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Based on document review and interview, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to ensure an adequate medical screening exam was performed by a qualified medical professional as appointed in the Bylaws, See A 2406; Failure to ensure transfer risks were documented with all transferred patients/guardians, See A 2409; failure to document the risks and benefits of transferring a patient to another medical facility.

Based on document review and interview, it was determined that the facility failed to ensure a medical screening exam (MSE) was performed on 3 out of 20 patients (#7, #10 and #12) with an emergency medical condition, by a qualified medical professional as specified in the Hospital Bylaws. Findings include:

On 1/29/2014 at approximately 1100 during review of the Hospital Bylaws, no evidence could be found of which providers were considered "qualified" to conduct a medical screening exam. This was confirmed in an interview with staff N who stated "Our policy is not very specific."

On 1/29/2014 at approximately 1600 during review of the policy titled Leave, No Treatment (LNT)/Elopement rev. 12/09 it was stated under "Provisions: Emergency Department staff having knowledge that a patient intends to LNT, are responsible to notify the Emergency Department physician and attempt to persuade the patient to be seen."

On 1/29/2014 at approximately 1330 during review of the medical record for patient #7 it was revealed that the patient presented to the ED with chest pain. An ECG was conducted and indicated abnormal findings and the patient left without a medical screening exam. The medical record did not indicate that the ED physician was notified or that an attempt was made to persuade the patient to wait and be seen. The patient arrived at 1250 on 1/13/2014 and left at 1917 on 1/13/2014, in that time frame no evidence of a provider seeing the patient was documented.

On 1/29/2014 at approximately 1350 during review of the medical record for patient #10 it was revealed that the patient presented to the ED on 12-19-2013 at 1727 with an injury to his thumb which he had severed while chopping wood. He then left without a medical screening exam, no evidence of a provider seeing the patient was documented. The medical record did not indicate that the ED physician was notified or that an attempt was made to persuade the patient to wait and be seen.

On 1/29/2014 at approximately 1400 during an interview with Staff J, the Patient Experience Manager, stated that patient #10 had reported a complaint regarding a conflict with the security guard and the triage nurse. Staff J stated that patient #10 relayed to her that the triage nurse suggested that he go somewhere else for care after the conflict with the security guard. Staff J stated that she forwarded the complaint to the Security Supervisor, but did not forward the complaint to the ED manager. She then "sent a letter to the complainant and closed the case."

On 1/29/2014 at approximately 1410 during an interview with staff K, the Security Supervisor, it was stated "I followed up with the security guard that had the conflict with the patient. We talked about using a different approach in the future. The security guard stated that the patient had said he was leaving and that the triage nurse said it might be faster to get care somewhere else."

On 1/29/2014 at approximately 1415 during an interview with staff N it was stated that "We probably could have handled things differently with this patient."

On 1/29/2014 at approximately 1500 during review of medical record #12 it was revealed that the patient presented to the ED with suicidal ideations on 12/19/13 at 2259. The patient was a 17 year old minor. The patient left without being given a medical screening exam at 0409 on 12/20/2013, no evidence of a provider seeing the patient was documented. The medical record did not indicate that the ED physician was notified or that an attempt was made to persuade the patient to wait and be seen.

On 1/29/2014 at approximately 1530 during an interview with staff N the findings in medical records #7, #10 and #12 were confirmed. Staff N stated that "these patients did not get a medical screening exam before leaving."

Based on document review and interview the facility failed to document the risks and benefits of transferring a patient to another medical facility for 4 out of 6 transfer patients (#3, #4, #5, #6) reviewed. Findings include:

On 1/29/2014 at approximately 1145 during review of the medical records for patient's #3, #4, #5 and #6 it was revealed that the risks of the transfer were not indicated on the "Patient Transfer Consent Form" under the "Risks and Benefits of Transfer" section.

On 11/29/2014 at approximately 1200 during an interview with Staff N it was stated that "I agree, the providers are not filling out this section all the time."