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Based on interviews, record reviews, policy and procedure review, the emergency department (ED) complaints log review, and the ED log review, it was determined the facility failed to comply with 42 CFR 489.20(r)(3) and follow the facility policy and procedure "EMTALA - Emergency Department Log Book Maintenance" in regard to ensuring all individuals who present to the facility seeking assistance were placed in the central log. Patient #1 presented to the facility ED on 04/30/12 at 1:00 AM seeking care, but staff failed to enter Patient #1's name on the ED log.

The facility failed to comply with 42 CFR 489.24(r), 489.24(c), and to follow their policy "EMTALA - Medical Screening" related to all individuals who come to the ED were provided an appropriate medical screening exam (MSE). Patient #1, who was pregnant, presented to the ED on 04/30/12 with complaints of lower abdominal pain. Nursing staff encouraged Patient #1 to go to Hospital #2 to obtain obstetric services. Registered Nurse #1 used her personal vehicle and transported Patient #1 to a local grocery store parking lot and then called an ambulance. Patient #1 was transported to Hospital #2 by ambulance without receiving a MSE at Hospital #1. Patient #2 presented to the ED on 04/28/12 at 8:02 PM with complaints of "lower abdominal pain. Patient #2 left the ED at 8:30 PM after being informed by nursing staff that they could not help her because there were no gynecologist on staff at the facility. Patient #2 did not receive a MSE prior to leaving. Patient #3 presented to the ED on 04/29/12 at 11:51 PM with complaints of severe pain in her lower abdomen. Patient #3 left the ED at 11:55 PM prior to receiving a MSE, after being told by staff that she would have to wait two hours for a person to get to the facility to perform an ultrasound. On 05/01/12 Patient #3 returned to the facility with the same complaints of severe abdominal pain. An ultrasound was performed and a "uterine mass" was diagnosed. Patient #3 was transferred by ambulance to Hospital #2 where a surgical procedure was performed. Patient #9 presented to the ED on 04/18/12 at 9:09 AM with vaginal bleeding and cramping. Patient #9 left the ED at 9:30 AM, prior to a MSE, after being told by the registration clerk that the ED had some trauma cases coming in and Patient #9 would have to wait five to six hours before being seen by a physician. Patient #11 presented to the ED on 01/30/12 at 10:04 AM with a cut on the top of the right hand. Patient #11 left the ED after his/her hand was wrapped by a nurse and was told that it would be ok to go to another facility for care. Patient #11 did not receive a MSE at Hospital #1. Patient #11 required 13 stitches. Patient #17 presented to the ED on 01/21/12 at 1:56 PM with complaints of abdominal pain that started on 01/17/12. Review of the "Physician Record" revealed no physical examination of the abdomen was documented. The only laboratory test that was ordered was a urinalysis. Patient #17 was discharged from the ED on 01/21/12 at 2:50 PM. After discharge from Hospital #1, Patient #17 went to Hospital #3 where he/she was admitted with an elevated white blood count. A Diagnostic Laparoscopy and Exploratory Laparotomy with an Incidental Appendectomy was performed on 01/24/12. Patient #17 was discharged from Hospital #3 on 01/29/12. Interview with the ED Medical Director on 05/18/12 at 11:35 AM revealed that an appropriate MSE on a patient complaining of abdominal pain would consist of a physical exam of the abdomen and at least a complete blood count."

The facility failed to comply with 42 CFR 489.24(e)(1)-(2) and to follow their policy and procedure "EMTALA Stabilization," in regard to a transfer of an unstable patient requiring written certification containing a complete picture of the benefits to be expected from appropriate care at the receiving facility. Patient #3 on 05/01/12, Patient #6 on 04/06/12, and Patient #20 on 04/21/12 were transferred in an unstable condition to other facilities. The facility failed to ensure the physician documented the specific benefits of a transfer for Patients #3, #6, and #20.

Based on interviews, policy and procedures review, the Emergency Department (ED) log review, and review of the internal investigation documents, it was determined the facility failed to ensure all individuals who came to the facility seeking assistance, were placed in the central log for one patient (#1) in the selected sample of 20. Additionally, the facility failed to follow their policy and procedure "EMTALA - Emergency Department Log Book Maintenance" related to all patient presentations being entered in the central log.

