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Based on observation, staff and paramedic interviews, review of the medical records, Emergency Room (ER) Central Log, ambulance trip reports, ER policies and procedures, Medical Staff Bylaws and Medical Staff Rules and Regulations, ER physicians' contract, credential files, and personnel files, it was determined that the facility failed to comply with 42 CFR Parts 489.20 and 489.24 for one (1) patient #10, of twenty (20) sampled patients.

Findings were:

Cross refer to A2403, the facility failed to created medical record for patient #10, who presented to the ER, with an EMC with threats of self-injury;

Cross refer to A2405, the facility failed to maintain documentation in the facility's central log of each patient who presented to the Emergency Room, including patient #10, who presented with threats of self-injury;

Cross refer to A2406, the facility failed to provide an appropriate Medical Screening Exam (MSE) to patient #10, when a request was made in his/her behalf, to determine whether or not an Emergency Medical (EMC) existed;

Cross refer to A2407, the facility failed to provide stabilizing treatment as required for patient #10, who presented to the emergency department with threats of self-injury; and

Cross refer to A2409, the facility failed to provide an appropriate transfer for patient #10, with an EMC, with threats of self-injury

Based on review of facility policies entitled "Process of Computer Assignment of Medical Record Number", and "Health Information Services Department Minimum Requirements for Patients' Medical Records", Emergency Room (ER) Central Log, medical records, staff and paramedic interviews, it was determined that the facility failed to ensure that a medical record was created and completed for one (1) patient (#10) of twenty (20) sampled patients.

Findings were:

Review of facility policy entitled "Process of Computer Assignment of Medical Record Number", policy number 6231.02.010, effective November 1998, revealed that when a patient was registered into the ER's electronic system a medical record number would be assigned.

Review of facility policy entitled , "Health Information Services Department Minimum Requirements for Patients' Medical Records", no policy number, effective 10/04/11, revealed the purpose of the policy was to provide guidelines for "noting minimum content requirements of the patients' medical records" for inpatients and outpatients.

Review of the facility's ER Central Log for 07/14/13 and a computer query using patient #10's name revealed there was no evidence of patient #10 being registered nor evidence that a medical record was initiated for patient #10.

Interview on 07/22/13 at 1:30 p.m., with the ER Charge Nurse #1, confirmed being on duty and assigned as Triage and Charge Nurse on 07/14/2013, when patient #10, was brought to the ER. The ER Charge Nurse #1, revealed that patient #10, was brought in through the ambulance entrance by a local police officer and identified as a psychiatric patient. The nurse revealed no understanding as to why the patient #10 was not registered. The nurse explained that the ER Registration Clerks enter all patients into the electronic system and that "sometimes the nurses have to notify the ER Registration Clerks when a patient enters through the ambulance entrance". In addition, the nurse confirmed that the medical record started when the patient's name was entered into the ER's electronic system.

Interview on 07/22/13 at 10:45 a.m., the Clinical Coordinator of the ER confirmed that patient #10 was not registered into the ER's electronic system and/or ER Central Log thus, a medical record was therefore never generated.

Interview on 07/22/13 at 11:00 a.m., the ER Registration Clerk explained that psychiatric patient's brought in by a law enforcement officers were usually brought in through the ambulance entrance. The ER Registration Clerk continued to reveal the the ER nurses usually notify the Registration Clerk, then the ER Registration Clerks goes to the patient, obtains and registers the patient.

Interview on 07/23/13 at 10:00 a.m., the paramedic confirmed being on duty on 07/14/13. The paramedic revealed that patient #10 and the law enforcement officer were outside the ambulance entrance to the ER. The paramedic explained that the officer explained that the patient had been brought to the ER for a psychiatric evaluation. The paramedic stated the officer reported that the patient could not be accepted because the facility was requesting the officer to stay and monitor the patient and the officer could not stay. The paramedic stated that patient #10, confirmed that they had said, they wanted to harm self, but now patient #10, stated, I didn't mean it, I was just upset.

Based on review of the facility's policy entitled, "Patient Access ER Registration Process for EDM", Emergency Room (ER) Central Log, and staff interviews, it was determined that the facility failed to ensure that each patient who presented to the facility's ED seeking assistance was recorded in the Central Log for one patient (#10) of the twenty (20) sampled patients.

