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Based on observation, review of patient records, hospital policies and procedures and staff interviews, the hospital failed to comply with all requirements of 489.24.

Refer to citations and examples at:

A 2402 (489.20(q)) Required Signage - Hospital failed to ensure that public signage clearly specified that there was no Emergency Department at the Women and Children's Hospital campus and was posted in areas likely to be noticed by individuals entering the building.

A 2405 (489.20 (r) (3)) Emergency Room Log - The hospital failed to ensure that all individuals who arrived at the Women and Children's Hospital requesting care were registered in a Log with pertinent information and documentation of their condition and disposition as determined by a qualified staff member.

A 2406 (489.24(a)) Medical Screening Exam - The Hospital failed to appropriately assess and stabilize a mental health patient prior to sending them to the Mental Health Crisis Office (Patient #26); and failed to provide a procedure at the Women and Children's Hospital by which a staff member qualified by education and experience was available to screen individuals entering the building seeking medical assistance. A procedural change put into place on 10/26/18 called for Security staff to ask questions and determine whether or not the individual was just needing to be redirected to the main hospital Emergency Department, or to call 911 to provide transport to the main hospital Emergency Department; and

A 2406 (489.24(a)) Medical Screening Exam By Qualified Medical Personnel - The Hospital failed to have language in by-laws, approved by the Governing Body that specified which medically qualified personnel had been determined qualified to conduct emergency medical screening exams (MSEs).

Based on observation and interview, the Hospital failed to ensure that public signage clearly specified that there was no Emergency Department at the Women and Children's Hospital campus and that the information was posted in areas likely to be noticed by individuals coming to the campus or entering the building.

Failure to effectively educate and notify the public of the absence of emergency services delayed access to care, and risked patient health.

Findings were:

During Tour of the Women and Children's Hospital campus on 12/13/18 at 12:30 PM, it was noted that signage outside the hospital, readily seen by the public, specified "Women and Children's Hospital." There was no signage information that Emergency Services were not available at the campus. Staff interview verified the signage information.

Review of 41 days of the "Walk-in Log" (dated 8/30/18 to 10/9/18) documented 23 entries of people seeking medical care who entered the building.

The hospital failed to effectively educate and notify the public of the absence of emergency services at the Women and Children's Hospital campus.

Based on observations and interviews, the hospital failed to ensure that all individuals who arrived at the Women and Children's Hospital seeking Emergency Care were registered in a Log with pertinent information and documentation of their condition and disposition as determined by a qualified staff member.

Failure to log these patients risked losing important information as to the number of patients arriving at the Women and Children's Hospital for emergency care, their care needs, and disposition.

Findings were:

During interview with the Security Guard at the Women and Children's Hospital campus on 12/13/18 at 12:40 PM, it was revealed that the "Walk In Disposition Log" that staff previously used to document each patient arriving and seeking medical care had been discontinued. He stated that an email issued by the Director of the Family Birth Center on 10/26/18 directed that, "No logging of people who present to entrance needs to be kept any longer."

He stated there was a case (Patient #25) that required 911 to be called on 12/6/18. There was no log entry for Patient #25:
He stated the patient had been found "down" and unresponsive on the Women and Children's Hospital Campus on 12/6/18 by a passer-by who came in seeking assistance. The Security Guard called 911 per the new algorithm issued 10/26/18, and the patient was transported by ambulance to the Trios Southridge ED where they were provided a medical screening exam and treatment. The patient was admitted for on-going care.

Review of 41 days of the "Walk-in Log" (dated 8/30/18 to 10/9/18) documented 23 entries of people who entered the building.
seeking medical care.

There was no current record of the number of patients seeking care, their condition on arrival, or their disposition to receive care.

Based on review of hospital policy and procedure, record review and staff interview, the hospital failed to appropriately assess and stabilize a mental health patient prior to sending them to the Mental Health Crisis Office (Patient #26); failed to ensure that individuals entering the building seeking medical assistance were initially screened by qualified staff; and failed to specify in hospital regulations or bylaws which medically qualified personnel had been determined qualified to conduct emergency medical screening exams (MSEs).

