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Based on document review and interview, it was determined that for 2 (#14 and #25) of 27 patients, the hospital failed to ensure compliance with 489.24 in that the hospital failed to perform a complete medical screening examination, failed to have a triage policy addressing current triage practice, and failed to have a current sexual assault exam policy addressing the current practice within the department.

Findings include:

1. See findings cited at 489.24 (r) (3) and 489.24 (r) and (c).

2. The facility failed to have a triage policy addressing the system in place for triage.

3. Facility policy titled "SEXUAL ASSAULT PROCEDURE" was last reviewed/revised 6/2007. Additionally, the policy does not address the current program in place that only a "SANE" trained nurse will collect evidence or that patients under age 14 will not have a sexual assault exam within the department.

4. Staff member #4 indicated at 1:50 p.m. on 8/24/10 that the facility does not have a triage policy addressing the triage practice within the department and that patients under age 14 will be sent to another acute care facility for a sexual assault exam.

5. Staff member #A1 indicated at 11:00 on 8/26/10 that the facility has a new sexual assault policy in draft form only.

Based on document review and staff interview, the facility failed to maintain an accurate log of patients presenting to the emergency department (E.D.) for 5 (#4, #5, #15, #21 and #25) of 27 entries.

Findings include:

1. Patient #4 was listed as a transfer under disposition on the E.D. log dated 7/16/10, however the patient was admitted to the hospital.

2. Patient #5 was listed as "registered in error" under disposition on the E.D. log dated 7/31/10, however the patient was triaged with a soft tissue injury to the left ankle and left the E.D. prior to an M.D. exam and should have been coded as left without being seen (LWBS) on the log.

3. Patient #15 was listed as LWBS under disposition on the E.D. log dated 6/16/10, however the patient was examined by the physician 5 minutes after arrival, was in the E.D. for over 3 hours and was admitted to the hospital.

4. Patient #21 was listed as against medical advise (AMA) under disposition on the E.D. log dated 8/22/10, however the patient was triaged and left prior to being seen by a physician and should have been coded as LWBS.

5. Patient #25 was listed as "registered in error" on the E.D. log dated 8/15/10, however upon investigation, the patient actually presented to the department and was sent to another facility.

6. Staff member #4 verified the above information at 1:50 p.m. on 8/24/10.

Based on document review and staff interview, the facility failed to provide a medical screening examination to 2 (#14 and #25) of 27 patients presenting to the emergency department (E.D.).

Findings include:

1. Review of patient #14 E.D. record indicated the following:
(A) The patient (17 y/o female) presented to the E.D. on 6/14/10 after an alleged sexual assault.
(B) The patient was examined by a registered nurse.
(C) The patient did not receive a medical screening exam from a physician. The record stated on both page 2 and page 3 "not seen by MD."

2. Review of the E.D. log for 8/15/10 indicated patient #25 (6 y/o male) was listed as "registered in error" on the log and there was no medical record for a visit dated 8/15/10. Upon further investigation, it was discovered that the patient presented to the department after an alleged sexual assault and was sent to another facility for treatment.

3. The medical staff bylaws, rules and regulations do not allow for an RN to perform a medical screening exam.

4. Facility policy titled "TRANSFER GUIDELINES FOR PATIENT" last reviewed/revised 6/2010 states on page 1, under procedure: "1. The (facility #1) physician will complete a medical screening exam which may include ancillary services to determine if an emergency medical condition exists and to attempt to stabilize the patient."

5. Staff member #4 verified the lack of medical screening for patients #14 and #25 at 1:50 p.m. on 8/24/10.

6. RN #2 indicated the following in phone interview at 9:45 a.m. on 8/25/10:
(A) He/she was the triage nurse when patient #25 presented to the E.D.
(B) The patient was brought to the E.D. on 8/15/10 after an alleged sexual assault several days prior to visit.
(C) He/she recalled the SANE policy indicating that the facility did not do a sexual assault exam on patients under age 13.
(D) The patient had already showered and changed clothing.
(E) He/she checked with the charge nurse who verified that the facility did not do SANE exams on patients under 13.
(F) He/she felt it was a waste of time and money for the patient to go through the E.D. and told the family that they did not do the exam there and sent the patient to another acute care facility.
(G) He/she indicated he/she was aware that all patients presenting to the E.D. had to have an M.D. exam.