Findings include:

Review of facility policy entitled "Patient Access ER Registration Process for EDM", no policy number, effective 02/22/11, revealed patients presenting to the ER were to be registered in a timely and efficient manner through the facility's electronic medical record system.

Review of the facility's ER Central Logs dated 07/14/13 revealed there was no documented evidence of patient #10 presenting to the facility's property for evaluation and/or treatment in the ER.

Interview on 07/22/13 at 1:30 p.m., the ER Charge Nurse #1 confirmed being on duty at the time patient #10 arrived, escorted by a law enforcement officer, because of threats of self-injury. The nurse explained that the ER Registration Clerks enter all patients into the electronic system and that "sometimes the nurses have to notify the ER Registration Clerks when a patient enters through the ambulance entrance".

Interview on 07/22/13 at 10:45 a.m., the ER Clinical Coordinator confirmed that patient #10, was never registered into the ER's electronic system/ER Central Log.

Based on review of the facility's Medical/Dental Staff Bylaws and Rules & Regulations, policy entitled, "Emergency Services Department Triage Assessment for Emergency Department", ER physicians' agreement, ER physician's staffing schedule, credential files, ER nurses' staffing schedule, personnel files, staff interviews, medical records, physician statement, it was determined that the facility failed to perform a Medical Screening Examination (MSE) to determine whether or not an emergency medical condition exists for one (1) patient # 10 of twenty (20) sampled patients.

Findings include:

Review of the facility's Medical/Dental Staff Bylaws and Rules & Regulations, approved by the Medical/Dental Staff on 11/19/12 and by the Hospital Board on 12/17/12, revealed in Section 1.3 Emergency Admissions, 1.3-4 that the ER would be opened 24 hours a day. Continued review of the Rules & Regulations, 11.1 Emergency Center, 11.1-6 revealed all patients would be triaged (assessment to determine a patient's priority of need) immediately upon arrival to the ER by a nurse or paramedic. In addition, all patients were to receive a Medical Screening Examination (MSE) by the ER physician unless otherwise ordered.

Review of facility policy entitled "Emergency Services Department Triage Assessment for Emergency Department", no policy number, revised November 2011, revealed all patients who presented to the ER would receive a triage assessment by a Registered Nurse (RN) and a MSE by an ER physician.

Review of the ER physicians agreement revealed the agreement was effective as of 11/16/09 and ER services were to be provided 24 hours a day. In addition, each Emergency Physician's Staff Privileges were to be contingent upon, among other things, the Emergency Physician's compliance with the Hospital's medical staff bylaws, rules and regulations (collectively, the "Hospital Policies").

Review of the ER physician's staffing schedule revealed ER #3 was on duty at the time the patient #10 presented to the ER on 7/14/2013. The physician's credential file had documented evidence that the physician had agreed to abide by the facility's Medical Staff Bylaws, Rules & Regulations, and hospital policies and procedures. In addition, the physician had completed EMTALA training on 08/12/11.

Review of the ER nurses' schedule revealed a RN #1 was on duty along with two (2) Licensed Practical Nurses (LPN) #2 and #3. All three (3) nurses personnel files revealed evidence that all three (3) nurses had received EMTALA training between 06/28/12 and 07/10/13.

Interview on 07/22/13 at 1:30 p.m., the ED RN #1 confirmed being on duty on 7/14/2013 at the time patient #10 and was escorted by a law enforcement officer. The nurse explained that the facility had only one (1) psychiatric lockdown room that could be used to secure psychiatric patients. The nurse went on to explain that a local police officer had brought in a psychiatric patient #10, through the ambulance entrance. The nurse informed the officer that the facility was on psychiatric diversion and that dispatch had been notified. The nurse informed patient #10 and the officer that the facility would be glad to provide care but that the officer would have to stay and monitor the patient. In addition, the nurse stated no awareness of whether the ER physician had been notified of patient #10's arrival. The nurse stated the officer reportedly went outside to call dispatch and never brought the patient back into the ER.

The ER physician #3 who was on duty on 07/14/13 provided a statement which included having no knowledge of patient #10 presenting to the ER. The ER physician #3, continued to reveal that the hospital was required to provide patients who presented to the ER requesting services a MSE in order to determine whether an EMC existed, stabilizing treatment, and an appropriate transfer in order to be in compliance with EMTALA regulations.

