HospitalInspections.org

Based on staff interviews, and review of the facility's EMTALA ED Log, Medical Staff Rules and Regulations, On call Physician schedules, Policies and Procedures, and medical records, the hospital failed to comply with 42 CFR 489.20 and 489.24.

Findings included:

1. The hospital failed to ensure that Medical Staff by-laws determined who was qualified to conduct/perform appropriate medical screening examinations that were within the capability of the hospital's emergency department to include ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 5 (#5, #7, #8, #11, & #13) of 26 of sampled patients. Refer to findings in Tag A-2406.


2. The hospital failed to ensure that all individuals who presented to their facility are provided stabilizing treatment as required within the capabilities of the staff and facilities available at the hospital for 5 ( #5, #7, #8, & #13) of 26 sampled patients. Refer to findings in Tag A-2407.

3. The hospital facility failed to ensure that a medical screening examination was not delayed in order to inquire about the individual's method of payment or insurance status for one (#7) of 26 sampled patients who presented to the hospital seeking medical care. Refer to findings in Tag A-2408.

4. The hospital failed to ensure that medical treatment was provided that was within its capacity that minimize the risk to the individuals health; failed to ensure that the receiving hospital had available space and qualified personnel for the treatment of an individual; failed to ensure that the receiving hospital had agreed to accept the individual; failed to send the receiving facility a copy of the individuals medical records; failed to ensure the individual's transfer was effected through qualified personnel and/or transportation equipment as required during the transfer; and failed to obtain a written certification of transfer for transfer for 1 (#5) of 26 sampled patients. Refer to findings in Tag A-2409.



5. Based on review of the facility's policies and procedures the facility failed to adopt a policy and procedure related to Recipient Hospital Responsibilities 489.24, to ensure compliance with the requirements for 489.24 Review of the facility's policies and procedure failed to reveal a policy which addressed Recipient Hospital Responsibilities.

1. Based on review of the facility's policies, central log, and staff interview, the facility failed to maintain an emergency department central log on each individual who comes to the emergency department seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged for 135 of 2769 randomly sampled patients. Refer to findings in Tag A-2405.

Findings include:

Review of facility's policy PC.005, Log of Individuals Presenting for Emergency Services, issued 1/10, reviewed/revised 01/14, revealed that the facility ensures that all individuals who presented themselves for emergency services would be documented on the Log of Individuals Presenting for Emergency Services.
1.0 All individuals who presented themselves for emergency treatment at the facility and the disposition of each case would be logged on the Log of Individuals Presenting for Emergency Services. This log includes any individual who is physically present on the property of the facility or who is in an ambulance or other vehicle owned by the facility. The log would be maintained in Assessment and Referral Services.
2.0 The following information would be included in the log:
2.1 Date of request for emergency services
2.2 Patient name
2.3 Patient age
2.4 Arrival time
2.5 Mode of arrival
2.6 Nature of complaint
2.7 Whether an emergency medical condition does, in fact, exist
2.8 Departure time
2.9 Disposition
2.10 Initials of Assessment Staff
3.0 The Assessment and Referral Services Director or designee would review each completed log form for accuracy and completeness. Upon review, the Director or designee would sign and date each log.


ED LOG 2016 Reviews 10/2016 through 04/2017
1. Random Sample Patient #1: Review of the ED log dated 10/3/2016 revealed the patient presented to the ED at 10:22 p.m., via car. There was no disposition documented for the patient.

2. Random Sample Patient #2: Review of the ED log dated 10/5/2016 indicated the patient presented to the ED at 12:00 and again on this same day but no time listed There was no documentation of a disposition listed for the patient at either times he presented to the hospital ED.

