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Based on a review of the emergency department's (ED) policies and procedures and staff interviews, the facility failed to ensure its ED's policies and procedures were reviewed, up-to-date and followed by all ED staff in conjunction with the facility's COBRA policies as it relates to the EMTALA requirements of 42 CFR ?489.24 and the related requirements at ?489.20. In addition, the facility did not ensure medical records were complete for 7 of 20 ED records reviewed.

Findings include:

1) On 1/14/14 at 9:17 A.M., during an interview with Licensed Nurse #1 (LN #1), she confirmed she was one of the nurses who worked the night shift on 11/22/13 and treated an elderly male patient (Patient #1, a "John Doe") who came to the ED with family members during the early morning hours of 11/23/13. She stated as an ED nurse, she does the medical screening. "Yeah, I do the medical screening." Upon further inquiry, LN #1 acknowledged she was not that familiar with EMTALA and unable to explain what her "screening" entailed for the patients she received in the ED. She also stated, "I do screen the patient, triage and then call the doctor up afterward."

LN #1 recalled on the morning of 11/23/13, everything happened quickly and before she knew it, an ambulance arrived in their ED parking lot. She wheeled Patient #1 out to the parking lot and stated the patient's family called 911. LN #1 said she assisted the patient into the ambulance and the patient was driven off without being seen by their ED physician (Physician #1), who was on duty that night.

LN #1 said she triaged Patient #1 as "emergent." Review of the ED policy "Triage" (Eff. 12/1/05) stated, "All patients will be seen by the ED physician as soon as possible; however, patients categorized as Emergent will have first priority, followed in order by Urgent and Non-Urgent patients." LN #1 said she did not call Physician #1 who had been in his quarters when Patient #1 came to their ED, but that she should have.

During the interview, LN #1 said Patient #1 had atrial fibrillation because she felt his pulse, which was fast and irregular. She also said based on her assessment of the patient, she came to the conclusion the patient "was having congestive heart failure." She said his blood pressure was also high and because the patient said he was short of breath, she placed him on 4 liters of oxygen via a nasal cannula. LN #1 said starting oxygen at 4 liters was one of the things she always did.

A review of an ED policy and procedure, "Mission, Administrative Organization, and Scope of Care" (Eff. 12/1/05) noted within the scope of care it stated, "Persons presenting to the Emergency Department are not turned away for any reason without first undergoing a medical screening examination. Medical screening is performed by a registered nurse, who in consultation with the physician determines treatment urgency."

However, a review of the ED's EMTALA policy and procedure produced by the acting Director of Nursing (DON) on 1/13/14 found the "COBRA Emergency Transfer Policy" (Eff. 1/18/08) for "Nursing-General Services Emergency" stated the policy's purpose was to comply with COBRA requirements... including, "To ensure that a medical screening exam is provided to all patients who present to SMMH... to determine whether or not an emergency medical condition exists, and to provide stabilizing care for the emergency condition." The policy stated within its definitions that a "Qualified medical person may be a professional other than a physician..." but included, "(At SMMH, the QMP is the physician)".

Review of the corporate policy, "Emergency Care, Transfers (COBRA)" (Eff. 9/15/2000), noted SMMH's policy was similar to the corporate policy. Within its QMP definition, the facility had to specify which of their personnel were determined to be the QMPs. Separate interviews with Physician #1 on 1/14/14 and Physician #2 on 1/14/14 revealed only physicians were the QMPs to provide a medical screening examination (MSE) to all patients who came to the SMMH ED seeking care.

During the interviews conducted with the DON on 1/14/14, the Regional Quality Manager (RQM) on 1/16/14, the CEO and Regional Medical Director (RMD) on 1/17/14, they were not aware that one of the ED policies stated, "Medical screening is performed by a registered nurse..." The DON said, "The nurses in the ED does triage, but the medical screening is the doctor's domain." The RQM stated she really did not know when their ED policies were last reviewed but the MSE should only be done by the physician.

In addition, the RQM said they have started to work on a process to capture unusual occurrences in the ED to review things systematically via a checklist. The CEO acknowledged the policy reviews and other quality measures were not done, stated that he held his administrative staff accountable and that they have to revisit their policies in accordance with the federal regulations.

2) Clinical record review for Patients #7, 8, 11, 12, 13, and 21 found the "Time" was not documented on the witness signature on the Terms and Conditions of Service for these patients. For Patient #17, the "Date" and "Time" entries were missing on the form. In addition, for Patients #7 and 12, the acceptance to be bound by the Terms and Conditions of Service (e.g., Emergency room, Outpatient, Inpatient) were not marked. Patients #7, 8, 13, 17 and 21 also had missing documentation for the disclosure of information under the Patient's Rights and Responsibilities. For Patients #7, 17 and 21, the Acknowledgement of Receipt of the Notice of Privacy Practices had missing documentation as well. The DON and LN #2 verified the time entries should be completed on the Terms and Conditions of Service on 1/14/14. The SA found there was more clinical documentation on the forms that were left incomplete but not addressed.

