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Based on review of medical records, emergency department (ED) log, medical staff bylaws, rules, regulations, physician credential files, hospital documents, nurse training documentation, receiving facility medical records, policies, procedures, and interviews, it was determined the hospital failed to comply with 489.24, as evidenced by failing to:

489.24(a) Tag 2406
a. ensure 22 of 22 ED patients had a appropriate medical screening examination (MSE) conducted by a qualified medical person who was determined qualified by the hospital bylaws or rules or regulations and met the requirements of 482.55 conditions of participation for emergency services (Patients #1-22 inclusive); and

489.24(e) Tag 2409
b. require a physician signed a transfer certification for 3 of 3 patients transferred (Pts #'s 3, 4, and 20);

c. require the hospital documented the receiving facility accepts the transfer of the patient (Pt # 4);

d. require the hospital send a copy of all medical records related to the patient (Pt # 4);

e. require risks and benefits associated with the transfer be documented (Pts # 4 and 20); and

f. require policies and procedures for transfer of emergency patients were established and documented.

The cumulative effect of these system processes resulted in non compliance with the Special Responsibilities of Medicare hospitals in emergency cases.

Based on review of medical records, ED patient log, and staff interview, it was determined the hospital failed to maintain medical records for 3 of 22 ED patients (Pts #'s 8, 13 and 15).

Findings include:

The Medical Staff Rules and Regulations for 2011 and 2012, required: "...Medical Records. 1. The practitioner shall be responsible for the timely completely (sic) of an accurate and legible medical record for each patient...The contents of the record shall be pertinent and current...."

Review of the ED patient log revealed the following:

Patient #8 presented in the ED on 05/05/11 at 1325 hours. The notes indicated the patient's complaint included "feet hurt need pain pill, antibiotics, thinks he has tuberculosis, transferred to (name of acute care hospital)." The hospital did not have a medical record for Pt #8.

Patient #13 presented in the ED on 02/02/11 at 1415 hours, with a complaint of "feels like something in R eye, eye wash station." The hospital did not have a medical record for Pt #13.

Patient #15 presented in the ED on 09/25/10 at 0400 hours, with a complaint of Chest Pain. Notations in the ED patient log included: "...VS (vital signs), Nitro, ASA (aspirin), EKG (electrocardiogram)...(name of acute hospital) ER via PMT (name of ambulance). The hospital did not have a medical record for Pt #15.

The Director of Quality Management (DQM) confirmed on 04/06/12 at 1140 hours, that the hospital did not have medical records for Pts #'s 8, 13 and 15.

Based on review of policies, procedures, physician on-call lists and staff interviews, it was determined the hospital failed to maintain a list of physicians who could be called after the initial examination for further evaluation, treatment, or stabilization for a patient with an emergency medical condition.

Findings include:

The DQM explained on 04/03/12 at 1030 hours, that the physicians who are on duty or cover the ED are "on-call." The hospital maintains a list of physicians for the hours of 0630-2000 hours, that are to be called to evaluate a patient in the ED. The physicians volunteer to be on-call. She explained the hospital does not maintain a list of physicians to provide further evaluation, treatment or stabilizing treatment.

The ED entrance is always locked. A patient can press a button and call for help. The House Supervisor will then be notified there is a patient at the ED entrance. A security guard accompanies the nurse to the ED. Emergency Department patients may also enter the hospital through the main entrance, if they don't see the ED entrance area. The hospital is open for ED patients 24 hours a day, seven days a week.

If an emergency patient arrives between the hours of 0630 and 2000 hours, the staff are to call the on-call physician to see the ED patient. If that physician is not in the hospital making rounds the staff are to page overhead for any physician in the building to see the ED patient. If there is not a physician in the hospital when an emergency department patient arrives, the RN House Supervisor is called to conduct a medical screening examination. The DQM stated on 04/05/12, this is the practice for the ED patients and she verified that there is not a physician in the hospital, immediately available, at all times, to care for emergency patients.

The hospital did not have written policies and procedures if specialty physicians are not available.