3. Random Sample Patient #3: Review of the ED log revealed the patient presented to the ED on 10/5/2016 at 5:05 PM via EMS (emergency medical services). There was no disposition documented for the patient.
4. Random Sample Patient #4: Review of the ED log revealed the patient presented to the ED on 10/10/2016 at 7:33 p.m. via EMS. There was no documentation of a disposition for the patient.
5. Random Sample Patient #5: Review of the ED log revealed the patient presented to the ED on 10/10/2016 via car at 5:42 p.m. There was no disposition documented for the patient.
6. Random Sample Patient #6: Review of the ED log revealed the patient presented to the ED on 10/12/2016 at 10:26 a.m. via EMS. There was no disposition documented for this patient.
7. Random Sample Patient #7: Review of the ED log revealed the patient presented to the ED on 10/12/2016 at 10:47 a.m. via EMS. There was no disposition documented for this patient.
8. Random Sample Patient #8: Review of the ED log revealed the patient presented to the ED on 10/12/2016 at 11:48 a.m. via EMS. There was no disposition documented for this patient.
9. Random Sample Patient #9: Review of the ED log revealed the patient presented to the ED on 10/12/2016 at 1:35 p.m. via EMS. There was no disposition documented for this patient.
10. Random Sample Patient # 10: Review of the ED log revealed the patient presented to the ED on 10/13/2016 as a walk-in (time not completely specified). There was no disposition documented for this patient.
11. Random Sample Patient #11: Review of the ED log revealed the patient presented to the ED on 10/13/2016 (no time or mode of arrival specified. There was no disposition documented for this patient.
12. Random Sample Patient #12: Review of the ED log revealed the patient presented to the ED on 10/14/2016 at 2:30 p.m., via EMS. There was no disposition documented for this patient.
13. Random Sample Patient #13: Review of the ED log revealed the patient presented to the ED on 10/15/2016 at (no time specified) via "Foot." There was no disposition documented for this patient.
14. Random Sample Patient #14: Review of the ED log revealed the patient presented to the ED on 10/17/2016 at 10:00 p.m. via EMS. There was no disposition documented for this patient.
15. Random Sample Patient #15: Review of the ED log revealed the patient presented to the ED on 10/20/2016 at 10:13 a.m. (no arrival mode listed). There was no disposition documented for this patient.
16. Random Sample Patient #16: Review of the ED log revealed the patient presented to the ED on 10/20/2016 at 2:07 p.m., via EMS. There was no disposition documented for this patient.
17. Random Sample Patient #17: Review of the ED log revealed the patient presented to the ED on 10/21/2016 at 3:16 p.m. via EMS. There was no disposition documented for this patient.
18. Random Sample Patient #18: Review of the ED log revealed the patient presented to the ED on 10/24/2016 at 4:30 p.m. There was no disposition documented for this patient.
19. Random Sample Patient #19: Review of the ED log revealed the patient presented to the ED on 10/25/2016 at (no time stated) via EMS. There was no disposition documented for this patient.
20. Random Sample Patient #20. Review of the ED log revealed the patient presented to the ED on 10/26/2016 at 5:17 p.m., via EMS. There was no disposition documented for this patient.
21. Random Sampled Patient #21: Review of the ED log revealed the patient presented to the ED on 10/29/2016 via EMS at 5:26 p.m. There was no disposition documented for this patient.
22. Random Sampled Patient #22: Review of the ED log revealed the patient presented to the ED on 10/30/2016 at 11:00 p.m. via car. There was no disposition documented for the patient.
23. Random Sampled Patient #23: Review of the ED log revealed the patient presented to the ED on 11/02/2016 at 11:31 a.m., via EMS. There was no disposition documented for the patient.
24. Random Sample Patient #24: Review of the ED log revealed the patient presented to the ED on 11/3/2016 (no time or arrival mode specified). There was no disposition documented for the patient.
25. Random Sample Patient #25: Review of the ED log revealed the patient presented to the ED on 11/04/2016 at 12:08 p.m. via car. There was no disposition documented for the patient.
26. Random Sample Patient #26: Review of the ED log revealed the patient presented to the ED on 11/06/2016 at 7:35 p.m., via EMS. There was no disposition documented for the patient.
27. Random Sample Patient #27: Review of the ED log revealed the patient presented to the ED on 11/7/2016 at 3:05 a.m. via car. There was no disposition documented for the patient.
28. Random Sample Patient #28: Review of the ED log revealed the patient presented to the ED on 11/10/2016 (no mode or time specified). There was no disposition documented for the patient.
29. Random Sample Patient #29: Review of the ED log revealed the patient presented to the ED on 11/10/2016 as a walk/in (no time specified). There was no disposition documented for the patient.
30. Random sample Patient #30: Review of the ED log revealed the patient presented to the ED on 11/10/2016 at 4:16 p.m., via car. There was no disposition documented for the patient.
31. Random Sample patient #31: Review of the ED log revealed the patient presented to the ED on 11/10/2016 at 5:30 p.m., via EMS. There was no disposition documented for the patient.
32. Random Sample Patient #32: Review of the ED log revealed the patient presented to the ED on 11/11/2016 at 3:00 p.m., via EMS. There was no disposition documented for the patient.
33. Random Sample Patient #33: Review of the ED log revealed the patient presented to the ED on 11/11/2016 at 5:20 p.m. via EMS. There was no disposition documented for the patient.
34. Random Sample Patient #34: Review of the ED log revealed the patient presented to the ED on 11/11/2016 at 7:09 p.m., via EMS. There was no disposition documented for this patient.
35. Random Sample Patient #35: Review of the ED log revealed the patient presented to the ED on 11/21/2016 at 12:42 p.m., by Law Enforcement. There was no disposition documented for this patient.
36. Random Sample Patient #36: Review of the ED log revealed the patient presented to the ED on 11/21/2016 via EMS. There was no disposition documented for the patient.
37. Random Sample Patient #37: Review of the ED log revealed the patient presented to the ED on 11/23/2016 at 11:54 am via car. There was no disposition documented for this patient.
38. Random Sample Patient #38: Review of the ED log revealed the patient presented to the ED on 12/01/2016 at 8:51 a.m., via EMS. There was no disposition documented for this patient.
39. Random Sample Patient #39: Review of the ED log revealed the patient presented to the ED on 12/2/2016 at 10:58 a.m., via car. There was no disposition documented for this patient.
40. Random Sample Patient #40: Review of the ED log revealed the patient presented to the ED on 12/2/2016 at 2:00 p.m. via EMS. There was no disposition documented for this patient.
41. Random Sample Patient #41: Review of the ED log revealed the patient presented to the ED on 12/2/2106 at 5:26 p.m., via EMS. There was no disposition documented for this patient.
42. Random Sample Patient #42: Review of the ED log revealed the patient presented to the ED on 12/3/2016 at 1:34 p.m. via car. There was no disposition documented for this patient.
43. Random Sample Patient #43: Review of the ED log revealed the patient presented to the ED on 12/4/2016 at 1:00 p.m. via car. There was no disposition documented for this patient.
44. Random Sample Patient #44: Review of the ED log revealed the patient presented to the ED on 12/5/2016 at 1:10 p.m., via EMS. There was no disposition documented for this patient.
45. Random Sample Patient #45: Review of the ED log revealed the patient presented to the ED on 12/5/2016 at 3:42 p.m., (no mode specified). There was no disposition documented for this patient.
46. Random Sample Patient #46: Review of the ED log revealed the patient presented to the ED on 12/6/2916 at 7:37 p.m. via EMS. There was no disposition documented for this patient.
47. Random Sample Patient #47: Review of the ED log revealed the patient presented to the ED on 12/6/2016 at 5:00 p.m., via car. There was no disposition documented for this patient.
48. Random Sample Patient #48: Review of the ED log revealed the patient presented to the ED on 12/8/2016 at 4:12 p.m. via EMS. There was no disposition documented for this patient.
