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

Based on interviews, the hospital failed to maintain a central log that tracked each patient's care, who presented to the emergency department for services. Findings include:

Interviews with nurses (A, B, C, and D) during the site visit of 04/15/10, indicated that some patients who presented to the emergency department (ED) for emergency care were not always evaluated in the ED. Rather, the triage nurse has the discretion to refer patients with minor illnesses or needs (i.e., sore throats, colds, etc.) to the clinic for care. As a result, the patient's care and disposition are not included in the ED log.

Based on observations, documentation, and interviews, the hospital failed to provide a medical screening examination for each patient who presented to the ED for care. Findings include:

Observations revealed the hospital complex has two main entrances, one located at the adjoining clinic and the other located at the ED. The hospital and clinic are separated by a hallway. The ED triage nurse is stationed next to the ED entrance; the triage nurse is the first hospital employee that a patient or visitor would encounter, if they entered through the ED entrance.

An interview with Nurse (B)/Clinic staff, on 04/15/10 at 8:45 a.m., established that many people often enter the hospital through the ED entrance, rather than the clinic entrance. Some of them are seeking the location of the clinic for scheduled appointments, and may stop at the triage desk for directions. Others are seeking emergency medical care. Nurse (B) was aware that during periods of seasonal upper respiratory illnesses, some patients (who presented through the ED) preferred to be evaluated in the clinic, rather than in the ED, because it was quicker to be evaluated in the clinic. These preferences were honored, when possible. The patient is seen by a triage nurse and directed to the clinic. No medical screening examination is completed before the patient is sent to the clinic.

An interview with Nurse (A)/Hospital staff, on 04/15/10 at 9:10 a.m., verified Nurse (B) ' s statements exactly. Nurse (A) added that the ED triage nurse may refer a patient to the clinic for treatment, when this is requested by a patient or when the patient's medical problem is minor (such as an upper respiratory illness or small laceration). According to the hospital's by-laws, nurses are not qualified to conduct a MSE. As a result of this practice, patients who have presented through the ED for emergency care and have been referred on to the clinic, do not have an ED record. There was no evidence of medical screening examinations for these patients, nor are the patients entered on the ED log. Nurse (A) was unaware of any instance in which a patient with chest pain was evaluated in the clinic instead of the ED.

Interviews with ED nurses (C and D)/RNs, during the 04/15/10 site visit, confirmed the above information. Although the investigator approached three different staff in the clinic, all declined interviews and directed the investigator to Nurse (B).