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Based on staff interview and review of medical records, hospital policies, and meeting minutes, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. This resulted in the lack of an apprpriate MSE, or the lack of an MSE by qualified medical professionals, for 3 of 31 ER patients (#27, #30 and #31) whose medical records were reviewed. In addition. this resulted in the lack of stabilizing treatment for 1 of 31 patients (#11) whose medical records were reviewed. Findings include:

1. Refer to C2406 as it relates to the failure of the hospital to provide appropriate MSEs to ER patients.

2. Refer to C2407 as it relates to the failure of the hospital to provide stabilizing treatment to an ER patient with an emergency medical condition.

The failure to provide MSEs and stabilizing treatment resulted in the hospital's inability to appropriately diagnose and treat emergency patients.

Based on staff interview and review of medical records, hospital policies, and meeting minutes, it was determined the hospital failed to ensure 3 of 31 ER patients whose medical records were reviewed (#27, #30 and #31), received appropriate Medical Screening Examinations by appropriately qualified personnel. This resulted in the inability of the hospital to ensure patients were not discharged with undetected emergency medical conditions. The findings include:

1. Two patients received MSEs by unqualified staff. Examples include:

a. Patient #27's medical record documented a 21 year old female who presented to the ER on 6/23/10 at 11:35 PM. The form "EMERGENCY ROOM RECORD," was written by Staff A, an RN. The note, dated 6/23/10 at 11:35 PM, stated Patient #27 complained of "feeling like she's not getting any air. [right] arm tingling. Light headed. 2 hrs ago." The note stated Patient #27 had been smoking an herbal marijuana substitute called "Black Mamba." Her vital signs were-blood pressure 143/96, pulse 77, respirations 18. The nursing note stated the examination was unremarkable. The bottom of the form contained boxes for discharge information. These boxes indicated Patient #27 was discharged home, was ambulatory, and was given discharge instructions. The time of discharge was not documented. Under the heading "DISCHARGE SUMMARY," not timed, the form stated "EMTALA screening done. [Patient] to follow up [with] her PCP within the week." Discharge vital signs were documented at 12:30 AM on 6/24/10. These included blood pressure 126/74, pulse 66, and respirations 18. No documentation was present that the RN had spoken to a physician or other provider about Patient #27.

Staff A was interviewed on 7/28/10 at 10:50 AM. He confirmed he had performed the MSE on Patient #27 on 6/23/10. He stated he thought he had spoken by telephone to the Nurse Practitioner who was on call for the hospital on 6/23/10. He said he did not know if he had documented this or not.

Staff A's personnel file was reviewed with the Director of Human Resources on 7/28/10 at 11:20 AM. His "EMPLOYEE ORIENTATION CHECKLIST," dated 6/09/10, contained an box for "ER Patient Screening video." Most of the items on the checklist were checked but this item was not. The Director confirmed the documentation and stated Staff A had not been approved by the hospital to conduct MSEs. She presented surveyors with "Credentialing Sheets" for 9 RNs which stated these nurses had been approved to conduct medical screening examinations. Staff A did not have a Credentialing Sheet.

The hospital's Board of Directors Meeting minutes for 5/17/10 approved the Credentialing Sheets to conduct MSEs for the 9 nurses as noted above. Staff A was not listed as a nurse who was approved to conduct MSEs.

The DON was interviewed on 7/29/10 at 9:00 AM. She stated Nurse A was not approved to conduct MSEs. She said a list of nurses that were approved to conduct MSEs was not available to staff or to providers.

Patient #27's MSE was performed by unqualified staff.

b. Patient #31's medical record documented a 78 year old male who presented to the ER on 6/09/10 at 9:15 PM. The form "EMERGENCY ROOM RECORD," written by Staff A and dated 6/09/10 at 9:15 PM, stated Patient #31 complained of lower abdominal pain and had "[large] blood in his urine x1 week ago." The nursing note stated Patient #31 had severe pain in his abdomen which decreased after he urinated. The note stated Patient #31 had been seen by at a clinic but did not state when that was. The note stated Patient #31 had blood in his urine until 6/09/10. The note stated Patient #31's current pain level was 2 of 10. The note documented a physical examination by the RN. The note stated Staff A called the Nurse Practitioner who asked him to conduct the medical screening examination. Under the heading "DISCHARGE SUMMARY," dated 6/09/10 at 10:15 PM, the RN documented Patient #31 was to follow up with his PCP or come back to the emergency room if the pain returned.

Staff A was interviewed on 7/28/10 at 10:50 AM. He stated he had performed the MSE on Patient #31.

Patient #31's MSE was performed by unqualified staff.

2. The hospital failed to provide direction to nurses who performed MSEs. The policy "MEDICAL SCREENING EXAM-ER EMTALA," approved 11/14/07, stated all patients presenting to the Emergency Department would receive an MSE by "Qualified Medical Personnel (QMP), which may be any active member of the Medical Staff (DO, MD) or mid-level practitioners (PA, FNP), or Registered Nurses, (RN) who have been approved to perform the MSE in consultation with an on-call provider who is an active member of the Medical Staff. The policy stated "The approved RN will complete the MSE, following the 'ED Patient History Form' and will contact the on-call provider immediately." A form labeled "ED Patient History Form" was not included with the policy. The only form present in the 9 medical records that were reviewed, where an RN performed the MSE, was the form titled "EMERGENCY ROOM RECORD." This was a 2 sided form that contained identifying information, the chief complaint, admission and discharge vital signs, and a nursing assessment that consisted of boxes to check. For example, the section of the nursing assessment labeled "Speech" had a choice of 6 boxes the nurse could check, such as "Incoherent, Silent, Crying," etc. This assessment did not contain areas for the nurse to write descriptions in addition to the boxes to check. The second page of the form contained a section for nursing notes, a discharge summary, a section to document medications and fluids that were given, and sections for transfer or discharge. This was the same form that nurses used when the MSE was completed by a physician.

