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Based on current hospital policy and procedure review, medical record reviews, Medical Staff Rules and Regulations, Emergency Department Logs, and staff interviews; the hospital failed to comply with 42 CFR 489.20 and 489.24.


The findings included:

1. The hospital failed to ensure that all individuals who presented to their emergency department were provided with an appropriate medical screening examination that was within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists for one (1- #20) of twenty (20) patients medical records reviewed.

~ Cross refer to findings in Tag A-2406.


2. The hospital failed to inform and document the risks of leaving to individuals not consenting to examination and/or treatment; and failing to ensure the medical record contained a description of the examination and or treatment that was refused by the individuals for 2 (#6 and #7) of 20 sampled medical records reviewed.

~Cross refer to findings in Tag A-2407.

Based on a review of the facility's Medical Staff Rules and Regulations, emergency room log, and staff interviews, the facility failed to create and maintain a medical record for all patients who presented to the facility's ER for treatment on one (1) of twenty (20) patients reviewed (#20).

Findings include:


Review of facility's Medical Staff Rules and Regulations, approved 1/12/2015, revised: 12/16/2015, revealed:
7. An appropriate emergency department medical record shall be kept for every patient receiving emergency service and shall be included in the patient's permanent medical record.

A review of the facility's emergency room log dated 7/3/2017 failed to reveal documentation that Patient #20 had presented to their emergency room on 7/3/2017 for treatment.

Interview with the ER Director on 7/18/2017 at 2:38 PM in the conference room confirmed that ER staff had not created a medical record for Patient #20 on 7/3/2017 when she presented to the emergency department seeking treatment.






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Based on a review of the emergency room log, review of an obstetric outpatient record, staff interviews, personnel file reviews, and review of the facility's Medical Staff Rules and Regulations, the facility failed to create and maintain a medical record for all patients who presented to the facility's ER for treatment on one (1) of twenty (20) patients reviewed (#20).

Findings include:

Review of facility policy 2603, EMTALA.01.EMTALA, effective 2/26/2008, revised 5/2/2016, revealed:
7. All patients presenting to the hospital would be logged in with complaint, diagnosis, and disposition. A patient is considered to have presented when they enter onto the premises.

Review of facility's Medical Staff Rules and Regulations, approved 1/12/2015, revised: 12/16/2015, revealed:
7. An appropriate Emergency Department record or log shall be kept listing every person who presents himself or is brought to the Emergency Department for treatment or care and a notation concerning treatment or transfer. An appropriate emergency department medical record shall be kept for every patient receiving emergency service and shall be included in the patient's permanent medical record. A review of the facility's emergency room log dated 7/3/2017 failed to reveal documentation that Patient #20 had presented to their emergency room on 7/3/2017 for treatment.

Interview with the ER Director on 7/18/2017 at 2:38 PM in the conference room confirmed that ER staff had not entered Patient #20 in the ED central log on 7/3/2017. The ER Director explained that Patient #20 presented to the ER registration desk mid-morning on 7/3/2017. The ER Director stated further that the only person at the registration desk was the ER technician, and that the ER was not very busy during that time. The ER Director stated that he/she became aware of the situation on 7/3/2017 at about 11:00 AM when he/she received a phone call from the Chief Nursing Officer (CNO) asking if he/she was aware of Patient #20's situation.


Interview with the ER Charge Nurse on 7/18/2017 at 4:01 PM in the conference room revealed that he/she had worked as Charge Nurse for approximately ten (10) years, and received EMTALA training annually. The Charge Nurse confirmed that he/she had been in the charge position on 7/3/2017 during the day shift when Patient #20 presented to the ER for treatment. He/she stated that he/she was in the back working when the ER technician telephoned him/her stating that Patient #20 was present and was requesting that her IUD be removed. The Charge Nurse stated that Patient #20 had been seen the preceding day or two, treated, and advised to see her OB-gyn physician for the IUD removal. The Charge Nurse stated that he/she asked the technician if Patient #20 had seen her OB-gyn physician or not, and the technician responded "no". The Charge Nurse explained that he/she had instructed the technician to tell Patient #20 it was unlikely that the IUD would be removed in the ER, but that they would be happy to see her if she wished to sign in. The Charge Nurse further stated that the technician had told him/her that Patient #20 had left after the conversation, and had not signed in at that point. The Charge Nurse stated that he/she was just trying to be honest with Patient #20 because Patient #20 wouldn't want to sit back there for four or five (4 or 5) hours, then find out that the ER would not be able to give her the treatment she wanted.

An interview was conducted with the ER technician on 7/18/2017 at 4:26 PM in the conference room. The technician confirmed that Patient #20 had never signed in.

