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Based on document review and interview, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically providing an adequate medical screen exam, see A 2406 and the documentation of risks and benefits of transfer, see A 2409.

Based on document review and interview, the facility failed to perform a medical screening examination (MSE) and monitor a patient presenting for emergency medical treatment of chest pain for 1 of 6 (patient #1) patients reviewed with a chief complaint of chest pain, from a total sample of 20, resulting in the potential for poor patient outcomes. Findings include:

On 3/30/16 at approximately 0900 review of patient #1's medical record revealed the patient was a 68 year old female who presented to the Emergency Department (ED) on 2/2/16 with a chief complaint of chest pain, stating "It feels like when I had a heart attack 2-3 years ago." Patient #1's past medical history states "Heart attack" and "Diabetes Mellitus". Her past surgical history states "Coronary artery stents." Patient #1's medical record states on 2/2/16 she presented to the ED at 1244, triage was started at 1249, acuity level of 3 assigned at 12:53 and triage completed at 12:53. Patient #1 had an electrocardiogram (EKG) completed at 12:57. "No STEMI (ST elevation myocardial infarction)" written on the EKG with initials circled underneath. The ED Information Coordinator (Staff E), assisting with navigation of the electronic medical record, was queried as to facility procedure for what to do after an EKG has been completed. Staff E stated that upon completion, the EKG is shown to an Attending physician who initials the EKG. The medical record states at 1318 patient transferred from waiting room to "room Orange Area BT". At 1321 patient transferred from room Orange Area BT to waiting room. At 1335 patient transferred from waiting room to "room Green area BT" . No evidence of patient #1 being monitored from the time of EKG was noted in the medical record.

On 3/29/2016 at 1245 during tour with the ED manager he was asked what happens when a patient presents with chest pain. The ED manager explained that a patient with chest pain would be assigned an acuity level of 2. Per the ED manager the facility uses " The Canadian E.D Triage and Acuity Scale " . The charge nurse would be notified to facilitate a bed. The patient would be taken to the EKG area, which is a second room attached to the triage area, placed on a stretcher and an EKG completed. The patient would wait on the stretcher while the EKG was shown to the physician for reading and a signature. Then the registered nurse (RN) would help the patient to re-dress, assist into a wheel chair and be moved either to a room or to the lobby if no rooms were available.


On 3/29/16 at 1630 upon request of medical records the ED manager guessed the identity of the patient #1 and proceeded to discuss patient #1's date of service and the changes the facility had initiated. The ED manager stated on that day the ED was very busy. He stated the patient was placed in the EKG bay, the EKG was completed, and the charge nurse assigned the patient a room. Before the patient could be brought back to the room it was given to an ambulance patient that had arrived. While waiting for staff to make room (move other patients) the complainant was moved to the lobby. Once a room was ready, staff went to the lobby to take the patient back but she was no longer in the facility.

On 3/30/16 at approximately 0950 review of the document titled "The Canadian E.D. Triage and Acuity Scale" undated revealed "Triage Level II-Emergent, Time to NURSE assessment - IMMEDIATE*, Time to PHYSICIAN assessment - 15 MINUTES*, Usual Presentation...Chest Pain - Visceral, Non-Traumatic, +- Associated Symptoms..." and "Triage Level III - Urgent, Time to NURSE assessment - 30 Minutes*, Time to PHYSICIAN assessment - 30 minutes*, Usual Presentation...Chest Pain - No Visceral Symptoms (Sharp, MSK), No previous heart disease...".

On 3/30/16 at approximately 0955 review of the document titled "Triage" dated 10/2015 revealed on page 2 "Priority II: Emergent...5) Chest pain - Known cardiac history...diabetes, patient should be PRIORITY II no matter what the character of the pain or symptoms..."

On 3/29/16 at approximately 1645 the ED manager revealed the patient #1 was triaged incorrectly at a level 3, when according to their scale, she should have been a level 2.

Based on document review and interview the facility failed to document the risks and benefits of transferring a patient to another medical facility for 2 out of 6 transfer patients (#5, #18) reviewed resulting in the potential for patient harm. Findings include:

On 03/30/2016 between 0830 and 1300 during medical record review it was found that the transfer forms were not completed by the transferring physicians:

Review of Patient #5's medical record, encounter date 11/29/2015, revealed she was transferred on 11/30/2015 by ambulance. The document titled "Transfer of Patient to another facility" is incomplete. The patient initials in the space provided for patient acknowledgment in the "Patient Section" of the risks and benefits of the transfer.

Review of Patient #18's medical record, encounter date 03/26/2016, revealed she was transferred on 03/26/2016 by ambulance. The document titled "Transfer of Patient to another facility" could not be found.

On 3/30/2016 at 0930 Staff E was queried as to the incomplete documentation and missing form. Staff E stated "We have had some obstacles to overcome with the new computer system and the transfer sheet is one of them."

On 03/30/2016 at 1000 the policy #E124P titled "Emergency Medical Treatment and Transfers to other Acute Care Facilities." dated March 2013 was reviewed. On page 5 of 11 it states "B...2...b. Physician Certification...i...A physician must complete the Physician Section of the "Transfer of Patient to another facility" form..." And "...ii...A patient must consent in writing to the transfer after an explanation ......of the risk of transfer..."