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Based on review of facility policy, review of Emergency Medical Services (EMS) Patient Care Report, medical record review, and interviews, the facility failed to provide an appropriate medical screening exam (MSE) for 2 patients (Patient #1 and Patient #26); and failed to ensure an appropriate transfer for 2 patients (Patient #35 and #36) who presented to the Emergency Department (ED) of 37 ED patients reviewed.

The findings include:

Patient #1 presented to Facility A's ED by ambulance on 1/25/2022 due to hip pain that began after the patient had fallen at home. Upon arrival to the ED, EMS was advised there was a long wait for an ED bed and orthopedic services were not available at the facility. Patient #1 was not listed on the ED Central Log. Review of Facility A's hospital/ED electronic admissions by patient name showed Patient #1 was not listed and there was no medical record to indicate a medical screening exam was performed. Patient #1 was transported by EMS to Facility B on 1/25/2022.

Patient #26 presented to Facility A's ED on 10/1/2021 with complaint of 38 weeks pregnant (40 weeks is full term) and possible contractions (sign of labor). Patient #26's MSE was not performed by a qualified medical provider. Patient #26 was discharged to home on 10/1/2021.

Patient #35 presented to Facility A's ED on 11/30/2021 with complaint of Suicidal Ideation. Patient #35 was transferred to Facility B on 11/30/2021. Medical record review showed a Certificate of Need (CON- legal document which is required by the court for an individual who is admitted to an inpatient behavioral health treatment resource without the consent of the individual receiving services) was not present in the medical record indicating the patient was a voluntary commitment to Facility B. Medical record review showed no evidence of a physician's certification of need for a higher level of care nor certification of benefits of medical treatment outweighed the risk of transfer to another facility. Medical record review showed no evidence Patient #35 consented to be transferred to Facility B.

Patient #36 presented to Facility A's ED on 2/7/2022 with complaint of Suicidal Ideation. Patient #36 was transferred to Facility C (Crisis Stabilization Unit-specialized treatment setting where people with more severe mental health needs can get the treatment they need) on 2/8/2022. Medical record review showed a CON was not present in the medical record indicating the patient was a voluntary commitment to Facility C. Medical record review showed no evidence of a physician's certification of need for a higher level of care nor certification of benefits of medical treatment outweighed the risk of transfer to another facility. Medical record review showed no evidence Patient #36 consented to be transferred to Facility C.

Refer to A-2406, and A-2409.

Based on review of facility policy, Central Log, review of Emergency Medical Services (EMS) Patient Care Reports, medical record review, and interviews, the facility failed to enter all patients on the Emergency Department (ED) Central Log for 1 patient (Patient #1) of 37 ED patients reviewed.

The findings include:

Review of Facility A's policy "Triage and Medical Screening/EMTALA (Emergency Medical Treatment and Active Labor Act)" reviewed 11/2020 showed "...Patients arriving via EMS patients are generally taken directly to an ED treatment room as available. However, EMS patients determined to be of non-urgent or semi-urgent status may be directed to the triage/registration area...At the time of triage the patient's name, chief complaint, acuity [urgency for treatment]...and arrival time will be documented in [named electronic medical record system]..."

Review of an EMS Patient Care Report showed EMS was dispatched to Patient #1's home for a reported fall on 1/25/2022 at 7:13 PM. Upon arrival, Patient #1 was sitting in a chair with complaint of hip pain. The patient reported he had tripped on a rug and fell approximately 2 hours prior to EMS arrival. The patient complained of pain with touch of the right hip. Patient #1 requested to be transported to Facility A's ED "...TRANSPORTED TO [Facility A] ON ARRIVAL WHERE [were] ADVISED THAT THERE WAS NOTHING THAT [Facility A] COULD DO FOR THE PATIENT AND THAT WE SHOULD HAVE NOT EVEN BROUGHT THE PT [patient] THERE. THEY APPARENTLY HAVE NO ORTH [orthopedic physician] AT THE HOSPITAL. AFTER ADVISING THE PATIENT OF THE SITUATION HE ADVISED THAT HE WOULD LIKE TO GO TO [Facility B]. I ADVISED [named house supervisor] WHAT THE PATIENT ADVISED AND HE TOLD US TO TAKE HIM ON TO [Facility B]. HE REFUSED ANY INTERACTION WITH THE PATIENT AND DID NOT DO A MEDICAL SCREENING WE WERE ADVISED TO TAKE HIM ON TO [Facility B]..." Arrival time to Facility A was documented as 8:18 PM.

Review of Facility A's ED Central log for 1/25/2022 showed Patient #1 was not listed on the log.

During a telephone interview on 3/29/2022 at 3:45 PM, Paramedic #1 confirmed Patient #1 was transported to Facility A on 1/25/2022 with complaint of hip pain after the patient had fallen at home.

