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Based on observations, interviews and document records, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

Findings:

1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag A2406 - Medical Screening Examination
Based on interviews and record reviews, the facility failed to provide a Medical Screening Exam (MSE) for patients who presented for emergency services in 3 records reviewed (Patients #12, #14 and #32).

Tag A 2407 - Stabilizing Treatment
Based on interviews and document review the facility failed to appropriately stabilize and resolve patients' Emergency Medical Conditions (EMC), pursuant to EMTALA guidelines, within its capacity before the patient was discharged in 10 records reviewed (Patients #4, #6, #8, #9, #10, #11, #22, #23, #33 and #35).

Based on interviews and record reviews, the facility failed to provide a Medical Screening Exam (MSE) for patients who presented for emergency services as required by Emergency Medical Treatment and Active Labor Act (EMTALA) regulations in 3 of 36 records reviewed (Patients #12, #14 and #32).

The failure created the potential for negative patient outcomes related to potential unidentified emergency medical conditions as no medical screenings were performed.

FINDINGS:

1) The facility did not provide a Medical Screening Exam (MSE) for all patients who presented for emergency services, as required by EMTALA regulations.

a) Medical record review revealed Patient #14 (16 year old) presented to the Emergency Department (ED) for emergency services on 06/12/15 at 4:30 p.m. The patient stated s/he was involved in a motor vehicle accident the night prior where airbags were deployed and s/he was cleared by EMS at the scene. During his/her ED triage assessment, on 6/12/15 at 4:41 p.m., the patient reported to Registered Nurse (RN) #1 sudden onset chest pain, hyperventilating, coughing, and a feeling of choking. S/he also stated his/her hands and face started to tingle. The patient was given ibuprofen 400 mg by RN #1.

Review of Patient #14's medical record showed the Discharge Disposition was a routine discharge to home or self care at 6:22 p.m. (more than 1 ½ hours after the patient's triage assessment). However, the ED Disposition contained contradicting documentation that Patient #14 left before a formal evaluation.

There was no documentation in the physician or nursing progress notes which indicated why the patient did not receive a MSE or that the patient left before a MSE was performed.

During an interview, on 06/30/15 at 11:12 a.m., Employee #4 stated a MSE was not performed, and that RN #1 failed to document any information in the medical record indicating the patient left before receiving a MSE.

b) Record review revealed Patient #12 (2 year old) presented to the ED for emergency services on 06/13/15 at 8:31 a.m. During his/her ED triage assessment, the parent of the patient reported to RN #2 that the patient ' s finger tips were blue. There was no documentation the patient received a MSE by qualified medical personnel.

According to the discharge information in the medical record, Patient #12 was routinely discharged to home or self care and the patient "Left After Medical Screening Exam."

Further review, showed an ED note by RN #2 which stated the parent of the child was requesting to leave and signed a release form indicating his/her child did not have a MSE performed before leaving the ED.

During an interview with Employee #4, on 06/30/15 at 11:25 a.m., s/he confirmed Patient #12 did not receive a MSE. Further, s/he stated a signed release form could not be located.

c) Record review revealed Patient #32 (78 year old) presented to the hospital's offsite urgent care on 06/17/15 at 6:55 p.m. with a chief complaint of black stools and central abdominal pain yesterday and today. The patient was identified as an emergency services patient. A Nursing Triage Assessment was conducted by RN #11 at 7:23 p.m. Under the assessment, RN #11 documented the patient was assessed per the physician and instructed to go to another hospital. At 7:53 p.m., RN #11 documented the patient was "escorted to [the] exit door" and the patient understood instructions to go to another hospital for further evaluation.

Further review of the record showed conflicting documentation as to the patient's disposition. According to the Discharge Disposition the patient "Left Against Medical Advice or Discontinued Care." In contrast the ED Disposition documented the patient "Left After Medical Screening Exam."

However, there was no documentation from the physician that a MSE had been completed. There was no documentation of the physician's assessment or of a medical screening exam by qualified medical personnel in the medical record.

Based on interviews and document review the facility failed to appropriately stabilize and resolve patients' Emergency Medical Conditions (EMC) within its capacity before the patient was discharged for 10 of 36 records reviewed (Patients #4, #6, #8, #9, #10, #11, #22, #23, #33 and #35).

