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Based on document review and interview, the facility failed to ensure documentation indicating an MSE (Medical Screening Exam) was performed on 1 out of 27 patients that presented to the ED. (see tag A2406).

Findings include:

1. See findings cited at 489.24(1) Medical Screening Exam A2406.

Sample size per Appendix V, Part IV, Task II A: 20 emergency department (ED) medical records were reviewed. Sample selection per Appendix V, Part IV, Task II B: Patient's P1 - P20 medical records (MR) were reviewed due to each presenting to the facility Emergency Department. These records included patients that were admitted, discharged, transferred, 48 hour returns, those that left "Against Medical Advice" and "Left without being seen."

Based on document review and interview, the facility failed to keep a log of each individual presenting to the emergency department for medical care on 1 (P27) of 27 patients reviewed.

Findings include:

1. Review of policy/procedure, "EMTALA Compliance and Transfer", no policy number, indicated the following: Each department of the hospital that provides medical screening examination shall maintain a central log recording the names of patients who present for emergency services. The log shall record the name of each person who presents for emergency services and whether the person refused treatment, was refused treatment by the hospital or whether the patient was transferred, admitted and treated, stabilized, transferred or discharged. This policy was last reviewed/revised on 12/2020.

2. Review of EMS Care Report dated 11/19/21 at 1401 hours arrived to facility F1 ambulance bay and an RN came out and informed EMS that hospital is on diversion and refused to take patient. P27 was then transfered to facility F2 for emergency services.

3. Review of the ED log dated 11/19/2021 from 0048 hours through 2330 hours lacked P27 as a patient that had presented to the ED for services.

4. On 12/17/2021, beginning at approximately 1630, S51, Director Performance Improvement, confirmed that P27 was not recorded on the (ED) log on 11/19/2021.

Based on document review and interview, the facility failed to ensure documentation indicating an MSE (Medical Screening Exam) was performed on 1 (P27) of 27 patients reviewed.

Findings include:

1. Review of policy/procedure titled, "EMTALA Compliance and Transfer", no policy number. Per policy/procedure a medical screening examination must be offered to any individual presenting for examination or treatment of a medical condition. This policy/procedure was last reviewed/revised on 12/2020.

2. Review of EMS Care Report dated 11/19/21 at 1401 hours arrived to F1 ambulance bay and and N came out and informed EMS that hospital is on diversion and refused to take patient. P27 was then transferred to facility F2 for emergency services.

3. Request MR/ED report for P27 dated 11/19/21 at 1401 hours. S50 (Administrator/Chief Nursing Officer) and S51 (Director Performance Improvement), were unable to provide this MR for the date requested.

4. On 12/17/21, at approximately 1600, S51, Director Performance Improvement, verified that N1 (Registered Nurse) did tell the EMS parked in the ED bay that the facility was on diversion and that P27 was not screened prior to transfer to facility F2.