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Based on review of clinical record and facility documents and staff interview, it was determined that the facility failed to ensure compliance with the Emergency Medical Screening regulation for patients seeking emergency medical care for one (#3) of 20 sampled patients. This practice may cause a delay in treatment that may lead to adverse outcomes.

Findings include:

1. Patient #3's Emergency Medical Services (EMS)ambulance report dated 7/25/2009, revealed that the patient presented to the Emergency Department (ED) at 8:34 p.m. The documentation noted a complaint of flu-like symptoms and fever. The vital signs obtained by EMS were completed at 8:14 p.m., the blood pressure was 98/60, heart rate 120, respirations 20, and oxygen saturations on room air was 95%. The vital signs done by EMS at 8:33 p.m., just prior to arrival at the ED were as follows: blood pressure, 96/64, heat rate 116, respiration 16, and oxygen saturations 95%. EMS noted the patient's skin temperature as being hot. The EMS narrative revealed the patient was transported to the ED triage and report was given to the triage personnel.

A review of the ED central log for the month of July 2009, failed to reveal patient #3's entry for July 25th, 2009.

An interview with the Quality Director on 6/9/10 at 1:00 p.m., revealed the facility failed to find any documentation except for the EMS run sheet pertaining to patient #3's visit on 7/25/09.

A review of the facility policy #EMTALA HM-RI-21a, revised on 4/10, section for Hospital Policies, General Requirements, revealed any individual who comes to the emergency department will receive an appropriate Medical Screening Examination to determine whether or not an emergency medical condition exists.

Based on clinical record and central log reviews and staff interview, it was determined the facility failed to maintain a record of the request for individual seeking assistance and whether s/he refused treatment, was refused treatment, or whether s/he was transferred, admitted and treated, stabilized and transferred, or discharged for 1 (#3) of 20 sampled patients. This practice does not ensure tracking and trending of all persons presenting to the Emergency Department and the disposition.

Findings include:

1. Patient #3's Emergency Medical Services (EMS)ambulance report dated 7/25/2009, revealed that the patient presented to the Emergency Department (ED) at 8:34 p.m. The documentation noted a complaint of flu-like symptoms and fever. EMS noted the patient's skin temperature was hot. The EMS narrative revealed the patient was transported to the ED triage and report was given to the triage personnel.

An interview with the Quality Director on 6/9/10 at 1:00 p.m., revealed the facility failed to find any documentation except for the EMS run sheet pertaining to patient #3's visit on 7/25/09.

A review of the facility policy #EMTALA HM RI-21a, revised 4/10/10, the section named Central Log, requires the hospital to maintain a log on each individual who "comes to the emergency department" seeking assistance that documents whether s/he refused treatment, was refused treatment, or whether s/he was transferred, admitted and treated, stabilized and transferred or discharged. Under the section for Hospital Policies section (C), when the individual leaves before the EMTALA obligations is met the individuals information must be entered into the Central Log whether or not the individual is triaged.

Based on clinical record review and staff interview, it was determined that the facility failed to provide a Medical Screening Examination within the capability of the hospital's Emergency Department to determine whether or not an emergency medical condition existed for 1 (#3) of 20 sampled patients.

Findings include:

Patient #3's Emergency Medical Services (EMS)ambulance report dated 7/25/2009 revealed that the patient presented to the Emergency Department (ED) at 8:34 p.m. The documentation noted a complaint of flu-like symptoms and fever. The vital signs obtained by EMS were completed at 8:14 p.m., the blood pressure was 98/60, heart rate 120, respirations 20, and oxygen saturations on room air was 95%. The vital signs done by EMS at 8:33 p.m., just prior to arrival were as follows: blood pressure, 96/64, heat rate 116, respiration 16, and oxygen saturations 95%. EMS noted the patient's skin temperature was hot. The EMS narrative revealed the patient was transported to the ED triage and report was given to the triage personnel.

A review of the ED logs revealed that patient returned to the ED on 7/28/09 at 7:19 p.m. via ambulance with a chief complaint of shortness of breath. The triage notes dated 7/28/10 at 7:21 p.m. revealed the initial vital signs were temperature, 99.2, blood pressure 83/56, heart rate 107 and oxygen saturations 82% on room air. A review of the ED physician record revealed a chief complaint of shortness of breath, coughing, fever, blood-tinged sputum, with a past medical history of Mitral Valve Repair. Physician and nursing documentation noted the patient was admitted to the Intensive Care Unit for further treatment. The physician's Death Summary revealed a diagnosis of respiratory failure secondary to Hemophilus influenza pneumonia and severe acute respiratory distress syndrome. The patient expired on 8/8/09. The cause of death reported on the death certificate was Influenza A and adult respiratory distress syndrome.
An interview with the Quality Director on 6/9/10 at 1:00 p.m., revealed the facility failed to find documentation except for the EMS run sheet pertaining to the patient's visit to the ED on 7/25/09. The facility failed to ensure that a medical screening examination was provided for patient #3 on 7/25/2009 when s/he presented to the emergency room via ambulance.

A review of the facility policy #EMTALA HM-RI-21a, revised on 4/10, section for Hospital Policies, General Requirements, reveals any individual who comes to the emergency department will receive an appropriate Medical Screening Examination to determine whether or not an emergency medical condition exists.