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Based on medical record review, interview and document review, it was determined that the Emergency Department physician at the Woman's Christian Association at Jamestown (WCA) did not provide Patient #1 with an appropriate medical screening examination to ensure compliance with 42 CFR 489.24 and related provisions at 42 CFR 489.20.

Findings Include:

Review of Patient #1's medical record, staff interviews and hospital documentation revealed the Emergency Department physician did not comply with all of the provisions of providing an appropriate medical screening examination for Patient #1.

Please reference findings under Tag A-2406.

Based on medical record review, staff interview and document review, Staff #3 did not provide an appropriate medical screening examination for 1 of 33 patients who presented to the Emergency Department (ED) for care (Patient #1).

Findings Include:

Review of the WCA "Admission, Discharge and Transfer" administrative policy last revised 10/09 revealed patients will be evaluated, treated, transferred (when appropriate) in accordance with the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA/COBRA). A medical screening examination must be provided to all patients who present to the hospital's emergency department. Patients who need specialized or a higher level of care not available at WCA should be transferred to an appropriate facility if the attending physician has determined that the benefits outweigh the risk to the individual. The facility and a physician must agree to accept the patient prior to the transfer. The certificate of transfer and Patient Transfer Order and Confirmation Forms must be completed and signed prior to transfer. The physician must include a summary of the risks and benefits upon which the transfer is based. When a patient and/or their representative refuses a medical screening examination, stabilizing treatment, transfer to another facility, or transport by a medical vehicle, the physician must explain the risks and benefits of the refused service and an against medical advice (AMA) form must be completed and signed.

Review of the WCA ED physician history and treatment record dated 7/9/12 at 1630 revealed the chief complaint was new onset seizures. Patient #1 was a 3 day old neonate who was seen by the pediatrician today for possible seizures. The pediatrician recommended Patient #1 go to Women and Childrens Hospital of Buffalo (WCHOB). Patient #1 had another seizure outside so the pediatrician sent Patient #1 to WCA to arrange for transfer to WCHOB. Patient #1 was examined briefly. The father arrived and was informed that the WCHOB transfer unit would take at least 2.5 hours to come to Jamestown. The parent's did not want to wait here as the workup will be done at WCHOB. The father wishes to drive to Buffalo now. Both parents appear comfortable with the decision. The physician assessment section indicates Patient #1 had good color, temperature good and bowel sounds. Patient #1's heart was tachy, pulse is 120 and respirations 31. The review of systems section of the form is blank. The diagnosis listed is Neonate Seizure. The physician discharge instructions/consultation/admission/transfer of care documentation section of the form lists " No medical action taken here. " Staff #3 signed off on the record at 1645.

Review of the WCA ED nursing notes triage and nursing assessment sections dated 7/9/12 at 1630 revealed Patient #1 arrived via ambulance and was triaged with an acuity of " 3 " . Oxygen is provided by non-rebreather mask. Per mother, Patient #1 has had possible seizure activity x 2 days. Patient #1 has a healthy appearance, age appropriate, skin pink/dry/warm, respirations easy, lungs clear, heart rate regular at 120, respirations 32, abdomen soft with no trauma or pain noted. The past medical history section of report is blank.

Review of the WCA ED nursing notes narrative section revealed the following:
- At 1630 Patient #1 was brought in by Emergency Medical Services (EMS) from the pediatrician ' s office for " stabilization " of new onset seizure or transport to WCHOB. Patient #1 is sleeping in her mother's arms. Patient #1' s skin is pink, warm and dry with no distress or seizure activity noted. Mother states they were discharged from the hospital yesterday and was at the pediatrician ' s office today for multiple episodes of hand and feet clenching, shaking and purple lips. Episodes are brief lasting less than 30 seconds and occurred 4 times today.
- At 1632: Staff #3 is at the bedside and advises the parents that the pediatric team from WCHOB will take at least 2 hours to come to WCA to transport to Buffalo. The father stated "that is 4 hours before she gets to Buffalo, I can get her there in 1.5 hours". The mother voices concern about Patient #1 having a seizure enroute while in their private vehicle. Staff #3 stated " she needs to be in Buffalo ultimately for evaluation and care. That is the best place. "
- At 1635: Questions regarding the case were answered by Staff #3. The father feels Patient #1 should get to Buffalo now rather than later. Staff #3 stated " This is your decision. I either need to get started on my evaluation or you need to head for Buffalo. "
- At 1640: Staff #11 asked the mother if she is ok with this plan. She tears up and states she is scared. Emotional support is provided and assured her feelings are appropriate.
- At 1645: Patient #1 is secured into the infant seat. Staff #11 encouraged the parents to call 911 at anytime they are concerned or if the infant's condition changes.

