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A. Based on review of clinical records, review of Hospital Bylaws, Rules and Regulations, ED (Emergency Department) and OB (Obstetrics) logs and staff interview, it was determined the Hospital failed to document all patients on a central log when presenting to the Hospital requesting treatment, refer to A2405. The Hospital failed to provide approrpriate medical screening examinations to all patients that presented to the ED. (Emergency Department), refer to A2406. The Hospital failed to ensure an appropriate transfer process was followed, refer to A2409.

A. Based on review of the Hospital Emergency Log and staff interview, it was determined that in 1 of 34 (Pt. #1) clinical ED records reviewed, the Hospital failed to ensure all patients that presented to the ED (Emergency Department) are documented on the central log.
Findings include:

1. On survey date 09/20/11, the ED logs for August and September of 2011 were reviewed. There was no documentation that Pt. #1 had been entered into the log book.

2. The ED Nurse Manager and Vice President (VP) of Compliance was interviewed on 09/20/11 at 11:30 am. The ER Nurse Manager and VP of Compliance confirmed the above findings.

A. Based on Hospital policy, ambulance reports, a review of clinical Emergency Department (ED) records, internal documentation (emails) and staff interview, it was determined that in 1 of 34 (Pt. #1) clinical records reviewed, the Hospital failed to provide a medical screening examination as required.

Findings include:

1. The Hospital policy titled "Emergency Department Compliance Policy," indicates: "All patients who present to the hospital.... will be provided with a medical screening examination.."

2. On survey date 09/20/11 the Hospital owned ambulance system report was reviewed and it indicated on Sept 04, 2011 at 3:31 am the hospital received a call for a battery victim with loss of consciousness. The victim, Pt. #1 was brought to the ER and put on bed #1. The emergency physician (Physician #1) told the ambulance crew to reload the patient and take the patient to another Hospital because the CT scanner was not working at the hospital. The ambulance crew transferred Pt. #1 to the receiving hospital on 09/04/11. During the course of the investigation, the Hospital was unable to produce a clinical record that indicated the patient had been seen by a physician and received a medical screening examination.

3. An interview with RN #1 was conducted per telephone on 09/20/11 at 3:10 pm. RN #1 was working at the time of the presentation of Pt. #1. RN #1 indicated he heard physician #1 say "what am I supposed to do? I can't scan his head. He needs a trauma hospital." RN #1 indicated the paramedic was on the phone and then they were wheeling Pt. #1 out of the hospital. RN #1 was uncertain as to how long the CT scanner was down. "They were trying to reboot the CT scanner."

4. An interview with the ED nurse, RN #2, who was on duty when Pt. #1 arrived at the ED, was conducted per phone at 3:30 pm on 09/20/11. RN #2 indicated Pt. #1 was transported in from the field and had lacerations to his face, was placed in bay #1 and was transferred out while she was conducting telephone calls concerning transfers for 2 other patients. It was verbalized by the RN #2 that she told the ambulance crew and Physician #1 "you can't do that without examining the patient, that is an EMTALA violation." The ED Director (Physician #2) was notified by RN#2 on 09/05/11 regarding the inappropriate transfer and Pt. #1 being transferred out without a medical screening examination.

5. Internal emails were reviewed on 09/20/11, it was verified the Ambulance Director notified Physician #2 via email on 09/05/11 regarding the improper transfer of Pt. #1 by Physician #1. Physician #2 then sent Physician #1 an email to obtain further information. Physician #1, who transferred the patient out, indicated in an email to Physician #2 "I looked at "Pt. #1," saw he was in no distress, was alert and following commands and was stable for transfer. Unfortunately, I am unclear of these particular policies of "the Hospital" and really didn't think about the transfer issue because of the delay in treatment it might have caused."

6. Documentation of the receiving Hospital's patient record indicated that Pt. #1 was received at the hospital at 5:45 am on 09/04/11 with an elevated blood alcohol, trauma and facial injuries, status post assault and required a Spanish speaking interpreter. Pt. #1 was positive for head injury, a large laceration to his right side of head/ear and lower lip. Pt. #1 was expectorating blood, had abrasions to his mid thoracic spine and face. Pt. #1 was stabilized and then transferred to another hospital at 7:59 am for a plastics consult and evaluation by the ears, nose and throat physician.

