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Based on documentation and interviews, the hospital failed to ensure compliance with requirements of 42 CFR 489.24, when the hospital failed to provide a medical screening examination to all patients who presented to the emergency department requesting to be seen in the emergency department resulting in deficient practice cited at 42 CFR 489.24 (a) and (c) at 2406.

Based on observations during a tour of the emergency department on November 16, 2010, the hospital failed to post conspicuously in the emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination, signs specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment in the emergency department (ED). The findings include:

A tour of the ED was conducted with employee (A)/Regional Nurse at 10:15 a.m. on November 16, 2010. The hospital ED has one waiting room and five bays. Patients are brought directly to the bays. Once the bays are full, the patients wait in the one waiting room to be seen. There were no signs referencing EMTALA rights in the waiting room.

This was confirmed with employee (A) during the tour.

Based on a review of the central log maintained by the hospital's Emergency Department (ED) between June 1, 2010 and November 15, 2010, the hospital failed to ensure that the central log accurately reflected the discharge disposition of 10 of 22 patients (#5, #6, #8, #9, #12, #13, #14, #17, #18, and #22) who presented to the ED. Findings include:

The central log between June 1, 2010 and November 15, 2010 was reviewed and was compared with patient ED records and indicated the following:

Patient #5 presented to the ED on November 5, 2010 with a hand laceration. The central log indicated that the patient expired. A review of patient #5's ED record indicated that patient #5 was discharged to home.

Patient #6 presented to the ED on November 5, 2010 via ambulance. The central log did not indicate the discharge disposition for the patient. A review of the patient's ED record indicated that patient #6 was discharged home.

Patient #8 presented to the ED on November 1, 2010 with abdominal pain. The central log did not indicate the discharge disposition for the patient. Patient #8's ED record indicated that patient #8 was transferred to another hospital for further medical care.

Patient #9 presented to the ED on October 31, 2010 via ambulance with chest pain. The central log did not indicate the discharge disposition for the patient. Patient #9's ED record indicated that patient #9 was transferred to another hospital.

Patient #12 presented to the ED on October 29, 2010 with abdominal pain. The central log did not indicate the discharge disposition for the patient. Patient #12's ED record indicated that patient #12 was discharged to home.

Patient #13 presented to the ED on October 28, 2010 with anxiety. The central log did not indicate the discharge disposition for the patient. Patient #13's ED record indicated that patient #13 was discharged.

Patient #14, presented to the ED on October 24, 2010 with back pain. The central log did not indicate the discharge disposition for the patient. Patient #14's ED record indicated that patient #14 discharged to home.

Patient #17 presented to the ED on October 9, 2010 via ambulance with chest pain. The central log did not indicate the discharge disposition for the patient. Patient #17's ED record indicated that patient #17 was transferred to another hospital.

Patient #18 presented to the ED on October 9, 2010 with a fever. The central log did not indicate the discharge disposition for the patient. Patient #18's ED record indicated that patient #18 was discharged.

Patient #22 presented to the ED on October 2, 2010 with syncope. The central log did not indicate the discharge disposition for the patient. Patient #22's ED record indicated that patient #22 was admitted to the hospital.

Based on observations, interviews, and documentation review, the hospital fails to provide a medical screening examination for 2 of 8 patients (#1 and #2) who presented to the ED for care on October 13, 2010. Findings include:

Observations while onsite on November 16, 2010 revealed the hospital campus has an ED entrance and at the other end of the building a clinic entrance. The ED entrance opens to a registration desk. During the tour employee (A)/Regional Nurse stated that the registration staff immediately takes each patient ' s name and date of birth and then a nurse triages the patient.

Employee (D)/registration staff, was interviewed on November 16, 2010 at 2:06 p.m., and stated that nursing staff will ask patients that present to the ED if they want to be seen in the clinic or urgent care instead of the ED.

Employee (E)/registration staff was interviewed on November 16, 2010 at 2:33 p.m., and stated that patients who present to the ED are given a choice by the nurse of whether they want to be seen in the ED, clinic, or urgent care.

Nurse (B) was interviewed on November 16, 2010 at 1:40 p.m. and stated that she will direct patients to the clinic or urgent care if they request either of the two. Nurse (B) denied asking the patients who present to the ED if they want to be seen in the clinic or urgent care.

Nurse (C) was interviewed on November 17, 2010 at 9:39 a.m. and stated that she gives patients the option to be seen in the ED, clinic, or urgent care, because some times they come in the wrong door. Nurse (C) stated if the patient is someone that needs to be seen in the ED, they are taken directly into the ED, for example a laceration, chest pain, or shortness of breath. She makes this determination by her observations of the patient(s). There is no medical screening examination completed prior to sending the patient to the clinic or urgent care. Nurse (C) was re-interviewed at 12:47 p.m. and stated that the she does not do any documentation on the patients that present to the ED who have chosen to be seen in either the clinic or the urgent care.

Clinic nurse (F) was interviewed on November 16, 2010 at 3:24 p.m. and stated that if a person who presents to the ED has symptoms not severe enough to be seen in the ED, they are brought or directed to the clinic. The nurse from the ED will walk the patient to the clinic registration during business hours or urgent care after the clinic is closed. The patient does not need to be an established patient in the clinic to be seen in the clinic and it is not uncommon for the clinic to see patients from out of town.

Patient #1 and #2 presented to the ED on October 13, 2010. The ED central log was reviewed for October 13, 2010 and patient #1 and #2 were not listed on the log. However, patient #1 and #2 were seen in the clinic that is located at the other end of the building on October 13, 2010. Interviews were conducted with the staff (E, C, and G) who were working in the ED the same time patient #1 and #2 were seen in the clinic and none of the staff could recall the two patients. Clinic documentation indicates that patient #1 was seen and diagnosed with bronchitis and asthma. The clinic documentation indicates that patient #2 was seen and diagnosed with gastroenteritis.

According to the document titled Rules and Regulations of Waseca Medical Center-Mayo Health System Medical Staff & Allied Health Professional Staff, referenced in the bylaws, all individuals who present to the hospital requesting to be seen shall receive a medical screening examination to determine if an emergency medical condition exists. Either a physician or an Allied Health Practitioner can perform a medical screening examination.

According to employee (A)/Vice president/Regional Nurse on November 16, 2010 at 9:40 a.m. a Physician's Assistant or Nurse Practitioner are the Allied Health Practitioners who are identified in the bylaws as the qualified person to complete a medical screening examination.