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Based on policy review, review of the hospital's By-laws Rules and Regulations, medical record review and interview, it was determined the hospital failed to ensure the Dedicated Emergency Department (DED) provided an adequate Medical Screening Examination (MSE) within the capabilities of the hospital DED in order to determine if an emergency medical condition existed; ensure there is no delay in treatment and failed to ensure patients were informed of the risks and benefits of refusing treatment and leaving against medical advice (AMA) for 18 of 21 (Patients #1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19) sampled patients.

Based on review of hospital bylaws, policy review, record review and interview, the hospital failed to ensure all patients presenting to the Dedicated Emergency Department (DED) seeking medical attention received an appropriate Medical Screening Examination (MSE) to determine if an emergency medical condition existed for 1 of 21 (Patient #3) sampled DED patients.

The findings included:

1. The facility's "Medical Staff Rules & Regulations" By-Laws documented, "...There shall be a triage system to identify patients requiring urgent care. A qualified medical professional will conduct a medical screening examination of those individuals presenting to the emergency care center [DED]...for examination and treatment to determine if an emergency condition exists...The disposition of each patient shall be a physician responsibility..."

The facility's "EMTALA" policy documented, "...The purpose of this policy is to set forth policies and procedures for Hospital's use in complying with the requirements of the Emergency Medical Treatment and labor Act (EMTALA)...'Medical Screening Examination' means the screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist...Triage a. As soon as practical after arrival, individuals who 'come to the emergency department' should be triaged in order to determine the order in which they will receive a medical screening examination. Triage...simply determines the order in which individuals will receive a medical screening examination...Medical Screening Examination...should be tailored to the patient's complaint, and depending on the presenting symptoms...Monitoring must continue until the individual is stabilized or appropriately admitted or transferred...."

The facility's "Triage" policy documented, "The purpose of this policy is to ensure that all patients have a rapid assessment and are sorted based on their presentation and medical condition...The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department [DED] using the Emergency Severity Index (ESI)..."
The triage policy continued, "Classification will be based on ESI standards: Level 1, 2, 3, 4, 5.... Level 1: requires immediate life saving intervention... Level 2: High risk situation or confused/lethargic/disoriented/severe pain/distress/ vital signs abnormal... Level 3: vital signs within normal limits but intervention requires the use of more than 2 resources... Level 4: requires the use of 1 resource... Level 5: requires no resource..."
The attached key to the triage policy documented, "...Level 2...High risk situation is a patient you would put in your last empty bed. Severe pain/distress is determined by clinical observation and/or patient rating of greater than or equal to 7 on a 0-10 pain scale..."

Review of the Hospital's "Falls Prevention and Resources" policy revealed, "...This policy pertains to all patient care settings with the healthcare facility...Providing appropriate action in the event of a fall including follow-up assessments and documentation... Post-fall Management: 1. Assess for injury (e.g. [for example], abrasion, contusion, laceration, fracture, head injury, bleeding)...until physician notification...Complete Post-Fall Assessment Form...5. Notification of fall...physician...6. Objective documentation in the medical record...9. Complete an Event Report..."

2. During an interview on 3/12/13 at 10:00 AM when asked about the registration process, Emergency Medical Technician (EMT) #1, working at the Registration desk stated, "When they [patients] present to the ER [emergency room]...start here with registration...then they come in, I get their name and chief complaint. I use my judgment to see if they can do paperwork or if they need to go back [to the triage area]...get name, date of birth and complaint, Quick registration...Info comes up on the Triage nurses computer unless it is an emergency. If it is an emergency, I would go tell [the nurse] and take the patient to the triage nurse. I use my clinical judgment to determine if its an emergency."

During an interview on 3/12/13 at 10:30 AM when questioned about the triage process, RN#1 (Triage Nurse) stated, "[EMT#1's name] registers them and checks them out...will pull out someone who is not emergent and put an emergent in triage... when they get to me...do a focused assessment... click on the diagnosis and it will give me the protocol, labs to do...then they go to the back if there is a room open..."

3. Review of the medical record for Hospital #1 dated 3/1/13 revealed Patient #3 presented to the DED at 03:22 AM with complaints of acute back pain and constipation. The patient's blood pressure was 158/106 and the patient complained of pain at a level of 8 on a scale of 0 - 10 with 10 being the most painful.
The patient was assigned an acuity level of ESI 3 (the hospital's triage policy and procedure revealed a pain level of 7 or above should be triaged at an ESI of 2).

