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Based on documentation and interviews, the hospital failed to ensure compliance with requirements of 42 CFR489.24, as evidenced by the deficient practice cited at 42 CFR 489.24 (a) and (c).

Based on documentation and interviews, the hospital failed to ensure that that emergency department maintained and utilized an on-call list of physicians on it's medical staff in a manner that best met the needs of one of twenty-six patient's (#1) who presented to the emergency department with an emergency medical condition. Findings include:

Medical Record review indicated that Patient #1 presented to the hospital's emergency department (ED)on 09/09/10 at 3:00 a.m., for evaluation of respiratory symptoms,coughing, and anxiety.

Patient #1 did not have an ED record. Rather Patient #1's ED visit on 09/09/10 was documented on an "Outpatient Medical Record." The progress notes indicated that when the patient arrived at 3:00 a.m., he was accompanied by his guardians. Nurse (F)/RN assessed the patient and noted that he had a cough with ronchi auscultated bilaterally in both lungs. He was afebrile with oxygen sats of 92% on room air. His respirations were 24 but his breathing was nonlabored. His pulse was 97. Nurse (F) documented that Patient #1 was given Robitussin 2 teaspoons. His vital signs were then re-assessed. He remained afebrile. His respiratory rate had decreased to 18. His breathing remained nonlabored. His oxygen sats had improved to 93% on room air, but his pulse had increased to 111. He was discharged from the ED at 3:35 a.m.

The hospital's physician on-call schedule indicated that Nurse Practitioner (D) was the designated provider on-call, from 8:00 a.m. on 09/08/10 to 8:00 a.m. on 09/09/10.

Nurse (F)/RN was interviewed on 09/27/10 at 8:00 a.m. She stated that she was familiar with Patient #1, as he had just been discharged from the hospital sometime that afternoon (the afternoon of 09/08/10). When Patient #1 presented to the ED at 3:00 a.m. on 09/09/10, he was accompanied by his guardians. The patient's guardians reported that they brought him in to the ED because he was coughing continuously and couldn't stop. She conducted the patient's initial assessment. He had a raspy cough but he did not have any shortness of breath. His vital signs were stable and his oxygen sats were 92%. She discussed her findings with Charge Nurse (G)/RN, who instructed her to telephone the provider on-call, because the patient needed a medical screening examination. She called Nurse Practitioner (D), who was the designated provider on-call. Nurse (F) informed Nurse Practitioner (D) that Patient #1 and his guardians were in the ED. Nurse (F) reviewed her assessment findings with Nurse Practitioner (D) and the patient's need to be seen. Nurse Practitioner (D) stated that she was not coming in to evaluate Patient #1. Nurse Practitioner (D) instructed Nurse (F) to give the patient Robitussin cough syrup and place the patient on an "Outpatient Nursing" status. Charge Nurse (G) then spoke to Nurse Practitioner (D) and she still refused to come in. At that point, the two nurses created an Outpatient Nursing record, gave the patient Robitussin cough syrup as ordered, and sent him home. The outpatient nursing record indicated that the patient was discharged at 3:35 a.m.

Charge Nurse (G) was interviewed on 09/24/10 at 7:35 a.m. She stated that Patient #1's guardians spoke to her when they first arrived at the ED. His guardians stated that none of them had slept due to the patient's continuous coughing and shortness of breath. The patient had been sitting on the edge of his bed all night, unable to catch his breath and coughing non-stop. She observed Patient #1. The patient kept clearing his throat and coughing. The patient's cough appeared shallow, like he was not getting a full cough. He was not dyspneic. His breathing was not labored. Nurse (F) conducted the patient's assessment and then notified the provider on-call that the patient needed a medical screening examination. She was present when Nurse (F) contacted the provider on-call, Nurse Practitioner (D), who refused to come in to evaluate the patient. It became necessary for her to speak to Nurse Practitioner (D), to remind Nurse Practitioner (D) of her obligation to conduct the medical screening examination. Even after Charge Nurse (G) directed the conversation with Nurse Practitioner (D), Nurse Practitioner (D) still refused to come in. She refused several times and informed Charge Nurse (G) that "We will do this as an outpatient." Per instruction, an outpatient nursing record was created, Nurse Practitioner (D)'s telephone orders were implemented, and the patient was discharged.

Neither Nurse (F) nor Charge Nurse (G) contacted Physician (C) on 09/09/10, when Nurse Practitioner (D) refused to come in to the ED to evaluate Patient #1.