Specifically, the hospital discharged patients prior to the EMC being resolved, pursuant to EMTALA guidelines, with the expectation the patient would be transported, via private vehicle without medical oversight, to the main hospital's emergency department for continued evaluation and treatment.

The failure created the potential for negative patient outcomes related to the lack of available medical care should the patient decompensate during their transport, in a personal vehicle, from one location to another for continued treatment of an emergency medical condition.

POLICY

Medical Staff Policies and Procedures, September 2013, Article XV, Section 1514.6 Emergency Medical Screening stated the MSE continues until, the patient is deemed stable and an EMC no longer exists, then hospital has no further obligations under EMTALA; or when the patient has been successfully transferred and accepted for treatment by the receiving facility.

FINDINGS:

1. The facility failed to ensure patients were stable pursuant to EMTALA regulations, which included resolution of the EMC that caused the individual to seek emergency treatment, prior to discharging patients from the hospital and referring them for continued treatment of the EMC at another location.

a) On 06/22/15 at 1:35 p.m., an interview was conducted with the Senior Vice President of Ambulatory Services (Employee #7), the Director of Ambulatory Services (Employee #8) and the Clinical Manager of Pediatrics Call Center (Employee #9). Employee #7 stated all of the hospital's off-campus emergency departments and urgent care locations were held to EMTALA standards if a patient presented with an emergency condition.

b) On 06/25/15 at 3:40 p.m., an interview with the Accreditation and Regulatory Manager (Employee #4) and the Corporate Compliance Officer (Employee #5) was conducted. Employee #4 stated the facility held all of it's offsite urgent care and emergency departments to EMTALA requirements if a patient presented to the location with an emergency medical condition.

c) During an interview, on 06/25/15 at 9:15 a.m., Employee #10 stated if a patient, who presented with an emergency condition, were to go by private vehicle to the main hospital from any of the offsite urgent care or emergency departments the patient would be discharged from the hospital and readmitted once they arrived at the hospital's main location.

Employee #10 stated the facility would discharge the patient anytime they went by private vehicle in case the patient's caregiver decided to stop along the way, decided to go somewhere else (another hospital), or decided not to seek further treatment. Employee #10 stated anytime the patient was out of the hospital's care they were discharged from the hospital as they did not have oversight.

d) Medical record reviewed showed pediatric patients were discharged from the hospital's offsite urgent care and Emergency Departments (EDs) with directions to proceed to the hospital's main emergency department for continued treatment or observation of their presenting emergency medical condition.

i) Review of Patient #6's (6 year old) medical record showed, on 01/30/15 at 2:29 p.m., the patient presented to the hospital's offsite ED with a chief complaint of discomfort after swallowing a coin (quarter) and feeling the coin was still in his/her throat. The physician diagnosed the patient as having swallowed a foreign body and radiology studies revealed a coin in the patient's esophagus. The emergency medical condition that caused the patient to seek emergency treatment was not resolved when the patient was discharged from the offsite ED at 4:03 p.m. The patient's caregivers received instructions to go directly to the hospital's main ED for further evaluation and care and for the patient not to ingest anything by mouth.

Patient #6 arrived, via private vehicle, to the main ED for further evaluation and treatment by a gastroenterology (GI) specialist with likely surgical/endoscopic removal of the coin required. The patient was without medical oversight for 49 minutes during his/her commute to the main hospital location.

Patient #6 presented to the main hospital location for continued management of the emergency medical condition which caused him/her to seek treatment initially. Continued assessment and treatment included a foreign body x-ray series, reordered at the main ED. The patient vomited while awaiting the x-rays in radiology, and the quarter was observed in the patient's emesis.

ii) Review of Patient #9's (2 year old) medical record showed, on 05/03/15 at 8:50 p.m., the patient presented to the hospital's offsite ED with a chief complaint of choking and vomiting food with parental concern for food stuck in the patient's esophagus and a patient surgical history of transesophageal fistula and stricture. The physician documented his/her exam was consistent with esophageal obstruction. Food and fluids were given by mouth and the patient gagged and regurgitated food within a few seconds of ingestion. The emergency medical condition that initially caused the patient to seek emergency treatment was not resolved when the patient was discharged from the offsite ED at 10:04 p.m. The patient's caregivers received instructions to go directly to the hospital's main ED for further evaluation and care and for the patient not to ingest anything by mouth.

