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Based on medical record review, personnel file review, ED Committee meeting minutes review, facility policy review, incident report review, and staff interview , it was determined the facility failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. The facility failed to ensure MSE's were provided to 2 of 27 patients (#24 and #27) whose records were reviewed. The facility failed to ensure stabilizing treatment was provided to 1 of 16 patients (Patient #26) who transferred to another facility for higher level of care and whose records were reviewed. This resulted in the inability of the facility to ensure patients with potential emergency medical conditions were cared for in a safe and effective manner. Findings include:

A facility policy "Left Without Being Seen," dated 12/06/17, stated "Admit patient as a full admit in [EMR] if they choose to leave [CAH name] without being seen and have not already been registered." The policy also stated "Document in the notes section of the EMR of why patient arrived at hospital, what was said by both parties and where and why patient LWBS."

A second facility policy "Stabilization and Transfer of Patients to Outside Facilities/EMTALA," dated 12/21/16, stated "Medical Screening Examination: If a person comes to the hospital and a request is made for their emergency care or, if the person is unable to communicate, a reasonable person would believe that the person is in need of emergency care, then qualified medical personnel will, within the hospital's capability and capacity, conduct and document an appropriate medical screening examination...". The policy also stated "All patients will receive and [sic] appropriate medical screening exam by a credentialed Medical Staff Member or allied health professional."

A third facility policy "Patient Triage," dated 4/04/16, stated "It is the policy of [CAH name] to triage all persons presenting to the Emergency Department or Hospital seeking medical attention who do not have a scheduled appointment and/or scheduled outpatient/procedure."

The CAH failed to implement policies to ensure compliance with the requirements at 42 CFR Part 489.24.

Based on medical record review, personnel file review, ED Committee meeting minutes review, facility policy review, incident report review, and staff interview, it was determined the facility failed to ensure a Medical Screening Examination was provided to 2 of 27 patients (#24 and #27) whose records were reviewed. This resulted in an absence of treatment and potential deterioration of a patient's condition. Findings include:

A facility policy "Left Without Being Seen," dated 12/06/17, stated "Admit patient as a full admit in [EMR] if they choose to leave [CAH name] without being seen and have not already been registered." The policy also stated "Document in the notes section of the EMR of why patient arrived at hospital, what was said by both parties and where and why patient LWBS."

A second facility policy "Stabilization and Transfer of Patients to Outside Facilities/EMTALA," dated 12/21/16, stated "Medical Screening Examination: If a person comes to the hospital and a request is made for their emergency care or, if the person is unable to communicate, a reasonable person would believe that the person is in need of emergency care, then qualified medical personnel will, within the hospital's capability and capacity, conduct and document an appropriate medical screening examination...". The policy also stated "All patients will receive and [sic] appropriate medical screening exam by a credentialed Medical Staff Member or allied health professional."

A third facility policy "Patient Triage," dated 4/04/16, stated "It is the policy of [CAH name] to triage all persons presenting to the Emergency Department or Hospital seeking medical attention who do not have a scheduled appointment and/or scheduled outpatient/procedure."

The facility failed to follow their policies and provide Medical Screening Examinations. Examples include:

1. ED Committee meeting minutes, dated 4/27/18, stated "Left because she thought she was in labor. [Physician A] came out and spoke with her...Patient decided to go to [acute care hospital name] to be evaluated." This individual was identified as Patient #27 and her medical record was requested.

Patient #27 was a female, age not documented, who presented to the ED on 2/07/18, who was 21 to 22 weeks pregnant, with a chief complaint of possible amniotic fluid leak.

Patient #27 did not have a medical record for review.

Incident report for Patient #27, #38-19-2018-000035, dated 2/07/18, unsigned, stated "Pt came to the ER [sic] she was 21 almost 22 weeks pregnant and her water had broken and was leaking large amounts of fluid. [Physician A] advised her to go straight to [acute care hospital name]. Pt agreed. Pt refused to fill out any paperwork. Pt left immediately for [acute care hospital name]. We got her name from [staff name] in maintenance who is her cousin." The acute care hospital referenced was 37 miles from the facility.

Additionally, the incident report stated "This patient was not registered. It was noted in the occurrence that she did speak with [Physician A]. Documentation needs to be completed that the conversation happened and that the patient was given choices about her treatment which would include coming to the ED, or going to her primary Ob [sic] physician." "Education was given to the nurse on duty. RN needs to remind [Physician A] to document conversation with the patient."

Physician A was interviewed on 5/30/18, beginning at 2:30 PM. When asked if she had received EMTALA training while employed at the facility, she stated no. She stated, when thinking of EMTALA, she usually "thinks of patient transferring."

