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Based on interview 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 an appropriate medical screening exam (MSE).
(See A-2406).

Based on document review and interview the facility failed to log 1 of 20 (Patient #1) patients presenting to the Emergency Department (ED) seeking emergency services resulting in the failure to identify patients leaving the facility without being seen and the potential for less than optimal outcomes. Findings include:

On 06/28/22 at 1100 during record review, it was determined that the facility had three (3) separate logs for the purpose of keeping track of all the patients who presented to the ED. All three (3) logs were reviewed. During an interview at the same time with the Director of the ED, Nurse Manager Staff K the following information was determined:

Emergency Department Census Log
This log contains the patients name medical record number, reason for the visit, discharge disposition, arrival date and time, financial class, discharge date and time, discharge to location and encounter type class.

Confidential Sign-In Log
This log contains the date, patient name and the time of arrival only.

Mini Registration Log
This log contains the "patient sticker" that was produced after each patient gets registered (patient name, date of birth, encounter number and medical record number.

During this review at the same time, Staff K was queried as to why Patient (Pt) #1 was not on the "Emergency Department Census Log" that contained the required information. Staff K stated, "because she did not complete the registration process".

On 06/28/22 at 1200 it was determined that Pt #1 did not have an Emergency Department chart for 06/13/22, because she did not complete the "registration process" to be assigned a medical record number and an event id number. Staff K confirmed that Pt #1 should have been on the ED Census log, because she did present to the facility.

On 06/29/22 at 1300 a document review with Staff K of the policy titled, "EMTALA: Treatment of Emergency Medical Conditions and Patient Transfers," policy number 2 ED 156, effective date of 06/28/2022. The policy states the following, "Central Log 1). The hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged." Staff K confirmed that the facility was not following their process of documenting patients who present to their Emergency Department.

Based on interview and document review the facility failed to complete an appropriate medical screening exam for one (#1) of 20 patients reviewed for treatment and medical screening presenting to the Emergency Department (ED) resulting in the potential to delay care and less than optimal patient outcomes. Findings include:

On 06/28/22 at 1300, during an interview with Staff H and Staff L, Registered Nurses who were present on the day that Patient (Pt) #1 presented to the ED, Staff H stated that "when she gave us her license and insurance card, Staff I(registration clerk) became aware the patient was a minor and said we might need to get your mom's consent. Pt #1 said her mom was at work and did not want to bother her". Staff L stated "we can and will still treat you, what is going on? I remember her standing and taking back her license and insurance card saying, "I will just come back with my mom when she gets out of work." Staff L stated "I told her no, we can treat you now, we will get consent later. What is going on?" Pt #1 stated "that's ok, I have someone watching my newborn, I will be back in a bit. Staff L did state that "she never did return".

On 06/29/22 at 1300 a document review with Staff K of the policy titled "Medical Treatment of Minor policy # 2 AMB 012 effective 6/2/2021". Review of the policy shows 1) "An appropriate consent must be obtained prior to providing services ...If the minor requires emergency medical treatment, such treatment may be given absent parental/guardian consent."