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Based on document review and interview, the hospital failed to ensure compliance with requirements at 42 CFR 489.24 as evidenced by the deficient practice cited at 42 CFR 489.24(a) and 489.24(c).

The hospital's emergency department (ED) failed to ensure every patient that presented to the ED received a medical screening examination (MSE).

Based on document review and interview, the hospital failed to maintain a central emergency department (ED) log which accurately tracked the care of patients who presented to the ED, for 1 of 20 patients reviewed (P1), who presented to the ED for evaluation of an emergency medical condition (EMC).

Findings include:

Review of the hospital's ED log did not indicate that P1 presented to the ED, seeking emergency medical treatment on May 21, 2018. P1's medical record contained documentation that P1 was triaged at 10:10 a.m. but there was no further documentation and no entry made in the ED log.

When interviewed on November 16, 2018, at 4:06 p.m. P1 said family told him to be seen in the ED because P1's eyes were yellow. P1 contacted his physician in another community and was told to be seen by a physician at the local ED. P1 presented to the ED on May 21, 2018. P1 asked to speak to the physician in charge. Registered Nurse (RN)-A left P1 to speak to a physician and came back and told P1 he would need to find a primary physician. RN-A gave P1 contact information for the clinic. P1 was not offered a medical screening examination and he left the ED.

When interviewed on November 20, 2018, at 10:38 a.m., RN-A said she was the triage nurse on May 21, 2018. RN-A said P1 came into the ED sometime in the morning. P1 requested the ED physician contact his primary physician in another community. RN-A obtained P1's vital signs and assessment. RN-A spoke to the ED physician and informed P1 the physician would need to provide a MSE. Following the MSE, the physician would contact his physician in the other community. RN-A said P1 refused to be examined and be roomed in the ED. RN-A encouraged P1 to be examined by the ED physician, she felt he should be examined. P1 continued to refuse an examination in the ED. P1 asked for alternatives to the examination. RN-A told P1 he should find a primary physician and be examined. RN-A provided P1 with the main clinic's contact information. P1 left the ED. RN-A documented in the electronic medical record the triage data and canceled the ED visit in the electronic medical record. Later, RN-A was told by canceling the appointment in the electronic medical record, P1's information was not carried over into the ED log. RN-A said she should have entered P1 into the record as left without being seen (LWBS).

When interviewed on November 20, 2018, at 1:00 p.m., the Director of the Emergency Department said P1's visit to the ED on May 21, 2018, was investigated in June 2018, when the hospital became aware of P1's ED visit. It was discovered staff sometimes canceled the ED visit in the patients electronic medical record when patients LWBS or against medical advise (AMA). When the visit was canceled, the patient information from the ED visit was not transferred into the ED log. Staff education was provided to ensure the correct documentation in the patients ED record.

Review of the hospital's policy and procedure titled EMTALA Compliance Enterprise, with a revision date of January 5, 2018, stated, a central log on each individual that came to the dedicated ED seeking treatment would be maintained. The log would indicate whether the individual refused treatment, was refused treatment and the reason for the refusal, was admitted and treated or stabilized and transferred or was discharged.

Review of the ED staff meeting education dated June 13, 2018, stated LWBS and AMA documentation was required to be completed in the electronic medical record. The nurse should provide a written note of the circumstances for the patient leaving the ED without a medical screening examination.

Based on documentation review and interviews, the hospital failed to provide all patients who presented to the emergency department (ED) with an appropriate medical screening examination (MSE) for 1 of 20 (P1) patients who presented to the ED.

Findings include:

Review of P1's ED triage documentation dated May 21, 2018, at 10:10 a.m., revealed P1 presented to the ED by personal vehicle and provided triage. P1's said family noticed he was yellow and told him to be seen in the emergency department (ED). P1 was told by a physician in another community to request to see a specific physician in the ED. P1 had no other complaints. RN-A obtained P1's vital signs. P1's heart rate was 70 beats per minutes (BPM), respiration 16, temperature 97 degrees Fahrenheit, blood pressure 177/94 when sitting. On room air, P1's oxygen saturation was 97 %. RN-A completed the triage assessments that included a psychosocial and infection disease exposure assessment and Glasgow score. RN-A scored P1 at three or urgent, using the acuity Emergency Severity Index (EMS) on a scale from one to five. A score of one required immediate screening to five as non-urgent. The record indicated RN-A assigned a physician and an ED room for P1. There was no further documentation including a medical screening examination and disposition of P1.

