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Based on record review, review of the critical access hospital (CAH) and medical staff Bylaws, review of the CAH's policy, review of the Medical Staff Meeting and minutes, review of the CAH Quality Assurance/Program Improvement (QA/PI) Plan and Committee Meeting minutes, monitoring information, review of staff education information, and family and staff interview, the CAH failed to comply with the requirements of ?489.24, regarding failure to maintain a central log which identified who came to the emergency department (ED), if the patient refused treatment, what treatment the CAH provided, and if the CAH transferred, admitted, stabilized and transferred, or discharged the patient (Refer to C2405); failure to ensure patients who presented to the ED received an appropriate medical screening examination (MSE) by qualified staff (Refer to C2406); and failure to develop governing body bylaws, medical staff bylaws, rules and regulations, and CAH policies and procedures regarding ?489.24 on 2 of 2 days of survey (May 7-8, 2012).

Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements of ?489.24. Failure to adopt and enforce policies and procedures regarding availability of on call physicians, MSE, and failure to provide an appropriate MSE to patients seeking assistance at the CAH's ED placed patients at risk of increased pain and illness related to their reasons for seeking assistance.

Findings include:

Review of the CAH's BYLAWS occurred on May 07-08, 2012. The BYLAWS, approved 07/18/05, stated "ARTICLE IV, Governing Board, Section 1. General Powers: The administrative powers of the corporation shall be vested in the Board of Directors which . . . shall have overall responsibility for maintaining quality patient care . . .
ARTICLE VIII, Administration, Section 1. Administrator: The chief executive officer shall select and appoint a competent administrator who shall be the chief executive officer's direct executive representative in the management of the hospital. The administrator shall be given the necessary authority and responsibility to operate the hospital in all its activities and departments . . . Section 2. Duties of Administrator: The authority and duties of the administrator shall include responsibility for: . . . h) cooperation with the medical staff of this hospital and with all those concerned with the rendering of professional service, to the end that high quality care may be rendered to the patients; i) development of an appropriate medical staff organizational structure which will assist the medical staff; in carrying out the medical staff's responsibilities in providing quality health care, including reporting on their activities and mechanisms for monitoring and evaluating the quality of patient care . . .
ARTICLE IX, Medical Staff . . . Section 2. Medical Care and Its Evaluation: a. The Board of Directors, in the exercise of its discretion, shall assign to the medical staff the responsibility for providing appropriate professional care to the patients . . . The Board of Directors shall assure that the medical staff has a mechanism for . . . ongoing monitoring of critical aspects of care . . . and such matters as the board may deem necessary from time to time for the preservation and improvement of the quality and efficiency of patient care. . . ."

Review of the CAH's BYLAWS OF THE MEDICAL STAFF occurred on May 07-08, 2012. The BYLAWS, adopted on 09/16/08, stated "PREAMBLE . . . Recognizing that the medical staff is responsible for the quality of medical care in the hospital and must accept and discharge this responsibility . . . the physicians and licensed health care practitioners . . . shall carry out the functions delegated to the medical staff by the board of directors . . .
ARTICLE TWO, PURPOSES, It is the responsibility and obligation of the Medical Staff, Licensed Health Practitioners . . . A. To see that all patients admitted to or treated in any of the facilities, departments, or services of the hospital shall receive generally recognized standards of care. . . . D. To initiate and maintain rules and regulations for self-government of the medical staff. . . .
ARTICLE TEN, COMMITTEES, Section 10.1 Executive Committee: a. Composition: The executive committee shall consist of the active medical staff as a whole, and administrator, who shall serve as the designee of the board of directors. . . . b. Duties: The duties of the executive committee shall be: 1. To represent and act on behalf of the medical staff, subject to such limitations as may be imposed by these bylaws and make recommendations to the board of directors for its approval. 2. To coordinate, receive and act upon the activities and general policies of the various departments and make appropriate recommendations to the board of directors. 3. To receive, and act upon reports and make recommendations from medical staff committees, clinical services and assigned activity groups. . . . 8. To fulfill the medical staff's accountability to the board of directors for the medical care rendered to patients in the hospital and to review quality assurance functions under the purview of the medical staff and to report on the same to the board of directors. . . ."