Patient #9 was discharged from the hospital's offsite ED and arrived by private vehicle for further evaluation by a gastroenterology (GI) specialist and esophagram at the main ED. The patient was without medical oversight for approximately an hour during his/her commute to the main hospital location.

Subsequently, Patient #9 presented to the main hospital location for the continued management of the original emergency medical condition. After arriving to the main ED, the patient was placed on continuous pulse oximetry in an observation room for a resting heart rate of 60-64. Continued assessment and treatment included gastroenterology consultation, fluroesophagram, peripheral IV, and an esophagoscopy with foreign body removal and esophageal dilation. The patient was found to have an esophageal stricture and food impaction.

iii) Review of Patient #10's (9 year old) medical record showed, on 05/11/15 at 9:47 a.m., the patient presented to the hospital's offsite ED with a chief complaint of fevers and headaches. The physician documented his/her exam was consistent with mastoiditis. The emergency medical condition that caused the patient to seek emergency treatment was not resolved when the patient was discharged from the offsite ED at 1:00 p.m. The patient's caregivers received instructions to go directly to the hospital's main ED.

Patient #10 was discharged from the offsite ED and instructed to go by private vehicle, to the main hospital's ED with a peripheral IV in place, for further evaluation by an ear, nose, and throat (ENT) specialist and possible surgical intervention. The patient was without medical oversight during his/her commute to the main hospital location.

Subsequently, Patient #10 presented to the main hospital's ED for the continued management of the original emergency medical condition. After arriving to the main ED, there was concern for meningitis as the patient had a positive Brudzinski sign. The patient underwent right ear tympanostomy tube placement, and a lumbar puncture (LP) under sedation. The patient was admitted to the hospital's inpatient unit for concerning cerebral spinal fluid (CSF) findings for meningitis, intravenous (IV) antibiotics, two hour neurological checks to monitor for altered mental status, and Ativan ordered as a rescue medication in case of seizure. The patient ultimately was diagnosed with mastoiditis (and underwent a mastoidectomy while inpatient), epidural abscess, and bacterial meningitis due to a contiguous spread from infected mastoid and otitis media and inner ear infection.

(iv) Review of Patient #11's (10 year old) medical record showed, on 06/24/15 at 10:35 p.m., the patient presented to the hospital's offsite ED with a chief complaint of swallowing problems and food stuck in his/her throat. The patient was not able to drink water and stated "it's too hard to swallow." The patient then vomited.

Review of a Nursing Note showed at 11:02 p.m. the patient had spit up pork into the waste basket and stated s/he felt there was a piece of pork in his/her throat. A physician's examination revealed the patient had not been able to swallow anything since the pork got stuck, s/he would spit out saliva, and when s/he tried to take a sip of water, the water came right back up. The facility was unable to obtain a water soluble esophagram because the diagnostic machine needed was not working.

The patient was discharged from the hospital, on 06/25/15 at 3:50 a.m., and instructed to proceed via private vehicle to the hospital's main ED for continued evaluation of the EMC and an esophagram later in the morning.

At 4:43 a.m. (52 minutes after being discharged from the offsite ED) Patient #11 presented to the hospital's main ED for continued management of the original EMC. Esophagram results showed obstruction by foreign object noted in the esophagus below the carina. Subsequently, the patient was scheduled to have endoscopic removal of the food impaction.


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v) Review of Patient #22's (7 year old) medical record showed, on 04/28/15 at 2:12 a.m., the patient presented to the hospital's urgent care with a chief complaint of vomiting and abdominal pain. The patient was identified by the hospital as an emergency services patient. A Computerized Tomography (CT) scan was performed and the results showed acute appendicitis without CT evidence of perforation, a 5 millimeter appendicolith (calcified deposit) in the appendix with trapped intraluminal fluid and an enlarged distal appendix.

The physician documented the final diagnosis as acute appendicitis and Patient #22 was discharged from the hospital on 04/28/15 at 9:30 a.m. without the EMC resolved. Patient #22's caregiver was instructed to go to the main hospital's ED, by private vehicle, for further treatment of the EMC.

Subsequently, at 10:22 a.m. (52 minutes after being discharged), Patient #22 was evaluated and admitted to the main hospital's ED for continued management of the original EMC. The patient was then transferred to the main hospital's operating room at 12:48 p.m.


