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Based on observation, record review, review of policies/procedures, review of physician privileges, review of the facility's referral log, review of patient safety event documentation, and staff interview, the facility failed to ensure compliance with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases, and the related requirements at 42 CFR 489.20 on 2 of 2 days of on-site survey (May 15-16, 2013).

Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements of ?489.24. Failure of the facility to adopt and enforce their policies and procedures relating to the Emergency Medical Treatment and Labor Act placed patients at risk of increased anxiety, suffering, distress, and pain related to their reasons for seeking assistance.

Findings include:

The facility failed to ensure staff conspicuously posted signs informing all emergency department patients of their right to receive a medical screening examination and the facility's participation in the Medicare/Medicaid programs (refer to A2402).

The facility failed to enforce their policy/procedure regarding providing an appropriate medical screening examination (MSE) for individuals presenting to the emergency department (refer to A2406).

The facility failed to ensure compliance with the recipient hosptial responsibilities by failing to accept a patient with needs for services within the capabilities of the hospital (refer to A2411).

Based on observation and staff interview, the emergency department failed to conspicuously post signs informing all emergency department patients of their right to receive a medical screening examination and the facility's participation in the Medicare/Medicaid programs during 1 of 1 observation (05/16/13). Failure to post the required signage in all areas likely to be noticed by all individuals entering, registering, waiting, and receiving treatment in the emergency department may result in patients not receiving services available to them regardless of their ability to pay.

Findings include:

Observation of the emergency department, at 11:00 a.m. on 05/16/13, showed a lack of signage in the registration area, waiting areas, entrance areas, and triage and treatment areas. The seventeen treatment room department showed two signs posted in the corridors adjacent to the nurses station. These signs lacked the ability for patients to read the sign unless standing in front of them. Observation showed one of the signs posted at a height above average/normal standing eye level and placed above stored equipment and fire evacuation signage.

During interview at approximately 11:00 a.m. on 05/16/13, nurse management staff members (#6 and #7) concurred the emergency department lacked signage in areas as required.

Based on record review, review of policies/procedures, and staff interview, the facility failed to conduct a medical screening examination (MSE) for 4 of 4 patients (Patient #2, #9, #17, and #18) who presented to the emergency department (ED) and "eloped," and failed to follow their established policies/procedures regarding triage and providing each patient with a (MSE). Failure to provide a patient with a MSE allows medical emergencies to go unrecognized and untreated/unstabilized, placing the patients at risk for complication and/or significant harm.

Findings include:

Review of the facility's policies/procedures occurred May 15-16, 2013, and included the following:
Policy #50.113, Page 1 of 9. Last approved 10/23/08: "Subject: EMTALA [Emergency Medical Treatment and Labor Act]/Medical Screening Examination. Policy: 1. Any individual who comes to the Emergency Trauma Center (ETC) and requests examination or treatment for a medical condition is entitled to and will receive an appropriate medical screening examination (MSE) performed by individuals qualified to perform an examination to determine whether an emergency medical condition (EMC) exists. . . ." Page 8 of 8 included a schematic diagram regarding the flow of the patient following presentation as follows: "Individual presents to the hospital ED [emergency department] OB [obstetrical], or labor & delivery - Patient Triaged - Enter into EMTALA log - Initiate MSE . . "
The facility's policy/procedure #13.E042, last revised 6/09: "Subject: Triage. Policy: The duties of the triage nurse are as follows: 1. Greet incoming patients; inquire to determine the patient's reason for seeking care. 2. Perform brief patient assessment, record patient information on the record such as medications, allergies, and vital signs and other information that the triage nurse might obtain about the patient. 3. Sort ETC patients according to their need for urgent care. . . . Assign appropriate triage acuity on the ETC grease board. 4. Initiate advanced triage as needed (e.g. - giving ice, dressing for a bleeding wound, initiating protocol for triage standing orders). 5. Coordinate patient flow . . . 6. Orientation of the patient to the waiting room and expected time of wait until ETC evaluation and care. . . . 8. Reassessment and re-triage of patients during the waiting period. . . ." The triage levels are determined with a scale ranging from Level I (most urgent) to Level V (least urgent). Identified times for triage reassessment while waiting for evaluation and treatment indicated, Level I - continuous care, Level II - every 15 minutes, Level III - every 30 minutes, Level IV - every 60 minutes, and Level V - every 120 minutes.

- Review of Patient #2's emergency room record occurred 05/15/13, and showed the patient presented to the ED at 12:37 p.m. on 01/02/13 with complaints of "back and abdominal pain and fever." The record indicated Patient #2 "eloped" from the ED at 4:39 p.m. on 01/02/13, however, the record did include a signed "Against Medical Advice [AMA]" form. The signed form indicated Patient #2 did not elope, and informed staff prior to leaving. The record lacked evidence of the reason Patient #2 left the ED.

The record showed the triage nurse first conducted a triage assessment and determination of Patient #2 at 1:31 p.m. on 01/02/13, and determined the patient's triage level at "3" and identified the patient's pain intensity at that time as "6 - like a dagger" on a scale of 1 to 10.

The record showed no further assessment/reassessment of Patient #2. The facility failed to provide Patient #2 a MSE to determine if an EMC existed during the four hours the patient remained in the ED.

- The emergency room record of Patient #9, reviewed 05/15/13, showed the patient presented to the ED at 6:40 p.m. on 01/03/13, with complaints of having "burned self with boiling water," and "eloped" at 8:08 p.m. on 01/03/13.

The record included no assessment or triage of Patient #9, including observation of the sustained burn, no provision of advanced triage per policy, no reassessment per triage policy, no MSE to identify the presence of an EMC, and no treatment provided the patient.