Findings include:

A review of the facility policy and procedure "EMTALA - Emergency Department Log Book Maintenance," dated 03/2010 as the last approval date, revealed "A central log will be maintained on each individual who comes to the Emergency Department seeking assistance. Each individual will be entered in the central log whether the patient refuses treatment, was refused treatment or whether transferred, admitted and treated, stabilized and transferred, or discharged."

A review of the facility's internal investigation documents revealed Patient #1 presented to the ED registration desk on 04/30/12 at 1:00 AM. Patient #1 was 27 to 28 weeks pregnant and was experiencing lower abdominal pain. Registered Nurse (RN) #1 entered the registration area and informed Patient #1 that it would be best for her to go to another facility that provided obstetrical services. RN #1 picked Patient #1 up in her personal vehicle and transported her off of the facility grounds to a local grocery store parking lot. An ambulance was called to transport Patient #1 to another facility.

A review of the ED log revealed Patient #1's name did not appear on the log for the date of 04/30/12.

Interview with with the Risk Manager on 05/16/12 at 11:00 AM revealed, Patient #1's name did not appear on the ED log.

Based on interviews, record reviews, policy and procedure review, and internal investigation document review, it was determined the facility failed to ensure six patients (#1, #2, #3,#9, #11, and #17) in the selected sample of 20, received an appropriate medical screening exam (MSE) within the capability of the hospital's emergency department (ED). The facility failed to follow their policy "EMTALA - Medical Screening" related to all individuals who come to the ED were provided an appropriate medical screening exam (MSE).

Review of the facility policy and procedure "EMTALA - Medical Screening" with an approval date 02/01/05 revealed "The hospital with an emergency department must provide to an individual that is not a patient who "comes to the emergency department" an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists, regardless of the individual's ability to pay."

1. Record review of the facility's internal investigation regarding Patient #1's ED visit on 04/30/12 at 1:00 AM revealed she was 27 or 28 weeks pregnant and presented with lower abdominal pain. Registered Nurse (RN) #1 informed Patient #1 that the facility did not have obstetrics services and it would be best if she went to Hospital #2. RN #1 called Patient #1's mother and spoke with her. After talking with the mother, RN #1 used her personal vehicle and drove Patient #1 to a local grocery store parking lot. RN #1 called an ambulance to transport Patient #1 to Hospital #2. The ambulance responded and transported Patient #1 to Hospital #2. The internal investigation determined that Patient #1 did not receive a MSE.

Review of Patient #1's ED record from Hospital #2 revealed she arrived at Hospital #2 by ambulance on 04/30/12 at 1:50 AM. She was provide a MSE and was discharged home on 04/30/12 at 4:36 AM with the final diagnosis of "Other current maternal conditions classifiable elsewhere, antepartum" and "Abdominal pain, unspecified site."

Interview with the Radiology Technician on 05/16/12 at 1:45 PM and with the Registration Clerk on 05/16/12 at 2:00 PM revealed that RN #1 had informed Patient #1 on 04/30/12 that it would be best if she went to Hospital #2 for obstetric services. RN #1 called Patient #1's mother and explained what was going on. They stated the mother was going to be awhile before she could get to the hospital so RN #1 transported Patient #1 to a grocery store parking lot and called an ambulance. They revealed Patient #1 was not examined by the physician at Hospital #1.

Interview with ED Physician #1 on 05/17/12 at 12:15 PM revealed he was on duty in the ED on 04/30/12 when Patient #1 presented to the registration area. He stated he was not aware that Patient #1 was there on 04/30/12, therefore a MSE was not provided.

Interview with Patient #1 on 05/17/12 at 12:35 PM revealed she presented to Hospital #1's ED on 04/30/12 with back and abdominal pain. She stated she thought she was in labor. Patient #1 revealed the ED staff did not want to check her in because they did not do deliveries at Hospital #1. A nurse took her to a local grocery store parking lot and called the ambulance. She stated she was not examined by a physician while at Hospital #1. She stated she was transported to Hospital #2 by ambulance. Patient #1 stated Hospital #2 kept her a few hours and released her, she was not in labor.

