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Based on documentation review and interview, the hospital failed to ensure compliance with the requirements of 42 CFR 489.24 as evidenced by the deficient practices cited at 489.24(r) and (c). In addition, the hospital was found out of compliance with 489.20(q), and 489.20(r)(3).

The hospital failed to ensure all patients who entered the emergency department (ED) knew their rights under section 1867 of the Social Security Act, were entered into the central log, and received an appropriate medical screening examination.

Based on observations and interview, the hospital failed to post conspicuously in the emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination, signs specifying the rights of individuals under section 1867 of the Social Security Act with respect to examination and treatment in the emergency room. Findings include:


A tour of the emergency department (ED) was conducted with registered nurse (RN)-C on 1/15/2015 at 9:45 a.m. The hospital had three entrances, including the main ED entrance leading to the waiting room, the ambulance entrance, and the entrance for patients arriving via helicopter. There were no signs specifying the rights of individuals under section 1867 of the Social Security Act with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA) in the entrance to the waiting room, no signs in the ambulance entrance area, and no signs in the entrance for patients arriving via helicopter. There were no EMTALA signs in individual ED rooms for individuals to view while waiting for an examination. There was one sign located in the waiting room, but the waiting room was divided into two sections due to influenza season and there was no EMTALA sign on the non-influenza side of the waiting room. This was verified with RN-C on 1/15/2015, during the ED tour. In addition during the tour, RN-C confirmed that prior to a medical screen examination, patients are brought to the triage area where a nurse assessed the patient. There was no EMTALA sign in the triage area.

Based on interview and document review the hospital failed to maintain an accurate and complete central log on each individual who presented to the emergency department (ED) for 6 of 25 patients (P1, P2, P3, P4, P24, and P25) reviewed. Findings include:

P25:
An interview was conducted with P25 on 1/20/2015 at 2:25 p.m. P25 presented to the ED on 12/28/2014 sometime around 7:00 p.m. - 7:30 p.m. The security guard asked if she needed to see a physician and she informed him she did. The security guard then told her there was a two hour wait, to sign her name on the sign in sheet, and sit down to wait. P25 wrote her name on the sign in sheet, but left without being seen.
The hospital's ED central log was reviewed for patients that arrived on 12/28/2014. P25 was not on the ED central log.

P24:
An interview was conducted with P24 on 1/20/2015 at 5:13 p.m. P25 presented to the ED on 12/28/2014 between approximately 7:00 p.m. and 8:00 p.m. He waited at the triage desk between 5-10 minutes. The security guard approached him and asked him if he needed to see a physician , and he told the security guard he did need to be seen. The security guard told him to put his name on the sign in form at the desk, that it would be at least two hours before someone could meet with him, and if he needed to be seen sooner he should go to a different hospital. P24 did not put his name on the sign in form but left the ED.

The hospital's ED central log was reviewed for patients that arrived on 12/28/2014. P24 was not on the ED central log.


P3:
The ED central log was reviewed and it indicated P3 presented to the ED on 12/28/2014 at 4:36 p.m. for a catheter problem. The log did not include the physician who saw the patient or the patient's disposition.

P3's ED documentation for 12/28/2014 was reviewed. Registered Nurse (RN)-H documented, "Pt's problem with catheter was very simple. Pt didn't understand how to apply screw on valve end to end of tubing. Nurse assessed, applied end easily and flushed per protocol. Family happy and left without being seen by provider. The patient was dismissed at 4:55 p.m.

P2:
The ED central log was reviewed and indicated that P2 presented to the ED on:
*12/29/2014 at 7:07 p.m. and the log did not include a chief complaint or disposition
*12/30/2014 at 6:54 p.m. and no chief complaint was listed.
*1/09/2015 at 7:00 p.m. and no chief complaint was listed.
*1/10/2015 at 7:04 p.m. and no chief complaint was listed.
*1/11/2015 at 6:44 p.m. and no chief complaint was listed.
*1/12/2015 at 6:49 p.m. and no chief complaint or disposition was listed.
*1/13/2014 at 6:51 p.m. and no chief complaint was listed.

P1:
The ED central log was reviewed and indicated that P1 presented to the ED on 12/28/2014 at 6:38 p.m. for shortness of breath and was transferred on 12/29/2014 at 1:07 a.m. The ED central log did not reflect the accurate time the patient left the ED. According to the ED record the patient left the hospital at 12:00 a.m.