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vi) Review of Patient #4's (10 year old) medical record showed, on 01/21/15 at 11:45 a.m., the patient presented to the hospital's offsite ED with a chief complaint of right lower quadrant abdominal pain. Physician evaluation revealed the patient had associated tenderness with mild guarding, which was a concern for early appendicitis, with a pain level of 6 out of 10.

A CT scan was performed which showed possible early appendicitis. Documentation of a surgical consultation revealed the CT findings warranted transfer to the main campus ED for likely overnight observation and surgical evaluation with possible surgical intervention.

However, the patient was discharged from the hospital at 6:01 p.m. with a peripheral intravenous (IV) in place and instructions to go to the main hospital's ED, by private vehicle, for continued treatment of the presenting EMC. Patient #4's EMC was not resolved prior to discharge.

Subsequently, at 7:21 p.m., approximately 1 1/2 hours after being discharged from the offsite ED, Patient #4 received an initial triage assessment at the hospital's main ED for continued management of the original EMC. The patient was admitted for overnight observation and reevaluation the next morning to rule out appendicitis.

vii) Review of Patient #23's (13 year old) medical record showed, on 04/07/15 at 9:57 a.m., the patient presented to the hospital's urgent care with a chief complaint of a sore throat for the past 6 days, and the inability to open his/her month or swallow anything. Patient #23 was classified as an emergency services patient. The patient had a rapid Strep culture done which was positive. The physician's diagnosis was right peritonsillar abscess and Strep pharyngitis. Physician documentation showed the patient needed to be transferred to the hospital's main ED for an ENT evaluation of the EMC.

Subsequently, the patient was discharged from the hospital, at 11:23 a.m., with the need for continued evaluation of the EMC that caused to patient to originally seek emergency treatment.

On 04/07/15 at 11:58 a.m., Patient #23 presented to the hospital's main ED, arriving by private vehicle, for continued management of the EMC. ENT consultation showed the patient required drainage of the peritonsillar abscess and antibiotic treatment.

viii) Review of Patient #8's (11 year old) medical record showed, on 04/14/15 at 6:52 p.m., the patient presented to the hospital's offsite ED with a chief complaint of severe migraine headache with sharp and constant 8 out of 10 pain and history of a ventriculoperitoneal shunt (VP). The patient had been seen on 04/12/15 and 04/13/15 in the hospital's main ED for similar complaints.

The patient was at his/her primary care physician's office and was referred to the ED for a magnetic resonance imaging (MRI) shunt series. At 9:01 p.m., the patient had a large emesis. Physician documentation showed the patient was to go to the main hospital for further management of headache.

The patient was discharged from the hospital at 9:59 p.m. with instructions to go, by private vehicle, to the hospital's main campus for admission and continued treatment of the EMC.

At 10:50 p.m. (51 minutes after being discharged from the offsite ED) Patient #8 presented to the main hospital's neurosurgery service. Evaluation revealed the patient had raised intracranial pressure, the shunt was revised and the patient's symptoms were relieved.

ix) A review of Patient #35's (6 week old) medical record showed, on 06/15/15 at 9:12 p.m., the patient presented to the hospital's offsite urgent care with a chief complaint of redness, bruising, and mild swelling to the left head after a fall. The patient was identified as an emergency services patient. The physician documented the patient had an area of asymmetry over the right frontal-parietal suture that could be consistent with a hematoma or skull fracture. The physician documented a final diagnosis of a closed head injury and rule out skull fracture.

Patient #35 was discharged from the hospital at 10:12 p.m. with instructions to go, by private vehicle, to the hospital's main emergency department for further observation and a possible CT scan.

Subsequently, at 11:08 p.m. (56 minutes after being discharged from the hospital), Patient #35 was admitted to the hospital's main ED for observation of a possible closed head injury.

x) Review of Patient #33's (3 year old) medical record showed, on 06/16/15 at 9:29 p.m., the patient presented to the hospital's offsite ED with a chief complaint of swallowing a penny and one episode of vomiting. X-ray revealed a penny located at the thoracic inlet at the level of the clavicles. According to the physician's plan the patient was to go to the main campus ED for observation overnight in the ED and then have the foreign body removed in the morning.

Patient #33 was discharged from the hospital at 11:10 p.m. with instructions to go, by private vehicle, to the hospital's main emergency department for further observation and treatment.

On 06/17/15 at 12:46 a.m., Patient #33 was admitted to the hospital's main ED for continued management of the unresolved EMC including observation and removal of the foreign body by GI in the operating room.