Review of the DED nurse's notes dated 3/1/13 revealed at 03:24 AM the nurse documented, "Presenting complaint: Patient states, 'I got up to go to the bathroom and my feet started tingling and it moved up my legs into my abdomen and it felt like little balls of fire in there. I haven't had a BM since yesterday. I have a fractured disc in my back...' "
At 03:27 AM the nurse documented, "...Complains of pain in back and abdomen Quality of pain is described as burning, sharp..."
At 03:30 AM the nurse documented, "...patient reports being diagnosed with cracked vertebrae this week and sent home...states has had numbness and tingling in bilateral feet. States tonight started having pain in upper abdominal quadrants and back...reports numbness in bilateral feet and legs and paresthesias in bilateral feet and legs...Range of motion limited in all extremities..."
At 03:53 AM the nurse documented Physician #1 visited the patient.

Review of Physician #1's notes dated 3/1/13 revealed the physician documented at 04:00 AM, "...The patient presents with constipation...Abdomen/GI [gastrointestinal] Inspection; abdomen appears normal, Bowel sounds hyperactive...abdomen is soft and non-tender." The physician ordered an X-ray of the abdomen.
There was no documentation the physician performed an assessment of the patient's back, legs or Neuro-musculoskeletal system.

Review of the abdominal X-ray results dated 3/1/13 at 04:31 AM revealed, "The bowel pattern is nonspecific. No evidence of bowel obstruction...no soft tissue mass...No acute findings..."

There was no documentation additional assessments or screenings were performed by Physician #1.

At 06:48 AM on 3/1/13 the nurse documented Patient #3 had a bowel movement (BM).

Physician #1 documented on 3/1/13 at 06:49 AM, "problem is new. Symptoms have improved."

The nurse documented on 3/1/13 at 06:49 AM that Physician #1 discharged the patient.

There was no documentation Physician #1 assessed the patient again prior to discharge.

On 3/1/13 at 07:05 AM the nurse documented, "Patient left the ED."
At 07:11 AM the nurse documented, "Patient restored to ED..."
At 07:26 AM the nurse documented, "Discharge undone..."

A note by Physician #1 on 3/1/13 at 07:28 AM revealed, "GOOD BM BUT WHEN PT [patient] WAS BEING DISCHARGED, NOTED PT UNABLE TO WALK WITHOUT ASSISTANCE/ NORMAL AMBULATION BEFORE 2 DAYS AGO PER FAMILY/ UNDID DISCHARGE AND TALKED TO [NAME OF PHYSICIAN #2] ABOUT PT." There was no documentation Physician #1 performed an assessment and examination of the patient's inability to ambulate without assistance.

At 07:38 AM on 3/1/13 the nurse documented Physician #1 ordered a Magnetic Resonance Imaging (MRI) of the lumbar spine.

Physician #1 documented on 3/1/13 at 07:28 AM that the patient's care was being transferred to on-coming Physician #2.
There was no documentation Physician #2 performed an examination and assessment of the patient.

Review of the results of the MRI dated 3/1/13 at 09:26 AM revealed, "...No abnormal signal is present to suggest an acute fracture...A hemangioma is present in the L2 vertebral body...L3-L4 A mild diffuse disc bulge is present..." There was no documentation Physician #2 reviewed the MRI results.

On 3/1/13 at 11:46 AM the nurse's notes documented, "...Discharge ordered by [Physician #2]...12:02 [PM] Patient left the ED...Weakness present in back of left leg and back of right leg."
There was no documentation Physician #2 had examined and assessed the patient during his shift from 07:00 AM - 12:02 PM. There was no documentation Physician #2 assessed the patient prior to his being discharged.

4. RN #2 was interviewed on 3/13/13 beginning at 7:00 PM with Patient #3's medical record from 3/1/13 present for referral. RN #2 stated the patient had been discharged by [Physician #1] when a family member came back to the DED and told Physician #1 the patient was unable to walk. The nurse stated Physician #1 brought the patient back to the DED and ordered a MRI. When asked if the patient had fallen in the DED the nurse stated the patient had fallen after the MRI had been completed and prior to being discharged the second time that day. The nurse stated the fall was not reported to the physician [Physician #2], and there was no documentation of the fall or an assessment or examination related to the fall in the medical record.

5. During a telephone interview on 3/19/13 at 4:00 PM when asked why the patient came to the DED, Physician #1 stated, "...Constipation..." was the main complaint for Patient #3 and it had been 2 days since the patient had a BM. Physician #1 stated the patient complained he was "on fire from feet to belly" and "back pain had been there for a while...was a chronic problem...I think he had a stable fracture...I will look at the record and call you back when I get to work..."

