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Based on review of facility policies and procedures, Medical Staff Bylaws/Rules and Regulations, Emergency Room Schedule, Medical Records, Emergency Room Central Log, Facility Correspondence, Credential Files, Personnel Files, Quality Data, Computer Query entitled "Master Patient Index" and staff interviews, it was determined that the facility failed to comply with 42 CFR Parts 489.20 and 489.24 for one (1) patient (#2), of twenty (20) sampled patients.

Findings include:

Cross refer to A2403, the facility failed to create a medical record for patient #2, who presented to the ER;

Cross refer to A2405, the facility failed to maintain documentation in the facility's central log of each patient who presented to the ER, including patient #2, who presented to the ER;

Cross refer to A2406, the facility failed to provide an appropriate Medical Screening Exam (MSE) to patient #2, who presented to the ER;

Cross refer to A2407, the facility failed to provide appropriate stabilizing treatment as required for patient #2, who presented to the ER;

Based on review of the policy entitled, " Medical Staff Bylaws/Rules and Regulations, Computer query" Master Patient Index", and staff interviews, it was determined that the facility failed to ensure that a medical record was created for one (1) patient (#2) of twenty (20) sampled patients.

Findings include:


Review of the Medical Staff Bylaws/Rules and Regulations, reviewed and approved 2011, Section "H", item 2, entitled, "Duties; Ensuring that appropriate medical records are maintained on all patients cared for in the ER.

Review of a computer query titled "Master Patient Index" revealed that patient #2 was entered into the Patient Index with a Medical Record Number on August 21, 2013, and discharged on August 21, 2013. However, there was no evidence of a medical record, or services provided for patient #2. The computer query verified that on 8/21/2013 patient #2 presented to the hospital's emergency department.

The RN ER Manager stated that RN #4, was on duty when patient #2, arrived at the hospital. The RN ER Manager stated that RN #4, stated that the admissions clerk requested assistance on August 21, 2013, when patient #2 presented to the hospital after being advised by a police officer to seek medical treatment after a dog bite attack. The admission clerk stated patient #2, was under the age of eighteen (18) and did not have a legal guardian present.


During an interview on 9/22/2013 at 12:00 noon, the RN ER Manager confirmed that patient #2 , did not have a medical record generated..

Interview on September 11, 2013 at 11:45 a.m. the Chief Nursing Officer (CNO), reported that there was a current investigation regarding patient #2, who presented to the ER after sustaining a dog bite. The CNO confirmed that patient #2's name appeared on a computer query, "Master Patient Index", on August 21 , 2013, but patient #2, was not on the Central ER log and confirmed there was no medical record for patient #2.

Interview on September 11, 2013 at 2:00 p.m. RN #4, confirmed being on duty on August 21, 2013 when patient #2, present to Miller County Hospital. RN #4, stated patient #2, presented to the ER after sustaining a dog bite and as directed by the police. Continued interview revealed that RN #4 went to the registration area to speak with the patient. Patient #2 was under 18 years old and stated that her parents could not be reached as they were out of town. RN #4 stated that patient #2 did not want to be evaluated in the ER.

RN #4 reported that the dog bite appeared to be an abrasion with no broken skin, and told patient #2 to seek medical attention the next day. RN #4 confirmed that patient #2 was not entered into the Central ER Log, and there was no medical record generated. The facility failed to ensure that the " Medical Staff Bylaws/Rules and Regulations " were followed by failing to maintain a medical record for patient #2 on 8/21/2013.

Based on review of facility policy and procedure entitled, "Patients Leaving without Being Seen ER" Emergency Room (ER) Central Log, medical records, Facility correspondence, staff interviews, and computer query of the Master Patient Index, it was determined that the facility failed to ensure that each patient who presented to the facility's ER seeking medical assistance was recorded in the Central Log for one (1) patient (#2) of twenty (20) sampled patients.

Findings include:

Review of facility policy, "Patients Leaving without Being Seen" (no policy number identified and no adoption date recorded) revealed that any patient that presents to the ER for treatment but leaves prior to receiving treatment should have documentation including the time the patient left the facility, the reason the patient left, the form entitled, "Withdrawal of Request for Treatment" should be completed, and the patient should be entered into the ER Central log as left without being seen.

