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Based on review of policies and procedures, record review, and interviews the facility failed to follow its policies for compliance with the requirements of the Emergency Medical Treatment and Labor Act related to 2 of 20 sampled patients [Patient 3, 17]

Findings are:

A. A review of the policy with the Subject: Medical Screening Examination (MSE) effective 2/2001 and revised 1/2005 was reviewed. The stated purpose of the policy "is to determine if an Emergency Medical Condition (EMC) exists." The policy states, "A medical screening exam is the process required to reach with reasonable clinical confidence, the existence/ absence of an emergency medical condition." The policy further states, "A Medical Screening Exam is a spectrum that may include a brief history and physical, to complex lab, radiology or other diagnostic tests. A MSE is an ongoing process, and should reflect presenting complaints and symptoms. Documentation will show monitoring according to patient needs until stabilized, admitted or transferred." Refer to deficiency statement at C2406 related to sampled Patient 17, a 15-year old, that presented to the Emergency Department (ED) on 3/20/10 at 01:45 (AM) with a chief complaint of drinking alcohol at a party resulting in vomiting, hysteria, feeling cold, having an oral temperature of 95.6 degrees (F)Fahrenheit, and a pulse in the 100s upon arrival, but failed to be provided with a medical screening exam.

B. Record review of facility policy and procedure titled "Transfer and Emergency Examination" approved 9/13/07 states that if the Medical Screening Examination (MSE) reveals the individual has an Emergency Medical Condition (EMC) the hospital shall provide either: "1. Within the capabilities of the staff and facilities available at the Hospital, for further medical examination and treatment as required to stabilize the medical condition; or
2. Appropriate transfer to another medical facility." Refer to C2407 related to sampled Patient 3 who presented to the ED by ambulance on 4/13/10 at 9:20 PM. The patient complained of vomiting blood, chest and abdominal pains. Blood alcohol testing showed alcohol intoxication with a level of 0.290. The patient was discharged without being provided stabilizing treatment 1 hour and 10 minutes after arrival.


C. The facility has a policy with the Subject: Admission of Patients to the Emergency Department with an effective date of 2/2001. The policy directs that all patients will have information completed on the Emergency Room Outpatient Record. Review of the medical record for Patient 17 revealed the facility failed to make a medical record for Patient 17 until 3 days after the visit. An interview with the Department Head of Medical Records (DHMR) on 8/17/10 at 4:30 PM revealed she had received a call from the patient's mother on 3/22/10 and was informed of the visit on the 20th. Based on the call DHMR started to investigate the event. The Administrator and the Director of Nursing became involved in the investigation as well. The nurses working the night of 3/19 - 20/10 were required to write a summary of what they remembered about the visit; a medical record was written on 3/23/10 by the Registered Nurse (RN-A) that provided the care at that visit, and the visit was added to the Central Log for emergency room visits for the date of 3/20/10.

D. Review of the policy regarding the Emergency Room Log found it had an effective date of 10/14/07. The policy directs "A log will be kept of all patients that receive emergency services at [Name of Hospital]. The log will document the following information: Patient Name, Medical Record Number, Time of Arrival in the Emergency Department, Time of Discharge from the Emergency Department, Mode of Arrival, Chief Compliant, Physical Findings, Care and Treatment Provided, Practioner Name, Disposition." The procedure included "Nursing Staff will be responsible for entering the information for each patient ... This will be done on a 24 hour a day/seven day a week basis." The facility failed to log Patient 17 until the nurse assigned to the patient was directed to do so 3 days after the visit. Other problems were also found in the log. Refer to deficiency statement at C2405.

E. An interview with the Administrator on 8/18/10 at 3:15 PM found he stated he was first aware of Patient 17's 3/20/10 visit to the emergency department on 3/22/10. The Administrator said he spoke with the patient's mother on either Monday 3/22/10 or the next day on 3/23/10. He revealed the hospital obtained written statements from all the staff involved. He said since it happened they have talked about it a lot. He felt it was a "bad deal", "bad judgment", and a "gut- wrenching experience." The Administrator said he did not take it to the Medical Staff because it dealt with "corporate compliance" and none of the Medical Staff were consulted because it was a "personnel issue."

Review of the report of the Administrator's findings of the investigation found it had a date of 4/8/10. The findings included:
- No documentation regarding the visit was made;
- The patient encounter was not logged in the required log for emergency room visits as required by the Emergency Medical Treatment and Labor Act;
- No telephone contact was made to the provider on call regarding the patient encounter per hospital policies and procedures;
- No information was available as to whether or not the patient had been stabilized prior to discharge or voluntarily leaving the hospital as required by the Emergency Medical Treatment and Labor Act.

