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Based on reviews of the facility's investigation report and policies and procedures the facility failed to maintain a medical record and other related records for 1 (#21) of 21 sampled patients that presented to the hospital's emergency department.

Findings include:

The facility's Policy and Procedure titled, "EMTALA Policy" policy Number: VH-RM37, Effective 2/2007, Reviewed: 2/15 was reviewed. The policy specified in part, "All nursing staff shall record the details and times of all relevant medical information,history, observations, patient complaints, viral signs, tests, ordered, ,medical orders received, and care or treatment rendered on the triage form or Emergency Department record for each patient."

The investigation revealed a report completed by Vidant Chowan Hospital (Hospital A) filed on 09/28/2015 that patient #21 (no medical record) an 11-year old female was brought to the hospital by a county sheriff's deputy on 09/23/2015 at approximately 2035. .

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that a medical record was maintained for patient #21 on 9/23/2015 when she presented to the hospital's emergency department.

Based on reviews of the facility's investigation report and policies and procedures the facility failed to maintain a central log on each individual who comes to the emergency department seeking assistance as to whether or not he or she refused treatment, or was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged for 1(#21) of 21 sampled patients.
Findings include:

Review of the facility's policy and procedure titled, "EMTALA Policy, Policy Number: VH-RM37, Effective:2/2007, Reviewed: 2/15, revealed in part, "...3. All individuals coming to the Emergency Department shall be logged in. "

A Review of the facility ' s investigation report (filed on 9/28/2015) and the review of hospital staff interviews revealed that patient (#21) was never registered on 9/23/2015.
The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that when patient #21 presented to the ED on 9/23/2015 she was logged into the facility ED log.

Based on reviews of the facility's investigation report and policies and procedures and interviews the facility failed to ensure that an appropriate medical; screening examination was provided that was within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists for 1 (#21) sampled patients.

Findings include


The facility's policy and procedure titled, "EMTALA Policy" Policy Number: VH-RM37, Effective: 2/2007, Reviewed: 2/15 specified in part, Emergency Department Patient Medical. Purpose: To define the process for medical screening of individuals "coming to the Emergency Department" as defined by EMTALA. This provision requires hospital to offer a Medical Screening Examination any individual who "comes to the Emergency Department ...Scope: 1. The individual has presented at a Dedicated Emergency Department and requests examination or treatment or a medical condition or has such a request made on his or her behalf. In the absence of such a request, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition."

The investigation report( filed on 09/28/2015 )by the hospital revealed that patient's (#21) great grandparent's (legal guardians) reported she was throwing a "tantrum" with no other details to Hospital A. The review and hospital staff interviews during the investigation revealed the hospital had started "diversion" earlier on 09/23/2015 due to lack of capacity and staff for VC (Involuntary Commitment) patients. The review of information revealed the sheriff's deputy brought 11 year old to the DED (Dedicated Emergency Department) through the back (DED) entrance. The deputy reported to the hospital's staff that he was aware the hospital was on diversion; however, he did not know what to do with the 11 year old. The deputy reported that he wanted to leave the child with the DED staff and had to return to duty, but he was instructed by the hospital's supervision staff that he would have to stay with the child until the grandparents arrived. The hospital's house supervisor was reported to have asked the deputy if he wanted to register the child (patient #21) but stated that he was waiting for ____(Name) Mobile Crisis (Local County Services) staff to come in hospital. The review revealed that the Mobile Crisis staff came to the hospital after the deputy to talk with the 11 year old (patient #21). The Mobile Crisis staff were reported to have stayed with the child also and that was reported as a confusion to the hospital staff on whether or not the patient was brought to DED for screening of an emergency medical condition or was able to have an informed consent appropriately given by anyone to medically screen the patient as the legal guardians were not present. The review revealed the great grandparents were contacted by the Mobile Crisis staff and worked with the magistrate to complete VC papers for behavior health placement. The review indicated the 11 year old child remained in the custody of the deputy while in the DED lobby. The report revealed that on 09/23/2015 at 2350 the VC papers were obtained and the deputy left with the child (patient #21) to take them to another hospital (Hospital B) for evaluation and treatment. The interviews with the hospital's risk management staff revealed that they received a phone call from Hospital B staff on 09/24/2015 at 0102 that patient #21 had arrived at their DED in the custody of the local county's deputy sheriff from Hospital A. The review revealed that the house supervisor at Hospital A thought that the patient was being directly admitted to Hospital B at the behavioral health unit per arrangements of the Mobile Crisis staff. The report and interviews revealed the patient (#21) was never registered for treatment at Hospital A. The documentation and interviews during the investigation revealed no other documentation for patient #21 was found for patient #21 and that the hospital's DED medical staff never new the patient was in the DED lobby.

Review of Hospital B's closed medical record for patient #21 revealed that on 09/24/2015 at 0103 the patient arrived with the county sheriff's deputy and VC papers. The documentation of the medical screening examination from Hospital B medical staff revealed that the "patient had become belligerent last night, screaming and cursing at the home where she lived with her great grandparents who have legal guardianship." The documentation of the medical screening examination from Hospital B's DEAD medical staff revealed the "Patient most likely would most likely not benefit from inpatient psychiatric admission at the time and was not an immediate danger to herself or others at the time." The documentation revealed the patient denied suicidal or homicidal ideation's and the VC was overturned and a discharge home with her grandfather was done at Hospital B on 09/24/2015 at 1545.

The hospital failed to ensure that there policy and procedure was followed as evidenced by failing to provide an appropriate medical screening examination( MSE) for patient #21 on 9/23/2015 when a request was made in her (#21) behalf by the Deputy based on her behavior determined that the patient needed a MSE for a medical condition.

Based on reviews of the hospital's investigation report and policies and procedures the hospital failed to provide within the capabilities of the staff and facilities available at the hospital for further medical examination and treatment as required to stabilize the medical condition for 1 (#21) of 21 sampled patients.

Findings are:

The facility's Policy and Procedure titled "EMTALA Policy", Effective: 2/2007, Revised: 2/14, page 6 of 21 was reviewed. The policy specified in part, "5. If an Emergency Medical Condition is detected, Necessary Stabilizing Treatment to Stabilize a patient's Emergency Medical Condition shall be rendered in the hospital to an Appropriate Transfer shall be initiated."

The hospital's investigation report and reviews of staff interviews revealed that patient #21 was never registered for treatment and evaluation at Vidant Chowan Hospital on 9/23/2015 and the deputy and child were reported as sitting in the lobby of the registration area

The hospital failed to ensure that there policy and procedure was followed as evidenced by failing to ensure that stabilizing treatment was rendered/provided when patient #21 presented to the DED on 9/23/2015 with an identified emergency psychiatric condition.