During an interview on 3/29/2022 at 4:00 PM, in the conference room, the ED Supervisor stated all patients who presented to the ED were expected to be on the ED Central Log. The ED Supervisor confirmed Patient #1 was not on the ED log for 1/25/2022.

Based on review of facility policy, review of Emergency Medical Services (EMS) Patient Care Reports, employee file, house supervisor report, medical record review, and interviews, the facility failed to ensure a medical screening exam (MSE) was performed for 1 patient (Patient #1) with hip pain; and failed to ensure a MSE was performed by a qualified medical provider (QMP) for 1 obstetrical (labor and delivery) patient (Patient #26) of 3 obstetrical patients who presented to the Emergency Department (ED) of 37 ED patients reviewed.

The findings include:

Review of Facility A's policy "Medical Screening Exam-Protocol, Registered Nurse Performance of the Obstetrical" dated 12/2017 showed "...PURPOSE To define the circumstances under which an Obstetrical Registered Nurse may perform the Obstetrical Medical Screening Exam...Registered nurses with demonstrated clinical competency in obstetrics may perform medical screening examination on persons requesting or requiring this type of emergency medical services...' Demonstrated clinical competency' means the ability to conduct the tasks listed...as demonstrated by: [successful completion of the hospital's skill validation process and departmental orientation at the time of the nurse's hire, successful completion of an advanced fetal monitoring course; successful completion of a neonatal resuscitation program; other]. The registered nurse's personnel file should reflect documentation of the nurse's continued competency..."

Review of Facility A's policy "Triage and Medical Screening/EMTALA (Emergency Medical Treatment and Active Labor Act)" reviewed 11/2020 showed "...PURPOSE To ensure all patients presenting to [Facility A] for emergency treatment receive an appropriate medical screening exam by a qualified medical professional [QMP] to determine if an emergency medical condition exists...Patients arriving via EMS [emergency medical services] patients are generally taken directly to an ED [emergency department] treatment room as available. However, EMS patients determined to be of non-urgent or semi-urgent status may be directed to the triage/registration area...At the time of triage the patient's name, chief complaint, acuity [urgency for treatment]...and arrival time will be documented in [electronic medical record system]...Emergency Department patients will have a medical screening exam performed by the Emergency Department physician or mid-level practitioner...The purpose of the medical screening exam will be to determine if a emergency medical condition exists. An emergency medical condition is defined as...A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric conditions, and substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in...Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in jeopardy...serious impairment to bodily functions...Serious dysfunction of any bodily organ or part...If an emergency medical condition exists the patient will be stabilized, treated, admitted, or transferred as appropriate..."

Review of an EMS Patient Care Report showed EMS was dispatched to Patient #1's home for a reported fall on 1/25/2022 at 7:13 PM. Upon arrival, Patient #1 was sitting in a chair with complaint of hip pain. The patient reported he had tripped on a rug and fell approximately 2 hours prior to EMS arrival. The patient complained of pain with touch of the right hip. Patient #1 requested to be transported to Facility A's ED. "...TRANSPORTED TO [Facility A] ON ARRIVAL WHERE [were] ADVISED THAT THERE WAS NOTHING THAT [Facility A] COULD DO FOR THE PATIENT AND THAT WE SHOULD HAVE NOT EVEN BROUGHT THE PT [patient] THERE. THEY APPARENTLY HAVE NO ORTH [orthopedic physician] AT THE HOSPITAL. AFTER ADVISING THE PATIENT OF THE SITUATION HE ADVISED THAT HE WOULD LIKE TO GO TO [Facility B]. I ADVISED [named house supervisor] WHAT THE PATIENT ADVISED AND HE TOLD US TO TAKE HIM ON TO [Facility B]. HE REFUSED ANY INTERACTION WITH THE PATIENT AND DID NOT DO A MEDICAL SCREENING WE WERE ADVISED TO TAKE HIM ON TO [Facility B]..." Arrival time to Facility A was documented as 8:18 PM.

Review of Facility A's hospital and ED electronic admissions by the patient's name showed Patient #1 was not listed and there was no medical record to indicate a medical screening exam was performed.

Review of a house supervisor report presented to Facility A's Performance Improvement Coordinator dated 1/25/2022 at 8:45 PM showed EMS brought a patient to the ED related to a fall with hip and knee pain. The house supervisor informed EMS "...for future reference..." the ED was currently on orthopedic divert due to the orthopedic surgeon was not available. Continued review showed EMS was informed patients "...would not be able to get proper treatment that they need d/t [due to] our ortho [orthopedic] physician being out..." The EMS medic was informed it may be a while before the patient was seen due to the number of patient's waiting and another EMS patient waiting for a bed. After approximately 15 minutes, EMS told the house supervisor the patient wanted to go on to Facility B because he was scheduled to have a heart catheterization (procedure to examine how well the heart is functioning) there the following day. The patient was taken back to the ambulance by EMS staff. Further review showed ER registration had the patient's last name but the patient was never registered.

