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Based on interviews, medical record review and policy review, the facility failed to comply with 489.24(A 2405) by failure to maintain an emergency log of all patients who presented to the Emergency Department, (A2406) by failing to provide an appropriate medical screening examination for a patient who presented to the Emergency Department. The cumulative effect of these systemic practices resulted in the facility's inability to ensure that all patients presenting to the Emergency Department would receive a medical screening exam, stabilizing treatment and have their Emergency Department visit placed on a log. The average monthly census of the Emergency Department is 9,074 patients.

Based on review of the facility's emergency department log, record review and interview, the facility failed to ensure a log of all patients who presented to the emergency department was maintained for one (Patient #21) of 20 medical records reviewed. The average monthly census of the Emergency Department is 9,074 patients.

Findings include:

The facility's Emergency Medical Treatment and Active Labor Central Log policy was reviewed. The policy stated the facility will maintain a central log to include information on each patient who comes to the facility requesting emergency treatment. Department and patients and entries to the central log should be made at the point of first contact.

The facility's Emergency Medical Treatment and Active Labor Act (EMTALA) Definitions were reviewed. Central Log was defined as a log that each facility is required to maintain for all patients who come to the emergency room seeking assistance and the disposition of such patients, whether such patients refused treatment, were transferred, admitted and treated, stabilized and transferred or discharged.

1. The facility's emergency department log for 08/24/16 was reviewed. The log did not contain the name of Patient #21.

2. On 10/07/16 at 2:47 PM, Staff E was interviewed. Staff E reported Patient #21 arrived with another woman. Staff E reported checking Patient #21 in at the emergency department on 08/24/16. Staff E reported he/she was able to hear Staff F speaking with Patient #21 informing her/him of the physician being severely allergic to dogs. Staff E reported he/she informed Patient #21 that he/she could wait for another doctor or go somewhere else for treatment. Staff E reported Patient #21 had a service animal.

3. On 10/07/16 at 2:56 PM, Staff F was interviewed. Staff F reported clearly remembering the incident with Patient #21 from 08/24/16. Staff F stated Patient #21 arrived to the emergency department with a service dog and the physician in the emergency department was allergic to dogs. Staff F reported going back and informing the physician about Patient #21 and the physician responded to Staff F by stating "you know I'm allergic to dogs". Staff F stated the physician instructed Staff F to inform Patient #21 the facility would be happy to call in another physician. Staff F went and told Patient #21 what the physician said. Staff F stated he/she informed Patient #21 that he/she could go to another satellite. Patient #21 responded by saying he/she needed to make a phone call and then will decide. Staff F went to report the conversation to the physician and by the time Staff F returned Patient #21 was gone. Registration reported Patient #21 had left and was pleasant and understanding.

4. The facility's Electronic Patient Record System for Patient #21 was reviewed. The record contained a Patient Information form which stated Patient #21 arrived to the facility's emergency department on 08/24/16 at 9:29 AM following a motor vehicle accident (MVA).

5. The facility's Patient Relations Worksheet regarding the facility's investigation of Patient #21's grievance was reviewed. The worksheet stated the grievance was received on 08/29/16. The worksheet revealed on 09/08/16, Staff G reported having interviewed the emergency department staff and the staff reported Patient #21 was told about the physician's allergy to dogs and that the physician offered to call in a different physician. Patient #21 decided not to sign in or wait for another provider. The facility also gave Patient #21 the option of going to another facility. Per the report from the nurses, Patient #21 was not angry at the time he/she left and he/she was given options and alternatives.

6. On 10/07/16 at 2:52 PM, Staff D was interviewed and verified Patient #21 was not listed on the emergency department log.

7. On 10/07/16 at 2:53 PM, the findings regarding Patient #21 not being listed on the emergency department log were shared with Staff A and verified.

Based on interviews, facility document review, record review and policy review, the facility failed to provide a medical screening examination for two (Patient #17 and #21) of 20 medical records reviewed of patients presenting to the emergency department. The average monthly census of the Emergency Department is 9,074 patients.

Findings include:

The facility's Emergency Department Standards of Nursing Care policy was reviewed. The policy stated patients who present to the emergency department can expect to be triaged/assessed by a registered nurse trained in emergency care.
The facility's Emergency Medical Treatment and Active Labor Medical Screening Policy was reviewed. The policy stated any patient who comes to the facility requesting emergency services regardless of diagnosis or financial status will receive a Medical Screening Examination within the capabilities of the facility's emergency department, by individuals qualified to perform such examination. Patients who present to the facility requiring a Medical Screening Exam should not be directed to the facility-owned contiguous or on-campus facility, unless:
a. All persons with the same medical condition are moved to this location regardless of their ability to pay for treatment;
b. There is a bona fide medical reason to move the patient;
c. Qualified medical personnel will accompany the patient.
Individuals coming to the emergency department must be provided a Medical Screening Examination. The policy stated the emergency department physician on duty is responsible for individuals presenting to the emergency department until the patient's private physician or an on-call specialist assumes that responsibility, or the patient is discharged.

