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Based on interviews, record reviews, policy and procedure reviews, internal investigation documents review and the emergency department (ED) log review, it was determined the facility failed to comply with 42 CFR 489.20(r)(3), 42 CFR 489.24(r) and 489.24(c), and failed to ensure the facility policy and procedure "EMTALA Guidelines For Emergency Department Services" was followed in regard to ensuring all individuals who present to the facility seeking assistance were provided an appropriate medical screening exam and their name placed in the ED central log.

Patient #1 was transported to the facility ED on 06/01/12 by ambulance, in need of a medical screening exam. Upon arrival to the facility the ED Physician and the ED Registered Nurse (RN) informed the ambulance crew that Patient #1 was not supposed to be transported to Hospital #1. The ED Physician and the ED RN informed the ambulance crew that Patient #1 was supposed to be seen at another facility's ED (Hospital #2). The ambulance crew left with Patient #1 without receiving a medical screening exam (MSE).

Patient #1 arrived in Hospital #2's ED on 06/01/12 at 6:18 PM by ambulance. Documentation revealed Patient #1 was triaged at an acuity level of 2 with an oxygen saturation level of 90%. At Hospital #2's ED a MSE was conducted and a nebulizer treatment was administered at 7:24 PM along with Solu-Medrol 125 mg intravenously. Documentation on the "Emergency Physician Record" by the Physician Assistant (PA) revealed a diagnosis of Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Patient #1 was admitted to Hospital #2. Interview with the Physician Assistant (PA) at Hospital #2's ED on 06/07/12 at 4:45 PM revealed he provided the MSE for Patient #1 on 06/01/12. The PA stated it was his opinion that Patient #1 needed to be seen in the ED on 06/01/12 and Patient #1 was emergent. He stated Patient #1 needed immediate interventions to stabilize him/her and Patient #1 was hypoxic (deprived of adequate oxygen supply). Review of the ED log from Hospital number 1 revealed Patient #1's name did not appear on the ED log for the date of 06/01/12.

The facility had identified the EMTALA violation prior to the initiation of the investigation. Corrective actions were implemented to include internal investigation, policy and procedure review, and training of the staff.

Based on interviews, policy and procedures review, the Emergency Department (ED) log review, and review of the internal investigation documents, it was determined the facility failed to ensure all individuals who came to the facility seeking assistance, were placed in the central log for one patient (#1) in the selected sample of 21. Additionally, the facility failed to follow their policy "EMTALA Guidelines For Emergency Department Services" related to patients being entered into the ED log.

Findings include:

A review of the facility policy "EMTALA Guidelines For Emergency Department Services" last revised November 2011 revealed, all patients presenting to the Emergency Department and seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay. All patients shall receive a medical screening exam. A medical screening exam should include at a minimum an Emergency Department log entry including disposition of patient.

A review of the facility's internal investigation revealed Patient #1 was transported to the facility ED on 06/01/12 by ambulance, in need of a medical screening exam. Upon arrival to the facility the ED Physician and the ED Registered Nurse (RN) informed the ambulance crew that Patient #1 was not supposed to be transported to the facility. The ED Physician and the ED RN informed the ambulance crew that Patient #1 was supposed to be seen at another facility's ED. The ambulance crew left with Patient #1 without receiving a medical screening exam.

Review of the ED log revealed Patient #1's name did not appear on the ED log for the date of 06/01/12.

Interview on 06/06/12 at 9:10 AM with the Administrator revealed Patient #1's name did not appear on the ED log. She stated all patients who present to the ED should be entered on the ED log.

The facility reviewed their policies and procedures and bylaws; informed and involved the Governing Board of the situation; and provided mandatory training to all ER staff on medical screening exams in the ER and completing the ER Log.

The facility had identified the EMTALA violation prior to the initiation of the investigation. Corrective actions were implemented to include internal investigation, policy and procedure review, and training of the staff.

Based on interviews, record reviews, policy and procedures review, and internal investigation review, it was determined the facility failed to ensure one patient (#1) in the selected sample of 21, received an appropriate medical screening exam (MSE) within the capability of the hospital's emergency department (ED). Additionally, the facility failed to follow their policy and procedure "EMTALA Guidelines For Emergency Department Services" resulting in Patient #1 not receiving a MSE prior to the ambulance transporting Patient #1 to another ED(Hospital #2).

Findings include:

A review of the facility policy "EMTALA Guidelines For Emergency Department Services" last revised November 2011 revealed "All patients presenting to the Emergency Department and seeking care, or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay. All patients shall receive a medical screening exam. A medical screening exam should include at a minimum an Emergency Department log entry including disposition of patient, patient's triage record, vital signs, history, physical exam of affected systems and potentially affected systems, exam of known chronic conditions, necessary testing to rule out emergency medical conditions, notifications and use of on-call personnel, notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary, vital signs upon discharge or transfer, and complete documentation of the medical screening exam."

