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Based on observations, interviews and record reviews the hospital failed to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24 of the provider's agreement as follows:

An EMTALA (Emergency Medical Treatment and Labor Act) complaint investigation survey was conducted from 11/10/2010 through 11/12/2010. The complainant indicated in a telephone call to the CMS Regional Office he/she had been present in the Hospital's ED waiting area when a young female (patient #1) had miscarried in the clinic bathroom of the hospital. In the investigation the failures identified with the care of this patient as well as other patients in the ED constituted an Immediate Jeopardy situation.

On 11/11/2010 at 2:00 PM, in a meeting with Hospital administrative staff and representatives from the governing body (Area Office), an Immediate Jeopardy situation was called. The surveyor provided information regarding the failures and the need for a written plan of action to remove or abate this serious situation. The Hospital was unable to provide a written plan of action and was unable to implement sufficient actions to abate the situation by the end of the investigation on 11/12/2010. The Hospital was provided information regarding the 23-day termination procedures if the situation could not be abated.

1. The Hospital failed to ensure a prenatal patient (#1) received an appropriate/timely MSE on 11/5/2010 to determine if she has having significant bleeding, an ectopic pregnancy, or contractions and failed to evaluate the status of the fetus. See A2406 for patient specifics.

2. The Hospital failed to use available resources to ensure ED patients received timely and adequate services.

a. Although the hospital ED staff indicated the ED was very busy on 11/5/2010 and examination rooms/bays were not available, interviews with patients/individuals present on 11/5/2010 indicated empty bays were available when the prenatal patient arrived and was triaged.

b. Review of medical records for the patients who present to the ED (prior to, during and immediately after this prenatal patient was triaged) revealed incomplete documentation and no evidence the ED staff was unable to place the patient in an examination room/bay.

c. There was no evidence a reassessment of patients currently in the ED examination areas was conducted in order to address more critical levels of care.

d. The Hospital failed to ensure call-in procedures were implemented when the ED became busy/backed up with patients. There was no evidence additional medical provider staff had been called in to assist during this time of extreme ED activity.

e. Although interviews indicated Friday nights and weekends were routinely very busy times in the hospital's ED, only one provider was scheduled and working on Friday evening, 11/5/2010.

f. Observation of a security video of the evening of 11/5/2010 showed that although the surveyor was told the ED was 'swamped', the provider appeared in the triage area and the hallway several times but did not go directly to the area of the bathroom and the prenatal patient.

3. The Hospital failed to ensure ED triage staff were competent, experienced and comfortable with the triage assessment of prenatal (first/second trimester) patients.

4. The Hospital failed to ensure medical record history was available for patients seeking ED services 24-72 hours after an initial ED presentation.

5. The Hospital failed to ensure patients presenting to other areas of the Hospital requesting ED services were provided ED services without a delay in treatment.

6. The Hospital failed to ensure accurate and complete documentation of events regarding this prenatal patient. Alterations of time were noted throughout the patient's medical record.

7. The Hospital failed to ensure patients presenting with emergency medical conditions (severe pain, bleeding, chest pain and suicide attempts) were triaged and had MSEs conducted expediently.

8. The Hospital failed to ensure bathrooms were available to patients in the ED waiting area. Interview with patients in the waiting area on 11/11/2010 revealed the only accessible bathroom was the one which had been used by the patient who had the miscarriage. This bathroom (including the handicap stall) had no alarm system to alert hospital staff of an emergency event.

9. The Hospital failed to ensure adequate MSE and stabilizing treatment for patients presenting with suicidal ideation to show evaluation of suicide or homicide risk, orientation, or assaultive behavior that indicated danger to self or others.

10. The Hospital failed to ensure critical events were reported to administration and investigated immediately per hospital policy.

11. The Hospital failed to ensure monitoring of patients returned to the ED waiting room who had not received a MSE to determine presence of an EMC.

Based on medical record reviews, observations, policy review, and staff/family interviews, it was determined the Hospital failed to provide an appropriate and timely medical screening exam (MSE) for four of 20 sample patients (#1, #8, #10 and #14) who presented to the Emergency Department (ED) to determine whether or not the patient had an emergency medical condition (EMC).

a. The Hospital failed to ensure a prenatal patient (#1) received an appropriate/timely MSE on 11/5/2010 to determine if she has having significant bleeding, an ectopic pregnancy, or contractions and failed to evaluate the status of the fetus.

b. The Hospital failed to ensure patients (#1, #8, #10 and #14) presenting with emergency medical condition (severe pain, bleeding, chest pain and suicide attempts) were triaged and had MSEs conducted expediently.

