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Based on document review and staff interview, it was determined that for 4 (#N4, #N6, N14, and N17) of 23 patients, the hospital failed to ensure compliance with 489.24 in that the hospital failed to perform an appropriate medical screening examination and failed to follow facility policy for medical screening.

Findings include:

1. See findings cited at 489.24 (a) and (c). C2406

Based on staff interview and document review, the facility failed to ensure the logging of each individual who comes to the emergency department (ED) for treatment for 1 of 23 patients.
Findings include:
1. L.P.N. #1 (at facility #1) indicated the following in interview at 5:00 p.m. on 9/7/10:
(A) On 8/25/10, LTC facility #1 phoned the ED to report they were sending patient #N6 to the ED. He/she did not take the call but was aware that the call came in.
(B) The patient (#N6) arrived by ambulance in the ambulance bay. M.D. #1 went out to the bay, spoke with the EMT and the ambulance left.
2. The E.D. log lacked documentation that patient #N6 presented to the E.D. on 8/25/10.
3. Staff member #1 verified in interview at 12:30 p.m. that patient #N6 arrived at the facility and was not medically screened, treated or logged in prior to transfer to another acute care facility.

Based on interview and document review, the facility failed to provide an appropriate medical screening for 4 (#N4, N6, N14, N17) of 23 patients.

Findings include:

1. L.P.N. #1 (facility #1) indicated the following in interview at 5:00 p.m. on 9/7/10:
(A) On 8/25/10, LTC facility #1 phoned the ED to report they were sending #N6 to the ED. He/she did not take the call but was aware that the call came in.
(B) The patient (#N6) arrived by ambulance in the ambulance bay. M.D. #1 went out to the bay, spoke with the EMT and the ambulance left.

2. The ED log lacked documentation of #N6 presenting to ED.

3. There was no documentation to indicate an appropriate medical screening had been completed.

4. Review of patient #N6 medical record for visit to facility #2 indicated the following:
(A) The patient presented to the ED at 4:00 p.m. on 8/25/10 via ambulance with CPR in progress.
(B) Dictated emergency room report indicated:
1. the patient's condition declined 5 minutes prior to ED arrival.
2. page 4 of 4 stated: "After speaking with the paramedics, they advised me that when they picked up the patient at the nursing home that the patient was unstable and his blood pressure was in the 50's systolic. However, he was alert and slightly confused. They felt that they needed to take the patient to the closest, nearest hospital, which was (facility #1). At their request to transport the patient to (facility #1), (M.D. #1) refused to see the patient and told them that they needed to go to (facility #2). Once they loaded the patient in the ambulance, they actually did drive to the ambulance bay of (facility #1) and spoke with (M.D. #1) who came to meet them out in the ambulance bay. Per the paramedics, they actually advised (M.D. #1) at length that the patient was unstable, that the patient's blood pressure was in the 50's, and that he needed immediate care, and, per the medics, (MD. #1) still refused to see the patient and told them they needed to go to (facility #2).
3. Clinical impression was listed as cardiopulmonary resuscitation, unsuccessful, pulseless electric activity, deceased.
(C) The ambulance report sheet in the medical record stated "..........Pt transported emergent to nearest ER per protocol.............(M.D. #1) initiated contact with (EMT #1) before he could exit the driver's seat of M71 on arrival at (facility #1) ER bay. (M.D. #1) told (EMT #1) that he didn't "want to be a part of it" & refused to receive pt. I informed (EMT #1) from the back of M71 who relayed to (M.D. #1) that the pt's BP was 57 systolic & that the pt was critical. (M.D. #1) continued to refuse to receive pt......."

5. Review of patient #N14 medical record indicated the following:
(A) The patient presented to the ED on 7/14/10.
(B) The patient was triaged/examined by RN #3 at 4:26 p.m. with chief complaint listed as lower abdominal pain rated a 7 on scale 1-10 and coughing up blood. He/she had been coughing up blood previously and it had stopped but came back.
(C) No tests were performed. The patient was not examined by a physician nor was the exam reviewed by the physician on duty. The patient was sent to the urgent care clinic (facility #4).

6. Review of patient #N17 medical record indicated the following:
(A) The patient presented to the E.D. on 7/28/10.
(B) The patient was triaged/examined at 7:35 a.m. by RN #2. Chief complaint was listed as headache rated a 10 on a scale of 1-10, nausea, blurred vision, photophobia, and neck discomfort. The patient indicated the headache was "the worst ever".
(C) No tests were performed. The patient was not examined by a physician nor was the exam reviewed by a physician. The patient was sent to the urgent care clinic (facility #4) for treatment.

7. Review of patient #N4 medical record indicated the following:
(A) The patient presented to the facility emergency department (ED) on 8/13/10.
(B) He/she was triaged and examined by RN #3 at 4:05 p.m. with chief complaint listed as laceration to the right thigh by a box knife. The patient indicated pain was a 6 on a scale of 1-10 and his/her tetanus status was unknown.
(C) The record did not indicate how deep or how severe the laceration was.
(D) No treatment was provided and the patient was sent to the urgent care clinic for treatment. The patient was not examined by a physician nor were the findings of the exam reviewed by the physician on duty.

8. Facility policy titled "MEDICAL SCREENING EXAM" last reviewed/revised 6/10 stated under purpose: "All patients presenting to the Emergency Department shall receive a medical screening exam by the Emergency Department physician that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requiters that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician's office or clinic."

9. Facility policy titled "ADMISSION OF PATIENTS TO ED" last reviewed/revised 6/10 states on page 1, under policy: "7. All patients shall receive a medical screening exam by the Emergency Department physician that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis."

10. Facility policy titled "TRANSFER POLICY" last reviewed/revised 6/10 stated under Medical Screening on page 1: "The hospital shall provide an appropriate medical screening examination, including ancillary services routinely available to the Emergency Services Department, to any patient presenting to the hospital. The purpose of this examination is to determine whether or not an emergency medical condition exists. The ED physician will perform the medical screening examination."

11. Facility policy titled "Qualifications for Non-Physicians Providing Medical Screening Examinations (QMP) last reviewed/revised 6/10 stated on page 2: "Emergency department registered nurses serving as Qualified Medial Personnel must have completed and maintained ACLS training." and under policy on page 2: "The associate (QMP) must review findings of the emergency medical examination with a physician."

12. Staff member #1 verified in interview at 12:30 p.m. and 5:30 p.m. that patient #N6 arrived at facility and was not treated at the facility and did not receive a medical screening exam or treatment prior to transfer to another acute care hospital and he/she verified that patients #N4, N14, and N17 were examined by an RN with no physician involvement.