Staff B and Staff C, RNs who performed MSEs, were interviewed on 7/28/10 at 4:20 PM and 7:50 PM, respectively. Both RNs stated they performed the same assessment whether a physician performed the MSE or the nurse conducted the examination. Both RNs stated they did not perform any kind of special examination if they were performing the MSE. Both nurses stated they documented either assessment the same way.

The DON, interviewed on 8/02/10 at 4:00 PM. She stated there was no form labeled "ED Patient History Form." She stated nurses used the form titled "EMERGENCY ROOM RECORD" to document the MSE and no special forms were used.

3. One patient received an incomplete MSE by a nurse as per the following example:

a. Patient #30's medical record documented a 40 year old female who presented to the ER on 6/19/10 at 4:50 PM. The form "EMERGENCY ROOM RECORD," was written by Staff D, an RN. The form, dated 6/19/10 at 4:50 PM, stated Patient #27 complained of a headache since 3:00 AM that day. Patient #27 stated her pain had a severity of 10 out of 10. The form stated Patient #30 routinely took Lamictal-a drug for seizures and bipolar disorder, Lexapro-an antidepressant, Ambien-a sleeping pill, Trazadone-an antidepressant, and extended release Morphine and Norco for pain. The form at 4:50 PM described the MSE by the RN. Patient #30's headache was not described. The nursing note at 4:50 PM stated Patient #30 "Has not taken any of her [prescribed] pain meds because 'the morphine makes me nauseated and I threw up 3 times.' After discussing with [a physician], medicated pt for nausea with injection." A nursing note at 5:20 PM stated "Reports nausea feeling improved. Able to take washcloth off face & walk into lighted room." She was discharged at 5:25 PM with a pain level documented at 5 of 10.

A medical history was not documented. A history of her headaches was not described. The reasons Patient #30 had been prescribed 4 psychotropic medications and 2 narcotic pain medications was not documented. Her psychiatric history was not described. Patient #30's medication compliance history was not documented to determine if she was going through withdrawal. The nursing assessment described Patient #30 as oriented and stated her pupils were reactive to light. Otherwise, a neurological examination was not documented.

Staff D was interviewed on 7/28/10 at 4:00 PM. She confirmed the documentation. She stated she had conducted the medical screening examination for Patient #30. She stated 6/19/10 was her first encounter with Patient #30. She said Patient #30 had a history of back pain and headaches but had not taken the Morphine for 4 days due to nausea. She stated this was not documented. She stated she did not know Patient #30's psychiatric history.

Patient #30's MSE was incomplete and did not include a medical history or a complete neurological assessment.

Based on staff and family interviews and review of medical records, hospital policies, and meeting minutes, it was determined the hospital failed to ensure 1 of 31 ER patients whose medical records were reviewed (#11), received stabilizing treatment for pain. This resulted in the inability of the hospital to ensure patients were stabilized prior to transfer or discharge. The findings include:

Patient #11's medical record documented a 6 year old male who was brought to the emergency room by his father after falling from a slide. The form "EMERGENCY ROOM RECORD," written by Staff B and dated 6/26/10 at 9:40 PM, stated Patient #11 had fallen and complained of left arm pain. The form stated Patient #11 had a "deformity" of his left elbow. The form stated his pain rating was 10 of 10 and he was "crying histerically." An xray of the arm was documented at 9:55 PM. The nursing note at that time stated Patient #11 was crying and difficult to console. The nursing note dated 6/26/10 at 10:05 PM, stated Patient #11's arm was splinted and he continued to cry hysterically. The final nursing note, dated 6/26/10 at 10:15 PM, stated Patient #11 was "...carried out of ER by Dad, will be transferred to [another hospital] via private car. Pt in stable condition but continues to cry." Patient #11's pain was rated at 8 of 10 at the time of transfer. Patient #11 was transferred to another hospital approximately 27 miles away.

The xray report, for the xray taken at 9:55 PM on 6/26/10, was dictated 6/27/10 at 11:54 AM. The report stated Patient #11 had a fracture of his ulna and a dislocated radius [forearm bones].

The "Emergency Room Report" by Staff G, the physician who treated Patient #11, was dictated on 6/26/10 at 10:38 PM. The report stated Patient #11 "...is crying incessantly though and is in a significant amount of pain. There is also some mild growth deformity of the elbow." The report stated the 6 year old patient "...declined any kind of shot for pain."

Patient #11's father was interviewed by telephone on 7/28/10 at 8:25 PM. He stated Patient #11 was in severe pain while at the hospital. He stated it was especially painful when the xray technician manipuated the arm for the xray. The father stated he asked the physician for pain medication to treat the child. He said the physician refused.

Staff B, the RN that treated Patient #11, was interviewed on 7/28/10 at 4:20 PM. She stated the child was screaming and writhing in pain. She stated she offered to give Patient #11 pain medication but the physician refused.

Staff G, the physician who treated Patient #11, was interviewed on 7/28/10 at 2:45 PM. He stated Patient #11 was in a lot of pain but said the child did not want a shot for pain so he did not order it. He said the arm was splinted and ice was applied. An IV was not inserted while Patient #11 was at the hospital. Staff G said he did not remember why he did not order an IV.

The medical record from the receiving hospital stated Patient #11 was admitted there at 11:05 PM on 6/26/10. The receiving hospital started an IV shortly after admission and administered a narcotic pain medication with relief. Patient #11 was then examined by an orthopedic surgeon who later performed a closed reduction and pinning of his elbow.

Harms Memorial Hospital failed to provide stabilizing treatment by not administering pain medication prior to transferring Patient #11.