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Based on interview, record and document review, the facility failed to comply with 42 CFR 489.24 by

a. not providing a complete medical screening examination to 2 of 23 patients (Patients 18 and 20) who both arrived to the emergency department with abdominal pain,

b. by failing to document a patient's refusal of 3 of 23 patients (Patients 16, 18 and 19) who refused further examination or treatment, and

c. by failing to execute an appropriate transfer of 1 of 23 patients (Patient 19).

Findings include:

1. On August 11, 2010, the records of Patients 18 and 20 were reviewed. The patient arrived to the emergency department complaining of abdominal pain and Patient 20's medical screening exam did not include a cardiac examination to rule out any cardiac issues and did not assessment for past medical history of acute lymphocytic leukemia. Patient 18 arrived to the emergency department with a complaint of lower abdominal pain and did not include any history of present illness or past medical history. (See A2406).

2. On August 11, 2010, a review of the records of Patients 16, 18 and 19 did not include a refusal form as required by 42 CFR 489.24(d)(3), when the patient left or refused a transfer against medical advice (See A2407).

3. From August 11, 2010 to August 12, 2010, the record of Patient 19 was reviewed. Patient 19, a 35 week pregnant female, felt the need "to push" and went via private car to Hospital 2 when the hospital was not aware (See A2409).

Based on observation and interview, the facility failed to post conspicuously in their emergency department in a place where individuals waiting for examination and treatment in areas other than traditional emergency departments a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor. The facility also failed to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital participates in the Medicaid program for one of three signs posted on the hospital's entrances.

Findings include:

On August 10, 2010, at approximately 4:10 P.M., a tour was conducted around the emergency department. The ambulance entrance was observed with the Quality Risk Manager. The Quality Risk Manager stated that individuals that arrive via ambulance, come through this entrance and right into the emergency department. There was no sign regarding specifying the rights of individuals under section 1867 of the Act at this entrance. The entrance to the emergency department waiting room was then observed. The sign specifying the rights of individuals under section 1867 of the Act was posted on the door however information indicating whether or not the hospital participates in the Medicaid program was not. The waiting room, a room called the "screening room" and all six treatment rooms were toured. there were no signs were posted specifying the rights of individuals under section 1867 of the Act.

A review of the policy " Emergency Medical Treatment and Labor Act (EMTALA)," under "Policy:" stated, "it is [the facility's] policy to comply with Emergency Medical Treatment and Labor Act (EMTALA) and related laws and requirements. 42 U.S.C., & 1395dd; 42 C.F.R. & 489.20 et seq." Under "Procedure:" there was no mention of posting of signs and the requirements of such signs.

Based on interview and record review, the facility failed to provide an appropriate medical screening examination for 2 of 23 sampled patients (Patient 20) by not providing a cardiac evaluation for patient experiencing signs that a cardiac examination is warranted and further screening based on her past medical history of cancer.

Findings include:

1. Patient 20 is 16 years old and according to her medical record arrived to the emergency department on May 17, 2010 at 0238 with a chief complaint of "epigastric pain, radiating." Patient 20 also reported as having acute lymphocytic leukemia (a cancer that affects white blood cells) in her past medical history. The physician saw Patient 20 at 0248, and examined her eyes, ears, oropharynx, neck, lungs, abdomen, and back. There was no assessment of Patient 20's heart, and no further assessment based on her past medical history of acute lymphocytic leukemia (assessment for active cancer or metastasis).

2. Patient 18, a 45 year old female, presented to the emergency department on February 20, 2010 at 1804 with a chief complaint of "L[eft] Lower Abdomen Sharp Pain." Patient 18 reported to the physician that her pain was "8 out of 10." Patient 18's medical screening exam revealed that Patient 18 has an excerbation of an ovarian cyst, however her medical screening exam revealed no history of present illness, no past medical history and no screening for possible pregnancy. There was no imaging to rule out a rupture or laboratory work to rule out infection.

Based on interview, record review and document review the hospital failed to document the refusal of the 3 of 23 sampled patients (Patients 16, 18 and 19) and that the patient had been informed of the risks and benefits of refused the examination and /or treatment for an emergency medical condition.

