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Based on record review, review of policies/procedures, and staff interview, the facility failed to enforce policies and procedures to ensure compliance with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases, and the related requirements at 42 CFR 489.20 on 2 of 2 days of on-site survey (May 2-3, 2012).

Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements of ?489.24. Failure of the facility to enforce their policies and procedures relating to the Emergency Medical Treatment and Labor Act placed patients at risk of increased anxiety, suffering, distress, and pain related to their reasons for seeking assistance.

Findings include:

The facility failed to enforce their policy/procedure regarding providing an appropriate medical screening examination (MSE) for individuals presenting to the emergency department (refer to A2406).

The facility failed to enforce their policy/procedure regarding advising patients who leave without being seen/against medical advice of the risks of leaving without medical examination and treatment; failed to enforce their policy/procedure regarding documentation in the medical record for patients who leave without being seen/against medical advice; and failed to enforce their policy/procedure regarding patients receiving stabilizing treatment prior to discharge (refer to A2407).

Based on review of policies/procedures, medical record review, and staff interview, the facility failed to complete a medical screening examination for 2 of 23 sampled patients (Patients #6 and #23) who presented to the emergency room for care/services. Failure to conduct a medical screening examination placed Patients #6 and #23 at risk of complications due to the lack of identification of potential medical problems requiring diagnoses and treatment.

Findings include:

Reviewed on May 2-3, 2012, an emergency department (ED) policy/procedure titled "STANDARD POLICY. Title: TRANSFER OF PATIENTS FROM ER [EMERGENCY ROOM] TO ANOTHER FACILITY," dated 2/10, stated, "The purpose of this document is to ensure that all patients are evaluated, stabilized, and if necessary transferred to another facility in a safe efficient manner . . . A medical screening will be provided to all patients who present to the Emergency Department (ED) for care. . . . [Page 2] 1. Any patient presenting to the ED and requesting examination or treatment will be seen by the ED physician or her private physician to determine whether or not an emergency medical condition exists. . . . 2. If an emergency medical condition exists, or the patient is in active labor, the patient will receive examination and treatment to ensure stabilization of the medical condition or the labor (unless the patient refuses to consent to further examination and treatment); or the patient will be transferred to another facility . . ."

- Review of Patient #6's medical record occurred 05/03/12 and showed the patient presented to the ED at 10:57 p.m. on 04/30/12 with the following complaint: "I was in a domestic dispute on the 25th [04/25/12] and I was seen here on that day and I just don't feel like my injuries are getting better." Nursing note indicated, "Pt [patient] relates bruising to left arm, pain to neck, back of head." Nurses' notes identified Patient #6 rated her pain at "8 - very severe" on a scale of 1 to 10.

Patient #6's medical record from 04/30/12 lacked evidence of the completion of a medical screening examination and showed the patient left the emergency room without examination at 11:53 p.m. (almost one hour after arrival). The record lacked evidence of a reason for Patient #6 leaving the emergency room without completion of a medical screening examination.

- Review of Patient #23's (a seven month old child) medical record occurred on 05/03/12 and showed Patient #23's parents brought their child to the emergency room at 9:10 p.m. on 04/29/12. A nurse's note stated, "Parents state infant has been vomiting since yesterday and developed a fever of 102 tonight. Had Motrin at 8:30 p.m. [at home] Child is sleeping now."

The record lacked evidence of the completion of a medical screening examination. A nurse's note, dated 04/29/12 at 10:44 p.m. (one hour and 34 minutes following arrival in the emergency room), stated, "Mother came to triage desk and states child's temperature is normal and chooses to leave. Did offer peds [pediatric clinic] walk-in in am. Told to return if symptoms return or worsen."

Interviews occurred with management staff members (#2, #5, #6, #7, and #8) during the morning and afternoon of 05/03/12 to review the above identified findings and obtain additional information. The staff members concurred Patients #6 and #23 did not receive medical screening examinations, staff members could not determine the reason for the lack of examination, and indicated the facility did not review cases of patients who do not receive medical screening examinations to determine the cause/reason and implement appropriate systemic/procedural action(s) to ensure the hospital meets the needs of emergency patients.

Based on review of policies/procedures, medical record review, and staff interview, the facility failed to advise 2 of 2 sampled patients (Patient #6 and #23), who left without being seen/against medical advice (LWBS/AMA), of the risks of leaving without medical examination and treatment; failed to document information in the medical record consistent with the facility's policies/procedures; and failed to ensure 1 of 23 sampled patients (Patient #6) received stabilizing treatment prior to discharge home resulting in a return visit to the emergency department (ED). Failure to advise patients of the risks of leaving without being seen/against medical advise and failure to ensure staff stabilized the patient's condition before discharge placed the patients at risk of developing complications.

