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Based on document review and interview, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to ensure a medical screening exam (MSE) was performed by a qualified medical professional as appointed in the Bylaws and failed to document MSE's in the labor and delivery (L&D) patients' medical records, see A 2406; failure to stabilize a patient that presented to the emergency department (ED) see A 2407 and failure to document risks and benefits of transfer see A 2409.

Based on document review and interview, it was determined that the facility failed to specify in the Hospital Bylaws who was qualified to perform a medical screening exam (MSE) and failed to document MSE's in the labor and delivery (L&D) patients' medical records for 1 of 2 L&D patients reviewed (#16). Findings include:

On 9/25/14 at approximately 1535 during review of the Hospital Bylaws, no evidence could be found of which providers were considered qualified to conduct a MSE.

On 9/25/14 at approximately 1555, during an interview with staff A it was confirmed that the hospital bylaws did not indicate which providers were qualified to conduct a MSE.


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On 9/25/14 at approximately 1250 during review of medical record #16 it was revealed that a MSE was not documented in the patient's medical record, neither in the emergency department record nor in labor in delivery record.

On 9/25/14 at approximately 1255 during an interview with staff Z it was confirmed that the MSE was not documented in the medical record for patient #16.

On 9/25/14 at approximately 1500, during an interview with staff D, the Obstetrical unit manager, who was asked whether pregnant women, who come in through the Emergency Department are given a medical screening exam after being directly transferred up to the Obstetrical Unit for evaluation to which she replied, "I don't think so."

Based on document review and interview the facility failed to stabilize 1 of 20 patients (#8) that presented to the emergency department (ED) resulting in the potential to harm the patient or the patient's child. Findings include:

On 9/25/14 at approximately 1430 during review of the medical record for patient #8 it was revealed that the patient came into the facility at 1121 with complaints of "female GU (genitourinary)" and the triage comment documented was "Pt (patient) states she was sent to the emergency room by Dr. X. She states she is having suicidal thoughts and thoughts of harming her child." The triage nurse then triaged the patient and sent her back out to the waiting room at approximately 1156. The next interaction documented with the patient was at 1405 when it was documented that the patient left without being seen. The staff did not attempt to stop the patient from leaving the hospital, the patient was left unattended in the waiting room after she reported that she had thoughts of self harm and harming her child.

On 9/25/14 at approximately 1438 during an interview with staff L this surveyor asked, "What do staff normally do when a patient reports feelings of self harm or expresses that they have thoughts of harming others?" Staff L stated, "We normally would put them with a sitter and have them evaluated by the doctor to see if they need to be held for treatment." This surveyor asked staff L if she felt the patient should have been allowed to leave the hospital. Staff L replied, "Based on what I am reading [in the medical record], I don't think so."

Based on document review and interview the facility failed to document the risks and benefits of transferring a patient to another medical facility for 1 out of 3 transfer patients (#14) reviewed. Findings include:

On 9/25/14 at approximately 1230 document review of patient #14 revealed that the patient was admitted to the ED on 7/1/14 with a diagnosis of "fall" and "possible fracture". In patient #14's medical record on the document titled, "Emergency Department Note" dated 7/1/14 revealed under "Medical Decision Making" that the decision to transfer the patient had been made and the physician indicated, "I discussed with the patient and he does have these fractures present and will need to be transferred to the the hospital of his choice XXXX." The document titled, "Patient Transfer Form" dated 7/1/14 was reviewed. Under the section titled, "Certification: I have examined the patient and explained the risks of not consenting to the transfer are_____:" was left blank and the physician signed it. Staff Z was asked if there was any place else in the medical record where the risks and benefits of the transfer were explained to the patient and documented to which staff Z replied, "No."