During a second telephone interview on 3/19/13 at 5:45 PM Physician #1 stated she had reviewed Patient #3's medical record for 3/1/13 and "...the back pain was chronic...ongoing...in the mid back area and was stable...reversed the discharge...was wobbly...I was concerned..." Physician #1 stated she turned the care over to Physician #2 at the change of shift at 7:00 AM on 3/1/13.
Physician #1 was asked if the mid back pain was chronic, ongoing and stable, why did the patient report that it started "tonight" with the tingling in the lower extremities. Physician #1 stated, "I couldn't say."
Physician #1 stated, "I realize there is no documentation...did have him push on my hands... [related to no Musculoskeletal or Neuro assessment for the back pain and numbness/tingling in legs and feet]." There was no documentation of this assessment in the medical record. When asked if constipation could have caused the leg/feet numbness and tingling, Physician #1 stated, "No."

6. During a telephone interview on 3/19/13 at 5:20 PM Physician #2 stated, "I was told" last week you would be calling me. Physician #2 stated he had worked the shift following Physician #1 for the care of Patient #3 on 3/1/13. Physician #2 stated that Physician #1 had told him the patient had complained of constipation and had a T6 fracture from a prior [2/25/13] MRI. Physician #2 stated Physician #1 was concerned about the patient being "wobbly" on his feet and that this was "a new finding" so they stopped the discharge as there could be a new lesion. Physician #2 stated he did a lumbar [MRI] because the patient had already had a thoracic [MRI]. When asked why he had not written any notes from the time he came on duty to care for the patient at 7:00 AM until the patient was discharged at 12:02 PM, Physician #2 stated, "I didn't find any notes and I don't know why." When asked if he was aware the patient had fallen in the DED after the MRI had been performed Physician #2 responded, "No." Physician #2 stated, "I would have been concerned with anyone that couldn't walk out of my ED" and if reported "would look into it further."

7. Medical record review revealed on 3/2/13 at 11:58 AM Patient #3 presented a second time to the DED with complaints of lower extremity weakness. The Nurse's Notes documented at 12:03 PM, "...Presenting complaint: child states dad w [with] bilat [bilateral] LE [lower extremity] weakness x [times]1 week-here for same yesterday." The patient was assigned an ESI Acuity 3.

Physician #3 documented on 3/2/13 at 13:25 PM, "...The patient presents to the emergency department with weakness of the left lower extremity, right lower extremity, that is severe. Onset: The symptoms/episode began/occurred yesterday at 2 [02:00 AM] Current symptoms: paralysis or paresis of the right and left leg..." At 13:36 PM Physician #3 documented, "...Patient noted increased back pain with weakness in LEs 2 am yesterday and was seen here... Constipation presumably from pain meds [medications]... the patient was dc'd [discharged] home and paralysis with numbness to both LEs increased to the point of inability to walk." Physician #3 performed an examination and assessment of the patient's Neuro and Musculoskeletal Systems and documented, "...the patient is unable to track heel to shin on both sides...strength is 1/5 [1 on scale of 1 - 5 with 5 being most strength] in the right and left leg... Sensation: numbness, pin prick is decreased in the right knee, right shin, anterior aspect of the right ankle, dorsum of right foot, left knee, left shin, anterior aspect of left ankle and dorsum of left foot. Gait: unable to assess, the patient is nonambulatory..."

Physician #3 ordered an MRI and an Orthopedic consultation. The Orthopedic Physician documented the results of the MRI as, "MRI T-Spine shows mass effect at T-6 with cord compression...Imp [impression] Thoracic cord compression [recommend] transfer to facility with neurosurgery/spine available this evening..."

Patient #3 was transferred to Hospital #2 for emergent surgery on 3/2/13 at 21:02 PM.

8. Review of Hospital #2's DED records, and physician's notes dated 3/2/13, and the discharge summary dated 3/8/13 revealed the patient had a "...T6 epidural tumor with bony invasion and epidural canal invasion with cord compression and paraparesis ...inability to ambulate since March 1, 2013 in the morning ...was found to be profoundly weak...was taken to the Operating Room emergently and underwent a laminectomy with resection of the epidural tumor at the T6 level and subsequent fusion from T4 - T8 posteriorly with screws and rods..." The patient was discharged from Hospital #2 on 3/8/13 to a rehabilitation hospital.

9. During a telephone interview on 3/12/13 at 7:00 PM Patient #3's son stated, "...He [Patient #3] couldn't use his legs and was crying. He lost a lot of time" related to the fall and being discharged home on 3/1/13 and then having to return to the DED on 3/2/13. The son stated "He has bowel and bladder loss of control and lost the use of his legs...I don't think he will be able to come home again, ever. Mom will not be able to take care of him."

