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Based on documentation and interviews, the hospital failed to ensure compliance with requirements of 42 CFR 489.24, as evidenced by the deficient practice cited a t 42 CFR 489.24 (a) and (C).

Based on documentation, the hospital failed to maintain a central ED log which accurately tracked the care provided to 3 of 20 patients (P13, P15, and P8), who presented to the ED for evaluation of an emergency medical condition. Findings include:

The hospital's ED log indicated that P13 presented to the ED on 08/22/13 at 7:30 p.m. for evaluation of a possible stroke. The ED log entry for P13 was a late entry made on 08/27/13; the provider's name and patient's disposition were blank.
The ED log for P15 indicated that P15 presented to the ED on 06/28/13 in cardiac arrest and was later discharged from the ED. P15's ED record indicated that EMS brought P15 to the ED via ambulance and CPR was in progress at the time of P15's arrival. The history of present illness indicated that P15's arrest was witnessed by family 12 minutes prior to ED arrival and CPR was performed the entire 12 minutes. The ED record indicated that CPR and other resuscitative efforts were continued in the ED for 40 minutes, at which time P15 was pronounced dead. P15 expired in the ED, which was not included on the ED log.

The ED log for P8 indicated that P8 presented to the ED on 08/04/13 with symptoms of shortness of breath and asthma. The ED log did not indicate the patient's disposition from the ED. P8's ED record indicated that P8 was seen in the ED for an acute asthma attack that occurred while P8 was camping in damp conditions. A medical screening examination (MSE) was conducted. P8's asthmatic symptoms were treated and once the symptoms subsided, P8 was discharged to home.

Based on observation, interview, and document review, the hospital failed to provide a medical screening examination (MSE) for 1 of 20 patients reviewed (P13), who presented to the emergency department for evaluation of an emergency medical condition (EMC). Findings include:

Observations of the hospital's ED on 09/03/13 at 8:20 a.m. revealed that the ED is comprised of three patient examination rooms; one of the three patient rooms is designated for trauma patients. The only public access that leads directly into the ED is through the ambulance garage. One physician and one RN were present in the ED at the time it was toured.

Nurse (D)/RN was interviewed on 09/03/13 at 8:30 a.m. Nurse (D) stated that the ED is typically staffed with one physician and one registered nurse, both who work a 12-hour shift. Additionally, one of the RNs on the Medical-Surgical unit serves as a back-up to ED staff, when patient acuity demands additional resources.

The hospital's ED log indicated that P13 presented to the ED on 08/22/13 at 7:30 p.m. for evaluation of a possible stroke. The ED log entry for P13 was a late entry made on 08/27/13; the provider's name and patient's disposition were blank.
P13's ED record for 08/22/13 consisted of a one-paragraph physician note. The note indicated that Physician (G) spoke to P13's family member near the ambulance bay, at approximately 7:00 p.m. on 08/22/13. The physician note indicated that Physician (G) told the family member s/he was in the middle of a code on another patient, could not talk to the family member any further at that moment, and the family member would need to wait.P13's ED record did not contain a MSE or any information regarding the disposition of P13. Physician (G) was interviewed on 09/03/13 at 10:55 a.m. S/he stated that s/he was on duty in the ED from 6:00 p.m. to 6:00 a.m. on 08/22/13. S/he was the only physician working that shift, which is consistent with the hospital's usual staffing pattern for the ED. Early in the shift, the ED received a critical trauma patient. The ED already had two patients roomed, prior to the trauma patient's arrival. After the trauma patient arrived, the ED was at capacity. The trauma patient required all of the hospital's resources, including mobilization of the staff from the Medical-Surgical unit. During care of the trauma patient, "someone" told Physician (G) that a "woman" was in the ambulance garage and wanted to see the doctor. Physician (G) stepped out of the trauma bay and went to ambulance garage door. Physician (G) thought the woman was possibly related to the trauma patient and could provide more information about the trauma patient's mechanism of injury. After Physician (G) discovered that the woman in the garage was not connected to the trauma patient, Physician (G) did not attempt to ascertain any more information from her. Physician (G) told the woman that s/he was in the middle of a code and it was going to be awhile before Physician (G) could talk to him/her. Physician (G) stated s/he did not know the woman was another patient seeking care until Physician (G) received a phone call later that night from the receiving hospital, who called to inquire about the patient.Nurse (I)/RN was interviewed on 09/04/13 at 9:10 a.m. S/he stated that s/he was working a 12-hour shift in the ED on 08/22/13. Nurse (I)'s responsibilities included patient triage and patient care. The ED received a serious trauma patient around 6:00 p.m. and after the patient arrived, Nurse (I) did not leave the trauma bay until care was completed on the trauma patient, which was several hours. Nurse (I) first became aware that P13 had had presented through the ambulance garage door for evaluation of an emergency medical condition when the receiving hospital called to ask questions about P13, later on during the shift. Nurse (I) had no knowledge that P13 was ever in the hospital on 08/22/13.

