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Based on review of the facility's Medical Staff Bylaws, Policies, and Rules and Regulations, facility policies, MSE checklist, ED central log, medical records, employee files, EMTALA and MSE training and test, staff interviews, Memo from and ED Nursing Director it was determined that the facility failed to ensure compliance with CFR 489.24, for eleven (11) patients (#s 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, and 29) of twenty-nine (29) sampled patients.


Findings:

Cross refer to A2404 as it relates to failure to maintain an on-call list and availability of on-call physicians.

Cross refer to A2406 as it relates to failure to provide an appropriate Medical Screening Exam(MSE).

Cross refer to A2409 as it relates to failure to ensure that all transfers are appropriate.

Based on reviews of medical records, policies and procedures on-call schedules, Medical Staff Rules and Regulations, Physician Directory, delineation of privileges and interviews, the facility failed to ensure that obstetrical/gynecological on-call physicians fulfilled his or her on-call obligations. This is evidenced by failing to ensure that the hospital's obstetrical/gynecological on-call list of physicians, who are on the hospital's medical staff, and have privileges at the hospital, are available to provide treatment necessary, after the initial examination, to stabilize individuals with emergency medical conditions, who are receiving services within the resources available at the hospital for one (#29) of twenty-nine (29) sampled patients medical records reviewed.

The findings were:

Patient #29's medical record from DeKalb Medical Center at Hillandale was reviewed. Review of the triage note dated 9/15/2015 revealed that patient #29 walked into the ED and was triaged at 3:24 a.m. The patient's chief complaint was listed as "vaginal complaints/OB (obstetrical)-less than 29 weeks". Further review indicated-chief complaint: Pt (patient) c/o (complains) of lower abdominal pain with associated vaginal bleeding. Pt states that she is eight (8) weeks gestation (pregnant). Pt is G (Gravid-previous pregnancies) 3P ( Para-live births)2 ... ". The patient's vital signs were listed as blood pressure 140/88; Pulse 73; Respirations 18; Temperature 98.1. Documentation by the ED physician revealed that patient #29 was medically screened by the ED physician at 5:46 a.m. Further documentation by the ED physician revealed in part: "History of Present Illness: The patient is a 24- year-old woman who believes she is about eight (8) weeks pregnant, who comes with vaginal bleeding for 4 hours ... The patient states that she noticed the bleeding when she went to the bathroom. She denies any pain, but states that she has used one pad. She states that she has seen a midwife once during this pregnancy, but has not had an ultrasound. She is seen in Dr. (MD name) office but apparently affiliated with (name of acute care hospital- Hospital B). Number at the office is (phone number listed) ...Physical Examination is as follows: ...GENITOURINARY: Pelvic exam, at this time, is deferred. ...EMERGENCY DEPARTMENT STUDIES ... There appears to be an ill-defined complex right ovarian lesion, possibly hemorrhagic+ cyst. The left ovary is normal in the setting of a positive beta hCG (pregnancy test to detect pregnancy hormones). The differential diagnoses would include early IUP (intrauterine pregnancy), failed IUP, and ectopic pregnancy (fetus develops outside the uterus, typically fallopian tubes) ... IMPRESSION: This is a 24-year old woman who comes with vaginal bleeding in early pregnancy. Her beta hCG is definitely high enough that we should expect to see something in the uterus at this time, if this was a viable pregnancy, however, we do not. Because we do not, we have to assume that this is an ectopic pregnancy until proven otherwise. I have spoken with the patient's midwife by calling (listed phone number), as she was the one on call, and she was unable to tell me who the physician was on call, as she states that it was just her tonight. She does state that she works for (Patient #29's OB Physician). The midwife suggested that we call Hospital B to see if they could tell us whether she was on call. Initially, we were told from Hospital B that it was (a physician's name); however, when contacted him, he stated that he was not on call. The midwife proceeded to work further on her own and try to figure this out, but an hour and half later, we still are left without an on-call physician for the group. Because of this, the midwife did call and speak with the OB/GYN (OB-short for Obstetrician- a physician who delivers babies/GYN-short for Gynecologist- a physician who specializes in treating diseases of the female reproductive organs) on-call physician (# 18) at DeKalb Medical -Hillandale, at approximately 7:15 a.m. and she suggested that since patient (#29) was stable and not having any pain, that we should wait until the patient's doctor's office opens. The midwife did express to her (#18) that this could be another hour and 45 minutes, as the office was not open until 9:00 a.m., but she (#18) felt that if the patient is stable that the patient can wait. Therefore, the patient will be signed out to my colleague, ED physician #22 to try and get in touch with the patient's (OB) physician once their office opens this morning, so that the patient can be transferred with continuity of care from her own physician. Disposition: Still pending consultation by the physician's obstetrician ...Diagnosis: Possible ectopic pregnancy. The facility failed to ensure that the OB on-call physician (#18) came to the ED to provide further evaluation and treatment for patient #29 on 9/15/2015.

