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Based on policy review, document review, medical record review and interview, it was determined the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical care received a medical screening examination (MSE) to determine if an emergency medical condition existed for 1 of 1 (Patient #15) sampled patients who was refused care by the hospital.

Refer to findings in deficiency A2406.

Based on policy review, document review, medical record review and interview, it was determined the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical care received a medical screening examination (MSE) to determine if an emergency medical condition existed for 1 of 1 (Patient #15) sampled patients who was refused care by the hospital..

The findings included:

1. Review of the hospital's "MEDICAL STAFF RULES AND REGULATIONS" revealed, "...Medical Screening Exam: 1. Federal and State laws and regulations provide that any individual who comes to the Hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by individuals qualified to perform such examination to determine whether or not an emergency medical condition exists. An appropriate Medical Screening Examination includes routinely available ancillary services. A Medical Screening Examination shall be provided to determine whether an emergency medical condition exists or, with respect to a pregnant woman having contractions, whether the woman is in labor. This medical screening examination must be provided to all individuals regardless of diagnosis, race, age, creed, sex, handicap, sexual preferences, national origin or financial status. 2. No delay to a medical screening examination or stabilizing treatment shall occur due to inquiries as to method of payment or insurance status. An appropriate Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists or a woman is in labor. Such screening must be done within the facility's capability and available personnel, including on-call physicians. The medical screening examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred..."

2. Review of the hospital's Emergency Department (ED) Central Log dated 2/3/15 revealed Patient #15 arrived at 8:30 PM. The entry documented the reason for the visit, "FALL: 30 WEEKS PREGNANT." The disposition category documented, "Was Refused Treatment." The disposition type/disposition plan documented, "AGAINST MEDICAL ADVICE Left Prior to Med Screen."

3. Review of the "EMERGENCY PATIENT RECORD" for Patient #15 revealed arrival date/time as 2/3/15 at 8:30 PM. The stated complaint was documented as "fall; 30 weeks pregnant." The chief complaint was documented as "Hip/pelvis." The assessment section of the "EMERGENCY PATIENT RECORD" documented the disposition category: "Was Refused Treatment." The Other Notes section of the "EMERGENCY PATIENT RECORD" documented an entry dated 2/9/15 11:22 AM "PT. LEFT THE EMERGENCY DEPARTMENT WITHOUT BEING ASKED TO SIGN IN, OR PROVIDING ANY PERSONAL INFORMATION."

4. During an interview in the conference room on 2/12/15 at 9:22 AM the Emergency Department Nurse Manager (EDNM) stated Patient #15's father called her on 2/4/15 to report an incident that occurred 2/3/15. Patient #15 had come to the Emergency Department to have an ultrasound after falling in the shower. He stated his daughter was 30 weeks pregnant. Patient #15's father stated the patient was unable to receive an ultrasound, and they left the building.

5. During an interview in the conference room on 2/12/15 at 9:22 AM the EDNM stated she spoke with Patient #15 about the incident. The EDNM stated Patient #15 told her she came into the ED and asked the SecurityOfficer #1 if the hospital did ultrasounds. The EDNM stated Patient #15 said the Security Officer went to talk with staff, came back to the desk and told her they were unable to do ultrasounds at night.

6. During a telephone interview in the conference room on 2/12/15 at 10:45 AM, Security Officer #1 stated Patient #15 came into the ED 2/3/15 between 8:00 PM and 8:30 PM. Security Officer #1 stated the patient said she was 30 weeks pregnant and had fallen in the shower and needed an ultrasound. Security Officer #1 stated Patient #15 said she did not want to be seen (by a physician), she wanted an ultrasound. Security Officer #1 stated he verified with nurses and Physician #1 ultrasounds were not performed after 7:00 PM at night. The Security Officer stated when he told Patient #15 this, she and the gentleman with her, left the building.

7. During a telephone interview in the conference room on 2/12/15 at 2:05 PM, Physician #1 stated Patient #15 came into the ED and asked for an ultrasound. Physician #1 stated the hospital did not do ultrasounds at night. Physician #1 stated he saw the patient on video camera leaving the ED. Physician #1 stated Patient #15 left the building, her question was answered, "... don't do ultrasounds at night..." Physician #1 stated he thought it was Patient #15's choice to leave.

8. During an interview in the conference room on 2/12/15 at 2:32 PM, Registered Nurse (RN) #1 stated on 2/3/15 the Security Officer walked back to the ED wanting to know if a patient could have an ultrasound that night. RN #1 stated she and the physician stated the ultrasound could not be done tonight. She stated if a patient came in after 7:00 PM and needed an ultrasound, they would have to go somewhere else.

9. During a telephone interview in the conference room on 2/12/15 at 3:00 PM, RN #2 stated the Security Officer came to the back of the ED to question if we had ultrasound at night and we (RN #1, 2 and Physician #1)told him no. RN #2 stated when the Security Guard asked about an ultrasound, she got the impression he was just asking a question. She stated she did not get the impression anyone needed to be seen.

10. Review of training documentation and interviews for verification revealed corrective actions initiated included Security Officer #1 completed a web-based EMTALA training on 2/9/15 and informed of the rearrangement of personnel at the front desk so that Security is now located at a desk in the back of the reception area with video monitors, radios and ear buds for communication.
The two RN's involved [RN # 1 & #2] completed the web-based EMTALA training and both will receive written Corrective Actions for failure to respond to a clinical request of an individual that presented to a dedicated emergency department.
During an interview in the Administrative Conference Room on 2/12/15 at 2:45 PM, the Vice President of Quality and Risk Management stated, "I will be meeting with the CMO [Chief Medical Officer] tomorrow and the CMO will do a collegial conversation with [Physician #1] to emphasize the importance of being more patient focus instead of service provider."
The Director of Ethics and Compliance stated that EMTALA training will be done system-wide quarterly instead of the current, annually with emphasis on Security personnel and a portion of the EMTALA regulations will be discussed each month at the Security staff.