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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in §489.24, related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

Tag A2406 - Medical Screening Exam - Based on interviews and document review, the facility failed to ensure a Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided in 2 of 21 records reviewed (Patients A and #15).

Based on interviews and document review, the facility failed to ensure a Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided in 2 of 21 records reviewed (Patients A and #15).

Facility findings:

Facility policy:

The Admission to the Emergency Room and EMTALA policy read, all patients presenting to the emergency room will be triaged by the registered nurse (RN) on duty, screened by the qualified medical provider and receive a medical assessment per EMTALA guidelines.

A medical screening examination is an ongoing process. Evaluation must be in evidence prior to discharge or transfer.

According to the policy the medical screening examination includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an emergency medical condition.

1. The facility failed to ensure patients presenting to the emergency department seeking emergency medical care received a medical screening exam.

a. Review of an emergency medical service (EMS) Prehospital Care Report, completed on 1/3/19, showed the ambulance received an emergent call for an elderly male (Patient A) with a fever and weakness. According to the report the patient's oxygen saturation (a measurement of how much oxygen red blood cells are carrying) was "low in the 80s." The patient required oxygen (O2) to be administered at 6 liters for a O2 saturation of 93% (normal is above 92%). The patient's temperature was documented at 101.6 degrees Fahrenheit (normal temperature is 98.6 degrees Fahrenheit). Additionally, the patient complained of pain on inhalation and had some wheezing (a high-pitched whistling sound made while breathing, often associated with difficulty breathing).

The report noted the hospital was contacted, advised of the patient's history and vital signs, and the estimated time of arrival. Documentation in the report noted "upon arrival at the hospital once inside" EMS was advised the hospital was full and EMS would have to take the patient to another hospital. EMS "loaded the patient back into the ambulance and diverted" to another hospital approximately 50 miles away. According to the report the patient "said it would be ok."

Review of a hospital Incident Report, dated 1/2/19 and completed by Chief Nursing Officer (CNO) #1, documented EMS brought a patient to the emergency department (ED), not aware the hospital was going on divert. According to the report when the ambulance driver "saw how busy" the facility was stated maybe we should go to another hospital. CNO #1 answered "OK if ok [with] the patient."

During an interview, on 2/5/19 at 1:06 p.m., CNO #1 stated she was in the ED when EMS arrived on 1/2/19. CNO #1 stated the facility had been extremely busy all day and currently had four patients in the ED. CNO #1 stated she heard the "radio traffic" that EMS was heading towards the hospital and mentioned the hospital probably needed to go on divert. CNO #1 stated she was at the nurses station when the EMS provider came in and they discussed that maybe the patient needed to go to another hospital. CNO #1 stated she was alright with that if the patient was "ok with it."

CNO #1 reported "it was a problem with what I said;" the patient should have come in, received a medical screening and the hospital could have transferred him. CNO #1 stated it was extremely busy and she had "never been that overwhelmed." CNO #1 stated "I didn't know how we were going to handle all of this; we don't do that anymore."

CNO #1 stated the last EMTALA training she had received was in the summer of 2018 and acknowledged there had been no additional training since the incident on 1/2/19. CNO #1 stated EMTALA "never crossed my mind; I was thinking how long was he going to have to wait." The CNO reported the physician was never made aware an ambulance had arrived at the hospital.

On 2/5/19 at 3:30 p.m., Physician #3, who was on duty on 1/2/19, was interviewed. Physician #3 stated she remembered the date of the incident as the facility was nearly full. She stated a few days later she overheard staff talking about a possible situation where the ambulance had come to the facility and was told to turn around. Physician #3 stated she didn't know until then that the ambulance had actually come to the hospital and stated the hospital had to see patients when they were "on your property."

b. Review of the Emergency Nursing Record, revealed Patient #15 presented to the ED on 12/13/18 at 2:29 p.m. According to the triage, the patient's chief complaint was back pain, headaches and a sore throat off and on for one week. Registered Nurse (RN) #6 documented, in the nursing record, the patient was "triaged" over to the "clinic" to be seen by Physician Assistant (PA) #5 at 2:45 p.m. Under the section, titled Disposition, RN #6 documented the patient was "triaged by on-call provider to be seen in the clinic [at] this time."

According to the ED Triage Notes, the patient's mother wanted the patient seen related to chronic back pain and headaches for one week as the patient had been missing several days at school.

Review of the Discharge Summary, dated 12/13/18 at 2:45 p.m., showed PA #5 documented under Condition, the patient was "Triaged by on call provider to be seen in the clinic. Patient was seen by me for screening medical exam and sent to clinic."

However, there was no documentation in the medical record of the medical screening exam, which included an assessment based on the patient's chief complaint, and to determine the presence or absence of an emergency medical condition.

On 2/7/19 at 10:28 a.m., CNO #1 stated PA #5 was not available for an interview as she was offsite.

On 2/7/19 at 11:14 a.m. Employee #7 presented an unsigned typewritten note, dated 2/7/19, identified as an addendum to Patient #15's ED visit on 12/13/18. Employee #7 stated PA #5 just typed the noted and emailed it to her. Employee #7 stated the note would now become part of the record but stated it had "just been typed up" and wasn't signed as PA #5 was offsite and had emailed it to her.

During an interview, on 2/7/19 at 10:51 a.m., Physician #3 reviewed Patient #15's medical record and acknowledged there was no documented medical screening examination (MSE) in the record. Physican #3 stated she would expect to at least see acknowledgment of the patient's nursing triage and vital signs. Additionally, Physician #3 stated there should be objective assessment data reflecting completion of the MSE. Physcian #3 stated the facility utilized a T Sheet (template based documentation) for nursing and the facility should probably utilize one for physicians as well.