DeKalb Medical Center at Hillandale Transfer Form dated 9/15/2015 for patient #29 was reviewed. The form indicated in the section titled, " Reason for Transfer:...Services not available OB ...II. CONDITIONS TO BE MET FOR TRANSFER TO ANOTHER FACILITY " ...1. Name of Receiving Facility: DMC (Dekalb Medical Center-North Campus ) Main ER ...3. Accepting Physician: OB/GYN on call physician #18 .
The medical record for patient #29 from DeKalb Medical Center at North Decatur was reviewed. The medical record revealed that patient #22 arrived via ambulance, and the patient was triaged at 11:35 a.m. The emergency room report was reviewed. The ED physician wrote in part, " MEDICAL DECISION MAKING/ASSESSMENT AND PLAN: This is a 24-year-old female who comes to the emergency department, transferred from DeKalb Hillandale, for evaluation by OB/GYN. Dr. OB/GYN on call physician (#18) evaluated the patient here in the emergency department, and at this time, the plan is to take the patient to the operating room for a D&C (dilation & curettage-a procedure to remove tissue from the inside of the uterus) versus Laparoscopy (surgical procedure to examine the abdominal cavity and pelvic organs) for diagnostic purposes for a possible ectopic pregnancy ...she is awaiting admission to the operating room at this time". The post-operative data entry report dated 9/15/2015 was reviewed. The report indicated that the surgeon was on-call OB/GYN physician (#18) who performed the D&C suction. The pre-op diagnosis was Pregnancy Ectopic and post -op diagnosis was listed as Pregnancy Ectopic: Right.

The facility's policy and procedure, Emergency Department "On-call Physician Unavailability Procedure", policy number ED-159, Effective Date: 10/07/2014 was reviewed. The policy specified in part, " 1. Policy: Members of the medical staff are required to provide on-call specialty coverage for the emergency department in accordance with the Medical Staff Bylaws, Rules and Regulations ...3. Emergency Department physicians make the decision to call an on-call physician depending on the condition and clinical needs of the patient who present to the Emergency Department (ED) ...5. On-call physicians are expected to come to the Emergency Department to examine the patient in accordance with the timelines specified in the Medical Staff By-laws, Rules and Regulations".

DeKalb Medical at Hillandale Obstetrics &Gynecology (OB/GYN) Delineation of Privileges for the OB /GYN Physician (#18) were reviewed. The privileges revealed in part, " CORE PRIVILEGES: Gynecology Core Privileges ...Requested at DM (DeKalb Medical) at Hillandale ...Core Privileges in gynecology include ...evaluate, diagnose, treat, and provide consultation to female patients of all ages presenting with illnesses, injuries and disorders of gynecological ...system. Privileges also include, but are not limited to, the following: Perform gynecology screenings, which include ...pelvic exams ...Performance of the following procedures- ...suction curettage for pregnancy termination and management of incomplete abortion, missed, or inevitable abortion ...Exploratory Laparotomy, for diagnosis and treatment of pelvic pain ...Level 2- includes Core Privileges as well as problems/conditions of moderate to high-risk ... Requested at DM Hillandale ...Second trimester abortion by suction and curettage and/or D&E (>=12 weeks but <20 weeks). Further review indicated that on 11/14/2014, the Department Chief signed and checked off " recommend approval for all requested privileges" ... for OB/GYN Physician #18.

The DMC (DeKalb Medical Center) at Hillandale Emergency Department Daily on-call schedule dated September 15, 2015 was reviewed. The ED on call schedule verified that OB/GYN physician #18 was on call when the ED physician called and notified her(OB/GYN Physician #18) that on 9/15/2015, patient #29 required further evaluation and treatment of her identified emergency medical condition.
DeKalb Medical at Hillandale Physician Directory dated September 15, page 4 was reviewed. Review of the Physician Directory verified that OB/GYN on call physician # 18 is an active staff member at DeKalb Medical at Hillandale.

