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Based on review of hospital policy, dedicated emergency department (DED) log, closed medical record review, and staff and physician interviews, the facility failed to ensure compliance with 42 CFR 489.24.

Findings included:

The hospital failed to provide stabilizing treatment within its capability and capacity for 1 of 20 sampled patients (Patient #3) that presented to the hospital's dedicated emergency department with an emergency medical condition.

~cross refer to 489.24(d) (1-3) Stabilizing Treatment - Tag A2407

Based on review of hospital policy, dedicated emergency department (DED) log, closed medical record review, and staff and physician interviews, the hospital failed to provide stabilizing treatment within its capability and capacity for 1 of 20 sampled patients (Patient #3) that presented to the hospital's dedicated emergency department with an emergency medical condition.

Findings include:

A policy related to EMTALA procedures was requested on 06/11/2013. Hospital administrative staff presented an "Emergency Medical Treatment and Active Labor Act (EMTALA) Including Patient Transfers" policy that was hospital reviewed 03/2009. Review of the Hospital's policy revealed "A. A medical screening examination (MSE) will be performed on any person presenting to the hospital that either personally, or for whom any person, requests emergency service or care to determine whether or not an emergency medical condition exists. D. If it has been determined by qualified medical personnel that an emergency medical condition exists: emergency physician, and when medically necessary, by the on-call specialist physician, to relieve, eliminate or stabilize the emergency medical condition within the capabilities of the staff, ancillary services and facilities available to the hospital."

Review on 06/11/2013 of the DED log for patients presenting to the hospital revealed the patient #3 presented to the Hospital's DED on 01/19/2013 for a documented complaint of "High Blood Sugar". The log revealed the patient had a disposition of being discharged home on 01/19/2013.

A closed medical record on 06/12/2013 for patient #3 revealed the 46 year old patient presented to the DED on 01/19/2013 for a complaint of "High Blood Sugar." Review of the medical record revealed the patient authenticated the Hospital's general consent for treatment in the DED on 01/19/2013. At 2323, the patient was triaged by a Hospital Registered Nurse #1 with documentation as "Patient states he has not taken sugar medicine in approximately one (1) month. Checked BS (Blood Sugar) tonight around 2200, was 463 (elevated). Patient just rechecked BS and read "HI" (too high to registered on glucometer) on his meter. States also has not been taking BP (Blood Pressure) medications. Has been taking Levemir (Insulin Pen Medication) but did not know that the medication was outdated." Triage documentation revealed the patient's blood pressure was"150/94" and his fingerstick blood sugar taken by Triage Registered Nurse #1 was elevated at "365". Review of the medical record also revealed the patient had documented laboratory studies taken at the hospital while in the DED that included the tests "Urinalysis Culture, Complete Blood Count, Basic Metabolic Panel" all obtained at "STAT"(Immediately) level with the patient's blood glucose level elevated at "373" (normal hospital range 70-110 milligram/deciliter).

Review of DED Physician #1's treatment for the patient revealed on 01/20/2013 at unknown (not documented) time, that DED physician #1 documented on the Hospital's DED "Miscellaneous Complaints General Adult" screening tool. The documentation revealed "Patient is a DM2 (Diabetes Mellitus Type II) with HTN (Hypertension) who needs his medications refilled (has been out for days). Refuses treatment of elevated blood glucose-just wants medications refilled." Further review of the physician's documentation revealed the documentation tool was left blank for the "ROS (Review of Symptoms) , Full Problem List, and parts of the Physical Exam" sections. The sections were left blank with no documentation found in the medical record. to indicate the patient refused treatment or signed an "against medical device" form to indicate he refused treatment. Further documentation by the DED physician revealed the patient had a clinical impression of Diabetes Type 2 that was uncontrolled with Hypertension. The patient's disposition was documented as "Home with condition unchanged." The physician also documented "medication refilled, refused exam and all other treatments, has Levemir available." The review of the medical record revealed the DED physician gave the patient prescriptions for the medications "Metformin (Diabetes Medication) and Lisinopril (Hypertensive Medication)" with no other documentation of treatment while the patient was in the DED. The patient was discharged home from the DED on 01/20/2013 at 0153 with the patient's blood sugar documented as "258" (elevated) at the time of discharge.

Interview on 06/12/2013 at 1503 via telephone with DED Physician #1 revealed the physician did not remember patient #3 and his visit on 01/19/2013. The interview revealed that he had no chart to reference the patient by. The interview did reveal that almost all of the prescriptions written for patient's are computer generated and are not hand written.

Interview on 06/12/2013 at 1520 with the Hospital's DED Lead Clinical Supervisor revealed that the patient should have been provided a medical screening examination when he presented to the DED. The interview also revealed the patient did have laboratory work while in the DED that was ordered per patient protocol and by the DED physician #1. The interview also revealed the patient was discharged against medical advice (AMA) and should have been provided a medical screening examination if he did not sign AMA.

Consequently, Patient #3 presented to the Hospital's DED on 01/19/2013 for "High Blood Sugar" and evaluation of an emergency medical condition. DED nursing staff triaged the patient that included implementing protocol and signed laboratory studies that the patient consented to. The laboratory results indicated the patient's blood glucose levels were elevated. The DED Physician #1 failed to complete a medical screening examination and provide stabilizing treatment within the hospital's capability and capacity for stabilization of the patient. No evidence was found that the patient refused treatment or examination to determine an emergency medical condition. The DED Physician #1 discharged the patient and provided prescription for medications to the patient although the documentation revealed the patient refused examination and treatment. The patient was discharged home without being evaluated and stabilized before he was discharged home.