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Based on interview and document 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 for 1 (#1) of 20 patients resulting in the potential for less than optimal outcomes for all patients seeking emergent care. Findings include:

1. Failure to perform a medical screening exam for 1 (#1) of 20 patients. (See tag 2406)

Based on observation and interview, the facility failed to post Emergency Medical Treatment and Labor Act (EMTALA) signage in the ambulance bay or near the emergency department entrance from the ambulance bay resulting in the potential for all emergency department patients arriving through the ambulance bay to be un-informed of their rights to have a medical screening exam and stabilizing treatment in the emergency department. Findings include:

On 10/18/2021 at 1445, during the tour of the emergency department (ED), the ambulance bay was entered and found to have no EMTALA signage posted. Additionally, it was not posted on the outside wall of the hospital by the ambulance bay or just inside the ED from the ambulance bay. This was confirmed by Staff C at the time of discovery who stated, "There is no sign in or around the ambulance entrance. There is a sign in each patient room." When queried if hallway beds or hall recliners were used for patients in the ED, Staff C stated they did use hall beds and hall recliners for patient care areas.

Based on interview and document review the facility failed to log all individuals presenting to the Emergency Department (ED) seeking emergency services resulting in the failure to identify patients leaving the facility without being seen for emergency services and the potential for less than optimal outcomes for patients. Findings include:

During a phone interview with Patient #1's mother on 10/12/2021 at 1345, she confirmed she had Patient #1 at the emergency department on 9/24/2021 at approximately 1330 for the treatment of a broken arm.

On 10/18/2021 at 1630, review of the emergency department log for 09/24/2021 revealed no entry for Patient #1.

During a phone interview on 10/19/2021 at approximately 0825 with Staff I (Emergency Medical Technician (EMT)/Arrival staff member), it was confirmed that Patient #1 did enter the ED on 9/24/2021 during the late afternoon with a chief complaint of fall with possible broken arm. Staff I stated Patient #1 was carried in by her father, taken to triage, and seen by the registered nurse with her two parents. Staff I stated the Patient left and went to another hospital.

Review of medical record for Patient #1 on 10/19/2021 at 0945 revealed a document titled "ED Arrival Information" which indicated Patient #1 arrived to the ED on 09/24/2021 at 1352 via car with a family member with a complaint of arm injury. The ED disposition was documented as "arrived in error" and Patient #1 was discharged at 1352.

In an interview with Staff C, the Emergency Department (ED) Manager, on 10/19/2021 at approximately 1330, she stated she had reviewed the ED log for 09/24/2021 and did not locate Patient #1 on the log. Staff C stated Patient #1 should be on the log, and when staff entered "arrival in error" it essentially deleted Patient #1 from the system and the log. She said staff should have documented Patient as "left without being seen".

In an interview with Staff K on 10/18/2021 at 1435, an EMT/Arrival staff member, she stated it is procedure for all patients who come into to the emergency department requesting treatment to be entered into the system, whether they decide to stay or not.

Based on interview and document review, the facility failed to provide a medical screening examination (MSE) for 1 (#1) of 20 patients presenting to the emergency department seeking emergent care resulting in the potential for a less than optimal patient outcomes.

During an interview on 10/12/2021 at 1330 confidential informant A stated Patient #1 arrived with her parents at their acute care hospital (Facility B) after driving for over an hour from another hospital. Patient #1 had a displaced fracture of her arm which required sedation, reduction (bones to be re-aligned), and splinting. The parent's reported the child was only quickly seen by a nurse and told they were busy, they would need to go to the large hospital anyway. A physician never saw the child.

In an interview on 10/12/2021 at 1345, Patient #1's mother stated she and Patient #1's father presented to the emergency room at Facility A with Patient #1 after the school called to report she (#1) had fallen from the monkey bars, broken her arm and the bone was almost through the skin. The mother stated, upon arrival at Facility A, the women at the desk initially stated "we are full and you will probably have to go (Facility B) anyway". Then the nurse took them to a chair, unwrapped the child's arm and said, "we don't have a bed, we don't have an ortho (orthopedic physician specializing in bones/bone injuries). We could get an x-ray, but you will need to go to (Facility B) anyway. The wait (at Facility A) is going to be several hours." The mother asked the nurse if they were going to call (Facility B). The nurse told her it wouldn't get them in line any faster if the hospital called or if they called. The mother stated the nurse did not obtain vital signs on Patient #1, did not check for a pulse in Patient #1's arm or hand, and did not assess Patient #1 for a head injury. The mother stated at no time did a physician, nurse practitioner or Physician Assistant assess Patient #1. She and the father of Patient #1 left with Patient #1 and drove over an hour to the hospital recommended by the nurse.

In an interview with Staff I (Emergency Medical Technician (EMT)/Arrival staff member) on 10/19/2021 at approximately 0825, she confirmed the school called in the afternoon of 09/24/2021 to report the parents of Patient #1 were coming with her due to a fall from the monkey bars and she had a possible broken arm with bone almost through the skin. Staff I stated when the parents arrived, the child appeared to be in a lot pain, the nurse saw her in triage right away, and the Emergency Department (ED) was full. Staff I stated she knew they would need to go to (Facility B) because they didn't have any ortho, and they did leave due to the wait. Staff I said Patient #1 was not seen by a physician before she left.

In an interview on 10/19/2021 at 0850, Staff H, the nurse on duty at the time of Patient #1's arrival stated she did not recall anything about a child with a fracture on the afternoon on 9/24/2021. She stated a lot of people come through complaining of fractures, so I can't recall one patient.

Review of The Bylaws of the Medical Staff for Facility A on 10/19/2021 at 0930, dated 03/2021 states that an appropriate medical screening examination will be provided to any and all individuals presenting to the hospital requesting an examination or treatment of a medical condition (See Administrative Policy PC-05 EMTALA). The examinations will be conducted by qualified individuals including:
1. Physicians
2. Mid-level providers and Nurse Practitioners

In an interview on 10/19/2021 at 1105, Staff R, ED Director stated when a patient presents for treatment, all patients are seen in team triage and should receive a medical screening exam. If they are to be transferred, the nearest hospital with necessary services is contacted and transfer is arranged.

On 10/19/2021 at 1350 Staff T, Chair of the Emergency Department, stated a physician does a medical screening exam on patients and all patients are entered into the system, even if they leave. If the needed services are not available, they are transferred to the nearest receiving hospital.