Based on review of medical records, ED patient log, hospital bylaws, rules, regulations, physician credential files, hospital documents, nurse training documentation, and staff interviews, it was determined the hospital failed to ensure 22 of 22 ED patients had an appropriate medical screening examination (MSE) conducted by a qualified medical person who was determined qualified by the hospital bylaws or rules or regulations and met the requirements of 482.55 conditions of participation for emergency services (Patients #1-22 inclusive).

Findings include:

During the investigation, a deficient practice was identified that posed a health and safety risk to patients presenting in the ED, resulting in an Immediate Jeopardy (IJ) situation. Specifically, 22 of 22 ED patient medical records revealed that the patients did not have a medical screening examination conducted by an individual who was determined qualified by hospital bylaws or rules and regulations who met the requirements of 482.55 Emergency Services Condition of Participation. Of those 22 ED patients, 12 were assessed by a Registered Nurse. Eight (8) patients were evaluated by a physician who was not determined qualified by the hospital bylaws, rules or regulations. Three patients recorded in the ED log did not have medical records.

Prior to 03/28/12, the hospital bylaws, rules and regulations did not determine who was qualified to perform a medical screening examination. On 03/28/12, the governing body approved new medical staff rules and regulations which included: "...When a person presents themselves to the Emergency Services at the Phoenix campus, an RN who has training and competency to conduct a MSE (medical screening examination) will do so. The RN will then proceed to call a physician to give a full report and receive orders. On days, the RN will use the Emergency Call List. During evening hours the RN will involve the House Physician...."

The hospital directed the Surveyors to the hospital bylaws section below as the requirements for a physician to conduct a medical screening examination.

Review of the hospital bylaws approved by the Governing Board 03/22/11, included: "...Emergency Privileges...Individual Emergency...In the case of an individual emergency as defined in this Section, any Physician, dentist or podiatrist Member of the Medical Staff, to the degree permitted by his/her license, education and training -- regardless of Medical Staff status or lack of it--shall be permitted and assisted to do everything possible to prevent serious permanent harm to an individual, using every available facility of the Hospital necessary including the calling for any consultation necessary or desirable...."

The Surveyors requested the Medical Staff criteria that established qualifications that a medical staff member must possess in order to be granted privileges for the provision of emergency services. The hospital provided a credentialing form that the House Physicians use to request privileges. The physicians could request the following privileges: "Abdominal paracentesis; anoscopy; arterial cannulation/arterial puncture; arthrocentesis; central line insertion; chest tube placement; control epistaxis; I&D abscesses; Intubation; IV anesthesia; local anesthesia; lumbar puncture; management of cardiac emergencies; management of extremity strains, sprains, and muscular injuries; management of superficial localized burns; other airway management; preliminary x-ray interpretation; regional anesthesia; removal of foreign body by minor incision, speculum or forceps, repair of simple lacerations, temporary pacing; temporary splinting of dislocations and fractures thoracentesis; venous cannulation; ventilator management; and Level IV Emergency Service: Determine if an emergency exists, render life saving first aid and make appropriate referral to the nearest organization that is capable of providing needed service."

The hospital considered the Level IV Emergency Service request as criteria delineating privileges ("qualifications") as an ED physician. If the physician was approved for the Level IV Emergency Services they were then qualified to supervise the emergency department and conduct medical screening examinations. No qualifications were included.

The Director of Quality Management stated the term "qualifications" referred to the above quoted privileges listing.

Review of 5 physician credential files revealed the House Physician credential files contained approval for Level IV Emergency Services and the non House Physician files did not include privileges for supervising the ED.

The DQM verified on 04/04/12, that all of the House Physicians who provide hospital coverage at night have been privileged for Level IV Emergency Services. She explained the House Physicians are like hospitalists, and confirmed the Non House Physicians did not have additional privileges granted by the hospital for supervising the ED.