Based on facility policy review, medical record review and interview the hospital failed to provide stabilizing treatment prior to discharging 1 of 21 (Patient #3) sampled patients who came to the Dedicated Emergency Department (DED) seeking emergency care and services. Failure to determine the cause of the patient's illness led to the patient being released without having received treatment and stabilization.

Additionally, the hospital failed to ensure all patients who left without examination and treatment were informed of the risks and benefits and failed to seek written informed refusal of the examination and treatment for 8 of 8 (Patients #1, 4, 9, 10, 13, 16, 17 and 18) sampled patients that left the DED without examination and treatment.

The findings included:

1. The facility's "EMTALA" policy documented, "...Medical Screening Examination...should be tailored to the patient's complaint, and depending on the presenting symptoms...The medical screening examination must be provided in a non-discriminatory manner...Monitoring must continue until the individual is stabilized or appropriately admitted or transferred...'To Stabilize' or 'Stabilize' or 'Stabilized' means 1. With respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer or discharge of the individual from the hospital...Refusal of Treatment...If the Hospital offers further examination and treatment and informs the individual or the person acting on the individual's behalf of the risks and benefits of the examination and treatment, but the individual or person acting on the individual's behalf does not consent to the examination and treatment, the Hospital shall take all reasonable steps to have the individual or the person acting on the individual's behalf acknowledge their refusal or further examination and treatment in writing. The medical record shall contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual; the risks/benefits of the examination and/or treatment; the reasons for refusal; and if the individual refused to acknowledge their refusal in writing, the steps taken to secure the written informed refusal. The Hospital personnel involved with the individual's care or witnessing the individual refusing consent should document the patient's refusal in the medical record..."

2. Medical record review for Patient #3 revealed the patient presented to the DED on 3/1/13 at 03:22 AM with complaints of back pain rating 8 on a scale of 0 -10 with 10 being the most painful and constipation. Physician #1 documented the patient's abdomen appeared normal, was soft, non-tender and bowel sounds were present. The X-ray of the abdomen revealed no masses, obstructions or acute findings. There was no documentation Physician #1 had performed an assessment or examination of the patient's Neuro-Muscular Skeletal system. Physician #1 discharged the patient home. As the patient was leaving the DED the patient's family noticed the patient could not walk and returned the patient to the DED for further treatment. Physician #1 ordered an MRI of the patient's back and then transferred the patient to the care of on-coming Physician #2. There was no documentation Physician #1 assessed or examined the patient upon his return to the DED due to inability to walk. There was no documentation Physician #2 performed an assessment or examination of the patient. The patient was discharged home by Physician #2 at 12:02 PM. There was no documentation the patient was treated and stabilized for back pain, numbness, tingling and weakness.

On 3/2/13 at 11:58 AM the patient returned to the DED with complaints of lower extremity weakness. Physician #3 performed an assessment and examination of the patient and documented, "...Patient noted increased back pain with weakness in LEs [lower extremities] 2 am yesterday and was seen here...the patient was dc'd [discharged] home and paralysis with numbness to both LEs increased to the point of inability to walk. Physician #3 documented the Neuro-Muscular Skeletal systems examination as, "...the patient is unable to track heel to shin on both sides...strength is 1/5 [1 on a scale of 1 - 5 with 5 being the strongest] in the right and left leg...Sensation: numbness, pin prick is decreased in the right knee, right shin, anterior aspect of the right ankle, dorsum of right foot, left knee, left shin, anterior aspect of left ankle and dorsum of left foot. Gait: unable to assess, the patient is nonambulatory..." An Orthopedic physician was consulted, assessed the patient, documented the patient had a Thoracic cord compression and to transfer the patient to a higher level of care for emergent surgery.

The patient was transferred to Hospital #2 on 3/2/13 and an Emergent laminectomy with resection of the epidural tumor was performed.
Refer to A2406

3. Review of the DED log dated 9/1/12 revealed Patient #1 presented to the DED at 14:23 PM with complaints of Cold Symptoms.

Review of the nurse's notes revealed at 14:24 PM the patient's "presenting complaint" was "...cough and congestion x 1 week...triage completed..." The nurse documented at 14:25 PM the patient's behavior is "cooperative, crying" At "14:26 [PM] patient moved to waiting...14:27 [PM] patient moved to triage...15:47 [PM] Patient moved to a [DED room]...16:25 [PM] left without being seen...left the ED." There was no documentation the risks and benefits of examination and treatment were explained to the patient or written informed refusal obtained.

