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Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires that hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by:

1) Failing to maintain an accurate and complete Emergency Department Central (patient) Log on each individual, who came to the Emergency Department, as evidenced by failing to document in the central log a pregnant patient who sought emergency care in the Emergency Department of Hospital A's offsite campus (See Findings in A2405).

2) a. Failing to ensure a comprehensive medical screening examination was performed on a 36 weeks gestational age pregnant patient (Patient #8), who presented to Hospital A's Offsite Campus with the complaint of dizziness,and

b. Failing to ensure all agency ED (Emergency Department) hospital nursing staff were trained on EMTALA regulations and policies for 3 of 3 agency nurses (S4RN, S14RN, S15RN) before working at Hospital A's Offsite Campus (See Findings in A2406).

Based on record review and interview, the hospital failed to maintain an accurate and complete Emergency Department Central (patient) Log on each individual who came to the Emergency Department as evidenced by failing to document in the central log a 36 weeks pregnant patient (Patient #8) who sought emergency care in the Emergency Department of Hospital A's Offsite Campus. Findings:

Review of the Hospital A's (Offsite campus and Main Campus) Policy titled Admission, Discharge and Transfer Guidelines for the Emergency Department, Policy Number OSE.ED.001, revealed in part, A. All persons presenting for care in the ED (Emergency Department) will receive a basic registration which will include the patient's name and date of birth...1. The patient information gathered in the basic registration will generate a patient encounter number and populate the patient's medical record. 2. A registration log containing the patient's name, date and time of arrival and chief complaint will be maintained on paper or electronically.

Review of the Emergency Department (ED) Record from 5/26/15 at 21:52 from Hospital A's Main Campus ED revealed Patient #8 was a 23 year old female who was 36 weeks pregnant with onset of a pressure type headache and vision change. Her means of transportation was ambulance. Patient #8's chief complaint was 7/10 (pain level rated as a score of 7 with 10 being the highest level) headache with some blurred vision in lt (left) eye for approximately 1.5 hours, denies n/v (nausea/vomiting) Pt. (Patient) is 36 weeks pregnant.

Review of the ED Nurses Notes on 5/26/15 from Hospital A's Main Campus at 10:21 p.m. revealed Pt presents with left sided h/a (headache) with reported blurred vision and floater in left eye x (times) 1.5 hours. Also reports "the baby is balling up." No photophobia, n/v, vaginal bleeding. NAD (No Apparent Distress) noted.

Review of the Prehospital Care Report Summary from the ambulance service revealed in part, Call was received at 21:12, on scene at 21:17 and was at destination at 21:49.


Review of the Narrative History Text of the report revealed, Upon EMS (Emergency Medical Service) arrival, Pt is sitting upright outside on the front porch with a young child (2 years old) with her. Pt appeared to be awake and alert and oriented. Pt stated that she is dizzy, with a headache 7/10 and abd (abdomen) pain in the middle of her stomach that is 6/10, that comes and goes. Pt states that it has been going on for about 1 hour. Pt states that she went to Hospital A's Offsite Campus ED and they told her since she was pregnant that they couldn't see her and she needed to leave and call 911 and go to Hospital A's Main Campus ED.

Review of the Emergency Log for Hospital A's Offsite ED revealed no documentation Patient #8 went to the ED at Hospital A's Offsite Campus on May 26, 2015.

An interview was conducted with S11Rev Cycle Representative on 6/11/15 at 9:00 a.m. S11Rev Cycle Representative verified that Patient #8's visit to Hospital A's Offsite ED on May 26, 2015 was not documented on the Emergency Department Central Log. S11Rev Cycle Representative stated she had planned to register the patient in the Emergency Room Central Log when S4RN had finished speaking to the patient, but when she returned to her desk, the patient had left the ED.

Based on record review and interview, the hospital failed to:

1) ensure a comprehensive medical screening examination was performed on a 36 weeks gestional age pregnant patient (Patient #8), who presented to Hospital A's Offsite Emergency Department with the complaint of dizziness; and

2) ensure all agency ED (Emergency Department) hospital nursing staff were trained on EMTALA regulations and policies for 3 out 3 agency nurses (S4RN, S14RN, S15RN) before working at Hospital A's Offsite ED.

Findings:

1. Failing to ensure a comprehensive medical screening examination was performed on a 36 weeks gestional age pregnant patient (Patient #8), who presented to Hospital A's Offsite Emergency Department with the complaint of dizziness.

