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Based on observation; family, caregiver, physician, and staff interview; and review of medical records, internal investigations, the central ED log, and policies and procedures, the hospital failed to comply with the requirements at 489.20 and 489.24. Specifically, the hospital failed to ensure the proper posting of signage, maintain a complete and accurate central log, ensure the availability of a surgeon when on simultaneous call, and ensure a MSE was performed for 2 of 24 sample patients who presented to the emergency room. Refer to C2402, C2404, 2405, and C2406.

Based on observation and staff interview, the provider failed to conspicuously post legible signs in 1 of 1 emergency departments and 3 of 3 examination and treatment areas (laboratory, radiology, and obstetrical) specifying the rights of individuals with respect to examination and treatment for EMCs and women in labor. In addition, the provider failed to post information indicating whether or not the hospital participated in the Medicaid program. The findings were:

Observation on 2/22/12 at 8:45 AM showed signs specifying the rights of individuals with respect to examination and treatment for EMCs and women in labor were posted in five places in the emergency department. However, the signs were on 8.5 by 11 inch paper and were not legible from a distance. At 8:52 AM that morning ED unit secretary #4 stated this size of sign was the only one available. After attempting to read the sign from a distance of approximately twenty feet, she confirmed it was not legible. At 8:55 AM the risk manager stated he was unable to read the sign from the gurney in the treatment bay. After reviewing the signage, he also confirmed that information related to the hospital's participation in the Medicaid program was lacking. Furthermore, observation throughout the survey showed legible signs were not conspicuously posted in the laboratory, radiology, or obstetrical areas.

Based on staff interview and review of policies and procedures, the provider failed to develop and implement policies and procedures to meet the needs of individuals with EMCs when the on-call surgeon was not available to respond while performing simultaneous surgical procedures at a second facility. The findings were:

During an interview on 2/23/12 at 7:57 AM, RN #12 stated that surgeons sometimes performed simultaneous call between this hospital and a second provider. When asked for a policy specifying how an EMC requiring immediate surgery would be handled if the surgeon was already involved in a procedure at the second hospital, the RN was unable to locate one. Review of the ED's policies showed simultaneous call was not included. At 8:35 AM that morning, the DON confirmed the hospital lacked a policy and procedure addressing simultaneous call.

Based on review of internal investigations, review of the central log, review of policies and procedures, and staff interview, the provider failed to keep a complete and accurate centralized ED log. This failure affected 2 of 2 sample patients (#2, #13) identified by the provider as coming to the ED, but not being seen, during the past year. The findings were:

1. According to the internal investigation of a self reported incident, patient #2 was brought to the ED on 2/6/12 at 7 PM and registered as a patient. Further review of the investigation showed the registration was later cancelled and the patient's name was not placed on the central log. Review of the central log showed no evidence the patient's name was entered on 2/6/12. On 2/21/12 at 3:15 PM, the DON verified that the patient's name was not placed on the central log.

2. Review of an internal investigation of a compliant allegation filed on 4/18/11 revealed patient #13 was brought to the ED on 4/16/11. Review of the central log showed no evidence the patient was in the ED on that date. On 2/22/12 at 11:30 AM the risk manager reported there was no medical record for the patient for that date, nor was his/her name on the central log.

3. According to the provider's ED policy and procedure entitled "Admission and Discharge Policy" last revised January 2009 ,"An Emergency Room record will be completed for each and every person presenting themselves to the ED, and pertinent information will be recorded in the ED log." In addition, review of the provider's policy titled "Emergency Room Emergency Medical Treatment and Labor Act (EMTALA) Standards" effective 2/4/12 showed the hospital would "Maintain a central log on each individual who 'comes to the emergency department,' seeking assistance..."

Based on review of internal investigations, review of medical records, review of policies and procedures, and family, caregiver, physician, and staff interviews, the hospital failed to provide an appropriate MSE for 2 of 24 sample patients (#2, #13) who presented at the ED and were identified by the provider as not receiving a MSE. The findings were:

1. According to the internal investigation of an incident self-reported by the provider on 2/9/12, patient #2 was previously discharged on 2/6/12 at 12:30 PM from an observation stay at the hospital. The admitting diagnoses for the admission included abdominal pain, vomiting, constipation, colostomy, and Down syndrome. A caregiver brought the patient back to the ED on 2/6/12 at 7 PM for evaluation of the patient's stoma which was protruding more than usual. Continued review of the investigation showed RNs #3, the RN coming on duty, and RN #10, the RN who discharged the patient earlier that day, assessed the patient's stoma and determined it was protruding further. RN #3 notified ED on-call physician #9 who informed the nurse of the patient's periostomal hernia and that the stoma could "come in and out at times on its own..." The physician then questioned RN #3 about the patient's pain. The RN relayed the question to RN #10, who in turn questioned the patient and reported back to RN #3 that the patient complained of soreness in the stoma but not in the surrounding area; RN #3 relayed the patient's answer to the physician. Physician #9 instructed RN #3 to provide information to the patient and caregiver and tell them he would be happy to come in and explain the information personally if they wished. The caregiver declined as the physician "...will probably just tell me what you just told me..." The following deficient practice was identified:
a. Review of the documented investigation showed the caregiver brought the patient to the ED because the "ostomy was protruding approximately 1 1/2 inches and was very red and inflamed." Prior to the ED visit, the patient also reported to the caregiver that "the ostomy hurt."
b. According to information obtained during the investigation, the physician provided instructions for the RNs to relay to the patient/caregiver, but did not come to the hospital and perform a MSE. Although the physician knew the patient was in the ED, further review of the internal investigation showed the physician stated "he was unaware that the patient was registered in the emergency department." On 2/22/12 at 5:30 PM the physician stated he did not feel he refused care; he "assumed the patient had not been entered in the system."
c. Interview with ED unit secretary #2 ,who was on duty the evening of 2/6/12, revealed patients were entered into the system before being taken to the ED bay area if their problem was not urgent. If it was urgent, registration waited until later. In this instance, the unit secretary stated she sat with the caregiver to enter the patient into the system while the patient was taken into a bay and the nurse called the physician. She further stated RN #10 told RN #3 that the patient's stoma "looked worse."
d. Interview with RN #3 on 2/22/12 at 3:29 PM revealed she took the patient into the ED area and then notified on-call physician #9. She confirmed information was relayed to the physician, that he asked questions and received answers, and that he provided instructions to relay to the patient and caregiver. She also confirmed the physician said he would be happy to come and repeat the information personally, but the caregiver declined.
e. On 2/23/12 at 9:07 AM RN #10 stated she went with RN #3 to see the patient. RN #10 stated the caregiver wanted to have a physician see if the patient's stoma was "okay." She confirmed the above information.
f. During an interview on 2/22/12 at 10:50 AM, the caregiver stated that although she did not specifically request a physician see the patient, that was her expectation. The caregiver reported she continued to watch the patient throughout the night and that the stoma continued to protrude "approximately 6 to 7 inches." She also stated their nurse (nurse for a residential area) took the patient to the clinic the morning of 2/7/12 and that he had emergency surgery later that day. However, she stated the surgeon told her it was not for a hernia.
g. Review of the 2/7/12 history and physical, completed by surgeon #11, showed "...there is a large protuberant area through the ostomy. This extends out approximately 6 cm [centimeters]. There is an area of colon which appears to be somewhat necrotic. Approximately 3 cm of this is noted to be nonviable in appearance with gross ischemic appearance." Continued review showed the patient "has evidence of prolapse of [his/her] colostomy. I have tried to reduce this without significant success. This is an emergent situation where immediate treatment is warranted." Review of the 2/7/12 consultation showed physician #8 concurred with the surgeon's assessment and plan. Review of the 2/7/12 operative report showed the postoperative diagnosis was "prolapsed bowel through colostomy with ischemic bowel as well as internal colostomy hernia."
h. According to the provider's ED policy and procedure entitled "Admission and Discharge Policy" last revised January 2009 ,"Any person...will be admitted to ED for treatment whenever he/she presents his/her self." Review of the "Emergency Room Emergency Medical Treatment and Labor Act (EMTALA) Standards" effective 2/4/12 showed the hospital would "Provide an appropriate medical screening within capability of the hospitals emergency department..." Further review showed the MSE must be conducted by QMP as defined by the "Medical Screening Examination Policy." Review of that specific policy, effective 3/31/09, revealed "The physician on call will be available on site within 30 minutes of notification and the medical screening examination shall be initiated by the physician..."

2. Review of an internal investigation of a compliant allegation filed with the provider on 4/18/11 revealed patient #13 was brought to the ED on 4/16/11 with a temperature of 104.9 degrees Fahrenheit, but RN #7 "pretty much turned me away and would not call the doc in." Further review of the investigation revealed an interview conducted by the DON with the complainant on 4/20/11. In this documented interview, the complainant stated his/her "intent was to see the MD." The complainant further stated s/he felt as if the nurse was trying to tell him/her how to care for his/her child and this was offensive; the complainant finally left because s/he became angry.
During an interview on 2/22/12 at 8:15 PM, the complainant stated s/he "was turned away at the door" by one of the head nurses. The complainant further stated s/he "was disappointed" not to see the physician as s/he went to the ED with the expectation of being seen by him.
Review of the 4/21/11 written statement by RN #7 confirmed she was the nurse on duty that night. She wrote that physician #9 had started the patient on an antibiotic the afternoon of 4/15/11; she then questioned the complainant as to the last time the patient had been given Motrin or Tylenol, reminded the complainant the doctor told him/her it would be 24 to 48 hours before the antibiotics worked, and asked the complainant if s/he still wanted to see the physician. RN #5 reminded the complainant about not swaddling the child in heavy blankets when running a temperature. Both RNs also mentioned a tepid bath to the complainant. RN #7 wrote that the complainant was asked twice about seeing the physician but did not give a clear answer. There was no evidence in this statement indicating either RN ever notified on-call physician #9. During an interview on 2/22/12 at 5:30 PM, physician #9 stated he was unaware of this incident.

3. While interviewing physician #9 on 2/22/12 at 5:30 PM, the physician stated he has never received EMTALA education but is aware of EMTALA requirements in a general way defined as "a flat refusal to see a patient is a violation." Interview with the Chief of Staff, physician #1, on 2/22/12 at 1:50 PM revealed he was unaware of either incident until 10 minutes prior to the interview. He stated he has been Chief of Staff for over a year but has never been informed of any EMTALA issues. He further stated he had not been educated in EMTALA requirements by the provider.
During an interview on 2/23/12 at 8:40 AM, physician #6, the medical director of the ED, stated EMTALA education was presented to the medical staff, in the form of the EMTALA policies and procedures, three times in the last two and one half years. He stated he could not guarantee all physicians reviewed the policies and procedures nor that they were present at the medical staff meetings. However, all physicians did receive the policies and procedures prior to the staff meetings and were expected to read them. Physician #6 further stated he was aware of the incident with patient #2 but not of the one with patient #13. He reported monitoring the the central log but was unaware patient #2's name had been removed from the log. The medical director stated patient names were not supposed to be removed from the log.