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Based on one of twenty emergency room patient records reviewed and staff interviews, the facility failed to provide Patient #7 with a Medical Screening Evaluation (MSE) when she presented herself to the emergency room with a medical complaint.

The findings include:

1. An interview was conducted with the Director Emergency Care Center on 10/9/12 at approximately 9:30 a.m. She stated she discovered the possible EMTALA infraction on 9/5/12 while reviewing the emergency room (ER) log. A patient left the emergency room and did not receive a Medical Screening Examination (MSE). She then notified Risk Management of a possible EMTALA violation.

At 10/9/12 at 10:45 a.m. an interview was conducted with the nurse who was working the emergency room on 9/4/12 when this possible EMTALA infraction took place. She stated she was standing with Patient #7 and the doctor when the doctor told Patient #7 he will do an exam on her and then call an ambulance to transfer her to another hospital since this hospital does not have OB/GYN. Patient #7 said she will go to the other hospital and got up and left the emergency room. There was no medical screening completed by the physician and the patient was not given a form to sign to refuse medical treatment.

The policy and procedures for EMTALA requirements were reviewed. The " Florida Medical Screening Examination and Stabilization Policy " dated 8/11 was reviewed. The Director Emergency Care Center stated since this incident some minor areas were revised on this policy. This policy shows when a medical screening examination (MSE) is required. The hospital must provide a MSE within the capability of the hospital's emergency department to a pregnant woman who requests an examination. An MSE is required when the individual comes to the ER and a request is made by the individual for an examination. The policy shows " The hospital should not move the individual to an off-campus facility or department (such as an urgent care center or satellite clinic) for an MSE. " If the patient refuses to be examined the policy instructs the staff to inform the patient "...the risks and benefits and the hospital's obligations under EMTALA..." The staff will attempt to have the patient sign a form refusing to be examined or treated or document in the patient's record the patient refused to sign this form (Partial Refusal or Care or Against Medical Advice Form).

On 10/9/12 at approximately 1:00 p.m. Patient #7's medical record was reviewed. It showed on 9/4/12 at 2031 she arrived at the ER. Her complaint is she is 8 months pregnant and bleeding. At 2039 the doctor talked with Patient #7 and was given the option to have a MSE or "go to her OB hospital of choice." The patient chose to go to another hospital and left the hospital. The " Disposition Category " showed the patient refused treatment. The comment under this category showed "physician spoke with pt. pt. declined a MSE". The physician dictated a note stating Patient #7 was " never seen in the Emergency Room. " She left prior to a MSE. She had no abdominal pain or cramping. When she found out there is no OB services at this hospital she decided to leave. Her OB/GYN is at another hospital and decided to drive to that hospital to be evaluated. Further review of this medical record showed there is no form or documentation Patient #7 refused MSE and left the hospital against medical advice (AMA). The form Partial Refusal or Care or Against Medical Advice mentioned in the policy was not in Patient #7's medical record. An interview was conducted with the Director Emergency Care Center at the end of this review at 1:00 p.m. She stated there is no AMA form in this record for Patient #7 to sign. If she refused MSE then the staff should have had her sign the AMA form.

Therefore, once Patient #7 presented herself in the emergency room and complained of bleeding a Medical Screening Examination should have been completed for this patient as per the policy and regulation. If the patient refuses to be treated then the Refusal or Care or Against Medical Advice form should have been completed as per the policy. Both of these incidents were not completed for Patient #7.