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On June 11 2012, an unannounced on-site EMTALA (Emergency Medical Treatment and Labor Act) complaint investigation survey authorized by the Centers for Medicare and Medicaid Services (CMS) was conducted at Broadwater Health Care Center. Two deficiencies were cited as a result of this investigation: the maintenance of a central log (C2405) and regarding the approval of which medical staff, nurses, or providers could provide the required medical screening exam (MSE) (C2406). The facility is not in compliance with CFR ?489.24. The facility was notified of the Immediate Jeopardy finding on 6/12/12 at 4:00 p.m. the Immediate Jeopardy was not abated when the surveyor exited the facility at 4:35 p.m. on June 6/12/12. Findings include:

On 6/11/12 at 11:00 a.m., the surveyor requested a copy of the by-laws, rules, and regulations of the governing board. The by-laws of the governing board were reviewed and lacked any documented information regarding the maintenance of a central log and which medical staff, nurses or providers could perform the required MSE.

On 6/11/12 at 3:30 p.m., Staff member A, the CEO (Chief Executive Officer), stated that only the providers (not the nurses) could perform MSE. Staff member A stated that this information should be in the governing board by-laws or in the medical staff by-laws. Review of the medical staff by-laws lacked any documented information regarding EMTALA compliance and which medical staff, nurses or providers could perform the required MSE. A policy was provided to the surveyor which stated only providers (not nurses) could perform MSEs.

On 6/12/12 at 10:00 a.m., the MSE Policy, revised 12/8/2011, was reviewed. According to the policy "all patients arriving at the hospital emergency room will receive a medical screening exam by the on call provider. This screening is to determine the patient's condition based on the definitions in the triage policy. All on call providers are required to be available to respond to the ER within 30 minutes of notification."

On 6/12/12 at 1:45 p.m., a meeting was held with the CEO, staff member L, the medical director, and staff member M, a physician on the Medical Staff. Staff member L stated that nurses can perform and have performed the MSE, and staff member L was not aware that providers (not nurses) were required to perform the MSE.

CMS requires that designated practitioners who perform MSE are to be identified in the hospital by-laws or in the rules and regulations governing the medical staff following governing board approval. The surveyor or facility staff could not locate this information.

Based on review of the Emergency Department (ED) log and staff interviews, it was determined that the Critical Access Hospital (CAH) failed to maintain accurate documentation in the ED log of patients presenting to the ED. The facility was notified of the Immediate Jeopardy finding on 6/12/12 at 4:00 p.m. Immediate jeopardy was not abated when the surveyor exited the facility at 4:35 p.m. on June 6/12/12. The findings included:

On 6/11/12 at 11:15 a.m., the surveyor reviewed the ED log.
a. The surveyor could not locate patent #1 in the ED log book.
b. Patient #2 was on the ED log, but marked as a non-emergency patient. The information columns regarding if patient #2 was treated or not treated, stabilized, and transferred were blank. The column titled REASON documented "MD referral."
c. Patient #10 was on the Ed log but nothing was marked other than the name.

On 6/11/12 at 12:45 p.m., staff member B, a RN (registered nurse) stated during an interview that the ED log book was filled out after the patient was discharged. "There are many times when patients are not put in the ED log book because the RNs forget."

On 6/11/12 at 3:30 p.m., staff member A stated that the facility policy directed the staff to document everyone who entered the ED on the ED log.

Based on record reviews, interviews with the staff and physicians, the facility failed to ensure that 6 (#s 1, 2, 21, 22, 23, and 24) of 24 sampled patients of the emergency department (ED) had an appropriate medical screening exam (MSE). Furthermore, staff that was interviewed revealed that they had not received training on the Emergency Medical Treatment and Labor Act (EMTALA) and Medical Screen Exam (MSE). The examples in this deficiency represent Immediate Jeopardy. The facility was notified of the Immediate Jeopardy finding on 6/12/12 at 4:00 p.m. Immediate jeopardy was not abated when the surveyor exited the facility at 4:35 p.m. on June 6/12/12. Findings include:

1. According to the initial report from the hospital, dated May 10, 2012, patient #1 arrived at the emergency room complaining of cramping and back pain. Patient #1 was 16 weeks pregnant. The nurse on shift entered the patient in the computer at 00:34 a.m., took the vitals signs and placed a call to the on call physician, staff member L. The nurse was instructed by staff member L, via the telephone to tell the patient "we do not treat OB [sic Obstetrics] patients here" and to go to another hospital which was 34 miles away. The patient was discharged from the ER (emergency room) without the MSE being completed.