If an emergency patient arrives between the hours of 0630 and 2000 hours, the staff is to call the on-call physician to see the ED patient. If that physician is not in the hospital making rounds the staff are to page overhead for any physician in the building to see the ED patient. If there is not a physician in the hospital when an emergency department patient arrives, the RN House Supervisor is called to conduct a medical screening examination. The DQM stated on 04/05/12, this is the practice for the ED patients and she verified that there is not a physician in the hospital, immediately available, at all times, to care for emergency patients.

Review of the House Supervisors personnel files for Personnel #'s 4, 5, 6 and 7, revealed the files contained no documentation of training or competencies for the ED. On 04/05/12, the DQM identified that the hospital provided a class for the House Supervisors that would qualify them to work in the ED. The name of the class was "Critical Thinking In Defensive Triage." She verified the hospital has had one training class to date.

The hospital provided the attendance sheet for this triage class which indicated there were 3 House Supervisors that attended the training on 06/01/11. The hospital has 9 House Supervisors working for the hospital currently. Of those 9 House Supervisors, 3 have attended the "Critical Thinking In Defensive Triage" class.

The DQM confirmed on 04/05/12, that the hospital considered the "Critical Thinking In Defensive Triage" as training for the nurses to conduct the medical screening examinations for ED patients.

Review of ED patient medical records revealed:

Patient #1:Presented to the ED on 03/25/12, with a complaint of nausea, abdominal pain, left upper quadrant and left lower quadrant. A registered nurse (Personnel #5 ) assessed the patient. The ED physician (Physician #2) documented the following: "Young male with ulcerative colitis presented for abd. pain. Transfer to (Name of acute care hospital) hospital. Ambulance was offered. Pt refused and called his wife to take him to ER. Hemodynamically stable."

Patient #2:
Presented to the ED on 01/20/11, with a complaint of chest pain, feels like "something is sitting on her chest." The patient was assessed by a RN (Personnel #15). No physician documentation is in the medical record. The nurse started an intravenous (IV) line, administered oxygen (O2) at 2 liters (L). The nurse called 911 and sent the patient to an acute care hospital. No physician documented evaluating the patient and ordering the IV or O2. The ED did not have protocols or standing orders for the nurses.

Review of the receiving hospital's medical record included the following documentation: "...The following Life or Limb Threatening Differential Diagnosis were considered: Myocardial Infarction; CAD; Pulmonary Embolus; Thoracic Aorta Dissection (TAD); Pneumonthorax; AAA; Myocarditis; Pericarditis; Pericardial Effusion; Pneumonia; Mediastinitis...01/20/2011...13:25...."

Patient #3:
Presented to the ED on 11/15/11, with a complaint of lower back pain. RN Personnel #5 assessed the patient. The patient was transferred to an acute care hospital. No physician documentation is on the medical record. The transfer documentation included a verbal order from Physician #2 to transfer the patient to another acute care hospital. Physician #2 signed the medical record without documenting any notes or signing the transfer certification form.

Review of the receiving hospital's medical record indicated the patient was admitted with diagnoses of: back pain; renal insufficiency; tachycardia; diverticulits and hypertension.

Patient #4:
Presented to the ED on 01/27/12, with a complaint of nausea, vomiting, diarrhea for 2 days. RN Personnel #16, assessed the patient and called 911 for transfer to another acute care hospital. The RN documented: "...Dr (name) notified of transfer and he agrees...." No laboratory tests or treatments were initiated for this patient.

Review of the receiving hospital's medical record indicated the patient was admitted with a Mallory-Weiss tear, intractable vomiting, and dehydration.

Patient #5:
Presented to the ED on 01/20/12, with a complaint of diarrhea six times and vomiting three times. RN Personnel #5 assessed the patient and called physician #2 who ordered the patient to be discharged home and go to an ER if fever, headache, abdominal pain or further vomiting. The physician did not evaluate the patient.

Patient #6:
Presented to the ED on 08/13/11, with a complaint of pain in the right leg after a fall. The physician documented the following: "Alert and Oriented. Heart: Regular, Lungs: clear, Abd: soft, Ext(remities): Pain in R thigh...Patient stable for transfer to ER for further evaluation." The patient was transferred to another acute care hospital.