49. Random Sample Patient #49: Review of the ED log revealed the patient presented to the ED on 12/10/2016 at 4:20 p.m. via car. There was no disposition documented for this patient.
50. Random Sample Patient #50: Review of the ED log revealed the patient presented to the ED on 12/10/2016 at 4:45 p.m., via car. There was no disposition documented for this patient.
51. Random Sample Patient #51: Review of the ED log revealed the patient presented to the ED on 12/17/2016 at 10:45 a.m., via EMS. There was no disposition documented for this patient.
52. Random Sample Patient #52: Review of the ED log revealed the patient presented to the ED on 12/20/2016 at 1:55 p.m. via car. There was no disposition documented for this patient.
53. Random Sample Patient #53: Review of the ED log revealed the patient presented to the ED on 12/20/2016 (no time or mode of arrival specified). There was no disposition documented for this patient.
54. Random Sample Patient #54: Review of the ED log revealed the patient presented to the ED on 12/21/2016 at 2:10 p.m. via EMS. There was no disposition documented for this patient.
55. Random Sample Patient #55: Review of the ED log revealed the patient presented to the ED on 12/26/2016 at 12:00 noon. There was no disposition documented for this patient.
56. Random Sample Patient #56: Review of the ED log revealed the patient presented to the ED on 12/27/2016 at 3:00 p.m. via EMS. There was no disposition documented for this patient.
57. Random Sample Patient #57: Review of the ED log revealed the patient presented to the ED on 12/28/2016 at 1:09 p.m., via EMS. There was no disposition documented for this patient.
58. Random Sample Patient #58: Review of the ED log revealed the patient presented to the ED on 12/29/2016 as a walk-in at 2:07 p.m. There was no disposition documented for this patient.
59. Random Sample Patient #59: Review of the ED log revealed the patient presented to the ED on 01/02/2017 at 5:15 p.m. via police. There was no disposition documented for this patient.
60. Random Sample Patient #60: Review of the ED log revealed the patient presented to the ED on 01/02/2017 at 7:29 p.m. (no mode of arrival). There was no disposition documented for this patient.
61. Random Sample Patient #61: Review of the ED log revealed the patient presented to the ED on 01/03/2017 at 3:58 p.m. via Law Enforcement. There was no disposition documented for this patient.
62. Random Sample Patient #62: Review of the ED log revealed the patient presented to the ED on 01/05/2017 via car, and no time was specified. There was no disposition documented for this patient.
63. Random Sample Patient #63: Review of the ED log revealed the patient presented to the ED on 01/05/2017 at 3:30 p.m., as a walk-in. There was no disposition documented for this patient.
64. Random Sample Patient #64: Review of the ED log revealed the patient presented to the ED on 01/05/2017 at 7:50 p.m. via car. There was no disposition documented for this patient.
65. Random Sample Patient #65: Review of the ED log revealed the patient presented to the ED on 01/09/2017 at 1:21 p.m. via EMS. There was no disposition documented for this patient.
66. Random Sample Patient #66: Review of the ED log revealed the patient presented to the ED on 01/09/2017 at 3:30 p.m. (no mode of arrival specified). There is no disposition documented for this patient.
67. Random Sample Patient #67: Review of the ED log revealed the patient presented to the ED on 01/10/2017 at 409 p.m., via car. There is no disposition documented for this patient.
68. Random Sample Patient #68: Review of the ED log revealed the patient presented to the ED on 01/10/2017 via car, (no time specified). There was no disposition documented for this patient.
69. Random Sample Patient #69: Review of the ED log revealed the patient presented to the ED on 1/11/2017 at 11:34 a.m., via EMS. There was no disposition documented for this patient.
70. Random Sample Patient #70: Review of the ED log revealed the patient presented to the ED on 1/12/2017 via EMS (no time specified). There was no disposition documented for this patient.
71. Random Sample Patient #71: Review of the ED log revealed the patient presented to the ED on 1/13/2017 at 12:15 p.m., via EMS. There was no disposition documented for this patient.
72. Random Sample Patient #72: Review of the ED log revealed the patient presented to the ED on 1/13/2017 at 12:25 p.m., via EMS. There was no disposition documented for this patient.
73. Random Sample Patient #73: Review of the ED log revealed the patient presented to the ED on 01/13/2017 at 3:15 p.m., via EMS. There was no disposition documented for this patient.
74. Random Sample Patient #74: Review of the ED log revealed the patient presented to the ED on 1/13/2017 at 6:30 p.m. as a walk-in. There was no disposition documented for this patient.
75. Random Sample Patient #75: Review of the ED log revealed the patient presented on the ED on 1/14/2017 at 2:30 p.m. as a walk-in. There was no disposition documented for this patient.
76. Random Sample patient #76: Review of the ED log revealed the patient presented to the ED on 01/14/2017 at 8:24 p.m., as a walk-in. There was no disposition documented for this patient.
77. Random Sample patient #77: Review of the ED log revealed the patient presented to the ED on 1/15/2017 at 2:00 p.m. as a walk-in. There was no disposition documented for this patient.
78. Random Sample Patient #78: Review of the ED log revealed the patient presented to the ED on 1/15/2017 at 8:10 p.m., via car. There was no disposition documented for this patient.
79. Random Sample Patient #79: Review of the ED log revealed the patient presented to the ED on 1/16/2017 at 1:00 p.m., via car. There was no disposition documented for this patient.
80. Random Sample Patient #80: Review of the ED log revealed the patient presented to the ED on 01/16/2017 at 1:20 p.m. via car. There was no disposition documented for this patient.
81. Random Sample Patient #81: Review of the ED log revealed the patient presented to the ED on 01/18/2017 at 8:13 p.m. (No time specified). There was no disposition documented for this patient.
82. Random Sample Patient #82: Review of the ED log revealed the patient presented to the ED on 01/19/2017 at 6:000 a.m., via EMS. There was no disposition documented for this patient.
83. Random Sample Patient #83: Review of the ED log revealed the patient presented to the ED on 01/22/2017 at 11:50 a.m., (no arrival mode specified). There was no disposition documented on this patient.
84. Random Sample Patient #84: Review of the ED log revealed the patient presented to the ED on 01/22/2017 at 6:30 a.m., via Law Enforcement. There was no disposition documented on the patient.
85. Random Sample Patient #85: Review of the ED log revealed the patient presented to the ED on 01/22/2017 (no time of arrival mode specified). There was no disposition documented on the patient.
86. Random Sample Patient #86: Review of the ED log revealed the patient presented to the ED on 01/22/2017 at 11:12 p.m. via ambulance. There was no disposition documented on the log for this patient.
87. Random Sample Patient #87: Review of the ED log revealed the patient presented to the ED on 01/23/2017 at 4:50 p.m., via car. There was no disposition documented on the log for this patient.
88. Random Sample Patient #88: Review of the ED log revealed the patient presented to the ED on 01/24/2017 at 2:50 p.m., via EMS. There was no disposition documented on the log for this patient.
89. Random Sample Patient #89: Review of the ED log revealed the patient presented to the ED on 02/01/2017 (no time or mode of arrival specified). There was no disposition documented on the log for this patient.
90. Random Sample Patient #90: Review of the ED log revealed the patient presented to the ED on 02/02/2-17 at 5:23 p.m., via EMS. There was no disposition documented on the log for this patient.
91. Random Sample Patient #91: Review of the ED log revealed the patient presented to the ED on 02/02/2017 at 7:06 p.m. via car. There was no disposition documented on the log for this patient.
92. Random Sample Patient #92: Review of the ED log revealed the patient presented to the ED on 02/02/2017 at 7:39 p.m., via EMS. There was no disposition documented on the log for this patient.
93. Random Sample Patient #93: Review of the ED log reveled the patient presented to the ED on 02/03/2017 at 3:10 p.m. via EMS. There was no disposition documented on the log for this patient.

