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Based on document review and interview, the facility failed to ensure documentation indicating an MSE (Medical Screening Exam) was performed (see tag A2406), and failed to ensure copies of all medical records related to the presenting EMC (Emergency Medical Condition) were sent with the patient at or around the time of transfer (see tag A2409).

Findings include:

1. See findings cited at 489.24(1) Medical Screening Exam A2406 and 489.24(e)(2)(iii) Appropriate Transfer A2409.

Based on document review, observation and interview, the facility failed to maintain a central log of each individual that comes to the ED (Emergency Department) seeking assistance and medical care including information whether the patient refused treatment, or was refused treatment, or was transferred, or treated and discharged, or admitted and treated, or stabilized and transferred for 1 of 20 medical records (MR) reviewed (Patient #3).

Findings include:

1. Review of the policy/procedure Emergency Medical Screening Exams (approved 3-21) indicated the following: "A Central Log must be maintained at each area where emergency services are provided. Each individual seeking emergency services must be entered on the log whether he/she refused treatment, was refused treatment....this includes patients that present... and leave without being seen."

2. Review of facility 083 administrative security video recording (no audio) of the ambulance bay on 3-22-21 at 2312 hours indicated an ambulance EMS0345 drove up and stopped at the entrance and the driver side door was approached by Registered Nurse N21 (identified by Administrator and Chief Nursing Officer A1) who appeared to speak with the driver before walking to the back of the vehicle and disappearing out of view at 23:12:40 for approximately one minute before reappearing at 23:13:40 from the back of the vehicle and walking toward the entrance as the ambulance was observed to drive out of view of the camera.

3. Review of facility 083 administrative documentation titled ED Log Report lacked documentation indicating Patient #3 was registered on or after arrival to the ED by ambulance on 3-22-21 at approximately 2312 hours.

4. On 4-22-21 at 1035 hours, staff A1 confirmed no ED log documentation indicated Patient #3 was registered after arrival to the ED around the time of the allegations.

5. Review of the MR for Patient #3 obtained from facility 100 indicated the patient arrived to the ED on 3-22-21 at 2343 hours and was examined and treated by the ED Physician MD25.

Based on document review, observation and interview, the facility failed to perform a MSE (medical screening exam) by a physician or other QMP (qualified medical provider) for 1 of 20 medical records (MR) reviewed (Patient #3).

Findings include:

1. Review of the policy/procedure Emergency Medical Screening Examinations (approved 3-21) indicated the following: "All patients that present to the emergency department shall receive a medical screening examination. Medical screenings may be provided by either a physician (LIP) or a qualified medical person (QMP)... A medical screening exam is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist."

2. Review of facility administrative security video recording of the ambulance bay beginning on 3-22-21 at 2312 hours indicated an ambulance EMS0345 drove up and stopped at the entrance and the driver side door was approached by Registered Nurse N21 (identified by Administrator and Chief Nursing Officer A1) who appeared to speak with the driver before walking to the back of the vehicle and disappearing out of view at 23:12:40 for approximately one minute before reappearing at 23:13:40 from the back of the vehicle and walking toward the entrance as the ambulance was observed to drive out of view of the camera.

3. On 4-22-21 at 1035 hours, the Administrator and Chief Clinical Officer A1 confirmed on 3-22-21 at 2312 hours the facility failed to provide a medical screening examination to Patient #3 after the patient arrived by ambulance to the ED.

Based on document review and interview, the facility failed to ensure consent for transfer was obtained from a patient or patient's representative for 1 of 20 medical records (MR) reviewed (Patient #8) or ensure that copies of all MR were sent with the patient upon transfer to an accepting facility for 5 of 20 MR reviewed (Patients #8, 10, 11, 17 and 18).

Findings include:

1. Review of the policy/procedure Consent to Medical Care for Adult Patients (approved 7-20) indicated the following: "Authorized Representative: Individual designated to act on behalf of the patient... Informed Consent is the agreement by the patient or the authorized representative to receive a medical intervention following a discussion between a patient or authorized representative and the patient's Performing Provider about the patient's condition, the proposed medical intervention including the risks, benefits, and alternatives to receiving that medical intervention... If the patient lacks Decisional Capacity to provide Informed/General Consent, Informed/General Consent should be obtained from an Authorized Representative."

2. Review of the MR for Patient #8 (Pt#8) indicated on 1-18-19 at 1652 hours a facility document titled Advance Directive and Organ Donor Questionnaire was signed by Pt#8 indicating the patient had executed an Indiana Healthcare Representative Appointment and designated their family member FM31 as the patient's representative.