Review of P1's medical record indicated P1 presented to the local walk-in clinic on May 22, 2018, at 10:15 a.m. with the primary concern of jaundice. P1's skin and eyes were yellow. P1 had no other complaints. The physician provided a complete system assessment, and ordered a complete blood count (CBC), basic metabolic panel (BMP), urinalysis, serum lipase and an abdominal ultrasound (US). P1's urine was brown and cloudy. P1's bilirubin was 20. 5, with normal range of 0.2 to 1.2, had an elevated alkaline phosphatase of 402, with a normal range of 30 to 150, minimally elevated liver function tests (LFT)'s and a normal lipase. The abdominal US showed non-specific dilatation of the common bile duct. The physician recommended P1 return for a multi-phase contrast enhanced CT scan for further evaluation and assessment of the distal biliary duct and pancreas. P1 scheduled the CT scan for May 24, 2018. P1's discharge diagnoses from the walk-in clinic included severe jaundice, hyperbilirubinemia or elevated bilirubin and common bile duct dilatation.

P1's medical record established the CT scan on May 24, 2018, showed diffuse dilation of the intrahepatic and extrahepatic biliary ducts or tubes that carry bile between the liver, gallbladder and small intestine extending to the region of the ampulla or area formed by the union of the pancreatic duct and common bile duct.

On May 30, 2018, at 5:18 p.m. P1 presented to a second hospital's ED for complaints of jaundice and weight loss. P1's bilirubin was more elevated at 23.9. Due to P1's significant jaundice, P1 was admitted to the hospital for on-going evaluation and an endoscopic procedure to examine the liver, bile ducts and pancreas. During the procedure, multiple stones were removed from P1's common bile duct. P1 discharged from the hospital on June 3, 2018, with discharge diagnoses of obstructive jaundice with underlying non-alcoholic steatohepatitis or fatty liver disease and acute kidney injury.

When interviewed on November 16, 2018, at 4:06 p.m. P1 said family told him to be seen in the ED because P1's eyes were yellow. P1 contacted a physician in another community that he went to approximately fifteen years prior. That physician also told the patient to be assessed in the ED. P1 presented to the ED on May 21, 2018. P1 asked to speak to the physician in charge. Registered Nurse (RN)-A left P1 to speak to a physician and came back and told P1 he would need to find a primary physician. RN-A gave P1 contact information for the clinic. P1 was not offered a medical screening examination and he left the ED.

When interviewed on November 19, 2018, at 3:25 p.m., the ED Chief of Service said triage alone was not the MSE. Staff were encouraged to have conversations with patients when they were attempting to leave the ED without a MSE. If not possible to encourage the patient to stay, staff should document they educated the patient on the risks of leaving without an examination.

When interviewed on November 20, 2018, at 10:38 a.m., RN-A said she was the triage nurse on May 21, 2018. RN-A said P1 came into the ED sometime in the morning. P1 provided RN-A with a first name of a physician he was to see in the ED. There was no physician in the ED or in the hospital by the name provided by P1. RN-A obtained P1's vital signs and triage assessment. RN-A spoke to the ED physician and informed P1 the physician would need to provide a MSE. Following the MSE, the physician would contact his physician in the other community. RN-A said P1 refused to be examined and be roomed in the ED. RN-A encouraged P1 to be examined by the ED physician, she felt he should be examined. P1 continued to refuse an examination in the ED. P1 asked for alternatives to the examination. RN-A told P1 he should find a primary physician and be examined. RN-A provided P1 with the main clinic's contact information. P1 left the ED. RN-A agreed there was no documentation in P1's medical record that P1 left without being seen (LWBS) or evidence RN-A discussed the risks of leaving the ED without a MSE.

When interviewed on November 20, 2018, at 1:00 p.m., the Director of the Emergency Department said P1's visit to the ED on May 21, 2018, was investigated in June 2018, when the hospital became aware of P1's ED visit. There was documentation of P1's triage with a triage score of 3, but no further documentation of whether P1 was offered or refused a MSE. All staff have been educated to document when a patient LWBS or AMA and that the patient was provided the risks of not being provided a MSE.

Review of the hospital's policy and procedure titled EMTALA Compliance Enterprise, with a reviewed/revised date of January 5, 2018, stated, all individuals presenting to the dedicated ED seeking emergency care, shall receive a medical screening examination by a qualified medical person to determine if an emergency medical condition exists. The policy also established if an individual voluntarily withdrew the request for an examination or treatment, an appropriately trained individual of the ED staff would discuss the benefits of the examination and treatment and the risks of withdrawal prior to receiving the examination and treatment. This should be documented.

Review of the hospital's policy and procedure titled EMTALA Compliance Enterprise, with a revision date of January 5, 2018, stated, a central log on each individual that came to the dedicated ED seeking treatment would be maintained. The log would indicate whether the individual refused treatment, was refused treatment and the reason for the refusal, was admitted and treated or stabilized and transferred or was discharged.

Review of the ED staff meeting education dated June 13, 2018, stated LWBS and AMA documentation was required to be completed in the electronic medical record. The nurse should provide a written note of the circumstances for the patient leaving the ED without a medical screening examination.