Review of the patient's DED demographic sheet revealed the patient was admitted to the DED on 9/1/12 at 14:26 and discharged from the DED on 9/1/12 at 16:23. The patient's payor source on the demographic sheet was listed as "self pay."

4. Review of the DED log dated 3/1/13 revealed Patient #4 presented to the DED at 12:40 PM with complaints of back pain.

The nurse's notes at 12:41 PM revealed the patient presented with complaints of pain in right lower back radiating down to the pelvis. The notes documented the patient stated, "it feels like my vagina is about to rip out." At 12:42 PM the nurse documented, "...pain currently is 8 out of 10 [on a scale of 0 -10 with 10 being the most painful]." At 14:21 PM the nurse documented the patient left without being seen. There was no documentation the risks and benefits of examination and treatment were explained to the patient or written informed refusal obtained.

Review of the patient's DED demographic sheet revealed the patient was admitted to the DED on 3/1/13 at 12:41 and discharged from the DED on 3/1/13 at 23:59. The payor source on the demographic sheet was listed as "self pay."

During a telephone interview with Patient #4 on 3/18/13 at 2:00 PM the patient stated, "...I had to wait so long...I went and told the desk I was leaving and they sent me back to the nurses station. When I told the nurses I was leaving they said 'OK'. They did not inform me of any risks or benefits..."

5. Review of the DED log dated 3/9/13 revealed Patient #9 presented to the DED by the Fire Department emergency medical services (EMS) at 16:26 PM with complaints of being assaulted.

The nurse's notes revealed the patient arrived at 16:26 PM, and "EMS states: assault today by in law - c/o [complains of] headache with hematoma to Rt [right] parietal-denies LOC [loss of consciousness]/neck/back paint-pt [patient] smells of ETOH [alcohol]." At 17:33 the nurse documented the patient left without treatment (LWOT). There was no documentation the risks and benefits of examination and treatment were explained to the patient or written informed refusal obtained.

Review of the patient's DED demographic sheet revealed the patient was admitted to the DED on 3/9/13 at 16:35. The payor source listed on the demographic sheet was "self pay."

6. Review of the DED log dated 3/9/13 revealed Patient #10 presented to the DED at 15:12 PM with complaints of nose pain.

The nurse's notes revealed, "...15:28 left without being seen...15:29 patient left the ED." There was no documentation the risks and benefits of examination and treatment were explained to the patient or written informed refusal obtained.

Review of the patient's DED demographic sheet revealed the patient was admitted to the DED on 3/9/13 at 15:13 PM. The payor source listed on the demographic sheet was insurance.

7. Review of the DED log dated 3/8/13 revealed Patient #13 presented to the DED on 14:52 PM with complaints of abdominal pain.

The nurse's notes revealed the patient arrived by EMS at 14:52 PM with the presenting complaint of lower abdominal pain with nausea and vomiting for 4 hours. The patient rated the pain an 8, on a scale of 0 -10 with 10 being the most painful.

The DED Physician documented the MSE was performed at 16:56 PM and, "...pt refused CT [computerized tomography] scan...the work up was not completed, still don't know what is going on other than a UTI." The patient left the DED against medical advice (AMA). There was no documentation the risks and benefits of examination and treatment were explained to the patient or written informed refusal obtained.

Review of the patient's DED demographic sheet revealed the patient was admitted to the DED on 3/8/13 at 14:52 PM. The payor source listed on the demographic sheet was "self pay."

During a telephone interview with Patient #13 on 3/18/13 at 4:00 PM, when asked if the hospital explained the risks and benefits of leaving without treatment, the patient stated, "No." When asked if the hospital had requested her to sign an AMA form, the patient stated, "No."

8. Review of the DED log dated 1/1/13 revealed Patient #16 presented to the DED at 14:06 PM with complaints of vagina bleeding. The patient was 16 weeks pregnant.

The nurse's notes documented, "...vaginal bleeding and clots this am...14:07...complains of pain in pelvis..." At 20:22 PM the nurse documented, "Patient left against medical advice..."

The DED Physician documented, "...20:21...I will discharge patient...pt has eloped before we are able to perform pelvic exam. likely having a miscarriage...20:23...Patient left against medical advice...patient discharged to location home, in Stable condition..." There was no documentation the risks and benefits of examination and treatment were explained to the patient or written informed refusal obtained.

Review of the patient's DED demographic sheet revealed the patient was admitted to the DED on 1/1/13 at 14:07 PM. The payor source listed on the demographic sheet was "self pay."

9. Review of the DED log dated 1/1/13 revealed Patient #17 presented to the DED at 18:44 PM with complaints of abdominal pain and Flu symptoms.

