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Based on interview, policy and procedure review, and documentation in 1 of 25 emergency department (ED) records reviewed (Patient #1) it was determined that the hospital failed to comply with all of the requirements of 42 CFR 489.24 as it failed to provide a medical screening examination (MSE) for Patient #1 to determine whether or not an emergency medical condition existed. However, the findings reflected that hospital staff had immediately identified the failure to provide the MSE, had identified the cause for the failure, had developed and implemented a plan of correction, which included self-reporting to the State Agency, before this investigation was initiated on 06/10/2010. Refer to A2406, CFR 489.24, Medical Screening Exam.

Based on interview, policy and procedure review, and documentation in 1 of 25 emergency department (ED) records reviewed (Patient #1) it was determined that the hospital failed to provide a medical screening examination (MSE) for Patient #1 to determine whether or not an emergency medical condition existed. However, the findings reflected that hospital staff had immediately identified the failure to provide the MSE, had identified the cause for the failure, had developed and implemented a plan of correction, which included self-reporting to the State Agency, before this investigation was initiated on 06/10/2010. Findings include:

1. Documentation on the "ED Clinical Service Record" for Patient #1 reflected that the patient presented to the ED on 06/01/2010 at 1125. The patient's "chief complaint" was recorded as: "[Patient] state was sexually assaulted last [night] 1130". The record reflected that the patient had walked into the ED with "fam/friends". The record further reflected that a Registered Nurse (RN) had triaged the patient which included vitals signs, which were within normal limits, and pain assessment, which was "0".

The "ED Flow Sheet" documentation by the RN reflected that at 1145 the patient was taken to the "family room" for privacy and to wait for police arrival for interview. Attempts were initiated to contact a SANE nurse (Sexual Assault Nurse Examiner) at that time.

At 1200 the "ED Flow Sheet" reflected that a SANE nurse was not available for Sacred Heart University District (SHUD) and the RN contacted SHUD's sister hospital, Sacred Heart Riverbend (SHRB). (SHRB is located 5.7 miles from SHUD.)

At 1230 the "ED Flow Sheet" reflected that the RN was informed that a SANE nurse was on duty at SHRB. The note reflected that "Charge at Riverbend states unable to send sane nurse to UD but is willing to have pt come there for exam."

At 1300 the "ED Flow Sheet" reflected that the police arrived to interview the patient in the family room.

At 1330 the last entry on the "ED Flow Sheet" reflected that police officer requested that the sexual assault exam be completed. The note by the RN reflected that the patient was willing to have the exam and willing to go to SHRB for the exam. The patient and friend were discharged to go to SHRB for the sexual assault exam.

2. The review of the hospital's "EMTALA Compliance Policy" last dated 06/27/2008 reflected a requirement that "If any individual comes to the SHMC ED and a request is made for examination or treatment of a medical condition or comes to an area of the hospital outside the ED requesting emergency services, the hospital will provide an appropriate medical screening examination by qualified medical personnel within the capability of the hospital...". The policy reflected that "Emergency Department Licensed Independent Practitioners or other qualified medical personnel shall provide medical screening examinations...Physicians or other designated providers are responsible for determining whether the individual has an emergency medical condition using the capability of the ED."

3. During an interview on 06/11/2010 at 0900 the ED Nurse Manager stated that physicians (MDs) are scheduled in the ED 24 hours a day, seven days a week and that on 06/01/2010 MDs were scheduled and were present in the ED. The manager also stated that NPs are scheduled in the ED from the hours of 1100 to 2100 seven days a week and that on 06/01/2010 NPs were scheduled and were present in the ED. Review of the "WebSked Emergency Department Master Schedule" for February 2010 through June 2010 reflected that scheduling.

4. The review of the hospital's "Sexual Assault Nurse Examiner Procedure" last dated 04/26/2010 reflected that "Specialty trained and certified RNs to do complete sexual assault exam and evidence collection...The nurse examiner will do complete Forensic Evidence exam on all sexual assault victims in the Emergency Department 15-years and older." The policy reflected the MSE was the "ED physician responsibility".

5. An interview with the hospital Risk Manager was conducted on 06/17/2010 at 1130 to verify information obtained during the interviews on 06/10 and 06/11/2010 regarding SANE nurse availability. The Risk Manager verified that RNs who are also SANE nurses are not necessarily scheduled on a 24/7 basis in the ED. If a SANE nurse is not scheduled in the ED and a sexual assault victim presents, the ED staff would use the SANE nurse call list to call a SANE nurse in to do the exam. If none of those SANE nurses were available the ED staff would use the chain of command for assistance in locating a SANE nurse to conduct the exam.

