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Based on record review, surveillance video review, interview and policy review, the hospital failed to log the arrival of a patient who presented to the emergency department for treatment (A2405); failed to provide a medical screening exam to all patients who presented to their emergency department (A2406); and failed to ensure a signed physician certification was obtained prior to transfer (A2409). This had the potential to affect all patients who presented to the hospital emergency department. The facility logged 2,436 individuals into the emergency department for October 2021.

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe setting.

Based on record review, interview and policy review, the hospital failed to log the arrival of a patient who presented to the emergency department for treatment. This affected one (Patient #1) of 20 records reviewed. The facility logged 2,436 individuals into the emergency department for October 2021.

Finding include:

Review of the municipal police department report dated 10/18/21 revealed Patient #1 arrived at the hospital's emergency department (ED) on 10/18/21 at approximately 3:53 P.M., escorted by police. Patient #1 was hand cuffed, escorted and supervised by two uniformed municipal police officers who approached the hospital ED registration desk.

Review of the municipal police report documented the hospital "advised this unit (police) that the hospital was turning the patient [Patient #1] away and he was not permitted to receive treatment at this hospital." The local police department transported Patient #1 to another area hospital for treatment.
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Review of the hospital security log revealed security was summoned to the emergency department of the hospital to assist with with the local police department on 10/18/21 at 3:58 PM. The identity of Patient #1 was confirmed and the hospital had a "no contact order" (court ordered restraining order). The municipal police were informed the hospital would not accept the patient.

Review of the hospital emergency department (ED) log revealed Patient #1 was not listed. Review of the ED registration chronological event documentation revealed the patient was initially registered on 10/18/21 at 4:01 PM. The SP's ED registration was canceled 10/18/21 at approximately 4:04 PM.

During interview on 11/16/21 at 3:00 P.M., Facility Staff A stated all people who come to the facility's emergency department were to be placed on the ED log. Staff A confirmed during this interview that Patient #1 was not on the ED log.

During interview on 11/18/21 at 8:22 A.M., Registration Clerk (Staff E) revealed she was on duty the afternoon of 10/18/21 and remembered Patient #1. Staff E stated she began the quick registration process for the ED log and then was instructed to cancel the registration, which removed Patient #1 from the ED log.

During interview on 11/18/21 at 11:16 A.M., ED Physician (Staff F) revealed the ED log generated the work flow for the ED and patients were placed on the log, triaged and seen by the physician staff on duty in order of triaged need. Staff F the log was the master keeper of all patient that presented to the ED.

Review of the hospital policy and procedure titled "EMTALA", effective 08/14/19 and most recent review date of 08/14/21 directed as follows:

The hospital will keep a central log identifying each individual who came to the DED or
elsewhere on Hospital Property seeking care and whether the individual:

1. refused treatment;
2. was refused treatment;
3. was transferred, or stabilized and transferred;
4. was admitted and treated; or
5. was discharged.

The hospital has the discretion to maintain the log in a form that best meets its needs. The central
log should include, directly or by reference, patient logs from other areas of the hospital, such as
pediatrics and labor and delivery where a patient might present for emergency services.

Based on record review, surveillance video review and interview, the hospital failed to provide a medical screening exam to all patients who presented to their emergency department. This affected one (Patient #1) of 20 medical records reviewed. The facility logged 2,436 individuals into the emergency department for October 2021.

Findings include:

Record review revealed Patient #1 had been admitted on 08/31/21 to this hospital with diagnoses including developmental delay, schizoaffective disorder, psychosis, seizures and aggressive behaviors. The medical record documented Patient #1 had been bound over to police following discharge for an unprovoked attack and punching a fellow patient during this visit.

Review of the municipal police department report dated 10/18/21 revealed Patient #1 arrived at the hospital's emergency department (ED) on 10/18/21 at approximately 3:53 P.M., escorted by police. Patient #1 was hand cuffed, escorted and supervised by two uniformed municipal police officers who approached the hospital ED registration desk.

Review of the hospital's ED surveillance video dated 10/18/21 at 3:55 P.M. revealed two uniformed police officers escorted a handcuffed male into the ED registration area. The patient was identified as Patient #1. The hospital safety officers approach the emergency department registration area and talk with the local police officers. Multiple hospital staff are observed to approach the area and observe the situation involving Patient #1. At no time was the patient escorted to a triage area or observed and assessed by the facility's emergency department physicians or qualified medical practitioner.