94. Random Sample Patient #94: Review of the ED log revealed the patient presented to the ED on 02/05/2017 at 4:57 p.m. via EMS. There was no disposition documented on the log for this patient.

95. Random Sample Patient #95: Review of the ED log revealed the patient presented to the ED on 02/05/2017 at 5:20 p.m., via EMS. There was no disposition documented on the log for this patient.

96. Random Sample Patient #96: Review of the ED log revealed the patient presented to the ED on 02/04/2017 at 8:20 p.m. via Law Enforcement. There was no disposition documented on the log for this patient.

97. Random Sample Patient #97: Review of the ED log revealed the patient presented to the ED on 12/10/2017 at 3:10 p.m. via car. There was no disposition documented on the log for this patient.

98. Random Sample Patient #98: Review of the ED log revealed the patient presented to the ED on 01/12/2017 at 7:00 a.m., via EMS. There was no disposition documented on the log for this patient.

99. Random Sample Patient #99: Review of the ED log revealed the patient presented to the ED on 02/13/2017 at 5:50 p.m. via car. There was no disposition documented on the log for this patient.

100. Random Sample Patient 100: Review of the ED log revealed the patient presented to the ED on 02/16/2017 at 2:10 p.m., via car. There was no disposition documented on the log for this patient.

101. Random Sample Patient 101: Review of the ED log revealed the patient presented to the ED on 02/16/2017 at 3:50 p.m., via car. There was no disposition documented on the log for this patient.

102. Random Sample Patient #102: Review of the ED log revealed the patient presented to the ED on 02/16/2017 at 11:10 p.m., via ambulance. There was no disposition documented on the log for this patient.

103. Random Sample Patient #103: Review of the ED log revealed the patient presented to the ED on 02/17/2017 at 6:16 a.m., via car. There was no disposition documented on the log for this patient.

104. Random Sample Patient #104: Review of the ED log revealed the patient presented to the ED on 02/20/2017 at 12:46 p.m. via Law Enforcement. There was no disposition documented on the log for this patient.

105. Random Sample Patient #105: Review of the ED log revealed the patient presented to the ED on 02/21/2017 (no date or mode of arrival). There was no disposition documented on the log for this patient.

106. Random Sample Patient #106: Review of the ED log revealed the patient presented to the ED on 02/23/2017 at 7:25 p.m., via EMS. There was no disposition documented on the log for this patient.

107. Random Sample Patient #107: Review of the ED log revealed the patient presented to the ED on 03/02/2017 at 2:20 p.m., via EMS. There was no disposition documented on the log for this patient.

108. Random Sample Patient #108: Review of the ED log revealed the patient presented to the ED on 03/03/2017 (no time or mode of arrival specified). There was no disposition documented on the log for this patient.

109. Random Sample Patient #190: Review of the ED log revealed the patient presented to the ED on 03/07/2017 at 4:46 p.m. via EMS. There was no disposition documented on the log for this patient.

110. Random Sample Patient #110: Review of the ED log revealed the patient presented to the ED on 3/8/2017 at 4:40 p.m., via EMS. There was no disposition documented on the log for the patient.

111. Random Sample Patient #111: Review of the ED log revealed the patient presented to the ED on 3/8/2017 at 2:55 p.m., via the Police. There was no disposition documented on the log for the patient.

112. Random Sample Patient #112: Review of the ED log revealed the patient presented to the ED on 03/08/2017 at 8:30 p.m., via the Police. There was no disposition documented on the log for this patient.

113. Random Sample Patient #113: Review of the ED log revealed the patient presented to the ED on 3/10/2017 at 10:48 a.m., via car. There was no disposition documented on the log for this patient.

114. Random Sample Patient #114: Review of the ED log revealed the patient presented to the ED on 3/14/2017 at 11:21 a.m., via car. There was no disposition documented on the log for the patient.

115. Random Sample Patient #115: Review of the ED log revealed the patient presented to the ED on 3/20/2017 at 7:00 PM., via car. The section of the disposition of the log was scratched out and no new disposition of the patient's status was entered.

116. Random Sample Patient #116: Review of the ED log revealed the patient presented to the ED on 3/23/2017 at 3:20 p.m., via the police. There was no disposition documented on the log for the patient.

117. Random Sample Patient #117: review of the ED log revealed the patient presented to the ED on 3/14/2917 at 3:35 p.m., EMS. There was no disposition documented on the log for the patient.

118. Random Sample Patient #118: Review of the ED log revealed the patient presented to the ED on 3/26/2017 at 6:00 a.m., via EMS. There was no disposition documented on the log for this patient.

