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Based on interview and record review the facility failed to follow the policies and procedures and did not examine one individual (Patient #23) out of 23 patient medical records reviewed from July to December, 2010. The facility sees an average of 719 emergency cases per month.
Findings included.

1. Record review of the Administrative Policy & Procedure Manual, SUBJECT: Patient Transfers and Emergency Medical Treatment and Active Labor Act (EMTALA), SECTION: Risk Management states, in part:
PURPOSE To comply with federal regulations regarding the treatment of persons in emergency situations by ensuring that all persons are provided care for emergency medical conditions, without discrimination . . .
POLICY All persons receive an appropriate medical screening examination (MSE) within Hospital's capability to determine whether or not an emergency medical conditions exists.
E. Withdrawal of Request For Examination or Treatment
If a patient refuses or withdraws his or her request for examination or treatment, Emergency Department staff will discuss the medical issues related to a voluntary withdrawal. During the discussion, the Emergency Department staff member will:
1. Offer the patient further medical examination and treatment as may be required to identify and Stabilize an Emergency Medical Condition;
2. Inform the patient of the benefits of the examination and treatment, and of the risks of withdrawal prior to receiving the examination and treatment;
3. Take all reasonable steps to obtain the patient's signature on the Hospital's AMA (against medical advice) form.
4. If a patient leaves the Hospital without notifying Hospital personnel, this should be documented on the Hospital's AMA form. The documentation must reflect that the patient had been at the Hospital and the time the patient was discovered to have left the premises.

2. Hospital video camera footage for 12/13/10 at 12:45 AM to 1:45 AM was viewed in the facility room with the hospital Facilities Manager. The footage showed two people (Patient # 23 and her companion) arriving at the admission desk. The two individuals walked down the hall to a red phone located outside the doors to the OB (Obstetrical) Department. Patient #23 picked up the red phone and talked, making motions across her abdominal area. After hanging up, patient # 23 and her companion walked away from the red phone and down the hall. Patient #23 walked out the emergency room doors while her companion stopped briefly at the admissions desk before leaving the emergency room entrance. Video camera footage from camera # 6 on 12/13/10 from 1:00 AM to 2:30 AM did not show the OB doors opening or anyone coming out the doors attempting to look for patient # 23. Patient #23 was not logged in, triaged, or examined as required by hospital policy.

3. During an interview on 12/21/10 at 9:38 AM Staff L, Admissions Clerk stated he/she remembered the events on 12/13/10 and was on duty when patient # 23 presented to the emergency department. Staff L stated Patient #23 said she had gone to a different hospital the night before because she was spotting and cramping. Patient # 23 told Staff L that she felt the other hospital didn't do anything so she came to Hedrick Medical Center. Staff L stated she directed Patient #23 and her companion to the red phone located outside the OB department and that a few minutes later, Patient # 23 left the Emergency Department (ED) but her companion stopped at the desk. Staff L stated she asked the companion if Patient # 23 wanted the ED to help out but the companion said no and left the ED. Staff L stated she doesn't know what EMTALA means and hasn't received any training.
4. Review of the personnel file for Staff C, RN, OB nurse showed she received her RN designation in 2009 and had been working in the OB Department since March of 2010. During an interview on 12/21/10 at 3:48 PM Staff C, RN said patient # 23 complained of abdominal pain and vaginal bleeding and that she directed patient # 23 to the hospital where her medical records were available. Staff C confirmed that she did not examine patient # 23.

Based on interview, record review, and observation, the facility failed to maintain a central log for patients presenting to the emergency department for care. This system failure and routine practice has evolved and allowed each department to maintain a log but does not combine the logs or maintain a central log for all patients that present to the emergency department. If the presenting patient is referred to another department for triage or a Medical Screening Exam (MSE) and leaves without being seen, there is no record of the patient presenting to the emergency department for tracking purposes and there is no information documented on a Left against Medical Advice form. The facility sees an average of 719 emergency cases per month.
Findings included:
1. During an interview on 12/20/10 at 11:30 AM, Staff P, Emergency Room (ER) Admissions Clerk stated that he/she greets everyone that presents to the ER for care. Staff P stated that if the potential patient is under 20 weeks pregnant, they are triaged and receive an MSE in the ER but if the patient is over 20 weeks pregnant they are sent to the red phone in the hall (around the corner and approximately 120 feet from the admission desk) for triage and MSE. Staff P stated the patient ' s information is logged in the obstetrics (OB) department and the paperwork is then returned to the Admissions Clerk for processing. Staff P stated he/she does not log each individual as they present.

2. During an interview on 12/21/10 at 9:38 AM Staff L, ER Admission Clerk stated he/she remembered two people (Patient #23 and a companion) presented to the ER for care early in the morning on 12/13/10. Staff L stated patient #23 was over 20 weeks pregnant so he/she sent them to the red phone outside the OB Department. Staff L stated she did not log Patient #23 into the ER log or contact the OB Department to notify them of Patient #23's arrival. Staff L stated a short while later he/she observed Patient # 23 and her companion leaving. Staff L said he/she asked if they wanted to be seen by the ER physician but patient # 23's companion refused.

3. Review of the ER and OB Logs dated 12/12/10 and 12/13/10 did not show documentation indicating Patient # 23 had presented to the ER or the OB Departments. A search in the electronic data system for all hospital departments did not generate a profile for Patient #23.

