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Based on a review of facility documentation and medical records (MR) and staff interviews, it was determined that the facility failed to define in their hospital bylaws and/or Medical Staff Rules and Regulation as to who other than a physician is qualified to perform a medical screening examination (MSE) to determine if a emergency medical condition (EMC) exists.

Finding include:

1) Review of facility bylaws and Medical Staff Rules and Regualtions revealed no documentation that defined who other than a physician is qualified to perform a MSE to determine if an EMC exists.

2) During interview of September 4, 2014, at 2:20 PM, EMP1 confirmed the above findings and revealed. "It is not in the bylaws or the rules and regulations."

Based on a review of facility documentation and staff interviews, it was determined that the facility failed to develop a backup plan that would ensure on call physician coverage for those physicians who are approved for simultaneous on call at other facilities.

Findings include:


1) Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" reviewed March 6, 2012, revealed " ... Emergency Department On-Call Physician Coverage ... 8. An on-call physician may take simultaneous call at another facility. An on-call physician may perform surgery while on-call if a suitable back up plan exist."

2) Review of facility Medical Staff Rules and Regulations reviewed July 15, 2014, revealed " ... 8.4 Concurrent Call/Elective Surgery ... the on-call physician may perform elective surgery or other patient care services while on call, and may perform elective surgery or other patient care services while on call, and may be on call at another hospital ... Under such circumstances, the hospital shall follow its applicable policies and procedures, in effect from time to time, to meet the needs of patients when a particular specialty is unavailable ... "

2) On September 4, 2014, at approximately 1:00 PM a request was made to the facility to provide a copy of their "back-up" plan for physician who takes simultaneous on-call at other facilities. During interview on September 4, 2014, at approximately 2:10 PM, EMP1 revealed " ... we don't have a policy, the practice is to go to the next person ... we will need to develop a policy for that."

Based on a review of facility documentation and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to provide a medical screening examination for one of 39 medical records reviewed (MR1).
Findings include:
1) Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)," reviewed March 6, 2012, revealed, " ... Comes to the Dedicated Emergency Department with respect to an individual requesting examination and treatment for what may be an Emergency Medical Condition means that the individual is at the dedicated emergency department or outpatient provider based entity operated to treat emergency medical conditions without an appointment. An individual in an emergency vehicle on hospital property or premises is considered to have come to the hospital's emergency department ... IV. Policy Guidelines 1. Medical Screening Examination ... If an individual arrives on Hospital property or premises or an off campus dedicated emergency department and is not technically in the Hospital Emergency department, and requests emergency care, he or she must receive a Medical Screening Examination within the Capacity and Capabilities of the Hospital ... An individual in an emergency vehicle, which is on Hospital Property, or Premises, is considered to have come to the Emergency Department ... ."
2) Review of the local police department incident report dated August 27, 2014, 19:19 revealed " ... Juvenile ran away from home after speaking of suicide ... was located at a friend's house ... contacted [family member (FM)] and advised that we located ... [MR1] ... [FM] advised ... still at [facility] obtaining 302 .... transported [MR1] to [facility] to be with [FM]. We met [FM] in the parking lot where [FM] explained that the staff at [facility] advised her that it would be easier for [FM] to transport [MR1] by car to [receiving hospital] and sign [MR1] in there. [FM] was concerned about the car ride to [receiving facility] and that [MR1] may try to get out of the car on the way down ... [police officers] were also concerned about that and set up transportation with ... EMS ... ."
3) Review of Ambulance Trip Sheet dated August 27, 2014, at 21:20 revealed "...Crew members were advised by police officers that ... Hospital Medical Staff recommend patient be evaluated by [receiving hospital] ... ."
4) Review of MR1 from receiving hospital dated August 27, 2014, at 10:00 PM revealed " ... FM] states that upon arrival, the physician in the ED suggested they go straight to [receiving hospital] for an evaluation versus being seen at [transferring hospital] first so an ambulance was called and the pt. brought to the DEC ... ."
Interview with family memeber of MR1 on September 4, 2014, revealed that MR1 ran away and FM called the police. Police suggested that FM take MR1 to transferring hosptial to fill out a 302 warrant. FM went to the facility, as suggested by police, and spoke with the ED Physician EMP4. The 302 commitment process was explained to FM. There was concern that the petitioner was under 17 years of age. The ED Physician EMP4 told FM that it would be better if MR1 would go to another hospital, one that had an adolescent behavior health unit, to be evaluated. EMP4 also told FM that MR1 could be screened by the facility, but it was a timely process which would involve a bed search. The FM then met the police and MR1 in the parking lot. MR1 was then taken to another facility, at the suggestion of EMP4. FM added, "I did not refuse to take [MR1] back into the facility for treatment, I was looking to [ED Physician EMP4] for guidance. [ED Physician EMP4] suggested it would be better if we took [MR1] to other facility for evaluation, and I didn't know the process."
During an interview on September 4, 2014, at 11:00AM, EMP4 confirmed that MR1 was not provided a medical screening examination.
During an interview on September 5, 2014, at approximately 1:00 PM, EMP3 confirmed the above findings and replied "no" when asked if MR1 received a medical screening examination.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure that all elements of an appropriate transfer were met for three of four obstetrical medical records reviewed (MR34, MR37, and MR38).

Findings include:

Review of facility policy "Transfer of a Patient to a Tertiary Care Center," reviewed 12/19/13, revealed, "IV. Policy Guidelines ... E. Obtain a Consent for Release of Medical Information from the patient. ... F. A copy of the entire medical record shall accompany the patient."

Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)," reviewed March 6, 2012, revealed, "III .... 3. The transferring hospital must send copies of all available medical records pertaining so the individual's condition to the hospital where the patient is being transferred. 4. These documents include copies of the available history, records related to the individual's emergency medical condition, observation of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided results of any tests and the informed written consent or written certification of the physician."

1. Review of MR34, MR37, and MR38 revealed the patients were transferred to a tertiary facility. Further review revealed the absence of a "Consent for Release of Medical Information" form or documentation that copies of the patient's medical record had accompanied the patient on transfer or were forwarded to the receiving facility.

Interview with EMP11 on September 4, 2014, at approximately 11:30 AM confirmed the above findings and revealed, "We don't have anything in the medical records that says we sent a copy of the medical record. They [staff] ask the patients to sign a consent so we can send a copy. I don't see it."