Medical record review of Facility B's Emergency documentation showed Patient #1 presented to Facility B's ED on 1/25/2022 at 9:35 PM (1 hour 17 minutes after arrival at Facility A).

Medical record review of Facility B's ED Physician documentation showed Patient #1 presented to the ED with complaint of right hip and right knee pain after falling at home. Continued review showed diagnostic X-rays were performed and showed Patient #1 had a right femoral neck fracture (hip fracture). Patient #1 was admitted to Facility B with diagnoses including Femoral Neck Fracture, Coronary Artery Disease, Peripheral Vascular Disease, and History of Cerebrovascular Disorder.

Medical record review of an Operative Report showed Patient #1 had a Right Hip Replacement performed on 1/28/2022 at Facility B. The patient's preoperative and postoperative diagnoses included Right Hip Femoral Neck Fracture.

Medical record review of a Discharge Summary showed Patient #1 was discharged from Facility B on 2/2/2022.

During a telephone interview on 3/29/2022 at 3:45 PM Paramedic #1 stated EMS notified the ED they were transporting Patient #1 to Facility A's ED. Continued interviewed revealed Patient #1 was offloaded from the ambulance and taken into the ED. Upon arrival, the person behind the desk (house supervisor) informed Paramedic #1 it was "...going to be a while...you shouldn't have brought him here anyway..." because the facility did not have an orthopedic physician. Paramedic #1 waited with Patient #1 in the ED hall next to the ambulance entrance. Further interview revealed Paramedic #1 notified the house supervisor that Patient #1 and the patient's wife had asked if EMS could take the patient to Facility B because the patient had an appointment there the next day. Paramedic #1 stated Patient #1 was loaded back onto the ambulance and was transported to Facility B. Paramedic #1 stated Patient #1 was not evaluated by a physician at Facility A.

During an interview on 3/29/2022 at 4:00 PM, in the conference room, the ED Supervisor stated all patients who presented to the ED were expected to receive a MSE. The ED Supervisor confirmed Patient #1 did not receive a MSE during the ED encounter on 1/25/2022.

During a telephone interview on 3/29/2022 at 4:35 PM, the House Supervisor stated he informed EMS it was "...going to be a long wait...informed them ortho [orthopedic physician] was...unavailable as an FYI..." The House Supervisor confirmed Patient #1 was physically in the ED and EMS waited with the patient in the hall. After about 15-20 minutes, EMS notified the House Supervisor the patient wanted to go to Facility B. The House Supervisor stated "...I didn't know the rules...thought once in the ED they were our patient...wasn't sure if they could just leave with patient...I was so busy trying to take care of patients..." The House Supervisor confirmed Patient #1 was not evaluated by a physician while in the ED.

Medical record review showed Patient #26 presented to Facility A's ED with complaint of 38 weeks pregnant (40 weeks is full term) and possible contractions (sign of labor) on 10/1/2021 at 12:01 PM. Patient #1 was triaged and moved to the Obstetrical Unit at 12:04 PM.

Medical record review of labor and delivery nursing documentation showed Patient #26 had a MSE by Registered Nurse (RN) #1 at 12:37 PM. Patient #26's cervix (opening to birth canal) was dilated to 1 centimeter (10 centimeters is fully dilated) and was 50% effaced (thinning of cervix).

Medical record review of physician notes dated 10/1/2021 at 1:32 PM showed "...False labor. Ok to discharge home...Trace reviewed...I hearby state that the patient has been examined for a reasonable time of observation...and certify that the patient is in false labor..."

Medical record review of labor and delivery nursing documentation dated 10/1/2021 at 1:33 PM showed the RN notified the obstetrician of Patient #26's status and vaginal exam. "...POC [plan of care] is to continue to monitor pt. [patient] and baby on the monitor and to recheck cervix when it has been an hour since previous exam. If no cervical change, pt. is able to leave with verbal teaching on precautions. Will update provider with any changes..."

Medical record review showed Patient #26 was discharged to home on 10/1/2021 at 1:58 PM.

Review of RN #1's employee file showed the nurse had not met Facility A's education and training requirements to perform obstetrical MSE's.

During an interview on 3/29/2022 at 1:40 PM, in the Obstetrical Unit, RN #2 stated Patient #26's MSE was performed by RN #1. RN #2 stated a physician did not evaluate Patient #26 in person.

During an interview on 3/30/2022 at 11:10 AM, in the conference room, the Obstetric Supervisor confirmed RN #1 had not met the facility requirements to perform obstetrical MSE's and confirmed Patient #26's MSE was not performed by a QMP.

