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Based on record review and interview, the hospital failed to ensure compliance with all requirements listed in 489.24. This was evidenced by the hospital's failure to provide a medical screening examination and arrange for the appropriate transfer for a patient who presented to the hospital's ED (Emergency Department) seeking treatment for cardiac symptoms related to problems with his pacemaker; and by failing to ensure that information was included in the hospital's Emergency Department Log relating to all patients who present to the hospital's Emergency Department seeking treatment and/or services. This was noted for 1 of 25 sampled patients (Patient #6). (Cross reference to findings cited at C2405, C2406 and C2409)

Based on record review and interview, the hospital failed to ensure that information was included in the hospital's Emergency Department Log relating to all patients who present to the hospital's Emergency Department seeking treatment and/or services. This was noted for 1 of 25 sampled patients (Patient #6). Findings:

The Director of Nursing (S2) was interviewed on 6/15/10 at 9:50 a.m. regarding the registration and admission process for patients who present to the hospital's ED. The Director of Nursing reported that all patients who present to the ED should receive a triage assessment by a nurse and a medical screening examination. The Director of Nursing reported that upon a patient's arrival to the ED, information including the patient's name, age, time of arrival, and nature of complaint should be documented on the "Emergency Department Sign In Form" by the staff member who initiates contact with the patient. The Director of Nursing reported that a medical record will be opened on the patient once the triage assessment is initiated and indicated that information relating to the patient's visit is documented on the Emergency Department Register or ED log at that time (time of triage).

The "Emergency Department Sign In Form" for the date of 5/29/10 was reviewed. Review of this form revealed that information such as the name, age, time of arrival, and nature of complaint was to be included on this form. An entry was noted near the bottom of the page (out of chronological order) that had "LE" written beside it. This entry was reviewed with the Director of Nursing on 6/15/10 at 10:20 a.m. as there was no documentation of this patient in the ED log. The Director of Nursing reported that the entry was a late entry and written in reference to a black male who was approximately 35 - 40 years old who had presented to the ED sometime between 4:00 p.m. and 6:00 p.m. requesting to have his defibrillator checked. When asked why there was no documentation on the ED log to indicate that this patient had presented to the hospital's ED requesting services, the Director of Nursing reported that no assessments or screening examinations were done on the individual while in the ED. The Director of Nursing explained that she first became aware of this person presenting to the hospital's ED after receiving a phone call on 6/01/10 from the girlfriend of a patient who she identified as Patient #6. The Director of Nursing reported that the girlfriend informed her that she had brought Patient #6 to the ED on Saturday (5/29/10) afternoon to be seen for problems the patient was having with his pacemaker and was met at the door by two nurses who told her that she needed to bring Patient #6 to Hospital A. The Director of Nursing also reported that the girlfriend of the patient informed her that the patient had to be transported to another hospital by ambulance because her husband's condition declined while she attempted to transport him in her automobile from St. Helena's Emergency Department to Hospital A.

Based on record review and interview, the hospital failed to ensure that a medical screening examination was provided to a patient who presented to the hospital's Emergency Department seeking treatment for cardiac symptoms related to problems with his pacemaker. This was noted for 1 of 25 sampled patients (Patient #6). Findings:

The Director of Nursing (S2) was interviewed on 6/15/10 at 9:50 a.m. regarding the registration and admission process for patients who present to the hospital's ED. The Director of Nursing reported that all patients who present to the ED should receive a triage assessment by a nurse and a medical screening examination. The Director of Nursing reported that upon a patient's arrival to the ED, information including the patient's name, age, time of arrival, and nature of complaint should be documented on the "Emergency Department Sign In Form" by the staff member who initiates contact with the patient. The Director of Nursing reported that a medical record will be opened on the patient once the triage assessment is initiated and indicated that information relating to the patient's visit is documented on the Emergency Department Register or ED log at that time (time of triage).

