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Based on interview and record review the facility failed to follow their policies and procedures and did not perform a Medical Screening Examination (MSE) on one patient (Patient # 30), within the hospital capability, to determine if an emergency medical condition existed. This occurred on one patient (Patient # 30) out of 30 Emergency Department (ED) patient medical records reviewed from January, 2012 to June, 2012. The hospital sees an average of 550 emergency room cases per month.

Findings included.

1. Review of the hospital's Policy & Procedure Manual, SUBJECT: COBRA/EMTALA, Revised July 2010 showed the following staff direction:
It is the policy of this hospital that all persons presenting for unscheduled procedures or evaluation shall receive a medical screening examination within the capabilities of the Emergency Department and the ancillary services routinely available to the emergency services of this hospital, including examination, testing, treatment and the services of appropriate on call physicians where indicated. Patients shall not be denied evaluation, screening, treatment, or stabilization on the basis of means or ability to pay, race, creed, color, national origin, age, sex or actual or perceived disability. Patients shall not be denied evaluation, screening, testing, treatment or stabilization on the basis of their presenting complaint, condition, or lack of physician on the medical staff of this hospital.

In addition, section E, under Procedure on Page 6 showed: No presenting patient shall be denied medical screening examination by any employee or medical staff member of this hospital.

2. Review of hospital's policy, "Procedure-Sexual Assault Collection (Victim)" showed step by step instructions for the physician and nurse on the process for notifying law enforcement, process for obtaining informed consent, process for specimen collection and maintaining the specimen chain of custody, and documentation to be included in the patient medical record.

3. Review of the medical record showed Patient #30 presented to the ED on 6/7/12 at 4:11 PM requesting care after being raped. Documentation revealed ED physician L declined to perform the rape exam. Further documentation revealed the rape Victim Advocate arrived in the ED and arranged for Patient # 30 to go to the ED at Hospital B for an examination. The ED nurse documented the following " Aftercare Instructions " , " 1. Seek treatment elsewhere to check for sexually transmittent [sic] diseases and have rape exam as soon as possible. " Further documentation revealed Patient # 30 signed an " AMA [against medical advice] - Informed Consent To Refuse Form " at 5:10 PM.

4. During an interview on 06/27/12 at 10:00 AM ED Physician L stated he told ED nurse O, that he would do the MSE on Patient # 30 but he was not comfortable doing the evidence collection part of the examination. ED Physician L stated that Patient # 30 would need to go elsewhere to get that part of the exam. ED Physician L stated that he never spoke directly to the patient, he never spoke directly to the Victim Advocate, and that he was not trained to emotionally stabilize " this type of patient. "

5. During a phone interview on 6/28/12 at 8:50 AM, Patient # 30 stated she was surprised the ED physician never came to speak with her, and that " when the ED nurse asked me to sign the " Against Medical Advice form " I asked " why do I have to sign this paper when you can ' t do the exam? " " I don ' t want to leave, I have to leave because you can ' t do the exam. " Patient # 30 stated the nurse just said " that ' s the way it has to be done. " " I didn ' t want any more hassle so I just signed it. "

6. Review of "Memorandum", dated June 21, 2012, sent by Staff K, ED Regional Medical Director, to All ED Physicians at Samaritan Hospital showed: The Emergency Department has a policy to follow when evaluating patients of alleged sexual assault. The ED physician is expected to perform a Medical Screening Exam on the patient along with a sexual assault exam. Kits are available in the ED for collection of forensic evidence. The hospital has verified with state attorneys and patient advocate who deal with these types of crimes that the ED physician is authorized to collect this evidence. Patients should never be transferred solely to perform this exam.

See Tag A2402 and A2406 for additional details.

Based on observation and interview the facility failed to post appropriate signage in sufficient manner to provide notice of Patient Rights under EMTALA (Emergency Medical Treatment and Labor Act) regulations to those seeking treatment in the emergency department (ED). The facility has about 550 emergency cases per month.

Findings include:

Observation of the emergency department entrance, lobby, and waiting room on 06/26/12 showed no signage stating the Patient Rights required under the EMTALA regulations.

During an interview on 06/26/12 Staff C, ED Manager, stated that there had recently been construction in that area and the signs must have been taken down and stored. Staff C stated, "We haven't gotten around to putting them back up yet".

Based on interviews and record review the facility failed to provide a Medical Screening Exam (MSE) for one patient (Patient #30) who presented to the emergency department (ED) requesting care. This occurred on one patient (Patient # 30) out of 30 ED patient medical records reviewed from January 2012 to June 2012. The hospital sees an average of 550 emergency department cases per month.