Based on a review of medical records, review of an obstetric outpatient record, review of the facility's Medical Staff Rules and Regulations and Policy and Procedure review and staff interviews the facility failed to ensure that all individuals who presented to their emergency department were provided with an appropriate medical screening examination that was within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists for one (1- #20) of twenty (20) patients medical records reviewed.

Findings include:


1. Review of facility policy 2603, EMTALA.01.EMTALA, effective 2/26/2008, revised 5/2/2016, revealed that every individual who presented to the Emergency Department and requests examination or treatment for a medical condition, and every individual who is not a hospital patient who went elsewhere on hospital property (that is, the individual who went to the hospital but not to the dedicated Emergency Department), who either requests examination or treatment for a medical condition, or if a prudent layperson observer would believe that the individual is suffering from an emergency medical condition (EMC), must at a minimum have an appropriate medical screening examination (MSE) to determine if an EMC does or does not exist, regardless of the individual's ability to pay.

2. Review of facility's Medical Staff Rules and Regulations, approved 1/12/2015, revised: 12/16/2015, revealed:
6. All patients who present to the Emergency Department must be seen by a credentialed qualified medical provider. The patient may request his family physician or physician of choice but a medical screening examination to rule out an emergency medical condition and any necessary stabilizing treatment shall not be delayed while waiting for a requested physician to arrive. At no time will patients be discharged from the Emergency Department without a provider evaluation.

3. Patient #20's medical record dated 6/30/2017 was reviewed. Documentation by the ED nurse revealed that Patient #20 presented to the ED on 6/30/2017 at 5:12 PM, ambulatory and alone. The medical record also revealed the patient's insurance was listed as "Self-Pay." The patient's initial vital signs were: Temperature: 98.1 (oral); Heart rate 96; Blood Pressure: 142/75; and Oxygen saturation was 99% on room air. Further review of the medical record revealed blood laboratory work and urine was collected for a pregnancy test, Urine microscopic and urine analysis were ordered. A CT of the abdomen without contrast was also ordered. The Emergency Department Note Draft, dated 6/30/2017 revealed in part, "HPI (history of Present illness. Review of Systems)...Chief Complaint: Vaginal bleeding for 3 weeks. History of Present illness: The patient (#20) ...with bleeding every day for the past 3 weeks. She is on no hormonal medications.....she has a ParaGard IUD (intra uterine device). There has been bleeding every day that is similar in severity to her normal menses an is associated with some clots being passed. She is going through 6-7 pads per day... She talked to a nurse at the gynecologist office today who directed her here." Further review revealed the patients "Discharge Disposition: Home Condition: Fair. Departure: Clinical Impression: Vaginal Bleeding." There was no documentation in the medical record to indicate that Patient #20 received a vaginal examination on 6/30/2017. The facility failed to ensure that an appropriate medical screening examination was performed for Patient #20 on 6/30/2017.


4. Interview with the ER Director on 7/18/2017 at 2:38 PM in the conference room confirmed that Patient #20 had not received an MSE (medical screening examination) 7/3/2017. The ER Director explained that Patient #20 presented to the ER registration desk mid-morning on 7/3/2017. The ER Director stated further that the only person at the registration desk was the ER technician, and that the ER was not very busy during that time. The ER Director stated that he/she became aware of the situation on 7/3/2017 at about 11:00 AM when he/she received a phone call from the Chief Nursing Officer (CNO) asking if he/she was aware of Patient #20's situation. The CNO stated that he/she had received a phone call from the hospital's accrediting agency. The accrediting agency informed the CNO that they had received a phone call from Patient #20, who stated that the ER would not see her, and the CNO asked the ER Director to look into it. The ER Director stated that he/she phoned Patient #20, who explained that she was still bleeding, that she had tried to follow up with her OB-gyn MD that day, but that the office was closed due to the holiday. Patient #20 also stated that she had spoken to the OB-gyn office's nurse, who had instructed her to return to the ER. Patient #20 further explained that when she arrived at the ER to get her IUD out, the registrar/technician told her that the hospital's ER doesn't remove IUDs, but they would be happy to see her. After being given that information, Patient #20 stated that she left. The ER Director stated that he/she told Patient #20 that he/she would contact the OB-gyn MD or nurse to learn where the hospital was in the process of getting her care, and call her back. The ER Director stated that he/she then left a voice mail for the OB-gyn MD, and had a mid-level provider send a text the MD with a message to contact him/her. The ER Director further stated that after approximately twenty to thirty (20-30) minutes, he/she heard a lullaby over the intercom, which indicated that a baby had been born, and so went to the labor and delivery department to see if the on-call OB-gyn MD was there. The ER Director found OB-gyn MD #9 the labor and delivery department and explained the situation to concerning Patient #20 to MD #9. The ER Director further explained that the Women's Services manager was also present and that the three of them discussed the best course of action to get care for Patient #20. The ER Director, MD #9 and the Women's Services manager decided that the ER Director would contact Patient #20, and have her return to the women's services area of the hospital, where MD #9 would remove the IUD as an outpatient procedure. The ER Director further stated that he/she returned to his/her office and phoned Patient #20 a couple of times, was unable to leave a voice message, therefore also sent Patient #20 a text. The facility failed to ensure that Patient #20 received and appropriate medical screening examination by a Qualified Medical Personnel (QMP) on 7/3/2017; instead the Patient #20 was discouraged by emergency department staff from being evaluated by a QMP indicating the hospital was not capable of removing the IUD.