119. Random Sample Patient #119: Review of the ED log revealed the patient presented to the ED on 3/26/2017 at 8:36 p.m., via EMS. There was no disposition documented on the log for this patient.

120. Random Sample Patient #120: Review of the ED log revealed the patient presented to the ED on 3/29/2017 at 5:50 p.m., via car. There was no disposition documented on the log for this patient.

121. Random Sample Patient #121: Review of the ED log revealed the patient presented to the ED on 4/1/2017 at 11:27 via Law Enforcement. There was no disposition documented on the log for this patient.

122. Random Sample Patient #122: Review of the ED log revealed the patient presented to the ED on 4/2/2017 at 11:15 a.m., via car. There was no disposition documented on the log for this patient.

123. Random Sample Patient #123: Review of the ED log revealed the patient presented to the ED on 4/2/2017 at 2:10 p.m., via EMS. There was no disposition documented on the log for this patient.

124. Random Sample Patient #124: Review of the ED log revealed the patient presented to the ED on 4/5/2017 at 12:49 p.m., via Law Enforcement. There was no disposition documented on the log for the patient.

125. Random Sample Patient #125: Review of the ED log revealed the patient presented to the ED on 4/5/2017 at 1:15 PM., via EMS. There was no disposition documented on the log for this patient.

126. Random Sample Patient #126: Review of the ED log revealed the patient presented to the ED on 4/23/2017 at 1740, via PED. There was no disposition documented on the log for this patient.

127. Random Sample Patient #127: Review of the ED log revealed the patient presented to the ED on 4/24/2017 at 10:20 p.m., via PED. There was no disposition documented on the log for the patient.

128. Random Sample Patient #128: Review of the ED log revealed the patient presented to the ED on 4/27/2017 at 7:30 p.m., via PED. There was no disposition documented on the log for this patient.

129. Random Sample Patient #129: Review of the ED log revealed the patient presented to the ED on 4/27/2017 at 9:04 p.m., via car. There was no disposition documented on the log for this patient.

130. Random Sample Patient #130: Review of the ED log revealed the patient presented to the ED on 4/29/2017 at 2:06 a.m. via EMS. There was no disposition documented on the log for this patient.

131. Random Sample Patient #131: Review of the ED log revealed the patient presented to the ED on 4/29/2017 at 11:18 via EMS. There was no disposition documented on the log for the patient.

132. Random Sample Patient #132: Review of the ED log revealed the patient presented to the ED on 4/29/2017 at 5:36 p.m., via EMS. There was no disposition documented on the log for this patient.

133. Random Sample Patient #133: Review of the ED log revealed the patient presented to the ED on 4/29/2017 at 5:53 p.m., via EMS. There was no disposition documented on the log for the patient.

134. Random Sample Patient # 134: review of the ED log revealed the patient presented to the ED on 4/29/2017 at 6:06 p.m., via EMS. There was no disposition documented on the log for the patient.

135. Random Sample patient #135: Review of the ED log revealed the patient presented to the ED on 4/29/2017 at 6:69 (no mode of arrival was specified). There was no disposition documented on the log for this patient.

During an interview on 5/1/2017 at (time) the Intake Director acknowledged the above findings related to the ED logs.

Based on review of medical records, ED logs, , policies and procedures Medical Staff Rules and Regulations and staff interviews the facility failed to ensure the hospital Medical Staff by-laws determined who was qualified to conduct/perform appropriate medical screening examinations that were within the capability of the hospital's emergency department to include ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 5 (#'s 5, 7, 8, 11, & 13) of 26 of sampled patients.


Findings include:


1. Review of facility's EMTALA log revealed that Patient #5, a forty-seven (47) year old, walked into the facility's ED on 3/15/17 at 5:45 PM with psychiatric complaints. Documentation in the section of the ED log titled "Emergency Medical Psych Condition (Yes or No)" in this section "N", no was documented; and the Patient #5's departure time was documented as 7:15 PM. Further review revealed that Patient #5 was referred to Hospital 'A' via 'cab'. Review of the medical record sheet for Patient #5 revealed that the disabled patient was registered on 3/15/17 at 5:53 PM. Patient# 5's presenting problem was schizophrenia. An assessment was completed by Assessment Counselor #3. According to the medical record Patient #5's closed disposition was that Patient #5 was referred to inpatient non-UHS facility (REFIP), to an Inpatient Psychiatric Adult Program and the patient's legal status was 'voluntary'. Comments by Assessment Counselor #3 on 3/15/2017 on the medical record included that Patient #5 denied suicidal ideations/homicidal ideations (SI/HI), lacked inpatient criteria and requested to be sent to Health Clinic 'A'. The facility's Referral Recommendations and Crisis Safety Plan dated 3/15/2017 validated patient #5 was referred to Hospital 'A.' No Behavioral Health Assessment were found for Patient #5. There was no documentation in the medical record to indicate that an appropriate Medical Screening examination was provided. for patient #5 on 3/15/2017.

The Medical Record for patient #5 dated 3/15/2017 from Hospital A ( receiving Hospital) was reviewed. Review of the Care Activity report from Hospital A revealed in part, " ... Continuous Charting 3/16/2017 late entry of events starting on 3/15/2017 ...3/15/2017 223- (10:30 PM) Writer called (Anchor Personnel) from Anchor back to inquire about current situation. (Anchor Personnel) stated "He is voluntary and does not meet Anchors requirement for admission." Writer asked what requirements were not met and she replied "He is not having SI/HI." Patient did not have medical clearance available information available and Assessment Counselor #3 responded "Not all patients need medical clearance but some do and that we (Anchor Personnel) called him a cab because he was voluntary. The only reason I called you in the first place was a courtesy call. We did not admit him here." Documentation by the Physician on 3/16/2017 revealed in part, " ...He (#5) presents to the ER via 1013 due to active psychosis. He was sent form Anchor hospital who placed him in a taxi and paid for fare to be sent to this hospital. Review of the medical record revealed that patient #5 presented with a complaint of acute depressive episode with auditory and visual hallucinations with a history of schizophrenia. Patient #5 was admitted to the hospital on 3/15/2017 at 10:15 p.m.


