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A. Based on document review, and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to provide a medical screening exam for the patient presenting for treatment. (A 2406)

Based on document review and interview, it was determined that for 1 of 20 (Pt #1) Emergency Department (ED) clinical records reviewed, the Hospital failed to ensure a medical screening examination was provided to a patient presenting for emergency treatment.

Findings include:

1. On 4/27/15 the Hospital Medical Staff by-laws was reviewed and included, "...27.2. Qualified Medical/Psychiatric Personnel...are individuals determined qualified by the medical staff to perform a medical screening....medical staff in the following positions are authorized to perform medical screening and stabilization...27.2.4. Registered Nurses..."

2. Hospital policy entitled, "Admission Procedure: Level of Care Assessment (1/13) was reviewed and required, "A. Triage: 1. Once a patient presents for assessment, they are screened by a Mental Health Counselor...B. Every patient who presents for an assessment is seen by a Registered Nurse who completes a nursing assessment..."

3. On 4/27/15 the Emergency Department record of Pt. 1 was reviewed. Pt. #1 was a 24 year old male who arrived at the ED on 3/26/14 at 3:06 PM with a request for assistance with methadone detoxification. Pt. #1 history was significant for Heroin addiction. Pt #1's vital signs at time of triage were: temp 98, blood pressure 108/76, pulse 81, respirations 20 oxygen saturation 97%, pain level 6 (noted area of pain knee and teeth). Triage level was green (non-urgent). After Pt. #1's triage was completed by a mental health counselor (MHC), Pt. #1's name was placed on the call board at 5:00PM for the medical screening examination (MSE) and intake assessment. The ED record lacked documentation that a MSE was provided by the RN in accordance with Hospital by-laws. On 3/26/15 at 8:15 PM (5 hours and 9 minutes after Pt. #1's arrival) a licensed professional counselor (LPC #1) performed an assessment and notified the on-call psychiatrist at 9:30 PM. Upon the on call psychiatrist's recommendation, Pt. #1 was instructed to call 911 for any emergency; follow up with the primary care physician and or call the toll free insurance hotline for guidance. Pt. #1 was discharged at 9:30 PM without an MSE or additional vital signs.

4. On 4/28/15 at approximately 12:00 PM, the Director of Admission and Referrals (E #1) and the Chief Nursing Officer (E #5) stated E #3 (Registered Nurse), was qualified to perform a medical screening examination; that the examination was performed but the document could not be located.