Review of the CAH's RULES AND REGULATIONS OF THE MEDICAL STAFF occurred on May 07-08, 2012. The RULES AND REGULATIONS, adopted on 09/16/08, stated "ENABLING PROCEDURES, These Rules and Regulations have been created pursuant to and under the authority of the medical staff bylaws of [CAH name]. . . . A. MEDICAL STAFF MEETINGS AND GENERAL DUTIES . . . 2. The medical staff discussions at meetings held as provided for under these rules and regulations shall constitute a thorough review and analysis of the clinical work done in the hospital organization, including . . . analysis of clinical reports from each department and reports of committees of the active medical staff and regular review of policies and procedures. . . . 5. A member of the medical staff shall be responsible for the medical care and treatment of each patient in the hospital . . .
C. GENERAL CONDUCT OF CARE & INFORMED CONSENT: . . . 7. On Call Procedure: If a practitioners's name appears on the "Call List", it is implied that the practitioner is available . . . to handle emergency care for patients. . . . The following procedures will be used in contacting the "Practitioner On Call": . . . d. The practitioner will respond within 30 minutes. . . . f. Violations of the policy may be subject to corrective action as outlined in the medical staff bylaws. . . ."

Review of the CAH's BYLAWS, MEDICAL STAFF BYLAWS, RULES AND REGULATIONS OF THE MEDICAL STAFF, and departmental policies and procedures, on May 07-08, 2012, failed to identify policies or procedures regarding ?489.24.

Review of the CAH's staff educational materials regarding ?489.24, on May 07-08, 2012, identified the materials are not developed for the medical staff and do not identify the CAH's policies or procedures.

The CAH failed to develop, adopt, follow, monitor, and educate its' staff regarding the requirements of ?489.24.

Based on record review, review of the critical access hospital's (CAH) emergency department (ED) log, and staff interview, the CAH failed to maintain a central log which identified who came to the ED, if the patient refused treatment, what treatment the CAH provided, and if the CAH transferred, admitted, stabilized and transferred, or discharged (disposition) the patient, for 12 of 12 months requested (May 2011 through April 2012). Failure to maintain an appropriate central log limited the CAH's ability to determine ED from Treatment Room patients, limited the CAH's ability to track and trend the disposition of patients seen in the ED, and may have contributed to failure to identify patients sent to the clinic from the ED without a medical screening examination (MSE). (Refer to C2406.)

Findings include:

During the entrance conference, on 05/07/12 at 9:30 a.m., upon request for the CAH's ED log for the past 12 months, an administrative nursing staff member (#5) reported the CAH maintained a "call back" log in the ED which included CAH patients other than those seen in the ED. The "call back" log lacked information if the patient refused treatment or was refused treatment and the disposition of the patient.

During interviews with licensed nursing staff members (#1), (#2), and (#3), on 05/07/12 at 9:55 a.m., 10:40 a.m., and 11:05 a.m., respectively, these staff members reported the CAH Business Office registers patients who present to the ED for treatment during business hours and nursing staff register the patients after hours. These staff members (#1), (#2), and (#3) reported the nursing staff do not always have time to complete all the registration documentation and the "call back" log is not accurate.

An administrative nursing staff member (#5) reported staff obtained the information desired for the ED log from the "call back" log, the Business Office, the medical records department, and the individual patient medical records. The staff member (#5) provided the compiled ED log intermittently as staff completed it. On 05/08/12 at 11:00 a.m., more than 25 hours after the initial request, the CAH failed to provide the ED log for the months of March and April 2012.

