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Based on review of medical records, staff interviews, and review of facility documents, it was determined that the facility is not in compliance with §489.24 as evidenced by failure to ensure: 1.) all entries in the ED (Emergency Department) log are complete and accurate (A-2405); 2.) a medical screening exam (MSE) was completed by qualified medical personnel in one of five obstetric medical records reviewed (Patient (P) 19) (A-2406); 3.) the physician certification and consent forms were completed at the time of transfer for two of three transfer medical records reviewed (P7 and P16) (A-2409).

Cross Reference:
489.20(r)(3) - Emergency Room Log
489.24(a)(1)(i) - Medical Screening Exam
489.24)e)(1)-(2) - Appropriate Transfer

Based on the review of four of 22 medical records (Patient (P)10, P12, P14, and P15), staff interviews, and review of facility documents, it was determined that the facility failed to ensure all entries in the ED (Emergency Department) log are complete and accurate.

Findings include:

Review of the facility policy titled, "Emergency Department (EHR)" revised 9/6/24, states, " ...Policy: To maintain an accurate log of every patient presenting to the Emergency Department. Procedure: The Emergency Department log will record the following information on each patient. ...Disposition ..."

On 11/13/24, a review of the ED Log for P10 indicated the patient's disposition as "Eloped." A review of the medical record revealed P10 presented to the facility's ED on 11/1/24 at 3:07 PM, with a chief complaint of vomiting and abdominal pain. P10's vital signs were obtained, and lab work completed. A CT [computed tomography] of the abdomen/pelvis was ordered, and P10 refused. The ED Nursing Note dated 11/1/24 at 4:41 AM, stated, "Pt [patient] and family member observed leaving, pt pulled out [his/her] own iv [intravenous] access does not want dressing to be applied, pt stated [he/she] does not want to have ct scan done, felt much better and [he/she] has to take care of [his/her] pets, [doctors name] notified pt leaving."

On 11/15/24 at 11:10 AM, the above findings were reviewed with S4, ED Director. S4 stated, P10's discharge disposition should have been documented as "AMA [Against Medical Advice]," and if P10 refused to sign an AMA form, the nurse should have noted that the patient refused to sign. S4 indicated a disposition of elopement is used when a patient leaves the facility unwitnessed and without notifying facility staff.


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On 11/13/24, a review of the ED Log for P14 indicated the patient's disposition as "Eloped." A review of the medical record revealed P14 presented to the facility's ED on 9/20/24 at 6:29 AM, with a chief complaint of a hand injury. The ED doctor suspected that P14's injuries resulted from a gunshot wound, therefore, he/she notified the police. P14 no longer wanted to be treated once the police arrived. The ED doctor documented a conversation regarding the risks of P14 leaving without treatment. P14's response was "I don't care." The ED doctor documented that P14 left AMA and he/she refused to sign the paperwork. The ED nurse documented P14 was discharged and the ED log lists P14 as eloped. On 11/15/24 at 11:00 AM, S4 confirmed that P14's discharge disposition was inaccurate on the ED log. S4 explained that P14's disposition should have been logged as left AMA.


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On 11/13/24, a review of P12's medical record revealed P12 presented to the facility's ED on 3/6/24 at 12:00 AM with a chief complaint of vomiting and abdominal pain. The Registered Nurse (RN) completed triage at 12:13 AM. At 1:05 AM, P12's ED disposition was documented as "dismissed" in the medical record. A review of the ED log for P12 demonstrated a blank space in the patient disposition column.

On 11/14/24, a review of P15's medical record revealed P15 presented to the facility's ED on 9/7/24 at 9:20 AM with a chief complaint of ankle pain. At 9:31 PM, P15's ED disposition was documented as "dismissed" in the medical record. A review of the of the ED log for P15 demonstrated a blank space in the patient disposition column.

On 11/15/24 at 10:00 AM, an interview was conducted with S17, Director of Patient Access. S17 does not fully understand when "dismissed" is used for disposition. He/she explained that registration staff reported being asked to enter "dismissed" when a patient leaves the waiting area without being treated. According to S17, this would be considered "Left without treatment." S17 thinks patient "dismissed" would be used if a patient is registered for the ED in error instead of a different department, such as radiology. S17 indicated registration should not be entering discharge dispositions for patients.