DeKalb Medical At Hillandale Medical Staff Rules and Regulations, approved 9/14/2015, (Board of Trustees) was reviewed. The Rules and Regulations revealed in part, " 5B. Physicians on Call for the Emergency Department ...2. No patient may be directed to another location, including but not limited to a physician's office or a different hospital, until (i) the patient has been fully evaluated according to law and requirements of these Rules and Regulations and, (ii) the patient has been evaluated by a specialty physician as deemed appropriate by the Emergency Department physician ...Physicians on call for the Emergency Department shall be responsible for seeing patients ...when requested by an Emergency Department physician".

An interview was conducted with ED Physician (#22) on 9/15/2015 at 11:35 a.m. ED Physician #22 stated that it was unclear what was going on with patient #29, possible ectopic pregnancy. ED Physician #22 stated that if an on-call physician is on call, they should respond telephonically and discuss the case with the ED physician. Their obligation is to take care of the patient. ED Physician #22 also stated that patient #29's private OB physician at another acute care hospital was called regarding the patient (#29) and he/she refused to accept the patient because the patient had an emergency medical condition, and the patient could not be transferred. He further stated that the OB/GYN on-call physician (# 18) was notified of what had happened to patient #29, and that OB/GYN on-call physician #18 "needed to take her now- no reason not to take her". ED physician #22 stated that patient #29 had an emergency medical condition and until ruled/out, the patient was considered to have an emergency medical condition. He stated that patient #29 was transferred to DeKalb Medical Center at North Decatur on 9/15/2015.

A telephone interview was conducted on 9/15/2015 at 2:00 p.m. with the on-call OB/GYN (#18). The OB/GYN physician on call (#18) stated that the ED physician was trying to get in touch with patient #29's OB physician at another acute care hospital to see what they wanted to do with patient #29. OB/GYN physician # 18 stated that we tried to send patient #29 to the acute care hospital where her OB physician was located. OB/GYN on-call physician # 18 stated that she had an agreement with her group to treat patients only at DeKalb Medical Center at North Decatur. The OB/GYN on call physician #18 stated that she never comes to DeKalb Medical Center at Hillandale to see a patient when she/he is on-call. She/He also stated that if the patients are stable, they (patients) are transferred to her at DeKalb Medical North Decatur. The OB/GYN on-call physician # 18 verified that she/he was on call at DeKalb Medical at Hillandale after 7 am on 9/15/2015, but she/he "never comes over there physically at Hillandale". The facility failed to ensure that the on-call OB physician came to DeKalb Medical at Hillandale's ED in person to evaluate and treat patient #29 on 9/15/2015 after being notified to appear by the ED physician. Patient #29 was transferred to DeKalb Medical North Decatur for the convenience of the OB on-call physician on 9/15/2015.

A telephone interview was conducted on 9/16/2015 at 2:00 p.m., with the hospital's ED Director. The ED Director verified that OB/GYN on-call physician (#18) was not on-call technically at DeKalb Medical at Hillandale. The ED Director also stated that OB/GYN on-call physician # 18 should not be on the on-call list, and that this has been the facility's policy for the past 3-4 years.

The facility failed to ensure that their policies and procedures were followed as evidenced by failing to ensure that the on-call OB physician came to the ED at DeKalb Medical at Hillandale to provide further evaluation and treatment of patient #29's identified EMC on 9/15/2015, in accordance with the timelines specified in the Medical Staff By-laws and Rules and Regulations.

Based on review of the facility's Medical Staff Bylaws, Policies, and Rules and Regulations, facility policies, Medical Screening Examination (MSE) checklist, ED central log, medical records, employee files, Emergency Medical Treatment and Labor Act (EMTALA) and MSE training and test, staff interviews, and Memo from ED Nursing Director, the facility failed to provide an appropriate MSE that was within the capability of the hospital's emergency department including ancillary services routinely available to the ED to determine whether or not an emergency medical condition existed for ten (10) patients (#s 14, 15, 16, 18, 19, 20, 21, 22, 23, and 24) of twenty-nine (29) sampled patients.