The "Emergency Department Sign In Form" for the date of 5/29/10 was reviewed. Review of this form revealed that information such as the name, age, time of arrival, and nature of complaint was to be included on this form. An entry was noted near the bottom of the page (out of chronological order) that had "LE" written beside it. This entry was reviewed with the Director of Nursing on 6/15/10 at 10:20 a.m. The Director of Nursing reported that the entry was a late entry and written in reference to a black male who was approximately 35 - 40 years old who had presented to the ED sometime between 4:00 p.m. and 6:00 p.m. requesting to have his defibrillator checked. When asked why there was no documentation on the ED log to indicate that this patient had presented to the hospital's ED requesting services, the Director of Nursing reported that no assessments or screening examinations were done on the individual while in the ED. The Director of Nursing explained that she first became aware of this person presenting to the hospital's ED after receiving a phone call on 6/01/10 from the girlfriend of a patient who she identified as Patient #6. The Director of Nursing reported that the girlfriend informed her that she had brought Patient #6 to the ED on Saturday (5/29/10) afternoon to be seen for problems the patient was having with his pacemaker and was met at the door by two nurses who told her that she needed to bring Patient #6 to Hospital A. The Director of Nursing also reported that the girlfriend of the patient informed her that the patient had to be transported to another hospital by ambulance because her husband's condition declined while she attempted to transport him in her automobile from St. Helena's Emergency Department to Hospital A. The Director of Nursing reported that she met with the two nurses involved and identified the nurses as S9 (Registered Nurse) and S10 (Registered Nurse). The Director of Nursing indicated the results of her investigation revealed that nursing staff had deferred a patient complaining of a failed pacemaker to another hospital without providing any nursing assessment and indicated that a medical screening examination was not done. The Director of Nursing indicated she was not able to follow-up with the complainant due to the fact that she had failed to get the complainant's name, address, or telephone number at the time of the call and there was no documentation in the ED as to the patient's name or contact information.

The hospital staffing schedules for May of 2010 were reviewed. This review revealed that the two nurses working on the day shift (7:00 a.m. thru 7:00 p.m.) on 5/29/10 were S9 and S10 and the physician working in the ED was S8.

S9 (Registered Nurse) was interviewed on 6/16/10 at 9:15 a.m. S9 reported that she worked as the shift charge nurse on the day shift (7:00 a.m. through 7:00 p.m.) on 5/29/10. S9 reported that sometime between 4:30 p.m. and 5:30 p.m. on 5/29/10 she heard the ED door bell and went to the door and saw a black male (Patient #6) standing at the door. S9 reported that the ED automatic door switch had been temporarily turned off by housekeeping as the heavy rains were causing the door to continuously open and close. S9 reported that the switch was only turned off for a short period of time during the heavy rain. S9 explained that there have been problems with the ED doors constantly opening and closing during heavy rains since the old ED roof was removed from the covered entrance. S9 reported that she walked over and opened the ED doors for Patient #6 to come in to the hospital immediately after seeing him at the doors. S9 reported that the patient and the lady who brought the patient came in through the ED doors. S9 reported that the patient stood just inside the ED door and reported that he needed to talk to someone because he did not feel right. S9 reported that the patient informed her that he had recently been seen by his cardiologist and that the nurse at the cardiology clinic had turned his pacemaker down to save on the battery. S9 reported that she asked the patient where he went to see his cardiologist and that the patient reported that his cardiologist was at Hospital A. S9 reported that she informed the patient that they (St. Helena Parish Hospital) did not have any way of checking his pacemaker and told him that it would be best for him to contact his cardiologist and that he would probably want to go to Hospital A to have them check his pacemaker. S9 reported that the patient did not appear to be in any distress. S9 reported that the patient agreed to go to Hospital A and stated that he (patient) was assisted to his car by her (S9) and S10. S9 reported that the patient left St. Helena Parish Hospital in a private automobile being driven by the lady who was with the patient. S9 reported that there was no triage assessment completed on the patient and that the patient was not seen by the ED physician prior to leaving for Hospital A.