The findings include:

A complainant indicated in a telephone call to the CMS Regional Office he/she had been present in the Hospital's ED waiting area when a young female (patient #1) had miscarried in the clinic bathroom of the hospital. In the investigation the failures identified with the care of this patient as well as other patients in the ED constituted an Immediate Jeopardy situation:

1. According to the hospital policy titled "Patient Assessment & Reassessment" indicated five triage groups as follows:

a. "Level 5 Resuscitative-Immediate care, life threatening conditions

b. Level 4 Emergency-Major injury or illness (treat within 5-15 minutes)

c. Level 3 Urgent-Treat in 15-45 minutes

d. Level 2 Semi-Urgent-Treat in one to two hours

e. Level 1 Routine-Treat within 4 hours".

f. "A pregnant patient with active bleeding" was listed as a level 4.

2. The initial visit to the ED by patient #1 was on 11/5/2010 at 9:35 AM. At this ED visit, the patient was complaining of pelvic pain and bleeding and had indicated she was at least 12 weeks pregnant. Although policy indicated a pregnant patient with active bleeding was a level 4, the patient was triaged at a level 3.

3. There was no indication of the time the patient was taken to the ED bay/exam room. At 9:45 AM the ED physician took a verbal history but the patient did not want this physician (male) to do a pelvic examination. A female provider (a certified nurse midwife) did not conduct a MSE until 12:25 PM, over two and ? hours later. This exam showed the patient was 12-16 weeks pregnant and had copious red malodorous vaginal discharge. Assessment of the status of the fetus showed fetal heart tones (FHT) of 160 beats per minute. Patient #1 was diagnosed with "Vaginal bleeding, urinary tract infection, bacterial vaginosis and intrauterine pregnancy", given an antibiotic and discharged home. The OB/GYN (Obstetric/Gynecology) physician did not examine the patient prior to discharge home.

4. Although the triage assessment showed vital signs had been assessed, no further blood pressure was taken during the patient's three hour ED visit. A pulse was taken at 11:45 AM but no BP. There were no discharge vital signs recorded at 12:35 PM.

5. Patient #1 returned to the ED approximately 9 ? hours later (on 11/5/2010 at 9:52 PM). The patient was assessed to have pain at a level of 10/10 and indicated she had a UTI (urinary tract infection). The ED Nurse record also indicated the patient was pregnant. Although patient returned to the ED within 9 ? hours of initial visit with similar symptoms, the triage nurse did not evaluate the presenting symptoms and consult the provider in a timely manner. No assessment of the degree of possible vaginal bleeding was conducted (earlier copious amounts of blood was noted on vaginal exam). Although this pregnant patient was complaining of a 10/10 pain and had a recent history of vaginal bleeding, she was triaged as a level 2 and returned to the ED waiting room.

The Hospital failed to ensure monitoring of patients returned to the ED waiting room who had not received a MSE to determine presence of an EMC.

6. In an interview on 11/10/2010 at 7:20 PM with the triage nurse, he indicated he did not have a lot of experience or comfort examining prenatal patients. He indicated he had not assessed the status of the fetus and had placed the patient back in the ED waiting room after initial assessment of her vital signs. He stated he was unaware that the patient had presented to the ED earlier in the day with signs of possible miscarriage and the medical record was not available at this ED event. He indicated the ED was very busy and there were no open bays/rooms to put the patient into. He indicated he had obtained a urine sample (UA) due to the patient's stated complaints of UTI, placed it in a sealed bag, and gave it to the patient because he had not obtained an order for the UA from the provider yet.

a. The Hospital failed to ensure ED triage staff were competent, experienced and comfortable with the triage assessment of prenatal (first/second trimester) patients.

b. The Hospital failed to ensure medical record history was available for patients seeking ED services 24-72 hours after an initial ED presentation.

7. Interview on 11/11/2010 at 7:00 PM with an ED nurse, who was working on the night shift on 11/5/2010, indicated the ED did not have a Doppler monitor in the ED to assess FHT. She also indicated she was not aware Patient #1 had been in the ED earlier in the day with vaginal bleeding.

8. In an interview on 11/10/2010 at 8:00 PM with the physician was present in the ED on 11/5/2010, he indicated he had given the triage nurse an order for the UA but he had not seen the patient.

Review of the medical record for patient #1 did not show evidence of an order for this UA.

Observation of a security video of the evening of 11/5/2010 showed that although the surveyor was told the ED was 'swamped', the provider appeared in the triage area and the hallway several times but did not go directly to the area of the clinic/hallway bathroom and patient #1.

9. Review of medical records for the patients present in the ED prior to, during and immediately after this patient was triaged revealed incomplete documentation and no evidence the ED bay/exam rooms were unavailable to place patient #1 in the ED for timely examination and treatment.