The ED log, reviewed on all days of survey, included information indicated as ER (emergency room) or TX (treatment). During interview, on 05/08/12 at 10:45 a.m., a licensed nursing staff member (#4) identified "treatment room" patients as those, generally, scheduled for routine medication or intravenous fluid administration. The ED log showed the following patient entries identified as "treatment":
*Patient #9 - 09/21/11, 9:30 a.m., left axillary pain, "Pt. [Patient] to tx. [treatment] room for examination per M.D. [physician], Rx [prescription] for Lorcet 10/650 p.o. [by mouth] prn [as needed] pain # [dispense] 30, pt. d/c [discharged] with instr. [instructions]."
*Patient #6 - 05/23/11, 7:12 p.m. - "Pt. to tx. room for 60 units of Lantus insulin."
*Patient #11 - 10/10/11, 5:15 a.m. - "Pt. to tx. room for accuck. [accucheck] [blood glucose check] on arrival. Novalog [insulin] 6 units SQ [subcutaneously] now, pt. d/c [discharged] with instr. [instructions]."

The Treatment Room records identified the following:
*Patient #9 - ". . . 4:00 p.m.) Pt. arrived to Tx. room. C/o [Complained of] (L) [left] under arm pain r/t [related to] prior procedure. 4:12 p.m.) Provider [HCP (#3)] here to examine pt. . . . 4:19 p.m.) Pt. D/C home after D/C instruction reviewed." Patient #9's Treatment Record included a physician's "Emergency Room Note" which identified a physical examination and the patient's "pain rating" ". . . a good 7/10 . . ."

*Patient #6 - ". . . Reason for Visit . . . Lantus [insulin] injection . . . Nursing/Procedure Notes: Pt. to tx. rm. for hs [hour of sleep] Lantus injection. Pt. denies c/o this eve. [evening]. Pt.'s accucheck is 245 [milligrams per milliliter] tonight. 60 units Lantus given sub Q [subcutaneously] to L) upper arm. Pt. tolerates well. Pt. discharged to home ambulatory. In stable condition." Patient #6's ED record included Doctors' Orders, dated 05/24/11 at 7:26 p.m., stated "V.O. [Verbal Order] To tx. rm. for 60 units Lantus insulin. [HCP (#1)/Licensed Nursing Staff Member]." The Nurses Notes identified the CAH admitted Patient #6 on 05/23/11 at 7:12 p.m. and discharged the patient at 7:35 p.m. (23 minutes later). The ED record included an Emergency Room Note dictated by HCP (#1) on 05/26/11 (three days later). The Nurses Notes and Discharge Instructions lacked evidence a HCP or HCP (#3) completed a MSE for Patient #6. Staff observed the Doctors' Orders on 05/24/11.

*Patient #11 - ". . . Reason for Visit . . . High Blood Sugar/Insulin Injection . . . Nursing/Procedure Notes: Pt. arrived to Tx. Rm. ambulatory [with] friend. Provider [HCP (#3)] notified of BS [blood sugar] - 379 [milligrams per milliliter] and order received. Humalog [insulin] 6 units given SQ [subcutaneously] (L) upper arm as ordered. Instructions given to pt. Pt. discharged ambulatory to vehicle [with] friend in stable condition." Patient #11's ED record included Doctors' Orders, dated 10/10/11 at 5:15 a.m., stated "Accucheck on arrival. Give Novalog units SQ [subcutaneously] now. Fill prescription for 70/30 flexpen today. Monitor blood sugars until insulin is available. Continue with scheduled insulin. TVO [Telephone Verbal Orders] [HCP (#3)]/[Licensed nursing staff member]." The Nurses Notes identified the CAH admitted the patient at 5:15 a.m. and discharged the patient at 5:29 a.m. (14 minutes later). The ED record included an Emergency Room Note dictated by HCP (#3) on 10/12/11 (two days later). The Nurses Notes and Discharge Instructions lacked evidence a HCP completed a MSE for Patient #11.

The patients' "treatment" visits were not scheduled, were related to immediate needs, and Patient #9's visit was related to acute pain. Failure to identify "treatment" visits as ED visits and failure to maintain an accurate central log limits the CAH's ability to accurately determine use of the ED and track and trend patient visits to the ED.

Based on record review, review of the critical access hospital's (CAH) and medical staff Bylaws, the CAH's policy, review of the Medical Staff Meeting minutes, review of the CAH Quality Assurance/Program Improvement (QA/PI) Plan and Committee Meeting minutes, monitoring information, review of staff education information, and family and staff interviews, the CAH failed to ensure patients who presented to the Emergency Department (ED) received an appropriate medical screening examination (MSE) by qualified staff, for 6 of 20 sampled patients (Patient #1, #3, #6, #11, #17, and #18) who presented to the ED. Failure to provide a MSE placed patients at risk of prolonged illness, pain, and complications related to lack of care.