On 6/12/12 at 10:30 a.m., Staff member K, a RN (registered nurse), was interviewed via telephone. Staff member K stated that patient #1 entered the ED about 1:40 a.m., and was complaining of cramping and back pain. He called the on call physician, staff member L and reported patient #1's medical complaints, vitals, and that she was 16 weeks pregnant. Staff member L instructed the RN to tell her that "we do not treat OB patients here" and to have her go to another hospital. Staff member K was asked by the surveyor if he had been trained by the hospital on a procedure for EMTALA compliance and he stated no. Staff member K stated he knew he was not allowed to do MSE because he was an RN. Staff member K stated that the former DON (director or nursing) was provided the information the next day. "Patient #1 left and I do not know if she was seen at another hospital."

On 6/11/12 at 1:00 p.m., staff member C, a RN and QA (Quality Assurance) department manager, was interviewed and stated that she was aware that patient #1 came into the ED, was 16 weeks pregnant, was complaining of cramping, and that staff member L sent her away. Staff member C stated that staff member L does not come into the ED to complete MSEs especially on graveyard shifts and he would not come in for patient #1." Staff member C was asked if she was monitoring the ED in the QA program of the hospital and she stated "no." Staff member C stated that she did talk with the Chief Executive Officer (CEO) regarding patient #1, but she did not know the results after her discussions. The surveyor asked staff member C if she had received training on EMTALA compliance or procedures and she stated "no". Staff member C stated she knew that patients who came into the ED needed to be seen by a physician.

Staff member D, the medical records manager, was interviewed on 6/11/12 at 2:00 p.m. Staff member D stated that she was aware that patient #1 was turned away from the ED and she was 16 weeks pregnant. Staff member D stated she was informed by a RN that staff member L instructed the RN on duty not to admit patient #1 and to send her to another hospital. "The complete chart on patient #1 is missing. I cannot find it." Staff member D stated she had not received any training on EMTALA from the hospital.

Staff member H, a PA (physician assistant), was interviewed on 6/11/12 via telephone at 4:20 p.m. Staff member H stated that staff member L and staff member M, both physicians, would not come into the ED to complete MSEs on patients when asked repeatedly by the ED RNs. Staff member H stated that RNs would receive telephone medical treatments, "tele-medicine happened there all the time, it is not right." There was no training offered to any of the ED staff on EMTALA compliance and procedure. "Staff member L would have RNs do the duties [sic] out of their scope, but would sign all the paperwork."

Staff member A, the CEO, was interviewed on 6/11/12 at 3:30 p.m. Staff member A stated that she was made aware of patient #1 being turned away from the ED for treatment. "I have a problem with staff member L and M coming into the ED to complete required MSEs." Staff member A stated she had informed the governing board members and medical staff committee members of the EMTALA regulations, the issue with the MDs coming into the ED, and that only medical doctors were allowed to do MSEs as of January 1, 2012. "Patient #1 should not have been turned away. Staff member L should have come into the ED and done a MSE." When the surveyor asked if she knew patient #1 was treated at another hospital, she stated "no." The surveyor asked the CEO what was the procedure to follow regarding an alleged EMTALA violation. Staff member A stated that the director of nursing was to investigate the allegation then report to her. Staff member A stated that there was not a DON for some time and that she was not sure who would investigate the alleged EMTALA violation now. "I guess it would be me." The surveyor asked staff member A if she provided any training to her ED staff on EMTALA compliance and procedure. She stated in "the medical staff minutes, EMTALA was talked about but there had been no formal training for any of the ED staff members. Staff member A stated as of 1/1/12, only medical providers were allowed to do MSEs not RNs. Staff member A stated that this was in the governing board by-laws of the hospital."

Review of the Governing Board by-laws and rules, and Medical Staffing by-laws did not contain any documentation of EMTALA requirements or that medical providers were required to do MSEs.

According to the Medical Staff meeting minutes, information dated 9/27/11 and 11/2/11, information of the EMTALA requirements for MSE were discussed. Included in the 11/2/11 Medical Staff meeting minutes was the statement "Staff member L had 26 ER visits with 7 unseen for 27 % not seen. Staff member M had 34 ER visits, 1 unseen for 3% not seen for the month of September 2011." Staff member L and Staff member M were at these meetings.

According to the Board of Directors Meeting Minutes, dated 2/21/12, a policy change would be completed that only providers do MSEs. This change was not included in the by-laws or approved by the governing board.

On 6/12/12 at 10:00 a.m., the revised 12/8/2011 Medical Screen Exam Policy was reviewed and included "all patients arriving at the hospital emergency room will receive a medical screening exam by the on call provider. This screening is to determine the patient's condition based [sic] the definitions in the triage policy. All on call providers are required to be available to respond to the ER within 30 minutes of notification."

