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Based on medical record review, policy review and staff interviews it was determined the facility was not in compliance with 42 CFR 489.20 and 42 CFR 489.24.

The facility failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for one (#2) of 21 sampled patients presenting to the emergency department that was within the facility's capabilities. (Refer to Tag - A2406).

The facility failed to ensure a proper transfer with all information was completed for one (#14) of 21 sampled patients. (Refer to Tag- A2409).

Based on observational tour of the emergency department, medical record reviews, policy review and staff interviews it was determined the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine if an emergency medical condition existed for one (#2) of 21 sampled patients who presented to the emergency department complaining of pain.

Findings included:

The review of the facility policy titled "EMTALA Medical Screening Stabilization Policy", no policy number, revision date 9/1/2013 indicated all individuals presenting on hospital property requesting emergency medical services shall receive an appropriate Medical Screening Examination and Stabilization services. The policy further indicated the Medical Screening Examination is an on-going process and the record must reflect continued monitoring according to the patient's needs until the patient is stabilized or an appropriate transfer occurs.

The review of the facility policy titled "Triage", no policy number, last revised 12/16/16 included documentation indicating the responsibilities of the triage nurse included reassessing waiting clients as necessary, at a minimum of one half hour increments or sooner as needed.

The review of the record for Patient #2 revealed the patient presented to the Emergency Department (ED) on 1/1/17 at 4:58 p.m. as a walk-in. The patient's payor source was a State funded program. The Nurse's Notes dated 1/1/17 at 5:14 p.m. and signed by the Triage RN (Registered Nurse) included documentation Patient #2 was complaining of nausea and vomiting. The note indicated Patient #2 had just been discharged from an inpatient nursing unit by the attending physician. The patient's vital signs were blood pressure 100/62, pulse 113, respirations 20 and temperature 98.0F. The pain score was 8 on a pain scale of 0-10 (Pain scale rating 7-10 - severe pain unable to perform activity of daily life). The patient's blood glucose level was 353 (normal 74-106 per facility). The Triage Nurse documented Patient #2's acuity was ESI (Emergency Service Indicator) 3-Urgent, indicating the patient had a condition that could potentially progress to a problem requiring urgent intervention. There was no documentation in the medical record to indicate that on 1/1/2017 Patient #2 received an appropriate medical screening examination. The facility failed to ensure that their policy and procedure related to medical screening examination was followed as evidenced by, once the patient was found on the floor sleeping in the ED, the ED staff had security remove Patient #2 from the ED on 1/1/2017 without receiving an appropriate medical screening examination that was within the capability of the hospital's ED.

The documentation noted Triage was completed on 1/1/17 at 5:17 p.m. and at 5:20 p.m. an armband was placed on the patient's wrist. No medications were administered. The Outcome was documented as "Patient left the ED for unknown reasons" at 9:17 p.m., approximately 4 hours after arrival. There was no documentation indicating the patient was called or the waiting area was assessed for the patient. There was no evidence of reassessment or monitoring for an ongoing MSE to determine any change in condition had occurred.

The Physician Documentation dated 1/1/17 at 9:17 p.m. and signed by the Charge Nurse indicated Patient #2 left the facility after triage for unknown reasons and did not receive a Medical Screening Examination (MSE).

The detailed review of the record failed to reveal evidence Patient #2 was reassessed at any time during the approximate 4 hour period the patient was in the waiting area. The record failed to reveal evidence Patient #2 was offered a medical screening examination at any time between the completion of Triage on 1/1/17 at 5:20 p.m. and 9:17 p.m. when the Charge Nurse documented the patient had left the ED.

The Risk Manager presented a picture showing the lower part of a wheelchair and what appeared to be 2 pairs of legs wearing uniform pants. The picture did not include a date or time stamp. She indicated the picture was Patient #2 being escorted out of the ED by security.

A telephone interview was conducted on 2/7/17 at 4:20 p.m. with the security guard who identified himself as having escorted Patient #2 out of the ED on 1/1/17 at approximately 9:30 p.m. The security guard indicated he received a telephone call from an admitting clerk in the ED who informed him "Some guy is sleeping on the floor". The security guard indicated he escorted Patient #2 out of the ED in a wheelchair after checking with the admitting clerk and the triage nurse who both told him Patient #2 had been discharged.

An interview was conducted on 2/8/17 at 11:00 a.m. with the Charge RN on duty on 1/1/17 at the time Patient #2 was triaged. She indicated the facility did have a policy regarding reassessing emergency patients while the patients were in the waiting room. She indicated she thought the policy required reassessments every two hours.

An interview conducted with the triage nurse at the time of the observational tour of the ED on 2/8/17 revealed none of the 5 patients waiting longer one hour had been reassessed. The Triage nurse indicated she was responsible for maintaining a log sheet to document patient reassessments. The triage nurse confirmed the finding patients were not being reassessed for an going MSE to determine any change in their condition.

The Director of Risk Manager confirmed the finding the facility failed to provide Patient #2 with a medical screening examination on 1/1/17 by having security escort the patient out of the ED prior to a MSE.

Based on medical record review, policy and procedure review, and staff interview it was determined the facility failed to ensure that the written certification for transfer included the reason for transfer and an explanation of the benefits of the transfer for 1 (#14) of 3 sampled transfers of a total sample of 21 medical records.

Findings included:

1. Patient #14 presented to the Emergency Department (ED) via ambulance on 1/25/17 at 4:46 p.m. with a chief compliant of multiple trauma. The patient was transferred to another acute care hospital via ambulance on 1/25/17 at 10:27 p.m. The review of the Emergency Services Transfer Form dated 1/25/17 revealed there was no evidence of the reason Patient #14 was being transferred, and there was also no evidence of the expected benefits of the transfer. The facility failed to ensure that on 1/25/2017 Patient #14 was appropriately transferred as stated in their policy and procedure.

The policy titled "EMTALA Emergency Transfers Policy", no policy number, revision date 9/1/2013 was reviewed on 2/8/17. The document indicated the physician is required to sign a certification that contains a summary of the risks and benefits upon which it is based. The Physician Certification must state the reasons for Transfer. The Physician Certification form must contain a complete picture of the benefits expected from appropriate care at the receiving hospital and risks associated with the Transfer.

An interview was conducted with the Risk Manager on 1/8/17 at 2:30 p.m. who confirmed the above findings.