Nurse (H)/RN was interviewed on 09/03/13 at 10:00 a.m. S/he stated that s/he was working a 12-hour shift on the Medical Surgical Unit on 08/22/13. S/he was also the ED back-up RN and was called to the ED on 08/22/13 in connection with Trauma Team Activation for a patient who was enroute. After the trauma patient arrived, Nurse (H) remained in the trauma bay, rendering care. At one point, Nurse (H) left the trauma bay momentarily and passed by Volunteer Fireman/(K) in the hall, who indicated s/he was taking P13 to another hospital. Nurse (H) did not know who P13 was. Later in the shift, Nurse (H) received a call from the receiving hospital, who wanted a report on P13. Nurse (H) told the receiving hospital that there was no report on P13 because P13 was not seen in the ED.

Volunteer Fireman/(K) was interviewed on 09/03/13 at 2:40 p.m. He was the first responder at the scene of where the trauma patient was injured. He assisted EMS personnel and also transported flight nursing staff to the hospital when air transportation arrived. He waited in the ED hallway, while all other personnel were in the trauma bay. He checked on the two patients that were roomed in the other two examination rooms to see if they needed anything. While waiting in the ED hallway, he heard a knock on the door leading to the ambulance garage. He opened the door and Family member (L) was standing there, saying that P13 was having mini-strokes. Volunteer Fireman/(K) observed that P13 was sitting in the car, which was parked in the ambulance bay. Volunteer Fireman/(K) told one of the nurses about P13, but Volunteer Fireman/(K) could not recall which nurse s/he told. Volunteer Fireman/(K) observed Physician (G) come out of the trauma bay and go out to the ambulance garage. Volunteer Fireman/(K) heard Physician (G) have a conversation with Family member (L) next to the family's car. Volunteer Fireman/(K) heard Physician (G) tell Family member (L) that there was a lot going on in the ED right now and Physician (G) then asked Family member (L) if she was comfortable going to the receiving hospital. Family member (L) replied affirmatively. Physician (G) then went back inside the ED. Volunteer Fireman/(K) then offered to transport P13 in an ambulance to the receiving hospital, but Family member (L) declined. Volunteer Fireman/(K) drives a rescue truck (pick-up truck) and then offered to escort Family member (L) and P13 to the receiving hospital, which they accepted. On the way to the receiving hospital, Volunteer Fireman/(K) called the receiving hospital to inform them that P13, who was having mini-strokes, was on the way. Once they arrived at the receiving hospital, Volunteer Fireman/(K) assisted P13 inside, spoke briefly to staff, and then left the receiving hospital.

The receiving hospital's ED record indicated that P13 presented to the ED on 08/22/13 at 8:40 p.m. P13 walked in to the ED, accompanied by a family member and volunteer firefighter, who both stated that P13 was having a possible stroke and seizure-like episodes. The volunteer firefighter told ED staff that s/he had escorted P13 to the receiving hospital, with P13 and the family member following behind the volunteer firefighter's vehicle in their own car. The volunteer firefighter stated that the physician from the previous hospital "took a quick look at" P13 in the ambulance garage and told P13 and the family member that s/he "did not have time to take care of" P13 and they were directed to go to the receiving hospital for care.

The ED receiving hospital's record indicated that P13 was triaged within three minutes of arrival. P13 was complaining of head and neck pain, which P13 rated as a 9 on a scale of 1 - 10. P13's blood pressure was 154/120. P13's pulse was 44 and irregular. P13 was alert, but confused.The receiving hospital's ED notes, dated 08/22/13, indicated that P13 underwent several diagnostic tests after being examined by Physician (M). These included a CT of the head, a chest x-ray, an ECG, and laboratory studies. The ED notes indicated that Physician (M) reviewed all of the test results and noted abnormalities with some of P13's lab work and ECG. Physician (M) documented that P13 had bradycardia, "most likely third degree block in nature." The transfer form indicated that at 10:07 p.m., P13 was transferred to another hospital, by ambulance, for further cardiovascular intervention. At the time of transfer, P13's blood pressure was 147/93 and his/her pulse was 38. Attempts to contact Family member (L) for an interview were unsuccessful.

The hospital's policy on EMTALA indicated that "Patients shall not be denied evaluation, treatment, or stabilization on the basis of their presenting complaint, condition, or lack of physician on the medical staff of this hospital. It is the policy of (the hospital) to provide a medical screening examination to all patients presenting for treatment. A medical screening examination is all necessary testing and treatment within the capability of the hospital to reach a diagnosis. Elements of the MSE: A log entry with the disposition of the patient, a triage record, on-going vital signs, an oral history, a physical exam of affected systems, a physical exam of potentially affected systems and known chronic conditions, any testing to rule out presence of legally defined emergency medical conditions, use of on-call personnel, use of on-call physicians to diagnosis and treatment, discharge or transfer vital signs, adequate documentation of all of the above."