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Based on review of medical records, policies and procedures, and interviews the facility failed to ensure that an appropriate medical screening examination was completed within the capability of the emergency department to include ancillary services routinely available at the hospital ' s Emergency Department to determine whether or not an emergency medical condition existed as evidenced by failing to address the individual ' s pain and elevated blood pressure prior to leaving the hospital for 1 (#3) of 25 sampled patients medical records reviewed. Refer to findings in Tag A 2406.

Based on review of medical records, policies and procedures, and interviews the facility failed to ensure that an appropriate medical screening examination was completed within the capability of the emergency department to include ancillary services routinely available at the hospital 's Emergency Department to determine whether or not an emergency medical condition existed as evidenced by failing to address the individual ' s pain and elevated blood pressure prior to leaving the hospital for 1 (#3) of 25 sampled patients medical records reviewed.

Findings:
The facility 's policy and procedure titled, " EMTALA-Georgia Medical Screening Examination and Stabilization Policy " , PolicyStat ID: 806746, approved 2013 was reviewed. The policy revealed in part, " Statement of Purpose: To establish guidelines for providing appropriate medical screening examinations ( " MSE " ) ...Policy Am EMTALA obligation is triggered when an individual comes to the dedicated emergency department ( " DED " ) and 1. The individual or a representative acting on the individual ' s behalf requests an examination or treatment for a medical condition ...Procedure: 1. When an MSE is Required A hospital must provide an appropriate MSE within the capability of the emergency department including ancillary services routinely available to the DED to determine whether or not an EMC exists. "
The facility ' s policy and procedure entitled, "Procedure for Emergency Registration & Admission and ESP (Emergency Services Protocol) Program, Page 8, EFFECTIVE DATE 01/01/2014 was reviewed. Emergency Department Medical Screening Exam (examination) for Qualified Medical Person. The non-emergent patient is identified by the Qualified Medical Person via facility specific designated (e.g. Blue Folders, Lavender Physician T-sheets, etc.). Following the medical screening exam, these patients are routed to registration for upfront collection and registration according to the ED Medical Screening Exam Flow, Scripting and troubleshooting process... The non-emergent patient required to pay the facility assigned QMP maximum deposit. Upon discharge, the ED Discharge Disposition must be " HOME. " ... Non-emergent patients who do not pay the required QMP maximum deposit at time of service may elect to leave the ED to receive care from a family physician or local resource ...Non-emergent patients who pay the required QMP maximum deposit are treated accordingly."
Review of the policy entitled " Standards of Triage & Care in the Emergency Department, " last reviewed 10/2014, revealed that level 4 acuity patients included minor back pain, " Pulled something " - muscle spasms; localized back pain (4-7/10). Possible extremity fracture, swollen, hot " joint , tight cast-no neurovascular impairment.
Review of patient #3 ' s medical record revealed the patient was an uninsured patient who walked into the ED on 01/04/16 at 6:16 PM with complaints of back pain. The triage nurse #5 (a nurse who assessed a patient to determine in which a severity of the chief complaint and the priority in which a patient will be seen by the provider) noted that the patient was a level 4 (semi-urgent). Documentation the patient was initially with the provider at 6:19 PM and that the patient was placed in an ED room at 6:22 p.m. The triage nurse noted that the patient reported that his/her pain was a 4 on a pain scale of 1 (minimal pain) to 10 (severe pain) and that a level 3 was an acceptable pain level. The nurse noted that the pain was sharp and throbbing and that daily activities aggravated his/her back pain. In addition, the nurse noted that the symptoms had begun at 5:00 p.m. The nurse also noted that the patient had reported similar episodes that had never been evaluated and that the patient reported pain when walking. The nurse noted that the patient ' s temperature, pulse, respirations, and oxygen level were within normal limits. The patient ' s blood pressure was noted to be 157/101 ( Normal Blood Pressure 110-120/60-80). In addition, the nurse noted that the patient was alert and oriented to person place time and situation, moved all extremities, had no paralysis and ambulated independently. The Conditions of Admission and consent for Outpatient Care form was signed by patient #3 on 01/04/16 at 6:13 p.m. Further review revealed that at 7:07 p.m. the patient was discharged and the patient ' s pain intensity was still 4. Review revealed that patient #3 physically left the ED at 7:08 p.m. Documentation revealed that Discharge information was provided for patient #3 but the patient refused. Continued review of the medical record revealed that patient #3 was evaluated by a Physician ' s assistant (PA-#1) on 1/04/16 