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Based on record review and staff interviews the Hospital failed to ensure that 3 patients (Unsampled Patient #1, Unsampled Patient #2 and Patient #5) in a total sample of 31 patients, were provided with an appropriate medical screening examination (MSE).

Findings include:

Hospital #2's Policies and Procedures related to Emergency Medical Treatment and Labor Act (EMTALA), dated 8/18/15, indicated that a medical screening evaluation shall be conducted for every patient who presents to the Hospital's Emergency Department (ED) or who presents on Hospital property.

Hospital #2 did not generate a medical record for Unsampled Patient #1 and Unsampled Patient #2.


For Unsampled Patient #1

The Surveyor interviewed the Patient Access Coordinator at 11:10 A.M. on 4/21/16. The Patient Access Coordinator said Unsampled Patient #1 arrived to Hospital #2's ED and had cut her hand a few days prior to arrival. The Patient Access Coordinator said she told Unsampled Patient #1 that he/she would probably not get stitches because the cut occurred more than twenty-four hours prior to arrival to the ED; however, she could register Unsampled Patient #1 and have the cut evaluated for an infection. The Patient Access Coordinator said Unsampled Patient #1 said she was going to call his/her daughter.

Hospital #2's Report of the potential EMTALA violation, dated 4/15/16, indicated Unsampled Patient #1 walked away from the registration desk, sat in the ED's waiting room and then left the ED without being registered or seen by clinical staff.

For Unsampled Patient #2

An Emergency Medical Service (EMS) ambulance trip record, dated 4/21/16, indicated Unsampled Patient #2 was transported from Hospital #1 to Hospital #2 because of a myocardial infarction (MI). The EMS trip record indicated that upon arrival at Hospital #2, Unsampled Patient #2 was brought to Hospital #2's cardiac catherterization laboratory (cath lab) and EMS staff were informed that Unsampled Patient #2 was being transferred to Hospital #3's cath lab. The EMS trip record indicated that the EMS staff placed Unsampled Patient #2 back on the ambulance and transported Unsampled Patient #2 to Hospital #3.

Hospital #2 report of the potential EMTALA violation indicated that Hospital #2 failed to provide a medical screening evaluation to ensure stabilization for transfer to Hospital #3.


For Patient #5

The Hospital's Policy and Procedure titled, Care of Pregnant Patients presenting to the Hospital consistant with EMTALA, dated 7/23/13, indicated that all pregnant patients who present to the hospital shall be assessed, guided to the appropriate service and their medical needs will be determined by qualified medical personnel (QMP). The policy and procedure indicated an obstetrical registered nurse may determine false labor. The policy and procedure indicated obstetrical patients greater than 20 weeks gestation, by date or history, who report they are not in labor, must undergo a full MSE in the ED.

Patient #5's Labor and Delivery triage record, dated 11/9/15, indicated Patient #5 was 37.5 weeks pregnant, arrived at Hospital #2's Emergency Department to be evaluated because for the past two days, she had not felt her baby move. The Labor and Delivery triage record indicated an obstetrical nurse evaluated Patient #5 and determined Patient #5 had no uterine contractions and was not in labor. The Labor and Delivery triage record indicated Patient #5's ultrasound was normal and she was discharged home. Patient #5's medical record did not indicate a MSE by qualified medical personnel as indicated in the Hospital's policy and procedures.

Based on record review and staff interview, Hospital #2 failed to ensure one unsampled patient (Unsampled Patient #2) and 5 patients (Patient #16, #17, #20, #21 and #23) in a sample of 31 were appropriately transferred to another acute care hospital.

Findings include:

The Emergency Medical Service (EMS) ambulance trip record, dated 4/21/16, indicated Unsampled Patient #2 was brought to Hospital #1's cardiac catheterization laboratory with an emergency medical condition, a heart attack. The EMS ambulance trip record indicated that Unsampled Patient #2 was transferred from Hospital #2 to Hospital #3 without a medical screening examination and thus without the completed requirements for an appropriate transfer.

Hospital #2's policies and procedures related to Emergency Medical Treatment and Labor Act, dated 8/18/1, indicated that all applicable fields on the Authorization for Transfer Form were to be completed.

Patient #15's Authorization Transfer Form, dated 1/4/16, did not indicate whether Qualified Medical Personnel (QMP) stabilized Patient #15's emergency medical condition (EMC) or not.

Patient 16's Authorization Transfer Form, dated 1/7/16, did not indicate whether QMP stabilized Patient #16's EMC or not.

Patient #19's Authorization Transfer Form, dated 1/20/16, did not indicate whether QMP stabilized Patient #19's EMC or not.

Patient #20's Authorization Transfer Form, dated 1/13/16, indicated the QMP did not complete the authorization form, nor was it signed.

Patient #22's Authorization Transfer Form, dated 2/6/16, did not indicate whether QMP stabilized Patient #22's EMC or not.