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Based on observation, record review and interview, the facility failed to ensure compliance with EMTALA (Emergency Medical Treatment and Active Labor Act) regulations in 3 of 11 required areas (Medical Screening Examination, Stabilizing Treatment, and Appropriate Transfer). Failure to comply with these requirements has the potential to affect all patients presenting to the Emergency Department.

Findings include:

The facility failed to complete a comprehensive medical screening examination for 1of 20 patients presenting to the Emergency Department. See tag C2406.

The facility failed to complete the appropriate documentation for 1 of 2 patients who left the Emergency Department against medical advice. See Tag C2407.

The facility failed to complete the patient transfer form information for 1 of 3 patients transferred. See Tag C2409.

Based on record review and interview the Emergency Department staff failed to complete a comprehensive medical screening examination for 1 patient (Patient #17) in a sample of 20 medical records reviewed.

Findings include:

The facility's policy titled, "Emtala: Screening, Stabilization and Transfer", #179, dated 12/15 was received for review on 7/17/2017 at 3:13 PM. The policy states in part under 5. Procedures 5.1 Medical Screening Examinations (MSE) a) General i) A MSE is an examination performed by a physician or a QMP (Qualified Medical Provider) to determine with reasonable clinical confidence whether an EMC (Emergency Medical Condition) exists. If an EMC does exist, Medical Center staff must provide Stabilizing treatment for the patient's EMC within the Capabilities and Capacity of the Medical Center. 5.3 Medical Screening Examination Requirements, A physician or QMP must perform and document a MSE for each individual who presents in the following circmstances: a) Presentation to a Dedicated Emergency Department.

A medical record review was conducted on Patient #17's emergency department record on 7/17/2017 at 1:50 PM accompanied by Lead Emergency Department Nurse and Educator E who confirmed the following findings: Patient #17 is a 57 year old who presented to the emergency department on 7/6/2017 at 8:07 PM with the chief complaint of depression and homicidal ideation (with no specific target). Patient #17 requested an admission to the behavioral health unit however there were no available beds and the provider discussed with Patient #17 that a transfer to an alternate facility could be arranged. Patient #17 refused the transfer stating #17 only wanted to be admitted to this facility and according to the provider's note, "At this point Patient got up and walked out of the ER [emergency room]."

Per interview with Nurse E on 7/17/2017 at 1:56 PM regarding documentation in the medical record that states, physician did not perform a physical exam on the patient, Nurse E stated the patient left before an exam could be completed.

Based on record review and interview, staff at this facility failed to complete the appropriate documentation for 1 of 2 patients who left against medical advice (Patient #14) in a sample of 20.

Findings include:

A medical record review was conducted on Patient #14's emergency room record on 7/17/17 at 12:55 PM accompanied by Lead Emergency Department Nurse and Educator E who confirmed the following finding: Patient #14 presented to the emergency department on 7/9/17 at 6:08 PM with complaints of lower abdominal pain. According to the documentation, Patient #14 has an extreme fear of needles and refused any intravenous lines, laboratory tests or scans to determine the cause of the abdominal pain. Patient #14 left the emergency department against medical advice at 7:40 PM. According to the provider note, the provider documentation states, "The patient understands that they are taking their health and life into their own hands and putting themselves at risk for death, disability and worsening condition. The patient verbalized understanding of this and signed AMA [against medical advice]." The Informed Refusal form is incomplete. It does not indicate the recommendations from the provider or the risks, benefits, and alternatives related to the refusal.

Per interview with Nurse E on 7/17/17 at 2:09 PM regarding the missing documentation, Nurse E stated, "If this is an AMA [against medical advice] form they [the provider] will sometimes put that in their note." When asked if the patient signs or receives a copy of the provider note Nurse E said they do not and therefore would not have a written record of the risks and benefits of refusing treatment.

The facility's policy titled, "Informed Consent-Informed Refusal," #246, dated 5/30/17, was received for review on 7/17/17 at 3:13 PM. The policy states in part on page 12 of 24, "Document that the patient has been provided (or staff has attempted to prove) the information described in Section C.2. above, including information regarding the risks of forgoing treatment and request that the patient's review and sign an AHC-System [acronym for the facility corporation] approved informed refusal form. If the patient refuses to sign the informed refusal form, document the circumstances, the request, and the reasons for the patient's refusal on the informed refusal form and place it in the patients' medical record."

Based on record review and interview, staff failed to accurately complete the patient transfer form information in 1 of 3 patients transferred (Patient #12) in a sample of 20.

Findings include:

Patient #12's medical record was reviewed on 7/17/17 at 11:37 AM accompanied by Lead Emergency Department Nurse and Educator E who confirmed the following finding: Patient #12 was transferred to a higher level of acute care on 6/26/17 after presenting to the Emergency Department with stroke like symptoms. On the Patient Transfer form, the Emergency Department provider indicates the reason for transfer is "Specialty services/expertise not available at this facility." The section on the form for services/expertise not available is blank and states, "no data." This is in section 1 of the form.

Per interview with Nurse E on 7/17/17 at 11:44 AM regarding the services/expertise that were needed, Nurse E stated that the services not available could be in the provider note, but confirmed that they are not on the form.

The protocol for providers to fill out the electronic patient transfer form was received for review on 7/17/17 at 3:19 PM. The protocol indicates that the provider is to fill out section 1 and 2 in full. The protocol goes on to say that after sections 1 and 2 are completed, the form is to be printed to obtain signatures from the patient/representative/law enforcement, physician, and nurse.