P4:
The ED central log was reviewed and indicated that P4 presented to the ED on 1/14/2015 at 9:41 a.m. for arm pain/problem. P4 was transferred on 1/14/2015 at 11:30 a.m. The ED central log did not reflect the accurate time the patient left the ED. According to ED documentation the nurse documented at 11:14 a.m. that the patient was transferred.

RN-J was interviewed on 1/15/2015 at 9:55 a.m. and stated that the actual patient arrival times are not documented in the computerized record and confirmed since this time is not captured the ED log arrival time is inaccurate. The arrival time on the ED log is often documented at the time of triage which are not always the time the patient presented to the ED.RN-C was interviewed on 1/15/2015 at 8:45 a.m. and she stated patients sign in on the sheet at the triage desk only if not immediately received by the triage nurse. Their name is crossed off the sign in sheet by the triage nurse. The sign in sheet is a worksheet that is thrown away after each day. It is not used for date collecting.

Based on interview and document review the hospital failed to provide all patients that present to the emergency department (ED) with an appropriate medical screening examination for 5 of 25 (P3, P13, P20, P24, and P25) patients who presented to the ED. Findings include:
P25:An interview was conducted with P25 on 1/20/2015 at 2:25 p.m. P25 who was approximately 36 weeks pregnant presented to the ED of the hospital sometime around 7:00 p.m. -7:30 p.m. on 12/28/2014 after she felt no fetal movement for 2-3 days. When she entered the hospital through the ED doors, she saw a security guard talking with people. The security guard asked if she needed to see a doctor and she said yes. The security guard told her there would be a 2-3 hour wait. The security guard told her to put her name on the sign in sheet and wait. P25 said she was in the ED waiting room approximately 45 minutes. During that time, no one came out to the waiting room and she did not see the security guard talk with any other staff. P25 started to call other hospitals in the area while in the ED waiting room. She contacted hospital #2 and was told by staff from hospital #2 to come right in. P25 scratched her name off the sign in list and proceeded to hospital #2 where she had an emergency cesarean section. After delivery her infant was transferred to hospital #3 for a higher level of care and she was transferred to hospital #4 to be near her infant.

Hospital #1 had no documentation that P25 was at the hospital on 12/28/15.P25's ED and medical record from hospital #2 was reviewed. The ED Patient Record, dated 12/28/2014 noted P25 presented to hospital #2's ED at 7:41 p.m. The History and Physical, dated 12/28/2014, revealed P25 presented to the ED and then to the obstetrics unit of hospital #2. P25 was pregnant at 36 4/7 weeks gestation. P25 felt no fetal movement for the last three days and had mild contractions. Her pregnancy was complicated by the development of diabetes on 7/24/2014 that required Lantus insulin and glyburide, borderline high blood pressures, obesity, and tobacco use. Fetal heart rate monitor tracing at hospital #2 revealed decreased variability to the point where there was almost no variability. A consult with obstetrics was obtained and an urgent cesarean section was performed due to absent variability of fetal movement. P25 tolerated the procedure well and was in stable condition. The infant was delivered by STAT cesarean section at 10:15 p.m. The infant was limp, blue, and apneic with no detectable heart rate or respiratory effort at the time of delivery. The infant had no muscle tone and no gag reflex. Hospital staff initiated chest compressions, intubation, and a nasogastric tube. Apgars were 0 at 1 minute, 5 minutes, 10 minutes, and 15 minutes. Apgar was 4 at 20 minutes with 2 for a heart rate, 1 for tone, and 1 for color. The infant required a higher level of care and was transferred to hospital #3 after 11:05 p.m. P25 was transferred to hospital #4 to be near her critically ill newborn infant.P25's infant's medical record from hospital #3 was reviewed. The History and Physical, dated 12/29/2014, revealed the infant was a preterm, male born at 36 4/7 weeks gestation. Diagnoses included perinatal depression, neonatal encephalopathy, severe metabolic acidosis, infectious concerns, hypoglycemia, hypotension and acute respiratory failure. The infant was provided body cooling, multiple labs, x-rays and MRI, hyperalimentation and maintenance fluids, and respiratory support. Progress notes, dated 12/30/2014, noted neurology remained in consultation. The infant's prognosis was grave and consistent with severe hypoxic ischemia brain injury. P25's hospital record from hospital #4 was reviewed. P25 was admitted on 12/29/14. The Discharge Summary, dated 1/1/2015, revealed P25's postpartum and postoperative course was uncomplicated. An interview was conducted with Physician-R on 1/16/2015 at 4:10 p.m. who stated P25 presented to hospital #2 on the evening of 12/28/14. P25 was pregnant and told a triage nurse she had not felt the baby kicking for 2-3 days. P25 was close to full term at an estimated gestational age of 36 weeks and had questionable mild contractions. P25 was sent directly to the obstetrics unit for a medical screening examination.An interview was conducted with Physician-P on 1/20/2015 at 12:00 p.m. and he stated he received a telephone call from an obstetrics nurse on 12/28/14 in the evening that P25 presented to hospital #2 and tests revealed a non-reactive fetal monitor tracing. Physician-P called Physician-Q in consultation to review the fetal monitoring. Both physicians came to the hospital and evaluated P25. P25 had an emergency medical condition. An emergency cesarean section was performed approximately 10-30 minutes after P24 was evaluated by Physician-P and Physician-Q. P25 was stable, however, the infant required resuscitation and ventilator support. The infant had no heartbeat for the first 12 minutes of life. Physician-P and another physician performed resuscitative measures on the infant An interview was conducted with Physician-Q on 1/20/15 at 12:23 p.m. She received a call to review a fetal heart strip on P25 due to concerns noted about the infant and no fetal movement felt by the mother in approximately 3 days. An ultrasound revealed no fetal movement, although heart tones were seen. P25 told Physician-Q she had gone to hospital #1, spoke with a security guard who said there was a 3 hour wait and then decided to go to hospital #2. P25 had an emergent condition requiring the cesarean section delivery of the infant. P25 was quickly taken back to the operating room and an emergency cesarean section was performed.