5. Patient #20 responded to the ER Director's text with a message that she had just spoken to MD #9, and was returning to the hospital. The ER Director stated that he/she then instructed Patient #20 to go to the ER waiting room and that The ER Director would escort Patient #20 upstairs. The ER Director stated that he/she then went to the ER registration desk, requesting that Patient # 20 be pre-registered so as to avoid a long wait. The ER Director further explained that Patient # 20 arrived approximately thirty to sixty (30-60) minutes later. The ER director met Patient #20 in the ER to complete the registration process, then escorted Patient #20 to the labor and delivery (L&D) department, where the L&D nurse took over care of Patient #20. The ER Director stated that as he/she walked with Patient #20, the patient stated that she just wanted the IUD out, so the bleeding would stop, and she could return to work. Patient #20 also stated that she wondered if she was not seen because she did not have insurance, to which the ER Director had assured her that the registrars at the front desk did not know patients' insurance status and that many patients seen did not have insurance, so it did not matter.

6. Interview with the ER Charge Nurse on 7/18/2017 at 4:01 PM in the conference room revealed that he/she had worked as Charge Nurse for approximately ten (10) years, and received EMTALA training annually. The Charge Nurse confirmed that he/she had been in the charge position on 7/3/2017 during the day shift when Patient #20 presented to the ER for treatment. He/she stated that he/she was in the back working when the ER technician telephoned him/her stating that Patient #20 was present and was requesting that her IUD be removed. The Charge Nurse stated that Patient #20 had been seen the preceding day or two, treated, and advised to see her OB-gyn physician for the IUD removal. The Charge Nurse stated that he/she asked the technician if Patient #20 had seen her OB-gyn physician or not, and the technician responded "no". The Charge Nurse explained that he/she had instructed the technician to tell Patient #20 it was unlikely that the IUD would be removed in the ER, but that they would be happy to see her if she wished to sign in. The Charge Nurse further stated that the technician had told him/her that Patient #20 had left after the conversation, and had not signed in at that point. The Charge Nurse stated that he/she was just trying to be honest with Patient #20 because Patient #20 wouldn't want to sit back there for four or five (4 or 5) hours, then find out that the ER would not be able to give her the treatment she wanted.

7. Interview with the ER technician on 7/18/2017 at 4:26 PM in the conference room revealed that he/she had worked in his/her current position on day shift for approximately twelve (12) years, and had been trained in EMTALA. The ER technician stated that Patient #20 arrived in the ER stating that an OB-gyn physician had instructed her to meet him at his office, but when she arrived, the office was closed. Patient #20 was upset and enquired whether that physician was on-call or not. The ER technician stated that he/she had informed Patient #20 that the physician was not on-call, but another physician one was covering. The ER technician explained that he/she had asked Patient #20 what was going on, and Patient #20 stated that she thought her IUD was out of place, and she wanted to have it removed. The ER technician stated that he/she informed Patient #20 that the ER didn't normally remove IUDs there, but she was more than welcome to sign in and see the ER MD. The technician could not recall if he/she had consulted with the Charge Nurse, or not. The technician stated that Patient #20 then asked if she could have a copy of her X-ray procedure, and the technician had instructed that she could go down the hall to the radiology department to request a copy from them. The technician stated that he/she again asked Patient #20 if she wanted to see the ER MD, and Patient #20 said "no", that she would find someone else with whom to follow up. Patient #20 then walked in the direction of the radiology department, and the next time the technician saw Patient #20, she was with the ER Director. The technician confirmed that Patient #20 had never signed in.



