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Based on record review, review of facility polices and staff interviews the facility failed to ensure staff provided 1 of 21 (Patient 21) sampled patients with a medical screening examination. The facility had conflicting policies related to EMTALA and one for providing treatment of emergencies without consent. Findings are:

Record review of the facility document titled "Face sheet" revealed Patient 21 came to the ED (Emergency Department) on 6/22/12 at 11:27 PM. The form contains the patient's name, date of birth, Medicaid number and name of ED on call physician. The patient is noted to be age 17 (a minor). At the bottom of the form is a handwritten note signed by Registered Nurse (RN)-A. RN-A documented the patient "presented to the ER [Emergency Room] desk and complained of "throat pain." The document states "Pt [patient] was told that we couldn't treat her without parent's permission. Pt tried to call Dad multiple times without answer." The patient did not receive a MSE (Medical Screening Examination). The patient, who was not examined by the RN or any practitioner stated "she will go to [name of city where parents live] wake parents and have them take her to the ER there."

B. Staff interview with RN-A on 8/8/12 at 1:30 PM revealed RN-A was the nurse assigned to the ER on 6/22/12. RN A related that the patient rang the ER buzzer around 11:30 PM. RN-A responded to the buzzer with a Nurses Aide. The Nurses Aide got the patient's name and birth date. RN-A stated "right away I knew she was 17 and a minor." RN-A said she asked the patient if they could call the parents "for permission to treat her." RN-A stated the patient tried several times to call the parents without success. RN-A then called the other RN on duty, RN-B, who told her she did not think they could see a minor without the parent's permission and told her to call RN-C, the ED manager. RN-C told the staff that "if we didn't have parent's permission she could not be seen." RN-A stated " I did not take vital signs, check her throat or do any hands on examination of the patient." She said she wrote the comments at the bottom of the Face sheet at the end of her shift (6/23/12 at 6:00 AM). Her documentation related to her notifying Child Protective Services due to concerns for the patient and her living situation. RN-A stated "My worry was that if I examined the minor without their [parent's] consent that they could charge me with battery/assault."

C. Staff interview with RN-C, the ED Manager on 8/8/12 at 2:20 PM revealed the RN had worked in the facility for 22 years with the last 5 as the ED Manager. RN-C recalled the telephone conversation on 6/22/12 regarding Patient 21. She said the patient, age 17, came in with a sore throat or sinus infection with symptoms for a few days and staff were unable to contact the parents. Staff wanted to know if they had to get parental consent or if they could see the patient, a minor, without parental consent. RN-C recalled telling the staff nurses "If she's had symptoms a couple of days, not in acute distress, not emergency, I didn't believe we could see her without parental consent." RN-C stated "Somewhere along the line I thought you couldn't see a minor without parental consent unless an emergency, threat to life or limb." RN-C reviewed the facility policy titled "Treatment of Emergencies Without Consent" issued in 1/1980 and last reviewed 2/2011. RN-C stated that the policy applies to minors and leads staff to believe "that if not an emergency, we cannot treat a minor."

D. Staff interview with the DON (Director of Nursing) on 8/8/12 at 3:20 PM revealed that when she was reviewing ED charges she found the Face Sheet for Patient 21 and note on it but "no ER [Emergency Room] chart with exam." She asked the ED Manager and was told that was all they did as they didn't have parental consent for the exam. The DON stated that she informed the ED manager that "we always have to provide a MSE whether we have permission or not."

E. Record review of facility policy titled "Transfer and Emergency Examination issued 6/1980 and last revised 6/2011 states that "For any individual who comes to the Emergency Department, and on whose behalf a request is made for examination or treatment, an appropriate medical screening examination shall be provided within the capabilities of the Emergency Department."

Record review of facility policy titled "Treatment of Emergencies Without Consent" issued 1/1980 and revised 2/2011 states "An emergency medical situation, i.e., a condition which constitutes a tangible and immediate threat to life or health of a patient, justifies treatment without consent." The policy states "Treatment must be directed only towards the condition creating an emergency." Under the section titled "Procedure" the policy states "This rule applies also to minors if the parent or legal guardian cannot be located and delay would cause deterioration of the patient's condition. Hospital personnel must try at least 2 times to locate the parents and document the time of the calls. When the parent cannot be located (after 2 attempts); proceed with care without consent of parent." The policy further gives direction for Emergency Room personnel stating that staff must document that: "a. An emergency existed: b. The patient was unable to give or withhold express consent: c. Treatment was necessary to prevent immediate aggravation or deterioration of the patient's condition: d. The treatment was limited to what was necessary under the circumstances." This policy is in conflict with the EMTALA policy and leads staff to thinking they can only treat a minor without parental consent in the case of an emergency.

Based on record review, facility policy review and staff interview the facility failed to ensure 1 of 21 (Patient 21) sampled emergency patients received a medical screening examination. Findings are:

A. Record review of the facility document titled "Face sheet" revealed Patient 21 came to the ED (Emergency Department) on 6/22/12 at 11:27 PM. The form contains the patient's name, date of birth, Medicaid number and name of ED on call physician. The patient is noted to be age 17 (a minor). At the bottom of the form is a handwritten note signed by Registered Nurse (RN)-A. RN-A documented the patient "presented to the ER [Emergency Room] desk and complained of "throat pain." The document states "Pt [patient] was told that we couldn't treat her without parent's permission. Pt tried to call Dad multiple times without answer." The patient did not receive a MSE (Medical Screening Examination). The patient, who was not examined by the RN or any practitioner stated "she will go to [name of city where parents live] wake parents and have them take her to the ER there."