The hospital's policy regarding Emergency Room Call Coverage indicated that the hospital "will ensure that a Provider with training and experience in emergency care is on call and immediately available by telephone or radio, and available on site within 30 minutes, 24/7." The policy specifies that Physician (C) is the second provider on-call 24 hours a day, every day, unless otherwise indicated.

Nurse Practitioner (D) was interviewed on 09/24/10 at 9:35 a.m. She acknowledged that she was the provider on call on 09/09/10 when Patient #1 presented to the ED at 3:00 a.m. She stated she knew of the patient from his recent hospitalization and that he had been discharged from the hospital around noon on 09/08/10. After he was discharged, the patient's guardian contacted the clinic around 4:00 p.m. because the patient was still struggling with a nonproductive cough, but had no other symptoms. She had intended to write an order for cough syrup before she left that evening (that the guardian could have picked up from the pharmacy), but she forgot. She was in the hospital from 2:00 a.m. to 2:30 a.m. regarding another patient. She hadn't been home long before she was called again regarding Patient #1. She directed the nurses to give the patient Robitussin. She also directed the nurses to place the patient on "outpatient nursing" status, which she now realizes was improper. She did acknowledge that she declined to come to the ED to evaluate the patient.

Based on documentation and interviews, the hospital failed to maintain a central log in the emergency department (ED), that accurately tracked the care and disposition of each patient, in 6 of 26 patients reviewed (Patients #1, #3, #4, #5, #6, and #7). Findings include:

Medical Record review indicated that Patient #1 presented to the hospital's emergency department (ED)on 09/09/10 at 3:00 a.m., for evaluation of respiratory symptoms,coughing, and anxiety. Patient #1 was not listed on the ED log. Patient #1 had an "Outpatient Nursing" record.

The ED log indicated that Patient #3 presented to the ED on 08/13/10 at 8:04 a.m. with hypotension. After the medical screening examination was completed, the patient was returned to his residence, a skilled care facility. The ED inaccurately reflected that the patient was stabilized and transferred.

The ED log indicated that Patient #4 presented to the ED on 07/05/10 (no time documented) with symptoms of chest pain, shortness of breath, and swelling in his feet. The ED record indicated that after the medical screening examination was conducted, the patient was admitted for hospitalization. The ED log lacked this information.

Information on the ED log was also incomplete for patients #5, #6, and #7. Patient #5's name, address, date, and time of arrival, was written on the ED log and then crsossed out. Patient #6's name, address, date, and time of arrival was written on the ED log, but the remainder of the ED log (presenting problem, disposition, and time of discharge) was blank. Patient #7's name, address, date, and time of arrival was written on the ED log, but the presenting problem and provider sections were blank.

Administrative employee (B) was interviewed on 09/23/10. She stated that completion of the ED log was a nursing function. It is the responsibility of the ED nurses to ensure that the log is complete and accurate. The above examples were shared with employee (B), who did not dispute that the entries were incomplete and/or inaccurate.

Based on documentation and interviews, the hospital failed to ensure that each patient who presented to the emergency department received a medical screening examination, to determine whether or not an emergency medical condition existed, in one of 26 patients reviewed (Patient #1). Findings include:

Medical Record review indicated that Patient #1 presented to the hospital's emergency department (ED)on 09/09/10 at 3:00 a.m., for evaluation of respiratory symptoms,coughing, and anxiety.

Patient #1 did not have an ED record. Rather Patient #1's ED visit on 09/09/10 was documented on an "Outpatient Medical Record." The progress notes indicated that when the patient arrived at 3:00 a.m., he was accompanied by his guardians. Nurse (F)/RN assessed the patient and noted that he had a cough with ronchi auscultated bilaterally in both lungs. He was afebrile with oxygen sats of 92% on room air. His respirations were 24 but his breathing was nonlabored. His pulse was 97. Nurse (F) documented that Patient #1 was given Robitussin 2 teaspoons. His vital signs were then re-assessed. He remained afebrile. His respiratory rate had decreased to 18. His breathing remained nonlabored. His oxygen sats had improved to 93% on room air, but his pulse had increased to 111. He was discharged from the ED at 3:35 a.m., without having been examined by a physician or other health professional who was qualified to conduct the medical screening examination.