Review of the facility's ER Central Log beginning on April 11, 2013 through September 5, 2013, revealed no evidence that patient #2 was registered on the ER Central log, including August 21, 2013, the day patient #2, presented to Miller County Hospital.

Review of a facility correspondence, dated January 18, 2008, addressed to All Nursing Staff revealed, instructions for all nursing staff to review the form titled, "Withdrawal of Request for Treatment and instructing staff to enter all patients into the ER Central log even if the patient refuses to be seen.

Interview on September 11, 2013 at 11:45 a.m. the Chief Nursing Officer (CNO), confirmed that computer query titled, "Master Patient Index," patient #2, was entered into the Patient Index with a Medical Record Number on August 21, 2013, and discharged on August 21, 2013. However, there was no evidence of patient #2 on the ER Central Log.

During an interview on 9/11/2013 at 12:00 p.m. with the RN ER Manager revealed that RN #4, told patient #2, an examination in the ER did not have to be completed but the patient needed to seek treatment the next day. The RN ER Manager instructed RN #4, that patient #2 should have been logged in the Central ER Log, and identified as a "left without being seen" patient and asked to sign a "withdrawal of request for care" form, if patient #2, refused treatment.

Interview on September 11, 2013 at 1:45 p.m. the Registered Nurse (RN) #2 revealed, receiving a telephone call from Health Department Inspector requesting information related to the ER visit of patient #2. . The ER Registered Nurse (RN) #2 confirmed there was no evidence that patient #2 was entered into the ER Central Log. There was no documented evidence that patient #2 was listed/identified on the facility's Central ER log on 8/21/2013.

Interview on September 11, 2013 at 2:00 p.m., RN #4 revealed being on duty when patient #2 to the ER on August 21, 2013. RN #4, confirmed that there was no evidence of the patient entered into the ER Central Log.

Based on review of policies and procedures, Department/Call Schedule(s), ER staffing schedules, Centers for Disease Control and Prevention website information, computer query " Master Patient Index", and staff interviews, it was determined that the facility failed to perform a Medical Screening Examination (MSE) for one (1) patient (#2) of twenty (20) sampled patients who presented to the emergency department requesting medical evaluation to determine whether or not an emergency medical condition existed.

Findings include:

According to the Centers for Disease Control and Prevention (CDC) website, recommends that treatment post exposure begin as soon as possible, with the first dose of immune globulin and four (4) additional doses of vaccination to administered on days three (3), seven (7) and fourteen (14) post exposure.

Review of facility policy entitled "ER Triage and Medical Screening", effective February 2012, revealed that the purpose of the policy was to ensure that a Medical Screening Evaluation (MSE) was completed on all patients who presented to the ER. Continued review of the policy revealed that a patient who presented to the ER would register at the registration desk, be evaluated by the triage nurse, and then receive a MSE by a licensed, qualified ER provider to determine whether or not the patient had an Emergency Medical Condition. Further review of the policy also revealed that patients will have an assessment completed by the triage nurse on the assessment form. Continued review revealed that a patient will have a Medical Screen Evaluation (MSE) completed on the MSE form with date, time and signature of the ER provider.

Review of facility policy entitled, "Triage" revealed that all patients, upon presentation to the ER, were to be assessed in a preliminary fashion by the Triage Nurse. The triage nurse would complete an initial assessment thorough enough to determine the urgency of the patient's condition and allow the staff to prioritize patient flow based on a patient's acuity level.

Review of facility policy entitled, "Patients Leaving without Being Seen" (no policy number identified) indicated that staff were to follow specific procedures when a patient presented to the ER for treatment but left prior to receiving treatment. Review of the policy revealed that the staff were to document that the patient left, the reason the patient left, have the patient sign a "Withdrawal for Request for Treatment form" if possible, and enter the patient as left without being seen in the ER log book.

Review of facility policy entitled, "Emergency Treatment of Minors" (no policy number or effective date), revealed all attempts would be made to contact the parent or guardian of an unemancipated minor prior to treatment, however if permission from a parent or guardian could not be obtained, Child Protective Agency or the local law enforcement agency were to be contacted to assume responsibility.

