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Based on record reviews, staff interviews, and review of the facility's policies and procedures, the facility failed to ensure compliance with 42 CFR Section 482.24 (Special Responsibilities of Medicare Hospitals in Emergency Cases). The facility also did not have a triage policy for the emergency department.

Findings include:

1. Based on record reviews, staff interviews and a review of the facility's policy and procedure, the facility failed to provide a medical screening examination for patients who came to the emergency department (ED) for 1 of 25 patients (Patient #1) in the case sample. Cross reference to A2406.

2. Based on record reviews, staff interviews and a review of the facility's policy and procedure, the facility did not ensure an appropriate transfer was effected for 1 of 25 patients (Patient #1) in the case sample. Cross reference to A2409.

3. During a review of Patient #1's record on 12/5/14, it was found the nursing triage note did not have a reason or a chief complaint documented. The record showed the patient came to the facility's ED with police escort on 10/25/14 at 11:21 A.M. On 12/8/14 at 3:25 P.M., an interview with a licensed nurse (LN #1), who was the triage nurse on 10/25/14, stated that Patient #1 was there for a medical clearance, but her note did not include that. LN #1 was uncertain what was required for triage documentation and said, "as long as I put it somewhere in the record" is what was required.

Separate interviews with the ED Director, ED Nurse Manager, Chief Nurse Executive and the Director of Patient Safety during the survey revealed they did not have an ED policy and procedure for the triage of patients. In addition, on 12/10/14, the ED Director and ED Nurse Manager stated that related to the triage of Patient #1 on 10/25/14, there were no vital signs or assessment done for Patient #1 as part of the triage process. The ED Director only produced a copy of the draft ED Triage Policy and Procedure on 12/10/14 and confirmed it has not been approved.

Based on record reviews, staff interviews and a review of the facility's policy and procedure, the facility failed to provide a medical screening examination for patients who came to the emergency department for 1 of 25 patients (Patient #1) in the case sample.

Findings include:

Record review found Patient #1 came to the facility's emergency department (ED) on 10/25/14 at 11:21 A.M. with a police officer for a medical clearance. Once in the triage room, the patient became violent and struck his face using his handcuffs. The police officer and two security guards restrained Patient #1 to the ground and reapplied the handcuffs in the back instead of the front. Patient #1 sustained a laceration to his forehead per a pediatric emergency physician's (EP #1) entry.

EP #1's 10/25/14 late entry note stated the patient refused care, cursed and yelled at the nurses and physicians, but also documented, "I did see the patient from the doorway. He was medically stable." However, there was no documentation in the patient's legal health record that a medical screening examination was provided by EP #1, and there was no documentation of any medical care or treatment provided to the patient.

The record notes that EP #1 thereafter directed the police officer to take Patient #1 to another nearby hospital. EP #1 documented he "...discussed with the officer that we are unable to care for a patient that is violent, high on drugs, refusing care...he would be better served at [another medical facility." Patient #1 then departed the ED at 11:40 A.M. with the police officer and was brought to another medical facility. On 12/11/14, during an interview of EP #1, he acknowledged the receiving hospital's EP called him on 10/25/14 to inform him that Patient #1 was transferred without an accepting physician. The patient was seen and medically treated at the receiving hospital.

Review of the facility's EMTALA policy (effective date 12/14), states: III. Medical Screening Examination A. Process 1. A medical screening examination...shall be provided to any individual who comes to the hospital, by himself or with another person, requesting treatment regardless of the individual's ability to pay for medical care...6. The medical screening examination is not an isolated event; it is an ongoing process. The medical record must reflect ongoing monitoring in accordance with the individual's needs, and must continue until the individual is stabilized or appropriately transferred or discharge. The medical record should contain evidence of an evaluation prior to discharge or departure from the hospital for a transfer to another facility.

During an interview with the facility's risk manager on 12/9/14, he verified a medical screening examination was not done for Patient #1 on 10/25/14, prior to the patient's departure at 11:40 A.M.

Based on record reviews, staff interviews and a review of the facility's policy and procedure, the facility did not ensure an appropriate transfer was effected for 1 of 25 patients (Patient #1) in the case sample.

Findings include:

Cross-reference to findings at A2406.
Review of the facility's EMTALA policy (effective 12/14), states: IV. Transfers A1. If the medical screening examination establishes that no emergency medical condition exists, the following steps should be taken:...a. The medical record must reflect that the patient does not have an emergency medical condition. b. the patient may be admitted, discharged or transferred. 2. If an emergency medical condition was found to exist but the physician determines that the patient's medical condition is stabilized, the patient may be transferred when the following have been met: a. Treatment to stabilize the patient must be administered within the capabilities of the department's available staff and services. b. The Physician Certification for Transfer is completed. c. The patient may be transferred upon completion of the Transfer Data Summary. d. The acknowledgement of the notification of the transfer by the patient or the legal representative should be reflected in the medical record...C. The transfer must meet appropriateness of criteria, which include:...1. The transferring hospital provides: a. Medical treatment within its capacity, which minimizes the risks to the patient's health,...and b. Copies of all pertinent records related to the patient's emergency condition that are available at time of transfer. c. It should be the receiving physician's decision whether to re-evaluate the patient in the emergency department of the receiving medical facility or to "direct admit" the patient...2. The receiving facility:...b. Has available space and qualified personnel; and b. Has agreed to accept the transfer. The transferring hospital should documents its communication with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer. This should be noted on the Physician Certification for Transfer form.

During separate interviews with the facility's risk manager on 12/9/14, and with EP #1 on 12/11/14, it was found the patient left with police escort upon the direction of EP #1 to have the patient taken to another medical facility. Thus, the facility did not meet the specific transfer criteria outlined in their EMTALA policy. It was verified that: Patient #1 was discharged without a medical screening examination or any medical treatment provided, that the receiving hospital did not accept the transfer of Patient #1, and Patient #1 arrived at the receiving hospital without copies of records or transfer documentation. On 12/11/14, the Medical Director of Emergency Services stated on 10/25/14, there were two doctors and a nurse present and there was no excuse for this to have happened.