2. Review of the EMTALA Log date 12/01/2016 revealed that Patient #7 a seventeen (17) year-old patient walked into the facility with parents on 12/1/16 at 9:50 PM with a psychiatric complaint and that it was an emergency psychiatric condition. The medical record revealed the patient's presenting problem was "suicidal ideation." The section of the medical record titled Physician assigned was left blank. There was no documentation in the medical record to indicate that the on-call psychiatrist was called to evaluate Patient #7 who presented to the hospital's ED complaining of suicidal ideations. According to the comments section of the medical record revealed that Patient #7 absconded with parents prior to completing an assessment and refused to wait as assessor to verify the patient's insurance. The EMTALA Log revealed that Patient #7 left on 12/1/16 at 11:40 PM. No Behavioral Health Assessment was found for Patient #7. There was no documentation on the medical record to indicate that an appropriate medical screening was provided by a qualified medical personnel for patient #7 on 12/1/2016.


3. Review of the ED log reveled the patient #8 a 51 year old presented to the ED via car on 11/7/2016 at 12:45 p.m. The patient's complaint was listed on the ED log an psychiatric/ CD (Chemical Dependency), and that the patient did not have an emergency medical condition. Review of the facility's Behavioral Health System Initial Clinical Assessment form dated 11/7/2016 revealed the patient's presenting problem was "Suicidal Ideation" and no plan or prior attempts. Further review of the assessment form page 49 of 49 revealed that it was completed by a QMP Assessor. The section of the form titled "Physician Signature" was left blank. There was no documentation in the medical record to indicate the on-call physician was notified on 11/7/2016 that patient #8 was in the hospital with a complaint of suicidal ideation or chemical dependency. There was no documentation that a Medical Screening examination was completed by a Qualified Medical personnel for patient #8 on 11/7/2016



4. Review of the ED log dated 10/12/2016 revealed that Patient #11 presented to the ED via car for a psychiatric complaint and that the patient's psychiatric complaint was not an emergency. Further review of the ED log revealed that patient #11 was referred to acute care facility A. Review of the facility's "Acceptance of Referral /Recommendation for Service/Refusal of treatment" dated 10/12/16 revealed the patient was assessed on 10/12/2016. The form indicated that 2 acute care facilities were recommended for the patient, facility A and B. Patient #11 signed and the assessor signed the form. There was no documentation in the medical record to indicate that a behavioral assessment form was completed for patient #11. There was no documentation that a MSE was provided by a qualified medical personnel for patient #11 on 10/12/2016.

5. Review of the medical record for patient #13 revealed the patient's presenting problem was "Schizophrenia" Further review indicated that a face to face assessment was performed. The comment section of the medical record revealed, Referral Source pulled back. Review of Initial Clinical Assessment dated 9/16/2016 at 8:20 p.m. The patient's Presenting Problem revealed in part, "Per the patient he/she has been diagnosed with schizoaffective disorder. The patient has had recent outbursts and has not been compliant with prescribed meds (medications).Daughter Explains." Further review indicated that the patient did admit to hearing voices and not command. Review of the "Narrative Summary of Factors: The patient does not express SI thoughts and does describe any attempts. Documentation revealed the patient was not currently homicidal or suicidal, therefore the patients ranking is low. Further review revealed the patient has been in and out the hospitals for a month because the patient does not remember to take his/her medications. Review of the Assessment Summary revealed in part, Pt. (patient) did not present with a current episode." The section of the assessment titled "Physician signature was blank. Documentation revealed the patient did not meet the criteria for Emergent medical/psychiatric condition ... as determined by the QMP assessor." There was no documentation in the medical record to indicate that a physician was called to provide a MSE. The medical screening examination was not provided by a qualified medical personnel. Additionally, the medical record did not include vital signs.


Policies and Procedures

Review of facility policy PC.007, Assessing an Emergency, issued 01/10, reviewed/revised 01/17, revealed that it is the facility's policy to assess, stabilize, and/or appropriately transfer individuals who present with an emergency medical condition. Qualified Medical Personnel should provide an appropriate screening examination for any individual who comes to the facility and requests an examination to determine whether the person has an emergency medical condition. An individual who is determined to have an emergency medical condition should be stabilized within the fullest capability of the facility, or transferred pursuant to the facility's policy and procedure to another facility which can appropriately meet the person's needs.
2.0 Screening Examination. An appropriate screening examination should be provided to the individual by Qualified Medical Professional for determination as to whether or not an emergency medical/psychiatric condition exists.

Medical Staff Rules and Regulations

Review of the facility's Medical Staff Rules and Regulations, MS.002, Part 1 and Part 2, Emergency Services, revealed that emergency walk-in and evaluation services would be provided under the direction of the Medical Staff. A member of the staff, on a rotating schedule, would be on duty or on call at all times and available within a reasonable amount of time. The Medical Staff Rules and Regulations failed to reveal who was determined qualified to perform medical screening examinations and also failed to revealed the definition of Qualified Medical Personnel.


Interviews

During the opening conference on 5/1/2017 in the conference room, the Interim CEO confirmed the facility was an Emergency Receiving Hospital that treated adult chemical dependency and psychiatric patients ages thirteen (13) years and older. The CEO stated that medical screening examinations were performed by the Intake Department, who were staffed twenty-four (24) hours per day, seven (7) days per week. Intake Department staff were required to be an RN, or masters prepared in counseling, social work, marriage/family counselors, or related counseling fields. He/she also stated that physicians were in the hospital daily to check their patients; and, were available per on-call schedule during nights, weekends, and holidays. A review of the hospital's Medical Staff Rules and Regulations revealed no documented evidence that a Registered Nurse, Master's prepared in counseling, Social Work, marriage/family counselors, or related counseling fields were listed as determined Qualified Medical Personnel to conduct medical screening examinations


Interview with the Intake Director on 5/2/2017 at 11:48 AM in the conference room revealed that he/she had been in his/her current position for one (1) year, and had been trained in EMTALA upon hire and periodically. He/she was aware that patients should receive a medical screening examination, and that the results of such should be in their medical records.
The Intake Director stated that he/she performed staff evaluations at ninety (90) days, and annually. He/she also stated that he/she performed Quality Reviews monthly, primarily checking for:
" Time in door to disposition
" Quality of test calls
" Timeliness of assessments- within 8 hours of admission
" Completeness of assessments
" Completion of admission consents
" Documentation of fifteen (15) minute checks
He/she also stated that he/she did not routinely check the medical record for Behavioral Health Assessment recommendations versus disposition, but would do so if something stood out.