-Review of the emergency room record of Patient #17 occurred on 05/16/13 and showed the patient, a six month old child, presented to the ED with her father at 11:17 p.m. on 04/30/13 with "Uncontrolled bleeding left hand." The record showed the patient "eloped" from the ED at 11:40 p.m. on 04/30/13, however, the patient's father signed a "Nursing Service Informed Consent to Refuse" form. The form indicated the patient's father acknowledged refusal of a MSE, however, the form lacked completion of the prepared area identifying the facility informed the patient of the specific risks associated with the refusal and the benefits of receiving the MSE.

The record lacked evidence of assessment/observation of the injured hand, triage of the patient, and any advanced triage per facility policy.

- The emergency room record of Patient #18, reviewed 05/16/13, showed the 20 yr. old patient presented to the ED at 3:01 p.m. on 04/29/13 with complaints of vomiting and abdominal pain, and "eloped" at 5:31 p.m. on 04/29/13. Triage of Patient #18 occurred at 3:21 p.m. on 04/29/13, at which time the nurse determined the patient's triage level as "3." Findings at that time showed the patient with an elevated blood pressure, pain intensity of "10" on a scale of 1 to 10, and according to a laboratory report in the record, an elevated white blood cell count (17.5).

The record lacked evidence of further assessment/reassessment per triage policy, and no evidence of a MSE to determine the presence of an EMC, and/or treatment of the patient. The record included a "Nursing Service Informed Consent to Refuse" form signed by Patient #18. The signed form lacked evidence of what the patient refused, the specific risks associated with the refusal, and the specific benefits of not refusing.

During an interview with facility administrative staff members (#1 and #2) on the afternoon of 05/16/13, the staff members concurred the referenced patients should have received services consistent with the facility's referenced policies.

Based on the hospital's referral log, review of patient safety event documentation, review of delineation of physician privileges, and staff interview, the emergency department (ED) failed to ensure acceptance of the request for referral of 1 of 1 patient (Patient #10) identified on the referral log as "physician refused patient." Failure to accept a patient with needs for services within the capabilities of the hospital may place the patient at risk for significant decline in condition, delay in treatment/recovery, and possible death.

Findings include:

Review on 05/15/13 of the referral log maintained by the facility showed an entry dated 03/29/13 identifying three telephone calls between a referring critical access hospital (CAH) and the facility showing the CAH requested the transfer of a patient to the facility and an identified outcome by the facility of "Dr. (#3) refusing to accept Pt [patient]. Pt to Minneapolis." A "Patient Safety Event [PSE]" document identified the physician initially accepted the patient then called the referring facility and refused the patient because "It's going to be too much work for me."

An interview occurred the afternoon of 05/15/13 with a facility management staff member (#2), The staff member indicated he/she became aware of the above situation after receiving a call within a day or two following the incident from the CAH requesting the transfer. The staff member indicated the CAH did not feel this was an EMTALA issue, but wanted him/her to know the physician had initially accepted transfer of the patient but after several telephone calls changed his mind and refused the patient. The referring facility indicated they felt the physician's reason for refusing was justified, and were o.k. with the outcome.

Review of the Patient Safety Event document initiated by the staff member (#2) in response to this telephone call, verified the above referenced information provided. The CAH identified the facility physician (#3) called back eight minutes after agreeing to take the patient and indicated he had changed his mind and would no longer accept the patient stating, "It's going to be too much work for me." The patient requiring transfer had been involved in an industrial accident whereby he severed four fingers. The staff member (#2) indicated she referred the issue to the Director of Emergency/Trauma Services, and the facility began the process of investigation of the event.

An interview occurred at 8:45 a.m. on 05/16/13 with the physician (#3), a hand surgeon by specialty, who refused to accept the transfer of the above referenced patient (Patient #10). The physician provided the following information in regard to his refusal of the above referenced patient: "During the first call he was told the patient had 'crushed fingers - all [four] severed.' Based on that information I thought I would be dealing with care of the crushing injury to the stumps." The physician indicated after hanging up he felt he needed more information and he called back to inquire about the condition of the severed fingers. He indicated it was difficult to communicate and obtain reliable information due to staff in the CAH emergency room not having the knowledge to make a reliable evaluation of the viability of the fingers. However, they did indicate to him they felt all four fingers had the potential for reattachment.

After concluding the second call, the physician said he thought about the possible reattachment of four fingers and stated, "I know my limitations, and to give the patient the best chance for as many functional fingers as possible I could not take the patient. I have never performed multiple digit replants, only a single finger. During my fellowship we always had two hand surgeons for multiple replants. I was only thinking of the best interest of the patient when I called back and refused to take the patient." The physician indicated his experience with finger replants had occurred during his fellowship which he completed in August of 2012, the same month he was given medical staff membership and privileges at the facility. He indicated he had not performed any replants since becoming a member of the medical staff, but felt he could perform a single replant and maybe a double if there were no complications or problems during the surgery.

When asked if he had been specific in regard to the level of replant/reattachment of fingers/digits he could perform with and without assistance on his request for privileges, he said he did not remember.

Review of the physician's (#3) hand surgery privileges occurred on the morning of 05/16/13, and included no specific requested/approved privileges regarding reattachment/replant of single or multiple fingers/digits. During an interview, on the morning of 05/16/13, with a medical staff member (#5) involved in the hospital's credentialing process, the staff member concurred the current privileges for Physician #3 did not include specificity regarding finger reattachment/replant and when/if assistance would be required.

Failure to ensure physician privileges are specific and consistent with the training and scope of practice/experience of the medical staff member, does not provide clear and distinct evidence of the capabilities of care/services provided as a Regional Referral Center.