S10 (Registered Nurse) was interviewed on 6/16/10 at 9:45 a.m. S10 reported that she worked as a registered nurse on the day shift (7:00 a.m. through 7:00 p.m.) on 5/29/10. S10 reported that somewhere around 4:00 p.m. on 5/29/10, a black man with a cane and a woman came to the emergency room doors. S10 reported that the automatic door switch had been temporarily turned off by housekeeping due to the heavy rains causing the doors to continuously open and close. S10 reported that the doors were immediately opened by either her or S9 after seeing the man at the door. S10 reported that the man was complaining of feeling dizzy. S10 reported that the man had told her that the nurse at his cardiologist's office had turned down his defibrillator several days ago. S10 reported that the man did not appear to be in any distress. S10 reported that S9 asked the man who was his cardiologist and if he had tried to contact him today. S10 reported that the man said no because his office was closed on Saturday. S10 reported that she informed the man that his cardiologist had an answering service and that he could speak to someone about his pacemaker. S10 reported that S9 informed the man that he may want to call his cardiologist or go to Hospital A so they could get in touch with someone for him. S10 reported that the lady who was with the man got upset and told the man "Lets Go" and walked out of the hospital's ED. S10 reported that they told the man that he could be seen by the Dr. at St. Helena but he decided to leave with the lady. S10 reported that the man was assisted to his private automobile by her (S10) and S9. S10 reported that there was no triage assessment completed on the patient and that the patient was not seen by the ED physician prior to leaving for Hospital A.

S8 (Emergency Department Physician) was interviewed by telephone on 6/15/10 at 1:00 p.m. S8 reported that he was the Medical Director of the hospital's Emergency Department and indicated that he was the ED physician on duty on 5/29/10. S8 reported that he was never informed of Patient #6's arrival to the ED and was not aware of his complaints of having problems relating to his pacemaker. S8 reported that he did not provide a medical screening examination on the patient because he was not aware that the patient was in the ED. S8 reported that no one had discussed this case with him prior to today when the Director of Nursing contacted him to set up the telephone interview.

The hospital's policy/procedure titled "Interhospital/EMTALA, #1505" was reviewed. The policy/procedure documents in part, "All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of St. Helena Parish Hospital to reach a diagnosis. . .Medical Screening Exams should include at a minimum the following: Emergency Department Log entry including disposition of patient, Patient's ER form, vital signs, history, physical exam of affected systems and potentially affected systems, exam of know chronic conditions, necessary testing to rule out emergency medical conditions, notification and use of on-call personnel to complete previously mentioned guidelines, notification and use of Emergency Room physicians to diagnose and/or stabilize the patient as necessary, vital signs upon discharge or transfer, and complete documentation of the medical screening exam. . . . If a patient is to be transferred for medical necessity the following guidelines must be followed: . . . The patient must be transferred by an appropriate medical transfer vehicle. A patient may not be transferred in a private passenger vehicle unless the patient refuses to be transported by ambulance. The patient's refusal must be in writing and an incident report filled out. . ."

The hospital's policy/procedure titled, "St. Helena Parish Hospital EMTALA guidelines, #1000" was reviewed. The policy/procedure documents "St. Helena Parish Hospital will screen all individuals who come to the Hospital's Emergency Department and request examination or treatment for a medical condition, regardless of whether or not an emergency medical condition exists." The policy/procedure further documents "If a determination is made that an emergency medical condition exists, St. Helena Parish Hospital must provide either for the stabilization of the individual within it's capability and capacity to do so or for appropriate transfer".

The hospital's policy/procedure titled "Transfer of Patient with Emergency Medical Condition" was reviewed. The policy/procedure documents "Prior to transfer, necessary stabilizing treatment must occur within the capabilities of emergency services". The policy/procedure also documents "A physician is required to certify that medical benefits outweigh the risks of transfer. Written certification must contain a summary of these risks and benefits" and "Qualified personnel and appropriate transportation are used for the transfer".

The Director of Nursing reviewed the above policies/procedures and confirmed in an interview on 6/15/10 at 10:20 a.m. that the policies/procedures were not followed in the case of Patient #6. The Director of Nursing reported that Patient #6 did present to the hospital's ED and did not receive a medical screening examination as documented in the hospital's policy. In addition, the Director of Nursing reported that Patient #6 was not transferred by an appropriate medical transfer vehicle as indicated in the hospital's policy. The Director of Nursing reported that she counseled both S9 and S10 in regards to their failing to follow the hospital's policies/procedures regarding EMTALA.

