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Based on document review and interview, the hospital failed to ensure patient #1 received a medical screening exam and was transferred according to facility policy, resulting in the potential for patient harm. See findings cited at C 2405, C 2406 and C 2409.

Based on document review and interview, the facility failed to maintain a central log on each individual who comes to the emergency department (ED) for one of one patient (Patient #1), seeking medical assistance resulting in the potential for unmet patient needs and poor patient outcomes. Findings include:

On 9/28/15 at 1100 during review of the central log, patient #1 name was noted to be absent from the ED Log. Interview with staff A on 9/28/15 at 1100 confirmed that the ED staff spoke with the patient (Patient #1) upon arrival, encouraging him to go to another facility and that the patient (Patient #1) was never entered into the ED log.

Based on document review and interview, the facility failed to perform a medical screening examination (MSE) on an individual that came to the facility (and subsequently was sent to Facility B) (patient #1) resulting in the potential for a less than optimal patient outcome. Findings include:

On 9/28/15 at 1630 a review of the information regarding the patient (Patient #1) referred to in the complaint was conducted. The patient (#1) was never registered nor admitted into the emergency department for facility A, nor was he listed on the ED log. A review of the medical record for Patient #1 from Facility B took place. The patient was a 56 year old male who had presented with mild to moderate back pain and weakness. He had a history of back pain for the last three days and progressing renal failure (BUN (blood urea nitrogen) 134 mg/dl [normal 8-21] and Creatinine 7.47 mg/dl [normal 0.90-1.50] both laboratory tests measure kidney function). Patient #1 had recently completed Cipro (an antibiotic), treatment for hemorrhoids and "prostatitis." Patient #1 was accompanied to both emergency departments (facility A and facility B) by his wife. Patient #1's family physician had ordered laboratory testing to be done on 9/1/15. Results of that testing arrived to the physician late on 9/1/15. Patient #1's physician called Patient #1 at around 2200 and instructed him to report directly to Facility A's ED (emergency department). Patient #1 arrived to Facility A as directed by his physician, however, a nurse came out to the waiting room and suggested that the patient go to Facility B since they don't provide dialysis at Facility A.

On 9/28/15 at 1830 an interview with one of the two ED nurses on duty the night of 9/1/15 took place. An RN, (Staff J) took report from Patient #1's family physician, who indicated that he was concerned about Patient #1's declining condition and his critical laboratory results (renal failure) and was sending him in to the ED to be evaluated. Patient #1's physician indicated that if the ED physician, (Staff L) had any questions to call him. Staff J indicated that she relayed this information to Staff L. Later Staff L told Staff J that, "we shouldn't see that patient here." Staff J said that Staff L repeated it again, about an hour later. Both times she told Staff L that the ED had to see the patient when he comes in. Staff J said that she was occupied with a woman in labor when Patient #1 arrived to facility A in the waiting area. Staff J said the ED physician, staff L instructed the other nurse (staff K) to go out to the waiting room and tell the patient to go to [Facility B], where they have dialysis. Staff J was asked when and how often she has EMTALA training, she replied, "every year and just a few weeks ago."

On 9/28/15 at 2030, the second of two ED nurses (staff K), who was on duty at facility A on the evening of 9/1/15, was interviewed. Staff K indicated that registration let him know when the patient #1 had arrived, the Patient was never registered. The physician declined to speak with patient #1 however directed the nurse, Staff K to go out to the waiting area and tell patient #1 that he (the doctor staff L) recommended that he go directly to facility B. Staff K said the ED physician Staff L directed him to tell the patient that, "given his signs and symptoms it would be better for him to go to the [other facility B]" . Patient #1 asked staff K why, to which staff K replied, "The doctor thinks it better for your condition." Staff K said the patient thanked him and left with his wife to drive to Facility B. Staff K was asked whether the patient was registered, had been triaged, assessed or had a medical screening exam, to which Staff K replied, "no." Staff K was asked whether the physician, staff L evaluated Patient #1, to which staff K said, "No." Staff K was asked regarding their most recent EMTALA training to which he replied that he had it in March 2015 and again in September 2015, but he thought the doctor's order superseded the EMTALA rules, so he didn't question it. Staff K said he knows better now. Staff K was asked whether this scenario of directing patients to other hospitals or EDs happened often, to which he replied, "This was the only time."
On 9/29/2015 at 1200, a review of the facility's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA) dated 9/23/15," reads, "Any individual who is not already a patient and presents to the hospital or in an ambulance will be provided an appropriate medical screening examination regardless of ability to pay ... after examination if it is determined that an individual has an emergency medical condition, the hospital will provide, within the staff and facilities available at the hospital for such further medical examination and treatment as may be required to stabile the medical condition or else provide for the transfer of the individual to another medical facility, In no event will an individual with an emergency medical condition who present at the hospital be discharged until the patient ' s emergency medical condition is stabilized ... "

Based on document review and interview, the facility failed to transfer a patient (patient #1) who had low blood pressure, in a safe manner resulting in the potential for patient harm. Findings include:

On 9/28/15 an interview with Staff B, Chief Nursing Officer regarding the incident in the ED on the night of 9/1/15. Staff B was asked whether ED staff followed their policy for appropriate medical screening exam, stabilization treatment or appropriate transfer of patient #1 to which she replied, "no." Staff B indicated that the facility conducted a complete investigation of the incident and interviewed all staff and the patient involved. Staff B read the detail of their Patient #1 interview and said that the patient #1 and his wife drove the approximate one hour drive to facility B and during that drive between emergency departments, law enforcement stopped patient #1 due to erratic driving. On 9/28/15 at 1630 a review of the information regarding the patient referred to in the complaint was conducted. The patient (#1) arrived at facility B with a blood pressure of 81/61 with "poor oral intake and decreased urination." Facility B's ED started two IVs (intravenous fluid infusion) and infused three liters of fluid. Patient #1 had also reported "feeling weak and dizzy." The patient was admitted to facility B's "critical care" and was started on dopamine.