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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.

Findings:

1. The facility failed to meet the following requirement under the EMTALA regulations:

Tag A 2406 - Medical Screening Exam
The facility failed to conduct a Medical Screening Exam on a patient that was brought to the Emergency Department with an emergency medical condition.

Based on staff interviews and review of facility documents, the hospital failed to ensure that a patient that arrived at the Emergency Department entrance in a private vehicle, seeking emergency care for his/her emergency medical condition, receive a Medical Screening Exam.

Findings:

The hospital staff failed to conduct a Medical Screening Exam (MSE) on sample patient #1, who arrived at the Emergency Department in a private vehicle seeking emergency care for his/her crushed ankle injury. The patient was not assessed and did not receive a medical screening examination prior to leaving facility, creating the potential for negative patient outcome, because of a delay in initial assessment and treatment of the medical emergency.

a. Review of facility document on 03/26/13 revealed that the following information, in part:

Sample patient #1 was driven to the Emergency Department (ED) of the facility in a private vehicle to seek medical care for a crushed ankle injury that was sustained in a farm equipment accident. Facility staff, who received prior notification from a dispatch entity, was expecting the patient. The ED physician on duty had directed the staff to attempt to contact the patient/family and direct them to another hospital in another community approximately 8 miles away, because that facility had an orthopedic physician available to care for the patient. They were unable to contact the patient/family en route, so the patient arrived at the entrance to the ED, seeking care. Staff went to the doorway of the ED and met the driver of the vehicle and explained that the facility could try to stabilized the ankle injury and treat the patient's pain, but explained that they did not have an orthopedic physician, so the patient would ultimately need to be transferred to another facility for orthopedic care of the injury. The driver, a family member, chose to leave and take the patient directly to the other facility in the other community. The patient was not assessed at the facility and did not receive an MSE, before the patient left the facility in a private vehicle driven by a family member.

b. At approximately 12:10 p.m., the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO) met with the surveyors and were notified that CMS has authorized an EMTALA complaint about the failure to provide an MSE to sample patient #1 on 11/20/12, when s/he presented to the ED entrance with an emergency medical condition. They were very aware of the situation and acknowledged that it was probably an EMTALA violation. They stated that they had begun to re-educate their staff and physician as soon as they became aware of the lapse. They were asked to provide evidence of the staff training and any personnel actions taken to address the incident. They were told that in the case of EMTALA, even if they had corrected the problem, past deficient practice was supposed to be cited under EMTALA requirements. They were told that any corrective actions would also be provided as a part of the investigation report. They provided the names of the staff (a registered nurse and ED tech) and a provider (a family practice physician) that were involved and on duty at the time of the incident.

c. On 3/26/13, the name and facility medical record number and date of services (11/20/12) for sample patient #1 were submitted on the EMTALA sample list of records requested from the facility.
The facility had no medical record for the date of service for 11/20/12, when the patient presented to the ED entrance.

d. On 03/26/2013 at 1:08 p.m., an interview was conducted with ED nurse, and her supervisor. The interview revealed the following information:

The nurse stated that they had received a call from a dispatcher that stated that a patient with a crushed ankle from a farm equipment accident was being brought to the ED for care by family member in a private vehicle. S/he stated that the ED physician on duty directed the ED tech to try to contact the dispatcher, in order to contact the patient/family to tell them to go to the hospital in a community approximately 8 miles away, because they did not have an orthopedic specialist available to their ED that day. S/he stated that they were unable to contact the dispatcher or the patient/family. The patient arrived at the ED entrance and the nurse went out to meet the car with a wheelchair and was accompanied by the ED tech. S/he stated the driver/family member got out of the car and came to the doorway to speak to them. S/he stated that s/he told the family member that they could treat the patient's pain and try to stabilize the ankle, but that the patient would probably have to be sent to the community 8 miles away or to another hospital where they had orthopedic care available, The nurse stated the family member opted to leave and take the patient to the other community for care. S/he stated s/he called that hospital and told them about the injury and that they were on their way to that facility.

The nurse stated that after they left, s/he started having concerns about what had just happened. S/he stated s/he went in an re-read the EMTALA regulations and then called his/her supervisor to alert him/her about the case. S/he stated that the ED provider on duty never knew that the patient had been on the premises. S/he stated s/he saw the patient in the car, but did not speak to him/her or assess the patient in any way. S/he stated that the family member had stated that the patient was better than s/he was earlier, but no signs, symptoms or pain were discussed during the brief contact. S/he stated that s/he was aware s/he made a mistake and the patient should have been encouraged to come in to have a medical screening exam. S/he stated that the hospital had done a lot of training about these issues since then and s/he would handle the situation differently if it happened today.

His/her supervisor confirmed the training and education that the facility had provided to everyone. S/he also provided a copy of an e-mail from the CNO reminding staff about EMTALA requirements.

e. On 03/26/13, the CNO and the manager of the ED both provided evidence of extensive EMTALA re-training in classes (with attendance sheets) and meeting minutes from multiple committees. They also stated that the physician on duty in the ED on 11/20/12 (and who was also the medical director) was very involved in review of the events related to sample patient #1's ED presentation on 11/20/12, and in efforts to re-educate staff and providers, to better comply with all EMTALA regulations.