The medical record relating to Patient #6's visit to Hospital A was reviewed. This review revealed that Patient #6 presented to the ED at Hospital A on 5/29/10 at 5:52 p.m. Documentation under the section of "Nursing Triage and Assessment" revealed "54 yo male with c/o sob with activity since defibrillator was 'turned down' at Dr. (Cardiologist) office 2 wks ago-pt originally went to Greensburg hospital, and was told by 2 personnel that 'they could not help him and to go to (Hospital A)' - pt went to Truck stop and called 911- upon AASI arrival- pt hr in 50's- 115 upon arrival to NOMC ED- hr 48 - 51 bpm with episodes of 112 bpm- pt denies CP- only SOB". Documentation on the ED record revealed that the patient was admitted to an inpatient unit of the hospital from the ED as a result of this visit. Documentation on the "Discharge Summary" revealed "The patient is a 54-year old gentleman who was admitted from the emergency room with shortness of breath with bradycardia. He was seen by the emergency room physician. The patient had a heart rate which has dropped into the mid 40's. His native heart rhythm was that of an atrial fibrillation. The patient was admitted from the emergency room with bradycardia secondary to malfunctioning of pacer/defibrillator." Documentation revealed that the patient had a successful "lead revision of a single chamber automatic implantable cardioverter defibrillator" during his hospitalization and was discharged from the hospital on 6/03/10.

Based on record review and interview, the hospital failed to ensure the an appropriate transfer to an acute care hospital was arranged for a patient who presented to the hospital's Emergency Department seeking emergent treatment for cardiac symptoms relating to problems with his pacemaker. This was evidenced by the hospital's nursing staff informing the patient, while standing in the ED of the hospital, that he may want to go to another acute care hospital for services and then assisting this individual to his own private automobile without qualified personnel and transportation equipment available during the transfer and without proper certification by a physician. This was noted for 1 of 25 sampled patients (Patient #6). Findings:

The Director of Nursing (S2) was interviewed on 6/15/10 at 9:50 a.m. regarding the registration and admission process for patients who present to the hospital's ED. The Director of Nursing reported that all patients who present to the ED should receive a triage assessment by a nurse and a medical screening examination. The Director of Nursing reported that upon a patient's arrival to the ED, information including the patient's name, age, time of arrival, and nature of complaint should be documented on the "Emergency Department Sign In Form" by the staff member who initiates contact with the patient. The Director of Nursing reported that a medical record will be opened on the patient once the triage assessment is initiated and indicated that information relating to the patient's visit is documented on the Emergency Department Register or ED log at that time (time of triage).

The "Emergency Department Sign In Form" for the date of 5/29/10 was reviewed. Review of this form revealed that information such as the name, age, time of arrival, and nature of complaint was to be included on this form. An entry was noted near the bottom of the page (out of chronological order) that had "LE" written beside it. This entry was reviewed with the Director of Nursing on 6/15/10 at 10:20 a.m. The Director of Nursing reported that the entry was a late entry and written in reference to a black male who was approximately 35 - 40 years old who had presented to the ED sometime between 4:00 p.m. and 6:00 p.m. requesting to have his defibrillator checked. When asked why there was no documentation on the ED log to indicate that this patient had presented to the hospital's ED requesting services, the Director of Nursing reported that no assessments or screening examinations were done on the individual while in the ED. The Director of Nursing explained that she first became aware of this person presenting to the hospital's ED after receiving a phone call on 6/01/10 from the girlfriend of a patient who she identified as Patient #6. The Director of Nursing reported that the girlfriend informed her that she had brought Patient #6 to the ED on Saturday (5/29/10) afternoon to be seen for problems the patient was having with his pacemaker and was met at the door by two nurses who told her that she needed to bring Patient #6 to Hospital A. The Director of Nursing also reported that the girlfriend of the patient informed her that the patient had to be transported to another hospital by ambulance because her husband's condition declined while she attempted to transport him in her automobile from St. Helena's Emergency Department to Hospital A. The Director of Nursing reported that she met with the two nurses involved and identified the nurses as S9 (Registered Nurse) and S10 (Registered Nurse). The Director of Nursing indicated the results of her investigation revealed that nursing staff had deferred a patient complaining of a failed pacemaker to another hospital without providing any nursing assessment and indicated that a medical screening examination was not done. The Director of Nursing indicated she was not able to follow-up with the complainant due to the fact that she had failed to get the complainant's name, address, or telephone number at the time of the call and there was no documentation in the ED as to the patient's name or contact information.

