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Based on review of medical records, policies/procedures and staff interviews, it was determined that the hospital failed to comply with the provider agreement as defined in ?489.24 related to EMTALA (Emergency Medical Treatment and Active Labor Act) requirements.

Findings:

Refer to findings for Tag A 2406 - Medical Screening Examination:
The facility failed to ensure that sample patients #1 and #2 were provided an appropriate Medical Screening Examination (MSE) to determine whether or not an emergency medical condition (EMC) existed prior to directing both patients to the hospital's Rural Health Clinic.

Based on facility document review, medical record review and staff/physician interview the facility failed to ensure that sample patients #1 and #2 were provided an appropriate Medical Screening Examination (MSE) to determine whether or not an emergency medical condition (EMC) existed prior to directing both patients to the hospital's Rural Health Clinic.

Findings:

1. A review of the facility's policy titled, "EMTALA GUIDELINES FOR EMERGENCY DEPARTMENT SERVICES" last revised 11/2005 revealed the following,
"All patients presenting to Mt San Rafael Hospital's Emergency Department and seeking care must be accepted and evaluated regardless of patient's ability to pay.
All patients shall receive a medical screening exam that includes providing all necessary testing and on call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic.
Medical Screening Exams:
Medical screening exams should include at a minimum the following:
Emergency Department Log entry including disposition of patient
Patient's triage record
Vital signs
History
Physical exam of affected systems and potentially affected systems
Exam of known chronic conditions
Necessary testing to rule out emergency medical conditions
Notification and use of on-call personnel to complete previously mentioned guidelines
Notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary
Vital signs upon discharge or transfer
Complete documentation of the medical screening exam"

2. A review of the facility's emergency department (ED) log revealed that on 2/29/12 Sample Patient #1 presented to the ED at 1:25 PM and that Sample Patient #2 presented to the ED at 2:28 PM. The ED log stated that Sample Patient #1 was "sent to [the hospital's rural health clinic]" and "LWBS [left without being seen]" at an unknown time. The ED log stated that Sample Patient #2 "LWBS" at 3:05 PM.

3. A review of Sample Patient #1's record revealed that the facility did not have a record for review. The hospital did provide documentation that documented that the patient did present to the facility's rural health clinic (RHC) on 3/1/12 at 11:25 AM and was seen for a Upper Respiratory Infection. The facility was able to reprint the registration information that was obtained on 2/29/2012. The registration facesheet revealed that the patient was a Medicaid patient.

4. A review of Sample Patient #2's record revealed that the patient presented to the ED on 2/29/2012 at 2:28 PM. The patient (a 2 year old female) was triaged by Nurse #2 at 2:37 PM. The record indicated that the patient had a cough for 4 days with associated fever and pulling at both ears. The registration facesheet revealed that the patient was a Medicaid patient. The record indicated that at 2:39 PM, the patient was sent to the RHC and that at 2:50 PM, the patient was sent back to the ER. The record indicated that at 3:05 PM, the patient left the ED without being seen.