Review of the hospital's policy for Hospital A's Main campus and Offsite ED titled Admission, Discharge and Transfer Guidelines for the Emergency Department, Policy Number OHS.ED.001, in part revealed, B. All patients will be triaged in a timely manner and receive an initial acuity classification per the Emergency Severity Index (ESI) algorithm. C. All patients presenting for treatment will receive a medical screening examination by a physician or licensed independent practitioner (LIP)...The medical screening will not be delayed to obtain registration or financial information. The medical screening examination will be documented by the physician or LIP.

Review of the hospital's policy for Hospital A's Main Campus and Offsite Campus ED titled Emergency Department Assessment Standards, Policy Number OHS.ED.002 revealed in part, All patients presenting to the ED will be assessed in a timely manner within established standards. A. Triage: 1. All patients presenting to the ED will receive an initial classification utilizing the Emergency Severity Index (ESI) by a Registered Nurse (RN).
a. Time of ESI
b. Mode of arrival
c. Chief complaint
d. Acuity per ESI criteria
e. Pain scale
f. Vital signs (temperature, pulse, blood pressure, respirations)

Review of the Emergency Department (ED) Record from 5/26/15 at 21:52 from Hospital A's Main Campus revealed Patient #8 was a 23 year old female who was 36 weeks pregnant with onset of a pressure type headache and vision change. Her means of transportation was ambulance. Patient #8's chief complaint was 7/10 (pain level rated as a score of 7 with 10 being the highest level) headache with some burred vision in lt (left) eye for approximately 1.5 hours, denies n/v (nausea/vomiting) Pt. (Patient) is 36 weeks pregnant.

Review of the ED Nurses Notes from Hospital A's Main Campus on 5/26/15 at 10:21 p.m. revealed Pt presents with left sided h/a (headache) with reported blurred vision and floater in left eye x (times) 1.5 hours. Also reports "the baby is balling up." No photophobia, n/v, vaginal bleeding. NAD (No Apparent Distress) noted.

Review of the Prehospital Care Report Summary from the ambulance service revealed in part, Call was received at 21:12, on scene at 21:17 and was at destination at 21:49.
Review of the Narrative History Text of the report revealed, Upon EMS (Emergency Medical Service) arrival, Pt is sitting upright outside on the front porch with a young child (2 years old) with her. Pt appeared to be awake and alert and oriented. Pt stated that she is dizzy, with a headache 7/10 and abd (abdomen) pain in the middle of her stomach that is 6/10, that comes and goes. Pt states that it has been going on for about 1 hour. Pt states that she went to Hospital A's Offsite Campus ED and they told her since she was pregnant that they couldn't see her and she needed to leave and call 911 and go to Hospital A's Main Campus ED.

Review of the Emergency Log for Hospital A's Offsite ED revealed no documentation Patient #8 went to the ED at Hospital A's Offsite ED on May 26, 2015.

An interview was conducted with S11Rev Cycle Representative on 6/11/15 at 9:00 a.m. She reported she was the representative that had initial contact with Patient #8 at Hospital A's Offsite ED on 5/26/15. She further reported her job entails when a patient presents to the ED, to initially obtain their name, date of birth and chief complaint. S11Rev Cycle Representative reported Patient #8 arrived in her registered booth on the evening of 5/26/15. The patient sat down in the chair and reported she was 9 months pregnant and she was dizzy. S11Rev Cycle Representative reported immediately S4RN came from the nurses' station and started speaking to the patient while hanging over the back of her and her chair (due to the location of the nurses' station and the registration area, admitting information obtained from the patient can be easily overheard from the nurses' station). S11Rev Cycle Representative reported she got up and hovered between the door to the registration area and the nurses' station to allow the patient and nurse some privacy. S11Rev Cycle Representative reported she did not hear the full conversation, but she did hear S4RN tell Patient #8 that the Hospital A's Offsite Campus ED did not have obstetric services and it would be better if she went to Hospital A's Main Campus ED. She further stated she had planned to register the patient in the Emergency Room Central Log when S4RN had finished speaking to the patient, but when she returned to her desk, the patient had left the ED.