The hospital staffing schedules for May of 2010 were reviewed. This review revealed that the two nurses working on the day shift (7:00 a.m. thru 7:00 p.m.) on 5/29/10 were S9 and S10 and the physician working in the ED was S8.

S9 (Registered Nurse) was interviewed on 6/16/10 at 9:15 a.m. S9 reported that she worked as the shift charge nurse on the day shift (7:00 a.m. through 7:00 p.m.) on 5/29/10. S9 reported that sometime between 4:30 p.m. and 5:30 p.m. on 5/29/10 she heard the ED door bell and went to the door and saw a black male (Patient #6) standing at the door. S9 reported that the ED automatic door switch had been temporarily turned off by housekeeping as the heavy rains were causing the door to continuously open and close. S9 reported that the switch was only turned off for a short period of time during the heavy rain. S9 explained that there have been problems with the ED doors constantly opening and closing during heavy rains since the old ED roof was removed from the covered entrance. S9 reported that she walked over and opened the ED doors for Patient #6 to come in to the hospital immediately after seeing him at the doors. S9 reported that the patient and the lady who brought the patient came in through the ED doors. S9 reported that the patient stood just inside the ED door and reported that he needed to talk to someone because he did not feel right. S9 reported that the patient informed her that he had recently been seen by his cardiologist and that the nurse at the cardiology clinic had turned his pacemaker down to save on the battery. S9 reported that she asked the patient where he went to see his cardiologist and that the patient reported that his cardiologist was at Hospital A. S9 reported that she informed the patient that they (St. Helena Parish Hospital) did not have any way of checking his pacemaker and told him that it would be best for him to contact his cardiologist and that he would probably want to go to Hospital A to have them check his pacemaker. S9 reported that the patient did not appear to be in any distress. S9 reported that the patient agreed to go to Hospital A and stated that he (patient) was assisted to his car by her (S9) and S10. S9 reported that the patient left St. Helena Parish Hospital in a private automobile being driven by the lady who was with the patient. S9 reported that there was no triage assessment completed on the patient and that the patient was not seen by the ED physician prior to leaving for Hospital A.

S10 (Registered Nurse) was interviewed on 6/16/10 at 9:45 a.m. S10 reported that she worked as a registered nurse on the day shift (7:00 a.m. through 7:00 p.m.) on 5/29/10. S10 reported that somewhere around 4:00 p.m. on 5/29/10, a black man with a cane and a woman came to the emergency room doors. S10 reported that the automatic door switch had been temporarily turned off by housekeeping due to the heavy rains causing the doors to continuously open and close. S10 reported that the doors were immediately opened by either her or S9 after seeing the man at the door. S10 reported that the man was complaining of feeling dizzy. S10 reported that the man had told her that the nurse at his cardiologist's office had turned down his defibrillator several days ago. S10 reported that the man did not appear to be in any distress. S10 reported that S9 asked the man who was his cardiologist and if he had tried to contact him today. S10 reported that the man said no because his office was closed on Saturday. S10 reported that she informed the man that his cardiologist had an answering service and that he could speak to someone about his pacemaker. S10 reported that S9 informed the man that he may want to call his cardiologist or go to Hospital A so they could get in touch with someone for him. S10 reported that the lady who was with the man got upset and told the man "Lets Go" and walked out of the hospital's ED. S10 reported that they told the man that he could be seen by the Dr. at St. Helena but he decided to leave with the lady. S10 reported that the man was assisted to his private automobile by her (S10) and S9. S10 reported that there was no triage assessment completed on the patient and that the patient was not seen by the ED physician prior to leaving for Hospital A.