Review of the municipal police report documented the hospital "advised this unit (police) that the hospital was turning the patient [Patient #1] away and he was not permitted to receive treatment at this hospital." The local police department transported Patient #1 to another area hospital for treatment.

Review of Patient #1's medical record revealed no evidence a medical screening exam of Patient #1 was ever completed during the time the patient was present at the hospital.

During interview on 11/16/21 at 3:00 P.M., Facility Staff A stated Patient #1 did not receive a medical screening exam and was not evaluated by a physician to determine if an emergency medical condition existed. Staff A stated the hospital was unable to provide documented evidence Patient #1 received a medical screening exam or was evaluated by a physician for an emergency medical condition.

During interview on 11/18/21 at 11:16 A.M., ED Physician (Staff F) stated all patients who come to the ED and desired to be seen should all receive a medical screening exam to determine if a medical emergency existed. In the event of a patient presented to the ED and was on the hospital's "No Contact" list, the patient would still be seen and evaluated by a physician or qualified medical practitioner, stabilized if an emergency medical condition existed and then be transferred appropriately but would not be admitted.

Based on record review, interview and policy review, the hospital failed to ensure a signed physician certification was obtained prior to transfer. This affected three (Patients #3, #4, and #16) of eight medical records reviewed for emergency department transfers.

Findings include:

1. Patient #16 presented to the emergency department on 11/18/21 with chief complaints of abdominal pain, nausea and emesis. Patient #16 was determined to have an anterior wall hernia with bowel causing obstruction.

A physician note by Staff B on 05/03/21 2:24 PM stated the patient will likely need ICU (intensive care unit) admission and the hospital did not have any ICU beds available at this time. The physician suggested transfer to tertiary care center. Patient #16 was transferred to a different facility.

The record did not contain a signed Physician Certification for the transfer.

2. Patient #3 arrived at the facility's emergency department and was evaluated on the facility's labor and delivery unit on 10/18/21. Patient #13, 39 weeks 2 days pregnant, was complaining of contractions that began in the morning. Patient #13 was determined to have a low platelet count and the decision was made to transfer her to a different facility for higher level of care.

A "Patient Transfer from Emergency Department" form was filled out but did not contain a physician's counter signature.

3. Patient #4 arrived at the emergency department on 11/18/21 after experiencing suicidal ideation. Patient #4 was transferred to a different facility for treatment.

The medical record did not contain Physician Certification for the transfer.

During interview on 11/18/21 at 2:39 P.M., Staff A verified the above medical records did not contain a physician's certification for the transfers.

Review of the hospital policy tiled "ED (Emergency Department) policy MSCH-ED", revised 06/10/20, stated:

Transfer to another facility.

*Procedure:

A. Place a call to arrange for transport. Send with transporting agency, crew and patient.
B. Prepare a copy of the medical record from CarePATH, face-sheet and copy of EKG (Electrocardiogram). Send with transporting agency crew and patient.
C. Complete transfer form and certificate of necessity form.
1. Fax to transporting agency
D. Inform patient and family of expected time of transport and arrival.
E. Call report to facility where patient is being transferred to.

Review of the hospital policy titled "System Guideline for Obstetrical Patient Flow; Pregnant Patients Presenting for Care to Emergency Department or Obstetrical Units", Revision 2, effective 10/19/21, stated:

4. Pregnant patients presenting with obstetrical complaints that include but are not limited to abdominal pain, lower back pain, pelvic or rectal pressure, leakage of fluid from the vagina, vaginal bleeding and or nausea/vomiting may be seen:

a. In Labor & Delivery, by the OB (obstetrician) resident or registered nurse will document the care that he/she provides in the patient's medical record and require the physician acknowledgement and co-signature, to comply with applicable documentation requirements.

b. They will discuss each patient's examination and care with the attending, the on-call physician, or section chair.

c. The physician will direct the Labor/Delivery registered nurse in appropriate stabilization treatment and at the appropriate time, discharge or transfer will be conducted in accordance to the physician orders.