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Based on record review, staff interview, and policy and procedure review, the facility failed to ensure that its emergency department policies and procedures were followed.

Findings include:

Refer to Tag A-2406 for the facility's failure to follow its policies and procedures for medical screening.

Refer to Tag A-2409 for the facility's failure to follow its policies and procedures for appropriate transfer.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure that each individual arriving at the Emergency Department (ED) seeking treatment was provided a Medical Screening Examination (MSE) to determine if an Emergency Medical Condition (EMC) existed for seven (7) of 14 patients reviewed (Patient #3, #4, #6, #7, #8, #9, and #10).

Findings include:

Review of the hospital's policies and procedures for Evaluation, Treatment and Transfer of Individuals with Emergency Medical Conditions (undated) contained the following requirements.
"III. A. Medical Screening Examination:
1. The hospital shall provide a screening examination for every person who comes to the emergency department and makes a request for examination or treatment of an Emergency Medical Condition. The medical screening examination shall be done by a physician or qualified medical person as defined in the policies, Section II, E. In no event shall a Medical Screen be conducted by a Registered Nurse. A screening examination shall also be conducted when someone other than the patient makes the request of behalf of the individual, even if the person requesting the examination is not the patient's Legal Responsible Person.
III. A. 2. Within the capabilities of the emergency department, the screening examination shall determine whether or not an Emergency Medical Condition exits The nature of the examination should be sufficient to determine with reasonable clinical confidence whether or not the patient has a Emergency Medical Condition."

Review of ED records revealed the following information:

1. Patient #3 arrived at the ED on 12/29/10 at 10:25 a.m. complaining of sinus infection, headache, head and chest congestion, scratchy throat and yellow nasal drainage. The patient rated the pain level at "6-7" on a scale of one (1) to 10. Non-urgent was checked on the ED record. The patient's vital signs were within normal limits (WNL). There was no documented evidence that a MSE was provided. A note on the ED record revealed that the patient was instructed by ED staff to go to a clinic for treatment. An interview with ED Physician #1 on 03/04/11 from 2:35 p.m. to 3:40 p.m. revealed that he failed to document that a MSE was done.

2. Patient #4 arrived at the ED on 12/26/10 at 1:15 p.m. complaining of body aches, headache, fever, chest and head sore and burning, and productive cough with yellow sputum. The patient rated the pain at "8"on a scale of one (1) to 10. The patient's vital signs were WNL. Non-urgent was checked on the record. There was no documented evidence that a MSE was provided for Patient #4. A note on the ED record stated that the patient was told that a picture identification (ID) was required to receive treatment at the ED. A telephone interview with ED Physician #3 on 03/04/11 from 6:00 p.m. to 6:02 p.m. revealed that at the time of the incident, he did not know that he could see patients when they did not have any source of identification. The facility failed to ensure a MSE was provided to this patient on 12/26/10 when he/she presented to ED.

3. Patient #6, a five (5) year old child arrived at the ED on 12/23/10 at 8:25 a.m. with complaints of fever, headache, vomiting yesterday and one (1) loose stool. The patient was given Motrin two (2) teaspoons at 7:30 a.m. prior to arrival at the ED. The patient's pain was rated "8" on a scale of one (1) to 10. The patient's temperature was 101.1 degrees Fahrenheit, pulse was 106, and respirations were 20. Non-urgent was checked on the record. There was no documented evidence that a MSE was provided. A note on the ED record revealed that the patient's family member was instructed to take the child to a clinic for treatment. During a telephone interview on 03/04/11 from 6:30 p.m. to 6:33 p.m. ED Physician #4 revealed that sometimes he refers patients to his office. The facility failed to ensure that a MSE was provided to this patient on 12/23/10 to determine whether this was an EMC or not.

4. Patient #7 arrived at the ED on 9/22/10 at 6:00 p.m. complaining of a spider bite to the left thigh. The patient rated the pain at "3" on a scale of one (1) to three (3). The patient took the spider to the ED. A small area was observed on the back of the left thigh. Non-urgent was checked on the ED record. There was no documented evidence that a MSE was provided. A note on the ED record revealed that the patient was told that a picture ID was required for the patient to be treated at the ED. A telephone interview with ED Physician #3 on 03/04/11 from 6:00 p.m. to 6:02 p.m. revealed that at the time of this incident, he did not know that he could see patients when they did not have any source of identification. The facility failed to ensure a MSE was provided to this patient on 09/22/10 when he/she presented to ED.


