HospitalInspections.org

Based on document review and interview, it was determined that in 1 of 21 (Patient 21) medical records (MR) reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide a medical screening exam and failed to complete transfer forms per policy.

Findings Include:

1. See findings cited at 42 CFR 489.24, A2406 and A2409.

Based on document review and interview, the facility failed to maintain a central log on each individual who comes to the Emergency Department, as defined in 489.24 (b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was admitted and treated, stabilized and transferred or discharged for 1 of 21 patients (Patient 21).

Findings Include:

1. Review of policy titled: Emergency Department Triage last approved 10/2018, indicated that "All patients presented to the ED will first be quick registered in Cerner..." (computer system).

2. Review of facility's Administrative Documents indicated P53 (Associate Administrator) received a call from F2 (receiving hospital) on 01/26/20 indicating that F1 (sending hospital) sent Patient 21 to F2 requiring a SANE (Sexual Assault Nurse Examiner) assessment...indicated that F1 called F2 to see if they had an available SANE nurse - which they did not but would have one after 7:00 am..."pt suddenly showed up" at F2 without having registered or further medical evaluation at F1.

3. Review of the Emergency Department Activity Log lacked documentation that Patient 21 presented to the facility on 01/26/20.

4. Interview with P50 (Accreditation Regulatory Consultant) on 03/04/20 at 11:00 am confirmed that Patient 21 arrived on premises on 01/26/20 for medical care and was not registered or received a medical screening exam.

Based on document review and interview, the facility failed to provide a medical screening exam on 1 of 21 patients presenting to the Emergency Department for medical care (Patient 21).

Findings Include:

1. Review of policy titled: Emergency Medical Treatment and Active Labor Act (EMTALA) last revised 05/2017, indicated that individuals who present to the F1 facility seeking attention for a medical condition shall receive a Medical Screening Exam (MSE).

2. Review of facility's Administrative Documents indicated P53 (Associate Administrator) received a call from F2 (receiving hospital) on 01/26/20 indicating that F1 (sending hospital) sent Patient 21 to F2 requiring a SANE (Sexual Assault Nurse Examiner) assessment...indicated that F1 called F2 to see if they had an available SANE nurse - which they did not but would have one after 7:00 am..."pt suddenly showed up" at F2 without having registered or further medical evaluation at F1.

3. Review of facility Emergency Activity log indicated a lack of documentation of Patient 21 being registered or receiving a MSE.

4. Interview with P50 (Accreditation Regulatory Consultant) on 03/04/20 at 11:00 am confirmed that Patient 21 arrived on premises on 01/26/20 and was not registered or received a medical screening exam.

Based on document review and interview, the facility failed to ensure completion of transfer forms in 4 of 20 (Patients 3, 12, 13 and 14) medical records reviewed.

Findings include:

1. Review of policy titled; "Patient Transfer" (from F1), last reviewed 12/2019, indicated that the Transfer Form is to be completed.

2. Review of Patient's 3 and 12's medical records (MRs) lacked documentation of benefits and risk of transfer and patient condition at time of transfer. Patient 13's MR lacked documentation of risk of transfer and consent to transfer. Patient 14's MR lacked documentation of provider certification, accepting facility and physician, patient condition at time of transfer and benefits and risks of transfer.

3. Interview with P50 (Accreditation Regulatory Consultant) on 03/04/20 at 2:30 pm confirmed that Patient's 3 and 12's MRs lacked documentation of benefits and risk of transfer and patient condition at time of transfer. Patient 13's MR lacked documentation of risk of transfer and consent to transfer. Patient 14's MR lacked documentation of provider certification, accepting facility and physician, patient condition at time of transfer and benefits and risks of transfer.