The CNO and ED Coordinator were interviewed together on 5/31/18 at 9:00 AM, and Patient #27's incident report was reviewed in their presence. The CNO stated the incident was reviewed by her and the Director of Risk Management. She stated the facility made process changes regarding pregnant patients who presented to the ED. The CNO stated these changes were presented to staff during a nursing department meeting. The process changes regarding pregnant patients, and education provided to the RN, were requested on 5/31/18 at 9:30 AM, but were not provided. The CNO confirmed Patient #27 did not have a medical record to review and the conversation between Patient #27 and Physician A were not documented.

Physician A was interviewed a second time via telephone on 5/31/18, beginning at 1:40 PM, and Patient #27's incident report was reviewed. She stated she did not recall seeing Patient #27. Physician A stated if she saw a pregnant patient who had fluid leakage and was not contracting, she would send them to [acute care hospital name] to see their OB/GYN. She stated she "always would offer an exam," but would tell patients "it would delay you in getting the treatment you need." Physician A stated this would be considered her Medical Screening Examination due to the fact the facility did not offer OB/GYN services, did not have an NICU, and it would delay their treatment and getting services they need. She stated if a patient "wants an exam," she would provide one.

Patient #27 did not receive a Medical Screening Examination.

2. ED Committee meeting minutes, dated 4/27/18, stated "Left because she wanted her fetal heart tones checked. Fetal heart tones were present, but [RN A] gave her the option of being seen in our ED or going directly to [acute care hospital name] to be seen b [sic] OB/GYN. She was educated by [RN A] that just because her fetal heart tones were present, she still needed to be seen by her OB physician. Addendum was added to chart by [RN A]." This individual was identified as Patient #24 and her medical record was requested.

Patient #24 was a 22 year old female who presented to the ED on 2/23/18, with the chief complaint of absence of fetal movement.

Patient #24 did not have a medical record for review. There was 1 "Addendum Report," dated 2/23/18 at 10:15 PM, signed by RN A, which stated "Patient presented to front desk requesting FHT as she had not felt the baby move for several hours. FHT were found easily at 136 [sic] per minute. I explained that if there were concerns about the welfare of the fetus an ultrasound or Nonstress test needed to be done, neither of which are available here at this time. I also warned her not to have a false sense of security over the heart tones and to contact her OB or go to [acute care hospital name]. She did not want to be evaluated in the ER here and left without being seen by physician."

An incident report for Patient #24, #38-19-2018-000057, dated 2/23/18, completed by RN A, stated "Pregnant female, 35 weeks gestation, presented to the lobby requesting fetal heart tones as she had not felt the baby move for over 3 hours. I checked FHTs with the small Doppler and heard the easily [sic] at 136 - 140. I warned her about getting a false sense of security from the heart tones and that the welfare of the fetus would be determined by ultrasound or Nonstress test. I informed her that these were not available at [CAH name] at this time but could be done at [acute care hospital name] or by her OB. She did not want to be evaluated further at [CAH name] and did not have a MSE by [sic] physician."

Additionally, the incident report included "Patient chose to leave without being seen. All options and potential complications were explained. Fetal heart tones were present. [RN A] explained to the patient that this does not mean the baby is not in distress. An ultrasound and fetal hear monitoring should be completed. The patient reported she would go to [acute care hospital name]." The referenced acute care hospital was 37 miles from the facility.

RN A was interviewed on 5/30/18, beginning at 3:45 PM, and Patient #24's incident report was reviewed in her presence. She stated she remembered Patient #24 and recalled it was a very busy evening, ultrasound was not available, and there was no non-stress test capability at the facility. RN A stated she did not assess Patient #24 for her LMP or gestation of fetus. RN A stated she brought Patient #24 to a "private area" for fetal heart tone assessment, but confirmed she was not seen by a physician.

RN A's personnel file was reviewed on 5/31/18 at 9:04 AM, and it did not include documentation she was authorized or privileged to perform a patient Medical Screening Examination.

The CNO and ED Coordinator were interviewed together on 5/31/18 at 9:00 AM, and ED Committee meeting minutes were reviewed in their presence. The CNO stated data of patients who left the facility against medical advice, and patients who left the facility without being seen, were reviewed monthly and during Board meetings. She stated the ED Committee would look for trends and patterns regarding whether identified issues were physician or nursing related. The CNO stated the facility did not track or monitor times from when patients presented to the ED, when they received a Medical Screening Examination, and when they discharged. She stated these data sets were not quality indicators at this time. Documentation that RN A notified the ED physician of Patient #24's chief complaint was requested on 5/31/18 at 9:30 AM, but was not provided.