7. The above findings were verified with the ED Nurse Manager and Vice President (VP) of Compliance on 09/20/11 at 4:00 pm.

B. Based on a review of the Medical Staff Bylaws, Rules and Regulations, Hospital policies, Obstetrical (OB) log and staff interview, it was determined that in 13 of 13 (Pt. #'s 22,23,24,25,26,27,28,29,30,31,32,33,34) clinical records reviewed in which the patient was referred to the OB for the Medical Screening , the Hospital failed to provide documentation that the Registered Nurses in the OB department were competent to provide a medical screening examination per the strict protocols for OB patients, therefore no appropriate medical screening examination was completed.

1. The medical staff bylaws, rules and regulations, were reviewed on 09/20/11, it indicated: "All individuals will be provided a medical screening exam, beyond triage, by a physician or non-physician provider under strict protocols for OB patients."

2. The policy titled, "Protocol Medical Screening For OB" was reviewed on 9/20/11, the protocol's purpose was "To screen maternal patients from the Emergency Department". The Procedure was to perform maternal assessment and fetal assessment; to contact the OB provider to communicate data and to discharge per OB providers instructions.

3. The policy titled " Care of The Obstetrical (OB) Patient In The ED " was reviewed on 9/20/11. It indicated " 2. OB Patients of 20 weeks gestation or greater: a. In labor (or suspected of being in labor), or with a pregnancy related complaint, are ordinarily sent to the OB department. If, after assessment by the OB department, the patient ' s condition is deemed medical and not obstetrical, the patient should be returned to the ED for a medical screening exam and treatment by the ED physician. The patient can be discharged or admitted for further observation or treatment in the OB Department ... "

4. During an interview conducted with the ED Nurse Manager and the VP of Compliance on 09/20/11 at 4:00 PM, it was verbalized that there are 10 OB nurses and that all of them are allowed to assess OB patients who present to the ED and are directed to the OB department for evaluation. The hospital was unable to provide documentation of any competency training and testing to ensure the the nurses are competent to perform medical screening examinations on OB patients referred from the ED.

4. The OB outpatient register (log book) was reviewed on survey date 09/20/11. The log indicated from 09/09/11 - 09/19/11, thirteen OB patients presented to the ED, were logged in and examined in the OB unit for potential deliveries. There was no documentation to indicate that the 13 listed OB patients who were evaluated by the OB department from 09/09/11 - 09/19/11 had received an appropriate medical screening examination. The services rendered by the OB nurses, as addressed on the OB central log, indicated these women had been admitted and checked for contractions, rupture of membranes, abdominal pain, vaginal bleeding, etc. Three of 13 OB patients had been admitted, two were admitted for observation and eight had been discharged to home without having an appropriate medical screening examination.

5. The above findings were verified with the ED Nurse Manager and Vice President (VP) of Compliance on 09/20/11 at 4:00 PM.

A. Based on a review of Hospital policies and procedures, ambulance reports,clinical record review and staff interview, it was determined in 4 (Pt. #1, #3, #8, and #9) of 15 transfer clinical records reviewed, where the patient was transferred from the ED, the Hospital failed to ensure an appropriate transfer process was followed.

Findings include:

1. The Hospital policy titled: "Transfer of Patient, " was reviewed on 09/20/11, it indicated: "No patient will be transferred arbitrarily and every patient must be evaluated by a physician and stabilized (if possible) prior to transfer."

2. The ambulance report dated 09/04/11 at 3:58 am indicated Pt. #1, a battery/assault victim, was transferred to another Hospital because there was no CT scan availability at the presenting Hospital. The emergency physician told the ambulance crew to reload Pt. #1 and take him to the other Hospital after he presented to the ED. The Hospital was unable to produce a record that indicated Pt. #1 had received a medical screening examination, was provided stabilizing treatment, and contacted the receiving hospital to transfer Pt. #1.