On 6/12/12 at 1:45 p.m., staff member L stated that he did not come into the ED when he was called about patient #1. Staff member L stated he did tell the RN to send the patient to another hospital. This hospital does not do OB. Staff member M and Staff member A were present for this interview.

During an interview with patient #1 on 6/12/12 between 9:35 and 9:48 a.m., she verified the date of service as 5/10/12 and verified that she had been told to go to another facility by staff at Broadwater Health Center (BHC). She revealed during the interview that she did not have transportation to the other facility, approximately 34 miles away. She reported not being able to request ambulance transport because of the financial cost of an ambulance and not having insurance. She called her obstetrician who advised her to take a warm bath, and if the cramping and back pain did not subside, to go back to the hospital. The cramping did diminish and so patient #1 did not seek additional medical treatment until her next scheduled OB appointment.

In summary, patient #1 entered the ED at the hospital and was told she needed to go to another hospital to be treated. The patient did not receive a medical screening exam while in the ED at the hospital as required by EMTALA.

2. Training in EMTALA and MSE:
a. Staff member I, RN, on 6/12/12 at 8:00 a.m., was interviewed. Staff member I stated that "RNs have done the MSE not the MDs (medical doctors)." The only training I had on EMTALA was on how to fill out forms.
b. Six of six staff interviewed reported that they lacked training in EMTALA and/or MSE.

3. According to the initial report from the hospital, dated April 18, 2012, patient #2 arrived at the emergency room at 9:50 a.m., complaining of pain in her vagina. Patient #2 was 4 years old and was escorted by her grandparents. The grandparents requested a medical exam. The grandparents were concerned that patient #2 was sexually assaulted. Staff member I, the RN on duty, contacted staff member M. Staff member M told the RN not to touch, talk, or do anything for patient #2. Staff member M refused to do a MSE and sent patient #2 to another hospital which was 64 miles away. The Physician Care Documentation contained documentation by staff member M, "No formal exam. transfer (sic) to another hospital." The hospital was 64 miles away.

On 6/12/12 at 7:30 a.m., staff member I was interviewed. Staff member I stated that patient #2 did present to the ED with her grandparents. The grandparents requested a medical exam on the patient. Staff member I called the physician on call, staff member M, and was instructed "do not do anything to the patient, do not ask any questions, do not exam her at all. So I did not." Staff member I stated she then called the former DON and the CEO was notified by the DON.

On 6/11/12 at 3:30 p.m., staff member A was interviewed. Staff member A stated she was not sure what happened regarding patient #2 visit to the ED. Staff member A stated she was aware that the child was not screened by the physician on call and that the child was sent to another hospital.

On 6/12/12 at 1:45 p.m., staff member M was interviewed and stated she refused to do a MSE on patient #2 because it was a suspected sexual assault. Staff member M stated she did tell the RN on duty not to touch, talk or do anything to patient #2 even though the grandparents wanted a medical exam. Staff member M stated she saw the child in the waiting room. "She was dressed well, happy and running around, why would I put my hands on her. I sent her to another hospital." Patient #2 was sent away from the ED without a MSE.

Review of the Assessment of Pediatric patient policy for the ED documented "...pediatric patient shall have the following information documented ... emotional status, LOC, (loss/level of consciousness), communication appropriate for age, activity appropriate for age and vital signs...." Patient #2's ED record did not contain the above information.

Review of the ED reporting of Alleged Abuse Adult and Pediatric Policy documented "for the pediatric patient, contact the provider on call trained in evaluating alleged sexual abuse of the pediatric patients. Document assessment...." There was no MSE or assessment completed or documented in the ED record.

4. Patient #22 entered the ED at 9:20 p.m. on 5/2/11, complaining of body pain from a fall. The Emergency Record form indicated that staff member L was notified via telephone at 9:45 p.m. Staff member L did not come into the ED and do a MSE. Patient #22 left AMA (against medical advice) at 10:10 p.m.

5. Patient #23 entered the ED at 5:15 p.m. on 3/11/11, with a laceration to the forehead. The RN on duty called staff member L at 5:20 p.m. Staff member L did not come to the ED to perform a MSE. The RN placed two steri strips and derma bond on the laceration. The patient was discharged by the RN at 5:37 p.m.

6. Patient #24 entered the ED at 6:15 p.m. on 3/11/11, complaining of nausea with vomiting. The physician on call, staff member L, was called at 6:50 p.m. Staff member L did not come to the ED to complete a MSE. The patient was discharged by the RN. The time of discharge was not documented.

7. Patient #25 entered the ED at 6:00 p.m. on 3/14/11, complaining of pain in her right and left ear. The RN on duty placed a phone call to the physician on call, staff member L, at 6:20 p.m. Staff member L did not come to the ED to complete a MSE. The patient was discharged to home by the RN. The time of discharge was not documented.