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Based on staff interviews and a review of the facility's policy and procedure, the facility failed to maintain a central log on each individual who comes to the emergency department for 1 of 35 patients (Patient #1) in the case sample.

Findings include:

Cross reference to A2406

1) An interview was conducted with Security Officer #1 (SO #1) on 2/4/16 at 06:30 A.M. SO #1 stated, a minivan pulled up; SO #1 approached the vehicle; Mother was in the driver's seat. Mother was asking to see someone; SO #1 asked if they needed a wheelchair. The mother told SO #1 that daughter was a runaway, she is not compliant with her psych meds, and possibly raped. SO #1 told them "let's go" inside the ER; so all three of them walked into the ER. They were cleared by security. There were a lot of people in the waiting area; SO #1 told the mother and her daughter to have a seat. The mother was very worried about her daughter; AO #1 told them to wait and that SO #1 will speak to LN #1. SO #1 went into the ER bay area and spoke to LN #1. SO #1 conveyed the information to LN #1. LN #1 said they don't have a rape kit, but will be happy to see her daughter, but no rape kit; they will need to go to another hospital. So, SO #1 relayed the message from LN #1 to the patient's mother. When LN #1 had a chance to see the mom and the patient, they were gone.

2) An interview was conducted with LN#1 on 2/4/16 at 07:00 A.M. LN #1 stated he has been with the Queens Medical Center (QMC) for 3 years, initially as a staff nurse and has been a charge nurse for about 1 1/2 years in the ED. LN #1 recalled SO #1 informing him about a mom and her daughter who was possibly raped and wanted to check in. LN #1 informed SO #1 that they were busy and will talk to them as soon as possible. LN #1 mentioned typically other facility does rape kits. He acknowledged that alleged rape is a priority.

When State Agency (SA) asked LN #1, if this was an EMTALA case and staff responded "Yes." In retrospect he would not have told them to go to the other facility which specializes in rape kit. LN #1 said, would have check them in. LN #1 informed SA that QMC's ED do not have a rape team. However, KMCWC can come to QMC ED to do rape kit.

3) An interview was conducted with the Risk Management Coordinator (RMC) on 2/4/16 at 07:40 A.M. SA asked her if this is an EMTALA violation. She responded, "Yes it is; No record of patient." Management realized that we have a huge education gap, therefore, an immediate education was done with staff, security, and ER staff. RMC mentioned that she talked to ER Social Workers, and even reached out to QMC West, other hospital campus. She stated on a Tuesday morning after the morning briefing the ED Manager and RMC walked to see the Corporate Compliance Administrator and Privacy Officer because RMC wanted to turn everything over to Corporate Compliance.

4) The facility's EMTALA Compliance policy 610-14-208-B was reviewed and under General Policies #4.2 = Central log states: "Each department of QMC that provides medical screening examinations shall maintain a central log of persons who present for emergency services. The log shall record the name of each person who presents for emergency servives and whether the person refused treatment, was refused treatment by QMC, or whether the patient was admitted and treated, or stabilized and transferred, or discharged."

The facility's policy was not implemented on 7/4/15, although P#1 was already inside the ED. She was not registered in the central log and no ED staff had seen the patient.

Based on electronic record reviews, staff interviews, and a review of the facility's policy and procedure, the facility failed to provide a medical screening examination for 2 of 35 patients (Patient #1 and Patient #35) who came to the emergency department (ED) in the case sample.

Findings include:

Cross reference to 2405

1) Interviews were conducted with several staff who were on duty on 7/4/15 and it was found the P#1 was in the ED but MSE was not provided. And, she and her mother left when told that Queens Medical Center (QMC) did not have a rape kit.

An interview was conducted with Security Officer #1 (SO#1)on 2/4/16 at 06:30 A.M. The mother told SO#1 that daughter was a run away, she is not compliant with her psych meds, and possibly raped. SO#1 told them " let's go" inside the ER; so, all three of them walked into the ER, they were cleared by security. There were a lot of people in the waiting area; SO#1 told the mother and her daughter to have a seat. The mother was very worried about her daughter; SO#1 told them to wait and that SO#1 will speak to the Licensed Nurse #1 (LN #1). SO#1 went into the ER bay area and spoke to LN #1.

LN#1 said QMC do not have a rape kit, but will be happy to see her daughter, but no rape kit; they will need to go to another hospital. Tell them to wait and LN #1 will see them. SO#1 relayed the message from LN#1 to the mom. When LN#1 came out, the mom and daughter were gone. SO #1 informed State Agency (SA) this was the first time a situation like this had happened to him. SO#1 mentioned to the SA that he informed his supervisor. And, shortly thereafter, everyone had to go through an in-service on EMTALA. According to SO#1, this was his first in-service about EMTALA.

SO#1 states does not normally go into the ER bay and talk to the charge nurse; it depends on the severity of the situation. SO#1 went to speak to the charge nurse because the mom was so concerned about her daughter - noncompliant on her psych medications, and possibly raped. SO #1 thought it did not seem right to tell the patient to go to another hospital for care.

