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Based on record review and interviews, the hospital did not maintain a central log for 1 of 1 patient (Patient #3), that included the refusal of medical treatment by Patient #3's mother, after being told he had a non-emergent condition.

Findings included:

ED Central Log:
The computerized ED Central Log documented Patient #3, on his visit to the ED at Hospital A on Saturday, 04/14/12, was triaged at 9:02 AM by Personnel # 4, the ED registered nurse (RN). Chief Complaint: Asthma Attack - SOB (shortness of breath), Diagnosis: Asthma, Disposition type noted as Patient #3 left AMA (against medical advice), and time to Disposition: 31 minutes. The ED Central Log did not document the acuity/triage level for Patient #3, that determined his condition to be "non-emergent," and/or that Patient # 3's mother had refused medical treatment after being told he was "non-emergent."
The dispositions included on the hospital's Central Log were either "Discharged to Home or Self Care; or AMA (Against Medical Advice)," and did not include the regulatory required "refused treatment" category.

ED Medical Record:
The hospital's financial "Prompt Pay Price Listing," form, had been included in the ED medical record, which showed a grid of the number and types of services provided to patients, according to ED triage levels, and the associated price for that level. This form, that had Patient # 3's name and personal information sticker attached, had the $1,200.00 fee circled at the Level 4 Emergency Room Visit, and indicated a Triage Level 4/Less Urgent (Code ED 4), as the determined condition of this patient.

Posting of Signs:
The surveyor observed the required signs were posted in the admission area, regarding the EMTALA requirements for emergency medical conditions, and included a statement that indicated "this hospital does not participate in the Medicaid program," also required by regulation.

Interviews:
In a telephone interview at 3:00 PM on 04/30/12 with the nurse, Personnel # 4, she confirmed she had performed the initial triage assessment on Patient #3's admission to the ED. When asked why she had not documented Patient #3's acuity/triage level during her assessment, she said that "they had just gone to computerized charting in January 2012, and that she keeps forgetting to do it, as it is located somewhere else in the computerized records." She also verified that after her initial triage assessment, Patient #3 received a medical screening exam by the ED physician, Personnel #3, who had determined that Patient #3 did not have an emergency condition.

In a telephone interview at 4:25 PM on 04/30/12 with the ED physician (Personnel #3), he confirmed his documented MSE, that included mild wheezing, and that Patient #3 was in no dire distress. He stated that he does a MSE on all ED patients, and if he determines that it is not an emergency medical condition, and they are able to treat the patient in their ED, he had been instructed to inform patients or their families of the "Prompt Pay Charges" based on acuity triage level. He confirmed that Patient #3 was at an acuity triage Level 4/Less Urgent, and that he had only documented this "Code ED 4," associated with patient condition severity level on the financial form. He also said that when he informed Patient #3's mother that Patient #3 was non-emergent, afterward he had told her that the ED visit could be $1,200.00. He said he had ordered breathing treatments and prednisone to treat the patient, but that she had refused medical treatment.

Policies & Procedures:
Review of the hospital's Policies & Procedures required the following process for assessing the severity of the chief complaint, and assigning acuity levels according to their triage categories. This process documents Levels 1 and 2 as emergency medical conditions, and Levels 3, 4, and 5 as non-emergency conditions.

-The hospital Referral of Care Guidelines policy, dated 05/01/11, noted that "the triage nurse performs a rapid or comprehensive triage assessment ...and assigns a triage category." "Once the nurse has assigned a triage level to the patient the QMP (qualified medical professional) ie. Physician, will perform a MSE (Medical Screening Exam) ...and when completed there are two alternative outcomes: (a) ...the patient is determined to have a potential emergency medical condition, or (b) ...the patient is determined to NOT have an emergency medical condition, ...and the Patient Registration staff will provide the following alternative of care options to the patient ...
? Stay and continue to utilize the resources of the Emergency Department and accept financial responsibility for their decision, or
? Receive Referral of Care options to seek care and treatment from an alternative source ..."

-The hospital Triage Medical Screening Exam policy, dated 05/01/11, noted that "all patients presenting to the Emergency Department are assessed rapidly to determine the severity of the presenting chief complaint ...acuity is assigned to each patient during the initial assessment." "Triage categories are: Level 1/Resuscitative, Level 2/Emergent, Level 3/Urgent, Level 4/Less Urgent, and Level 5/Non-Urgent."