3. Review of the MR for Pt#8 indicated on 1-18-21 at 1145 hours the patient was transported to the Emergency Department (ED) of facility 083 due to a decreased level of consciousness and was seen by the ED Physician MD13. The MR entry by MD13 indicated the patient was difficult to arouse and was maintaining their airway but unable to tell staff what was going on. The MR indicated MD13 discussed the patient's status with the Gastroenterologist MD21 at facility 051 and MD21 accepted the patient transfer and responsibility for ongoing care.

4. Review of the document ED EMTALA Transfer Form indicated MD13 signed the transfer certification on 1-18-21 at 1755 hours after explaining the risks and benefits of transfer to the obtunded patient and the entry on 1-18-21 at 1756 hours by the ED Licensed Practical Nurse N35 indicated the..."pt [was] unable to sign..." in the area for recording the name and/or signature of the patient and/or legally responsible person giving consent for transfer to the accepting facility.

5. The MR indicated on 1-18-21 at 1223 hours that a General Consent for Treatment was obtained from Pt#8's family member and Healthcare Representative, FM31 and no MR documentation indicated MD13 spoke with Pt#8's representative FM31 and/or explained the risks and benefits and/or obtained consent for transfer from FM31.

6. On 4-23-21 at 1200 hours, the Administrator and Chief Nursing Officer A1 confirmed the MR for Patient #8 lacked the above.

7. Review of the policy/procedure EMTALA_Transfers (last revised 3-21) indicated the documentation requirements for the sending hospital when receiving patient transfers from another facility and failed to indicate any documentation requirements for patients being transferred from the Critical Access Hospital (facility 083) to another acute care facility for ongoing care.

8. Review of the ED EMTALA Transfer Form for Pt#8 indicated on 1-18-21 at 1755 hours the patient was ready for transfer and indicated the... "transport crew given pertinent paperwork..." and lacked documentation identifying the copies of the ED record, including a copy of the physician certification of transfer, consent for transfer, treatment provided, all physician and nursing documentation, and copies of diagnostic imaging reports and/or the results of testing that were sent with the patient to the accepting facility.

9. On 4-23-21 at 1200 hours, staff A1 confirmed the MR for Patient #8 lacked the above.

10. Review of the MR for Patient #10 indicated on 3-20-21 at 1518 hours the pregnant patient was transported by ambulance to the ED for evaluation of abdominal pain after being kicked several times by a juvenile. The MR indicated the patient was examined by the ED Physician MD15 and determined to need fetal monitoring overnight, MD15 discussed the patient's condition with the Obstetrician MD22 at facility 171 and MD21 accepted the patient transfer and responsibility for ongoing care. The MR indicated the patient was transferred by private vehicle and the... "transport crew given pertinent paperwork .." and lacked documentation identifying the copies of the ED record sent with the patient to the accepting facility.

11. On 4-23-21 at 1200 hours, staff A1 confirmed the MR for Patient #10 lacked the above.

10. Review of the MR for Patient #11 indicated on 2-5-21 at 2037 hours the patient was transported by private vehicle to the ED for a chief complaint of chest pain. The MR indicated the patient was examined by the ED Physician MD17 and determined to be experiencing a heart attack, MD17 discussed the patient's condition with the Cardiologist MD27 at facility 100 and MD27 accepted the patient transfer. The MR indicated the patient was transferred by ambulance and the... "transport crew given pertinent paperwork..." and lacked documentation identifying the copies of the ED record sent with the patient to the accepting facility.

13. On 4-23-21 at 1240 hours, staff A1 confirmed the MR for Patient #11 lacked the above.

14. Review of the MR for Patient #17 indicated on 2-07-21 at 0147 hours the patient was transported by ambulance to the ED after experiencing 10 out of 10 chest pain unrelieved by nitroglycerin medication. The MR indicated the patient was examined by the ED Physician MD18 and determined to need additional critical care services, MD18 discussed the patient's condition with the Cardiologist MD24 at facility 100 and MD24 accepted the patient transfer. The MR indicated the patient was transferred by ambulance and the... "transport crew given pertinent paperwork..." and lacked documentation identifying the copies of the ED record that were sent with the patient to the accepting facility.

15. On 4-23-21 at 1425 hours, staff A3 confirmed the MR for Patient #17 lacked the above.

16. Review of the MR for Patient #18 indicated on 1-06-21 at 1341 hours the unresponsive patient was transported by ambulance to the ED. The MR indicated the patient was examined by the ED Physician MD19 and determined to need critical care services including intubation and ventilator support, MD19 discussed the patient's condition with the Pulmonologist MD23 at facility 054 and indicated that MD23 accepted the patient transfer and responsibility for ongoing care. The MR indicated the patient was transferred by ambulance and the... "transport crew given pertinent paperwork..." and lacked documentation identifying the copies of the ED record that were sent with the patient to the accepting facility.

17. On 4-23-21 at 1450 hours, staff A3 confirmed the MR for Patient #18 lacked the above.