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HIGHLANDS ARH REGIONAL MEDICAL CENTER 5000 KENTUCKY ROUTE 321 PRESTONSBURG, KY 41653 Jan. 10, 2013
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and review of policies and procedures, it was determined the facility failed to comply with 42 CFR 489.24 Special Responsibilities of Medicare hospitals in emergency cases for two (2) of twenty (20) patients (Patients #1 and #6) that presented to the Emergency Department (ED). The facility failed to ensure a medical screening was provided for Patient #1 on 01/05/13 after the patient presented to the Emergency Department (ED) for treatment of a possible emergency medical condition. In addition, the facility failed to ensure Patient #6 received a medical screening when the patient (MDS) dated [DATE].

The findings include:

A review of the facility policy entitled "Hospital Policy on Emergency Medical Treatment and Active Lab or Act (EMTALA)," dated 09/27/11, revealed the facility had developed a procedure related to the care and services of patients that presented to the ED. The department specific policy applicable to the ED revealed medical care and treatment would be provided to those patients who came to the ED with or without emergency medical conditions. Further review of the policy revealed a Medical Screening Exam (MSE) would be performed on all patients who presented to the ED requesting medical care. The purpose of the MSE was to determine if the patient had an emergency medical condition. In addition, the person who performed the exam would not request information regarding the payer status. The policy further stated that the results of the MSE would be recorded in the electronic medical record (EMR). According to facility policy, patients with the same acuity level would be triaged and medically screened according to their time of arrival.

1. A review of the medical record of Patient #1 revealed the family members (parent and grandparent) of five-month-old Patient #1 brought the patient to the ED on 01/05/13 at approximately 7:59 PM and told the triage nurse the child had a fever. The triage nurse documented on 01/05/13 at 8:41 PM (approximately 42 minutes after the patient presented to triage) that the patient's temperature was 103.6 degrees Fahrenheit (F). Documentation revealed the triage nurse administered medications for the patient's elevated temperature, per facility protocol, at 9:02 PM (21 minutes after the temperature was documented). Continued review of the medical record revealed Registered Nurse (RN) #1 assessed Patient #1 on 01/05/13 at 10:00 PM (two hours after the patient presented to the ED). However, there was no documented evidence the facility conducted a medical screening for Patient #1.

An interview conducted with RN #1 on 01/08/13 at 5:30 PM revealed Patient #1 presented to the ED with a temperature of 103.6 degrees F. RN #1 stated she placed the patient in a treatment room (treatment room #5), and tested the patient for "flu, strep throat, or virus" per facility protocol, and the tests were negative. RN #1 stated she routinely rechecked the child's temperature and stated at 9:02 PM the child's temperature was 103 degrees F; at 10:45 PM the temperature was 99.8 degrees F; and at 2:05 AM the patient's temperature was 98.3 degrees F. RN #1 stated the patient's lungs sounded clear even though the patient was coughing. According to RN #1, Physicians and Physician Assistants were qualified to perform Medical Screenings in the ED and although the ED Physician and the Physician Assistant (PA) did not physically assess Patient #1, the PA ordered a chest x-ray for Patient #1. RN #1 stated the system in the ED to inform the Physicians/PAs of the triage order of patients was by means of an overhead computerized "grease board" (a type of marquee), and stated the system was functional at the time Patient #1 presented to the ED. In addition, RN #1 reported that she notified ED Physician #1 on more than one occasion that Patient #1's family members were upset that the patient had not been assessed by a Physician and the Physician continued to see other patients out of the triage sequence. RN #1 stated Patient #1's family members left the facility with the patient at approximately 3:45 AM and told the facility's House Supervisor they would take the patient to another hospital.