Based on review of facility policy, medical record review, and interviews, the facility failed to ensure an appropriate transfer for 2 psychiatric patients (Patient #35 and Patient #36) of 8 psychiatric patients reviewed of 37 Emergency Department (ED) patients reviewed.

The findings include:

Review of Facility A's policy "Transfer (Acute Care, Extended Care, Emergency Services, Testing)" reviewed 2/2021 showed "...An order certifying the medical benefits outweigh the risks of the transfer must be written and signed by the attending or Emergency Room Physician. The physician ordering the transfer must have personally arranged for a receiving physician at the other facility. The patient or appropriate family member or legal guardian must give written consent on the Transfer Authorization Form following an explanation of the risks and benefits of the transfer by the physician..."

Review of Facility A's policy "Care of the Psychiatric Patient" revised 7/2021 showed "...Psychiatric Referral Inpatient & [and] Outpatient...Each patient who presents for psychiatric purposes will receive a medical screening examination by the on duty Emergency Department physician. If the patient is determined to be medically stable, but requires further psychiatric evaluation/care, Mobile Crisis may be contacted or direct referral may be initiated by the Emergency Room provider...If the patient needs to be admitted, the Mobile Crisis worker shall secure a bed at an appropriate facility and the patient will be transferred per Transfer Guidelines..."

Medical record review of ED Nurses Notes showed Patient #35 presented to Facility A's ED on 11/30/2021 at 8:31 AM crying, stated he needed help, and stated he wanted "...to put a gun in his mouth and pull the trigger..." Patient #35 was triaged with an Emergency Severity Index (ESI) score of 3 indicating urgent but non emergent needs. Laboratory diagnostic tests were performed and inpatient psychiatric facilities were contacted for patient placement. Further review showed the ED physician ordered Patient #35's transfer to Facility B on 11/30/2021 at 5:07 PM. Continued review showed "...Patient [#35] transferred to [Facility B] by EMS [Emergency Medical Services] ground Transfer form completed..." Patient #35 left the ED on 11/30/2021 at 8:36 PM.

Medical record review of ED Physician Documentation showed Patient #35 presented to the ED with complaint of Suicidal Ideation and Alcohol Withdrawal. Patient #35 had a history of Depression, Alcohol Abuse, and Post Traumatic Stress Disorder. Continued review showed Patient #35's condition was stable and the patient transferred to Facility B for a higher level of care. Patient #35's diagnoses included Adjustment Disorder with Mixed Anxiety and Depressed Mood and Alcohol Abuse.

Medical record review showed: a Certificate of Need (CON- legal document which is required by the court for an individual who is admitted to an inpatient behavioral health treatment resource without the consent of the individual receiving services) was not present in the medical record which indicated Patient #35 was a voluntary commitment for Facility B.

Medical record review showed no evidence of a physician's certification of need for a higher level of care and no documentation certifying the benefits of medical treatment outweighed the risk of transfer to Facility B.

Medical record review of ED Nurses Notes showed Patient #36 presented to Facility A's ED on 2/7/2022 at 12:05 PM with complaint of suicidal ideation that began 3 days prior to arrival. The patient reported he wanted to hang himself from a bridge. Patient #36 was triaged with an ESI score of 3 indicating urgent but non emergent needs. Laboratory diagnostic tests were performed and Patient #36 was evaluated by Mobile Crisis. Continued review showed Patient # 36 was "...Instructed on need for transfer to a higher level of care..." The ED physician ordered Patient #36's transfer to a Crisis Stabilization Unit (specialized treatment setting where people with more severe mental health needs can get the treatment they need) on 2/8/2022 at 1:44 PM. Patient #36 left the ED on 2/8/2022 at 1:47 PM.

Medical record review of Facility A's ED Physician Documentation showed Patient #36 presented to the ED with complaint of suicidal ideation with a plan to commit suicide. Continued review showed Patient #36's condition was stable and the patient was transferred to a Crisis Stabilization Unit for a higher level of care. Patient #36's diagnoses included Adjustment Disorder with Mixed Anxiety and Depressed Mood and Suicidal Ideations.

Medical record review showed a CON was not present in the medical record which indicated Patient #36 was a voluntary commitment for the Crisis Stabilization Unit.

Medical record review showed no evidence of a physician's certification of need for a higher level of care and no documentation certifying the benefits of medical treatment outweighed the risk of transfer to the Crisis Stabilization Unit.

Medical record review showed no evidence the risks and benefits of transfer had been explained to Patient #36 and no evidence Patient #36 consented to be transferred to the Crisis Stabilization Unit.

During an interview on 3/30/2022 at 10:00 AM, in the conference room, the ED Supervisor stated transfer authorization forms showing the physician certified the need for a higher level of care and certified the benefits of medical treatment outweighed the risk of transfer were not completed for Patient #35 and Patient #36. The ED Supervisor confirmed there was no documentation to show Patient #35 and Patient #36 consented to be transferred to another facility.