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Based on tours/observations, staff interviews and review of medical records, policies/procedures and other facility documents, the facility failed to comply with the Medicare provider agreement as defined in ?489.20 and ?489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

Findings:

1. The facility failed to meet the following requirement under the EMTALA regulations:

Tag A 2402 - Posting of Signs
The facility failed to post signage visual to all individuals entering the emergency department that specifies the rights of individuals with respect to examination and treatment of emergency medical conditions, as well as whether the facility participates in the Medicaid program under a State approved plan.

Tag A 2406 - Medical Screening Exam
The facility failed to ensure that each patient that presented to the hospital's Emergency Department seeking care received a Medical Screening Exam, as required.

Based on tours/observations and staff interview and review of facility documents, the facility failed to post signage visual to all individuals entering the emergency department that specifies the rights of individuals with respect to examination and treatment of emergency medical conditions, as well as whether the facility participates in the Medicaid program under a State approved plan.
Findings:
1. The facility failed to adequately post EMTALA (Emergency Medical Treatment and Active Labor Act) signage, as required, throughout the Emergency Department (ED).

a) Tour/observations conducted at the facility's Emergency Department on 04/29/13 at 1:40 p.m. with the ED Manager, the Director of Emergency Services, Trauma & Capacity and the Manager of Regulatory Affairs and Patient Relations revealed that there was one set of EMTALA signs in the hallway outside of the ED lobby near the line for clearing security and the metal detector. During the tour it was observed that there were no signs posted by the ambulance entrance or inside ambulance door or anywhere else in the Emergency Department to be viewed by individuals who did not enter through the lobby. These findings were confirmed with the facility staff present on the tour.

Based on facility document review and staff interview, the facility failed to ensure that patients were provided an appropriate medical screening examination (MSE).

This failure had the potential to lead to patient harm due to patients not receiving the appropriate MSE and possibly not receiving necessary treatment or therapies.

FINDINGS:

1. The facility failed to ensure that one (Sample Patient #20) of 20 patients sampled received an appropriate MSE.

a) On 04/29/13, the facility's internal document regarding patient grievances was reviewed. It was documented on 04/22/13 that the facility received a grievance from Sample Patient #20. Sample Patient #20's grievance stated s/he had arrived to the Emergency Room (ER) on 04/20/13 and was told by the facility's ER triage nurse, "We can't do anything for you", and was refused treatment. Sample Patient #20's grievance stated s/he had to seek treatment at another facility. The facility's Manager of Regulatory Affairs and Patient Relations stated this grievance had been investigated by the ER manager.


b) On 04/30/13, a review of 20 patient medical records was conducted with the facility's Emergency Room (ER) Nurse Educator. One patient medical record (Sample Patient #20) of 20 medical records sampled did not contain a medical screening examination.


Sample Patient #20's medical record documented that the patient arrived to the ER on 04/20/13 at 7:28 p.m. with a complaint of shoulder pain. Sample Patient #20's medical record documented the patient's discharge disposition as, "ED Dismiss-Diverted Elsewhere" at 7:30 p.m. on 04/20/13.

Sample Patient #20's medical record contained documentation by the Care Team Associate (CTA), who was responsible for registering the patient into the facility's medical record system. At 7:30 p.m. on 04/20/13, the CTA documented, "Patient needed to see regular doctor. Did not need to visit the ER. Was never seen." There was no further documentation by the CTA. The facility's ER Nurse Educator verified these findings.

Sample Patient #20's medical record contained no documentation by the registered nurse (RN). The facility's ER Nurse Educator verified these findings.


Sample patient #20's medical record contained no documentation of a medical screening exam. The facility's ER Nurse Educator verified that Sample Patient #20's medical record did not contain documentation of a medical screening exam.

c) On 04/30/13 at 2:30 p.m., an interview was conducted with the facility's ER Director, ER Nurse Manager, and an EMTALA committee member. The ER Director stated that s/he was familiar with Sample Patient #20's grievance, and had personally reviewed the grievance.

The ER Director stated that s/he had spoken with Sample Patient #20 and that the patient was upset that the ER nurse repeatedly told him/her,"There's not much we can do for you", and made him/her feel that the facility did not want to treat him/her.

The ER Director stated s/he had personally interviewed the CTA, ER technician, and Registered Nurse (RN) who interacted with Sample Patient #20 on 04/20/13. The ER Director stated that that all three employees stated the RN told Sample Patient #20 that the facility would evaluate the patient but that there wasn't much that could be done.

The ER Director stated s/he watched the interaction between Sample Patient #20 and the facility's RN, ER technician, and CTA on facility surveillance footage from 04/20/13. The ER Director stated that s/he could not hear the audio on the footage, but that the RN's "body language was out of line".

The ER Director stated it was his/her expectation that all patients presenting to the ER and requesting treatment would receive a medical screening exam and that staff would not turn patients away from the ER. The ER Director stated that it was his/her expectation that if a patient left prior to receiving a MSE that the RN would document dialogue with the patient and the reason why the patient left.

The facility's EMTALA committee member stated that the facility's EMTALA committee had reviewed Sample Patient #20's grievance and that the facility planned to "self-report" this grievance as a possible EMTALA violation.

d) On 04/30/13, the facility's policy, "Medical Screening Examinations, Stabilizing Treatment, and Appropriate Transfers (EMTALA)", was reviewed. The policy stated, "All individual who present to the Emergency Department seeking examination or treatment for a medical condition will receive an MSE (Medical Screening Examination) by a physician or qualified medical provider". The facility's Manager of Regulatory Affairs and Patient Relations verified this was the current policy.