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Based on interviews, policy and procedure review, and document review, it was determined the Facility failed to provide a medical screening exam which caused a delay in treatment for Patient #22 on 10/26/13. The Facility also failed to designate per Medical Staff By-laws which personnel were qualified to perform a medical screening exam and also failed to ensure Patient #22 was entered into the Emergency Room Log. Failure to provide a medical screening exam had the potential to jeopardize the life of Patient #22 and her unborn child on 10/26/13.

Based on review of the Emergency Room (ER) Log, policy and procedure and interview, it was determined the Facility failed to accurately and completely record Patient #22's ER presentation in the ER Log. Failure to enter Patient #22's name into the ER log did not allow the Facility to track Patient #22's presentation, treatment, refusal of treatment or transfer. The failed practice affected Patient #22 on 10/26/13. Findings follow:

A. Review of the ED log did not reveal Patient #22's name. During an interview with Registered Nurse (RN) #2 from 0535 to 0700 on 11/14/13 he was asked when the last Obstetrical (OB) patient presented to this facility. RN #2 stated "There was a young couple from OK (Oklahoma) who presented here with bleeding. Patient #22 was 13 weeks pregnant." RN #2 stated Patient #22 came in between 10 PM (post meridian) and 2 am (ante meridian) on the 26th of October. RN #2 stated it was Diversity Week-end and he remembered it well. RN #2 stated he told the couple she needed an ultrasound and this facility did not have an ultrasound to check the patient with. RN #2 stated he told the couple the closest facility with ultrasound capability was Berryville, some 20 minutes East. RN #2 was asked if he had the couple complete the Rapid ER (Emergency Room) Information Sheet and he stated no. RN #2 was asked if he brought Patient #22 back to an exam room and/or checked vital signs and he stated he did not bring Patient #22 back from the waiting room to an exam room or check her vital signs. RN #2 stated at least twice during the interview that he was trying to save the couple money. RN #2 stated he offered to call an ambulance and have Patient #22 transported by ambulance but husband declined stating he was driving. RN #2 stated he cautioned husband to drive slow since he was unfamiliar with the area. RN #2 stated he gave Patient #22 a towel and pad to protect her car seat. RN #2 was asked if he sent any paperwork with Patient #22 to the other facility and he stated no. RN #2 stated he called the Berryville ED and told a nurse Patient #22 was en route. RN #2 was asked if he called the ED physician and reported to him Patient #22's chief complaint and he stated yes, after Patient #22 left for the other facility.

B. Review of the policy and procedure titled "Emergency Services" received from the Chief Nursing Officer at 1300 on 11/13/13 revealed under C. Adequate medical records shall be kept on every patient who presents to Emergency Services.

C. During an interview with RN #2 from 0530 to 0700 on 11/14/13 he stated he did not have Patient #22 or her husband complete a Rapid ER Information Sheet so the patient would not have been entered into the ER Log.

Based on review of Medical Staff By-laws, Emergency Room (ER) policy and procedure review and interview it was determined the Facility failed to designate who was qualified to conduct a medical screening exam and failed to perform a medical screening exam for Patient #22. Failure to designate who was qualified to perform medical screening exams did not ensure the patients presenting to the Emergency Room (ER) were afforded assessment and care rendered based upon that assessment, by individuals qualified and vetted through the Facility Medical Staff By-laws. The failed practice affected all patients who presented to the Emergency Room. Findings follow:

A. Review of the Medical Staff By-laws received from the Chief Nursing Officer (CNO) at 1300 on 11/13/13 revealed no designation of who was qualified to conduct a medical screening exam.

B. Review of the Emergency Room Policy and Procedure Manual received from the CNO at 1300 on 11/13/13 revealed no policy and procedure that defined who was qualified to perform a medical screening exam.

C. During an interview with Registered Nurse (RN) #2 from 0535 to 0700 on 11/14/13 he was asked when the last Obstetrical (OB) patient presented to this facility. RN #2 stated "There was a young couple from OK (Oklahoma) who presented here with bleeding. Patient #22 was 13 weeks pregnant." RN #2 stated Patient #22 came in between 10 PM (post meridian) and 2 am (ante meridian) on the 26th of October. RN #2 stated it was Diversity Week-end and he remembered it well. RN #2 stated he told the couple she needed an ultrasound and this facility did not have an ultrasound to check the patient with. RN #2 stated he told the couple the closest facility with ultrasound capability was Berryville, some 20 minutes East. RN #2 was asked if he had the couple complete the Rapid ER (Emergency Room) Information Sheet and he stated no. RN #2 was asked if he brought Patient #22 back to an exam room and/or checked vital signs and he stated he did not bring Patient #22 back from the waiting room to an exam room or check her vital signs. RN #2 stated at least twice during the interview that he was trying to save the couple money. RN #2 stated he offered to call an ambulance and have Patient #22 transported by ambulance but husband declined stating he was driving. RN #2 stated he cautioned husband to drive slow since he was unfamiliar with the area. RN #2 stated he gave Patient #22 a towel and pad to protect her car seat. RN #2 was asked if he sent any paperwork with Patient #22 to the other facility and he stated no. RN #2 stated he called the Berryville ED and told a nurse Patient #22 was en route. RN #2 was asked if he called the ED physician and reported to him Patient #22's chief complaint and he stated yes, after Patient #22 left for the other facility.

D. During an interview with the CNO at 0815 on 11/14/13 she verified there was nothing in the Medical Staff By-laws regarding who was designated as a qualified medical person. The CNO also stated her assistant had reviewed the Medical Staff Rules and Regulations and they did not contain any designation of qualified medical personnel.

E. The Non-Emergent Collections Guidelines policy and procedure was received from the CNO at 0925 on 11/14/13. The CNO stated this policy and procedure was what the facility used as their EMTALA policy and procedure.