6. The RN responsible for triaging and managing Patient #1 during that patient's ED experience on 06/01/2010 was interviewed on 06/10/2010 at 1545. The RN stated that he/she is a full-time ED staff who has been employed at the hospital for twenty-plus years and currently works as a Charge Nurse in that department.

The RN stated that on 06/01/2010 Patient #1 walked to the ED triage desk with a friend at approximately 1130. The RN stated the patient was tearful and reported being sexually assaulted by a new roommate the night before at around 2330. The RN stated that he/she triaged Patient #1 which consisted of a full set of vital signs and an assessment based on the patient's complaint. As a result of that process, and the emotional versus physical symptoms the patient manifested, the RN coded the patient as a triage level "3" and the patient and friend took seats in the ED waiting room.

The RN stated the he/she continued to triage other patients who had presented and while doing so noticed that Patient #1 was getting more emotional. As a result, the RN accompanied Patient #1 and the friend to the family waiting room inside the ED treatment area.

The RN stated that he/she began to try to locate a SANE nurse to come to SHUD for the sexual assault exam. He/she identified that a SANE nurse was on duty at SHRB and made a request that the SANE nurse come to SHUD to conduct the exam.

At approximately 1300 the police arrived on site and interviewed Patient #1 in the family waiting room.

The RN stated that he/she was told by the Charge Nurse at SHRB that a SANE nurse could not be sent to SHUD to conduct the exam and asked if it was okay to send Patient #1 to SHRB to have the exam conducted there.

The RN stated that around 1330 the police officer approached the RN and asked if Patient #1 could go to SHRB for the sexual assault exam. The RN stated that Patient #1 had no physical complaints or symptoms and because of the concern for evidence collection "wasn't even thinking about EMTALA" and told the officer "Yes". The RN stated that he/she acknowledged Patient #1 and the friend as they walked out of the ED with the police officer.

The RN stated that as soon as he/she walked back to his/her desk in the ED treatment area and saw Patient #1's chart on the desk he/she realized that the patient had not been seen by the MD.

The RN stated that the usual practice once patient's are triaged, is that the patient's charts are placed in designated racks inside the ED treatment area in accordance with the coded triage level. Once the nursing process has been completed they are moved to another set of racks designated specifically for MD or NP action to ensure that each patient is examined by an MD or NP. The RN indicated that Patient #1's chart had not been processed in accordance with this procedure. He/she stated that he/she had been holding onto the chart at his/her desk while waiting for the police arrival and interview, and resolution of the sexual assault exam.

The RN stated that in sexual assault cases only MDs conducted the MSEs, and it was preferred that the MD and the SANE nurse conduct the MSE and sexual assault examination together as much as possible based on the patient's physical condition to ensure the preservation/integrity of the forensic evidence. Therefore, the RN was holding onto the chart until provisions for the SANE exam could be made.

The RN stated that he/she contacted the ED department at SHRB twice to find out if Patient #1 had presented for the SANE exam. He/she indicated that the patient had.

The RN stated that he/she contacted the ED Nurse Manager by telephone and reported to the manager on 06/02/2010 that Patient #1 had not been seen by an MD.

7. Review of the "Annual Training Participation Information for EMTALA Regulations" reflected that all ED staff were in compliance with the hospital's annual EMTALA training and that the RN responsible for the management of Patient #1 on 06/01/2010 had completed the annual training on 05/16/2010.

8. The hospital Administrator, Director of Risk Management and Organizational Integrity, Risk Manager, and ED Nurse Manager were interviewed on 06/10/2010 at 1300. During the interview those individuals reported that on 06/01/2010 Patient #1 had not been seen by an MD in the ED. As a result the ED RN responsible had self-reported the incident to the ED Nurse Manager, the ED Nurse Manager had reported the incident to the Director of Risk Management and Organizational Integrity, the Director of Risk Management and Organizational Integrity along with the hospital Administrator had reported the incident to the State Agency. The hospital had conducted an investigation and had taken and planned multiple corrective actions. The specific corrective actions were shared during the interview and included counseling, education, revision of policies and procedures, and record reviews. Those actions are identified in the hospital's plan of correction which follows.