Nurse (F)/RN was interviewed on 09/27/10 at 8:00 a.m. She stated that she was familiar with Patient #1, as he had just been discharged from the hospital sometime that afternoon (the afternoon of 09/08/10). She recalled that Patient #1 was developmentally delayed and due to his disability, staff relied on his guardians for information about his health status because he was not a reliable historian. When Patient #1 presented to the ED at 3:00 a.m. on 09/09/10, he was accompanied by his guardians. The patient's guardians reported that they brought him in to the ED because he was coughing continuously and couldn't stop. She conducted the patient's initial assessment. He had a raspy cough but he did not have any shortness of breath. His vital signs were stable and his oxygen sats were 92%. She discussed her findings with Charge Nurse (G)/RN, who instructed her to telephone the provider on-call, because the patient needed a medical screening examination. She called Nurse Practitioner (D), who was the designated provider on-call. Nurse Practitioner (D) answered the telephone and Nurse (F) informed her that Patient #1 and his guardians were in the ED. Nurse (F) reviewed her assessment findings with Nurse Practitioner (D) and the patient's need to be seen. Nurse Practitioner (D) stated she was not coming in to evaluate the patient. Nurse (F) reviewed her assessment findings again, and informed Nurse Practitioner (D) that the patient's guardians were concerned about his condition. Nurse Practitioner (D) again stated she was not coming in to evaluate the patient. Nurse Practitioner (D) instructed Nurse (F) to give the patient Robitussin cough syrup and place the patient on an "Outpatient Nursing" status. As Nurse (F) read the telephone orders back to Nurse Practitioner (D), she was interrupted by Charge Nurse (G), who overheard her clarifying the orders with Nurse Practitioner (D). Charge Nurse (G) told Nurse (F) that they could not establish an outpatient nursing record because the patient was an ED patient, not an outpatient. Nurse (F) relayed this information to Nurse Practitioner (D). Again, Nurse Practitioner (D) stated she was not coming in to evaluate the patient. Charge nurse (G) spoke to Nurse Practitioner (D) and she still refused to come in. At that point, the two nurses created an Outpatient Nursing record, gave the patient Robitussin cough syrup as ordered, and sent him home. The outpatient nursing record indicated that the patient was discharged at 3:35 a.m.

Charge Nurse (G) was interviewed on 09/24/10 at 7:35 a.m. She stated that she spoke to Nurse Practitioner (D) about Patient #1's presenting problem, symptoms, and need to be seen. She verified that Nurse Practitioner (G) refused to come in to the ED on 09/09/10 to evaluate Patient #1.

Nurse Practitioner (D) was interviewed on 09/24/10 at 9:35 a.m. She acknowledged that she was the provider on call on 09/09/10 when Patient #1 presented to the ED at 3:00 a.m. She stated she knew of the patient from his recent hospitalization and that he had been discharged from the hospital around noon on 09/08/10. After he was discharged, the patient's guardian contacted the clinic around 4:00 p.m. because the patient was still struggling with a nonproductive cough, but had no other symptoms. She had intended to write an order for cough syrup before she left that evening (that the guardian could have picked up from the pharmacy), but she forgot. She was in the hospital from 2:00 a.m. to 2:30 a.m. regarding another patient, who presented to the ED. She hadn't been home long before she was called again, at 3:00 a.m., regarding Patient #1. She directed the nurses to give the patient Robitussin, which is what she had intended to provide for the patient earlier that day. She also directed the nurses to place the patient on "outpatient nursing" status, which she now realizes was improper. She did acknowledge that she declined to come to the ED to evaluate the patient. She was fully aware of her obligation to conduct medical screening examinations on patients who present to the ED, when she is the provider on call. She was also aware that medical screening examinations cannot be conducted by the RNs on staff in the ED, and that Patient #1 was being discharged without having had a medical screening examination, to rule out whether or not he had an emergency medical condition.

Review of Nurse Practitioner (D)'s personnel file reflected that she does possess the necessary credentials to function as an independent practitioner in the ED.

The hospital's policy on EMTALA indicated that "Any patient presenting to the hospital's emergency department or presenting on hospital property, requesting examination, care, or treatment for a medical condition, must be provided with a medical screening examination, by a provider, to determine if he/she is suffering from an emergency medical condition...the medical screening exam consists of an assessment and any ancillary tests or focused assessment based on the patient's chief complaint, necessary to determine the presence or absence of an emergency medical condition...the medical screening must be performed by a provider with experience in emergency care...the medical record shall reflect the findings of the medical screening...the emergency room where the medical screening occurs shall maintain an Emergency Room log which includes the patient name, date of service, presenting complaint, provider name, and patient disposition...this log is not to contain patients seeking elective outpatient care."

