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Based on observation, interviews and record review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide a medical screening exam to a patient who presented to the Emergency Department (ED) as determined in the hospital policy and procedure (see A-2406).

Based on observation, interview and record review the facility failed to ensure a medical screening exam (MSE) was performed for 1 of 30 patients (#1) requesting services of the Emergency Department (ED) resulting in patient #1 never receiving treatment for her presenting complaint of left ankle pain and, after departing the ED, was later found to have a fractured left ankle at another hospital ED. Findings include:

On 06/26/18 at 1535 the ambulance run-sheet documentation was reviewed. This documentation indicated Patient (Pt) #1, a 72-year-old female, was transported to the hospital ED by the local fire department ambulance on 05/10/18 arriving via stretcher at the destination at 1650. This documentation indicated Pt #1's chief complaint was left ankle pain with an onset of pain at 05/10/18 at 1215. The primary impression was injury of the ankle with possible injury. The examination section indicated, on 05/10/18 at 1631, Pt #1 had left ankle swelling and left ankle pain. The narrative section indicated Pt #1 was found sitting on her walker in no obvious distress and stated she "might've twisted her lt (left) ankle around 1200 PM". The history section indicated Pt #1 was hearing impaired, had a history of hypertension and heart attack, and had "possible bed bugs" on the lower extremities. The signature section indicated the ED registered nurse (RN O) signed for the transfer of patient care on 05/10/18 at 1657. The signature section also indicated Pt #1 did not sign for the permission to transport "due to distress level".

On 06/26/18 at 1545 Pt #1's medical record was reviewed. The patient care timeline indicated the following:

05/10/18 at 1702: Pt #1 arrived in the ED.

05/10/18 at 1703: The arrival complaint is left leg pain.

05/10/18 at 1703: The ED clerical staff assigns self to navigate Pt #1's record.

05/10/18 at 1911: The ED clerical staff removes self from navigating Pt #1's record.

05/10/18 at 2107: The ED notes written by RN O indicated, Pt #1 "was brought to ED for left ankle pain. Pt (#1) had bed bugs all over her. Pt was taken to decon (decontamination room) shower. Pt assisted in taking off clothes. Pt states she can shower on her own in wheelchair. Pt given supplies to bathe and new clothes to wear. When retrieving pt from shower she refused to wash hair. Pt asked to please wash hair because of bed bugs and pt became upset. Pt states she will leave because she is being treated poorly. Pt offered to wear cap and refused. Pt states she will call cab to take her home. Pt was asked to stay multiple time and refused. Pt taken to front entrance to wait for her cab".

05/10/18 at 2112: RN O documented that Pt #1 was dismissed with disposition of LWCS (left without completion of service).

Additional review of Pt #1's medical record for the 05/10/18 ED visit revealed no evidence that a triage assessment was completed, no evidence that a medical screening examination (MSE) was completed, and no evidence that Pt #1 was treated by a clinician for the presenting complaint of left ankle pain. The record did not contain any physician orders or diagnostic results. The clinical impressions were listed as "none". The disposition was documented as LWCS (left without completion of service) and the care timeline was documented as "1702 Arrived" and "2112 Dismissed". Based on this documentation, Pt #1's total care timeline in the ED was 4 hours and 10 minutes.

Review of additional records on 6/28/18 at 0900, showed evidence that Pt #1, after leaving the ED, went to a second hospital ED. These records revealed Pt #1 was assessed in the ED of the second hospital and found to have a fractured left ankle. Pt #1 was admitted to the second hospital for continuing treatment.

During tour of the ED on 06/26/18 at 1020, with the Emergency Medicine Administrator (RN A) present, the ED decontamination room was observed to be located in the high traffic ambulance entrance area directly across from the security station. This large vestibule area contained outer double doors leading from the ambulance entry point to another set of inner double doors leading to a hallway across from the triage area. The actual decontamination room was observed to be a rectangular-shaped tiled room with showering and drainage capabilities.