3. An interview with RN #1 was conducted per telephone on 09/20/11 at 3:10 pm. RN #1 was working at the time of the presentation of Pt. #1. RN #1 indicated he heard Physician #1 say "what am I supposed to do? I can't scan his head. He needs a trauma hospital." RN #1 indicated the paramedic was on the phone and then they were wheeling Pt. #1 out of the hospital. RN #1 was uncertain as to how long the CT scanner was down. "They were trying to reboot the CT scanner."

4. An interview with the ED nurse, RN #2, who was on duty when Pt. #1 arrived at the ED, was conducted per phone at 3:30 pm on 09/20/11. RN #2 indicated she had verbalized to the ambulance crew and ED physician (Physician #1) that "You cannot transfer the patient out without examining him, that is an EMTALA violation."

5. Documentation in the receiving Hospital clinical record, indicated Pt. #1 was received at at 5:45 am on 09/04/11 with an elevated blood alcohol, trauma and facial lacerations, status post assault and required a spanish speaking interpreter. Pt. #1 was positive for head injury, a large laceration to his right side of head/ear and lower lip. Pt. #1 was expectorating blood, had abrasions to his mid thoracic spine and face. Pt. #1 was stablilized and then transferred to another Hospital at 7:59 am for a plastics consult and evaluation by the ears, nose and throat physician.

6. The clinical record of Pt. #3 was reviewed on 09/20/11. It indicated Pt. #3 presented to the ED on 08/08/11 with the diagnoses Depression and Suicidal. Documentation indicated Pt. #3 was transferred. The physician certification failed to indicate the risks and benefits involved with transferring Pt. #3 to another facility and that Pt. #3 was aware of these.

7. The clinical record of Pt. #8 was reviewed on 09/20/11. It indicated Pt. #8 presented to the ED on 08/02/11 with the diagnoses Rollover, M V C (motor vehicle crash), Abdominal pain, and Left chest pain. Documentation indicated Pt. #8 was transferred. The physician certification failed to indicate the risks involved with transferring Pt. #8 to another facility.

8. The clinical record of Pt. #9 was reviewed on 09/20/11. It indicated Pt. #9 presented to the ED on 09/09/11 with the diagnoses Abdominal pain, and possible Intussucsception. Documentation indicated Pt. #9 was transferred. The physician certification failed to indicate the benefits involved with transferring Pt. #9 to another facility.

9. During interviews conducted with the ED Nurse Manager and Vice President (VP) of Compliance, on 09/20/11 at 4:00 pm, the above findings were confirmed

B. Based on Hospital policy, clinical record review and staff interview, it was determined in 2 of 15 (Pt. #4, #8) clinical records reviewed, where the patient was transferred from the ED, the Hospital failed to meet the transfer requirements of the medical record documentation to the receiving hospital.

1. The Hospitals Policy and Procedures were reviewed on 09/20/11. The Hospital policy titled "Transfer of Patient" #2 indicated "All pertinent information regarding the patient, diagnostic procedures, medications and treatment, will accompany the patient upon transfer..."

2. The clinical record of Pt. #4 was reviewed on 09/20/11. It indicated Pt. #4 presented to the ED on 08/15/11 with the diagnoses Small bowel obstruction in #1 ventral, Hernia below umbilicus, and 2nd Hernia may result in SBO (small bowel obstruction). Documentation indicated Pt. #4 was transferred. There was no documentation to indicate the Hospital sent medical records, test results, or information pertinent to Pt. #4's emergency condition to the receiving Hospital.

3. The clinical record of Pt. #8 was reviewed on 09/20/11. It indicated Pt. #8 presented to the ED on 08/02/11 with the diagnoses Rollover, M V C (motor vehicle crash), Abdominal pain, and Left chest pain. Documentation indicated Pt. #8 was transferred. There was no documentation to indicate the Hospital sent medical records, test results, or information pertinent to Pt. #8's emergency condition to the receiving Hospital.

4. During interviews conducted with the ED Nurse Manager and Vice President (VP) of Compliance, on 09/20/11 at 4:00 pm, the above findings were confirmed.