Based on record review, staff interviews and review of the facility's ED policies and procedures, the facility failed to ensure that each individual who comes to the ED seeking care and assistance is placed into a central log, of which the purpose is to track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition 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.

Findings include:

On 1/14/14, during the SA's case selection, it was revealed there was no patient information or documentation pertaining to an alleged 11/23/13 incident related to Patient #1 (a "John Doe") from the interviews conducted of the DON, Physician #1, LN #1 and LN #2. The interview of LN #1 on 1/14/14 revealed she was involved in an encounter with Patient #1 during the early morning of 11/23/13. LN #1 said an elderly male patient came into the ED with family members, but within 5-10 minutes, the patient left by ambulance from their ED to another hospital. LN #1 stated she did not obtain the patient's name, but confirmed she had started care and treatment by taking his vital signs, placed him on 4 liters of oxygen and took a pulse oximetry reading before he left. Interview of LN #2 revealed he heard LN #1 "hooking the patient up" and confirmed LN #1 was taking the patient's vital signs in room 3.

LN #1 verified although she provided care for Patient #1, she did not register the patient into the ED central log because she did not obtain the patient's name nor obtained the patient's consent to treat. Her only documentation of the patient was her written statement on an Event Report Form (ERF). LN #1 wrote the patient as a "John Doe" on the ERF, but did not enter the patient as John Doe in the central log on 11/23/13. LN #1 said she never had any orientation on how to put John Doe type patients in the central log nor patients who left the ED without being seen.

During the interview with LN #2 on 1/14/14, he said the reason Patient #1 had not been entered into the central log was because the consent to treat and registration had not been completed. LN #2 said he did not register any "John Doe" patients in the central log and said, "I think if there are any John Does, they will be in the ERFs. If we don't know who they are and they haven't registered, our process is only those who have registered goes into the registry--the central log." He further stated if care was initiated for a patient and they left, he would not generate an account number because the patient was not registered, was not seen by a doctor and had not signed a consent.

Interview with Physician #1 on 1/14/14 revealed his understanding about the central log was that all patients who walked into the ED were registered and put into the central log.

Review of the facility's policy, "Admission of Patients to the Emergency Department" (Eff. 12/1/05), stated, "II. Policy:...B. An Emergency Department Record shall be completed for each patient who comes to the hospital for emergency medical evaluation and treatment. C. The Emergency Department shall maintain a central log on each individual who comes to the Emergency Department seeking treatment."

Additionally, a review of the central log found there were patients listed as John Does. The SA found for Patient #9, the registration was cancelled, noted as a "LWBS," yet, was recorded in the central log. Similarly, Patient #14 was a LWBS and was found listed in the central log.

Review of the facility's policy, "Patients Leaving The Emergency Department Against Medical Advice" (Eff. 12/1/05), stated, "B. In the event a patient wants to leave or the family wants to remove a patient from the Emergency Department before assessment and treatment have been completed, the RN will notify the Emergency Department attending physician and, if present, the Assistant Director of Nurses (ADON). 2. A concerted effort should be made by the medical and nursing personnel to dissuade the patient who is refusing treatment. The risks involved with refusing treatment should be explained to the patient by the physician...5. In the event that a signature cannot be obtained, the nursing staff will document the steps taken to obtain or reasons for not getting the signatures...7. Staple AMA form to the Emergency Department Record. 8. Complete Event Form and attach copy of Emergency Department Record and AMA form...13. All AMA records will be reviewed by the Emergency Department Medical Director."

During an interview with the DON on 1/14/14, the DON stated after reviewing the ERF, "My expectation is that every patient would be logged in and he had some triage done." On 1/15/14 at 4:25 P.M., the DON informed the SA she asked the ED staff what their procedure was for entering patients into the central log. She found different responses amongst the staff and reported that some ED nurses logged patients in, but others did not based on the registration process.

The DON also asked LN #2 why a clinical record had not been created for Patient #1 when care was provided, but told it was because the patient "was not registered." The DON told LN #2, "Yes, but he was brought into the back, treated with oxygen, vitals--just because he wasn't registered?" The DON verified the central log did not contain Patient #1's name but should have been entered as a John Doe. The DON stated once care was provided by an ED nurse to a patient, her expectation was for the patient to be in the central log and for clinical documentation to exist. She said, "We have nothing on this patient." She did not know however, when their ED policies were last reviewed. She stated their risk manager was currently in the process of updating their EMTALA policy.