Based on facility record reviews and interviews, the facility failed to maintain the Central Log for the Emergency Department to ensure the log included documentation of all required information and documented the information in chronological order. The sample size of patients selected from the log was 20. Findings are:

Review of the Central Log for the Emergency Department found multiple examples of incomplete entries and entries that were out of chronological order. Some of the examples were selected to be included in the sample and are identified as such.

Review of the log found all times were identified as military or 24-hour time. The log had titled boxes across the top of the page with lines for each entry. The titles of the boxes were Name, MR# (medical record number), Time In, Time Out, MOA (Mode of Arrival), Chief c/o (complaint), Physical Findings, Care & Tx (treatment) Provided, MD/PA (physician/physician assistant), and Disposition.

Review of the log for 3/20/10 revealed sampled Patient 17 had a documented time in of 01:45 AM and time out of 03:00 AM; the MOA was noted as walk; the c/o was listed as "hard to keep awake"; the physical findings were noted as "awake, alert"; the care provided was noted as "screening"; the data field for MD/PA was left blank, and the disposition was H (home). Patient 17's name and associated information appeared at the end of the ED log on 3/20/10 instead of at the beginning. Four other patients were listed as though they presented to the ED before Patient 17.

In an interview with the Quality Assurance (QA) Manager on 8/17/10 at 3:36 PM revealed she had found out about Patient 17 about 3-4 weeks after she presented to the ED. She elaborated that the record had been written after the fact, and had been entered in the log at a later date. The Department Head for Medical Records confirmed this information again in an interview on 8/17/10 at 4:30 PM.

Review of the log for 3/19/10, revealed data entries that were not in chronological order. A patient with a time in of 5:50 AM was noted at the end of the day instead of after 2 other patients that presented before 5:00 AM. Instead of noting the time out for the patient that presented at 5:50 AM, staff wrote "admitted." The ED log did not reflect the correct order of arrival and this patient should have been 3rd on the log for 3/19/10.

Review of the log dated 4/3/10 revealed a non-sampled patient that had a line crossed through the information in the data fields beginning with the time in and running completely across the page for time out, MOA, chief c/o, physical findings, care & Tx provided, MD/PA, and disposition. The times crossed out looked like the time in could have been 00:10 AM and the time out 00:45 AM, but they were not clearly legible as they had been written over as well as crossed out. Above the crossed out information someone wrote different information including a time in of 20:30 PM and a time out of 21:10 PM, MOA of walk, c/o of gestational diabetic, findings "meds-insulin" care & treatment "insulin" and the rest of the data fields were crossed out and did not contain the required information.

Review of the log for 7/30/10 revealed an incomplete entry for sampled Patient 14. Missing information included the time out, the box for the name of the MD/PA was the letter " S " and the data field for disposition was left blank. Review of the medical record revealed sampled Patient 14 was not admitted to the facility. The log failed to have all the needed information for this patient. On the same page was another patient that failed to have a medical record number and disposition noted.

Review of the log dated 8/6/10 revealed the 3rd patient listed did not have a time out and did not have a disposition entered even though the patient received an exam and sutures for a dog bite.

Review of the log dated 8/11 (year not identified) revealed the medical record number, the time in and the time out data fields were left blank for sampled Patient 20. The patient's MOA was "ambulance", the chief c/o was "kicked by calf ", the physical findings were "laceration liver", the care & treatment provided was "CT, lab, meds", the physician was identified and the disposition was "transferred". The patient suffered a serious injury but the log failed to include all the required information.

Review of the log for 8/12/10 revealed the care & treatment, MD/PA, and disposition data fields for a non-sampled patient (4th patient entered in the log) were left blank. The non-sampled patient ' s complaint was " ?Ruptured ovarian cyst. "

Review of the log for 8/15/10 revealed a patient that came to the Emergency Department with a chief c/o of "seizure". The data field for physical findings was left blank. The patient received an "exam, lab" and the disposition was noted as "Home". The log was not completed as required.

