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Based on Record review and interview the facility failed to conduct a medical screening examination on 3 (#1A, #18 and #27 ) out of 31 (#1A, #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, and #31) Emergency Department records reviewed. This deficient practice has the potential to cause harm to all patients receiving care at the facility.

Findings:

Review of the medical record for patient #1A, revealed that patient #1A checked into the ED on 06/08/2012 at 10:34 a.m. and was placed in room #7 at 10:42 a.m. The triage nursing recorded by Nurse #6, states "appendicitis, CT scan this am showed appendicitis, ate full breakfast this a.m. at 0800." Vital Signs T98.0, P 97, R 20 and BP 125/97, O2 sat 96. The triage level is not documented. The record indicates the patient was in ED room #7. LWBS at 10:55 was written on the bottom of the record. There is no further documentation of a medical screen on the record.

In an interview with the triage nurse #6, on 06/19/2012 at 1:30 p.m., she confirmed that she was the nurse that triaged patient #1A on 06/08/2012. She stated she took him back to room #7, in the emergency room due to his diagnosis of acute appendicitis. She stated that the father then came to room #7 and that Dr #3 came in the room and was talking to the patient's father while she was getting the patient in a gown for an exam. She stated she never saw Dr #3 examine the patient and she did not hear the doctor's conversation with the father. She stated that the Doctor left and she helped the patient get dressed and since he had not been assessed by the physician she recorded on the bottom of the record "LWBS" which she stated meant left without being seen. "She stated she then took him to the lobby and asked them to wait until she got a CD copy of the CT scan, which she gave to him and they left. She stated she or Dr #3 did not make arrangements for transfer. She stated she thought because the patient was not seen by the emergency room physician she could discharge him as "left without being seen". When asked about her training to conduct Medical Screening she stated she reviewed the packet titled "EMTALA" and the Charge Nurse went over the information in the packet with her in a session that lasted approximately 20 minutes.

In an interview with Dr #3 on 06/19/2012 at 12 noon he stated he got a call from the nurse practitioner at the clinic. He stated she asked him to see a patient that had an outpatient CT scan that showed acute appendicitis. He stated he never saw the patient in the emergency department. He said he talked to the father on the phone and told him to come to his office. He then stated he saw the father in the hall of the ED and found out the patient had eaten. He confirmed he told the father they could not do surgery after 3 pm on Friday and that since his son had eaten, anesthesia would not put him to sleep here. He confirmed he told the father the options were to take him to another facility and he gave them options of Tyler, Texas and Mount Pleasant, Texas. When asked if he made arrangements for transfer to another hospital, he stated he had not seen the patient and did not make arrangements.

Review of written statement by Dr #3 (the record is not dated or timed but is signed by Dr #3).

A review of a written statement on 06/19/2012 revealed he wrote "In fact when the patient arrived he was sent to the ED. I had the conversation re: above mentioned timing of surgery with the father in the ED prior to the patient seeing the ED physician. The option of transferring to Hospital A after completing ED workup here versus the patient's father driving the patient to Hospital B was discussed. The father decided he would rather take the patient to Hospital B. This was decided so that the added expense of a second ED evaluation, ambulance transfer, and additional time commitment could be avoided."

A telephone interview was conducted with the patient's father on 06/20/2012 at 11:00 a.m. The father stated that his son was seen on 06/07/2012 at the clinic by the Nurse Practitioner (NP). He stated his son was having abdominal pain and she ordered a CT scan for the next a.m. He stated they had the CT scan around 9:00 a.m. and the NP's office called him and informed him the CT scan showed his son had acute appendicitis. He stated later he received a call from Dr #3's nurse, to bring him to the doctors office. He stated he later received a call from Dr #3's office, instructing him to take his son the emergency room. He confirmed that his son checked in to the Emergency Department (ED), had been taken to a treatment room and was being assessed by the nurse and Dr #3 came into the ED room #7. He stated the doctor was talking with him and after he found his son had already eaten he was told by Dr #3 since his son had already eaten he would not be able to have surgery at this hospital. He stated the doctor told him that the hospital did not have an on call OR crew on Fridays after 3pm and on weekends. He stated Dr #3 told him since his son had eaten that anesthesia would not put him to sleep until he had been without food for at least 6 hours. He stated Dr #3 told him, "These are your options, your son can leave without being seen which will prevent you from going through a lot "hullabaloo" and take him to Hospital A or you can take him to Hospital B. He stated the doctor told us they would give us a CD copy of the CT scan so it would not have to be repeated. He said the ED nurse helped his son get dressed and she took us to the ED lobby to wait until she got the copy of the CT scan. He stated they gave them the CT scan disk and they went to Hospital B. She confirmed that Hospital B was not contacted for transfer.

Review of the medical record for patient #18 revealed that nurse #4 conducted the medical screen in the ED on 05/14/2012 at 1935. The medical record reveals the patient arrived in the ED with c/o "Left foot pain states wants toenail removed." Nurse #4 further documents: redness L Foot, edema to BLE jaundice legs draining fluid", triage level 4, no tests ordered. Nurse # 4 documented "triage screened out to Clinic." At 2030 Nurse #4 documents "pt sent back to ER." (No reason was documented for the patient's return to the ED.) The physician documented an additional medical screen at 8:40 p.m., the patient was discharged home with DX of UTI and chronic cirrhosis and was given an RX for Cipro.