Review of the receiving hospital's medical record indicated the patient had leg pain with "fractured hardware."

Patient #7:
Presented to the ED on 07/07/11, with a complaint of sharp pain in the right lower quadrant of the abdomen. The patient said he drank 1 beer to kill the pain, but it didn't work. Vital signs upon arrival included: blood pressure (BP) 174/88, pulse (P) 120, respirations (R) 20, temperature (T) 98.0 Fahrenheit (F). The patient reported vomiting one time earlier in the day. The RN started an IV on the patient. The patient was transferred to another acute care hospital. The physician did not evaluate the patient. The nurse documented a verbal order from the physician for transfer.

Patient #8:
Presented to the ED on 05/05/11, at 1325 hours, with complaints of feet hurting, needing pain pills, antibiotics, and the patient thought he had Tuberculosis. Notations in the ED log indicated the patient was transferred to another acute care hospital. The hospital did not have a medical record for this patient.

Patient #9:
Presented to the ED on 04/11/11, with complaints of needing psychiatric help, after using $200-$300 dollars for cocaine. Nursing documented the patient reported struggling financially and was falling apart and had a "hard time breathing." The nurse documented the patient was not at risk for self harm or elopement. The physician did not document in the medical record other than to sign the certification for transfer, which had been dated and timed by the nurse. The DQM verified she could not be certain when the physician signed the transfer form or that the physician ever evaluated the patient.

Patient #10:
Presented to the ED on 03/29/11, with complaints of bilateral lower back pain starting on 03/28/11 and progressively getting worse. The patient's past medical history included bladder, prostate, lymph node cancer, with removal of the bladder, and prostate. The patient had a ureterostomy for 1.5 years. Nursing documented calling the ED physician at 1750. The ED physician called back at 1805 and ordered the patient to be transferred to another acute care hospital. The patient refused to be transferred and the nurse signed the patient out against medical advice. No laboratory tests were performed on the patient. Vital signs included: BP 154/101, P 83, R 20, T 97.2, pain 8 on a scale of 0 to 10, with 10 the worst pain ever.

Patient #11:
Presented to the ED on 03/29/11, with complaints of hitting the back of his head and reported "feeling weird," the room was spinning. A physician evaluated the patient, ordered Tylenol and observed the patient for 1 hour and sent the patient home. No neurological examination was documented. A Glascow Coma Scale of 15 was documented.

Patient #12:
Presented to the ED on 03/11/11, with complaints of back pain with burning and tingling in his feet with difficulty walking. The patient reported his legs felt weak. Past medical history included back surgeries in 1995, and 1997. The physician documented to transfer the patient for "pain control." The patient was transferred to another acute care hospital.

Patient #13:
Presented to the ED on 02/02/11, with complaints of the feeling like something is in her right eye. The hospital did not have a medical record for this patient.

Patient #14:
Presented to the ED on 10/13/10, with complaints of a stiff back. The patient refused vitals signs and treatment. The patient left without treatment.

Patient #15:
Presented to the ED on 09/25/10, with complaints of chest pain. According to notes in the ED log the patient received Nitroglycerine, Aspirin, Morphine and an EKG. The patient was transferred to another acute care hospital. The hospital did not have a medical record for the patient.

Review of the receiving hospital's medical record revealed the patient was admitted to the hospital with the following diagnoses: Chest Pain; Atrial Fibrillation.

Patient #16;
Presented to the ED on 09/02/10, with complaints of shortness of breath and chest pain. The patient's past medical history included a pericardial effusion. The patient's pain level was reported as a 7. The patient received Nitroglycerin and the pain was at a 5 level. The patient received an Aspirin and was transferred to another acute care hospital. A physician did not evaluate the patient or write orders for the medications given to the patient.

Review of the receiving hospital's medical record indicated the patient received an EKG, chest x-ray (CXR) and determined he did not have an emergency medical condition.

Patient #17:
Presented to the ED on 08/09/10, with complaints of pain to the genital area with swelling for 4 days. Nursing assessed the patient and called a physician who verbally ordered the patient to be transferred to another acute care hospital.

