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Based on interviews, a review of the hospital's Emergency Medical Treatment and Labor Act (EMTALA) Policies and Procedures, Emergency Department (ED) Triage Policies and Procedures, and the ED Log, the hospital failed to follow their provider agreement and provide a Medical Screening Exam (MSE) for 2 of 22 patients reviewed (Patient 21 and 22). The hospital's failure to provide a MSE to determine whether a patient had an emergency medical condition (EMC) placed all patients presenting to the ED seeking medical attention at risk for deterioration of their condition including death.

Findings Include:

Review of Hospital policy titled, "EMTALA-Definitions and General Requirements," reviewed by the hospital in April 2015 showed that a Medical Screening Examination is defined as being whenever an individual "comes to the emergency department," the hospital shall ensure the individual receives a medical screening examination from a physician, Advanced Registered Nurse Practitioner, Registered Nurse who is Advanced Cardiac Life Support (ACLS) certified (qualified within the parameters listed in the Medical Staff Rules and Regulations and the scope of his/her practice), or a physician assistant who has been designated as a qualified medical person ("QMP") to perform such screenings, according to established clinical practice, for the purpose of determining whether an emergency medical condition exists. For purposes of EMTALA, all members of the medical staff, nurse practitioners and physician assistants are deemed qualified to perform a medical screening examination ...The medical screening examination shall be documented in the medical record...Emergency Department Log. A central log shall be maintained in the ED and the Obstetrical (OB), indicating each individual who comes to the emergency department seeking assistance and documenting whether he or she refused treatment or was refused treatment, was transferred, admitted and treated, stabilized and transferred, or discharged. The central log shall be kept indefinitely.

Review of Hospital policy titled, "Triage of Emergency Department Patients," reviewed by the hospital in October 2010 showed, "This procedure is designed to ensure that all patients requesting medical attention are evaluated as soon as possible. It also provides a standardized system whereby patients presenting to the Emergency Department are treated in order of priority based upon acuity.

Review of the Hospital's Emergency Department Log on 08/06/18 showed no entries between 10:00 PM on 07/29/18 and 3:00 PM on 07/30/18 (Refer to A-2405 for further details).

However, during the entrance conference interview on 08/06/18 at 8:45 AM in the Chief Executive Officer's (CEO) office, Staff A, CEO, stated that the hospital self-reported a potential EMTALA violation on 08/02/18. Staff A stated the hospital's computer, phone, and internet systems failed at approximately 10:30 PM on 07/29/18 and between that time and 6:00 AM on 07/30/18 two people (Patient 21 and 22) presented to the ED and hospital staff told them they could not treat them and that they would need to go to another hospital for care.

On 07/29/18 around 10:30 PM, an unknown male, Patient 22, came to the ED with a fishhook in his finger. Staff K, Registered Nurse told the patient since the servers were down that the hospital did not have access to any numbing or pain medication and the patient should seek assistance at Hospital BB, located 10 miles away (Refer to A-2406 for further details).

On 07/30/18 between 4:30 AM and 5:00 AM, Patient 21, an 18-year-old female with a history of Type 1 Diabetes (usually diagnosed in children and young adults - a chronic condition in which the pancreas produces little or no insulin (a hormone produced in the pancreas that regulates the amount of glucose (sugar) in the blood) came to the ED seeking medical treatment for nausea/vomiting and her high blood sugars. Staff L, Registrar, informed her that the ED was closed due to server issues and she should seek assistance at Hospital BB (Refer to A-2406 for further details).

Based on document review and staff interview it was determined the hospital failed to record in the Emergency Department (ED) Log 2 of 22 patients (Patient 21 and Patient 22) who presented to the ED seeking medical attention. These two patients had no medical records from their time at the hospital. Failure to create a record of a patient who presents to the ED for treatment places patients at risk for delays in care, deterioration of their condition including death.

Findings Include:

Review of Hospital policy titled, "EMTALA-Definitions and General Requirements," reviewed by the hospital in April 2015 showed an Emergency Department Log. A central log shall be maintained in the ED and the Obstetrical (OB), indicating each individual who comes to the emergency department seeking assistance and documenting whether he or she refused treatment or was refused treatment, was transferred, admitted and treated, stabilized and transferred, or discharged. The central log shall be kept indefinitely.

Review of the Hospital's Emergency Department Log on 08/06/18 showed no entries between 10:00 PM on 07/29/18 and 3:00 PM on 07/30/18.

During an interview on 08/07/18 at 8:30 AM in the hospital's administrative offices, Registration Clerk L, stated that she was working the night of 07/29/18 and into the morning of 07/30/18 and was aware of two patients (Patient 21 and Patient 22) who presented to the ED seeking medical attention. Registration Clerk L stated that Registered Nurse (RN) K told Patient 22 that they could not be helped at that time due to the computer, telephone, and internet issues that were affecting access to medications and said they should go to another hospital. Registration Clerk L advised Patient 21 of the same information at approximately 4:30 AM - 5:00 AM. Registration Clerk L confirmed that she failed to document Patient 21 and Patient 22 in the ED log due to the computers being down and she did not want to create a bill for either patient since they did not receive any services.

During an interview on 08/07/18 at 12:00 PM in the ED staff breakroom, ED Supervisor N, stated that hospital staff have not had any training for situations when the computer, telephone, and internet systems go down. There is a big box of printed forms, so we can hand write on those, but I will honestly say we have not had a drill for anything like this. All emergency patients need to be treated, stabilized and admitted, transferred, or discharged depending on what their emergency is, and this should be documented on the computerized ED log or paper forms if the computer system is down.

