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Based on interview, medical record review, and facility policies and procedures review, it was determined that the facility failed to follow its policies and procedures and provide a medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (Patient 1) of 20 Emergency Department (ED) records reviewed from February to April 2019.

Please refer to C-2406.

Based on staff interview and record review it was determined that the facility failed to provide a medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (Patient 1) of 20 Emergency Department (ED) records reviewed from February to April 2019. The facility also failed to provide annual training to the ED providers related to the requirements of the Emergency Medical Treatment and Labor Act (EMTALA).

The facility's failure to provide a sufficient MSE to individuals who present to the ED and request evaluation, and the failure to provide EMTALA training updates to the ED providers has the potential for failure to identify an EMC, may cause delays in providing stabilizing treatment, and deterioration of the patient's condition.

Findings Include:

1. Review of the facility's policy titled, "Lincoln County Hospital COBRA Anti-Dumping Guidelines," last reviewed and approved 07/2018, showed, "Lincoln County Hospital will take the following measures:...Provide for an appropriate medical screening examination by a qualified medical person (to determine whether or not an emergency condition exists) to any individual that comes to the hospital and requests examination or treatment...Documentation of an individual's refusal of screening, examination, treatment or transfer will reflect what was offered and the steps taken to secure written, informed refusal it it was not secured."

Review of the ED Log for 04/26/l9, showed the entry, author unidentified, that read, "[Patient 1] EMS [Emergency Medical Services] stopped in ER bay, [but] did not get out of [the] EMS Vechile [sic] - I asked [Staff I, EMS Driver,] 'Whats [sic] going on'- he stated, 'I'm thinking its [sic] cardiac now - We are doing a 12 lead [sic] now [an EKG/electrocardiogram].' I then went and got [the] OCP [on call Provider] so she could speak to [Staff I,] EMS [Driver] personal [sic]."

Further review of the ED Log showed no documentation was entered in the column marked "Dismissal Code" to designate if the patient was discharged, admitted, transferred, refused treatment, left against medical advice, left before registering, or left before being seen by a provider.

During the Entrance Conference interview, on 05/01/19 at 11:45 AM, Staff A, Risk Manager (RM) stated that staff did not register Patient 1 and never started a medical record. Staff A was informed by the nurses and Staff D, Nurse Practitioner (NP), that Patient 1 arrived at the facility's ambulance bay on 04/23/19, and following a discussion between Staff I, EMS Driver and Staff D, NP, Staff I proceeded to transport Patient 1 to another facility (acute care Hospital B - located about 50 miles away). Staff A agreed that no MSE was documented.

During an interview on 05/02/19 at 9:45 AM, Staff I, EMS Driver recalled receiving a page on 04/23/19 to respond to a possible stroke at the address of Patient 1. Staff I reported having recently received training in cardiac signs and symptoms and stated, "This seemed cardiac to me." Staff I stated that EMS policy is to go to the nearest appropriate hospital, and Staff I proceeded to transport Patient 1 to this facility. Staff I stated that as the ambulance arrived at the facility's ED, Staff I attempted to complete a 12-lead EKG, and that while completing the EKG, Staff D, NP opened the back door to the ambulance. Staff I provided a brief report relaying no signs of stroke, but possible cardiac signs were present. Staff I handed the EKG results to Staff D, and Staff D stated, "If you think it's cardiac, we should probably be going to [name of other facility]." Staff I stated Staff D reviewed the EKG results, then stated, "Looks abnormal to me, you should just go." Staff I stated the ambulance then proceeded to (name of other facility).

During an interview with Staff D, NP, on 05/03/19 at 9:50 AM, Staff D recalled the events of 04/23/19 involving Patient 1. Staff D stated that having received notice of a possible stroke case coming in to the ED by ambulance, arrangements had been made for radiology, laboratory, and the on-call consulting physicians to be on stand-by. Staff D stated that a nurse reported that Staff I, EMS Driver, who was then in the ambulance bay of the facility's ED, wanted to discuss the case of Patient 1. Staff D stated that upon opening the ambulance's door, Staff I stated, "I think it's cardiac. I want to go to [name of other facility]. Staff D stated that after reviewing the EKG results, Staff D told Staff I, "If you want to go, okay." Staff D stated that an EMC was assumed, based on the report given by Staff I, and that no MSE was conducted. Staff D was unable to recall receiving EMTALA training since hired by the facility in June 2016.

2. During a second interview with Staff A, Risk Manager, on 05/03/19 at 3:30 PM, Staff A provided the training transcripts of all five ED providers. Staff A stated that the facility has no policy related to EMTALA training, but did expect the ED providers to complete EMTALA training annually.

Review of the training transcripts for all five ED providers: Staff D, NP; Staff E, Physician Assistant (PA); Staff G, NP; Staff H, PA; and Staff K, NP, showed none of the five ED providers received training on EMTALA requirements since 2017.