A review of the facility's internal investigation revealed Patient #1 was transported to Hospital #1's ED on 06/01/12 by ambulance, in need of a medical screening exam. Upon arrival to Hospital #1, the ED Physician and the ED Registered Nurse (RN) informed the ambulance crew that Patient #1 was not suppose to be transported to Hospital #1. The ED Physician and the ED RN informed the ambulance crew that Patient #1 was suppose to be seen at another facility's ED (Hospital #2). The ambulance crew left Hospital #1 with Patient #1 without receiving a medical screening exam.

Interviews with the Paramedic on 06/06/12 at 3:00 PM and with the Emergency Medical Technician (EMT) on 06/06/12 at 4:05 PM and review of Patient #1's ambulance run sheet for 06/01/12 revealed, the ambulance was dispatched to a nursing facility (Patient #1's residence) on 06/01/12 at 4:12 PM. They revealed the nursing facility informed the ambulance crew that Patient #1 had gotten upset and agitated over a bath, complained of having difficulty with breathing, and requested to go to a hospital. The ambulance crew obtained an oxygen saturation level and it was 90% on room air. Oxygen was administered by nasal cannula on 3 liters and Patient #1's oxygen saturation level improved to 97%. It was determined by the ambulance crew that Patient #1 was non-emergent and would be transported to Hospital #1's ED as per the ambulance service's protocols. Report was called to Hospital #1's ED. Upon arrival to Hospital #1, they unloaded Patient #1 and entered Hospital #1. They were met by the ED Physician and the ED RN who informed them that arrangements had been made to transport Patient #1 to Hospital #2 and they would not be seeing Patient #1 at Hospital #1's ED. The Paramedic stated that the ED Physician and ED RN were adamant that they were in the wrong place. The EMT stated the ED Physician instructed them to take Patient #1 to Hospital #2 because that was where he would be sending Patient #1. The ambulance crew placed Patient #1 back into the ambulance and transported him/her to Hospital 2's ED. The Paramedic and the EMT revealed no examination was conducted of Patient #1 at Hospital #1.

Interview with the ED Physician on 06/06/12 at 4:30 PM revealed he was on duty when Patient #1 was transported to Hospital #1's ED on 06/01/12. He stated he was aware that the ambulance was dispatched to the nursing home to pick up Patient #1 and was to transport Patient #1 to Hospital #2's ED. The ambulance crew brought Patient #1 to Hospital #1's ED on 06/01/12, instead of Hospital #2. The ED Physician stated he talked to the patient, evaluated the situation and knew the situation. He felt he facilitated the care needed, but he did not interview Patient #1 or do an examination.

Interview with the ED RN on 06/07/12 at 1:45 PM revealed she was present on 06/01/12 when Patient #1 was transported to Hospital #1's ED. She stated when Patient #1 arrived at Hospital #1's ED, Patient #1 was not registered and/or examined in Hospital #1's ED. The ED RN stated Patient #1 was suppose to be seen in Hospital #2's ED for evaluation. The ambulance crew placed Patient #1 back on the ambulance and transported Patient #1 to Hospital #2.

Review of Patient #1's ED medical record from Hospital #2 revealed Patient #1 arrived in Hospital #2's ED at 6:18 PM on 06/01/12 by ambulance. Documentation revealed Patient #1 was triaged as an acuity level 2 (on a scale of 1 to 5 with 1 being the most urgent and five being the least urgent). Patient #1's blood pressure was 135/84, pulse was 87, respirations were 18 and oxygen saturation level was 90% on room air. A MSE was performed that included a physical examination, cat scan of the chest, laboratory work, and x-rays. A nebulizer treatment was administered at 7:24 PM along with Solu-Medrol 125 mg intravenously. Documentation on the "Emergency Physician Record" by the Physician Assistant (PA) revealed a diagnosis of Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Patient #1 was admitted to Hospital #2.

Interview with the PA from Hospital #2's ED on 06/07/12 at 4:45 PM revealed he provided the MSE for Patient #1 on 06/01/12. He stated when Patient #1 was brought to the ED he/she was having respiratory difficulty. Patient #1's oxygen saturation level was 90%, the arterial blood gases were slightly abnormal, and Patient #1 had a "significant urinary tract infection." The PA stated Patient #1 improved with oxygen, a nebulizer treatment, and Solu-Medrol. The PA revealed it was his opinion that Patient #1 needed to be seen in the ED and that Patient #1 was emergent. He stated Patient #1 needed immediate interventions to stabilize him/her and Patient #1 was hypoxic (deprived of adequate oxygen supply).

An interview with the ED Medical Director on 06/08/12 at 8:30 AM revealed Patient #1 should have been provided with a MSE at Hospital #1. He stated once Patient #1 was brought to the grounds of Hospital #1 it was the facility's obligation to provide a MSE.

The facility reviewed their policies and procedures and bylaws; informed and involved the Governing Board of the situation; and provided mandatory training to all ER staff on medical screening exams in the ER and completing the ER Log.

The facility had identified the EMTALA violation prior to the initiation of the investigation. Corrective actions were implemented to include internal investigation, policy and procedure review, and training of the staff.