The policy and procedure for Emergency Room Log for the Department: Medical Records with an effective date of 10/14/07 was reviewed, finding the following: "A log will be kept of all patients that receive emergency services at [name of hospital]. The log will document the following information: Patient Name, Medical Record Number, Time of Arrival in the Emergency Department, Time of Discharge from the Emergency Department, Mode of Arrival, Chief Complaint, Physical Findings, Care and Treatment Provided, Practioner Name, Disposition ...Nursing Staff will be responsible for entering the information for each patient receiving emergency services in the Emergency Room Log. This will be done on a 24 hour a day/seven day a week basis....To ensure compliance with regulatory requirements the log will be reviewed on a monthly basis by the Supervisor of Medical Records or his/her designee."

In an interview on 8/17/10 at 3:36 PM the QA Manager revealed there had not been any monitoring performed for the Emergency Department records or log in 2010. The QA Manager stated the hospital last completed an audit for the Emergency Department EMTALA requirements in September 2009. The facility failed to follow their own policy and procedure for the Emergency Department log and failed to monitor as directed in the policy to ensure the log was maintained per policy and per requirements.

Based on record review, policy review and interviews, the facility failed to provide a medical screening exam for 1 of 20 sampled patients (Patient 17) presenting to the Emergency Department and requesting services.

Findings are:

Review of the Emergency Department Central Log for 3/20/10 revealed sampled Patient 17 was listed as the last patient for that date, but had a documented time in of 01:45 AM and a time out of 03:00 AM. All of the patients listed before Patient 17 (4 patients) had times listed that were after Patient 17. The total number of patients listed for that date was 5. An interview with the Quality Assurance (QA) Manager on 8/17/10 at 3:36 PM revealed she had found out about Patient 17 about 3-4 weeks after her trip to the emergency room. The QA Manager stated that the medical record had been written after the fact, and had been information entered in the log at a later date. The Department Head for Medical Records confirmed this information again in an interview on 8/17/10 at 4:30 PM.

A complete copy of the medical record was requested and obtained. The second page of the record, titled the "Emergency Room Outpatient Record" was partially complete and typed. The date and time of Patient 17 ' s admission to the emergency room was noted as 3/20/10 at 11:38. This time was not consistent with the information contained in the ED log or in a second copy of the page handwritten by registered nurse (RN) A. The handwritten copy of the "Emergency Room Outpatient Record" noted that patient 17 presented to the ED at 01:45 AM. The patient ' s last name was left blank, as were several other data fields on the handwritten copy including the field to document whether the patient had an emergency medical condition and the time the emergency room physician was notified and the time s/he arrived in the ED. RN A documented that patient 17 presented to the ED with a parent after consuming alcohol and vomiting, and was cold and felt cool to the touch. RN A documented that she applied a warm blanket to patient 17 and at 2:20 AM the patient vomited approximately 30 ml (1 tablespoon) and; at 02:35 AM patient 17 walked to the bathroom with assistance. Near the bottom of the page, in a field titled " Physician ' s Record / Treatment: " is handwritten "3/23/10 - This report generated after the date of service." In the data field for " Discharge Vital Signs " , RN A documented a range of values for patient 17 ' s heart rate " 100's", "18-22" for the respiratory rate, and "120s/60s" for the blood pressure. RN A documented she discharged patient 17 at 3:00 AM and instructed the parent to " keep pt (patient) upright for rest of night; continue to monitor for vomiting or any changes in level of consciousness. "

During an interview on 8/18/10 at 1:05 P.M., RN-A stated that she normally performs an exam, creates an outpatient record, calls the MD/PA on-call, and follows any orders they give but did not do this for patient 17 because patient 17 ' s parent was a hospital employee.

During an interview on 8/18/10 at 12:20 P.M., Physician B, the physician on-call on 3/19-20/10, stated the emergency room did not contact him while patient 17 was in the ED on 3/20/10. Physician B stated that if contacted he probably would have ordered lab work for an alcohol level and would have come to the ED to examine patient 17 to ensure there wasn ' t any risk for increased toxicity later.

An interview with the Medical Director (MD-C) was completed on 8/18/10 at 9:20 AM. MD-C said she had not previously reviewed patient 17 ' s medical record. MD-C said to her knowledge the nurses have always called no matter how minor the case may have been. She was very surprised they had not called the on-call physician in this case. MD-C stated Patient 17 warranted an exam by the MD or PA on call.

Review of the facility's investigation documentation revealed "No documentation regarding the visit was made." "The patient encounter was not logged in the required log for emergency room visits as required by the Emergency Medical Treatment and Active Labor Act." "No telephonic contact was made to the provider on call regarding the patient encounter as per the [name of facility] policies and procedures." "No information is available as to whether or not the patient had been stabilized prior to being discharged or voluntarily leaving the hospital as required by the Emergency Medical Treatment and Active Labor Act."