An interview was conducted on 01/08/13 at 6:00 PM with the PA who was working in the facility's ED on 01/05/13 when Patient #1 arrived at the hospital's ED. The PA acknowledged he had been approved by the facility to perform medical screenings and stated the ED was busy that night but was "nothing different than any other night." The PA stated he did not assess Patient #1 because his shift was going to end at midnight and he wanted to get all of his patients discharged without taking on any new patients. The PA recalled walking by the treatment room where Patient #1 was and heard the patient coughing. The PA stated he ordered a chest x-ray but did not go into the treatment room to assess Patient #1. The PA stated the ED Physician did not ask him (the PA) to stay over that night. The PA stated, "We usually follow facility protocol for screening but in this case we obviously didn't."

Additional medical record reviews revealed ED Physician #1 assessed three patients (Patients #4, #5, and #6) on 01/05/13 that had been triaged after Patient #1 and were determined to be at the same acuity level as Patient #1 (Level 3). As noted above, according to facility policy, patients with the same acuity level should be triaged and medically screened according to their time of arrival. However, based on record review, ED Physician #1 failed to ensure patients who presented to the ED were assessed in sequence of their acuity level.

A telephone interview conducted on 01/09/13 at 9:00 AM with ED Physician #1 revealed he was working in the facility's ED on 01/05/13 when Patient #1 presented to the ED seeking medical treatment. After reviewing the medical record, the ED Physician confirmed Patient #1 did not receive a medical screening. The ED Physician stated, "I don't understand how any of this transpired." ED Physician #1 acknowledged the ED had a computerized system for staff to follow the triage times in sequence but stated he did not know about Patient #1 and did not recall being told the family was upset about the patient not being seen timely. The ED Physician stated he was still trying to get adjusted to the hospital's program on levels and did not always look at the length of time the patient had been waiting.

A telephone interview conducted with the facility's ED Medical Director on 01/09/13 at 12:30 PM revealed the facility had not refused to see Patient #1 and did not tell the family to take the patient to the second acute care facility. The ED Medical Director stated he did not know why, and could not justify why, Patient #1 did not receive a medical screening on 01/05/13 and added, "This was poor quality service." According to the ED Medical Director it was an "oversight" on both medical providers (the PA and Physician #1) working at the time Patient #1 presented to the ED. In addition, the ED Medical Director had no explanation as to why Patients #4, #5, and #6, who had arrived at the ED after Patient #1 and assessed at the same triage level, had received a medical screening and Patient #1 had not. The ED Medical Director reviewed the medical records and gave no explanation why the ED Physician did not follow sequence.

Interview with Patient #1's family member on 01/10/13 at 6:00 PM confirmed they had taken Patient #1 to a second facility on 01/05/13 after waiting at the first facility for nearly eight hours for a medical screening that was never provided.

A review of Patient #1's medical record from the second ED revealed the patient (MDS) dated [DATE] at approximately 4:34 AM, was triaged at 4:56 AM, and received a medical screening at 4:58 AM. A review of the medical record from the second facility revealed Patient #1 had a history of an abdominal blood clot which resulted in a previous bowel resection. The second acute care facility diagnosed Patient #1 with Otitis Media (ear infection) and URI (upper respiratory infection). Antibiotic medication was prescribed and Patient #1 was discharged home with family.

2. A review of the medical record of Patient #6 revealed the patient (MDS) dated [DATE] at approximately 9:50 PM with complaints of fever and abscess on the buttock. According to the medical record, Patient #6 was triaged at 9:50 PM. Although the ED Physician requested a culture be obtained of the patient's abscess, there was no evidence that the Physician conducted a medical screening of Patient #6. Documentation revealed Patient #6 was transferred to the medical floor where the patient underwent a surgical procedure related to the abscess on the following day, 01/06/13.

Interview with ED Physician #1 on 1/10/13 at 12:40 PM revealed Patient #6 had been in the ED from 9:50 PM until 4:44 AM and a phone call was made to admit the patient to the services of a Pediatrician. The ED Physician acknowledged a medical screening for Patient #6 was never documented, and stated, "It was a busy night and unfortunately I didn't have time to document what I had done."