During an interview with RN O on 06/27/18 at 0900, RN O said he obtained a report from the local fire department that Pt #1's chief complaint was left ankle pain, however, after a brief assessment, Pt #1 was discovered to have bed bugs "all over her body". RN O said, despite the complaints of ankle pain, Pt #1 was otherwise stable. RN O said Pt #1 was transported through the inner double doors into the hallway across from the triage area, however, Pt #1 was never actually transported into the triage area. RN O said, after a very short stay in the hallway, Pt #1 was transported "straight back" into the decontamination room for showering and processing of personal belongings and clothing. RN O said during the decontamination process Pt #1 showered independently with minimal staff assistance while sitting in a wheelchair. RN O said during the decontamination process, Pt #1 refused to wash her hair claiming "she (Pt #1) just got over the flu". RN O said Pt #1 remained non-compliant with washing her hair despite efforts to provide hair covering and additional support. RN O said Pt #1 claimed that she was being treated poorly and requested to "call a cab" to leave the ED. RN O said Pt #1 departed the ED before the completion of service, however, RN O could not recall the actual time, estimating it was "around 1 to 1.5 hours later ...but I can't be sure of that". RN O said, on 05/10/18 the ED was busy but not anything "out of the ordinary" in terms of overall acuity. RN O said he documented Pt #1's disposition as LWCS "hours later" (05/10/18 at 2112) because he thought Pt #1 might change her mind and come back for service. RN O said he never contacted a physician during Pt #1's request for ED services on 05/10/18. RN O said Pt #1 was never transported to the triage area. RN O said no treatment was provided for Pt #1's chief complaint of left ankle pain as he focused on containing the bed bugs first. RN O said a medical screening examination was not completed because Pt #1 departed the ED.

The Department of Emergency Services Administrator (RN A) was interviewed on 06/26/18 at 0940, 06/26/18 at 1445, 06/26/18 at 1510, and 06/27/18 at 0840. During these interviews RN A indicated the hospital did not have a policy or procedure for the use of the ED decontamination room. RN A indicated the decontamination room was used infrequently by ED staff, usually reserved for incidents of higher magnitude like persons having toxic chemical exposure. RN A said there was no video evidence of the time frames Pt #1 was present in the ED on 05/10/18. RN A acknowledged Pt #1 did not have a medical screening examination performed. RN A was unable to provide any evidence that the ED acuity was extraordinarily high on 05/10/18. RN A was unable to provide a clear time frame in which Pt #1 departed the ED. RN A indicated ED clerical staff will document when they assign and remove self from the patients record, however this information was for clerical purposes, including to see if the patient has a primary care physician, or possible past history within the health care system.

During an interview with the Associate Chief Medical Officer and ED Physician (MD C) on 06/27/18 at 0930 MD C said the hospital has a tool (ESI, Emergency Severity Index) for use in the ED triage process to categorize ED patients by acuity and resource needs. MD C said this triage tool groups patients into 5 groups, from level 1 (most urgent) to level 5 (least urgent). MD C said the triage process is usually completed by the ED RN who communicates relevant information to other members of the treatment team, including physicians, so treatment can be organized and initiated. MD C said average wait times for patients vary, a level 1 patient is seen "immediately", a level 2 "usually within 30 minutes or less", and a level 3, 4, or 5 "usually within one hour or less, sometimes longer". MD C said, despite the use of triage tools, average patient wait times and MSE time frames vary and can be skewed by a variety of factors, including acuity. MD C said ED physicians and other qualified ED staff were expected to perform medical screening examinations. MD C said RN's cannot complete medical screening examinations. MD C was unable to provide any evidence that the ED acuity was extraordinarily high on 05/10/18. MD C was unable to provide any clear time frames showing the point Pt #1 departed the ED, however, MD C suspected it was most likely "around 7:00 -7:30 PM" as that was when the ED clerical staff documented removing themselves from navigating Pt #1's record. MD C said a medical screening examination was not performed on Pt #1 because Pt #1 departed the ED.

During an interview with Security Officer P on 06/27/18 at 1025, Security Officer P said he observed Pt #1 enter into the ED on 05/10/18 "around 5 PM" and was aware Pt #1 had bed bugs from the ambulance driver report. Security Officer P could not recall if Pt #1 was ever transported to the triage area, however he did recall Pt #1 quickly entering the decontamination room after entry into the ED. Security Officer P said he did not see Pt #1 depart the ED, as he is required to rotate postings in the hospital at varying intervals. Security Officer P said the ED decontamination room was used quite frequently, approximately every other day, usually for patients arriving with parasites on their bodies.

On 06/27/18 at 1410 the hospital policy and procedure titled, "Tier 1. Bed Bugs" with current approval date of 12/01/16 was reviewed. This policy indicated, under section labeled Outpatients, "Scenario 2: Patient states they have bed bugs at home, and bugs are found on the patient or their belongings", "Keep the patient in the exam room".

On 06/27/18 at 1415 the hospital policy and procedure titled, "Tier 1. Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance" with current approval date of 04/20/17 was reviewed. This policy indicated, under section 3.5, "Medical Screening Exam (MSE)- the process required to reach with a reasonable clinical confidence, the point at which it can be determined whether or not an EMC (emergency medical condition) exists ..." and, under section 4.1, "Any patient who presents for service seeking examination or treatment for an emergency condition will be provided a medical screening exam (MSE) to determine whether an EMC (emergency medical condition) exists", and, under section 4.1.3, "The MSE is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either stabilized or appropriately transferred".