Review of the facility's policy and procedure for " Who May Provide a Medical Screening Exam " (MSE) revealed that a physician or a physician assistant should perform the exam if a patient had symptoms that included "Poisoning/drug overdose and Unstable vital signs". The policy also states if the physician or physician assistant is not on site, an exam by a RN is allowed "in consultation with" a physician or physician assistant. The facility failed to follow this policy.

Based on record review, facility policy review and physician interview, 1 of 20 sampled patients (Patient # 3) failed to receive stabilizing treatment prior to discharge. The total sample was 20 patients selected from the ED (Emergency Department) log February through August 2010. Findings are:

A. Record review of facility policy and procedure titled "Transfer and Emergency Examination" approved 9/13/07 states that if the Medical Screening Examination (MSE) reveals the individual has an Emergency Medical Condition (EMC) the hospital shall provide either: "1. Within the capabilities of the staff and facilities available at the Hospital, for further medical examination and treatment as required to stabilize the medical condition; or
2. Appropriate transfer to another medical facility."

B. Record review of Patient # 3's ED record dated 4/13/10 at 9:20 PM: Patient # 3 arrived by ambulance to the Emergency Department (ED) at 9:20 PM. The ambulance report dated 4/13/10 at 9:16 PM stated that the ambulance was called for "patient who was throwing up blood and was having chest pain." The crew included 2 basic EMTs and 2 drivers. On arrival the patient was sitting on the bed. The notes state the "patient had been drinking" and had been sick for the past 2 days. Patient reported the pain starts in her chest and moves to her back and down to fingers. The patient told the crew she had "2 open heart surgeries as a child". The patient reported the blood was both bright and dark red that she had been vomiting. She also complained of abdominal pain in the lower right quadrant. The ambulance report notes "alcohol and/or drug paraphernalia at Scene." Vital signs were blood pressure (BP) 144/107, pulse 100 with regular rhythm, respirations of 16 with normal effort and normal oxygen saturation of 96% on room air. The patient also told the ambulance crew she had recently been prescribed prenatal vitamins for thyroid problems. The patient reported she had not taken any of her medications which included: pre -natal vitamins, Ventolin (used to treat difficulty breathing due to respiratory disease), Certirizine (used to treat seasonal allergies), Bupropion (antidepressant), Lisinopril (used to treat high blood pressure), Cyclobenzaprine (muscle relaxant) ascorbic acid (vitamin C) and ferrous gluconate (used to treat iron deficiency anemia). Assessment is noted as "Normal mental status for patient; Neuro: normal; Skin: Hot, Flushed; Chest/Lung: Normal, Clear & Equal Breath Sounds; Heart: Normal."

On arrival at the hospital Patient # 3 told nursing staff that the chief complaint was lower right abdominal pain which radiated around the back and up to the mid-right side. The patient also complained of left arm pain which was "shooting to my hands". She reported numbness and tingling and stated "I have carpal tunnel". Pain score 10/10. Nursing noted the patient had a red face and "smells of ETOH [alcohol]." The patient denied drinking today but confirmed drinking yesterday. Vitals were taken on admission and were recorded as oral temperature (T) of 99.2 degrees, pulse (P) 85, respirations (R) 20, oxygen saturation of 97% and blood pressure (BP) of 149/86. Nursing Notes (NN) at 10:00 PM note that when blood was drawn the patient was laughing and was instructing the laboratory technician where to draw the blood and reporting a history of intravenous drug use a year and a half ago. Back pain was unchanged. NN at 10:10 PM note the patient told the nurses "I don't want him here" referring to the boyfriend. She was given information regarding the "women's shelter per request." The patient denies any changes in abdominal complaints. At 10:19 PM, NN state the patient complained of "pain right upper abdomen that radiates up right breast. Rubbing area, tearful. Denies that has had this before." NN at 10:22 PM state the MD discussed the laboratory reports with the patient. The patient "still denying any ETOH" intake. Denies drug seeking behavior and reports has pain pills to take at home. Vital signs at discharge were T 99.2, P 79, R 16, BP 123/70 and pain score of 9/10.