2. Review of Patient #2's ED record revealed she presented to the ED on 04/28/12 at 8:02 PM with complaints of "lower abdominal pain." Documentation on the "Triage Sheet" revealed at 8:30 PM Patient #2 decided not to be seen and she would make an appointment with her personal physician on Monday (04/30/12). Review of the ED complaints log revealed Patient #2 made a complaint regarding the 04/28/12 ED visit. Review of the "Patient Care Concern" documents revealed Patient #2 called Administration on 05/04/12 and stated she came to the ED on 04/28/12 and was refused treatment. Patient #2 revealed that the nurse told her there was nothing they could do for her at the facility and she needed to find a gynecologist to treat her. Patient #2 left the facility without a MSE, went home, and was still in pain.

Interview with the Risk Manager on 05/16/12 at 11:00 AM revealed the investigation determined there was no triage or MSE performed, therefore it was an EMTALA violation. He stated they were unable to interview the nurse who documented on the record because she was no longer working at the facility and there were no other witnesses.

3. Review of Patient #3's ED (Hospital #1) record for 04/29/12 revealed she presented to Hospital #1's ED at 11:51 PM with complaints of severe pain in her lower abdomen. Documentation on the "Triage Sheet" revealed at 11:55 PM Patient #3 decided to go to Hospital #2 . There was no documented evidence of triage or a MSE being performed at Hospital #1.

Review of Patient #3's ED visit to Hospital #2 on 04/30/12 at 12:30 AM revealed she was provided a MSE and was diagnosed with a urinary tract infection.

Interview with Patient #3 on 05/18/12 at 3:30 PM revealed she went to the ED (Hospital #1) on 04/29/12 with complaints of abdominal pain. She stated she was told by someone in the ED that she would have to wait two hours for a person to get to the facility to perform the ultrasound. She stated she did not receive an examination by a physician. She stated she left and went to Hospital #2's ED. At Hospital #2 she was diagnosed with a urinary tract infection

Review of the ED log for Hospital #1 revealed Patient #3 returned to Hospital #1's ED on 05/01/12. Review of Patient #3's ED visit to Hospital #1 on 05/01/12 revealed she presented to the ED at 7:24 PM with complaints of severe pain in the lower abdomen. She rated her pain 10 on a scale of 1 to 10 (with 10 being the most severe pain). Patient #3 revealed she had a miscarriage on 02/12/12. A MSE exam was performed by the physician and Patient #3 was diagnosed with a "uterine mass" Documentation on the physician record revealed it was "very difficult in getting the patient's pain under control despite multiple doses of Morphine and Dilaudid." Review of the "Certificate of Transfer" revealed the physician certified that Patient #3 had suffered from an EMC and the benefits of transfer outweighed the risk. Arrangements were made for transfer and Patient #3 was transferred to Hospital #2 by ambulance on 05/02/12 at 3:15 AM.

Review of Patient #3's medical record for the ED visit to Hospital #2 on 05/02/12, revealed Patient #3 arrived at Hospital #2's ED at 3:47 AM, per ambulance, as a transfer from Hospital #1. A MSE was performed and it was determined Patient #3 required Dilatation and Curettage by a surgeon. Patient #3 was taken to surgery on 05/02/12 at 7:09 AM. Review of the Pathology report revealed the contents removed from the uterus was "Products of conception."

Additional interview with Patient #3 revealed on 05/01/12 she was in terrible pain again and returned to the ED at Hospital #1. She stated a pelvic exam and an ultrasound were performed. She was given pain medication and then transferred to Hospital #2 because she needed "Emergency" surgery (Dilatation and Curettage) related to her miscarriage in February 2012.

4. Review of Patient #9's ED record for 04/18/12 at 9:09 AM revealed she presented with vaginal bleeding and cramping. She rated her pain 10 on a scale of 1 to 10 (with 10 being the most severe pain). Documentation on the "Triage Sheet" revealed Patient #9 reported she had vaginal bleeding since childbirth eight months ago and stated it was very heavy at the present and she was cramping. Documentation by Registered Nurse (RN) #2 revealed Patient #9 left at 9:30 AM without seeing the physician and was going to see her obstetrician. There was no documented evidence a MSE was performed.

Interview with Patient #9 on 05/18/12 at 12:40 PM revealed she presented to the ED on 04/18/12 due to vaginal bleeding and abdominal cramping. She stated the registration clerk told her the ED had some trauma cases coming in and Patient #9 would have to wait five to six hours before being seen by a physician, therefore she left. She stated she went to her physician later and she had a cyst on her ovary.