5. Patient #8 arrived at the ED on 12/23/10 at 5:55 p.m. complaining of sharp pain to the right upper arm. The patient's blood pressure was 122/85. There was no documented evidence that the patient's condition was assessed. The classification of the patient's condition was not documented. A note on the ED record revealed, "1755 (5:55 p.m.) pt in triage. Seen by (ED physician #2) in triage. MD (Medical Doctor) told pt that due to pregnancy of nine (9) weeks she would need to go to ER (Emergency Room) in (another town) and see her OB/GYN (obstetrician/gynecologist) since since we don't provide OB services here. Pt verbalized understanding." During an interview on 03/04/11 from 5:15 p.m. to 5:18 p.m. ED Physician #2 stated, "I screen every patient that comes to the ED. Sometimes if the patient's vital signs don't change, they are screened out to go to the clinic." The facility failed to ensure a MSE was provided to this patient on 12/23/10 when he/she presented to ED.


6. Patient #9 arrived at the ED on 09/06/10 at 4:00 p.m. complaining of burning on urination with a white discharge. The patient's vital signs were WNL. The patient rated the pain at "3" on a scale from one (1) to 10. Non-urgent was checked on the ED record. A note found on the ED record stated, "1605 (4:05 p.m.) Determined to be non-emert & instructed to return c (with) ID for treatment per (ED Physician #3). He verbalized understanding and left." A telephone interview with ED Physician #3 on 03/04/11, from 6:04 p.m. to 6:06 p.m., revealed that at the time of this incident, he did not know that patients could be seen in the ED when they did not have any source of identification. The facility failed to ensure a MSE was provided to this patient on 09/06/10 when he/she presented to ED.


7. Patient #10 arrived at the ED on 09/02/10 at 11:35 a.m. complaining of nausea, vomiting, diarrhea, and abdominal cramps which started four (4) days ago. At 12:30 p.m. Patient #10's blood pressure was 140/95. Other vital signs were WNL. Non-urgent was checked on the record. ED notes stated, "1430 (2:30 p.m.) MSE done per MD- pt to go to WMC as walk-in at this time- pt instructed and voices understanding. Ambulatory from ED."
The facility failed to ensure a MSE was provided to this patient on 09/02/10 when he/she presented to ED.

Based on record review and staff interview, the facility failed to ensure that it met the requirements for appropriate transfer, including the patient's consent and that benefits outweigh the risks of transfer for Patient #9, one (1) of nine (9) patients reviewed.

Findings include:

Review of the hospital's undated policies and procedures for Evaluation, Treatment and Transfer of Individuals with Emergency Medical Conditions contained the following requirements.

The facility's EMTALA Procedures III
C. 3.b. With medical certification:
"The individual may be transferred if a physician has documented in the 'Transfer Authorization and Certification' (FORM A) that based on the information available at the time of transfer, the medical benefits reasonably expected from the transfer outweigh the risks to the patient (or in the case of a women in labor, to her and the unborn child) from being transferred. The certification must contain a summary of the risks and benefits of which it is based.
C.4. The transfer of an unstable individual with an Emergency Medical Condition shall be carried out in accordance with the following procedures.
C.4.g. "The Hospital shall notify the individual or, where applicable, the individual's Legally Responsible Person, both orally and in writing, of the transfer and the reasons therefore. An Acknowledgment of such notification shall be obtained by asking the individual or the Legally Responsible Person to sign the 'Transfer Authorization and Certification' (FORM A). If an individual's physical or mental condition is such that it is not possible to notify the individual, and the individual is unaccompanied, the Hospital shall make a reasonable effort to locate a Legally Responsible Person in order to notify that person of the intended transfer."

Review of the Emergency Department (ED) record revealed that Patient #15 arrived at the emergency department on 02/25/11 at 12:25 a.m. in labor. She was accompanied by family. The patient was transferred by ambulance to another hospital in satisfactory condition at 1:20 a.m. Review of the Transfer Authorization and Certification form revealed that the patient/family did not sign consent for the transfer. 'Patient unable to sign' was documented on the Transfer Authorization and Certification form. The reason the patient was unable to sign was not documented. The physician did not certify the expected benefits outweighed the risks to both the patient and the unborn child. The facility failed to ensure that it met the requirements for appropriate transfer for Patient #15 on 02/25/11.