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Based on documentation and interviews, the hospital failed to ensure compliance with requirements of 42 CFR 489.24, when the hospital failed to provide an individual, who presented to the dedicated emergency department, with a medical screening evaluation resulting in deficient practice cited at 42 CFR 489.24 (a) A2406.

Based on observations during a tour of the emergency department (ED) on September 6, 2011, and interviews, the hospital failed to post conspicuously in the emergency department or in a place likely to be noticed by individuals waiting for examination and treatment in the emergency department signs specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment in the emergency room. Findings include:

A tour of the ED was conducted on September 6, 2011, at 1:30 p.m. It was observed a sign informing individuals of their EMTALA rights was posted on a wall in a hallway across from entrances into two of three ED department bays. Interview with Employee (A)/Registered Nurse and Employee (B)/Administrative nurse revealed patients can enter the ED department through the front entrance of the hospital, the ambulance garage, an additional door in the back of the hospital and the clinic entrance. Employee (A) indicated patients are usually directed immediately to an ED bay for triage and the facility rarely utilized a waiting room however, the waiting room for radiology and clinic waiting room could potentially be utilized for ED patients. No signs were posted by any doors or waiting rooms referencing EMTALA rights.

This information was verified by Employee (B) during the ED department tour on September 6, 2011.

Based on review of the central log and interviews, the hospital failed to enter on the central log 1 of 20 (#1) patient names that had presented to the emergency department seeking medical care. Findings include:

Interview with Patient #1 on 9/2/2011, at 11:35 a.m. revealed the patient had the TURP procedure on 8/3/2011, and the night of 8/5/2011 into 8/6/2011 (exact time unknown) he had been unable to urinate. Upon arrival to the emergency department Patient #1 said it had become difficult to ambulate due to the pain. At the back entrance to the emergency department Patient #1 said he was stopped by a nurse and told he could not be treated at the emergency department and would need to go to the facility where the surgery had been performed. He left the facility, returned home and contacted his surgeon who instructed him to go to another emergency department.

Employee (C)/nurse was interviewed on 9/6/2011, at 3:02 p.m. and indicated the following:
On 8/6/2011, at (exact time unknown) Patient #1 presented to the backdoor of the emergency department and Employee (C) told the patient Employee (D)/physician could not treat him at the emergency department and he would need to be seen where he had the surgery.

There was no documented record or emergency department (ED) log report of Patient #1 presenting to the emergency department on 8/6/2011.

Based on review of documentation, interviews and policy review, the hospital failed to provide a medical screening examination for 1 of 20 (#1) patients who presented to the dedicated emergency department. Findings include:

There was no documented record or emergency department (ED) log report of Patient #1 presenting to the emergency department at hospital #1 on 8/6/2011.

Interview with Patient #1 on 9/2/2011, at 11:35 a.m. revealed the patient had the TURP procedure on 8/3/2011, and the night of 8/5/2011 into 8/6/2011 (exact time unknown) he had been unable to urinate. Patient #1 contacted the surgeon and was advised to go to the nearest emergency department for a catheter placement. He indicated his spouse called the local emergency department and the nurse said she needed a physician's order to place a catheter and the patient was instructed to come to the emergency department. Upon arrival to the emergency department Patient #1 said it had become difficult to ambulate due to the pain. At the back entrance of the emergency department Patient #1 said he was stopped by a nurse and told he could not be treated at the emergency department and would need to go to the facility where the surgery had been performed. Patient #1 stated he was shocked the facility would not help him. He left the facility, returned home and contacted his surgeon who instructed him to go to another emergency department. The nearest emergency department was approximately a forty mile drive and Patient #1 indicated every bump in the road was agony.

Employee (C)/nurse was interviewed on 9/6/2011, at 3:02 p.m. and indicated the following:
Employee (C) was the triage nurse assigned in the ED on 8/6/2011 during the day shift. At (exact time unknown) Patient #1's spouse contacted Employee (C) by phone and explained the patient had a TURP (transuretral resection of the prostate) procedure on 8/3/2011, at a different facility. The spouse told Employee (C) Patient #1 had been unable to urinate since the previous night and the surgeon was contacted and recommended the patient be seen at the closest emergency department for a urinary catheter insertion. Employee (C) instructed Patient #1 to come to the emergency department and left a phone message with the surgeon to obtain an order for a catheter insertion. Employee (C) contacted Physician (D)/on-call physician to inform of Patient #1's status and pending arrival at the emergency department. Physician (D) informed Employee (C) she would not treat a surgical patient or place a catheter and to call Patient #1 at home and inform him to be seen where he had the surgery. At (exact time unknown) Patient #1 presented to the backdoor of the emergency department and Employee (C) told the patient Physician (D) could not treat him at the emergency department and he would need to be seen where he had the surgery. According to Employee (C) Patient #1 was angry and left the hospital campus.

Physician (D)/on-call physician was interviewed on 9/8/2011, at 10:13 a.m. and indicated she had been informed of Patient #1's recent TURP at another facility and because the patient was a new surgical patient she was concerned inserting a catheter could cause a perforation. Physician (D) indicated she preferred the patient be seen where he had the surgery. According to Physician (D) she was not aware Patient #1 had presented at the hospital and had been turned away for treatment. She said she was not informed of Patient #1's arrival and said had she been aware she would have completed the required medical screening and examination.

Physician (E)/Medical Director was interviewed on 9/6/2011, at 3:25 p.m. and stated Patient #1 should have been treated in the emergency department. He indicated this was an EMTALA violation and that Patient #1 did not receive a required medical screening examination by a physician in the emergency department.

Employee (B)/Administrative nurse was interviewed on 9/6/2011, at 2:08 p.m. and verified Patient #1 was not seen in the ED. She indicated this was an EMTALA violation and that Patient #1 did not receive a required medical screening examination by a physician in the ED. The hospital is in the process of mandatory education for all ED staff regarding EMTALA policies and procedures.

Review of the hospital's EMTALA policy and procedure revised 1/09, stated, "...The medical screening examination is performed uniformly on all individuals seeking emergency medical care. In the event the medical screening is completed by a nurse or nurse practitioner, the physician on-call for the emergency room is ultimately responsible for the medical screening examination..."

Hospital #2's record dated 8/6/2011, at 1:35 p.m. revealed Patient #1 had a bladder scan and catheter placed with a return of 691 cc of burgundy colored urine with numerous blood clots and was in moderate distress. When Patient #1 arrived at Hospital #2's emergency department he rated his pain level on a scale of 1 to 10 with 10 the worst pain, at a 10. Patient #1 was stabilized and sent home with a urinary catheter in place. The documentation confirmed Patient #1 returned to Hospital #2 on 8/6/2011, at 7:33 p.m. for plugged catheter that required irrigation for blood clots and after additional education to the patient's spouse with instructions for irrigation and was sent home.