Findings include:

Review of the CAH's BYLAWS occurred on May 07-08, 2012. The BYLAWS, approved on 07/18/05, stated "ARTICLE IV., Governing Board, Section 1. General Powers: The administrative powers of the corporation shall be vested in the Board of Directors which . . . shall have overall responsibility for maintaining quality patient care . . . ARTICLE IX, Medical Staff . . . Section 2. Medical Care and Its Evaluation: a. The Board of Directors, in the exercise of its discretion, shall assign to the medical staff the responsibility for providing appropriate professional care to the patients cared for through the corporation. The Board of Directors shall assure that the medical staff has a mechanism for . . . ongoing monitoring of critical aspects of care . . . and such other matters as the board may deem necessary from time to time for the preservation and improvement of the quality and efficiency of patient care. . . ."

Review of the CAH's BYLAWS OF THE MEDICAL STAFF occurred on May 07-08, 2012. The BYLAWS, adopted 09/16/08, stated ". . . ARTICLE TWO, PURPOSES, It is the responsibility and obligation of the Medical Staff, Licensed Health Practitioners, and Licensed Independent Health Professionals: A. To see that all patients admitted to or treated in any of the facilities, departments, or services of the hospital shall receive generally recognized standards of care. . . . ARTICLE TEN, COMMITTEES, Section 10.1 Executive Committee: . . . b. Duties: The duties of the executive committee shall be: . . . 8. To fulfill the medical staff's accountability to the board of directors for the medical care rendered to patients in the hospital and to review quality assurance functions under the purview of the medical staff and to report on the same to the board of directors. . . . Section 10.2 Medical Staff Functions: The executive committee will assign medical staff functions . . . a. Monitor and evaluate care provided in and develop clinical policy for: . . . 3. An emergency . . . and other ambulatory care services. . . ."

Review of the CAH's policy, "Emergency Room," occurred on May 07-08, 2012. This policy, dated October 2009, stated "PURPOSE: 1. . . . All patients will be seen within 30 minutes of arrival. . . ." During the entrance conference, on 05/07/12 at 9:30 a.m., the surveyor requested the CAH's ED policies and procedures regarding EMTALA. No additional policies or procedures were provided.

Review of the CAH's Medical Executive Committee Meeting minutes occurred on May 07-08, 2012. These minutes, dated 05/24/11, stated ". . . NEW BUSINESS: . . . When patients present to the ER [emergency room] they have to be assessed before they can be brought to the clinic. . . ."

Review of the CAH's Quality Assurance/Program Improvement (QA/PI) Plan occurred on May 07-08, 2012. The QA/PI Plan, revised in September 1999, stated ". . . III. GOALS . . . 1. Increase the probability of desired patient outcomes, including patient and physician satisfaction, by assessing and improving those . . . clinical and support processes that most affect those outcomes. 2. Assure that patient care practices and professional performance are appropriately coordinated and evaluated. . . . 4. Establish priorities for the investigation and resolution of issues and problems by focusing on those with the greatest potential impact on patient care outcomes and patient satisfaction. . . . 7. Provide a foundation for fulfilling regulatory, statutory, and accreditation requirements. . . .
IV. AUTHORITY: The Board of Directors bears the ultimate responsibility for assuring the quality, efficiency, and effectiveness of patient care services provided by its medical staff members and other professional and support staff.
V. IMPLEMENTATION: . . . Components of the program include: 1. Development of a planned and systematic method for monitoring and evaluating the quality and appropriateness of services provided. 2. Routine collection of information about the important aspects of the service and periodic assessment of the information to assure conformance with acceptable levels of performance. . . .
VI. STRUCTURE AND PROCEDURE: The Quality Improvement Committee is responsible for the development, implementation, maintenance, monitoring and evaluation of the Quality Improvement Program. . . . All organized services relating to patient care must be evaluated. These services include but are not limited to: . . . medical records, medical staff . . . nursing . . . and other hospital wide functions or services. The Quality Improvement committee shall assure the following functions are obtained: 1. . . . processes to identify, assess, monitor and evaluate areas of potential problems and determine resolution. . . .
VII. PERFORMANCE ASSESSMENT & IMPROVEMENT: Topics for periodic assessment and improvement arise . . . from the medical staff . . . staff suggestions or from other sources. Intensive Assessment is triggered by the following: identification of an important undesirable single event, levels of performance, and/or patterns/trends . . ."

