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Based on a review of medical records and staff interview, it was determined that the facility failed to ensure that compliance with ?489.24 which states that the facility must obtain or attempt to obtain written and informed refusal of examination, treatment or an appropriate transfer in the case of an individual who refuses examination, treatment or transfer.

Findings include:

1. Medical Record (MR) #8 indicated a 90 year old patient presented to the ED on 10-11-10. Documentation in the medical record indicated that he/she left without treatment. There was no signed Against Medical Advice (AMA) form in the medical record. There was no documentation in the medical record that the patient was advised of the risks of leaving AMA.

2. MR #9 indicated that a 3 day old infant presented to the ED on 10-11-10. Documentation in the medical record indicated that he/she was taken from the ED by his/her father without treatment. There was no signed AMA form in the medical record. There was no documentation in the medical record that the patient was advised of the risks of leaving AMA.

3. The above was confirmed by Staff #2 during an interview.

Based on medical record review, it was determined that the facility failed to provide an appropriate medical screening examination within the capabilities of the facility to determine whether an emergency medical condition exist for one (1) of 30 sampled medical records.

Findings include:

Review of Patient #16's medical records revealed that Patient #16 was seen and treated in the Emergency Department on 11/12/10, 11/14/10 and 11/15/10 for the chief complaint of pain. The medical records revealed the following:

1. First visit:
Review of Medical Record #16's revealed the patient is a 36 year old who presented to the ED on Friday 11/12/2010 at 1912 with a chief complaint of "chest pain and Right Lower Extremity pain which started about 2 hours ago. Pain feels similar to sickle cell pain in past. "Triage vital signs B/P (not documented) Pulse 105, Respirations 20, Temp (not documented), Pain 10, Oxygen 99 on Room Air (RA), Emergency Severity Index Level 3 (ESI). Physician orders: Dilaudid 2 milligrams Intravenous Push (IVP) at 2059, Dilaudid 1 mg IVP at 2135, Diphenhydramine 25 mg IVP at 2335 and Sodium Chloride 0.9% Intravenous 1 liter at 2100. Electrocardiogram (EKG), Labs, Chest PA and Lateral, Creatine Phosphokinase (CPK), Complete Blood Count (CBC), Comprehensive Metabolic Panel, Reticulocyte Count, Oxygen, Saline Lock, Troponin I and Pregnancy Test Serum. History and Physical exam was completed. The medications were given as ordered. The laboratory results revealed abnormal morphology with sickle cells, macrocytes, ovalocyte teardrop cells and microcyte. Chest X-rays 2 views were ordered for pain and shortness of breath. Impressions: No active disease in chest, indication "sickle cell crisis." The patient's CBC values were out of normal range. According to Staff #4 the patient was discharged from the ED 11/13/10, shortly after midnight with instructions to follow-up with primary doctor in 2 days. Discharge instructions state, "Return to the ED if you start to vomit, develop a fever, or feel worse."

2. Second visit:
Medical Record #16 revealed the patient is a 36 year old who presented to the ED on 11/14/10 with a chief complaint of chest pain related to sickle cell since Friday. ESI level 2. Patient was triaged at 1350. Vital Signs: B/P (not documented) pulse 125, respirations 20, Temperature (not documented) Pain 9 and O2 saturation 99 room air. Medications ordered: Dilaudid 2 mg IVP ordered at 1534, Dilaudid 4mg IVP at 1644, Diphenhydramine 50 mg IVP at 1541 and 1648, Normal Saline 1,000 cc fluid-bolus. Labs CBC with Differential, Creatine Kinase (CK), Reticulocyte count, EKG. The History and Physical and review of systems was completed by the attending at 1524. Nursing administered meds as ordered. Pain was reassessed at level 0. Patient was discharged in stable condition with a diagnosis of atypical chest pain. Time of discharge not indicated.

3. Third visit:
Medical Record #16 revealed the patient is a 36 year old who presented to the ED on 11/15/10 with a chief complaint of Chest pain, Sickle Cell Disease. Nursing documented "C/O [complaint of] Chest Pain R/T [related to] Sickle Cell since Friday." Has been seen in this ED multiple times since onset of this pain. Appears in NAD [No acute distress]. "
The patient's triage time was Monday, November 15, 2010 at 15:43. ESI level 3. Pulse 113, O2 98 on room air, pain 8, respirations 20. EKG was ordered and performed at 1734. The 12 lead interpretation showed Atrial Fibrillation. History and Physical completed at 2100. The patient was ordered 30 milligrams of Ketorolac Tromethamine IVPB at 2141 and Xanax 0.25 milligrams by mouth at 2112. Nursing documented both medications were given at 2159. There was no evidence that laboratory tests were ordered during this ED admission. The medical record revealed the patient was discharged in stable condition at 2224 with instructions to follow-up with Primary Care Physician (PCP).

4. On 11/16/10 at 3:13 AM the patient presented to the ED of another hospital. Diagnositic test were done and the patient was admitted to the in-patient unit with a diagnosis of sickle cell crisis.

Based on review of the facility's policies and procedures, and medical records, it was determined that the facility failed to follow it's policies, and provide stabilizing treatment within the capability of the facility for one (1) of 30 patients who presented to the emergency department.

Findings include:

Reference: Policy Subject: "Management of the Patient With Pain" states under the subheading of Assessment that Severe Pain is a "pain score of 7, 8, 9, 10." Re-Assessment of Pain will be conducted. . . after pain medication administration in a time frame appropriate to the medication route."

1. Medical Record review revealed that Pt #16 was seen in the emergency department (ED) on 11/12/10, and 11/14/10 for a chief complaint of pain, was treated and discharged. "The patient presented to the ED on 11/15/10. Triage time 1543, Pain Level 8. Nursing documented Chief complaint of "Chest pain" onset Friday. Has been seen in this ED multiple times since onset of this pain. Appears in NAD [No acute distress]." Nursing then documented (time not indicated), "PT. STATES SHE HAS PAIN TO ENTIRE CHEST, INCREASED WITH MOVEMENT AND BREATHING." The attending physician ordered Ketorolac Tromethamine 30mgs, a nonsteroidal anti-inflammatory drug, (pain medication) IVPB at 2141. Nursing documented the medication was given at 2159.

a. Nursing documented Patient #16's pain level at 2200 was "8" which is indicated as severe pain, in the above reference. The patient was discharged from the ED at 2224, 24 minutes after receiving the pain medication without being reassessed for pain immediately prior to discharge.

b. There is no evidence provided or documented that the interventions ordered and provided alleviated or stabilized the patients presenting symptoms of pain prior to discharge.

2. The patient was discharge on 11/15/10 at 2224. The patient presented to another acute care facility ED on 11/16/10 at 0315 for severe pain, and was admitted at 0534.