Findings included:

1. Review of the medical record showed Patient #30 presented to the ED on 6/7/12 at 4:11 PM requesting care after being raped. Documentation revealed ED physician L declined to perform the rape exam. Further documentation revealed the rape Victim Advocate arrived in the ED and arranged for Patient # 30 to go to the ED at Hospital B for an examination. The ED nurse documented the following " Aftercare Instructions " , " 1. Seek treatment elsewhere to check for sexually transmittent [sic] diseases and have rape exam as soon as possible. " Further documentation revealed Patient # 30 signed an " AMA [against medical advice] - Informed Consent To Refuse Form " at 5:10 PM.

2. During a phone interview on 6/27/12 at 10:30 AM Physician J, ED Medical Director, stated that ED Physicians are capable of performing a rape exam, there is no specialized training; the [rape] kit is pretty self explanatory. ED physician J stated her expectation would be for the ED doctors to perform rape examinations in this facility. ED physician J stated that she has been called in to do a rape exam in the past and would come in to do the exam if she was called and available.

3. During a Phone Interview on 06/27/12 at 10:00 AM ED Physician L stated that:
- He was told that the Victim Advocate was taking the patient to another hospital because he would not do the rape exam and the patient didn't want to be examined twice;
- He never spoke directly to the patient;
- He never spoke directly to the Victim Advocate;
- He stated that he was not trained to emotionally stabilize this type of patient;
- He stated that he made sure ED nurse O knew to get an "Against Medical Advice" form signed.

4. During a phone interview on 6/28/12 at 8:50 AM, Patient # 30 stated she was surprised the ED physician never came to speak with her, and that " when the ED nurse asked me to sign the " Against Medical Advice form " I asked " why do I have to sign this paper when you can ' t do the exam? " " I don ' t want to leave, I have to leave because you can ' t do the exam. " Patient # 30 stated the nurse just said " that ' s the way it has to be done. " " I didn ' t want any more hassle so I just signed it. "

5. During a phone interview on 06/27/12 at 9:30 AM ED nurse O stated that:
-The patient came through triage and was quickly placed in a treatment room;
- The patient requested to speak to the County Victim Advocate;
- ED nurse O called the Victim Advocate who asked if the ED doctor on duty would perform a rape exam. ED nurse O asked ED Physician L if he would perform a rape examination and he said no he wasn't comfortable doing the exam;
- ED nurse O said the doctor never spoke to the patient or the Victim Advocate;
- ED nurse O said she believed all ED doctors were capable of doing this type of exam;
- Other doctors have done this exam before and she was not aware of a doctor ever refusing to do this;
- She wrote the instructions on the patient's Aftercare paperwork because she knew that was what the patient needed. The ED physician did not tell her to do this;
- ED nurse O stated ED Physician L said the patient would be better served in a facility that is trained for this type procedure, and that he (ED physician L) was not comfortable doing this exam;
- On the next day ED nurse O said she asked her supervisor (Staff C) if the ED physician had a choice to do this exam, she was told no, the ED doctor must do it.

6. During a phone interview on 06/27/12 at 9:00 AM Victim Advocate N stated that:
- She works for the prosecuting attorney;
- She was called by the hospital and advised that they had a patient that stated she was raped;
- She asked the ED nurse if the physician on duty would do the exam. The ED nurse spoke to doctor and stated that he would not do the evidentiary exam; he would test for sexually transmitted diseases but not collect evidence;
- The ED Physician never spoke to the patient or to her (Victim Advocate);
- She was in the room when the patient was asked to sign the "Against Medical Advice" form, the patient asked why she had to sign the form because "I'm not leaving because I want to, I'm leaving because I have to";
- She was not aware of any specific training physicians receive before performing sexual assault examinations and in her experience ED doctors are able to complete the examination.

7. During an interview on 06/26/12 at 3:15 PM Staff C, ED Manager, stated that:
-We had a recent issue where the doctor stated he was concerned about doing the evidence collection on a sexual assault examination;
- The physician offered to do the medical screening examination but the patient refused because she didn't want to be examined here and then somewhere else;
- Other physicians have done the entire exam in this ED;
- The nurses are trained and capable of assisting the physician with the exam;
- She didn't think the patient would have left the ED if she hadn't been advised that the physician wouldn't do part of the exam.

8. Review of "Memorandum", dated June 21, 2012, sent by Staff K, ED Regional Medical Director, to All ED Physicians at Samaritan Hospital showed: The Emergency Department has a policy to follow when evaluating patients of alleged sexual assault. The ED physician is expected to perform a Medical Screening Exam on the patient along with a sexual assault exam. Kits are available in the ED for collection of forensic evidence. The hospital has verified with state attorneys and patient advocate who deal with these types of crimes that the ED physician is authorized to collect this evidence. Patients should never be transferred solely to perform this exam.