The facility failed to ensure that on July 14, 2013 an appropriate medical screening examination was performed on patient #10 as per the facility ' s Medical Staff By-Laws and Rules and Regulations.

Based on review of policies "Patient Access Emergency Room (ER) Registration Process for EDM", "Emergency Services Department Triage Assessment for Emergency Department", ER Central Log, Medical/Dental Staff Bylaws and Rules & Regulations, ER physicians' agreement, ER physician's staffing schedule, credential files, ER nurses' staffing schedule, personnel files, staff interviews, receiving facility's medical record for patient #10, it was determined that the facility failed to provide stabilizing treatment as required for one (1) patient #10 of twenty (20) sampled patients.

Findings include:

Review of facility policy entitled "Patient Access ER Registration Process for EDM", no policy number, effective 02/22/11, revealed patients who presented to the ER for treatment were to be registered into the facility's electronic system. This process entered patients into the facility's Central Log and generated a medical record.

Review of the facility's Emergency Room (ER) Central Log dated 07/14/13 revealed there was no evidence of the patient (#10) presenting to the ER and therefore no electronic medical record had been generated for documentation of a MSE, stabilizing treatment, and/or appropriate discharge or transfer.

Review of facility policy entitled "Emergency Services Department Triage Assessment for Emergency Department", no policy number, revised November 2011, revealed all patients who presented to the ER would receive a triage assessment by a Registered Nurse (RN) and a MSE by an ER physician.

Review of the facility's Medical/Dental Staff Bylaws and Rules & Regulations, approved by the Medical/Dental Staff on 11/19/12 and by the Hospital Board on 12/17/12, revealed in Section 1.3 Emergency Admissions, 1.3-4 that the ER would be opened 24 hours a day. In addition, the Rules & Regulations, 11.1 Emergency Center, 11.1-6 revealed all patients would be triaged (assessment to determine a patient's priority of need) immediately upon arrival to the ER by a nurse or paramedic. In addition, all patients were to receive a MSE by the ER physician unless otherwise ordered. Section 11.1-7 When a patient without an established relationship with a member of the Medical/Dental Staff, "is seen by" an ER practitioner, the following protocol prevails: 11-.1-7.1 "Appropriate evaluation and care is rendered".

Review of the ER physicians agreement revealed the agreement was effective as of 11/16/09. This agreement revealed ER services were to be provided 24 hours a day. In addition, each Emergency Physician's Staff Privileges were to be contingent upon, among other things, the Emergency Physician's compliance with the Hospital's medical staff bylaws, rules and regulations (collectively, the "Hospital Policies").

Review of the ER physician's staffing schedule revealed physician #3 was on duty on 7/14/13 when patient #10 presented to the ER. The physician's credential file had documented evidence that the physician had agreed to abide by the facility's Medical Staff Bylaws, Rules & Regulations, and hospital policies and procedures. In addition, the physician had completed EMTALA training on 08/12/11.

Review of the ER nurses' schedule revealed a Registered Nurse RN #1 was on duty along with two (2) Licensed Practical Nurses (LPN) #2 and #3. All three (3) nurses personnel files revealed evidence that all three (3) nurses had received EMTALA training between 06/28/12 and 07/10/13.

Interview on 07/22/13 at 1:30 p.m., the ER RN #1 confirmed being on duty on 07/14/13 when patient #10 presented to the ER. The nurse went on to explain that he/she was notified that a local police officer had brought in a psychiatric patient through the ambulance entrance. The nurse informed patient # 10 and officer that the facility would be glad to provide care for the patient but that the officer would have to stay and monitor the patient. The nurse stated the officer reportedly went outside to call dispatch and never brought the patient back into the ER.

The ED physician #3 who was on duty on 07/14/13 provided a statement to include no knowledge of being informed that another psychiatric patient (#10) had presented to the ER. The physician explained that the hospital was required to provide patients who presented to the ER requesting services a MSE in order to determine whether an EMC existed, stabilizing treatment, and an appropriate transfer in order to be in compliance with EMTALA regulations. The facility failed to ensure that on July 14, 2013, patient #10 received stabilizing treatment as required to stabilize the medical condition.