Review of the facility policy entitled, "Emergency Department/Call Schedule, " for July 2013, August 2013, and September 2013 revealed the ER was staffed with twenty-four (24) hour coverage each day by either a Physician Assistant or a Nurse Practitioner, and a 24 hour physician on-call schedule.

Review of a computer query titled "Master Patient Index" revealed that patient #2, was entered into the Patient Index with a Medical Record Number on August 21, 2013, and discharged on August 21, 2013. However, there was no evidence that a medical screening examination was provided for patient #2 on August 21, 2013.

Interview on September 11, 2013 at 10:25 a.m. and 12:00 p.m. the RN ER Manager, revealed that the CNO had requested an investigation related to patient #2. Continued interview revealed that the Health Department Inspector reported that a family member was upset that patient #2 was not evaluated at Miller County Hospital.

Interview on September 11, 2013 at 11:45 a.m., the Chief Nursing Officer (CNO), revealed that an inspector from the Health Department had contacted the facility to obtain information related to patient #2, who reportedly had been evaluated in the ER for a dog bite, however, patient #2 left the ER without being examined. The CNO confirmed that on 8/21/2013 that a medical screening examination was not completed on patient #2.

Interview on September 11, 2013 at 2:00 p.m. RN #4, revealed that patient #2 was under 18 years old, that the facility policy was that an under age patient can be screened by the provider (nurse practitioner/physician assistant) but not treated unless numerous attempts were made to contact the parents. RN #4 stated, the dog bite area was assessed as an abrasion with broken skin and no bleeding, however the patient reported a drop of blood at the time of the dog bite. RN #4 confirmed telling patient #2, to be evaluated the next day, but the patient did not have to be seen in the ER. Continued interview with RN #4, confirmed that a MSE was not offered to patient #2 and the nurse practitioner was not notified of the patient's presence in the ER. The facility failed to ensure that their policy and procedure related to "Triage and Medical Screening Examination" was followed as evidenced by failing to ensure that on 8/21/2013 patient #2, was triaged and received an appropriate medical screening examination by a licensed qualified emergency room provider to determine whether or not an emergency medical condition existed.

Interview on September 11, 2013 at 3:30 p.m. the Admissions Clerk who was working on August 21, 2013 when patient #2 presented to the ER, stated that the patient had been advised by a police officer to seek medical attention related to a dog bite. Patient #2 was completing the registration form, as the Admissions Clerk was entering the information in the computer, at that time, it was discovered, that patient #2, was under the age of eighteen (18) years old and there was no family was available to sign forms as the parents were in Florida. Continued interview revealed that the Admissions Clerk communicated with the Registered Nurse (RN) #4, who came to the registration area to speak with patient #2, after speaking with the nurse the patient left and did not complete the registration form.

Interview on September 11, 2013 at 4:30 p.m. the Nurse Practitioner (NP) who was the designated ER provider on August 21, 2013, when patient #2 presented to the ER revealed the NP had no knowledge of the patient, or any patient with a dog bite injury in the past month. The NP confirmed that all patients who present to the ER should be provided an MSE. Further interview revealed the NP indicated in part, " With a dog bite, he/she might give tetanus, and antibiotics, and a report is filled out by the nurses to report the dog bite to the local health authorities. "

Based on review of policies and procedures, Facility's Quality Data, and staff interviews, it was determined that the facility failed to provide stabilizing treatment as required for one (1) patient (#2) of twenty (20) sampled patients.

Findings include:

Review of facility policy entitled, "ER (Emergency Room) Triage and Medical Screening", effective February 2012, revealed in part, Purpose To ensure a medical screening evaluation is done on all patients who presented to the Emergency Room... Once the MSE has been completed, the ER provider will identify one of the following: ...Further evaluation/testing are required to determine if an EMC is present."

An interview was conducted with the ER manager on September 11, 2013 at 12:00 noon. The ER manager confirmed that, " no treatment... was performed per the provider, " for patient #2 on August 21,2013. The facility failed to ensure that stabilizing was provided as required for patient #2 on 8/21/2013.

On September 11, 2013 at 1:30 p.m. the facility's Quality Data was reviewed. The Quality Data indicated, in part " the patient (#2) is currently getting rabies shots (Postexposure Prophylaxis (PEP) in Albany and was treated five (5) days post exposure.