at 6:19 p.m. and that the PA completed the facility ' s electronic " HPI (History of Present Illness)-Back pain 40 and Under " forms. The PA noted that the patient complained of spontaneous low back pain that had started earlier that morning. The PA also noted that the quality of the pain was " spasms " with no radiation of pain. The PA noted that patient #3 reported that initially the pain had been a 7 on a scale of 1 to 10, but that the pain was now a 3 on a scale of, 1 to 10. The PA noted that the patient denied abdominal pain, fever, inability to walk, incontinence, neurological symptoms, numbness or tingling of the lower extremities. The PA notes indicated that the patient ' s pain increased with movement and was relieved by lying still. In addition, the PA noted that the patient reported that he/she had chronic back pain and that the episode felt like prior episodes. The PA noted that a review of the patient ' s systems were negative with the exception of the low back pain. The PA noted that the patient had no neck, upper back, extremity, or joint pain. The PA noted that the patient had a past history and that the patient ' s medications, allergies, and vital signs were reviewed. The PA noted that patient #3 ' s physical examination revealed the patient was alert and oriented to person, place and time, and that the patient was not in acute distress. In addition, the physical examination included the following: full range of motion of the neck, neurovascular (nerves and blood flow) intact, extremities have full range of motion with equal pulses, movement, and tendon reflexes, back has no vertebral or peri-spinal tenderness and no muscle spasms. In addition, the physical examination revealed that the patient was able to perform a straight leg raise with no findings and that cranial nerves II-XII were intact. The patient also had normal movement deficits and equal reflexes bilaterally. The PA noted that the ESP (Emergency Services Protocol) was complete and the patient was discharged. The PA ' s notes were electronically signed on 01/04/2016 at 7:15 p.m. and were also reviewed and electronically signed by the ED Physician #2 on 01/04/2016 at 8:47 p.m. The electronic record noted that at 6:39 p.m. the PA entered the patient as having a non-urgent medical condition. The Non-Urgent MSE Determination >5 <65 Years of Age was completed by the PA on 01/04/2016. The form noted that the MSE was completed and that immediate medical attention was not necessary because there was no acute symptoms of sufficient severity and no immediate serious impairment or dysfunction of body functions or organs is reasonably expected. This form was also signed by the Registrar #9 on 01/04/2016. The Registrar checked the box noting that the patient had received an MSE and that no Emergency Medical Condition (EMC) was found by the qualified medical personnel (the PA). This box noted that the patient declined further treatment and had left the facility. In addition, in this box the Registrar provided a listing of community resources to the patient for follow-up care for the patient ' s non-emergent medical condition. The triage nurse also signed this form, signifying that the patient received an MSE, was found to have no EMC, that the patient declined further treatment and had left the facility, and that the Registrar had provided a list of Community resources for follow-up of a non-emergent medical condition.
The medical record did not contain evidence that any medications or treatment had been administered for patient #3's complaint of pain on 1/4/2016;despite the patient reporting to the provider of prior episodes of pain that were never evaluated prior to this ER visit. The medical record did not contain evidence that the patient's elevated blood pressure had been addressed following triage, or prior to discharging patient #3 on 1/4/2016. The facility failed to ensure that a complete medical screening examination was provided for patient #3 on 1/4/2016.
During an interview on 01/13/16 at 4:30 p.m. in the Administrative Board Room, the PA (#1) said that he/she recalled caring for someone who had presented to the ED in a semi truck. The PA reviewed patient #3's medical record and stated the patient did not seem to be in severe pain and that the patient did not trigger any red flags for anything. The PA confirmed that the patient's physical examination had been negative and that the patient had reported that the back pain felt like previous episodes. The PA also confirmed that the nurse documented the patient's pain as a 4 on a scale of 1 to 10. The PA stated the patient told me that the initial pain was a 7 but the pain level was now a 3 on a scale of 1 to 10. The PA explained he/she had not ordered any diagnostic tests because none were needed. The PA stated that after ensuring that the patient did not have an EMC he/she clicked the non-urgent button on the computer which triggered the Registrar to come in and talk with the patient. After the Registrar talks with the patients I am notified if the patient decides to continue treatment. The PA stated no pain medications were ordered because the patient decided not to stay and left the ED voluntarily. The PA stated that if patients decide to stay and continue treatment they agree to pay any insurance co-payment or the hospital's fee.