P24:An interview with P24 was conducted on 1/20/2015 at 5:12 p.m. P24 presented to hospital #1's ED on 12/28/2014 between approximately 7:00 p.m. - 8:00 p.m. with acute severe abdominal and chest pain and diaphoresis. He said he was in a stooped position due to the pain. He went to the desk and waited for staff to come and after a few minutes, less than 5-10 minutes, a security guard came over and told him to put his name down on the form at the desk. The security guard told him it would be at least two hours before someone could meet with P24 and if P24 needed to be seen sooner he should go to a different hospital. P24 said he saw and interacted with no other staff at the ED. P24 and his spouse left the ED and proceeded to another hospital where it was determined he needed surgery.Hospital #1 had documentation that P24 was at the hospital on 12/28/15.
P24's record from hospital #2 was reviewed. The ED note, dated 12/28/2014 indicated P24 was acutely uncomfortable with acute epigastric pain. P24 had epigastric tenderness and right upper quadrant tenderness, pain since 1:00 p.m., and some vomiting. Hospital #2 ran blood tests and performed a gallbladder ultrasound. There was dilatation of the common bile duct of 9 mm with no obstructing stone evident. P24 required 16 milligrams of intravenous morphine for significant residual pain. The patient was admitted to the hospital for further evaluation and management by surgery services with additional lab tests the next morning, followed by surgery. P24's Discharge Summary, dated 12/30/2014, noted P24 had a laparoscopic cholecystectomy with intraoperative cholangiography and choledochoscopy and laparoscopic common bile duct exploration on 12/29/2014. His findings included multiple gallstones in the distended gallbladder and a prominent common bile duct. The laparoscopic surgery cleared an obstruction of the distal common bile duct. P24 was discharged on 12/30/2014. An interview was conducted with Physician-R on 1/20/2015 at 1:47 p.m. who stated P24 presented to hospital #2 in acute pain. The patient appeared miserable with significant abdominal pain. Hospital #2 conducted a medical screening examination (MSE) and tests to determined P24 had an emergent medical condition requiring admission to the hospital. P24 was treated for the severe pain. Tests revealed P24 had gallstones and a dilation of the common bile duct with elevated white blood count and mildly elevated liver enzymes. P24 had laparoscopic cholecystectomy surgery the following morning at hospital #2. P24 had gallstones, including a stone which was retrieved from the distal common bile duct during the surgical procedure. P24 was discharged from hospital #2 two days after he was admitted to hospital #2.