Review of the WCA ED nursing notes admission/discharge/transfer section revealed at 1720 Staff #11 called report to the nurse practitioner at WCHOB " just to advise her of the patient " and that the parents were bringing the patient there. The Patient Disposition is listed as left without being seen.

Interview on 8/2/12 at 13:30 with Staff #11 revealed Patient #1 arrived at WCA via ambulance from her pediatricians ' office for stabilization of possible new onset seizure activity and transport to WCHOB. She triaged Patient #1 and put cardiac monitor on her. Her lungs were clear, no tremors were noted, was relaxed with no outward seizure activity. She anticipated drawing bloods and starting an IV but the charge nurse came in and told her not to start anything, the physician was coming to assess the baby. Staff #3 listened to Patient #1' s chest while she was resting in her mother ' s arms. Prior to the patient and her family leaving for WCHOB, neither she nor Staff #3 explained the risks of transfer to the family. The father drove Patient #1 in his private car to WCHOB. After the patient and her family left, she called the nurse practitioner at WCHOB to give an assessment and let them know the family was going to show up. No transfer documentation was done in this case and no vital signs were obtained prior to Patient #1 leaving the ED.

Telephone interview on 8/9/12 at 1530 with Staff #3 revealed the pediatrician called approximately 20 minutes before Patient #1 and her parents arrived to the WCA ED. He reported that Patient #1 was a 3 day old infant who had a seizure in the parking lot and was being sent over. The plan was to refer and transfer the baby to WCHOB. Patient #1 was seen at 1630. Staff #11 was taking a history from the mother when I entered the room and introduced myself. I told the mother I need to do an evaluation, draw bloods and contact the WCHOB transport team. At that point the father came in. He was very upset asking me what I was going to do. I explained again that I need to do an evaluation, obtain bloods and contact WCHOB transport team. The father had an I phone in which I viewed Patient #1' s left arm shaking. The initial examination was cursory and my evaluation was limited. The father wanted to know how long it was going to take. I told him 2-2.5 hours. The father envisioned 5 hours of wait time. I agreed but stated WCHOB is the place to be, they have a specialist. The father was adamant that he wanted to drive Patient #1 to WCHOB and at that point did not want an evaluation at WCA. There was no time for testing. There was no seizure activity during the 15 minutes the patient was in the ED. Patient #1 was asleep in her mother ' s arms with no changes in vital signs. I do not see that vital signs were taken before Patient #1 left. At this point, I was not thinking of a transfer, I was thinking of Patient #1's status as leaving without being seen. Staff #11 contacted the nurse practitioner at WCHOB after they had left.

Review of the Rural Metro Medical Services patient care report dated 7/9/12 revealed a call at 1758 for EMS staff to respond to I 90 & Exit 57 on the NYS thruway for a possible seizure. EMS arrived at the scene at 1806. Patient #1 was found in a car seat in a vehicle accompanied by her parents asleep and easily arousable. The mother describes seizure activity as her arms and legs twitching. EMS arrived at WCHOB ED at 1831, Patient #1's condition was unchanged and report was given to ED staff.

Review of the WCHOB ED physician note dated 7/9/12 at 1843 revealed Patient #1 is a 3 day old normal spontaneous vaginal delivery full term female who was well in the hospital and discharged yesterday. The parents noticed some lip smacking and eye deviation with stiffening. They took a video and went to the primary care doctor this morning who sent the patient to the ED. No fever, tolerating oral feeds, good wet diapers, no cough with a normal cry. Physical assessment is normal. After examination, a seizure was noticed. Patient #1's head and eyes deviated to the side, arms stiff and desaturation to 80%. Oxygen applied. A lumbar puncture was performed for possible meningitis and Ampicillin, Gentamycin and Acyclovir were ordered. A full sepsis work-up and CT of the head were done. Patient #1 was admitted to the Pediatric Intensive Care Unit.

There is no evidence to indicate that a complete medical screening examination was conducted on 7/9/12 at WCA ED. In addition, there is no evidence to indicate an inter-institutional patient transfer certification, an ambulance transfer form or a leave against medical advice form was obtained or that the patient's parents were provided with information related to the risks versus benefits of transporting Patient #1 via personal car.