The facility's Purpose and Objectives of the Emergency Department policy was reviewed. The policy stated its purpose was to provide adequate assessment and initial treatment and/or advice to any patient with an illness or injury who presents for treatment to the emergency department.

The facility's Emergency Medical Treatment and Active Labor Act (EMTALA) Definitions were reviewed. Medical Screening Examination was defined as the process required to reach with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition exists or a woman is in labor. Such a screening must be done within the facility's capabilities and available personnel, including on-call physicians.

The facility's Animal Permitted within Akron General Health System policy was reviewed. The policy stated no animals are permitted within the facility, community health centers or medical offices with the exception of patient or visitor service dogs.

The facility's Our Patient Care Partnership Understanding Expectations, Rights and Responsibilities poster was reviewed. The poster stated patients have the right to receive care, regardless of physical or mental disability.

1. The facility's Electronic Patient Record System for Patient #21 was reviewed. The record contained a Patient Information form which stated Patient #21 arrived to the facility's emergency department on 08/24/16 at 9:29 AM following a motor vehicle accident (MVA). The record did not contain evidence of Patient #21 being triaged. The record did not contain evidence of Patient #21 receiving a medical screening exam.

2. On 10/07/16 at 2:56 PM, Staff F was interviewed. Staff F reported clearly remembering the incident with Patient #21 from 08/24/16. Staff F stated Patient #21 arrived to the emergency department with a service dog and the physician in the emergency department was allergic to dogs. Staff F reported going back and informing the physician about Patient #21 and the physician responded to Staff F by stating "you know I'm allergic to dogs". Staff F stated the physician instructed Staff F to inform Patient #21 the facility would be happy to call in another physician. Staff F went and told Patient #21 what the physician said. Staff F stated he/she informed Patient #21 that he/she could go to another satellite. Patient #21 responded by saying he/she needed to make a phone call and then will decide. Staff F went to report the conversation to the physician and by the time he/she returned Patient #21 was gone. Registration reported Patient #21 had left and was pleasant and understanding.

3. The facility's grievance reports were reviewed. Patient #21 filed a grievance stating he/she was denied service, he/she has a service dog and the physician refused to see him/her. Patient #21 reported the emergency department staff told him/her that he/she would need to go downtown to be seen.

4. The facility's Patient Relations Worksheet regarding the facility's investigation of Patient #21's grievance was reviewed. The worksheet stated the grievance was received on 08/29/16. The worksheet revealed on 09/08/16, Staff G reported having interviewed the emergency department staff and the staff reported Patient #21 was told about the physician's allergy to dogs and that the physician offered to call in a different physician. Patient #21 decided not to sign in or wait for another provider. The facility also gave Patient #21 the option of going to another facility. Per the report from the nurses, Patient #21 was not angry at the time he/she left and he/she was given options and alternatives. This had come up before with this physician. The physician has a severe allergy and cannot have dogs in the room. Since the physician is our only provider here, we have to accommodate the physician.

The worksheet revealed Staff H responded on 09/02/16 to the incident involving Patient #21 from 08/24/16. Staff H reported the facility typically handles the situation by having the service dog placed in the waiting room with someone, have another physician who is working see the patient, or refer them to another facility if they will not leave the dog with someone else. At the time of the Patient #21's visit, there were no other physicians working. Staff H stated this was not the first time we have had a service dog and we have a plan in place for when it happens. Encourage Patient #21 that he/she can come anytime for care as we are there 24 hours a day, seven days a week for any emergency.

5. The facility's physician schedule for 08/24/16 was reviewed. The schedule revealed Staff J was the only physician scheduled from 7:00 AM through 7:00 PM and Staff I was scheduled on-call in case of emergencies.



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6. Patient #17 presented to the Emergency Department (ED) on 06/08/16 at 9:26 PM. Patient #17 reported to the triage nurse he/she was instructed to come to the ED by his/her physician for an elevated potassium level. The triage nurse noted Patient #17's Presenting Problem as "Abnormal Diagnostic Test."

Review of Patient #17's electronic medical record revealed a Discharge Note documented by the RN (registered nurse) on 06/09/16 at 1:17 AM. Per the note, Patient #17 was discharged to home.

There was no documented evidence Patient #17 received a Medical Screening Examination prior to being discharged. On 06/12/16 at 12:02 PM, four days after Patient #17 first presented to the ED, the MD documented under Doctor Notes "I did not see or evaluate the patient."

Patient #17 then returned to the ED on 06/09/16 at 11:56 AM. He/she reported to the triage nurse he was "advised to return today for high BUN, creatinine, K+." Patient #17 was subsequently admitted to the hospital for "Hyperkalemia" (elevated potassium).

Staff C was made aware of and confirmed these findings on 10/07/16 at 3:23 PM.