 at 6:25 pm, Registered Nurse (RN) B confirmed Patient 1 came in to the hospital at around 4 am on 4/15/16 complaining of the inability to urinate. RN B stated he called Dr. A who told him to tell the patient to return at 8 am for a urinalysis (lab test). RN B advised Patient 1 of this and Patient 1 told RN B he was going to another hospital's ED. RN B stated he did not include Patient 1's name in the ED log and did not know anything about the ED log. RN B stated he had no prior ED experience, before starting to work at this hospital.

Further review of the ED log indicated, from 4/1/16 through 4/26/16, 15 patients had been seen in the ED. The documentation in the ED log for four of these patients did not include whether they were transferred, admitted and treated, stabilized and transferred, or discharged.

During a concurrent interview and review of the ED log on 4/27/16 at 3 pm, the Director of Nurses (DON) confirmed the ED log did not include the above mentioned information. DON stated she's not sure when RN B knew of the need to complete the ED log.

Based on interview and record review the hospital (Hospital 1) failed to provide an appropriate medical screening exam (MSE) for one of 21 sampled patients (Patient 1).

On 4/15/16 at approximately 4 am, Patient 1 presented to Hospital 1 complaining of the inability to urinate and requesting a catheter (tube inserted into the bladder to drain urine) to be placed. Registered Nurse (RN) B spoke to a physician about Patient 1 but the physician did not examine or otherwise provide a medical screening exam to Patient 1. Patient 1 then went to the Emergency Department (ED) at Hospital 2 where he received a MSE and treatment for his condition.

This failure to perform a MSE had the potential to result in a significant worsening of Patient 1's condition.

Findings:

Hospital 1's policy titled "Cobra/EMTALA Transfer Policy/Protocols," last reviewed 5/27/15, was reviewed. It read as follows: "It is the policy of the hospital to provide appropriate medical response, screening, and stabilization to determine the nature and extent of any injury, medical condition, and/or pregnancy within its capabilities of persons needing or asking for assistance within the hospital 'campus'. The definition of campus includes the main hospital building, clinic, hospital owned ambulance and a zone of 250 yards surrounding the main hospital building. . . . . All persons presenting at the hospital campus requesting treatment shall be provided a medical screening exam for the purpose of determining whether they suffer from an emergency medical condition or are pregnant with contractions present. Screening will include necessary testing to rule out any condition with potential health risks."


During an interview on 4/27/15 at 4 :30 pm, RN B stated Patient 1 came in to the hospital on 4/15/16 at approximately 4 am, complaining of inability to urinate and requesting a catheter (tube placed to drain urine) to be placed. Patient 1 reported he'd had the same problem about a year prior and had been catheterized at that time. Patient 1 told RN B he had urinated 300 milliliters (ml) about two hours prior. RN B said he advised Dr. A of Patient 1's complaint and, was told by Dr. A, to tell Patient 1 to return to the lab at 8 am for a urinalysis (urine test). RN B advised Patient 1 of the above instructions who then told RN B he was going to go to the ED at Hospital 2.

A review of Patient 1's record at Hospital 2 indicated he presented on 4/15/16 and was examined by the ED physician at 4:45 am. Patient 1's chief complaint was "can't pee" and initial blood pressure was 220/116 (normal is 120/80) and pulse 97 (normal range is 60-100). A catheter was placed and drained 1000 ml of urine. The ED physician documented the following, "He drove to the ED at Hospital 1, arriving there at approximately 4 am. The nurse contacted the physician on duty and the physician on duty told the nurse to tell the patient that they could not do anything about this until 9 am. Because of that Patient 1 drove over Cedar Pass where he says it was not snowing too badly, he just had to drive slowly and came to our ED for evaluation and relief." The records indicated Patient 1 was homeless and lived in his van in the general vicinity of Hospital 1.

A review of Hospital 1's on-call physician list for 4/2016 listed Dr. A as being off until 8 am on 4/15/16 and Dr. C as being on call.

During an interview on 4/27/16 at 12:10 pm, Dr. A confirmed he was not on duty until 8 am on 4/15/16. He said if a nurse called him before he was on duty he would have told the nurse to call Dr. C. He said he does not recall receiving a phone call about a patient complaining of inability to urinate. Dr. A said he would not tell a patient to come back. He stated if a patient had urinary retention (inability to completely empty the bladder) that was "something you can't put off".

During an interview on 4/27/15 at 4:30 pm, RN B was asked to review the 4/2016 physician on call list. RN B did so and checked another on-call list kept at the nurses station and confirmed Dr. C, and not Dr. A, was the on-call physician listed for 4/15/16 at 4 am. RN B confirmed he was sure he spoke to Dr. A who told him to tell Patient 1 to return at 8 am. RN B said he recognized Dr. A's voice and he has Dr. A's phone number on his personal cell phone which he looked at before calling.

In a signed statement, RN E (RN who works in the ED at Hospital 2) stated she spoke to RN B who told her he had spoken to Dr. A who advised him to tell Patient 1 to come back at 8 am for a urinalysis.

During an interview on 4/18/16 at 6:25 pm, RN B stated, before starting to work at this hospital, he had no prior ED experience. He stated he didn't enter Patient 1's name on the ED log because he didn't know about the log. RN B said he did not take Patient 1's vital signs because after he told Patient 1 to return at 8 am, as advised by Dr. A, Patient 1 said he was leaving to go to Hospital 2.

During an interview on 4/27/16 at 2:25 pm, the Human Resources Director (HRD) said she was unaware of any orientation checklist for the ED. HRD said RN B "shadowed" a couple of the other ED nurses when he first started work at the facility. She confirmed he started working directly for the hospital on 4/6/16 but had worked for a few weeks prior through a nursing agency.

During an interview on 4/27/16 at 3 pm, DON stated there was no orientation checklist for the ED, although there should be one and there was no designated person to complete the orientation for a new hire. DON stated for the first few days RN B was scheduled, he would have worked with another nurse but after that he'd been on his own.