Based on interviews, medical record review, a review of the hospital's Emergency Medical Treatment and Labor Act (EMTALA) Policies and Procedures, and Emergency Department (ED) Triage Policies and Procedures, the hospital failed to provide a Medical Screening Exam (MSE) for 2 of 22 patients (Patient 21 and 22). Failure to provide a MSE to determine whether a patient had an emergency medical condition (EMC) placed all patients presenting to the ED seeking medical attention at risk for delays in care and deterioration of their condition including death.

Findings Include:

Review of Hospital policy titled, "EMTALA-Definitions and General Requirements," reviewed by the hospital in April 2015 showed that the hospital shall ensure the individual receives a medical screening examination from a physician, Advanced Registered Nurse Practitioner, Registered Nurse (RN) who is Advanced Cardiac Life Support (ACLS) certified (qualified within the parameters listed in the Medical Staff Rules and Regulations and the scope of his/her practice), or a physician assistant (PA) who has been designated as a qualified medical person ("QMP") to perform such screenings, according to established clinical practice, for the purpose of determining whether an emergency medical condition exists ...The medical screening examination shall be documented in the medical record.

Review of Hospital policy titled, "Triage of Emergency Department Patients," reviewed by the hospital in October 2010 showed, "This procedure is designed to ensure that all patients requesting medical attention are evaluated as soon as possible. It also provides a standardized system whereby patients presenting to the Emergency Department are treated in order of priority based upon acuity.

During an interview on 08/07/18 at 8:30 AM, in the hospital's administrative offices, Registration Clerk L stated that she was working the night of 07/29/18 and into the morning of 07/30/18 and was aware that two patients (Patient 21 and Patient 22) presented to the ED seeking medical attention. Registration Clerk L stated neither Registered Nurse (RN) K or PA D triaged or assessed the patients. Registration Clerk L, stated that at approximately 10:30 PM Patient 22 (unknown male) came into the ED with a fishhook in their hand and RN K told him that we couldn't offer him medications and he should go to Hospital BB, 10 miles away. The patient left without being seen.

During an interview on 08/07/18 at 7:45 AM in the administrative offices, RN K stated that since they couldn't offer Patient 22 a tetanus shot or pain medication he should go to Hospital BB. RN K stated that she did not take vitals or assess Patient 22.

During an interview on 08/06/18 at 2:00 PM, in the administrative offices, ED Technician M stated that PA D told us we should probably at least triage people after RN K told Patient 21 that he needed to go to another hospital.

During an interview on 08/07/18 at 8:30 AM, in the hospital's administrative offices, Registration Clerk L stated that between 4:30 AM and 5:00 AM Patient 21 came in to the ED with complaints of nausea and vomiting and believed that her blood sugars were high. Registration Clerk L stated that RN K told her they were on diversion and couldn't treat patients, so she directed Patient 21 to go to Hospital BB. Patient 21 left without being seen.

Review of a closed medical record from Hospital BB showed that Patient 21, an 18-year-old female with a history of Type 1 Diabetes (usually diagnosed in children and young adults - a chronic condition in which the pancreas produces little or no insulin) presented to Hospital BB's ED at 5:24 AM on 07/30/18. Documentation in the medical record showed that Patient 21 complained of nausea, vomiting, and elevated blood sugar levels. Patient 21 stated that her insulin pump (delivers rapid or short acting insulin to lower the blood sugar throughout the day through a catheter placed under the skin) delivered 11 units of insulin at approximately 4:00 AM and her blood sugar at that time was 384 (normal range is 70 - 120). The following represents the patient care timeline at Hospital BB:

5:34 AM Initial blood sugar was 471
5:42 AM Blood sugar from laboratory studies resulted with "High Critical" level of 522
5:52 AM Staff started an Intravenous (IV) (delivered directly into the bloodstream through a vein or artery) in the left arm and began administering 1,000 milliliters (ml) of Normal Saline (a medication used to increase the fluid in the body)
5:52 AM Staff administered 15 units of Lispro (a rapid-acting human insulin) via injection into the abdomen.
7:24 AM blood sugar was 481
7:55 AM Staff administered 10 units of regular (a short acting insulin) via IV.
8:14 AM Staff started a second IV in her right arm and began administering 1,000 mls of Normal Saline
8:14 AM Physician placed orders to initiate a transfer to Hospital CC for a higher level of care due to Patient 21's diagnosis of Diabetic Ketoacidosis (DKA) (a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones)
8:40 AM blood sugar decreased to 299
9:31 AM A paramedic unit transported Patient 21 via ambulance to Hospital CC's Intensive Care Unit.

During an interview on 08/07/18 at 12:00 PM in the ED breakroom, PA D, stated that she told RN K that they needed to look at and triage everyone before deciding if we should discharge or transfer them. PA D stated that none of the staff made her aware of Patient 21 until 6:00 AM and the patient was already gone.

During an interview on 08/07/18 at 12:00 PM in the ED staff breakroom, ED Supervisor N, stated that the expectation for hospital staff was to treat, stabilize and admit, transfer, or discharge all emergency patients that present to the ED. ED Supervisor N stated they should document on paper forms while the electronic system is down. ED Supervisor N stated that they have never had a situation when the computers, phones, internet, and other systems were down. ED Supervisor N also stated that each member of the ED team working on 07/29/18 have experience and should have known they must triage and perform a medical screening exam on every patient.