Review of the CAH's Quality Assurance Committee Meeting minutes, for the period January 25, 2011 through January 24, 2012, occurred on May 07-08, 2012. These minutes lacked any monitoring information, discussion or reference to medical screening examinations in the ED. During interview, on 05/08/12 at 11:00 a.m., an administrative nursing staff member (#1) reported no additional monitoring information available.

Review of the CAH's Nurses/Aide Staff Meeting minutes, for the period May 23, 2011 through April 16, 2012, occurred on May 07-08, 2012. These minutes stated the following:
*dated 07/13/11, ". . . EMTALA meeting info shared. [administrative nursing staff member (#5)] attended on 07/11/11. . . . ER's - if they state 'I would like to be seen', can put clinic option out there. If ask to be seen in the emergency room, must take in & register for ER. . . ." These minutes lacked additional information or attachments regarding the EMTALA meeting referenced.
*dated December 2011, a form titled "Program/Info: EMTALA info, date: 12/2011. I participated in the above program & understand the information presented." The form included names and signatures of licensed nurses. A memorandum, attached to the form, forwarded to "All Employees Group" by an administrative nursing staff member (#5), dated 11/28/11, stated ". . . all hospitals participating in the Medicare program must provide a medical screening exam to any person who comes to the Emergency Department (ED) requesting services . . ."
During interview, on 05/08/12 at 8:45 a.m., an administrative nursing staff member (#5) reported she posted the form, dated 12/2011 and attached memorandum, for nursing staff information and education. Their signatures indicated they read and understood the information contained in the memorandum.

Review of the ED Log occurred on all days of survey and showed the following entries:
Patient #1 - 01/10/12, 4:02 p.m. - "Pt. [Patient] went to clinic for medical care."
Patient #3 - 08/04/11, 2:40 p.m. - "Pt. came to ER & it was decided that provider would see in the clinic."
Patient #6 - 05/23/11, 7:12 p.m. - "Pt. to tx. [Treatment] room for 60 units of Lantus insulin."
Patient #11 - 10/10/11, 5:15 a.m. - "Pt. to tx. room for accuck. [accucheck] [blood glucose check] on arrival. Novalog [insulin] 6 units SQ [subcutaneously] now, pt. d/c [discharged] with instr. [instructions]."
Patient #17 - 12/13/11, 9:34 a.m. - "Pt. sent over to be seen in clinic."
Patient #18 - 10/19/11, 7:39 a.m. - "Pt. sent to be seen in clinic."

Review of the ED records identified the following:
*Patient #1 - The patient presented with bruised skin and swelling at the left elbow and right hand. The record stated "Chief complaint: 4:00 p.m.) Arrived to ER c/o [complained of] (L) [left] elbow pain and (R) [right] hand pain. Pain #8 [pain scale of 1 to 10 (least to worst)] in both sites. 4:10 p.m.) Provider notified. Pt. will be seen in clinic rather than E.R." The ED record lacked evidence a provider completed a MSE for Patient #1 before he went to the clinic.

*Patient #3 - The record stated "Chief complaint: 2:40 p.m.) Arrived to E.R. C/o Lt. (left) ear pain. #7 [pain scale] onset yesterday. Denies having cold symptoms. 2:45 p.m.) Provider notified. She will see them in the clinic since she has an opening. 2:47 p.m.) Pt. sent to clinic to see provider." The ED record lacked evidence a provider completed a MSE for Patient #3 before he went to the clinic.