4. Review of the Administrative Policy & Procedure Manual, SUBJECT: Patient Transfers and Emergency Medical Treatment and Active(sic) Labor Act (EMTALA), SECTION: Risk Management, dated 08/2010 states, in part:
D. No delay in the Medical Screening Examination or Stabilizing Treatment
4. The registration of a patient who comes to the Emergency Department shall be conducted so as to not discourage patients from remaining to receive an MSE and Stabilizing treatment, if necessary.
V. Central Log
Each department that receives individuals who may come seeking emergency care shall maintain a central log that documents the following information:
A. Patient identification;
B. Time of presentation to the specific department;
C. Mode of arrival;
D. Whether medically screened or referred to another department for medical screening; and
E. Whether the patient refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, Stabilized and transferred, discharged, or other disposition.
The purpose of the log is to track the care provided to each individual who comes to the Emergency Department seeking emergency medical care. If a patient presents for emergency medical treatment and does not have a scheduled appointment, he/she is entered into the log. If a patient presents and has a scheduled appointment, he/she is not entered onto the log.

6. Record review of POLICY #: ER/10, SUBJECT: EMERGENCY ROOM LOGBOOK states, in part:
STATEMENT OF PURPOSE:
The Emergency Room Log book will record all persons seeking emergency care.
LOG BOOK PROCEDURE
A. Complete the ER log as indicated for each patient.

The hospital staff failed to follow this policy and did not document in the ER or OB log as required.

Based on observation, interview and record review the facility failed to provide a Medical Screening Exam (MSE) for one patient (Patient #23) out of 23 patient medical records reviewed from July to December of 2010. The facility sees an average of 719 emergency cases per month.

Findings included:

1. Review of Policy #ER/7, titled, "Presentation of Patients to the Emergency Room Desk", dated 09/27/02 and revised on 04/04/05, showed, in part: . . . when a patient presents to the Emergency Department desk, the secretary will immediately call back to the nurses' station and request a nurse to triage the patient (page 1 of 1).

2. Review of POLICY #: ER/9, SUBJECT: Emergency Room Record states, in part:
STATEMENT OF PURPOSE:
A permanent record of all Emergency Room patients and the care rendered will be established.

PROCEDURE:
A record will be completed by the licensed nurse and physician and will be maintained by the Medical Records Department of the hospital. It will consist of but may not be limited to the following:
1. Patient identification and information. If unobtainable, the reason is documented.
2. Obtain written consent for treatment and witness the signature.
3. Time and means of arrival.
4. Pertinent history of the illness or injury.
5. Physical findings.
6. The patient's vital signs.
7. The emergency care given, prior to arrival.
8. Diagnostic and therapeutic orders.
9. Clinical observations.
10. The results of treatment.
11. Reports of procedures, tests and results, time of completion.
12. Diagnostic impression.
13. The final disposition of the patient.
14. Disposition of patient's valuables.

The hospital staff failed to follow these policies and patient # 23 left the emergency room and OB department without receiving an examination.

3. During an interview on 12/20/10 at 11:17 AM, Staff F Registered Nurse (RN) stated that all patients who come to the Emergency Room (ER) are seen by the ER RN. If the patient is greater than 20 weeks pregnant and presents with a pregnancy related complaint, the patient is placed in a wheelchair and taken directly to the Obstetric (OB) Department, if the patient appears stable to the nurse.

4. During an interview on 12/21/10 at 9:38 AM Staff L, ER Admission Clerk stated she remembered two people (Patient #23 and a companion) presented to the ER for care early in the morning on 12/13/10. Staff L stated patient #23 was over 20 weeks pregnant so he/she sent them to the red phone outside the OB Department. Staff L stated a short while later he/she observed Patient # 23 and her companion leaving. Staff L said he/she asked if they wanted to be seen by the ER physician but patient # 23's companion refused.

5. Observation on 12/20/10 at 1:25 PM of the hospital security camera video of the ER registration area, showed on 12/13/10 at approximately 1:00 AM, two people entering the hospital through the exterior emergency entrance and standing in front of the registration desk. In the video it appeared that patient # 23 was speaking to the registration clerk when the registration clerk pointed down the hall, in the direction of the OB Department. Patient #23 and her companion were then seen leaving the ER registration desk walking in the direction of the OB Department. Patient #23 and her companion stopped at the red phone located in the hall outside of the OB department. Patient #23 appeared to be speaking into the phone. At 1:08 AM, Patient #23 hung up the phone and began walking back in the direction of the ER registration desk.
6. Observation at the nurse ' s station inside the OB Department on 12/20/10 at 3:00 PM showed that OB nursing staff could see on the video monitor anyone who was talking on the red phone located outside the OB department.

7. During an interview on 12/21/10 at 3:35 PM, Staff N, Registered Nurse (RN) stated that the obstetric (OB) security video monitor which shows the hallway and red phone located immediately outside of the OB main entrance stays on at all times unless the electricity is out.

8. During an interview on 12/20/10 at 4:16 PM Staff C, RN, OB nurse stated she advised Patient #23 during a telephone call (on 12/13/10 around 1:00 AM) that she should go to her home town hospital where her records were located. Staff C stated that following the call with Patient #23, she had a conversation with Staff D, RN in the nursery. Staff C stated after taking with Staff D, she realized Patient #23 could have been calling from the red phone in the hall, outside the OB doors and went out to look for her (Patient #23), but didn't see her.

9. Observation on 12/20/10 at 1:25 PM of the hospital security camera video of the main OB entrance showed that no OB staff exited the OB Department on 12/13/10 between 1:00 AM and 2:30 AM (Patient #23 and her companion left the emergency entrance of the hospital at 1:08 AM on 12/13/10).


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