10. After the patient was placed back in the ED waiting room she left the ED area and went down a long hallway to a bathroom located past two outpatient clinic areas and registration.

Observation of the ED waiting room and clinic areas showed there were no bathrooms available to patients in the ED waiting area. Although the ED department had a bathroom this was not available to patients waiting for the MSE to be conducted.

11. Interview with patients in the waiting area on 11/11/2010 revealed the only accessible BR was the one which had been used by patient #1 who had the miscarriage. This bathroom (including the handicap stall) had no alarm system to alert hospital staff of an emergency event.

12. Review of the OB record and progress notes indicated delivery time at approximately 2240-10:40 PM (time had been written over). Another notation indicated a delivery time of 2330 (11:30 PM) almost an hour later. This notation indicated a statement by the patient that she had been waiting in ER for "some time". An Ambulatory Care Record note indicated a delivery time of 2330 (11:30 PM) also.

The Hospital failed to ensure accurate and complete documentation of events regarding this prenatal patient. Alterations of time were noted throughout the patient's medical record.

13. After the miscarriage patient #1 was monitored in an observation bed and discharged to home at 3:00 AM the next morning (11/6/2010). Interviews during survey indicated the hospital was not admitting adult patients due to a lack of providers for inpatient services

14. Patient #1 presented to the hospital again on 11/6/2010 but went to the labor and delivery (L&D) unit. She indicated she was continuing to have "really bad cramps and is bleeding heavily. Changes 3 pads an hour since delivery and states it's really gushing out every time she stands up."

15. A notation of this visit indicated the patient was told she needed to go to the ED because she was no longer pregnant. When the OB nurse called the ED, the ED staff indicated they were too busy to see the patient at that time. The OB Nurse Midwife "called to ER, they asked if she could stay down in L&D until a bed became available in ER. I said the patient needed to be triaged."

The Hospital failed to ensure patients presenting to other areas of the Hospital requesting ED services were provided ED services without a delay in treatment.

16. Although the patient was initially seen in L&D at 2:07 PM and not moved to the ER until after a call had been placed to the OB physician on call at 2:10 PM, the ED log indicated an incorrect time of 2:07 PM as arrival to the ED.

17. The patient was taken to a bay/ED exam room at 2:30 PM. Although the physician wrote orders for establishment of IV access and pain medication at 2:40 PM, these orders were not noted or implemented until 3:45 PM, over an hour later.

18. There was no evidence a reassessment of patients currently in the ED examination areas was conducted in order to address more critical levels of care or ensure patients who had a medical emergency were examined and treated in a timely manner. The ED consisted of three main bay/exam rooms, a trauma room and four additional exam rooms. The following patients were in the ED on 11/5/2010, during the time period from 2150 (9:50 PM) and 2230 (10:30 PM):

a. Patient #7 presented to the ED at 2055 (8:55 PM), was triaged as a level 3 which chest pain and left arm numbness. The patient was placed in Bay #1 at 2115 (9:15 PM).

b. Patient #12 presented to the ED at 2010 (8:10 PM) for an elevated blood sugar (FSBS of 473). There was no triage level indicated on the record. The patient was placed in bay/exam room #2 at 2020 (8:20 PM) and was resting quietly at 2200 (10:00 PM) the patient was discharged at 2250 (10:50 PM) home after receiving Regular Insulin 18 units IV ten minutes earlier. The patient's BS was only reassessed at discharge (FSBS 369).

c. Patient #15 presented to the ED at 2214 (10:14 PM) after patient #1 had been triaged. Patient #15 was placed in the trauma bay. This patient was triaged as a level 4 was unresponsive and had hypertension.

d. Review of the medical records for patients #3, #4, #5, #6, #8, #9, #10, #13, and #12 did not show the time or which bay the patient was moved to after triage.

1) Patient #3 had presented at 8:20 PM and was triaged at 8:40 PM at a level 2 with complaints of "foot pain". The nursing care record does not indicate what time or which bay the patient was taken to for the MSE. The time of the MSE was not recorded. The patient was diagnosed with a "foot contusion" and given a pain medication IM at 10:20 PM. This care was provided after patient #1 had been triaged at 10:10 PM. Patient #3 was discharged at 10:40 PM.

2) Patient #4 presented to the ED on 11/5/2010 at 10:36 PM (after the events of patient #1). Although the patient had complaints of difficulty breathing, nausea, vomiting elevated temperature and chest pain he/she was triaged as a level 3 (policy lists acute chest pain with dyspnea as a Level 5). There is no indication of when the patient was taken to a bay/exam room but he/she did not receive a MSE until 2300 (11:00 PM).