Findings:

Review of the facility's Medical Staff Bylaws, Policies, and Rules and Regulations, Revised August 6, 2014 by the Medical Executive Committee, and Approved August 11, 2014 by the Board of Directors, part 5.A. The Emergency Department, 6. A medical screening examination is required by federal law and regulation to be provided to any person who comes to the Hospital's ED or Labor and Delivery Department and requests examination or treatment. A medical screening examination may be provided in the ED by the following individuals:
A. A practitioner with appropriate clinical privileges;
B. An emergency triage nurse employed by the Hospital; or
C. A nurse practitioner or physician's assistant or by the emergency department physicians.

Review of facility policy PRB-6463, Emergency Medical Treatment, Stabilization and Transfer Policy, effective 02/03/2014, revealed:
II. Policy
A. Any individual who comes to the hospital (anywhere on the premises, including the parking lot, sidewalk and driveway) and requests examination or treatment for a medical condition, shall be provided an appropriate medical screening examination within the facility's capabilities to determine whether or not an emergency medical condition exists.
B. If it is determined that the individual has an emergency medical condition, the appropriate medical personnel shall provide such further examination and treatment as may be required to stabilize the condition, or transfer the individual to another medical facility in accordance with these policies. If the patient is stabilized or no medical emergency exists, the patient may be treated, transferred or discharged.
Definition(s):
A. Medical Screening Evaluation: A clinical evaluation performed by a physician or a mid-level provider (i.e., Physician's Assistant, Certified Nurse Practitioner, Certified Midwife), a registered nurse (RN) with training and experience in a specialized area (i.e., emergency department, labor and delivery, psychiatry), or a mastered prepared mental health professional (i.e., LCSW [Licensed Clinical Social Worker], LPC [Licensed Professional Counselor], MSW [Masters of Social Work], etc.) working under the supervision and direction of a physician, to determine if an emergency condition exists. The screening shall be within the capabilities of the hospital, including routinely available ancillary services.

Review of facility policy ED-124, Emergency Department Triage, effective 06/03/2014, revealed the emergency registered nurse triages each health care consumer utilizing age, developmentally appropriate, and culturally sensitive practices to prioritize and optimize health care consumer flow, expediting those health care consumers who require immediate care.
ll. Rationale:
Triage is the process of prioritizing incoming/arriving patients within the Emergency Department. The goal is to rapidly gather "sufficient" information to determine triage acuity.
lll. Related Educational Competency/Requirements:
A. Triage would be conducted by a trained, ED experienced registered nurse using subjective and objective data while providing physical, emotional and psychosocial support to the health care consumer, family and others as appropriate.
B. Documents relevant data and triage acuity for every health care consumer in a retrievable form.
C. Implements appropriate interventions according to established organizational policies/protocols, as warranted by the health care consumer's status.
V. Procedure:
B. The patient is assigned a level using the ESI (Emergency Severity Index), 5 level system, to determine priority of care. Level 1 (most urgent) to level 5 (least urgent).
C. The triage nurse will then complete a more in depth initial assessment including both subjective symptoms and objective signs, in addition to a screening history.
D. Once complete, the ED RN will update the ESI triage level. Level 3-5 patients will be seen according to their level of priority and time of arrival when a room is available.

Review of the facility's Emergency Department Triage Addendum 1, Five Level Triage, updated, revealed:
Level 4: Patients in this category were non-urgent, require a less in depth evaluation, and are stable. These patients may require one resource as predicted by the triage nurse. Examples: Migraine headache with history of migraines, sore throat/fever without respiratory compromise, low back pain with urinary symptoms, ankle pain after fall without chest pain or fainting, laceration with simple repair.
Level 5: Patients in this category were non-urgent patients, require a less in- depth evaluation, and are stable. These patients do not require any resources as predicted by the triage nurse. Examples: Back to work note, prescription refill, mild low back pain without urinary symptoms, and earache with or without fever greater than 3 months of age.