Medical Doctor (MD)-A was the ED physician on call and saw the patient at 9:40 PM. "Emergency Room Notes" written by MD-A note that after being in the ED the patient's boyfriend arrived and indicated she had been drinking. The patient challenged him and denied drinking today saying "that was just two, three and four days ago." The boyfriend referring to the ED physician told the patient that "if that is the doctor that is seeing you he won't be giving you any pain pills." The patient then threw off the covers and started to walk out. The boyfriend complained to the nurses that "you guys are not doing anything for her pain to take care of her." MD-A explained they were waiting to draw blood and again asked about her drinking. The patient again reported pain that started in the abdomen, moved up and then went into her hands and out her fingers. She said she had carpal tunnel. She said she took pain pills because of pain problems and that she was having her menstrual flow at this time. MD-A's notes state "it was hard to get her to understand that question." Exam showed abdomen was soft with active bowel sounds. MD-A's notes state Patient # 3 "acted uncomfortable with pressure over the epigastrium (the part of the abdomen above the naval), although she complained of pain in the right lower abdomen." Her mouth was examined and did not have any blood present. She moved about in no apparent distress. Police were called related to the boyfriend being loud and abusive with staff. After the police came the boyfriend left and the patient became more cooperative with getting the blood work done. Laboratory results showed a high blood alcohol of .290 mg/dl, nearly 3 times the laboratory reference of 0.100. A complete metabolic panel revealed a low serum calcium level of 8.6 mg/dl (laboratory normal is 8.9 - 10.1). A Complete Blood Count showed an elevated hemoglobin of 16.2 (normal is 12 - 15.5, one possible cause for an elevated hemoglobin is dehydration from vomiting or diarrhea) and an elevated hematocrit of 45.5 (normal is 34.9 - 44.5, an elevated hematocrit is most often associated with dehydration, a condition in which the amount of circulating plasma water is decreased). When MD-A confronted the patient with the laboratory report the patient again stated she had not drank for the last day. She was told she was apparently okay and the patient said she would go home and take the pain pills she had. MD-A documented "At the end of this I think the patient was at the ER [Emergency Room] because she was drunk and wanted further medicines. I do not think that she truly did have any heavy bleeding with her period. I do not think she had any blood in her stool. I think she did not vomit any blood at any time." The patient left the ER at 10:30 PM (1 hour and 10 minutes after arrival). The elevated blood alcohol along with the impaired judgment and difficulty processing questions posed by the physician indicated the patient was not stable when she left the ED. She walked out of the ED with discharge instructions of "Avoid Alcohol" and follow up with primary doctor as needed. Other than examination and initial blood work the patient did not receive any other treatment.

C. Interview with MD-A on 8/18/10 at 12:20 PM regarding Patient # 3's visit on 4/13/10 revealed the following. Patient # 3's complaint of pain was inconsistent, the hemoglobin and hematocrit should have been down (if vomiting blood as she reported). He stated that "when someone lies" everything is discounted. He said her labs were normal except the alcohol level of .290. With a chronic drinker, the liver can handle it and doesn't show it. He said Patient # 3 did not look cachetic (loss of weight and muscle mass) but was dirty, disheveled and smelled of alcohol. MD-A related Patient # 3 was alert and talkative when she was confronted regarding the alcohol level and able to get control of her behavior.

Regarding his clinical decision making, MD-A stated he did not order intravenous fluids for her "because she was stable and had enough trouble getting blood work." He said she wanted to leave when she found out she wasn't going to get pills. She "was gamey and dramatic but was thinking clearly." She cooperated when told the police were called. He was not aware the nursing staff gave her women's shelter information and that they questioned if she was abused by her boyfriend. MD-A said she got angry when the boyfriend told a different story than hers.

D. Record review of facility ER policy titled "Standard of Care-Immediate intervention of a patient under the influence of alcohol" effective date of 2/01 states "The patient arriving at the
Emergency Department under the influence of alcohol may receive the following care, but not limited to: Drawing bloods for lab, obtaining blood glucose levels; IV - Establish Normal Saline or physician order; Give 50 % Dextrose 50 cc IV, if hypoglycemia is present, Give Thiamine 100 mg IM or in 1 liter of Normal Saline per physician order, prior to 50% Dextrose. Medications, if necessary, per physicians order: Magnesium sulfate, Librium, MVI (vitamins) IV diluted into 1000 cc IV bag, Dilantin, Thorazine, Folic Acid." Documentation may include, but is not limited to: Initial Assessment of patient including history and duration of use, vital signs, medications and allergies, initial level of consciousness (LOC) and changes to (LOC), seizures and treatment, signs and symptoms of delirium tremens.

E. Record review of statutorily required Physician Peer Review by the Quality Improvement Organization (QIO) completed on 9/2/10 revealed Patient 3 had an emergency medical condition that was not stable at the time of discharge.