Findings include:

Reviewed on 05/03/12, the ED policy/procedure, "Title: PATIENT LEFT WITHOUT BEING SEEN OR AGAINST MEDICAL ADVICE (AMA)," Revision: 4/11, stated, "This guideline is in effect when any person leaves ED before evaluation and discharge is completed by staff. The ED physician will be notified of any patient who expresses intent to leave before completion of evaluation and treatment. 1. Required documentation on the patient chart will include answers to the following: a. Does the patient seem capable of making decisions (i.e., oriented, unimpaired)? b. Why is the patient leaving (quote preferable)? c. Was a nurse or physician notified? d. AMA documentation will include: A completed AMA form. If patient refuses to sign, state such on form. Documentation of potential consequences of leaving explained and verbalized as understood by patient. Documentation of family/friend (if present) involvement in decision."

Reviewed on 05/03/12, the ED policy/procedure, "STANDARD POLICY. Title: TRANSFER OF PATIENTS FROM ER [EMERGENCY ROOM] TO ANOTHER FACILITY," Issue Date 2/10, stated, "The purpose of this document is to ensure that all patients are evaluated, stabilized, and if necessary transferred to another facility in a safe efficient manner. . . . 2. If an emergency medical condition exists, or the patient is in active labor, the patient will receive examination and treatment to ensure stabilization of the medical condition or the labor (unless the patient refuses to consent to further examination and treatment); or the patient will be transferred to another facility . . ."

- Reviewed on 05/03/12, Patient #6's medical record showed the patient presented to the ED at 8:23 p.m. on 04/25/12 following a domestic assault and complaints of left arm and right side neck pain. The patient rated her pain as "8 - very severe" at 8:36 p.m. and "7 - severe" at 9:43 p.m. The record also identified Patient #6 as fourteen weeks pregnant

The record showed Patient #6 received Ibuprofen (a pain medication) 600 mg (milligrams) at 9:43 p.m. and Robaxin (a muscle relaxation medication) 1,000 mg at 9:46 p.m. in the ED. The record lacked evidence of assessment of Patient #6's pain following the administration of the Ibuprofen and Robaxin. The record showed emergency room staff discharged Patient #6 at 9:49 p.m. with a prescription for Robaxin and instructions to use Ibuprofen and Robaxin at home for pain control.

Patient #6's medical record showed the patient returned to the ED at 10:57 p.m. on 04/30/12 with the following complaint: "I was in a domestic dispute on the 25th [04/25/12] and I was seen here on that day and I just don't feel like my injuries are getting better." A nursing note indicated, "Pt [patient] relates bruising to left arm, pain to neck, back of head." A nurse's note identified Patient #6 rated her pain at "8 - very severe" on a scale of 1 to 10. A nurse's note showed Patient #6 had been using Ibuprofen and Robaxin as instructed on 04/25/12 to manage her arm and neck pain.

Patient #6's medical record from 04/30/12 lacked evidence of the completion of a medical screening examination and showed the patient left the emergency without examination at 11:53 p.m. (almost one hour after arrival). The record lacked evidence of notification of the ED physician of the patient's plan to leave, a reason for Patient #6 leaving the emergency room without completion of a medical screening examination, notification/explanation of the risks of leaving without examination and treatment, acknowledgement and understanding by the patient, and completion of the AMA form.

- Reviewed on 05/03/12, Patient #23's (a seven month old child) medical record showed Patient #23's parents brought the child to the emergency room at 9:10 p.m. on 04/29/12. A nurse's note stated, "Parents state infant has been vomiting since yesterday and developed a fever of 102 tonight. Had Motrin at 8:30 p.m. [at home] Child is sleeping now."

The record lacked evidence of the completion of a medical screening examination. A nurse's note, dated 04/29/12 at 10:44 p.m. (one hour and 34 minutes following arrival in the emergency room), stated, "Mother came to triage desk and states child's temperature is normal and chooses to leave. Did offer peds [pediatric clinic] walk-in in am. Told to return if symptoms return or worsen."

The record lacked evidence the ED physician received notification of Patient #23's mother's decision to leave without completion of the medical examination and treatment, the capability of the parent to make the decision, completion of the AMA form, and documentation of an explanation of the risks/consequences of leaving and verbalized understanding.

Interviews occurred with management staff members (#2, #5, #6, #7, and #8) during the morning and afternoon of 05/03/12 to review the above identified findings and obtain additional information. The staff members concurred Patients #6 and #23 left the ED without being seen and the facility had not followed their policy/procedure. The staff members were unable to provide any additional information regarding the lack of assessment and stabilization of Patient #6's pain during the patient's 04/25/12 admission to the ED.