9. The hospital's Director of Risk Management and Organizational Integrity submitted a document titled "Updated summary of the actions taken following the June 1, 2010, potential EMTALA violation" to the Surveyor on 06/11/2010. That document contained the hospital's plan of correction in response to it's identification that a potential EMTALA violation had occurred:

"Immediate counseling of the involved triage/charge nurse regarding [his/her] actions and judgment in this case and EMTALA requirements in general."
Responsible party - ED Nurse Manager
Completion date - June 2, 2010

"Immediate educational e-mail was sent by the UD ED Nurse Manager to ED staff and ED charge nurses regarding EMTALA requirements."
Responsible party - ED Nurse Manager
Completion date - June 2, 2010

"The ED Medical Director sent an e-mail to the ED physicians and staff at both hospitals reminding them of EMTALA requirements in every case."
Responsible party - ED Medical Director
Completion date - June 2, 2010

"The Charge Nurse is reviewing all transfers on a real-time basis for EMTALA compliance."
Responsible party - ED Nurse Manager
Completion date - June 2, 2010

"Self Reported the potential EMTALA violation to the State Agency, Oregon Public Health Division Health Care Regulation & Quality Improvement Department."
Responsible party - Joint report by the Administrators of the receiving hospital (RiverBend) and the sending hospital (University District)
Completion date - June 3, 2010

"A small group was assembled to review the circumstances of the potential violation and to develop additional follow-up tasks..."
Responsible party - ED Medical Director, SHUD and SHRB ED Nurse Managers, Triage/Charge RN, Director of Risk Management and Organizational Integrity, Risk Manager
Completion Date - June 7, 2010

"The "Sexual Assault for Adults" patient care guideline was revised to require that the patient chart not be kept on the Charge Nurse desk and instead be placed in the MD/NP chart rack and that it only be removed by the SANE nurse or the MD/NP. This will ensure that the patient whose sole chief complaint is sexual assault will receive an MSE before discharge or transfer. If the MD/NP picks it up, it will be for purposes of conducting the MSE. If the SANE nurse picks it up, it will be as part of her exam, a part of which is done with the MD/NP."
Responsible Party - ED Nurse Manager
Completion Date - June 9, 2010

"The "Sexual Assault for Adults" patient care guideline was also revised to clarify that an MSE in sexual assault cases may be conducted by a NP. At the time of this incident, MSEs in such cases were only done by MDs. Removing this variation so that NPs may do the MSE (as in all other patient presentations) will enhance our ability to get the MSEs done in a timely manner."
Responsible Party - ED Nurse Manager
Completion Date - June 9, 2010

"The "Sexual Assault for Adults" patient care guideline was revised to require the charge nurse to initiate the chain of command for problem solving when unable to locate a SANE nurse in these cases."
Responsible Party - ED Nurse Manager
Completion Date - June 9, 2010

"Revised the Sexual Assault Nurse Examiner Policy & the Medical Screening to clarify that MSEs will be offered by an MD or Licensed Independent Practitioner (LIP)."
Responsible Party - ED Nurse Manager
Completion Date - June 9, 2010

"E-mail communications were sent to staff about these changes."
Responsible Party - ED Nurse Manager
Completion Date - June 9 and 10, 2010

"Each staff member has been given a packet of the revised policies together with verbal instructions from their Charge Nurse. Each staff member must sign a statement acknowledging receipt of the packet and attesting to review, understanding and compliance."
Responsible Party - ED Nurse Manager
Completion Date - June 9, 2010

"The Nurse Manager and Clinical Educator are conducting 100% retrospective chart reviews. This will continue for 3 months and be re-evaluated for continuation at that time."
Responsible Party - ED Nurse Manager
Completion Date - June 10, 2010

"Discussion of this potential EMTALA violation and the policy revisions is on the agenda for the June 14th ED/Trauma Clinical Service Group (CSG) meeting. The ED Nurse Manager will be presenting."
Responsible Party - ED Nurse Manager
Completion Date - June 14, 2010

"The annual computer-based education (CBE) module regarding EMTALA required for ED nurses is being updated to reflect the policy changes."
Responsible Party - ED Nurse Manager
Completion Date - June 14, 2010

"The Director of Risk Management & Organizational Integrity is on the agenda of the July Charge Nurse Overlap Meeting to answer any follow-up questions that may have arisen by that time concerning EMTALA and the policy revisions."
Responsible Party - Director of Risk Management and Organization Integrity
Completion Date - July 2010

10. Copies of all policies, procedures, revisions and communications referred to in the hospital's plan of correction were reviewed. It was verified that the plan had been developed and implemented prior to the time of the entrance conference of this survey which was conducted at 1300 on 06/10/2010.

11. The findings reflected that on 06/01/2010 Patient #1 had not received a MSE in accordance with the hospital's policies and procedures. The review of 24 other patient ED records revealed MSEs in all those cases. Six of those were for other patients who presented to the ED with a chief complaint of sexual assault. In those cases, both the MSE and the SANE exam had occurred.

The failure on 06/01/2010 was determined to not be for lack of systems, policies and procedures, staff knowledge or awareness. Further evidence of that is the RN's immediate identification of the failure and his/her self-report to the supervisor. In response to the RN's self-report, supervisory, management, executive, and medical staff responded timely and appropriately to develop and implement a plan of correction to prevent the failure from occurring again.