8. Review of MD #9's documentation on Patient #20 from an obstetric outpatient record dated 7/3/2017 at 4:32 PM, revealed that Patient #20 had experienced vaginal bleeding for three (3) weeks, and was changing pads every two (2) hours. Patient #20 reported that she had called the OB-gyn office, and was told to go to ER where MD #9 would be contacted for consultation. Patient #20 had not been seen by the on-call OB-gyn physician on Friday (6/30/17). Patient #20 stated that she had called the office again on 7/3/2017 in the morning, and was instructed to go to the ER. Patient #20 explained that on arrival at the ER, staff told her nothing could be done for her at that time. The ER Supervisor informed of the situation and after reviewing the CT (computed tomography) and laboratory results for Patient #20 MD #9 phoned Patient #20, instructing her to return to the hospital for an examination and IUD (intrauterine device) removal. Patient #20 returned to the hospital on 7/3/2017 at 1:41 PM. Vital signs at 3:20 PM were: Temperature-98.5, heart rate-85, respirations-18, and blood pressure-139/78.
Ordered labs included: CBC (complete blood count), chemistry, blood type and screen, and urine culture. Results of CBC included: hemoglobin 7.9, hematocrit 26.
A procedure was performed to remove the IUD (contraceptive device) from the uterus, cervix. A culture was obtained on the IUD.
Patient #20 received an iron injection, Levaquin, and Flagyl (antibiotics).
Patient #20 tolerated the procedure well and was discharged to home in stable condition on 7/3/17 at 5:41 PM with diagnoses of anemia, IUD removal, malpositioned IUD, pelvic pain, and vaginal bleeding. Instructions were provided on dysfunctional uterine bleeding, and follow up with MD #9 in two (2) weeks. Patient #20 also received prescriptions for antibiotics.

Based on review of medical records and review of facility's policies the facility failed to inform and document the risks of leaving to individuals not consenting to examination and/or treatment; and failing to ensure the medical record contained a description of the examination and or treatment that was refused by the individuals for 2 (#6 and #7) of 20 medical records reviewed.

Findings included:


The facility's policy titled EMTALA.01.EMTALA, Policy number 2603, Effective Date: 2/26/2008, Date of last revision 5/20/2016 was reviewed. The Policy specified in part, "8. Consent or Refusal of Examination or Treatment . If the patient or his representative refuses the treatment after being informed of the risks and benefits to the patient of the examination and treatment and the risks of refusal in writing (use AMA form). The medical record must contain a description of the examination, treatment, or both if applicable that was refused by or on behalf of the individual. If written refusal cannot be obtained, ED personnel shall document the steps taken to secure written refusal and the reason it could not be obtained. The medical record must contain a description of the examination, treatment or both if applicable that was refused by or on behalf of the individual."
Review of patient #6's medical record revealed the seventy-four (74) year old patient presented to the facility's ER on 11/1/16 (Tuesday) at 2:34 PM with complaints of left flank pain, history of kidney stones.
The patient was triaged on 11/1/2016 at 2:36 PM, and designated as an ESI level 3A. Vital signs were:97.8-97-18 129/99 oxygen saturation 97% on room air. Pain was 10/10. The nurse noted the patient stated that he/she experienced pain on Sunday (10/30/2016); no pain previous day (Monday, 10/31/2016); and was experiencing pain for one (1) hr this day. The patient was noted to be restless.
A urinalysis was obtained per nursing protocol, with results: few bacteria, moderate blood.
The patient left prior to receiving a MSE.
At 3:05 PM, the nurse noted that the patient informed the ER greeter that he/she was going to try to make it home to north Georgia, and had ambulate out in "stable " condition.
The medical record did not contain evidence that the patient had been advised of the risks of leaving; there was also no documentation in the medical record to indicate that a description of the examination and or treatment that was refused There was no evidence of an against medical advice (AMA) form filled out in the medical record for patient #6 as stated in the facility's policy.

Review of patient #7's medical record revealed forty (40) year old patient presented to the facility's ER on 11/2/16 at 4:33 PM with complaints of lower abdominal cramping and vaginal bleeding.
The patient was triaged 11/2/2016 at 4:38 PM, and designated as an ESI level 3A. Vital signs were: 98.2-80-20 168/98, oxygen saturation 99% on room air. Pain was 8/10.
The patient was examined by the ER physician on 11/2/__ (no year, untimed), who noted the patient complained of pelvic pain with intermittent bleeding for three (3) days.
MD orders included complete blood count, chemistry, urine pregnancy test, urinalysis, prothrombin time (PT), partial thromboplastin time (PTT- both measure blood clotting time), lipase (checks pancreas).
An intravenous (IV) catheter was inserted, and the patient received normal saline (NS) 100 cc and Toradol (anti-inflammatory medication, also treats pain) 30 mg IV at 7:58 PM. Pain was 8/10.
A CT of the abdomen/pelvis was ordered, but not completed due to the patient checking out AMA.
At 8:44 PM the RN noted that the patient had advised him/her of the need to leave to care for her sick mother. The patient's IV was removed, and the patient left AMA.
The medical record did not contain evidence that the patient had been advised of the risks of leaving; there was also no documentation in the medical record to indicate that a description of the examination and or treatment that was refused by Patient#7 on 11/2/2016. There was no evidence of an against medical advice (AMA) form filled out in the medical record for patient #7 as stated in the facility's policy.