Patient #18:
Presented to the ED on 07/0910, with complaints of burning with urination with discharge from the urinary meatus. The physician did not document in the medical record except to sign the certification for transfer to another acute care hospital.

Patient #19:
Presented to the ED on 06/02/12, with complaints of dizziness and feeling faint. The patient reported being 10 weeks pregnant. The physician evaluated the patient and transferred the patient to another acute care hospital. No laboratory tests were performed on the patient.

Patient #20:
Presented to ED on 05/25/10, with complaints of chest pain radiating from the sternum to the back. The past medical history includes congestive heart failure, pacer, and hypertension. Documentation included the patient used street drugs and was on Methadone. An EKG was obtained and the report included: "...Sinus Tachycardia with occasional premature ectopic complexes, left atrial enlargement, nonspecific intraventricular block, inferior infarct, age undetermined...." A physician did not evaluate the patient. The patient was transferred to another acute care hospital. No treatment was initiated for the patient.

Review of the receiving hospital's medical record indicated the patient was admitted with the following diagnoses: Chest Pain; Congestive Heart Failure; Substance Abuse; and Human Bite.

Patient #21:
Presented to the ED on 05/23/10, with complaints of midsternal chest pain with dizziness. Past medical history included a mechanical heart valve, heart attack 8 years prior, and on coumadin. A physician evaluated the patient. The EKG report included: "Undetermined Rhythm, Inferior--Posterior infarct, age undetermined." The patient was transferred to another acute care hospital. The patient did not receive any treatment.

Patient #22:
Presented to the ED on 04/04/12, with complaints of kidney stones and left lower quadrant abdominal pain. Nursing assessed the patient and two physicians evaluated the patient. The patient received an IV, Morphine for pain and was transferred to another acute care hospital. The Surveyors were on site when this patient arrived and requested to observe the care of the patient.

On 04/05/12, the DQM confirmed the above information, and lack of 3 medical records in the findings as identified above.

Based on review of ED medical records, policies, procedures, medical staff bylaws, rules, regulations and staff interviews, it was determined the hospital failed to ensure:

1. a physician signed a transfer certification for 3 of 3 patients transferred and advised the patients of the risks and benefits associated with the transfer (Pts #'s 2, 4, and 20);

2. the hospital documented the receiving facility accepts the transfer of the patient (Pt #4);

3. the hospital sent a copy of all medical records related to the patient (Pt # 4); and

4. policies and procedures for transfer of emergency patients were established and documented.

Findings include:

The hospital policy titled "Emergency Room Services," revised 08/07, required: "...The physician will make decisions and give orders regarding...transfer...If able, have patient sign consent for transfer following the facilities policies and procedures...If the individual must be transferred to a higher level of care, the staff will follow the facility's EMTALA policies and procedures...."

The hospital provided a policy titled "Consent for Transport and Transfer of Inpatients" that included: "...Purpose: To adequately inform patients and/or their decision-maker regarding the risks, benefits and alternatives involved in a transport or transfer of an inpatient to another facility...."

1. The following patient records did not have a physician signature for transfer and did not indicate the patient was aware of the risks and benefits of the transfer:

Patient #2:
Presented to the ED on 01/20/11, with a complaint of chest pain, feels like "something is sitting on her chest." The patient was assessed by a RN (Personnel #15). No physician documentation is in the medical record. The nurse started an intravenous (IV) line, administered oxygen (O2) at 2 liters (L). The nurse called 911 and sent the patient to an acute care hospital. No physician documented evaluating the patient and ordering the IV or O2.

Nursing documented the patient was "...shaky, wanting to be transferred to (name of other hospital) ASAP (as soon as possible), refused to sign paperwork..." Two nurses documented on a transfer form that the patient refused transfer, however, no physician documentation is present on the form or in the patient's medical record.

On 04/05/12, the DQM confirmed the findings in the medical record.