Review of the receiving facility's medical record for patient #10 revealed that EMS arrived at 12:57 p.m. The nurse noted that the patient had been brought to the facility to receive a psychiatric evaluation. Documentation revealed the patient was triaged at 12:59 p.m. and received a MSE by the ER physician at 1:16 p.m. In addition, the physician noted that the patient reportedly had a fight with a significant other and had in anger threatened to hurt self. Documentation revealed the patient stated that had been a foolish gesture and that they would never hurt themselves. The physician noted that the patient's last menstrual period began 07/10/13, the patient denied suicidal and/or homicidal ideation's and had no auditory and/or visual hallucinations. The patient was discharged home at 1:51 p.m. in stable condition. The discharge instructions included the phone number for a psychiatric consultation.

Based on review of policy entitled, "Patient Care Services Patient Transfer", ER Central Log, ER physician's staffing schedule, credential files, ER nurses' staffing schedule, personnel files, staff interviews, staff job descriptions, medical records, EMS trip report, receiving facility's medical record (#21), physician statement, tour of the ED, interview with the Director of EMS, interview with a Paramedic, and Medical Surgical Unit staffing, it was determined that the facility failed to imitate an appropriate transfer for one (1) patient #10, of twenty (20) sampled patients.

Findings include:

Review of the facility's Emergency Room (ER) Central Log dated 07/14/13 revealed there was no documented evidence of the patient (#10) presenting to the ER and therefore no electronic medical record had been generated for documentation of a MSE, stabilizing treatment, and/or appropriate discharge or transfer.

Review of the ER physician's staffing schedule revealed physician (credential file #3) was on duty at the time the patient #10 presented to the ER. The physician's credential file had documented evidence that the physician had agreed to abide by the facility's Medical Staff Bylaws, Rules & Regulations, and hospital policies and procedures. In addition, the physician had completed EMTALA training on 08/12/11.

Review of facility policy entitled "Patient Care Services Patient Transfer", no policy number, revised August 2011, revealed the purpose of the policy was to provide an efficient, effective means of transferring patients, either within the hospital (interdepartmental) or from hospital to hospital. This policy required all "COBRA (Consolidated Omnibus Budget Reconciliation Act) regulations when transferring to other hospitals. The policy noted that no patient would be transferred from the facility until their medical condition had been stabilized, if at all possible. Measures were to be implemented to minimize the deterioration of the patient's condition. The policy required an appropriate transfer to include: acceptance by the receiving facility, an accepting physician, documentation of the date, time, and name of the accepting person, the patient's transferring nurse was to call report to the receiving nurse, transportation was to be arranged, and pertinent portions of the medical record sent to the receiving facility.

Review of the ER nurses' schedule revealed a Registered Nurse (RN) #1 was on duty on 7/14/13 along with two (2) Licensed Practical Nurses (LPN) #2 and #3 when patient #10 presented to the ER. All three (3) nurses personnel files revealed evidence that all three (3) nurses had received EMTALA training between 06/28/12 and 07/10/13.

Interview on 07/22/13 at 1:30 p.m., the ER RN #1 confirmed being on duty on 07/14/13 when patient #10 presented to the ER. The nurse went on to explain that he/she was notified that a local police officer had brought in a psychiatric patient through the ambulance entrance. The nurse informed patient # 10 and officer that the facility would be glad to provide care for the patient but that the officer would have to stay and monitor the patient. The nurse stated the officer reportedly went outside to call dispatch and never brought the patient back into the ER.

The ED physician #3 who was on duty on 07/14/13 provided a statement to include no knowledge of being informed that another psychiatric patient (#10) had presented to the ER. The physician explained that the hospital was required to provide patients who presented to the ER requesting services a MSE in order to determine whether an EMC existed, stabilizing treatment, and an appropriate transfer in order to be in compliance with EMTALA regulations.

Review of the receiving facility's medical record for patient #10 revealed that EMS arrived at 12:57 p.m. The nurse noted that the patient had been brought to the facility to receive a psychiatric evaluation. Documentation revealed the patient was triaged at 12:59 p.m. and received a MSE by the ER physician at 1:16 p.m. In addition, the physician noted that the patient reportedly had a fight with a significant other and had in anger threatened to hurt self. Documentation revealed the patient stated that had been a foolish gesture and that they would never hurt themselves. The physician noted that the patient's last menstrual period began 07/10/13, the patient denied suicidal and/or homicidal ideation's and had no auditory and/or visual hallucinations. The patient was discharged home at 1:51 p.m. in stable condition. The discharge instructions included the phone number for a psychiatric consultation.