Interview with RN #2 on 05/18/12 at 2:45 PM revealed she triaged Patient #9 on 04/18/12 but she did not advise her to leave or tell her it would be a five to six hour wait. She stated she told Patient #9 she did not know how long it would be before she would be seen by the physician. Patient #9 left from the lobby and informed the registration staff that she was leaving. RN #2 verified that the ED was expecting some trauma cases to arrive at that time.

5. Review of Patient #11's ED record for 01/30/12 at 10:04 AM revealed he/she presented to the ED with a cut on the top of the right hand. Review of the "Triage Sheet" revealed RN #3 documented the following: At time of patient's arrival, dressing applied due to bleeding. Patient called work and was advised to go to Hospital #2. Patient #11 advised admission staff and left Hospital #1. There was no documented evidence a MSE was performed.

Interview with Patient #11 on 05/17/12 at 10:30 AM revealed he/she had cut his/her hand while working on 01/30/12. His/Her work sent him to Hospital #1's ED and told him/her to have the ED look at his/her hand and if it was ok then he/she could go to their hometown for care. Patient #11 stated that he/she presented to the registration desk and a male nurse looked at the wound and informed Patient #11 that it would need stitches. He stated the male nurse wrapped his/her hand and told him/her it would be ok for him to go to his/her hometown for care. Patient #11 stated he/she went to a clinic and had to have 13 stitches.

Interview with RN #3 on 05/17/12 10:35 AM revealed he did not remember Patient #11 but he would not tell a patient that they were stable enough to travel to another facility.

6. Review of Patient # 17's ED record for 01/21/12 at 1:56 PM revealed he/she presented to the ED with complaints of abdominal pain that started on 01/17/12. Review of the "Triage Sheet" revealed Patient #17 rated his/her pain 6 on a scale of 1 to 10 (with 10 being the most severe pain). He/She had been seen in the ED at Hospital #2 on the previous night. Review of the "Physician Record" revealed no physical examination of the abdomen was documented. The only laboratory test that was ordered was a urinalysis. Patient #17 was discharged from the ED on 01/21/12 at 2:50 PM.

Review of the medical record of Patient #17 from Hospital #3 revealed Patient #17 presented to the ED on 01/21/12 at 7:19 PM with complaints of right sided abdominal pain and vomiting. A MSE was performed in the ED and Patient #17 was found to have an elevated white blood count of 16.01 (normal 4.80 - 10.80). Review of the "History and Physical" revealed Patient #17 was admitted to the surgical unit and was not to eat or drink fluids. A surgeon was consulted. Review of the "Operative Report" revealed a Diagnostic Laparoscopy and Exploratory Laparotomy with an Incidental Appendectomy was performed on 01/24/12. Review of the "Discharge Summary" revealed Patient #17 had been admitted with "discreet right lower abdominal pain, rebound, and referred pain to the right lower quadrant, elevated white blood count with left shift. His clinical symptoms persisted. He underwent the aforementioned procedures. Postoperatively he has recovered, the pain is gone and resolved. He has no further complaints." Patient #17 was discharged from Hospital #3 on 01/29/12.

Review of the ED complaints log revealed Patient #17 made a complaint regarding his/her visit to the ED on 01/21/12. Review of the "Patient Care Concern" document revealed the investigation determined ED Physician #2 failed to do a physical examination and no laboratory work or x-rays were performed. Documentation revealed ED Physician #2 had explained to Patient #17 that he would not call the surgeon on a Saturday for a non-emergency condition. ED Physician #2 recommended Patient #17 contact the surgeon on Monday (01/23/12). The facility investigation consisted of the ED Medical Director reviewing the ED record of Patient #17. Review of the written statement by the ED Medical Director revealed that "in retrospect, a physical exam and lab work would have been appropriate. To write off the bill is reasonable, in that our ED really did not do much."

Interview with ED Physician #2 revealed he was the ED physician when Patient #17 presented on 01/21/12. He stated Patient #17 was wanting to see a surgeon and Patient #17 did not want any more tests run. ED Physician #2 stated he failed to do a physical exam of the abdomen. Additionally, he stated "I would like to think I offered to do some blood work, but I usually chart that. A blood count would have been appropriate."

