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A. Based on a tour of the ED (Emergency Department) and staff interview conducted on October 21, 2014 at approximately 10:15 AM it was determined that the facility failed to conspicuously post signage specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor or information indicating whether or not the hospital participates in the Medicaid program.

Findings include:

1. Observation of the ED Triage Room revealed no signage posted.

2. Observation of the ED Prompt Care Area, revealed no signage posted in the Treatment Rooms.

3. Observation of the main entrance to the facility revealed no signage posted.

4. Observation of the ED Same Day Surgery entrance revealed no signage posted.

5. Observation of the ED ambulance entrance revealed no signage posted.

6. Observation of the ED SCIP (Screening and Crisis Intervention Program) area revealed no signage posted in patient rooms.

7. The above findings were confirmed by Staff #2.


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B. Based on a tour of the facility and staff interview conducted on October 22, 2014 at approximately 10:00 AM, it was determined that the facility failed to conspicuously post signage specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment of emergency medical conditions and women in labor or information indicating whether or not the hospital participates in the Medicaid program.


Findings include:

1. Observation of the satellite ED main entrance revealed no signage posted.

2. Observation of the satellite ED, which includes Treatment Areas #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12, revealed no signage posted.

3. Observation of the main entrance to the facility, where the satellite ED is located, revealed no signage posted.

4. Observation of the satellite ED outpatient entrance revealed no signage posted.

5. The above findings were confirmed by Staff #7, #13, and #14.

Based on medical record reviews, reviews of ED Logs, and staff interview it was determined that the facility failed to ensure that all entries in the ED Logs were accurate.

Findings include:

1. Medical Record #15 states that the patient left AMA (against medical advice).

a. The ED Log entry for Patient #15's visit states the patient left without treatment.

b. The ED Log entry does not match the disposition recorded in the medical record.

c. This finding was confirmed by Staff #1.

A. Based on Medical Record review, review of facility policies and procedures, and staff interview, it was determined that not all patients presenting to the ED were provided a medical screening exam by qualified medical personnel.

Findings include:

Reference: Facility Policy #LHS-D072EDS, Triage Emergency Severity Index states, "... Procedure ... 7a. Level I and Level II require immediate treatment. ..."

1. Review of Medical Record #5 revealed the following:

a. The patient was brought to the ED by ambulance at 19:32 on 5/5/14 for a psychiatric evaluation.

b. The patient was triaged at 19:51. The triage nursing note states that the patient stated, "I want to kill myself."

c. The patient was assigned a triage level of 2S (Level 2, SCIP unit) and sent to the waiting room.

d. Per facility policy a triage level 2 patient is to be examined right away.

e. The nurses' notes state that at 02:10 the patient was called to the treatment area and there was no answer.

f. The facility failed to provide a medical screening exam for this patient.

g. This finding was confirmed by Staff #1.

2. Review of Medical Record #4 revealed the following:

a. The patient was brought to the ED by ambulance at 18:07 on 5/5/14 for intoxication.

b. The patient was triaged at 18:26 and assigned a triage level of 2S and sent to the waiting room.

c. Per facility policy a triage level 2 patient is to be examined right away.

d. The nurses' notes state that at 08:05 on 5/6/14 states, "Patient triaged, not seen by physician. Not found in ED waiting room, or vicinity."

e. The patient was in the ED for approximately 12 hours and 30 minutes.

f. The facility failed to provide a medical screening exam for this patient.

f. This finding was confirmed be Staff #1.



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B. Based on medical record review, review of facility documentation, and staff interview, it was determined that not all patients presenting to the ED are provided a medical screening exam by qualified medical personnel.

Findings include:

1. Review of Medical Records #1, #2, and #3 revealed the following:

a. Medical Record #1 - The patient arrived at the ED on 6/16/12 at 12:32AM, was registered, and placed on the SCIP unit, at 12:42AM. The patient was triaged at 12:43AM. Documentation in the medical record indicated the physician evaluated the patient at 5:08AM; four hours and 23 minutes after triage. "Diagnoses: Depression."

b. Medical Record #2 - The patient arrived at the ED on 6/16/12 at 12:35AM, was registered, and placed on the SCIP unit, at 12:46AM. The patient was triaged at 12:46AM. Documentation in the medical record indicated the physician evaluated the patient at 5:09AM; four hours and 23 minutes after triage. "Diagnoses: Depression."

c. Medical Record #3 - The patient arrived at the ED on 6/16/12 at 1:44AM, was registered, and placed the SCIP unit, at 2:15AM. The patient was then triaged at 1:49AM. Documentation in the medical record indicated the physician evaluated the patient at 5:12AM; three hours and 23 minutes after triage. "Diagnoses: Alcohol abuse."