Review of facility policy ED-162, Medical Screening Exams ESI Level 4 & 5 Patients in the Emergency Department, effective 12/02/2014, revealed:
II. Rational
B. Utilizing Emergency Severity Index (ESI) triage scoring criterion, low acuity patients (Levels 4 & 5) are not considered high risk or a medical emergency.
III. Related Educational/Competency Requirements
A. Medical screening exam (MSE) was to be completed by the triage nurse on the ESI level 4 and 5 patients. The triage nurse is a registered nurse who has at least (6) months of ED nursing care experience.
B. The registered nurse was to complete a triage competency prior to working independently at triage.
C. The RN would also complete annual education and competency verification on the medical screening of ESI level 4 and 5 patients.
V. Clinical Policy
A. Medical screening is done on all ED patients to determine if an emergency medical condition is present.
VI. Procedure
A. Once the patient is identified as a level 4 or 5 by the triage nurse, the nurse will complete the MSE checklist.
B. Once the checklist is completed,
1. If the answers are all "No" then the nurse will check the "Patient is stable and appropriate for referral box".
2. If there is "Yes" circled, then the RN will check the box, "Referred to provider for MSE".
C. If the patient is referred to the provider for MSE, the chart will be evaluated by the provider.
D. If the patient is stable and appropriate for financial referral, the patient location would be changed on the electronic tracker board to WRFC (waiting room to financial counselor). The financial counselor would complete their financial screening process.
E. If the patient is unable to meet the financial requirements and chooses not to remain, the patient would be given a list of referrals in the community in which to access care. The tracker board disposition will be entered by the financial counselor as "referred out" and the chart taken to the ED for processing.

Review of the hospital's Medical Screening Exam Checklist (formally ED-162-a), dated 05/23/2007, revealed the following screening questions which were to be answered yes or no:
1. Is the Chief Complaint reflective of high acuity, high risk or a true emergency?
2. Are any vital signs abnormal?
3. Are any mental status changes present?
4. Are any abnormalities in the general appearance present that would suggest the presence of an emergency medical condition?
5. Is the patient unable to walk?
6. Does a focused physical exam reveal abnormalities that would be considered an emergency?
7. Does the patient complain of severe pain (greater than 7/10) and/or the presence of clinical signs suggestive of acute pain or distress?
8. Do any possible pitfalls apply to the patient?
9. Is the patient <10 or >70 years old?
** If a "yes" is answered to any of the above questions, the patient will need further medical screening by a physician.
__ Patient is stable and appropriate for referral.
__ Referred to provider for MSE.
RN Signature and Time.

Review of facility policy entitled Point of Service Collections, revised November 2012, revealed:
I. Patients receiving services throughout the hospital would be advised of up-front payment responsibilities and money would be collected at the time of service according to protocol.
II. Implementation
A. Insurance information would be secured at that point of pre-registration/registration and benefits would be verified either on-line or via telephone.
B. Point-of-service payment responsibilities would be determined by pre-registration/ registration/ancillary staff, including deposits, deductibles, co-payments and co-insurance amounts.
C. Payment responsibilities will be communicated to patients/family members and money will be collected and posted at the time of service according to cash collection policies/procedures.
IV. Procedure:
A. Pre-Registration
1. Insured patients were to be advised of all deductibles, co-payments, and/or co-insurance that would be due at the time of service or collected at Pre-Registration.
2. Private pay patients would be advised of scheduled test/procedure costs advised that payment was expected in full at the time of service.
3. Patients indicating an inability to pay would be referred to a financial counselor on a case-by-case basis to discuss payment arrangements.
C. Emergency Department Patients
1. Patients presenting for emergency services would receive a quick-registration at the onset of their visit, without any financial information gathered or assessed prior to a medical screening.
2. After the medical screening, patients would either be registered at bedside or in the hub (depending upon acuity) and at that point, insurance information and payment obligations would be discussed.
4. Point of service collection scripts would be used to communicate payment expectations to patients, and payments would be collected via cash, check, or credit/debit cards.
5. Private pay patients that were unable to meet their financial obligations at the time of service would be routed to a financial counselor for arrangements.
7. All private pay patients would be notified of current deposit requirements for emergency services. Patients that were classified as "non-urgent" would be provided with alternative healthcare treatment options whenever deposit requirements could not be met.