3) Patient #5 presented to the ED at 2049 (8:49 PM) with complaints of sore throat and coughing after choking on some food. The patient was triaged as a level 2. Neither the time of triage nor the time to bay/exam room was recorded. The patient had a MSE at 2150 (9:50 PM) and was discharged home at 10:20 PM after receiving a GI Cocktail at 10:15 PM.

4) Patient #6 presented to the ED at 2111 (9:11 PM) with right ear pain and was triaged at level 2. The time the patient was taken to a bay/exam area is not recorded but the patient received a MSE at 2250 (10:50 PM) after patient #1 had been triaged and returned to the waiting room. Patient #6 was discharged to home at 2330 (11:30 PM) but there was no indication the patient had received any treatment or monitoring from the time of the MSE through his/her discharge. No discharge vital signs were evident.

5) Patient #8 presented to the ED at 2205 (10:05 PM) with complaints of chest and jaw pain and was triaged as a level 3. The ED Nurse record indicated the patient was not triaged until 2305 (11:05 PM) one hour after he/she had arrived and after patient 1 had been admitted for OB observation. The Nursing Care Record showed the patient was placed in ED bay #2 at 2305 and was seen by the physician for the MSE at 2320 (11:20 PM). The patient was diagnosed with acute coronary syndrome and transferred by the flight team to a higher level of care. The hour wait before this patient was triaged and received a MSE of treatment created a critical delay in treatment.

6) Patient #9 presented to the ED at 2015 (8:15 PM), but there is no time recorded for when the patient was taken to the ED bay/exam room. The patient was discharged home at 2210 (10:10 PM) prior to the triage of patient #1.

7) Patient #10 presented to the ED at 2154 and was triaged as level 3 with complaints of chest and abdominal pain (7/10 pain level). The Nursing Care Record did not indicate when the patient was taken to the bay/exam area and the first set of vital signs were not noted until 2305(11:05 PM).

8) Patient #13 presented to the ED at 2100 (9:00 PM) with complaints of headache and possible urinary tract infection (triage level 2). The record does not show the time the patient was taken to a bay/exam area. The patient received a MSE at 2210 (10:10 PM), was diagnosed with cervical strain, given pain medications and sent home at 2245 (10:45 PM).

9) Patient #14 presented to the ED at 2248 (10:48 PM) after patient #1 had miscarried and been taken to the L&D unit. Although this patient was triaged as Level 4, he/she was not triaged until 2325 (11:25 PM) thirty seven minutes after presenting to the ED. The record does not indicate when the patient was taken to a bay/exam area. The patient did not receive a MSE until 2351 (11:51 PM) over one hour after presenting to the ED. The patient had been brought from the jail after a suicide attempt and was discharged back to the jail. There was no evidence of an evaluation of the patient's mental status (including suicide or homicide attempt or risk, orientation or assaultive behavior that indicates a danger to self or others).

The Hospital failed to ensure adequate MSE and stabilizing treatment for patients presenting with suicidal ideation to show evaluation of suicide or homicide risk, orientation, or assaultive behavior that indicated danger to self or others.

19. In an interview with patient #16's family members, they indicated the patient had been brought to the hospital with a high temperature and had been traumatized by the experience he/she had in the ED.

a) Review of the medical record showed patient #16 presented to the ED on 11/9/2010 with a temperature of 103.6 F (rectal temperature). The record indicated the patient had had a febrile seizure due to the high temperature. The initial nursing note showed the nurse had "baby (27 months old) stripped down to skin, ice pks (packs) applied to pulse points".

b) There was no order for this treatment. A professional standard for treatment for febrile seizures indicates that patients who are postictal (no active seizure activity) should receive supportive care and antipyretics as appropriate.

c) Placement of ice packs directly next to a child's skin and without physician orders is contrary to professional nursing practice.

The hospital failed to ensure stabilizing treatment was administered or implemented per physician orders and in a timely manner.

20. Review of policy titled "Sentinel Event" indicated adverse or sentinel events are unexpected events or occurrences involving death or serious physical or psychological injury, or the risk thereof and are to be reported to the hospital administration immediately. The purpose of the policy was to examine, in depth, the event to determine why the incident occurred and how to reduce the likelihood of recurrence.

21. There was no evidence this critical event had been reported to administrative staff until three days later (Monday 11/8/2010). Interviews with hospital staff revealed critical or sentinel events were to be reported to respective supervisors immediately. Although the ED nurse in charge the night of this event indicated she had notified the ER supervisor, the Director of Nursing, Hospital Administrator, and Clinical Medical Director were not notified until 11/8/2010. A Root Cause Analysis or investigation of the event did not occur until 11/10/2010.

The Hospital failed to ensure critical events were reported to administration and investigated immediately per hospital policy.