During a telephone interview on 01/14/16 at 1:30 p.m. in the Administrative Board Room, ED physician (#2) stated that since patient #3 was determined by the QMP (Qualified Medical Person) as not having an EMC and declined further treatment that he/she would not have seen the patient. The physician explained that after being evaluated by the mid-level provider all patient's can request to be re-evaluated by a physician but that as far as he/she knew this patient had not asked to be re-valuated by a physician The physician stated he/she had reviewed the PA's (#1) documentation and signed off after determining that the documentation was appropriate.

During an interview on 01/14/16 at 8:30 a.m. in the Administrative Board Room, the ED Medical Director (#3) explained that once a provider has screened a patient and determined that the patient does not have an EMC, the provider hits the non-urgent button on the computer screen, and this notifies the Registrar staff that they can now talk with the patient. The Medical Director stated the providers have no way of knowing whether the patient has insurance or any other payer source. The Medical Director stated once the determination is made that the patient has no EMC the patient can elect to stay and pay any co-payment or the hospital's fee of $175.00. In addition, the Medical Director stated that if the patient decides to leave and go elsewhere, the patient has received a triage assessment, been placed in an ED room, and has had a MSE at no charge to the patient.

During a telephone interview on 01/14/16 at 1:45 p.m. in the Administrative Board Room, the PA (#4) confirmed that he/she had been in with the triage nurse on 01/04/16 when patient #3 presented to the ED. The PA confirmed that he/she vaguely remembered patient #3 because the patient was driving a semi truck. The PA stated the patient had been ambulatory upon arrival and appeared to have mild discomfort. The PA confirmed that he/she was unaware of the patient's payer source and did not ask the patient. The PA said the patient was triaged and placed in a room to be evaluated by another provider. The PA confirmed that after being seen by the QMP and determined to have no EMC that the Registrar would speak to the patient regarding the patient's options of whether they wished to stay and continue treatment after paying any co-payment or the hospital's fee or declined further treatment and wished to leave.

During an interview on 01/14/16 at 10:15 a.m. in the Administrative Board Room, the Registered Nurse (#5) confirmed that he/she was the triage nurse when the patient (#3) presented with complaints of back pain. The nurse explained that he/she remembered that the patient was a semi-truck driver who presented with complaints of back pain. The nurse said that the patient ambulated into the ED with a spouse and that when the patient walked he/she had a painful facial expression. The nurse confirmed that the patient was evaluated by a PA, was determined not to have a EMC, and then seen by a Registrar staff member. The nurse stated he/she observed the patient walk out of the ED and that the patient did look a "little uncomfortable walking". The nurse said that about 50% of the patients who were determined not to have an EMC decided to stay and pay any required co-payments or the facility's require $175.00 for uninsured patients.

During an interview on 01/14/16 at 3:00 p.m. in the Administrative Board Room, the Director of the ED (#) confirmed that the facility followed the above QMP process. Medical records were audited to ensure patients who did not have an EMC, and were given the option to continue their treatment, and patients that decided to leave received a community resource list.

During interviews on 01/14/16 at 10:50 a.m. and 2:40 p.m. in the Administrative Board Room, the Registrar (#9) and the Director of Patient Access (#10), respectively, both interviewees confirmed that the facility's policy regarding the QMP patient was as follows:
--the provider evaluates the patient and determines that there is no EMC,
--the provider hits the computer button that signifies that there is no EMC,
--a Registrar staff member speaks with the patient and discusses the patient's options of continuing treatment which includes paying any required insurance co-payment or the facility's fee of $175.00 for non-insured patients, and
--if the patient decided to leave the patient was to be provided with a community resource list and would not accrue any charges.