Interview with RN #4 on 05/18/12 at 11:50 AM revealed he was working the ED during the time Patient #17 was in the ED on 01/21/12. He was not aware of Patient #17 refusing any test or examination that was offered to him/her.

Interview with the ED Medical Director on 05/18/12 at 11:35 AM revealed that an appropriate MSE on a patient complaining of abdominal pain would consist of a physical exam of the abdomen and at least a complete blood count."

Interview with Patient #17 on 05/18/12 at 1:00 PM revealed he/she presented to Hospital #1's ED on 01/21/12 with complaints of abdominal pain. Patient #17 stated the physician did not do anything for him/her. He/She stated he was hurting badly and wanted some help. Patient #17 denied refusing an examination or any test to be performed. He/She revealed after he/she was discharged from the ED at Hospital #1 and he/she went to Hospital #3. At Hospital #3 he/she was admitted due to abdominal pain and elevated white blood count. Surgery was performed on 01/24/12.

Based on interviews, record reviews, and policy and procedure review, it was determined the facility failed to ensure that during a transfer of a patient with an emergency medical condition (EMC), the physician's written certification contained a complete picture of the benefits to be expected from appropriate care at the receiving facility for three patients (#3, #6, and #20) in the selected sample of three unstable patients requiring transfer to another facility. Additionally, the facility failed to follow their policy and procedure "EMTALA Stabilization," related to the physician certification containing a detailed summary of the risks and benefits of an unstable transfer.

Findings include:

Review of the facility's policy and procedure "EMTALA Stabilization" with approval date of 02/01/05, revealed the hospital may arrange an appropriate transfer of an individual with an EMC that is not medically stable to another more appropriate or specialized facility. The physician must sign a certification that based upon the information available at the time of transfer, the medical benefits expected from the provision of appropriate medical treatment at another facility outweigh the increased risk to the individual. The certification must contain a summary of the risks and benefits upon which the decision was based.

1. Review of the medical record of Patient #3 revealed she presented to the Emergency Department (ED) on 05/01/12 at 7:24 PM with complaints of abdominal pain. She was triaged as a "Urgent" patient and rated her pain 10 on a scale of 1 to 10 (10 being the most severe pain). A medical screening exam (MSE) was performed and the physician determined Patient #1 had a uterine mass and would benefit from transfer to another facility. Review of the "Certificate of Transfer" revealed the physician certified that Patient #1 suffered from an EMC and the physician had determined that based upon the information available at the time, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweighed the increased risk to the individual's medical condition from effecting the transfer. The only risk of transfer documented was "Motor Vehicle Accident." There was no documentation of the specific risk of transfer for Patient #3, related to her condition.

2. Review of the medical record of Patient #6 revealed she presented to the ED on 04/06/12 at 2:33 PM with the chief complaint of 28 weeks pregnant and thought her amniotic fluid was leaking. A MSE was performed by the physician, it was determined Patient #6 had a "rupture of the membranes," and would benefit from transfer to another facility. Review of the "Certificate of Transfer" revealed the physician certified that Patient #6 suffered from an EMC and the physician had determined that based upon the information available at the time, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweighed the increased risk to the individual's medical condition from effecting the transfer. The only risk of transfer documented was "Motor Vehicle Accident." There was no documentation of the specific risk of transfer for Patient #6, related to her condition.

3. Review of the medical record of Patient #20 revealed he/she presented to the ED on 04/21/12 at 2:32 AM with complaints of abdominal pain. A MSE was performed by the physician. Review of the physician's documentation revealed Patient #20 was in acute respiratory failure with a possible acute myocardial infarction requiring intubation and a ventilator. Review of the "Certificate of Transfer" revealed the physician certified that Patient #20 suffered from an EMC and the physician had determined that based upon the information available at the time, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweighed the increased risk to the individual's medical condition from effecting the transfer. There were no documented risk related to the transfer of Patient #20 listed on the certification form.

Interview with the Risk Manager on 05/18/12 at 4:30 PM revealed the physician failed to list on the certification form, the specific risk related to the patients condition, for Patients #3, #6, and #20 when they were transferred in an unstable condition. He stated the physician did not meet the intent of the facility's "EMTALA Stabilization" policy and procedure.