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Based on record review and interview, the provider failed to comply with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. The provider failed to ensure:
*A medical screening examination (MSE) and ongoing assessments of the patient's condition was completed for 1 of 32 sampled emergency department (ED) patients (12) that presented to the ED for treatment of an emergency medical condition (EMC).
*Stabilizing treatment was provided to 1 of 32 sampled ED patients (12) that presented to the ED for treatment of an EMC.
*The certificate of transfer documentation was completed for one of one patient (14) transferred with an EMC.
Findings include:

1. Review of patient 12's ED record revealed she presented to the ED on 4/1/12 at 7:58 p.m. with complaints of an anxiety attack, was short of breath, and had tingling in her hands and feet.

Review of patient 12's ED record revealed:*She had been admitted to the ED at 8:05 p.m., and she signed her consent for treatment form at 8:07 p.m.
*The triage nurse had assessed the patient at 9:00 p.m., one hour and five minutes after she had been admitted to the ED.
*Documentation did not include a respiratory rate, respiratory effort, or ongoing assessments of the patient's condition during her ED stay by nursing staff or the physician.
*Documentation did not indicate where in the ED the patient was located.
*Documentation at 9:30 p.m. indicated the patient had left without being seen by the physician.
*There was no documentation of her intravenous (IV) fluids, IV rate, or an assessment of the IV site.

Refer to A2406, finding 1, and A2407, finding 1.

2. Review of patient 14's ED record revealed he had presented to the ED on 5/7/12 at 1:21 a.m. for treatment of an EMC. The physician had completed a MSE at 11:23 a.m., and the patient had requested to be transferred to another healthcare facility.

Review of patient 14's ED record revealed the certificate of transfer form had not been completely filled out by the hospital staff, and the patient had not signed that form. There was no documentation copies of the patient's medical record had been sent with the patient upon his transfer.

Based on record review, interview, and policy review, the provider failed to ensure 1 of 32 sampled emergency department (ED) patient's (12) records reviewed had an appropriate medical screening examination. Findings include:

1. Review of patient 12's ambulance record and entire ED record revealed:
*She had complained of shortness of breath and that she had not been able to take a deep breath.
*She complained her hands and feet tingled.
*Her respiratory rate was thirty-two breaths per minute (bpm) at 7:46 p.m.
*An intravenous (IV) line had been placed, and a solution of normal saline was running at a keep open rate.
*Her respiratory rate was coached, and she had improvement with her respiratory rate.
*Upon arrival to the ED her respiratory rate at 7:58 p.m. was sixteen bpm.
*She had been admitted to the ED at 8:05 p.m. and signed the consent for treatment form at 8:07 p.m.
*She had been seen by the triage nurse at 9:00 p.m.
*She had stated her chief complaint was "anxiety attack - stress."
*Her vital signs did not include a respiratory rate.
*She had been classified by the triage nurse as having an emergency severity index of four on a scale of one to five with one being the most severe and five being the least severe.
*There was no documentation that indicated where in the ED patient 12 was located.
*The next documentation was patient 12 had left without being seen at 9:30 p.m.
*On 4/2/12 at 2:30 p.m. a follow-up call revealed "States was told it may be a long wait for doctor and was feeling better so took IV out and decided to go home and rest. Feeling okay today but has an appt. (appointment) today with _______(another provider)."

Interview on 8/28/12 at 3:00 p.m. with the director of risk management and accreditation/certification confirmed:
*There was no documentation that patient 12 had received a medical screening examination.
*There was no documentation of where patient 12 had waited while she had been in the ED both before her triage assessment and after the triage assessment.
*There was no documentation she had an IV, what type of solution was infusing, or if the site was patent.
*There was no documentation of her respiratory rate and effort.

Review of the provider's revised December 2009 triage guidelines policy revealed:
*Initial triage would consist of a brief assessment that included the patient's stated complaint.
*If the initial assessment provided enough information to determine appropriate patient placement and a care location as well as staff available, the patient would have been escorted to the care area.
*Once the patient was in the care area the triage nurse would have transferred care over to the caregiver, and the remainder of the initial vital signs, medication history, and allergy history could be obtained.
*If more information was needed to make the appropriate care area assignment a more complete nursing assessment would have been completed in triage. That might have included vital signs, medications, allergies, medical history, and collection of more objective data.
*The initial assessment would have been completed by a registered nurse (RN) and should have contained both objective and subjective data.

Review of the provider's revised December 2010 ED patient assessment and documentation policy revealed:
*Ongoing assessment would be done by the RN as the patient's condition or length of stay warranted. *Designated data collection might have been delegated by the RN to other health care providers (paramedic or ED tech).
*All pertinent data was to have been documented on the patient's medical record.

Based on record review, interview, and policy review, the provider failed to ensure 1 of 32 sampled emergency department (ED) patient's (12) records received stabilizing treatment. Findings include:

1. Review of patient 12's ED record revealed no documentation she had received any stabilizing treatment for her complaint of shortness of breath after her admission to the ED.

Refer to A2406.

Based on record review, interview, and policy review, the provider failed to ensure one of one sampled patient's (14) transfer record included complete certificate of transfer. Findings include:

1. Review of patient 14's entire emergency department (ED) record revealed:
*He had arrived by ambulance on 5/7/12 at 11:21 a.m.
*He had a medical screening examination by a physician at 11:23 a.m.
*That physician documented his decision for admission to the hospital at 11:37 a.m.
*Patient 14 had requested to be transferred to another healthcare provider.
*He had been transferred by ambulance to another healthcare provider in stable condition at 12:55 p.m.

Review of the certificate of transfer form revealed:
*The reason for transfer was "patient request."
*A medical condition for the transfer was not identified by the transferring physician on that form.
*The transfer risks and benefits were indicated on the form.
*The patient consent/request for transfer portion of the form had not been filled out or signed by the patient.
*There was no documentation that any copies of his medical record had been sent with the patient or to the accepting healthcare provider.

Interview on 8/28/12 at 2:10 p.m. with the chief of emergency services confirmed the certificate of transfer form had not been completed as required.

Review of the provider's revised October 2011 transfer of patients to another healthcare instruction policy revealed:
*The physician was responsible for securing a transfer form indicating physician certification as well as patient consent signed by the patient or significant other, after the risks and benefits were explained by the physician.
*A copy of the medical record would accompany the patient.