On 11/15/24 at 11:00 AM, an interview was conducted with S4, who confirmed he/she reviews the ED logs daily. P12 and P15 lacked a discharge disposition on the ED logs. S4 indicated he/she was unable to provide an explanation as to why P12 and P15 lacked a disposition on the log. In addition, S4 stated "dismissed" is not a discharge disposition that should be used within the facility and that there is no related policy. S4 indicated he/she was unaware that dismissed was being used as a discharge disposition.

Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure a medical screening exam (MSE) was completed by qualified medical personnel in one of five obstetric medical records reviewed (Patient (P) 19).

Findings include:

Facility document titled, "[Facility] Medical/Dental Staff Bylaws", approved and adopted on 3/21/2012, states, "... E. EMTALA/Medical Screening ... 3. Authorized qualified medical personnel are those authorized by the Medical/Dental Staff Bylaws and approved by the Board of Trustees. In addition to the Licensed Independent Practitioner, the following personnel are designated as qualified medical personnel and authorized to conduct medical screening examinations for individual who come to the Emergency Department or Labor and Delivery department requesting examination and treatment: Labor and Delivery Department - Level II Registered Nurse (RNC [Registered Nurse Certified] or NP [Nurse Practitioner]) ..."

A review of P19's medical records revealed that the patient presented to the facility's Emergency Department on 7/19/24 at 4:53 AM with complaints of abdominal pain. P19 was quick triaged (time illegible), found to be over 20 weeks pregnant, and was transferred at 4:59 AM to the Maternal Child Health Unit for further triage and assessment. A nursing assessment was completed by Staff (S) 19, Registered Nurse (RN), at 5:37 AM. The communication/provider note by S19 identified a request for S18, an Obstetric Provider, to evaluate P19 in person. A telephone order was received by S19 from S18 on 7/19/24 at 6:32 AM to discharge P19 to home or self care. The medical record lacked evidence of an MSE for P19.

On 11/15/24 at 9:50 AM, upon review of S19's personnel file, it was revealed the personnel file lacked evidence that S19 was a Level II RN, RNC, or NP. Upon request, S1, Chief Nursing Officer, and S12, Director of Maternal Child Health Services, were unable to provide evidence of S19's Level II, RNC, or NP certification. On 11/15/24 at 12:44 PM, S1 and S12 confirmed that S19 was not a Level II, RNC, or NP and that P19's medical record did not have evidence of an MSE performed by a qualified provider.

Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure the physician certification and consent forms were completed at the time of transfer for two of three transfer medical records reviewed (Patients (P)7 and P16).

Findings include:

Review of the facility policy titled, "EMTALA/Medical Screening Evaluation", last reviewed 9/6/24, " ... If a patient is to be transferred for medical necessity, the following must be followed: ... A physician certification (located on the transfer sheet) that the risk of transferring the patient are outweighed by the potential health benefits. The individual risks and benefits must be documented and the patient's medical record must support these. The receiving hospital must give acceptance in advance. The accepting physician's name must be documented on the transfer sheet. The patient/representative give written consent for transfer (located on the transfer sheet). ..."

Review of the facility policy titled, "Transfer of Patient to Another Facility" last reviewed 9/5/23, states, " ... Policy: ... 2. If the provider determines, through the hospital policy that the patient should be transferred to another facility for further care, EMTALA standards must be followed. ... 5. Transfer paper will be completed with the following information included. -Physician Authorization for Transfer. -Patient Consent (or Refusal Signature) ..."

On 11/14/24 at 10:20 AM, a review of medical records revealed the following:

On 2/29/24 at 9:26 AM, Patient (P)7 arrived to the Emergency Department (ED) via ambulance, status post fall. The patient was transferred to another facility for a higher level of care at 3:43 PM. P7's medical record lacked documentation that the "Certification of Transfer" and "Consent for Transfer" forms were completed.

On 9/15/24 at 2:43 AM, P16 presented to the ED with a chief complaint of "Alcohol Intoxication and Assault Victim." P16 was transferred to another facility for a higher level of care at 5:11 AM. P16's medical record lacked documentation that the "Certification of Transfer" and "Consent for Transfer" forms were completed.

On 11/15/24 at 2:20 PM, S2, Director of Quality, and S3, Performance Improvement Coordinator, were unable to provide evidence that the "Certification of Transfer" and "Consent for Transfer" forms for P7 and P16 were completed.


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