*Patient #6 - The Nurses Notes stated ". . . Reason for Visit . . . Lantus [insulin] injection . . . Nursing/Procedure Notes: Pt. to tx. rm. for hs [hour of sleep] Lantus injection. Pt. denies c/o this eve. [evening]. Pt.'s accucheck is 245 [milligrams per milliliter] tonight. 60 units Lantus given sub Q [subcutaneously] to L) upper arm. Pt. tolerates well. Pt. discharged to home ambulatory. In stable condition." Patient #6's ED record included Doctors' Orders, dated 05/24/11 at 7:26 p.m., stated "V.O. [Verbal Order] To tx. rm. for 60 units Lantus insulin. [HCP (#1)/Licensed Nursing Staff Member]." The Nurses Notes identified the CAH admitted Patient #6 on 05/23/11 at 7:12 p.m. and discharged the patient at 7:35 p.m. (23 minutes) The ED record included an Emergency Room Note dictated by HCP (#1) on 05/26/11 (three days later). The Nurses Notes and Discharge Instructions lacked evidence a HCP completed a MSE for Patient #6.

*Patient #11 - The Nurses Notes stated ". . . Reason for Visit . . . High Blood Sugar/Insulin Injection . . . Nursing/Procedure Notes: Pt. arrived to Tx. Rm. ambulatory [with] friend. Provider [HCP (#3)] notified of BS [blood sugar] - 379 [milligrams per milliliter] and order received. Humalog [insulin] 6 units given SQ [subcutaneously] (L) upper arm as ordered. Instructions given to pt. Pt. discharged ambulatory to vehicle [with] friend in stable condition." Patient #11's ED record included Doctors' Orders, dated 10/10/11 at 5:15 a.m., stated "Accucheck on arrival. Give Novalog units SQ [subcutaneously] now. Fill prescription for 70/30 flexpen today. Monitor blood sugars until insulin is available. Continue with scheduled insulin. TVO [Telephone Verbal Orders] [HCP (#3)]/[Licensed nursing staff member]." The Nurses Notes identified the CAH admitted the patient at 5:15 a.m. and discharged the patient at 5:29 a.m. (14 minutes). The ED record included an Emergency Room Note dictated by HCP (#3) on 10/12/11 (two days later). The Nurses Notes and Discharge Instructions lacked evidence a HCP completed a MSE for Patient #11.

*Patient #17 - The patient presented with limited range of motion due to pain and mild swelling and bruising of the right great toe. The ED record identified pain level of "8, [with] activity" and "4-5 [with] rest" on a scale of 1-10, least to worst. The ED record stated " Chief complaint: "12/13/11, 9:35 a.m., 45 y.o. [year old] female ambulatory to ER post fall. Occurred yesterday [approximately] 1:00 p.m. [after] coming out of porta potty on a trailer [after] misstep affecting rt. [right] leg. Most pain Rt. great toe. Outer rt. ankle & knee & thigh pain. Bruising observed over bony prominence of rt. great toe. Ice pack applied. 9:40 a.m.: Provider aware. Provider recommended that pt. be given the option to be seen in clinic. 9:45 a.m.: Brought patient to clinic in wheelchair [without] incidence. Upon leaving, clinic staff registering patient." The ED record lacked evidence a provider completed a MSE for Patient #17 before she went to the clinic.

*Patient #18 - The ED record identified the patient arrived at 7:35 a.m. The ED record stated "Chief complaint: Child has had runny nose for 3 days. This A.M. awakened with cough, heavy breathing et [and] was restless during noc [night]. Has harsh cough et cl. [clear] nasal drainage. 8:04 a.m. [HCP (#1)] here. Talked to parent et instructed them to have child seen in clinic. Appt. [Appointment] made for [Patient #18] at 9:00 a.m. at [CAH's affiliated clinic name] [with] [HCP (#2)]. Parent agreeable but somewhat upset appearing." The ED record lacked evidence a provider completed a MSE for Patient #18. Review of documentation, dated 10/19/11, from the CAH's affiliated clinic, for Patient #18, provided by the CAH staff, stated "Failed appt [with] HCP (#2)." During telephone interview regarding the ED visit on 10/19/11, on 05/08/12 at 2:55 p.m., Patient #18's parent (Family Member (#1)) reported the CAH nursing staff assessed the patient's breathing and took his temperature. The family member (#1) reported they did not seek care from any other HCP and "Rode it out." and "Can't really remember much about that time."