Review of the facility's ED central log from 09/01/2014 through 09/14/2015 revealed ten (10) of twenty-nine (29) medical records reviewed were referred out. The ten (10) referred out records were as follows:
1. Patient #14, was a 19 year old female who presented to the ED on 09/08/2015, documentation revealed the patient was entered into the system at 10:26 a.m. with a chief complaint of abdominal pain. There was no triage notes, no vital signs (temperature, pulse, respirations, or blood pressure), and no evidence of the MSE checklist. The record revealed the patient was referred out by RN (#7). The medical record failed to reveal evidence that a medical screening examination had been performed; and, indicated that no treatment had been provided to the patient.
2. Patient # 15, was a 43 year old male who presented to the ED on 09/04/2014, documentation revealed the patient was entered into the system at 4:07 p.m. with a chief complaint of sleeping disorder. There were no triage notes, no vital signs, and no evidence of the MSE checklist. The record revealed the patient was referred out by RN (#7). The medical record failed to reveal evidence that a medical screening examination had been performed; and, indicated that no treatment had been provided to the patient.
3. Patient #16, was a 22 year old female who presented to the ED on 11/07/2014, documentation revealed the patient was entered into the system at 4:23 p.m. with a chief complaint of eight (8) months pregnant and motor vehicle crash. There was no triage notes, no vital signs, and no evidence of the MSE checklist. The record revealed the patient was referred out by RN (#7). The medical record failed to reveal evidence that a medical screening examination had been performed; and, indicated that no treatment had been provided to the patient.
4. Patient #18, was a 44 year old male who presented to the ED on 01/22/2015, documentation revealed the patient was entered into the system at 10:51 a.m. with a chief complaint of left shoulder and low back pain due to a motor vehicle crash. The triage RN (#17) noted that the patient was triaged as a level four (4) priority. The triage nurse noted that the patient was ambulating without difficulty and moving extremities well. In addition, the nurse noted that the patient's radial (inner wrist) pulses were present and that the patient was alert and oriented to person, time, and place. There were no vital signs documented. The MSE checklist questions were answered no, and the triage nurse noted that the patient was stable and appropriate for referral. The record revealed the patient was referred out by another RN. The medical record failed to reveal evidence that a medical screening examination had been performed; and, indicated that no treatment had been provided to the patient.
5. Patient #19, was a 34 year old male who presented to the ED on 01/01/2015, documentation revealed the patient was entered into the system at 2:56 p.m. with a chief complaint of left knee pain. There was no triage notes, no vital signs, and no evidence of the MSE checklist. The record revealed the patient was referred out by RN (#7). The medical record failed to reveal evidence that a medical screening examination had been performed; and, indicated that no treatment had been provided to the patient.
6. Patient #20, was a 14 year old female who presented to the ED on 03/05/2015, documentation revealed the patient was entered into the system at 4:21 p.m. with a chief complaint of a bump on the back. The triage RN (#7) noted that the patient's chief complaint was a dime sized nodule on the right flank area and that the patient denied pain, bleeding, pus, discomfort, or shortness of breath. The RN triaged the patient as a level four (4) priority. There were no vital signs and no evidence of the MSE checklist. The record revealed the patient was referred out by RN (#7). The medical record failed to reveal evidence that a medical screening examination had been performed; and, indicated that no treatment had been provided to the patient.
7. Patient #21, was a 30 year old male who presented to the ED on 03/07/2015, documentation revealed the patient was entered into the system at 7:04 a.m., the chief complaint was not documented. There was no triage notes, temperature was 97.8, pulse 76, respirations 16, and blood pressure 114/73 (normal vital signs), and no evidence of the MSE checklist. The record revealed the patient was referred out by RN (#7). The medical record failed to reveal evidence that a medical screening examination had been performed; and, indicated that no treatment had been provided to the patient.
8. Patient #22, was a 24 year old male who presented to the ED on 06/17/2015, documentation revealed the patient was entered into the system at 2:39 p.m. with a chief complaint of re-visit, contact-Methicillin Resistant Staphylococcus Auerus (MRSA) leg wound. There was no triage notes, no vital signs, and no evidence of the MSE checklist. The record revealed the patient was referred out by RN (#7). The medical record failed to reveal evidence that a medical screening examination had been performed; and, indicated that no treatment had been provided to the patient.
9. Patient #23, was a 25 year old male who presented to the ED on 07/23/2015, documentation revealed the patient was entered into the system at 3:28 a.m. with complaints of bilateral leg pain for one (1) day. The triage RN (#6) noted that the patient's vital signs were normal and that the patient complained of pain as a level ten (10) on a scale of zero (0) no pain to ten (10) severe pain. The triage nurse noted that the patient was a level four (4) priority. The record revealed the patient was referred out by RN (#6). The medical record failed to reveal evidence that a medical screening examination had been performed; and, indicated that no treatment had been provided to the patient.
10. Patient #24, was a 40 year old female who presented to the ED on 07/29/2015, documentation revealed the patient was entered into the system at 9:00 a.m. with complaints of left foot injury. The triage RN noted that the patient's vital signs were normal , that the patient was a level four (4) priority, but there was no evidence of the MSE checklist. The record revealed the patient was referred out by RN (#7). The medical record failed to reveal evidence that a medical screening examination had been performed; and, indicated that no treatment had been provided to the patient.