Failure to provide screening by a qualified staff member as defined by the Hospital's Governing Body, risked patient health and safety.

Findings were:

Review of the hospital's policy and procedure titled "Patient Transfers (Evaluation, Stabilization, and Transfer) EMTALA" [Emergency Medical Treatment and Labor Act], Policy #KGH003029 Revised 08/17 showed that any individual who presented to the Women's and Children's Hospital (Auburn Campus) and requested or had a request made on his or her behalf for an examination or treatment of a medical condition; or presented with appearance or behavior suggesting the individual needed emergency treatment, would be assessed by "qualified medical personnel." The definition of "qualified medical personnel" included a physician, registered nurse, advanced registered nurse practitioner, physician's assistant, or certified registered nurse anesthetist.
Qualified medical personal would initiate treatment to stabilize the patient, call an ambulance to arrange transfer of the patient to a facility that could meet the medical needs of the patient, call the emergency physician on duty at the Southridge campus, and notify the hospital supervisor.

1. Failed to appropriately assess and stabilize a mental health patient prior to sending them to the Mental Health Crisis Office for 1 of 1 mental health patients reviewed (Patient #26).

Review of the Women and Children's Hospital Walk In Disposition Log documented that Patient #26 was a mental health patient who arrived seeking Mental Health assistance on 9/26/18 at 8:40 AM with her boyfriend. The House Supervisor provided initial screening and contacted the Mental Health Crisis Office who spoke by phone with the boyfriend. The Office recommended that the boyfriend take the patient to the Crisis Office.

No medical screening exam was provided to rule out an emergency medical condition. The hospital failed to assess and stabilize the patient prior to discharge.


2. Failed to have procedures formulated, implemented and reviewed; and Failed to provide qualified staff for initial screening

During a tour of the Women and Children's Hospital on 12/13/18, the Security guard was asked how walk-in patients looking for emergency services were handled. He showed the investigator an email from the Director of the Family Birth Center and algorithm dated 10/26/18 which directed that individuals who arrived looking for emergency care at the Women and Children's Hospital would no longer be assessed by a clinical staff member.

Review of the email issued 10/26/18 showed that the patients who arrived looking for emergency care were to be interviewed by the security guard on duty:
If the patient stated she was pregnant, the patient would be taken to the Family Birth Center unit located in the building.
If the patient stated he or she was not pregnant, the security guard was to ask the patient what the person needed.
The security guard was to determine if the presenting problem was a "minor problem" or a "serious problem."
If the security guard determined it was a "minor problem," the patient would be given a map and instructions regarding how to get to the Southridge campus emergency department, which was five miles away.
If the security guard determined the patient had a "serious problem," the guard was to call 911 for an ambulance.
If an ambulance was summoned, the guard was to call the Family Birth Center, and a nursing staff member would "come and sit with the patient" until the ambulance arrived. The individual was not to be taken to the Family Birth Center and "put in a bed."
If the individual had a cardiac arrest, the security guard was to begin cardiopulmonary resuscitation and call 911.

He stated there was a case (Patient #25) that required 911 to be called on 12/6/18. He stated the patient had been found "down" and unresponsive on the Women and Children's Hospital Campus on 12/6/18 by a passer-by who came in seeking assistance. The Security Guard called 911 per the new algorithm issued 10/26/18, and the patient was transported by ambulance to the Trios Southridge ED where they were provided a medical screening exam and treatment. The patient was admitted for on-going care.

On 12/14/18 at 9 AM during an interview, the interim nursing director stated the entire procedure was currently under review by administration and medical staff, but remained in rough draft form. No changes had been made from the revised directive dated 10/26/18.

3. Failed to have language in by-laws, approved by the Governing Body that specified which medically qualified personnel had been determined qualified to conduct emergency medical screening exams (MSEs).

Review of Hospital Regulations failed to evidence language that specified which medically qualified personnel had been determined qualified to conduct emergency medical screening exams (MSEs). Staff interview on 12/14/18 verified that there was no specific directive in Hospital Regulations or Bylaws.