- Interviews with the CAH HCPs occurred and revealed the following information:
*HCP (#1) - 05/07/12, 10:10 a.m. - CAH nursing staff assess patients in the ED and then contact the HCP. The HCPs assess patients in the ED and staff do not direct patients to the clinic. HCP (#1) reviewed Patient #18's ED record, confirmed his signature, and could not recall the circumstances of the patient's ED visit.
*HCP (#2) - 05/07/12, 11:20 a.m. - CAH nursing staff assess patients in the ED and then contact the HCP or contact the HCP when staff are aware an ambulance will be arriving. HCPs complete screening examinations in the ED and staff usually do not send patients to the clinic. HCP (#2) reported she was not aware of any monitoring of ED records for completion of a MSE. HCP (#2) reviewed Patient #17's ED record and could not recall the circumstances of the patient's ED visit.
*HCP (#3) - 05/07/12, 11:40 a.m. - CAH nursing staff screen patients in the ED and then contact the HCP. The HCPs see all patients in the ED. Some patients present to the ED looking for the CAH affiliated clinic and CAH staff direct them to the clinic. Staff discuss EMTALA issues each month at medical staff meetings. HCP (#3) reported he was not aware of any problems related to EMTALA issues.
*HCP (#4) - 05/07/12, 12:10 p.m. - CAH nursing staff screen patients in the ED and then contact the HCP. The HCPs see patients in the ED, staff do not refer patients to the clinic. Staff discuss EMTALA issue at medical staff meetings.

- Interviews with CAH licensed nursing staff members occurred and revealed the following information:
*Staff member (#1) - 05/07/12, 9:55 a.m. - Nursing staff provide an assessment and then contact the HCP. HCPs respond in a timely manner when called for ED patients. Staff refer some patients to the clinic after seen by the HCP in the ED.
- 05/07/12, 4:00 p.m. - Staff member (#1) reviewed Patient #18's ED record, confirmed her signature, and could not recall the circumstances of the patient's ED visit except as documented in the record. This staff member reported HCPs have recently questioned the emergent nature of patient visits more frequently and have directed some patients to be seen in the CAH's affiliated clinic without a MSE in the ED. This staff member (#1) could not recall a specific patient or incident.
*Staff member (#2) - 05/07/12, 10:40 a.m. - CAH nursing staff assess patients and then call the HCP. HCPs screen the patient and if they determine there is a non-emergent condition, the HCP may direct the patient to the CAH affiliated clinic.
*Staff member (#3) - 05/07/12, 11:05 a.m. - CAH nursing staff assess patients and then call the HCP. HCPs always respond in a timely manner. HCPs see patients in the ED and occasionally send patients to the CAH affiliated clinic. The staff member (#3) could not recall a specific patient, incident, or provider. The staff member (#3) reported the CAH provided EMTALA training within the past 12 to 15 months, but could not recall the specific issue.
*Staff member (#4) - 05/08/12, 10:45 a.m. - CAH nursing staff assess patients and then call the HCP. HCPs usually respond within ten minutes. HCPs screen patients in the ED and may take patients to the CAH affiliated clinic.

Patients presented to the CAH's ED, did not receive a MSE, and staff referred patients to the CAH's affiliated clinic. The CAH staff provided treatment to Patient #6 and Patient #11 by telephone order. The ED record is unclear if the HCPs saw the patients. The Medical Staff Executive Committee Meeting minutes, dated 05/24/11, identified the requirement for a MSE for all patients presenting to the ED. Interviews with HCPs and CAH nursing staff revealed an awareness of the need for the MSE. The CAH's QA/PI program failed to monitor the provision of the MSE after identified by the Medical Staff Executive Committee and during staff education.

Failure to provide the MSE placed patients at risk of not receiving appropriate care in a timely manner and may have resulted in delayed treatment and prolonged illness. Failure to ensure and monitor the provision of the MSE after identified during the Medical Staff Executive Committee resulted in continued failure to provide the MSE.