5. An interview was conducted with Nurse #1, the Nurse Manager of the ED on 8/23/12 at 9:52 AM. S/he stated that on 2/29/12 the ED was "busier than busy" and saw 45 patients in that day when the department was used to seeing 25-30 patients a day. S/he stated that Sample Patient #1 and Sample patient #2 had come in at different times and were triaged. S/he stated that Physician #1 was the physician in the ED and was doing his/her best to see the patients promptly and discharging them after they were stabilized. S/he stated that Physician #2 was the on-call physician seeing patients in the patient care unit that day and that s/he called him/her and was told that s/he would see the patients in the clinic and that s/he refused to go to the ED to see patients. S/he stated that s/he then went to the ED's waiting room and had identified a couple of patients (Sample Patients #1 and #2) that were most appropriate to be seen in the clinic due to their presentation and triage acuity ("non critical"). S/he stated that s/he "asked these patients if they would be interested in seeing the physician in the clinic", and that "both were agreeable and were sent to the clinic." S/he stated that the patients were not accompanied by hospital staff and were sent with their ED record (t-sheet with nursing documentation, registration sheet, etc.). S/he stated that the ED staff was not aware of what s/he was doing and that Physician #2 had said that s/he would contact the clinic to notify them that the ED was going to send some patients over there. S/he stated that s/he did not recall if s/he had called over to the clinic or not. S/he stated that Physician #1 was not notified and was not involved in the decision to send the patients to the RHC. S/he stated that both patients were "sent back [to the ED] immediately." S/he stated that only Sample Patient #2 returned to the ED with his/her chart and that Sample Patient #1 never returned to the ED, nor did his/her record return to the ED. S/he stated that Sample Patient #1 left later without being seen. S/he stated that since 2/29/12 there was a facility discussion performed immediately after in which it was resolved that no patients would be sent to the RHC and rather the physician on-call would be required to come to the ED to see patients. S/he stated that since, there had been a couple of occasions where the physician had come over to the ED to see patients when requested. S/he stated that if a similar situation were to occur again, that s/he would go up the chain of command, up to and including the physician over the clinic physicians or CMO to come and see the patients in the ED.
S/he stated that s/he presented an option to the patients and that at no time did s/he state to either patient that they would not be seen in the ED. S/he stated that s/he told them that it would be an hour to two hours which s/he had "guesstimated".

6. An interview was conducted with the Operations Manager of the RHC on 8/23/12 at 9:11 AM. S/he stated that s/he was working on 2/29/12. S/he recalled the day and the situation with the two patients presenting to the RHC. S/he stated that the two patients were sent to the RHC, each came with a binder with their ED records. S/he stated that s/he called the Director of Nursing for the hospital at that time and was directed to send the patients back to the ED to avoid a potential EMTALA violation. S/he confirmed that both patient's had come over together at the same time and that they both had triage sheets that resembled a "T-sheet" that was contained in each ED record for nursing documentation. S/he stated that s/he apologized to both patients and both seemed okay with being sent back to the ED after being sent to the RHC. S/he stated that it was her recollection that one of the patients called for an appointment the next day and was seen the next day. S/he stated that both patients had been seen in the clinic in the past. S/he stated that the RHC had not been referred patients from the ED prior to 2/29/12 nor since. S/he did not recall if the patients were accompanied by any hospital staff over to the RHC. S/he stated that the two patients were at the RHC for no more than 5 minutes.

7. A telephone interview was conducted with Nurse #2 on 08/23/2012, 11:30 AM. S/he stated that s/he recalled 2/29/12 and that s/he had triaged the youngest patient (Sample patient #2). S/he stated that "we called Nurse #1 to ask for help because we were busy." S/he stated that s/he was aware that Nurse #1 had sent both patients to the RHC. S/he stated that s/he was not sure if they came back or not. S/he stated that s/he "would not send a patient to the clinic without being seen by a physician in the ED."

8. An interview was conducted with Physician #1, that was seeing patients on 2/29/12 in the ED, on 8/22/12 at 5:30 PM. S/he stated that he was well aware of possible EMTALA concerns with sending patients to clinics from the ED. S/he stated that s/he was made aware of the two patients being sent the RHC after it had occurred. S/he stated that s/he did not direct the ED staff to refer any patients to the RHC. S/he stated that it was his/her understanding that when the ED was in need of another physician that the on-call physician that saw patients on the medical/surgical floor and the RHC was to come to the ED and assist by seeing patients in the ED. S/he confirmed that only physicians were considered as QMPs (qualified medical personnel) by the hospital to be able to perform MSEs (medical screening examinations). He stated that it was his/her understanding that when the on-call physician (Physician #2) was contacted to come to the ED, that s/he refused. S/he stated that s/he was discharging 3 patients around the time of the referral of the two patients to the RHC and that s/he did not think that any of the patients would have to wait long.