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Based on interview, review of patient records and review of facility policies, it was determined the facility failed to comply with 42 CFR 489.20(r)(c) and 489.24(c) in regard to providing an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department (ER) for one (1) of twenty (20) sampled patients (Patient #1). The facility failed to follow their policies for EMTALA Guidelines for Emergency Department Services, last revised September 2014, regarding the Emergency Room (ER) Log, triage, and an appropriate Medical Screening Exam (MSE). Additionally the facility failed to follow the Admission Policy which states, "All patients will be evaluated by a Registered Nurse prior to being seen by a Registration Clerk. All patients will have the appropriate demographic information obtained by a Registration Clerk". Hosptal staff failed to triage, conduct a MSE and obtain demographic information which would of resulted in the patient being placed on the ER log, when she presented to the ER on 04/21/15 with complaints of leg pain and a concern of a blood clot.

Refer to C-2405 and C-2406.

Based on interview, review of patient records, and review of facility policies and procedures, it was determined the facility failed to enter one (1) of twenty (20 ) sampled patients (Patient #1) on the Emergency Room (ER) Log when he/she presented to the ER for treatment.

The findings include:

Review of the facility policy titled, "Admission Policy", last revised 09/2014, revealed "All patients will be evaluated by a Registered Nurse prior to being seen by a Registration Clerk. All patients will have the appropriate demographic information obtained by a Registration Clerk".

Review of policy titled, "EMTALA Guidelines for Emergency Department Services", last revised 09/2014, revealed "An individual that presents to the hospital requesting emergency services shall be triaged by a registered nurse or a paramedic acting within his statutory scope of practice, and in accordance with the hospital's formal operating policies and procedures". Further review of the policy revealed "The hospital must perform a Medical Screening Exam (MSE) to determine if an emergency medical condition (EMC) exists. It is not appropriate to merely "log in" or triage an individual medical condition and not provide an MSE".

Review of the ER Log for Tuesday, 04/21/15, revealed Patient #1 was not on the Log. There was no documented evidence Patient #1 had presented to the ER on that date.

Interview with Patient #1, on 04/30/15 at approximately 10:22, revealed he/she presented to the ER on 04/21/15 at approximately 2:35 PM with a complaint of leg pain and a concern of a possible blood clot; and at the advice of the staff at his/her Primary Care Physician (PCP)'s office requested an ultrasound. Patient #1 stated Hospital Physician #1 was at the registration desk and told him/her we don't do ultrasounds here except for pregnancy or men's testicles, and you don't fit these categories. Patient #1 stated he/she told Physician #1 his/her problem and Physician #1 replied the PCP's office needs to be informed of our policy. Patient #1 further revealed the physician then told him/her she could give him/her a shot of Coumadin, he/she could go to another area hospital for an ultrasound, or back to her PCP's office to have an ultrasound scheduled. Patient #1 stated he/she chose to return to his/her PCP's office.

Interview with Hospital Physician #1, 04/29/15 at approximately 2:05 PM, revealed Patient #1 did present in the ER and was not triaged on 04/21/15. She stated she told Patient #1 ultrasounds were not done through the ER. She revealed she offered to see the patient and told him/her she could get him/her started on Coumadin; he/she could go to his/her PCP to schedule an ultrasound; or he/she could go to another area hospital for an ultrasound. Physician #1 stated she contacted the patient's PCP to get him/her an appointment that day. She reported the Hospital Administrator came to her later and stated the ER does ultrasounds.

Interviews on 04/30/14 with Registered Nurse (RN) #2, at approximately 8:35 AM, and RN #5 at approximately 12:20 PM, revealed there was not a dedicated staff person positioned in the ER twenty-four/seven (24/7) as the Registration Clerk.

Interview with the Interim Director of Nursing (DON), on 04/29/15 at approximately 7:45 AM, revealed all patients should have appropriate demographic information obtained by the Registration Clerk, as this was how a patient was placed on the ER Log. Additionally, she confirmed Patient #1 was not on the ER Log, dated 04/21/15.

Based on interview, review of patient records, and review of facility policy and procedure, it was determined the facility failed to comply with their policy to ensure one (1) of twenty (20) sampled patients (Patient #1), was given a Medical Screening Exam (MSE) when he/she presented to the Emergency Room (ER).

The findings include:

Review of policy titled, "EMTALA Guidelines for Emergency Department Services", last revised September 2014, revealed "An individual that presents to the hospital requesting emergency services shall be triaged by a registered nurse or a paramedic acting within his statutory scope of practice, and in accordance with the hospital's formal operating policies and procedures". Further review revealed "The hospital must perform a Medical Screening Exam (MSE) to determine if an emergency medical condition (EMC) exists".

Review of patient records, revealed there was no documented medical record for Patient #1 verifying he/she presented to the ER on 04/21/15 and an appropriate MSE had been completed.

Interview with Patient #1, on 04/30/15 at approximately 10:22, revealed he/she presented to the ER on 04/21/15 at approximately 2:35 PM with a complaint of leg pain and a concern of a possible blood clot and was told by staff at his/her Primary Care Physician (PCP)'s office to go to the hospital and request an ultrasound. Patient #1 stated Hospital Physician #1 told him/her the hospital does not do ultrasounds except for pregnancy or men's testicles, and she/he did not fit these categories. Patient #1 revealed he/she told Hospital Physician #1 his/her problem and Hospital Physician #1 replied the PCP's office needed to be informed of the hospital's policy. Patient #1 stated the physician told him/her they could give him/her a shot of Coumadin, he/she could go to another area hospital for an ultrasound, or back to her PCP's office to have an ultrasound scheduled. Patient #1 stated he/she chose to return to his/her PCP's office.

Interview with Hospital Physician #1, on 04/29/15 at approximately 2:05 PM, revealed she was at the registration desk when Patient #1 arrived. She stated Patient #1 presented to the ER on 04/21/15 and he/she was not triaged and an appropriate MSE was not completed. She stated she told Patient #1 ultrasounds were not done through the ER. She further revealed she did offer to see the patient and told him/her she could get him/her started on Coumadin, he/she could go to his/her PCP to schedule an ultrasound or he/she could go to another area hospital for an ultrasound. Hospital Physician #1 reported she contacted the patient's PCP to get him/her an appointment that day, but Patient #1 chose to go to his/her PCP and not be seen in the ER. Additionally, Hospital Physician #1 stated the hospital Ultrasound Policy states ultrasounds were done through the ER for ectopic pregnancy and ovarian or testicular torsion; however, review of the hospital policy titled, "Emergency Ultrasound Procedures", dated 10/14, revealed the policy addressed emergency after hours procedures that would require an Ultrasound Technologist to be called in after hours and on weekends. This policy stated the patient must present with a sudden onset of testicular pain which could possible indicate Testicular Torsion or the patient must present with pain in the exact location of the ovaries which could possible indicate Ovarian Torsion. Further review revealed there was no documented evidence an ultrasound could not be obtained during normal business hours Monday through Friday.

Interview with the Director of Nursing (DON), on 04/29/15 at approximately 7:45 AM, revealed Patient #1 presented to the ER, was not listed on the ER Log and there was no MSE completed.