Risk Management Coordinator (RMC) summoned SO#1 about 2 days to one week later for an interview. He met with RMC and Night Shift Security Guard Supervisor in the risk management's office. SO#1 was told that a report came, saying QMC refused to see this patient. It was a verbal interview, nothing was written down.

An interview was conducted with LN#1 on 2/4/16 at 07:00 A.M. LN #1 states an alleged rape is a priority. In his experience, a rape report is usually told in private to a RN and not to a security personnel. At the time, it was busy and could not go to see the patient right away.
LN#1 did not inform the ED Manager, ED PI Coordinator, and the Director ED, Patient Flow & Care Coordination about the incident.

Since the incident, lots of in-services on EMTALA have been done per LN#1. His last EMTALA in-service prior to the incident was as a new grad in Northwest Indiana; some orientation for new hires at QMC 1/2013 or 6/2013 when LN#1 first started as a travel nurse for 4 months. LN#1 attended the EMTALA in-service on 7/2015 or 8/2015, staff cannot recall which date.

SA asked LN#1 if this was an EMTALA case, and LN#1 answered - "Yes." In retrospect he would not have told them to go to another facility. LN#1 would have said check them in. The QMC's ED do not have a rape team. There is another facility which specializes in rape kit which can be consulted. He acknowledged ED doctors do the MSE and then make decisions to transfer to another facility for follow-up on alleged rape cases. SA asked: Would you have documented incident that it had occurred? LN#1 stated there is nowhere to document, no medical record and no place to document.

2) A telephone interview was conducted with LN#2 on 2/4/16 at 08:40 A.M. and a follow-up interview on 2/5/16 at 11:05 A.M. LN#2 recalled that she took care of another patient claiming that she was rape. She mentioned that it was an early morning of 7/5/15, when Patient #35 (P#35) with a friend showed up in the ED. LN#2 stated, she did the triage for this patient. She recalled putting her in the system with a sexual assault as the reason for her visit.

After, the information provided by LN#2, surveyors looked into the copy of the central log provided by the facility for the month of July 2015. SA searched the central log for any patient who matched the description that was mentioned by LN#2. SA could not find anyone. SA requested a copy of this patient's chart.

During a follow-up interview with LN#2, she remembered P#35 reported that she was sexually assaulted during triage. LN#2 then talked to the Social Worker (SW) who was on duty at that time. The SW told LN#2 that QMC does not have the capabilities to do a rape kit and suggested she go to another facility that specializes. LN#2 relayed this message to the patient who decided to go to the other facility with her friend. LN#2 acknowledged that she did not document any of the information such as date, time, and what was told to P#35 and that the ED MD was not consulted. In retrospect, LN#2 said, "I should have consulted with the MD first."

Since SA was unable to find P#35 on the central log, the ED Director, ED PI Director, and LN#3 explained the reason why SA could not locate the patient in the central log. There was a "Register in error" showing in the system, so patient may not have been in the ED. Per ED PI Director, register in error was there. So, ED PI Director and LN#3 did a "reg in error" search from 7/3/15-7/6/15 and added age 20's female but could not find the patient, it showed, "no encounter." Finally, the ED Director mentioned that they found a sex assault person. The patient was indeed P#35, apparently no arrival date and time, and she was not on the original list.

The hard copy of P#35's chart was provided and reviewed. There was a triage date of 7/5/15 and vital signs were taken at 06:12 A.M. The vital signs were as follows: BP 111/71, Pulse 111, Respiratory Rate 18, Temperature 37 (98.6), and SpO2 at 98% on room air. The chart was incomplete: There was an entry under "ED Dismiss" comments: "reg in error-kapiolani medical center." The rest was blank. There was no note of LWBS by ED staff, there was no electronic signature by any ED staff, and no documentation that MSE was provided to P#35.

An interview was done with the Social Service Manager on 2/5/16 at 12:15 P.M. She acknowledged that the SW on duty should have done a psychosocial assessment and inform the patient of appropriate resources.

During the follow-up interview with LN#2, on 2/5/16 at 11:05 A.M. said, in retrospect "I should have done more of a complete charting."

3) The facility's EMTALA Compliance policy 610-14-208-B was reviewed and under #5: Medical Screening Examination/Policy = states: "A medical screening examination must be offered to any individual presenting at the Emergency Department for examination or treatment of a medical condition, or elsewhere on QMC campus requesting emergent care. The examination must be provided within the capabilities of QMC, including availability of on-call practitioners. The examination must be the same appropriate screening examination that QMC would perform on any individual with similar signs and symptoms, regardless of the individual's ability to pay for medical care."

The policy was not implemented for P#1 and P#35. MSE was not provided to P#1 and P#35. P#1 was not registered in the central log. P#35 was partially registered in the log; triage nurse had done vital signs. And, there was no documentation that P#35 left without being seen (LWBS) by any ED staff.