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Based on review of the emergency room log, medical record review, review of policies and procedures, and staff and patient, interview, the hospital failed to comply with the requirements at 489.20 and 489.24. Specifically, the hospital failed ensure a medical screening examination (MSE) was performed for 1 of 30 sample patients who presented to the emergency room and failed to perform a comprehensive MSE for 1 of 29 sample patients who were seen in the ER. In addition, there lacked evidence 1 of 30 sample patients were stable prior to discharge or transfer. The hospital also failed to ensure 1 patient was documented in the log when s/he presented to the ER. Refer to C2405, C2406, and C2407.

Based on staff and patient interview and review of the emergency room (ER) logs, the ER staff failed to document in the log 1 of 30 sample patients (#14) who presented to the ER. The findings were:

1. During a confidential interview with patient #14 on 2/1/12 at 2:10 PM, the patient stated s/he had gone to the ER on 1/17/12 at approximately 6:30 PM because s/he had redness and itching where stitches were previously placed on his/her wrist on 1/15/12. The following concerns were identified:

a. Review of the ER log showed this patient's presentation to the ER on 1/17/12 was not documented in the ER log.

b. Interview with RN #1 on 2/1/12 at 2:55 PM verified the patient did present to the ER but was seen in the lobby instead of the ER examination room. Interview with the nurse manager on 2/1/12 at 3:30 PM revealed the log was filled out only if the patient was taken back to the ER examination room, which this patient was not.

c. Review of the hospital's policy on ER staff coverage and duties, revised 1997, showed "every applicant for treatment shall be seen by a physician...Patients will be treated in the emergency room, not in the hallways or at the nurse's station..."

Based on staff interview, patient interview, medical record review, and review of the emergency room (ER) log and policies and procedures, the hospital failed to provide a medical screening examination (MSE) for 1 of 30 sample patients (#14) and failed to perform a comprehensive MSE for 1 of 29 sample patients (#23) who received an MSE. The findings were:

1. During a confidential interview with patient #14 on 2/1/12 at 2:10 PM, the patient stated s/he gone to the ER on 1/17/12 at approximately 6:30 PM with complaints of redness and itching where stitches were previously placed on his/her wrist on 1/15/12. The patient further stated s/he had several allergies and was concerned about having an allergic reaction at that time. The patient said when s/he arrived at the hospital there were no staff in the ER. The patient then rang the bell and a nurse came to the ER lobby. The patient told the nurse about his/her symptoms and history of allergic reactions. The patient said the nurse then looked at the wrist and said it "looked fine." The following concerns were identified:

a. According to the patient, who was interviewed on 2/1/12 at 2:10 PM, the nurse paged the on-call physician overhead and he did not respond. The nurse then called the physician's cell phone and again, he did not respond. Finally, according to the patient, the nurse called the physician at his home. This time the physician responded and the nurse described the patient's concerns to him. The patient was then told to go home, take some Benadryl, and request "blue stitches" the next time.

b. Interview on 2/1/12 at 2:55 PM, with the nurse who saw the patient on 1/17/12, revealed the wound looked like it was healing. She further said when she spoke with the on-call physician, he asked the nurse if the patient wanted to be seen. The nurse said she then asked the patient if s/he wanted to have the physician come in to see him/her and the patient said it was not necessary and left.

c. Review of the ER log showed no evidence the patient was seen, had vital signs taken, or was provided any care, and there was no medical record generated. Therefore, there was no evidence a medical screening examination (MSE) was performed.

Interview with the patient on 2/1/12 at 2:10 PM revealed when s/he presented to the ER, it was with the expectation that s/he would be seen by a physician for a MSE. The patient further said s/he did not say she did not want to be seen as stated by RN #1.

2. Review of the medical record for patient #23 showed s/he presented to the ER on 1/2/12 at 3:25 PM with complaints of sadness and worsening anxiety due to the recent death of his/her mother. Further review of the record showed the patient had a diagnosis of Bipolar Disorder. Review of the physician's ER note showed "It was felt that [his/her] condition is complex, involves a substantial amount of depression, which has been complicated by his recent inactivity and limited outdoor activity as well. [The patient] appears to have significant grief issues regarding the loss of [his/her] mother that have not been resolved over the past six months." Further review showed the physician gave the patient a prescription for a higher dose of Ativan (anti-anxiety medication) and discharged the patient, unaccompanied, at 4:20 PM. Review of the medical record showed no evidence the patient was assessed for his/her potential for suicide or self harm.

Interview with the ER nurse manager on 2/1/12 at 3:30 PM revealed this patient would probably have benefited from a more comprehensive assessment regarding his/her suicidal thoughts.

Based on staff interview,medical record review, and review of the emergency room (ER) log and policies and procedures, the hospital lacked evidence stabilizing treatment was established prior to discharge or transfer for 1 of 30 sample patients (#22). The findings were:

According to the ER log, patient #22 presented to the ER on 1/14/12 at 9:10 AM with complaint of right shoulder pain after sustaining a fall on the ice earlier in the day. Review of the physician notes showed the patient stated s/he did "black out" for an undetermined amount of time. The following concerns were identified:

a. Review of the physician's notes showed the patient's blood pressure (B/P) reading was elevated at 192/108 and remained elevated through his/her stay in the ER. Review of these notes revealed the patient said s/he periodically checks the B/P at home and they had been within normal limits. Review of the ER nursing record showed the patient was not currently prescribed any B/P medications. The physician told the patient the elevated B/P was probably due to stress and discomfort. The patient was discharged home at 10:15 AM with his/her B/P still elevated at 180/106. At 3:15 PM that same day, 1/14/12, the patient returned to the ER with complaints of tingling in the feet, a fullness in the chest and anxiety. The patient was concerned s/he was having a cardiac event. The patient's B/P at 3:15 PM was 196/107 at 3:30 the patient was administered Ativan (anti-anxiety drug) Upon recheck at 3:35 PM the patient's B/P was 161/101 and at 3:40 PM it was up to 173/99.

b. Interview with the patient on 2/1/12 at 2:07 PM revealed his/her systolic B/P was typically in the 130 to 140 range and that s/he had not seen a physician for follow-up of his/her elevated B/P because the ER physician said it was normal to have an elevated B/P after a head injury. Interview with the nurse manager on 2/1/12 at 3:30 revealed it is the practice of ER staff to send a patient home after a head injury as long as the computerized tomography (CT) was clear and this patient's CT showed no abnormality. The nurse manager said the elevated blood pressure at the time of discharge was not taken into consideration.