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Based on staff interviews and review of medical records, policies/procedures and Medical Staff Bylaws, the facility failed to comply with the Medicare provider agreement as defined in 489.20 and 489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

The facility failed to meet the following requirements under the EMTALA regulations:

Tag A2405 Emergency Room Log
The facility failed to maintain a central log on each individual who came to the emergency department seeking assistance.

Based on medical record review, facility document review, facility policy/procedure review, and staff interview the facility failed to maintain a central log on each individual who came to the emergency department seeking assistance.

Findings:

1. The facility failed to document in the central log when Sample patient #5 came to the emergency department with signs of an allergic reaction.

a. Policy/Procedure
The facility's policy, "Treatment and Transfer of Individuals with Emergency Medical Conditions (EMTALA)", stated:
"3. A central log must list each individual seeking or in need of emergency services who comes to the hospital, the dedicated emergency department anywhere else on the Hospital campus, or to off-campus departments that qualify as a dedicated emergency department of the Hospital designated with CMS provider-based status. The log must include an indication whether the individual did not consent to treatment or transfer, or was transferred, admitted and treated, stabilized and transferred, or discharged. Logs that are maintained in departments that qualify as dedicated emergency departments that perform medical screening examinations such as in labor and delivery, psychiatry, outpatient shall be deemed a part of the central log and are subject to the same requirements as the central log.
4. A central log must include the name of the individual who comes to the Hospital and makes it clear (or if it is unclear) that the medical condition is not an emergency nature, and a medical screening examination is performed to determine that the individual does not have an emergency medical condition."

b. Facility document review (ED Log)
A review of the computerized computer documentation "Daily Registration List" that was identified as the facility's "Central Log" as required for this regulation was reviewed on 06/06/12. The print out for 05/09/11 did not contain Sample patient #5.

c. Medical Record review
A review of Sample record #4 revealed that the patient in the record received care on 05/08/11. Within the records there was an entry dated 05/09/11 that stated: "0900 [Sample patient #5] came in to discuss being allergic to the prescribed antibiotic. His/her top lip is swollen. Reviewed with MD who prescribed a new antibiotic Clindamycin. Patient was given Benadryl (per [Physician's] order) to go as s/he was going to speak to pharmacist and then home, s/he did not want to be evaluated."

d. Staff interview
An interview was conducted on 06/06/12 at 9:47 a.m. with the Director of the Emergency Department. S/he confirmed that Sample patient #5 was not present on the "Central Log" and stated that the "Central Log" would only contain patients that were registered in the computer documentation system. S/he stated that the patient "came to the front and asked to speak to a nurse, and I responded as a nurse. There were only two RNs and I ended up talking to him/her." S/he stated that the facility "would not log in someone that presents for a blood pressure check or something like that [referring to Sample patient #5 asking to speak to a nurse]." S/he stated that the facility "took a service recovery approach. I did not take vital signs. When I saw him/her his/her top lip was a bit swollen. S/he just wanted to let us know that s/he had an allergic reaction to the medication. I then told him/her that [the physician who had treated the patient on 05/05/11] was here and went to speak to him/her. Then s/he wrote a new prescription." S/he stated, "if they come to the ED asking to speak to a nurse or something like that, would not expect that they be logged in unless they ask for care. There is an expectation that if someone asks to speak to a nurse, they are asked if they want to check in, if they say no, then it is viewed as a service recovery type concern." S/he then stated that "if a person presented like this patient, but had not been seen before, it would be expected that they would be logged in and seen. This was different, as the patient came and stated s/he wanted to let us know about his/her allergy and refused an MSE [medical screening examination] multiple times."