An interview was conducted with S9Rev Cycle Representative on 6/10/15 at 3:00 p.m. She reported she was a clerk on the evening shift of 5/26/15. She went on to report 2 clerks work the evening shift in the ED at the Offsite location. She reported she had gone to the bathroom, but when she returned Patient #8 was sitting in a chair in the registration room. S9Rev Cycle Representative asked the patient if she had been helped and she said she had been helped already. She reported she heard S4RN instructed Patient #8 that Hospital A's Offsite location didn't have obstetrics services and it would be better to go home and call 911. S9Rev Cycle Representative further reported she did not hear S4RN try to convince the patient to have a medical screen prior to leaving the hospital or to stay at the hospital.

A phone interview was conducted with S4RN on 6/10/15 at 2:50 p.m. He reported he worked for an agency and was a contract nurse for the hospital assigned to work the ED at the Offsite location. He reported on 5/26/15 a clerk in the ED reported there was a 9 month pregnant patient, who was dizzy at the front desk. S4RN reported he immediately went to assess the patient. S8Physician was the ED physician on at the time and was reported saying,"Oh no, another transfer." S4RN report Patient #8 overheard S8Physician. Patient #8 immediately stated I will leave if I have to be transferred. S4RN reported he immediately explained to the patient they did not have obstetric services and it would probably take about 1 hour to be transferred to another hospital. S4RN further reported Patient #8 stated she would walk home and drive herself to Hospital C. S4RN reported he tried to persuade the patient to stay and to be seen by the physician, but she refused. S4RN further reported he told the patient, not to drive herself to the hospital, call 911, it would be safer. S4RN reported he could not convince the patient to stay in the ED and be assessed.

A phone interview was conducted with S8Physician on 6/11/15 at 8:45 a.m. He reported on the evening of 5/26/15 he was charting in the ED (Offsite location), at the desk, when he heard a clerk announce there was a 9 month pregnant dizzy women at the desk who wanted to talk to someone. S8Physician reported he made the comment they would probably need to transfer her. S8Physician further reported he had another patient to examine and went to see that patient and afterwards asked where the pregnant patient was located. He then was told the patient was tired and feeling better and decided she didn't want to check in and would follow up with her MD in the morning.

An interview was conducted with S7Tech on 6/11/15 at 1:00 p.m. S7Tech reported she was working in the ED at the Offsite location as a ED Technician on the evening of 5/26/15. She reported her job duties entails assisting the nurses with such tasks as taking the patients to the bathroom, feeding patients, and doing blood draws. S7Tech reported she did not hear the whole conversation with Patient #8 and S4RN. She further reported the only part of the conversation she heard was when S4RN told Patient #8 the Hospital A's Offsite location did not have obstetric services and it would be better if she went to Hospital A's Main Campus. When the surveyor questioned S7Tech if the tone of the conversation was S4RN was encouraging the patient to go to a different hospital or trying to get her to be seen at Hospital A's Main Campus location, she reported he was encouraging the patient to go to Hospital A's Main Campus ED.


2. Failing to ensure all agency ED (Emergency Department) hospital nursing staff were trained on EMTALA regulations and policies for 3 out 3 agency nurses (S4RN, S14RN, S15RN) before working Hospital A's Offsite ED.

Review of the ED nursing schedule for Hospital A's Offsite location for May 2015 revealed three (3) contract agency nurses were working the ED consistently; S4RN, S14RN and S15RN.

Review of the hospital's Core Orientation agenda revealed no documentation that EMTALA training occurred in the hospital core orientation.

Review of the ED's Orientation check-off list for agency nurses revealed no documentation of EMTALA training occurred during the one buddy shift the agency nurses have during their orientation.

Review of the personnel records for S4RN, S14RN and S15RN revealed no training was provided by the hospital to the nurses related to EMTALA regulations/policies.

An interview was conducted with S16 In-house Pool Staff Coordinator and S17Lead Administrator Coordinator on 6/11/15 at 10:30 a.m. They reported the agency nurses get 1 day of the hospital core orientation, 2 days of training on the computer system and 1 shift with a buddy nurse, where they are trained by a nurse on the specific unit the agency nurse will work. S16 and S17 reported the agency nurses do not get EMTALA training in the Core Orientation

An interview was conducted with S2RN, Emergency Room Director for Hospital A's Offsite location on 6/11/15 at 11 a.m. She confirmed the agency nurses did not have EMTALA training during their scheduled buddy shift with a staff nurse.