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Based on interview and record review, the facility failed to provide timely access to the patient's medical records. This practice delayed the survey process because access to the patient's EMR were not readily accessible to the surveyor. Findings include:

Upon entry to the facility at 10:17 a.m., a request was made to staff member H for unlimited access to the CAHs patient's medical records. The staff member stated the CAH used the "Epic System" and full, unrestricted access would be granted to the surveyors.

On 7/5/17 at 11:45 a.m., a second request was made to staff members H and E for unlimited access to the Epic system.

During an interview on 7/5/17 at 11:46 a.m., staff member E stated the CAH should have already provided access to the Epic system. Staff member E stated she would inquire about the delay in EMR access to the surveyors.

During an interview on 7/5/17 at 1:00 p.m., staff member G stated she was "still working" on obtaining access from the Epic systems administrator. Staff member G stated she would provide the surveyors with assistance in navigating the Epic system, once access had been granted.

On 7/5/17 at 2:06 p.m., a third request was made to staff member H for access to the Epic system.

On 7/5/17 at 2:30 p.m., staff member J provided the CAH's Wi-Fi and password codes to the surveyors.

On 7/5/17 at 3:35 p.m., staff member G provided access to the CAH's Epic system for patient medical records. The staff member stated she was not sure why it took so long to obtain access, and it should have taken "30 minutes from the time access was requested to the time access was granted."

During a record review on 7/5/17 at 3:40 p.m. to 5:17 p.m., the survey team did not have full, unrestricted access to the Epic system.

During a record review on 7/6/17 at 7:16 a.m. to 5:10 p.m., the survey team did not have full, unrestricted access to the Epic system.

During an interview on 7/6/17 at 11:30 a.m., staff member F stated she did not have full access to the Epic system to review the patient's EMR with the surveyor. Staff member F stated she would have another staff member assist the surveyor with the review of the patient's EMR.

During a record review on 7/7/17 at 6:32 a.m. to 4:50 p.m., the survey team did not have full, unrestricted access to the Epic system.

During an interview on 7/7/17 at 11:20 a.m., staff member F stated the surveyor "access to Epic" was limited.

During an interview on 7/7/17 at 4:55 p.m., staff member E stated the survey team did not have full, unrestricted access to the Epic system to review patient medical records. The staff member stated the survey team was granted the "read only" access, which is highly restricted. She stated the CMS regulations are very clear, that full, unrestricted access to the survey team is required.

1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag C2402-Posting of Signs

Based on observation and interview, the facility failed to post signs specifying the rights of individuals to receive examination and treatment for emergency medical conditions and women in labor in a conspicuous area to be noticed by all individuals entering the emergency department. This has the potential to affect most patients entering the emergency department for services.

Tag C2406 - Medical Screening Exam Until Individual Is Stabilized

Based on interviews and record review, the facility failed to comply with the Medicare provider agreement as defined in §489.24 related to the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. Specifically, the facility failed to provide a medical screening exam for a patient who presented to the emergency department, signed a consent to be treated, and requested an exam for 1 (#1) patient out of 25 sampled. (Refer to C-2406)

Based on observation and interview, the facility failed to post signs specifying the rights of individuals to receive examination and treatment for emergency medical conditions and women in labor in a conspicuous area to be noticed by all individuals entering the emergency department. This has the potential to affect most patients entering the emergency department for services. Findings include:

1. During on observation on 7/5/17 at 10:17 a.m., the emergency department did not have signs posted in the emergency department waiting area, registration area, or entrances. One sign was observed to be placed at the ambulance entrance to the left side of the double doors that lead in to the emergency department. The sign was not at eye level and was not in a conspicuous area where the patient would see it in front of them as they entered the double doors.

During an interview on 7/6/17 at 12:25 p.m., staff member D stated the facility should have another at the registration desk, waiting room and both entrances. Staff member F stated the facility had them in the other registration rooms, but those rooms had been recently changed into registration rooms for outpatients.

Based on interview and record review, the facility failed to provide a medical screening exam for a patient who presented to the emergency department, signed a consent to be treated, and requested an exam for 1 (#1) patient out of 25 sampled. This has the potential to affect other patients presenting to the emergency department for care and services. Findings include:

1. Review of the emergency room registration record for patient #1 reflected an admit date of 7/1/17. The admission time was documented to be 2:39 a.m. The admit type documented on the form reflected, "emergency."