Based on review of the facility's EMTALA Log, medical records,On-Call Physician schedules, policies and procedures, Medical Staff Rules and Regulations, and staff interviews, the facility failed to ensure that all patients who presented to the facility receive stabilizing treatment as needed/required with the capabilities of the of the staff and facilities available at the hospital
for 5 (#5, #7, #8, #11 and #13) of 26 sampled patients.

Findings include:


1. Review of facility's EMTALA log revealed that Patient #5, a forty-seven (47) year old, walked into the facility on 3/15/17 at 5:45 PM with psychiatric complaints. Patient #5's departure time was 7:15 PM. Patient #5 was referred to Hospital 'A' via 'cab'. Review of the demographic sheet for Patient #5 revealed that the disabled patient was registered on 3/15/17 at 5:53 PM. Patient# 5's presenting problem was schizophrenia. An assessment completed by Assessment Counselor #3. According to the demographic sheet, Patient #5's closed disposition was that Patient #5 was referred to inpatient non-UHS facility (REFIP), to an Inpatient Psychiatric Adult Program and the patient's legal status was 'voluntary'.

Comments by Assessment Counselor #3 on 3/15/2017 included that Patient #5 denied suicidal ideations/homicidal ideations (SI/HI), lacked inpatient criteria and requested to be sent to Clinic 'A' . No transfer form or Behavioral Health Assessment were found for Patient #5. Patient #5 had no medical record and there was no evidence that stabilizing treatment was rendered


2. Review of the demographic sheet and EMTALA Log for Patient #7 revealed that the seventeen (17) year-old patient walked into the facility with parents on 12/1/16 at 9:50 PM with presenting problem of suicidal ideations. According to the comments in the demographic sheet, Patient #7 absconded with parents prior to completing an assessment and refused to wait as assessor verified the insurance. The EMTALA Log revealed that Patient #7 left the facility with her parents on 12/1/16 at 11:40 PM. No Behavioral Health Assessment was found, and no evidence that stabilizing treatment was rendered to Patient #7 on 12/1/2016..

3. Review of the demographic sheet and EMTALA Log for patient #8 revealed that the 54-year-old patient walked into the facility on 11/7/16 at 12:45 PM with the presenting problem of suicidal ideations, no plan. A Behavioral Health Assessment was performed on 11/7/16 at 2:10 PM. Review of The Acceptance of Referral/Recommendations for Service/Refusal of Treatment form revealed the recommendations of a transfer to Hospital 'B' an acute care hospital's, IP (in-patient) psych/detox. Patient #8's diagnosis was listed as bipolar disorder. There was no documented evidence that stabilizing treatment was rendered to Patient #8, on 11/7/2016.

4. Review of the EMTALA LOG revealed that patient #11 presented to the hospital on October 12, 2016 via privately owned vehicle. The patient Complaint was listed as "Psych" the section of the ED Log titled "Emergency Medical Condition" written was "N' meaning no. The patient's disposition was listed as "Referred to (name of an acute care hospital) . Review of the acceptance of the form Referral Recommendations for Service/Refusal of Treatment (dated 10/13/2016) validated Patient #11 was referred to two (2) acute care hospitals. There was no registration information for Patient #11 and no documentation of a mental health assessment was completed. There was also no evidence that stabilizing treatment was rendered to Patient #11 on 10/12/2016.

5. Review of the demographic sheet for Patient #13 revealed that the 56-year-old patient presented to the facility by private vehicle on 9/16/2016 at 7:20 PM presenting with schizophrenia. The medical record contained a Safety and Stress Management Plan from Hospital 'B' dated and signed by the patient on 9/15/16. A Behavioral Health assessment was performed on 9/16/16 at 8:20 PM which noted that Patient #13 had a history of Schizoaffective disorder, had recent outbursts and had been non-compliant with taking medications. The patient denied suicidal thoughts/plans and admitted to hearing voices. The assessment noted that Patient #13 did not meet the criteria for emergent medical /psychiatric condition as determined by QMP Assessor.
Review of The Acceptance of Referral/Recommendations for Service/Refusal of Treatment form revealed recommendations of Transfer to Hospital 'D'. An in-patient level of care was recommended. Also noted were the following:
Risks of Refusing: Lack of secure treatment environment; Benefits of Treatment: Monitored & secure treatment environment;
According to the EMTALA Log, Patient #13 was discharged 9/16/16 at 8:00 PM. There was no evidence of stabilizing treatment rendered, prior to discharge.



During the opening conference on 5/1/2017 at 9:15 AM in the conference room, the Interim CEO confirmed that the facility was an Emergency Receiving Hospital that treated adult chemical dependency and psychiatric patients ages thirteen (13) years and older. The CEO stated that medical screening examinations were performed by the Intake Department, who were staffed twenty-four (24) hours per day, seven (7) days per week. Intake Department staff were required to be a Registered Nurse or masters prepared in counseling, social work, marriage/family counselors, or related counseling fields. He/she also stated that physicians were in the hospital daily to check on their patients and were available per on-call schedule during nights, weekends, and holidays.