The nurse's notes dated 1/1/13 documented the patient rated the pain at an 8 on a scale of 0 - 10 with 10 being the most painful. At 20:41 PM the nurse documented the patient left without treatment. There was no documentation the risks and benefits of examination and treatment were explained to the patient or written informed refusal obtained.

Review of the patient's DED demographic sheet revealed the patient was admitted to the DED on 1/1/13 at 18:47 PM. The payor source listed on the demographic sheet was "self pay."

10. Review of the DED log dated 1/1/13 revealed Patient #18 presented to the DED at 19:58 PM with complaints of autistic -"nervous ticks" and possible headache.

The nurse's notes revealed, "...Mother states: pt has c/o [complained of] pain to the back of neck, having nervous 'ticks', L [left] hand tremors some...for past 5 days.." The nurse documented the patient left against medical advice at 03:05 AM.

The DED Physician documented, "07:14 [AM]...Patient left against medical advice with a preliminary diagnosis of Anxiety Reaction...discharged to location home...stable condition. patient left the ED at 01/02/2013 03:03." There was no documentation the risks and benefits of examination and treatment were explained to the patient or written informed refusal obtained.

11. During an interview on 3/14/13 at 1:15 PM when asked what was the hospital's policy for patients who left the DED without being seen, the Chief Nursing Officer (CNO) stated, "We don't have a policy and procedure for left without being seen [LWBS] and left without treatment [LWOT], we don't have to have one."

During an interview on 3/14/13 at 2:00 PM when asked if the patients who left without being seen were tracked and trended in Quality Assurance (QA), the QA Nurse stated the QA department did not conduct a review of the patients who LWBS or LWOT until the combined percentage was 3% or greater. The QA nurse stated the combined LWBS and LWOT goal is 2.5 % and at 3% there must be a corrective action plan to address. The QA nurse stated the combined LWOT and LWBS have not been at or above 3% for October 2012, November 2012, December 2012 and January 2013.
The QA nurse stated the only policy or procedure related to LWOT and LWBS is an "ED Tracking Standards" definition that the facility uses and what the staff are taught in orientation.

Review of the January 2013 "Daily Counts" form documented the DED had a total count of 3217 patients seen in the DED during January 2013. There were a total of 117 LWOT and LWBS for January 2013. This comes to a total of 3.6% for January 2013. The 3.6 % was not recognized by the Hospital QA and there was no corrective action plan to address the increase in this patient population.

Review of the "ED Tracking Standards" provided by the QA Nurse revealed "...Tracking Definitions LWBS (left without being seen)- Prior to being seen by a Triage Nurse. No clinical evaluation and not associated charges. LWOT (left without treatment)-No treatment or assessment by the Physician, but has had a Triage Assessment. Billing associated with this disposition...Elopement- Patient comes to the ED, triaged, registered, and MSE has been done but leaves unnoticed or without informing staff...AMA [against medical advice]-Patient comes to the ED, triaged, registered, has had and MSE and leaves against the advice of the physician. AMA form should be completed however, if the patient refuses to sign, documentation to that effect is made on the AMA form and in the physician and nursing notes..."

During an interview on 3/14/13 at 3:00 PM when questioned about patients who left without being seen, RN #4 stated if a "patient brings up AMA, they should come get me and I would explain risks of leaving...". RN #4 stated she had been taught if patients wanted to LWBS or LWOT the nurses should "go to the waiting room and call for them [patients] 2 times" to make sure they have not gone to the bathroom or to smoke. RN #4 stated this should be documented in the medical record as "called patient no response."

Based on policy review, medical record review and interview, it was determined the hospital sought and obtained signed verification the patient would be responsible for payment as a condition for the provision of services prior to performing a Medical Screening Examination (MSE) for 17 of 21 (Patients #2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19) patients reviewed.

The findings included:

1. The facility's "EMTALA" policy documented, "....Registration a. The Hospital may not delay the provision of an appropriate medical screening examination or any necessary stabilizing medical examination and treatment in order to inquire about the individual's method of payment or insurance status...The medical screening examination must be provided in a non-discriminatory manner. The examination provided to an individual must be the same medical screening examination that the hospital would provide to any individual coming to the Hospital's dedicated emergency department with those signs and symptoms, regardless of ability to pay..."