Review of the medical record for patient #27 revealed nurse #5 conducted a medical screen on 04/04/2012 at 16:35. The record revealed the patient presented with c/o "my back is hurting, I was in PE at school and was running my back on left side started hurting." There was no triage level documented. The record further indicates the patient signed a form that he had received a free medical screen and was given a referral to the clinic.

Review of 2 pages titled "Medical Screening Competency" that was provided as evidence of nurses that had been trained to conduct Medical Screening Examinations, revealed that nurses #4 and #5 had not received training to be qualified to conduct medical screening examinations. In an interview with staff #2 on 06/19/2012 at approximately 1:30 p.m., confirmed the nurses on the list were the nurses allowed to conduct medical screening examinations.

Based on record review and interviews the facility failed to ensure that 1 out of 1 patient (#1A) reviewed was provided an appropriate transfer to a hospital that was able to treat his emergency medical condition. These findings have the potential to cause harm to all patients needing a higher level of care to treat their emergency medical condition by the hospital staff's failure to ensure appropriate transfer procedures are implanted.

Findings:

Review of the medical record for patient #1A revealed that patient #1A checked into the ED on 06/08/2012 at 10:34 a.m. and was placed in room #7 at 10:42. The triage nursing recorded by Nurse #6, states "appendicitis, CT this am showed appendicitis, ate full breakfast at 0800." Vital Signs T 98.0, P 97, R 20 and BP 125/97, O2SAT 96. The triage level is not documented. The record indicates the patient was in ED room #7. LWBS at 10:55 was written on the bottom of the record. There is no further documentation of a medical screen on the record.

In an interview with the triage nurse #6 on 06/19/2012 at 1:30 p.m., she confirmed that she was the nurse that triaged patient #1A on 06/08/2012. She stated she took him back to room #7 in the emergency room due to his diagnosis of acute appendicitis. She stated that the father then came to room #7 and that Dr #3 came in the room and was talking to the patient's father while she was getting the patient in a gown for an exam. She stated she never saw Dr #3 examine the patient and she did not hear the doctor's conversation with the father. She stated that the Doctor left and she helped the patient get dressed and since he had not been assessed by the physician she recorded on the bottom of the record "LWBS" which she stated meant left without being seen. "She stated she then took him to the lobby and asked them to wait until she got a CD copy of the CT scan, which she gave to him and they left. She stated she or Dr #3 did not make arrangements for transfer. She stated she thought because the patient was not seen by the emergency room physician she could discharge him as "left without being seen." When asked about her training to conduct Medical Screenings, she stated she reviewed the packet titled "EMTALA" and the Charge Nurse went over the information in the packet with her in a session that lasted approximately 20 minutes.

In an interview with Dr #3 on 06/19/2012 at 12 noon he stated he got a call from the nurse practitioner at the clinic. He stated she asked him to see a patient that had an outpatient CT scan that showed acute appendicitis. He stated he never saw the patient in the emergency department. He said he talked to the father on the phone and told him to come to his office. He then stated he saw the father in the hall of the ED and found out the patient had eaten. He confirmed he told the father they could not do surgery after 3 pm on Friday and that since his son had eaten, anesthesia would not put him to sleep here. He confirmed he told the father the options were to take him to another facility and he gave them options of Tyler, Texas and Mount Pleasant, Texas. When asked if he made arrangements for transfer to another hospital, he stated he had not seen the patient and did not make arrangements.

Review of written statement by Dr #3 (the record is not dated or timed but is signed by Dr #3).

A review of a written statement on 06/19/2012 revealed he wrote "In fact, when the patient arrived he was sent to the ED. I had the conversation re: above mentioned timing of surgery with the father in the ED prior to the patient seeing the ED physician. The option of transferring to Hospital A after completing ED workup here versus the patient's father driving the patient to Hospital B was discussed. The father decided he would rather take the patient to Hospital B. This was decided so that the added expense of a second ED evaluation, ambulance transfer, and additional time commitment could be avoided."

A telephone interview was conducted with the patient's father on 06/20/2012 at 11:00 a.m. The father stated that his son was seen on 06/07/2012 at the clinic by the Nurse Practitioner (NP). He stated his son was having abdominal pain and she ordered a CT scan for the next a.m. He stated they had the CT scan around 9:00 a.m. and the NP's office called him and informed him the CT scan showed his son had acute appendicitis. He stated later he received a call from Dr #3's nurse to bring him to the doctor s office. He stated he later received a call from Dr #3 office instructing him to take his son the emergency room. He confirmed that his son checked in to the Emergency Department (ED) and had been taken to a treatment room and was being assessed by the nurse and Dr #3 came into the ED room #7. He stated the doctor was talking with him and after he found his son had already eaten he was told by the Dr #3 since his son had already eaten he would not be able to have surgery at this hospital. He stated the doctor told him that the hospital did not have an on call OR crew on Fridays after 3pm and on weekends. He stated Dr #3 told him since his son had eaten that anesthesia would not put him to sleep until he had been without food for at least 6 hours. He stated Dr #3 told him "These are your options, your son can leave without being seen which will prevent you from going through a lot "hullabaloo" and take him to Hospital A or you can take him to Hospital B. He stated the doctor told us they would give us a CD copy of the CT scan so it would not have to be repeated. He said the ED nurse helped his son get dressed and she took us to the ED lobby to wait until she got the copy of the CT scan. He stated they gave them the CT scan disk and they went to Hospital B. She confirmed that Hospital B was not contacted for transfer.