Review of eleven (11) employee files (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 17) revealed all files contained documented evidence of initial applications with references, job descriptions, orientation, annual mandatory training which included Emergency Medical Treatment and Labor Act (EMTALA). In addition, each employee had undergone competency testing and had received evaluations. The triage RNs files (#s 1, 4, 5, 6, 7, 8, and 17) had also received medical screening examination training. The MSE training included a test with the following questions:
1. What does EMTALA stand for? Answer: Emergency Medical Treatment and Labor Act.
2. According to EMTALA, the hospital is obligated to provide all patients with: Answer: A MSE.
3. The MSE is performed to determine if an emergency medical condition exists. Answer: True.
4. It is okay to ask about methods of payment or insurance coverage prior to the MSE or emergency medical treatment. Answer: False
5. Which of the following constitutes an appropriate transfer? Answer: D
A. Physician certified in writing, medical benefits of transfer outweigh the risks of transfer.
B. Receiving hospital agrees to accept transfer and has facilities to provide necessary treatment.
C. Copies of medical record are sent from transferring hospital.
D. All of the above.
6. What role does EMTALA play for the gunshot victim found on the pavement in the hospital parking lot? Answer: This is part of the 250-yard zone (code 250). EMTALA states the hospital is responsible for providing necessary emergency medical treatment.
7. If no emergency medical condition exists or the emergency medical condition has been stabilized, the hospital has no further obligation under EMTALA. Answer: True
8. Violations of EMTALA may result in fines of: Answer: $50,000.00
9. Who can perform a MSE? Answer: Qualified medical personnel as determined by the hospital in its rules and regulations.
10. Nurses may perform MSE only on patients with triage acuity of: Answer: 4 & 5
11. The MSE should include: Answer: all of these
A. Are the vital signs abnormal?
B. Are mental status changes present?
C. Does the general appearance show signs of poor skin perfusion or dehydration?
D. Can the patient walk?
12. The purpose and intent for the MSE process is to: Answer: all of these
A. To improve efficiency in the care of ALL patients that have emergent or potentially emergent conditions.
B. To prevent delays in the care of emergent or potentially emergent patients.
C. To promote proper utilization of emergency services.

During an interview on 09/14/2015 at 11:10 a.m., the Vice President of Administration stated the ED triage RN(s) had been doing the MSE on level four (4) and five (5) category patients up until last week. He/she stated a memo had been sent out to the ED nurses.

Review of the memo that was sent from the ED Nursing Director to the ED nurses on 09/09/2015 at 10:30 a.m. in the conference room, revealed effective 09/09/2015, the triage RN MSE process was to be placed on hold. The memo informed staff that the issue of referring level four (4) and five (5) patients to the financial counselor from triage was being reviewed and that financial counseling would only be performed after the MSE was completed by the physician or mid-level provider.

During an interview (#1) with the ED Nursing Director on 09/15/2015 at 2:45 p.m. in the conference room, the Director stated he/she had been in the position for five (5) months and had previously been the ED Nurse Manager for five (5) years. The Director explained that the ED triage classes are taught by the ED educators and that they also teach the EMTALA and MSE course. The Director explained that the EMTALA and MSE is a computer based learning tool. He/she stated, once the course is completed the triage RN(s) have to pass a test, once they pass the test an asterisk is place by the RN(s) name on the schedule to signify that they can work triage and do the MSE on level four (4) and five (5) patients. The Director confirmed that the RN(s) do not have to do any hands on training or competency testing to do the MSE and that in the past, the facility considered the MSE questionnaire to be the MSE. The Director stated that once the triage nurse refers the patient out, the patient is then sent to the financial counselor to obtain the patient's insurance information or if private pay, to set up some form of payment plan. The Director stated one (1) of the ED nurses (#7) had referred out most of the patient's that had been referred out. The Director stated the nurse (#7) had coded the patients incorrectly.

