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Based on review of medical records, policy and procedure and interviews the facility failed to ensure that hospital staff offered individuals (or a person acting on the individual's behalf) of the risks and benefits to the individual of the examination and treatment ; and failed to ensure the medical record contained a description of the examination, treatment or both if applicable, that was refused by or on behalf of the individual, and; failed to take all hospital must take all reasonable steps to secure the individual's informed refusal for 2(#6 and #26) of 28 sampled patients medical records reviewed. The facility also failed to ensure that the their EMTALA (Emergency Medical Treatment and Labor ACT) policies and procedures addressed "Refusal to consent to treatment."

Findings were:

The facility's Policy titled "COMMITMENT OF COMPLIANCE WITH EMTALA (PATIENT DUMPING) was reviewed. Review of the policy failed to address 489.24 (d)(2)(iii) (3) Refusal to Consent to Treatment.

Patient #6 medical record was reviewed. The medical record revealed that patient #6 presented ambulatory to the Emergency department (ED)with her grandmother on 3/04/16 at 6:34 p.m. According to the Nurse Triage/Assessment sheet the patient was triaged at 6:40 p.m., by the triage nurse and; triaged as "Visit Urgency: ESI (Emergency severity Index-is a 5 level Emergency Department triage Algorithm based on the acuity of the patient's health care problems and the number of resources their care is anticipated to require. Level 1-most severe, Level 4-less urgent and Level 5 non-Urgent) 5-Stable, may be seen non-urgently by a physician (or MLP-Mid Level Provider) no test or a procedure. Further review revealed in part, "7 year old ...patient to the Emergency Department today for Chief Complaint: r (right) pain. The patient's Vital Signs were: Blood Pressure: 102/71; heart rate:88; Respirations:14; temperature 98.4 and oxygen saturation was 99% on room air. The patient's disposition was listed as "Left without being seen... Follow-up activity-Limitations: PT MOVING ARM. NO DEFORMITY. GRANDMOTHER STATES SHE DOES NOT NEEDS TO HAVE X-RAY OR BE SEEN." There was no documentation in patient #6's medical record that the risks and benefits of an examination and treatment was explained or offered to patient #6 grandmother who was acting on the patient's behalf. There was no documentation in the medical record that the hospital took all reasonable steps to secure patient #6 grandmother written informed refusal to indicate that the patient's grandmother had been informed of the risks and benefits of the examination or treatment, or both on 3/4/2016.


Patient #26 medical record was reviewed. The medical record revealed that patient #26 presented to the ED on 3/26/2016 as at 1:17 p.m. Further review revealed the patients Disposition was listed as "Left without being seen. Date and time of discharge was documented as 3/26/2016 at 9:01 p.m. (8 hours after initial presentation to the ED). Documentation in the medical by the ED nurse revealed in part, "2100 (9:00 p.m.)-lobby informed of long wait times due to high volume of critical patients. Pt. reported to clerk ...would return on another day. Pt left prior to triage and prior to being seen for medical treatment." There was no documentation in patient #26's medical record to indicate the hospital staff offered patient #26 a medical screening examination and treatment and had inform the patient of the risks and benefits of the examination and treatment. There was no documentation in the medical record of a description of the examination , or treatment or or both that was refused by patient #26. Additionally, there was no documentation in the the medical record that the hospital staff took all steps to secure Patient #26 written informed refusal of the risks and benefits of the examination and treatment ,or both on 3/26/2016..



During an interview on 7/28/2016 at 4:00 p.m. the ED Nurse Manager and the Quality Director confirmed the above findings for patient #6 and #26. They also verified that their EMTALA policies did not address "Refusal to Consent for Treatment."