The Emergency Medical Services transport documentation included the following information: "...O/A (on arrival) E9 (Engine 9) witnessed Pt sitting upright unassisted in chair c/o of sharp chest pain in lobby of (name of hospital)...1315...(arrived) at (name of receiving hospital) Pt states feeling better...."

Review of the receiving hospital's medical record included the following documentation: "...The following Life or Limb Threatening Differential Diagnosis were considered: Myocardial Infarction; CAD; Pulmonary Embolus; Thoracic Aorta Dissection (TAD); Pneumothorax; AAA; Myocarditis; Pericarditis; Pericardial Effusion; Pneumonia; Mediastinitis...01/20/2011...13:25...Patient wishes to leave the ED AMA (against medical advice). She has alcohol on board but is clinically sober. She is alert/oriented x3, speaks w/o slurred speech and ambulates w/o ataxia. She is capable of making decisions. Risks of death/disability are explained and she expresses understanding...."

Patient #4:
Presented to the ED on 01/27/12, with a complaint of nausea, vomiting, diarrhea for 2 days. RN Personnel #16, assessed the patient and called 911 for transfer to another acute care hospital. The RN documented: "...Dr (name) notified (by phone) of transfer and he agrees...." No laboratory tests or treatments were initiated for this patient.

A physician did not document advising the patient of the risks and benefits of a transfer to another facility. The hospital's RN called 911 when the patient arrived to transfer the patient to another acute care hospital. According to the hospital's bylaws rules and regulations in effect at the time the patient presented to ED, they did not determine a RN could perform a medical screening examination or was a qualified medical person to sign the transfer certification. On 04/05/12, the DQM confirmed the findings.

Review of the receiving hospital's medical record indicated the patient had "...vomiting...for 2 days...The symptoms are severe, pain...vomiting x 2-3 days. now with coffee ground and blood clots...." The patient had multiple tests upon arrival at the receiving hospital and received a nasogastric tube, heparin lock, two doses of intravenous (IV) Zofran for nausea, 6 milligrams (mg) Dilaudid for pain, 2 mg Ativan, two doses of Benadryl, Reglan and 2 liters of normal saline IV's. The patient was admitted with the following diagnoses: Vomiting; Mallory-Weiss Tear; Dehydration; and Intractable Vomiting.

Patient #20:
Presented to ED on 05/25/10, with complaints of chest pain radiating from the sternum to the back. The past medical history includes congestive heart failure, pacer, and hypertension. Documentation included the patient used street drugs and was on Methadone. An EKG was obtained and the report included: "...Sinus Tachycardia with occasional premature ectopic complexes, left atrial enlargement, nonspecific intraventricular block, inferior infarct, age undetermined...." A physician did not evaluate the patient. The patient was transferred to another acute care hospital. No treatment was initiated for the patient.

A physician did not document advising the patient of the risks and benefits of a transfer to another facility. The RN called the physician and gave a verbal report of the nursing assessment. According to the hospital's bylaws rules and regulations in effect at the time the patient presented to ED, they did not determine a RN could perform a medical screening examination or was a qualified medical person to sign the transfer certification. On 04/05/12, the DQM confirmed the findings.

Review of the receiving hospital's medical record indicated the patient was admitted with the following diagnoses: Chest Pain; Congestive Heart Failure; Substance Abuse; and Human Bite.

2. The following patient records did not indicate the receiving facility accepted the patients:

Patient #4:
See #1 above for patient #4 information.
Documentation for Patient #4 did not include information that the hospital notified the other acute care hospital and that they accepted transfer of the patient. On 04/05/12, the DQM confirmed the findings.

3. The following patient records did not indicate the receiving hospital was sent available medical records for the patients:

Patient #4
See #1 above for patient #4 information.

On 04/05/12, the DQM confirmed the findings.

4. The DQM confimed on 04/05/12, the hospital does not have another policy and procedure for the transfer of ED patients or another policy titled EMTALA policy referenced in the Emergency Room Services policy. The only hospital policies regarding EMTALA and transfer of patients are referrenced above.

The hospital did not have a policy and procedure which met the EMTALA requirements for transfer of patients.