S8 (Emergency Department Physician) was interviewed by telephone on 6/15/10 at 1:00 p.m. S8 reported that he was the Medical Director of the hospital's Emergency Department and indicated that he was the ED physician on duty on 5/29/10. S8 reported that he was never informed of Patient #6's arrival to the ED and was not aware of his complaints of having problems relating to his pacemaker. S8 reported that he did not provide a medical screening examination on the patient because he was not aware that the patient was in the ED. S8 reported that no one had discussed this case with him prior to today when the Director of Nursing contacted him to set up the telephone interview.

The hospital's policy/procedure titled "Interhospital/EMTALA, #1505" was reviewed. The policy/procedure documents in part, "All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of St. Helena Parish Hospital to reach a diagnosis. . .Medical Screening Exams should include at a minimum the following: Emergency Department Log entry including disposition of patient, Patient's ER form, vital signs, history, physical exam of affected systems and potentially affected systems, exam of know chronic conditions, necessary testing to rule out emergency medical conditions, notification and use of on-call personnel to complete previously mentioned guidelines, notification and use of Emergency Room physicians to diagnose and/or stabilize the patient as necessary, vital signs upon discharge or transfer, and complete documentation of the medical screening exam. . . . If a patient is to be transferred for medical necessity the following guidelines must be followed: . . . The patient must be transferred by an appropriate medical transfer vehicle. A patient may not be transferred in a private passenger vehicle unless the patient refuses to be transported by ambulance. The patient's refusal must be in writing and an incident report filled out. . ."

The hospital's policy/procedure titled, "St. Helena Parish Hospital EMTALA guidelines, #1000" was reviewed. The policy/procedure documents "St. Helena Parish Hospital will screen all individuals who come to the Hospital's Emergency Department and request examination or treatment for a medical condition, regardless of whether or not an emergency medical condition exists." The policy/procedure further documents "If a determination is made that an emergency medical condition exists, St. Helena Parish Hospital must provide either for the stabilization of the individual within it's capability and capacity to do so or for appropriate transfer".

The hospital's policy/procedure titled "Transfer of Patient with Emergency Medical Condition" was reviewed. The policy/procedure documents "Prior to transfer, necessary stabilizing treatment must occur within the capabilities of emergency services". The policy/procedure also documents "A physician is required to certify that medical benefits outweigh the risks of transfer. Written certification must contain a summary of these risks and benefits" and "Qualified personnel and appropriate transportation are used for the transfer".

The Director of Nursing reviewed the above policies/procedures and confirmed in an interview on 6/15/10 at 10:20 a.m. that the policies/procedures were not followed in the case of Patient #6. The Director of Nursing reported that Patient #6 did present to the hospital's ED and did not receive a medical screening examination as documented in the hospital's policy. In addition, the Director of Nursing reported that Patient #6 was not transferred by an appropriate medical transfer vehicle as indicated in the hospital's policy. The Director of Nursing reported that she counseled both S9 and S10 in regards to their failing to follow the hospital's policies/procedures regarding EMTALA.

The medical record relating to Patient #6's visit to Hospital A was reviewed. This review revealed that Patient #6 presented to the ED at Hospital A on 5/29/10 at 5:52 p.m. Documentation under the section of "Nursing Triage and Assessment" revealed "54 yo male with c/o sob with activity since defibrillator was 'turned down' at Dr. (Cardiologist) office 2 wks ago-pt originally went to Greensburg hospital, and was told by 2 personnel that 'they could not help him and to go to (Hospital A)' - pt went to Truck stop and called 911- upon AASI arrival- pt hr in 50's- 115 upon arrival to NOMC ED- hr 48 - 51 bpm with episodes of 112 bpm- pt denies CP- only SOB". Documentation on the ED record revealed that the patient was admitted to an inpatient unit of the hospital from the ED as a result of this visit. Documentation on the "Discharge Summary" revealed "The patient is a 54-year old gentleman who was admitted from the emergency room with shortness of breath with bradycardia. He was seen by the emergency room physician. The patient had a heart rate which has dropped into the mid 40's. His native heart rhythm was that of an atrial fibrillation. The patient was admitted from the emergency room with bradycardia secondary to malfunctioning of pacer/defibrillator." Documentation revealed that the patient had a successful "lead revision of a single chamber automatic implantable cardioverter defibrillator" during his hospitalization and was discharged from the hospital on 6/03/10.