B. Staff interview with RN-A on 8/8/12 at 1:30 PM revealed RN-A was the nurse assigned to the ER on 6/22/12. RN-A related that the patient rang the ER buzzer around 11:30 PM. RN-A responded to the buzzer with a Nurses Aide. The Nurses Aide got the patient's name and birth date. RN-A stated "right away I knew she was 17 and a minor." RN-A said she asked the patient if they could call the parents "for permission to treat her." RN-A stated the patient tried several times to call the parents without success. RN-A then called the other RN on duty, RN-B, who told her she did not think they could see a minor without the parent's permission and told her to call RN-C, the ED manager. RN-C told the staff that "if we didn't have parent's permission she could not be seen." RN-A stated " I did not take vital signs, check her throat or do any hands on examination of the patient." She said she wrote the comments at the bottom of the Face sheet at the end of her shift (6/23/12 at 6:00 AM). Her documentation related to her notifying Child Protective Services due to concerns for the patient and her living situation. RN-A stated "My worry was that if I examined the minor without their [parent's] consent that they could charge me with battery/assault." RN-A related that she attended a nursing staff meeting 7/2/12 where the DON (Director of Nursing) informed them that ED staff had to do an examination and call the practitioner on call for all patients including minors who come to the ED. On 8/7/12 RN-A took the self study EMTALA retraining and competency test prior to working the ED on 8/7/12.

C. Staff interview with RN-C, the ED Manager on 8/8/12 at 2:20 PM revealed the RN had worked in the facility for 22 years with the last 5 as the ED Manager. RN-C recalled the telephone conversation on 6/22/12 regarding Patient 21. She said the patient, age 17, came in with a sore throat or sinus infection for a few days and staff were unable to contact the parents. Staff wanted to know if they had to get parental consent or if they could see the patient, a minor, without parental consent. RN-C recalled telling the staff nurses "If she's had symptoms a couple of days, not in acute distress, not emergency, I didn't believe we could see her without parental consent." RN-C stated "Somewhere along the line I thought you couldn't see a minor without parental consent unless an emergency, threat to life or limb." RN-C reviewed the facility policy titled "Treatment of Emergencies Without Consent" issued in 1/1980 and last reviewed 2/2011. RN-C stated that the policy applies to minors and leads staff to believe "that if not an emergency, we cannot treat a minor." RN-C stated she knew this policy and had reviewed it over the years. The policy will be reviewed and changed this month to include treatment of emergency patients without consent. RN-C related that when the incident occurred on 6/22 with Patient 21 it "didn't occur to me it was an EMTALA violation." RN-C felt confident that if a minor comes in that her staff will do a MSE and call the provider on call. She stated "these points were emphasized in the EMTALA training 8/6/12".

D. Staff interview with the DON on 8/8/12 at 3:20 PM revealed that when she was reviewing ED charges she found the Face Sheet for Patient 21 and note on it but "no ER [Emergency Room] chart with exam." She asked the ED Manager and was told that was all they did as they didn't have parental consent for the exam. The DON stated that she informed the ED manager that "we always have to provide a MSE whether we have permission or not." The DON stated that the ED manager was going to talk with RN-A, the nurse who saw Patient 21. The DON also confirmed that RN-A did not put the patient in the ER Central Log as required. On 7/2/12 the DON did an education session with the staff to ensure staff were aware that even if the patient is a minor that staff must do a MSE and call the provider who determines if the patient has an EMC (Emergency Medical Condition). She related the education session was not mandatory and was aware that the 4-5 staff working did not attend. The DON confirmed the minutes of the meeting were not available for staff who did not attend until 8/7/12. The DON spoke with the critical access hospital She stated "some staff may not have been aware of this until the Monday 8/6/12 EMTALA re-education." The DON stated that if staff could not attend the 8/6/12 session that they were required to complete the self study packet before they could work ER. She said the competency tests have demonstrated an understanding with most staff passing with 100% or missing one question.

E. Record review of the facility investigation and self report of an EMTALA violation on 8/2/12 (40 days after the violation occurred on 6/22/12) revealed the facility was not aware they had violated EMTALA until they contacted the Corporate Compliance Officer in the Network for the critical access hospital. The Corporate Compliance Officer assisted the facility in writing the self report letter and with slides for the education of nursing staff.

F. Record review of facility policy titled "Transfer and Emergency Examination issued 6/1980 and last revised 6/2011 states that "For any individual who comes to the Emergency Department, and on whose behalf a request is made for examination or treatment, an appropriate medical screening examination shall be provided within the capabilities of the Emergency Department."

Record review of facility policy titled "Treatment of Emergencies Without Consent" issued 1/1980 and revised 2/2011 states "An emergency medical situation, i.e., a condition which constitutes a tangible and immediate threat to life or health of a patient, justifies treatment without consent." The policy states "Treatment must be directed only towards the condition creating an emergency." Under the section titled "Procedure" the policy states "This rule applies also to minors if the parent or legal guardian cannot be located and delay would cause deterioration of the patient's condition. Hospital personnel must try at least 2 times to locate the parents and document the time of the calls. When the parent cannot be located (after 2 attempts); proceed with care without consent of parent." The policy further gives direction for Emergency Room personnel stating that staff must document that: "a. An emergency existed: b. The patient was unable to give or withhold express consent: c. Treatment was necessary to prevent immediate aggravation or deterioration of the patient's condition: d. The treatment was limited to what was necessary under the circumstances." This policy is in conflict with the EMTALA policy and leads staff to thinking they can only treat a minor without parental consent in the case of an emergency.