The CNO confirmed Patient #24 was not seen by a physician prior to her leaving the facility. She confirmed facility RNs were not authorized or privileged to perform patient Medical Screening Evaluations. The CNO stated RN A should have registered and triaged Patient #24. She confirmed RN A did not follow facility policy.

Patient #24 did not receive a Medical Screening Examination.

Based on medical record review, facility policy review, ED Committee meeting minutes review, and staff interview, it was determined the facility failed to ensure stabilizing treatment was provided to 1 of 16 patients (Patient #26) who transferred to another facility for higher level of care and whose records were reviewed. This resulted in the potential for patients' conditions to deteriorate without such treatment. Findings include:

A facility policy "Stabilization and Transfer of Patients to Outside Facilities/EMTALA," dated 12/21/16, stated "Stabilizing Treatment: If the medical screening examination indicates that the person has an emergency medical condition, the hospital will provide: (1) treatment within the capabilities of the staff and facilities routinely available at the hospital (including on-call physicians and ancillary services routinely available) as required to stabilize the person before the person is discharged or transferred to another facility; or (2) an appropriate discharge or transfer..." This policy was not followed.

ED Committee meeting minutes, dated 4/27/18, stated "To Risk-Inmate from [jail name] with seizures discharged from ER and returned only hours later with continuation of seizures, pt was transferred to [acute care hospital name]." This individual was identified as Patient #26 and his medical record was requested.

Patient #26 was a 39 year old male who was seen in the ED on 3/22/18, at 12:10 AM, with a chief complaint of multiple seizures. His medical history included traumatic brain injury and epilepsy.

Patient #26's medical record included a "Physician Clinical Report," dated 3/22/18 at 12:15 AM, signed by Physician A. Under the section titled "HISTORY OF PRESENT ILLNESS," Physician A documented "(other prisoners report pt has been seizing off and on all day. He refused transport to the ED yesterday, agreed to come today)." Under the section titled "PROGRESS AND PROCEDURES," Physician A documented the following seizure activity for Patient #26:

- "12:20 AM 3/22/18 grand mal seizure lasting 15 sec, then persistent foaming at mouth, small twitching for several more minutes."

- "1:03 AM 3/22/18 pt finished another 5 min seizure, only post ictal for a minute or two. Unsuccessful attempt at EJ [an intravenous line placed in the external jugular vein], able to get line in R [right] foot, Had [sic] been planning to do IO line for access and meds."

- "1:13 AM 3/22/18 another brief seizure, in post ictal state is still a little out of it but was able to be upset by straight cath when done for u/a."

Physician A documented "pt remained seizure free after keppra [anti-seizure medication] for about 1.5 hours, had brief seizure as stood up to leave...should be OK for discharge as seizures have improved dramatically since arrival." This entry was not dated or timed.

Under the section titled "Disposition," Physician A documented "Discharged. Condition: Stable." This entry was not dated or timed.

Patient #26's medical record included nursing progress notes, dated 3/22/18 at 3:45 AM, signed by RN C, which stated "Saline lock removed intact. Patient assisted to stand by police then started to seize. Police eased patient to the floor. 2 minute seizure witnessed. Doctor aware and advised to discharge patient into police custody. Police agreeable to take patient back to a padded cell and review condition with primary physician tomorrow."

Treatment for Patient #26's seizure during his facility discharge was not documented.

Patient #26 was discharged from the facility on 3/22/18 at 4:00 AM. He returned to the facility ED via ambulance on 3/22/18 at 7:18 AM, with a chief complaint of multiple seizures.

During this second ED presentation, Physician A documented a new "Physician Clinical Report," dated 3/22/18 at 8:01 AM. Under the section titled "HISTORY OF PRESENT ILLNESS," Physician A stated "pt returned to Jail around 4:30 AM. Since 6:00 AM staff has come on, he has been seizing off and on. Experienced repeated seizures. Seizure activity lasted (5 minutes). The patient lost consciousness." Under the section titled "PROGRESS AND PROCEDURES," Physician A stated "pt began violently seizing shortly after procedure started...pt had 3 seizures in his first 15 min in the ED."

Physician A signed out Patient #26's care to Physician B on 3/22/18 at 8:14 AM. Patient #26 was transferred to an ICU at another acute care hospital for higher level of care on 3/22/18 at 12:00 PM.

Physician A was interviewed on 5/30/18, beginning at 2:30 PM, and Patient #26's medical record was reviewed in her presence. She stated Patient #26 had been "seizing all day." Physician A confirmed Patient #26 had a seizure upon discharge. She stated she spoke about transferring Patient #26 back to jail, versus keeping him in the facility, with jail custody staff, but stated this conversation was not documented.

The facility did not provide stabilizing treatment to Patient #26.