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Based on observation, record review, review of policies/procedures, 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 3 of 3 days of on-site survey (December 10-12, 2012).

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 enforce their policy/procedure regarding providing all patients presenting to the emergency department with information on their right to a medical screening examination and the facility's participation in the State Medicaid program (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).

Based on observation and staff interview, the hospital failed to provide all patients presenting to the emergency department with information regarding their right to a medical screening examination and the facility's participation in the State Medicaid program during 1 of 1 emergency department observation (12/11/12). This failure created the potential for patients to be uninformed of their rights regarding examination and treatment for emergency medical conditions.

Findings include:

Observation of the emergency department on the afternoon of 12/11/12, showed no signage regarding the patient's right to a medical screening examination and the hospital's participation in the Medicaid program in emergency department examination rooms, triage areas, and treatment areas.

During an interview at the time of the observation, an emergency department management/administrative staff member (#1) verified signage existed only in the waiting room. The staff member confirmed many patients arrive or present for emergency services/care and staff place them immediately in an examination/treatment/triage area, and the patients would not receive information regarding their right to examination and the hospital's Medicaid participation.

Based on record review, review of policies/procedures, and staff interview, the hospital failed to complete a medical screening examination for 3 of 5 patients (Patient #3, #4, and #14) who presented to the emergency department for emergency care/services. Failure to identify the individual's chief complaint, presenting signs and symptoms, conduct appropriate triage to determine need for timely examination and treatment, and completion of a medical screening examination to determine the existence of a medical emergency, placed Patient #3, #4, and #14 at risk for leaving the emergency department in an unstable condition and at risk for further medically related harm/complication(s).

Findings include:

Review of hospital policies/procedures occurred December 10-11, 2012, and included the following: "Emergency Center [EC] Records, Original Date: 07/81, Revised Date: 12/04. . . . Purpose: To maintain accurate and timely patient medical records. An EC EMR [emergency medical record] is to be completed on all persons cared for by EC personnel. This includes patients who left the EC without being evaluated by EC MD [medical doctor]. Documentation will be done as soon as possible after information is obtained and/or changes occur. . . . If the registered patient is not treated, document reason for no treatment given and have patient complete 'Leaving before being seen' form."
"Patient Leaving Emergency Center Prior to Medical Screening Exam. Original Date: 01/00, Revised Date: 12/09. Policy: Patients choosing to leave after triage but prior to medical screening exam will be asked to sign the Release by Patient Leaving Before Medical Screening Examination (MR 750). Triage nurse or registration personnel may witness the document and sign accordingly."

Review of the emergency medical records for Patient #3, #4, and #14, occurred 12/11/12, and identified the following:

- Patient #3's emergency medical record showed the emergency department admitted the patient at 10:22 p.m. on 09/02/12, and at 10:29 p.m. on 09/02/12 placed the patient in a holding room. The record showed the patient "left without being seen," at 5:10 a.m. on 09/03/12 (over six hours after admission) as the identified discharge time.

The record lacked indication of Patient #3's means of arrival at the emergency department, the patient's chief complaint, presenting signs and symptoms, completion of a triage protocol, and completion of a medical screening examination to determine the presence/absence of a medical emergent condition.

An administrative emergency department staff person (#1) indicated, during an interview on the morning of 12/11/12, the hospital did not have additional information regarding Patient #3's admission to the emergency department, reason for presenting, and condition on leaving the department. The staff member indicated the discharge time may not be accurate. However, he/she could provide no additional information regarding Patient #3's waiting time in an emergency department holding room, including the lack of a signed/completed "Release by Patient Leaving Before Medical Screening Examination" form identifying emergency department personnel informed the patient of the risks of leaving prior to examination.

- The emergency medical record of Patient #4 showed the patient arrived at the emergency department by ambulance at 8:46 p.m. on 09/02/12 with a chief complaint of "arm and leg pain following a fall from his bike." The record indicated emergency department staff placed the patient in a holding room at 8:47 p.m. on 09/02/12. At 5:09 a.m. on 09/03/12 (more than eight hours after admission), the record indicated the patient left without being seen.

The record provided no information regarding Patient #4's condition on discharge, evidence of a medical screening examination, manner of discharge, and a signed/completed "Release by Patient Leaving Before Medical Screening Examination" form identifying emergency department personnel informed the patient of the risks of leaving prior to examination.

During an interview on the morning of 12/11/12, an administrative staff member (#1) indicated Patient #4 did not receive a medical screening examination and the hospital had no additional information regarding the above referenced emergency room admission.

-Review of Patient #14's emergency medical record showed the patient presented to the emergency department at 10:43 a.m. on 10/24/12. Triage information showed the patient's acuity as "urgent" and identified the patient's arrival complaint as "lower back pain." The record showed Patient #14 "left without being seen" at 4:23 p.m. on 10/24/12 (almost six hours after admission).

The record lacked evidence Patient #14 received a medical screening examination, the patient's condition on discharge, the manner the patient left the emergency department, and a signed/completed "Release by Patient Leaving Before Medical Screening Examination" form identifying emergency department personnel informed the patient of the risks of leaving prior to examination.

During an interview with an administrative staff member (#1) on the morning of 12/11/12, the staff member indicated the hospital has no protocol or procedure for follow-up with emergency room patients who leave prior to being seen.

Lack of follow-up to determine a patient's reason for leaving, current condition and possible need for return or treatment, does not provide the hospital information necessary to evaluate the effectiveness of the services provided, availability of adequate resources to meet patient needs/demands, and adequate monitoring of patients waiting for emergency care.