2. Documentation in the medical records indicated that the three patients were evaluated by the physician at 5:08AM, 5:09AM, and 5:12AM, respectively, while in the SCIP unit.

3. Documentation provided by the facility on a "Note to File," and written by the CMO, was dated 8/13/12 and revealed the following:

a. "Dr. (name) was reported by the nursing staff to have provided the documentation in the Emergency Department Record of Medical Evaluation on June 16, 2012 but was not seen to have examined the patient."

b. "A video surveillance system was reviewed of the room the patients were lodged in after initial registration in the Emergency Department."

c. "They were being evaluated for Behavioral Health issues in the SCIP area."

d. "Dr. (name) was to provide a Medical Evaluation."

e. "Our video surveillance did not indicate that he had entered the room."

4. Staff #6 indicated that all three patients were moved to the SCIP unit upon arrival.

5. Staff #4 confirmed the above findings.

Based on a review of facility forms and staff interview, it was determined that the facility's quick registration process for ambulatory patients may deter a patient from seeking medical treatment.

Findings include:

1. During an interview with Staff #5 at the main ED, he/she stated that during pre triage registration, staff will ask the patient for information which includes their name, social security number, date of birth, phone number, doctor's name, the reason for coming to the ED, and for a copy of their driver's license.

a. Asking the patient for their social security number and driver's license is a possible deterrent to individuals seeking treatment, possibly discouraging patients from remaining for further evaluation.

b. This was confirmed by Staff #2.

2. During an interview with Staff #14 at the facility's satellite ED, he/she stated that during the pre triage registration, staff will ask the patient for information which includes their name, date of birth, phone number, doctor's name, the reason for coming to the ED, and for a copy of their driver's license.

a. Asking the patient for their social security number and driver's license is a possible deterrent to individuals seeking treatment, possibly discouraging patients from remaining for further evaluation.

b. This was confirmed by Staff #7.

Based on medical record review, review of facility policy, and staff interviews, it was determined that the facility failed to ensure all transfers were conducted appropriately.

Findings include:

Reference: Facility policy titled "Patient Transfer From The Emergency Department" states, "...Acceptance of the patient by the other institution will. be documented in the patient's medical record. A Transfer Form will be completed for each transfer to an off site care provider. ...".

1. Upon review of Medical Records of transferred patients, (#7, #19, #21, #22, #25, #26, and #29), in 6 out of 7, the "REQUEST FOR TRANSFER CONSENT TO TRANSFER CERTIFICATION FOR TRANSFER" forms, were incomplete.

a. On the "REQUEST FOR TRANSFER CONSENT TO TRANSFER CERTIFICATION FOR TRANSFER" form contained in Medical Record #7, the following areas were incomplete:

(i) Patient Condition on Transfer

(ii) Accompanied By

(iii) Patient Consent to Transfer/Request of Transfer (Check Applicable Box)

b. On the "REQUEST FOR TRANSFER CONSENT TO TRANSFER CERTIFICATION FOR TRANSFER" form contained in Medical Record #19, the following areas were incomplete:

(i) Name of Staff Person

(ii) Title

(iii) Time Contacted

(iv) Transported By

c. On the "REQUEST FOR TRANSFER CONSENT TO TRANSFER CERTIFICATION FOR TRANSFER" form contained in Medical Record #21, the following areas were incomplete:

(i) Name of Staff Person

(ii) Title

(iii) Time Contacted

(iv) Transported By

(v) Accompanied By

d. On the "REQUEST FOR TRANSFER CONSENT TO TRANSFER CERTIFICATION FOR TRANSFER" form contained in Medical Record #22, the following areas were incomplete:

(i) Title

(ii) Time Contacted

(iii) Documentation Sent

e. On the "REQUEST FOR TRANSFER CONSENT TO TRANSFER CERTIFICATION FOR TRANSFER" form contained in Medical Record #25, the following areas were incomplete:

(i) Name of Staff Person

(ii) Title

(iii) Time Contacted

(iv) Risks of Transfer

f. On the "REQUEST FOR TRANSFER CONSENT TO TRANSFER CERTIFICATION FOR TRANSFER" form contained in Medical Record #26, the following areas were incomplete:

(i) Name of Staff Person

(ii) Title

(iii) Time Contacted

(iv) Risks of Transfer

(v) Benefits of Transfer

2. On 10/22/14 at 1:45 PM, the above findings were confirmed by Staff #1.