Interview with the Intake Director on 5/2/2017 at 11:48 AM in the conference room revealed that he/she had been in his/her current position for one (1) year, and had been EMTALA trained on hire and periodically. He/she was aware that patients should receive a medical screening examination, and that the results of such should be in their medical records.
The Intake Director stated that he/she performed staff evaluations at ninety (90) days, and annually. He/she also stated that he/she performed Quality Reviews monthly, primarily checking for:

" Time in door to disposition
" Quality of test calls
" Timeliness of assessments- within 8 hours of admission
" Completeness of assessments
" Completion of admission consents
" Documentation of fifteen (15) minute checks

He/she also stated that he/she did not routinely check the medical record for Behavioral Health Assessment recommendations versus disposition, but would do so if something stood out.

Review of facility policy PC.007, Assessing an Emergency, issued 01/10, reviewed/revised 01/17, revealed that an individual who is determined to have an emergency medical condition should be stabilized within the fullest capability of the facility, or transferred pursuant to the facility's policy and procedure to another facility which can appropriately meet the person's needs.

Based on review of medical records, ED Logs, and policies and procedures, the facility failed to ensure that a medical screening examination was not delayed in order to inquire about the individual's method of payment or insurance status for one (#7) of sixteen (1 of 16) patients who presented to the facility, out of a total of 26 sampled patients.

Findings include:


The facility's Policy and Procedure titled, "Assessing an Emergency", Policy No: PC.007, Date issued: 01/10, last Date Reviewed/Revised 01/17. The policy revealed in part, Policy ... Procedure: ... 2.0 SCREENING EXAMINATION: ... The screening examination shall not delayed in order to inquire as to whether or not the individual has sufficient financial resources; to pay for treatment, including the availability of insurance coverage."


Review of the medical record and ED Log for Patient #7 revealed that the seventeen (17) year-old patient walked into the facility with parents on 12/1/16 at 9:50 PM with presenting problem of suicidal ideations. According to the comments in the medical record #7 absconded with parents prior to completing an assessment and refused to wait as assessor verified the insurance. The EMTALA Log revealed that Patient #7 left on 12/1/16 at 11:40 PM. Review of the medical record contained evidence that a Behavioral Health Assessment/MSE had been delayed in order to inquire/verify insurance for Patient #7 on 12/1/2016.

Based on review of the facility's medical records, policies and procedures and ED logs the facility failed to ensure that medical treatment was provided that was within its capacity that minimize the risk to the individuals health; failed to ensure that the receiving hospital had available space and qualified personnel for the treatment of an individual; failed to ensure that the receiving hospital had agreed to accept the individual; failed to send the receiving facility a copy of the individuals medical records; failed to ensure the individual's transfer was effected through qualified personnel and/or transportation equipment as required during the transfer; and failed to obtain a written certification of transfer for transfer for 1 (#5) of 26 sampled patients.


Findings include:



Review of facility's EMTALA log revealed that Patient #5, a forty-seven (47) year old, walked into the facility on 3/15/17 at 5:45 PM with psychiatric complaints. Review of the medical record for Patient #5 revealed the disabled patient was registered on 3/15/17 at 5:53 PM. Patient# 5's presenting problem was schizophrenia. Further review revealed that an assessment was completed by Assessment Counselor #3 on 3/15/2017. Comments by Assessment Counselor #3 on 3/15/2017 included that Patient #5 denied suicidal ideations/homicidal ideations (SI/HI), lacked inpatient criteria and requested to be sent to Hospital 'A'. Review also revealed that a face to face assessment was performed and Behavioral Health Assessment were found for Patient #5. There was no documentation in the medical record to indicate that the receiving hospital was called to ensure the receiving hospital had available space and qualified personnel to for the treatment of patient #5; and no documentation that the receiving facility had agreed to accept patient #5 in transfer in order to provide appropriate medical treatment for the patient's psychiatric complaint; and no documentation that copies of the patient's medical records were sent with the patient, and the hospital failed to effect an appropriate transfer of the psychiatric patient through qualified transportation as evidenced by, review of the hospital's ED log revealed that Patient #5's departure time was 7:15 PM., the patient was referred to the receiving hospital (Hospital 'A') via 'cab'. There were no orders written by a physician giving orders to transfer patient#5 to a receiving hospital on 3/15/2017. There was no written certification of transfer form completed for patient #5 prior to transferring the patient on 3/15/2017.

Review of the medical record from the transferring revealed specified in part, " ...He (#5) presents to the ER via 1013 due to active psychosis. He was sent form Anchor hospital who placed him in a taxi and paid for fare to be sent to this hospital." Review of the medical record revealed that patient #5 presented with a complaint of acute depressive episode with auditory and visual hallucinations with a history of schizophrenia. Patient #5 was admitted to the hospital on 3/15/2017 at 10:15 p.m.

Review of facility policy PC.007, Assessing an Emergency, issued 01/10, reviewed/revised 01/17, revealed that it is the facility's policy to assess, stabilize, and/or appropriately transfer individuals who present with an emergency medical condition. Qualified Medical Personnel should provide an appropriate screening examination for any individual who comes to the facility and requests an examination to determine whether the person has an emergency medical condition. An individual who is determined to have an emergency medical condition should be stabilized within the fullest capability of the facility, or transferred pursuant to the facility's policy and procedure to another facility which can appropriately meet the person's needs.

5.0 Patient Transfer - Psychiatric Condition
5.4 Transfer When the Individual is Stabilized. An individual may be discharged or transferred to another facility for actual treatment of mental illness following stabilizing treatment such that an emergent condition no longer exists.
After stabilization, the individual may be offered the option of transfer in the following situations:
5.2.1 The insurance carrier, PPO, HMO, or other managed care organization requires service in another facility or does not cover services offered at the facility
5.2.2 The individual desires less costly services by another provider
5.2.3 Appropriate treatment may be provided in another environment because of certain considerations, i.e., familiarity with staff, availability of special services, geographic proximity to other resources, family or work-related considerations, etc.

Review of facility policy PC.010, Patient Transfer to Another Facility From SCBHS, issued 01/10, reviewed/revised 01/17, revealed that it is the facility's policy to provide for transfer of patients when clinically indicated, using the most appropriate mode of transport relative to the individual's clinical condition. The policy applies to patients for whom transfer is indicated after admission or stabilization following assessment and treatment of a medical or psychiatric condition.