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Based on document review and interview, it was determined that in 1 (patient #1) of 20 medical records (MR) reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide a medical screening exam.

Findings include:

1. See findings cited at 42 CFR 489.24(a)(1), A2406.

Based on document review & interview, the facility failed to maintain a central log on each individual who comes to the emergency department, for 1 of 20 patients presenting to the facility. (Patient #1)

Findings include:

1. Review of policy/procedure Patient Transfer to Another Facility, EMTALA Compliance indicated the following;
D. Documentation
1. The emergency rooms will keep a log of each patient presenting for medical care. This log will include whether the patient refused treatment, was transferred, admitted and treated, stabilized and transferred, or discharged.
This policy/procedure was last reviewed/revised on 12/13.

2. On 10-17-16 at 1130 hours staff #40, 41 & 42 confirmed that patient #1 presented to the facility's emergency department (ED) on 09-20-16 for complaint of facial/head trauma and patient #1's name was not present on the ED's Log Book.

3. Review of the ED Log lacked documentation that patient #1 presented to the facility on 09-20-16.

Based on document review & interview the facility failed to ensure that written policies and procedures governing an appropriate medical screening examination of all patients presenting to the facility was followed for 1 of 20 Emergency Department (ED) medical records (MR) reviewed. (Patient #1)

Findings include:

1. Review of policy/procedure Patient Transfer to Another Facility, EMTALA Compliance indicated the following;
A. Individuals who come to the dedicated emergency department will receive a medical screening examination appropriate to their presenting signs and symptoms and consistent with the capability and capacity of the hospital to determine whether or not and emergency medical condition exists.
This policy/procedure was last reviewed/revised on 12/13.

2. On 10-17-16 at 1130 hours staff #40, 41 & 42 confirmed that patient #1 presented to the facility's emergency department (ED) on 09-20-16 for complaint of facial/head trauma, staff #44, triage registered nurse, indicated to patient #1 should go to facility #2 and patient #1 left the facility.