A review of the nurse's triage note for patient #1 reflected, "Pt. arrived at ER to[sic] wanting to be evaluated for possible rape by her ex spouse pt registered and asked to wait in waiting room for Sane nurse to arrive for evaluation..." The emergency room medical record for patient #1 did not reflect a medical screen exam had been provided. The nurse's triage note reflected patient #1 waited for the SANE nurse, then left the emergency department and drove herself to a different hospital in a different town.

Documentation under the heading Patient Care Timeline, reflected the patient arrived in the emergency department at 2:01 a.m. The timeline reflected the registration was completed at 2:10 a.m. The timeline reflected the patient was "to be seen." The timeline reflected the patient discharged at 2:42 a.m., and was signed by staff member B.

During an interview on 7/7/17 at 11:30 a.m., staff member C stated patient #1 came to the registration desk and it was not clear to her what the patient wanted. Staff member C stated patient #1 walked in the door and did not have anyone with her. Staff member C stated the patient was glued to her cell phone. Staff member C stated patient #1 was calm and not acting like someone who had been raped. Staff member C stated the patient said she was here for a rape. Staff member C stated because patient #1 was calm and did not present to her as someone who had been raped she thought the patient was there as a support person. Staff member C stated she did not register patient #1 at that time, but was called back to the registration desk by staff member B and that was when she learned that the patient was the rape victim. Staff member C stated she registered patient #1. Staff member C stated the patient told her she did not shower. Staff member C stated staff member B was going to take patient #1 back to a room in the emergency department but because it takes quite a bit of time for the CRT to arrive to do an evaluation the patient waited in the waiting area where she could watch television and be more comfortable. Staff member C stated normally if a patient is presenting as a rape victim they are taken right back to a room. Staff member C stated she did not know if the doctor examined the patient. Staff member C stated the patient met the SANE nurse out in the parking lot and she did not know where she went from there.

During an interview on 7/6/17 at 3:45 p.m., staff member B stated patient #1 showed up at the emergency department and registered to be examined for rape because her ex husband raped her. Staff member B stated he asked the patient if her ex-husband was at the hospital, or if she was feeling threatened. Staff member B stated the patient told him no. Staff member B stated the patient told him the SANE nurse was coming to the emergency department to meet her. Staff member B stated staff member A was sitting in close proximity to the registration window during the patient's registration. Staff member B stated staff member A said he should not have to deal with this. Staff member B stated he asked the patient if he could call the SANE nurse and the patient agreed. Staff member B stated he spoke with the SANE nurse and told her the hospital emergency department did not have rape kits. Staff member B stated the SANE nurse told him she was almost there at which point he handed the phone to the patient. Staff member B stated the patient spoke on the phone for 3-4 minutes. Staff member B stated the patient told him she was going to go to Butte and get this taken care of. Staff member B stated he told her OK and walked her out to her vehicle to follow the SANE nurse. Staff member B stated the patient appeared calm and told him she was OK to drive to Butte. Staff member B stated the patient was in the emergency department approximately 20 minutes from the time of arrival until he walked her to her car. Staff member B stated he thought they should have got her registered, placed her in a room, obtained her vital signs and had staff member A provide a medical screening exam. Staff member B stated in the future his plan would be to register the patient, call the SANE nurse and make sure the medical screening exam was done prior to the patient's discharge for services. Staff member B stated, "we did the patient a disservice."

During an interview on 7/6/17 at 3:40 p.m., staff member A stated normally a patient receives a medical screening exam and stabilizing treatment, then a call is made to SANE to arrange the exam. Staff member A stated there was a disconnect with patient #1 due to her saying she was meeting the SANE nurse. Staff member A stated the patient was supposed to meet the SANE nurse at a different hospital. Staff member A stated he did not see the patient or perform a medical screening exam prior to her leaving. Staff member A stated the patient met the SANE nurse at the facility and went to the other hospital in another town.

During an interview on 7/6/17 at 11:45 a.m., staff member D stated only the physician provides the medical screening exam.

During an interview on 7/6/17 at 3:40 p.m., staff member F stated the emergency department procedure for a patient that presented with sexual assault or abuse required staff to: register the patient, do a medical screening exam, and discharge to SANE for a forensic exam. Staff member E stated the emergency department did not have the kits to do the exam, and staff was not trained to do a forensic exam.

Review of the facility EMTALA policy and procedure reflected all individuals who come to the hospital emergency department requesting examination or treatment shall receive an appropriate medical screening examination to determine if an emergency medical condition exists.