The hospital's Rules and Regulations regarding medical screening examinations indicated that "The initial and ongoing evaluation of the presenting patient shall be conducted by a qualified provider (Physician, Certified Nurse Practitioner or Physician Assistant)...to determine whether a patient has an Emergency Medical Condition...or to ensure that the patient does not have an Emergency Medical Condition."

Guardian (H) was interviewed on 09/29/10 at 9:13 a.m. She stated that Patient #1 has mental retardation. The patient is verbal and can converse, but he generally gives one-word responses that may not be reliable. The patient was hospitalized from 09/01/10 to 09/08/10 for "a breathing problem." Initially, the patient was in ICU, with an elevated heart rate, congestive heart failure, and a urinary tract infection. He received many medications and tests while hospitalized. On the day of discharge (09/08/10), she was not the person who picked him from the hospital at noon. She saw the patient later that afternoon. He didn't look good. He didn't want to eat. He was very quiet and didn't want to do anything. He was still wheezing. Before bed that night, she gave him a nebulizer treatment. Later, in the middle of the night, she could hear him breathing heavily and coughing. When she got up to check on him, he was sitting on the edge of the bed, coughing. His cough was continuous and he couldn't catch his breath. He looked scared. She took him to the ED. The nurse checked him in and then called Nurse Practitioner (D), so he could be examined and his condition could be treated. Nurse Practitioner (D) told the ED nurse to give him Robitussin. She told the nurse, "I don't think this is the answer," and the nurse agreed. After the nurse gave him the Robitussin, his cough did subside some and they went home. The next morning he again began coughing and coughing. He looked weak. She took him to Urgent Care, where he was examined by a physician. The physician ran some preliminary tests and said he needed to be hospitalized immediately. The physician facilitated his admission to a different hospital. The patient was admitted to ICU. The hospital physician said the patient had a blood clot in his lung, pneumonia, sepsis, congestive heart failure, atrial fibrillation, and a urinary tract infection. The patient spent two days in ICU and remained hospitalized through 09/17/10. The patient is home now and doing fine.

Patient #1's medical record, from the receiving hospital, dated 09/09/10, reflected that the patient "came in short of breath and was found to be in rapid atrial fib." Documentation noted that the patient was seen earlier that day in the clinic where he was quite tachypneic and diaphoretic, with oxygen sats at 88%. These same symptoms were noted by hospital staff, at the time of his admission. It was also noted that the patient had to sit up in bed with his head up at 45 degrees, to ease his respirations and coughing. His neck veins were distended and he had diffuse wheeziness in both lower lung lobes. The patient remained short of breath and hypoxic. His sats on 3.5 liters of oxygen were 92%. He also had bilateral pitting edema in both lower extremities. After diagnostic tests were completed, the patient was diagnosed with acute exacerbation of congestive heart failure, pneumonia (healthcare related), sepsis secondary to pneumonia, pulmonary embolism, and atrial fibrillation. It was noted that the patient's acute congestive heart failure was secondary to systolic dysfunction and that the patient would be placed on telemetry, to try to optimize rate control of his medications for atrial fibrillation. The patient showed gradual improvement over the course of the next few days. He was discharged to home on 09/16/10.

Based on documentation and interviews, the hospital failed to ensure that the appropriate transfer forms and medical records accompanied each patient, when it was necessary for the hospital to transfer a patient to a higher level of care (Patient #2). Findings include:

Medical record documentation indicated that Patient #2 presented to the ED, on 09/19/10 at 2:45 a.m., with a laceration to the helix of his left ear. Data on the ED log reflected that Patient #2 was "stabilized and transferred" at 4:15 a.m.

The ED record noted that the provider on-call evaluated the patient and determined that the patient's ear laceration needed to be repaired by a plastic surgeon. The provider spoke to a physician at the receiving hospital, who accepted the patient in transfer. Documentation also noted that a nurse-to-nurse report was given to the receiving hospital, at the time of transfer (4:15 a.m.). There was no evidence that a benefit/risk analysis of the transfer was discussed with the patient. In addition, there was no evidence that the appropriate medical records were sent with the patient. The patient's transfer instructions were documented on a discharge summary sheet, which indicated: "Go to St. Cloud Hospital to have ear laceration repaired by (name of specialist)."

On 10/06/10 at 12:15 p.m., Administrative nurse (E)/RN confirmed that the physician certification was not completed when Patient #2 was transferred to another hospital on 09/19/10. The patient was transferred only with the discharge instructions, as noted above.