Findings include:

1. Patient 16, a 71 year old female, presented to the emergency department on March 15, 2010 at 1343 with a chief complaint of "cough, congestion." A review of Patient 16's record revealed that the physician examined Patient 16 at 1346 and ordered a complete blood cell count (CBC) which showed a white cell count of 13.8 (normal is 4.5 -11.0, a high value can indicate infection). Under "Subject/Objective" the physician wrote "refusing to go to [Hospital 4], however on further review, there was no refusal form including the risks and benefits signed by the patient. On interview, the Emergency Department Nurse Supervisor stated there was a form that the hospital used for "Against Medical Advice" and she confirmed that this form was not in the record of Patient 16.

2. Patient 19, a 32 year old female, presented to the emergency department on March 28, 2010 at 1640 with a chief complaint of "pain in the back of the head." At 1648, the physician began to examine Patient 19, however at 1716, Patient 19, stated, "...I can't stay here for 2 [hours] I need to get a babysitter." Patient 19 then left. There was no refusal form in Patient 19's record for this encounter which the Emergency Department Nurse Supervisor confirmed.

3. Patient 18, a 45 year old female, presented to the emergency department on February 20, 2010 at 1804 with a chief complaint of "L[eft] Lower Abdomen Sharp Pain." Patient 18 reported to the physician that her pain was "8 out of 10." Patient 18's medical screening exam revealed that Patient 18 has an exacerbation of an ovarian cyst. Patient 18 received hydromorphone (a potent narcotic pain medication) at 1825. According to the patient's record at 1830 the hospital discharged Patient 18. Under "Patient Condition on Discharge or Transfer" the record read, "Pain Scale left before re-eval[uation]." The emergency department nurse supervisor stated that the pain scale should be reassessed before the patient is discharged, however this patient left. The emergency department nurse supervisor then reviewed Patient 18's record which revealed no "Against Medical Advice" form.

Based on interview and record and document review the facility failed to provide an appropriate transfer for 1 of 23 patients (Patients 19).

Findings include:


1. Patient 19 presented to the hospital's emergency department on March 10, 2010 at 1811 with a chief complaint of "35 wk (week) pregnant was given terbutaline (a medication to stop premature labor) last dose at 5pm today." The physician medically screened Patient 19 at 1823, under "subject/objective" Patient 19's record read, "36 wk pregnancy feels like she needs to 'push' on terbutaline, h/o (history of) premature delivery, followed by [Physician 3]. Under "Medications" Patient 19's record read, "Terbutaline sc (inject under the skin) 0.25mg (milligram) x i (for one dose) now...1840 pat[ient] left in POV (privately owned vehicle) c (with)heplock (a small tube connected to a catheter in a vein in the arm). Under "purpose" the record read, "[Physician 3] accepts for immediate care in [Hospital 2]. A review of the document "Request for Transfer, Consent for Transfer, Certification for Transfer" annotated that the patient was "stable" and had Physician 3's name as the accepting physician. Under "Acknowledgement Name of Receiving Facility:" no name was documented. Next to this was a box with the words, "Receiving Facility bed availability confirmed." This box was not checked.
The emergency department nurse manager stated on August 10, 2010 that the hospital has no obstretical department and that the obstetrician, Physician 3, was located near Hospital 2, about 50 minutes away.
An interview with Physician 2 occurred on August 11, 2010. Physician 2 stated he called Physician 3 and that Physician 3 stated that she had seen the patient the day before and that no ambulance was needed. When asked where in the record this was documented, Physician 2 stated "it was not documented well."
On August 11, 2010, a representative of Hospital 2 stated that Hospital 2 was not aware that Patient 19 was enroute on March 10, 2010 and at that point in time they did not have the bed space for the patient. The representative continued to state that Physician 3 was called and not Hospital 2 and that Physician 3 is not privileged at Hospital 2 to accept patients for them. The representative at Hospital 2 continued to state that the road between the two hospitals is "rural" and was "unsafe" for Patient 19 to be transfer via private vehicle in that point in time.
On August 12, 2010, the Acting Clinical Director stated that Hospital 2 called the hospital about this incident. The emergency department nurse supervisor stated that to communicate better with Hospital 2, the hospital created a communication sheet to document transactions with Hospital 2. The Quality Risk Manager stated that she was not aware of this new sheet so there was no quality assurance / performance improvement plan was implemented for this sheet.