2. The facility's "Right Care Right Medical Screening Exam Process" documented, "...The purpose of this policy is to establish guidelines for the Emergency Department to provide an appropriate Medical Screening examination to any individual...The Patient access representative will not impede or delay medical treatment to obtain or convey financial information prior to the MSE...Financial information may be collected after stabilizing treatment has begun or it has been determined...that an Emergency Medical Condition (EMC) does not exist...Neither the performance of the MSE nor the provision of stabilizing treatment will be conditioned on an individual's completion of a financial responsibility form, an advance beneficiary notification form, nor payment of a co-payment for any services rendered..."

3. Review of the "CONSENT/CONDITIONS OF SERVICE" form documented on page 1 of 2 "...9. Financial Obligations...I agree to promptly pay all hospital bills in accordance with the regular rates and terms of the hospital, including its charity care and discount payment policies, if applicable. I understand that all physicians and surgeons, including the radiologists, emergency physicians, anesthesiologist, and others, will bill separately for their services. Should any account be referred to an attorney or collection agency for collection, I will pay actual attorney's fees and collection expenses. All delinquent accounts shall bear interest at the legal rate, unless prohibited by law. I understand the hospital may request and use data from third parties such as credit reporting agencies in order to verify demographic data or evaluate financial options... 10. Assignment of Insurance or Health Plan Benefits to the Hospital. I assign and hereby authorize direct payment to the hospital of all insurance and plan benefits payable for this hospitalization or for these outpatient services. I agree that the insurance company's or health plan's payment to the hospital pursuant to this authorization shall discharge the insurance company's or health plan's obligations to the extent of such payment. I understand that I am financially responsible for charges not paid according to this assignment...15. Financial Responsibility Agreement by Person Other Than the Patient or the Patient's Legal Representative. I agree to accept financial responsibility for services rendered to the patient and to accept the terms of the Financial Obligations (Paragraph 9) and Assignment of Insurance or health Plan Benefits (Paragraph 10)..."

4. During an interview on 3/12/13 at 10:10 AM the Registration Clerk stated that when a patient is registered in the computer, it pulls up the previous financial information that a patient had on the previous visit.

5. Medical record review revealed Patient #2 presented to the Dedicated Emergency Department (DED) per ambulance on 9/1/13 at 19:01 PM with complaints of chest pain and lightheadedness.

The Demographic Sheet documented the patient was admitted to the ED at 19:01 PM and had insurance. The patient signed the "CONSENT/CONDITIONS OF SERVICE" form at 19:01 PM.

The patient was not triaged until 19:11 PM and did not receive an MSE until 20:14 PM.

6. Medical record review revealed Patient #3 presented to the DED on 2/21/13 at 07:47 AM with complaints of abdominal, chest and back pain.

The Demographic Sheet documented the patient was admitted to the DED at 7:48 AM and had insurance. The patient signed the "CONSENT/CONDITIONS OF SERVICE" form at 7:48 AM.

The patient was not triaged until 7:51 AM and did not receive a MSE until 08:51 AM.

Patient #3 presented again to the DED on 2/25/13 at 09:56 AM with complaints of chest pain.
The patient signed the "CONSENT/CONDITIONS OF SERVICE" form at 10:00 AM and the patient was documented to have insurance.

The patient was not triaged until 10:20 AM and did not receive a MSE until 10:26 AM.

Patient #3 presented a third time to the DED on 3/1/13 at 03:22 AM with complaints of back pain and constipation.

The patient's representative signed the "CONSENT/CONDITIONS OF SERVICE" form at 03:24 AM. The Demographic sheet documented the patient had insurance.

The patient was not triaged until 3:24 AM and did not receive a MSE until 03:53 AM.

7. Medical record review revealed Patient #4 presented to the DED on 3/1/13 at 12:40 PM with complaints of lower back pain radiating down the pelvis.

The patient signed the "CONSENT/CONDITIONS OF SERVICE" form at 13:00 PM and the demographic form documented the patient was self pay.

The patient was triaged at 12:42 PM and did not receive a MSE.

8. Medical record review revealed Patient #5 presented to the DED on 3/1/13 at 13:59 PM with the complaint of acute back pain. The patient had registered online for the "InQuickER" program and scheduled an appointment for 14:15 PM.

The patient signed the "CONSENT/CONDITIONS OF SERVICE" form at 14:00 PM and the demographic form documented the patient had insurance.

The patient was triaged at 14:04 PM. The patient did not receive an MSE until 15:43 PM.

9. Medical record review revealed Patient #6 presented to the DED on 3/11/13 at 5:07 AM per ambulance with the complaint of chest pain.

The patient signed the "CONSENT/CONDITIONS OF SERVICE" form at 5:10 AM. The demographic form documented the patient had insurance.

The patient was triaged at 5:08 AM. The patient did not receive an MSE until 5:15 AM.