An interview with security guard (SG)-I was conducted on 1/14/2015 at 1:45 p.m. SG-I stated he worked 6:00 p.m. - 6:00 a.m. starting on 12/28/2014. He did not remember any pregnant woman arrive at the ED on 12/28/2014 while he worked that evening. He stated he asked patients who presented to the ED if they needed to see a physician and to sign in and sit down to wait. He said he was directed by RN-H to tell all patients the wait would be 2-3 hours. He stated if he knew a patient was pregnant he directed or escorted them to the obstetrics unit but he does not ask a patient if they are pregnant. SG-I said it was a busy evening and he greeted patients in the ED. He denied remembering anyone arrive with acute abdominal pain but remembered a man in a stooped position asked the wait time for the ED. SG-I denied that he directed any patients to go to another hospital. RN-H was interviewed on 1/14/2015 at 12:15 p.m. and he stated the first person to meet patients may be the triage nurse, the secretary, or the security guard. Patients come into the ED and ask the wait time, what doctor is working and get upset if they are not told. The patients determine if they want to be seen by a physician. RN-H stated 12/28/2014 was a busy day. When the ED is busy, patients may have to wait. Patients are asked to sign in. If patients leave their names are crossed of the list and he skips to the next patient to triage.RN-C was interviewed on 1/15/2015 at 8:45 a.m. and she stated patients sign in on a sheet at the triage desk only if not immediately assessed by the triage nurse. The patients' names are crossed off the sign in sheet by the triage nurse. The sign in sheet is a worksheet that is thrown away after each day.

P3:
The ED central log was reviewed and it indicated P3 presented to the ED on 12/28/2014 at 4:36 for a catheter problem.

A review of P3's ED visit on 12/28/2014 indicated that Registered Nurse RN-H documented, "Pt's problem with catheter was very simple. Pt didn't understand how to apply screw on valve end to end of tubing. Nurse assessed, applied end easily and flushed per protocol. Family happy and left without being seen by provider." The patient was dismissed at 4:55.

RN-H was interviewed on 1/14/2015 at 12:15 p.m. and stated that he does a MSE when he triages patients.

P20:The ED central log was reviewed and indicated P20 presented to the ED on 1/3/2015 at 12:40 p.m.A review of P20's medical record indicated P20 presented with flu-like symptoms and was triaged at 12:41 p.m. The nurse conducted an influenza swab and provided Tylenol per standing orders. The influenza antigen was negative for Influenza A and B. The patient was roomed at 2:19 p.m. At 2:45 p.m. the patient stated he was leaving, had waited too long, and was feeling better. The patient discharged against medical advice (AMA). There was no evidence that a MSE was completed, and that the risks versus benefits of leaving before a MSE was explained. The hospital refusal of treatment form was not completed.

P13:A review of the ED central log indicated P13 presented to the ED due to fever on 1/10/15 at 4:42 p.m.A review of P13's ED record indicated P13 was triaged by the nurse at 4:42 p.m. At 5:46 p.m. the mother of P13 stated she wanted to monitor P13's fever at home as P13 was feeling better. No medical screening examination was completed. There is no documentation that a MSE was offered to the patient. There is no evidence of the risks versus benefits of leaving before a MSE was explained to the mother prior to leaving the ED and the hospital's refusal of treatment form was completed or reviewed with the patient.
Hospital #1's policies and procedures were reviewed. The policy related to classification of the ED last revised December 2010, indicates that the ED offers emergency care 24 hours a day, 7 days a week, and has at least one physician present.

Hospital #1's policy related to physician coverage in the ED last revised on March 2013, indicates that the ED is staffed with a physician 24 hours a day and the ED department physician on duty is responsible for the evaluation and treatment of all patients presenting to the ED unless prior arrangements have been made with another physician.

Hospital #1's policy related to EMTALA dated August 2012 identifies a medical screening examination is "An evaluation designed to determine whether an individual has an emergency medical condition. A medical screening exam is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist." The policy further indicates that every patient that presents to the hospital and requests examination or treatment will be provided with an appropriate medical screening examination by designated qualified medical person to determine if the patient has an emergency medical condition.

Hospital #1's Bylaws & Rules and Regulations 2012, indicate that all patients who present to the ED must be seen by a physician. The only exceptions include patients sent to the ED following examination by their physician, for treatment available in the local clinic. Patients seen by their local physician within the same day who are sent for additional treatment in the ED. However, if there is a change in the above patient's medical condition or the patient requests a medical examination, they will be seen by the ED or attending physician. In addition, the Rules and Regulations go on to include qualified medical personal in the ED include physicians, physician assistants, and nurse practitioners. In Women's Health Unit, where patients are sent if they are pregnant and greater than 20 weeks gestation, additional qualified staff include certified midwives and RNs. The hospital Bylaws & Rules and Regulations 2012 do not reference a MSE, rather indicate all patients must be seen by a physician and what personal is included as qualified medical personnel.