During an interview with ED RN (#6) on 09/16/15 at 9:40 a.m. in the conference room, the nurse stated he/she had worked in the facility for 10 years, and that most of that time had been in the ED. The nurse stated he/she had been a Clinical Coordinator for 3 1/2 years. He/she said the RN(s) were no longer doing MSE(s). The nurse confirmed that previously RN(s) could do the MSE on levels four (4) and five (5). The nurse stated the educators had taught the RN(s) how to use the MSE questionnaire, and that if the nurses had any concerns when doing a MSE, the patient could be seen by the provider. The nurse said the facility had been having the RN(s) do MSE for about four (4) to five (5) years.

During a telephone interview with the ED Medical Director on 09/16/15 at 2:00 p.m., the physician explained he/she had been the ED Medical Director for seven (7) to (8) years. The physician stated he/she was aware the RN(s) were using the MSE questionnaire to do the MSE on level four (4) and level (5) patients. The physician said he/she was under the impression that the nurses were determining whether an emergency medical condition existed prior to referring a patient out. The physician stated he/she agreed that if the MSE documentation was missing then he/she could not say that a MSE was performed. He/she stated a MSE on levels four (4) and five (5) should have a focused history and physical examination.

During an interview on 09/16/15 at 2:30 p.m. in the conference room, the Clinical Coordinator (#7) stated he/she had worked in the ED since March 2013. He/she explained that the Clinical Coordinators' role was to function as the Charge Nurse and that they sometimes had to work in triage and do MSEs. The nurse confirmed that computer based learning courses had been provided for RN(s) who worked triage and did the MSE(s). The nurse explained that a MSE was a head to toe once over of the patient to see if the patient could walk and talk and whether the patient was coherent. The nurse explained he/she had been performing the referred outs wrong because he/she had misunderstood and had coded patients wrong.


The facility failed to ensure that appropriate medical screening examinations were provided for patients that were within the capability of the hospital ' s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for patient #14, #15, #16, #18, #19, #20, #21, #22, #23, and #24. The facility also failed to ensure that an appropriate medical screening examination was provided for patient #14, #15, #16, #18, #19, #20, #21, #22, #23, and #24 by Qualified Medical Personnel.

Based on review of medical records, policies and procedures, on call schedules, Physician Directory and interviews, the facility failed to ensure that the hospital provided medical treatment within its capacity that minimizes the risk to the individuals health for on one (#29) of twenty-nine sampled cases reviewed.

The findings were:

The facility's Emergency Medical Treatment, Stabilization and Transfer Policy, PRB-6463, approved 2/3/2014 was reviewed. The section of the policy titled "B. Transfer of Patients with Emergency Medical Conditions: 1. Transfer Requirements:.. b.) specialized service needed by the patient is not available at the hospital. "

DeKalb Medical Center at Hillandale Transfer Form dated 9/15/2015 for patient #29 was reviewed. The form indicated in the section titled, " Reason for Transfer:...Services not available OB ...II. CONDITIONS TO BE MET FOR TRANSFER TO ANOTHER FACILITY " ...1. Name of Receiving Facility: DMC (Deal Medical Center) Main ER ...3. Accepting Physician: OB/GYN on call physician #18_(name)__.
DeKalb Medical at Hillandale Physician Directory dated September 15, page 4 was reviewed. Review of the Physician Directory verified that OB/GYN on call physician (#18) is an active staff member at DeKalb Medical at Hillandale.
Review of DMC (DeKalb Medical Center) at Hillandale Emergency Department Daily on-call schedule dated September 15, 2015 was reviewed. The ED on-call schedule at Deal Medical at Hillandale verified that OB/GYN physician #18 was on call when the ED physician called and notified her/him (OB/GYN Physician #18) that patient #29 required further evaluation and treatment for her identified EMC. The on-call list verified that Gynecology was available on 9/15/2015. The hospital had capacity on 9/15/2015 to provide the needed care for patient #29.

An interview was conducted with the Nurse Manager on 9/15/2015 at 11:50 a.m. The Nurse Manager stated that not long ago, a patient had an ectopic pregnancy and the OB physician that was listed on the on-call list at DeKalb Medical at Hillandale came in and performed the D&C surgical procedure at DeKalb Medical at Hillandale.

An interview was conducted with on-call physician #18 on 9/15/2015 at 2:00 p.m. The on-call physician stated that she/he had an agreement with her group to treat patients at DeKalb Medical North Decatur, not DeKalb at Hillandale. The facility failed to ensure that medical treatment, that was within its capacity to minimize the risks to patient #29's health, was provided. This resulted in an inappropriate transfer of patient #29 on 9/15/2015.