10. Medical record review revealed Patient #8 presented to the DED on 3/10/13 at 3:24 AM with the complaint of a abdominal pain.

The patient signed the "CONSENT/CONDITIONS OF SERVICE" form at 3:00 AM and the demographic form documented the patient had insurance.

The patient was not triaged until 03:27 AM and did not receive an MSE until 3:57 AM.

11. Medical record review revealed Patient #9 presented to the DED on 3/9/13 at 4:26 PM per ambulance with the complaint of assault and smelled of ETOH (alcohol). The patient was assigned an acuity level of ESI 3.

The "CONSENT/CONDITIONS OF SERVICE" form was timed at 16:35 PM and was documented for signature "LWOT [left without treatment]." The patient self pay .

The patient was triaged at 17:06 PM and did not receive an MSE.

12. Medical record review revealed Patient #10 presented to the DED on 3/9/13 at 3:12 PM with the complaint of nose pain.

The patient signed the "CONSENT/CONDITIONS OF SERVICE" form at 3:00 PM and the demographic form documented the patient had insurance.

The patient was documented LWOT at 15:29 PM.

13. Medical record review revealed Patient #11 presented to the DED on 2/12/13 at 12:46 PM with the complaint of lower abdominal pain.

The patient signed the "CONSENT/CONDITIONS OF SERVICE" form at 12:54 PM and the demographic form documented the patient had insurance.

The patient was triaged at 15:45 PM and did not receive an MSE until 5:07 PM.

14. Medical record review revealed Patient #12 presented to the DED on 3/8/13 at 9:51 PM with the complaint of fever, nausea and vomiting.

The patient signed the "CONSENT/CONDITIONS OF SERVICE" form at 9:55 PM and the demographic form documented the patient to have insurance.

The patient was triaged at 9:55 PM and did not receive an MSE until 10:45 PM.

15. Medical record review revealed Patient #13 presented to the DED on 3/8/13 at 2:52 PM with the complaint of abdominal pain.

The patient signed the "CONSENT/CONDITIONS OF SERVICE" form at 3:46 PM and the demographic form documented the patient was self pay.

The patient was triaged at 3:03 PM and did not receive an MSE until 4:56 PM and later was documented as AMA.

16. Medical record review revealed Patient #14 presented to the DED on 2/1/13 at 10:19 PM with the complaint of Hallucinations.

The patient's representative signed the "CONSENT/CONDITIONS OF SERVICE" form at 10:24 PM and the demographic form documented the patient had insurance.

The patient was triaged at 22:49 PM, did not receive an MSE until 23:32 PM and was later transferred to another hospital.

17. Medical record review revealed Patient #15 had registered online at 13:07 PM for the "InQuickER" program and scheduled an appointment for 2:00 PM. The patient presented to the DED on 1/1/13 at 1:49 PM with the complaint of an abscess to the buttock.

The patient signed the "CONSENT/CONDITIONS OF SERVICE" form at 2:00 PM and the demographic form documented the patient had insurance.

The patient was triaged at 1:51 PM and did not receive an MSE until 2:35 PM.

18. Medical record review revealed Patient #16 presented to the DED on 1/1/13 at 2:03 PM with the complaint of vaginal bleeding, clots and 16 weeks pregnant.

The patient signed the "CONSENT/CONDITIONS OF SERVICE" form at 2:07 PM and the demographic form documented the patient to be self pay.

The patient was triaged at 2:06 PM and did not receive a MSE until 4:19 PM.

19. Medical record review revealed Patient #17 presented to the DED on 1/2/13 at 6:44 PM with the complaint of abdominal pain and flu like symptoms.

The patient signed the "CONSENT/CONDITIONS OF SERVICE" form at 6:47 PM and the demographic form documented the patient was self pay.

The patient was triaged at 6:48 PM and did not receive an MSE. The patient was documented as LWBS (left without being seen).

20. Medical record review revealed Patient #18 presented to the DED on 1/2/13 at 7:58 PM with the complaint of neck pain, tremors and ticks.

The patient' parent signed the "CONSENT /CONDITIONS OF SERVICE" form at 8:06 PM and the demographic form documented the patient had insurance.

The patient was triaged at 8:16 PM and did not receive an MSE until 11:41 PM.

21. Medical record review revealed Patient #19 presented to the DED on 1/1/13 at 8:02 PM with the complaint of talking crazy psych issues.

The patient's representative signed the "CONSENT/CONDITIONS OF SERVICE" form at 8:07 PM and the demographic form documented the patient was self pay.

The patient received an triage at 20:16 PM, did not receive an MSE until 9:12 PM and was later transferred to a mental health hospital.