Patient #6 had already been discharged from the facility therefore an interview with the family was not conducted.

An interview conducted on 01/10/13 at 1:40 PM with the Vice-President (VP) of Patient Care revealed she provided coverage for the Administrator. The VP of Patient Care was aware of the wait time in the ED but was not aware that medical screenings had not been completed and that the medical screenings performed were not always conducted in sequence of triage levels per facility policy.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and review of policies and procedures, it was determined the facility failed to ensure two (2) of twenty (20) patients selected for review and who had presented to the facility's Emergency Department (ED) seeking medical care received a medical screening examination (Patients #1 and #6). A review of documentation in the medical record of Patient #1 revealed the patient (MDS) dated [DATE] at approximately 7:49 PM and received a triage assessment by the triage nurse at 8:41 PM. However, there was no documented evidence that Patient #1 ever received a medical screening from the Physician or mid-level provider approved by the facility to conduct the medical screenings. In addition, a review of documentation in the medical record of Patient #6 revealed the patient (MDS) dated [DATE]; however, a review of documentation revealed no evidence the patient received a medical screening.

The findings include:

A review of the facility policy entitled "Hospital policy on Emergency Medical Treatment and Active Lab or Act (EMTALA)," dated 09/27/11, revealed the facility had developed a procedure related to the care and services of patients that presented to the ED. The policy revealed medical care and treatment would be provided to those patients who came to the ED with or without emergency medical conditions.

In addition, a review of the facility's Bylaws/Rules and Regulations revealed the facility had established that a Physician, Advanced Registered Nurse Practitioner (ARNP), or Physician Assistant (PA) had been approved to perform the medical screening in order to determine if an emergency medical condition existed.

1. A review of the medical record of Patient #1 revealed the five-month-old patient's family members (parent and grandparent) brought the patient to the ED on 01/05/13, at approximately 7:59 PM, due to complaints of an elevated temperature. Patient #1 was assessed by the triage nurse and, based on documentation on 01/05/13 at 8:41 PM (approximately 42 minutes after the patient presented to triage) that the patient's temperature was 103.6 degrees Fahrenheit (F). Documentation revealed the triage nurse administered medications for the patient's elevated temperature, per facility protocol, at 9:02 PM (21 minutes after the temperature was documented). Continued review of the medical record revealed Registered Nurse (RN) #1 assessed Patient #1 on 01/05/13 at 10:00 PM (two hours after the patient presented to the ED). However, there was no documented evidence the facility conducted a medical screening for Patient #1.

A review of the facility's complaints log dated 01/05/13 (9:00 PM to 7:00 AM) revealed the ED staff had contacted the facility's House Supervisor to speak with Patient #1's family members who were upset because the patient had been in the ED for over seven hours and had not been assessed by a Physician.

Interview with RN #1 on 01/08/13 at 5:30 PM revealed Patient #1 presented to the ED with a temperature of 103.6 degrees F. RN #1 stated she placed the patient in a treatment room, and tested the patient for "flu, strep throat, or virus" per facility protocol and the tests were negative. RN #1 stated she routinely rechecked Patient #1's temperature and stated at 9:02 PM the patient's temperature was 103 degrees F; at 10:45 PM the temperature was 99.8 degrees F; and at 2:05 AM the patient's temperature was 98.3 degrees F. RN #1 stated that Physicians and Physician Assistants were qualified to perform Medical Screenings in the ED and although the ED Physician and the Physician Assistant (PA) did not physically assess Patient #1, the PA ordered a chest x-ray for Patient #1. According to RN #1, the system in the ED to inform the Physicians/PAs of the triage order of patients was by means of an overhead computerized grease board (a type of marquee) and the system was functional at the time Patient #1 presented to the ED. In addition, RN #1 reported that she notified ED Physician #1 on more than one occasion that Patient #1's family members were upset that the patient had not been assessed by a Physician, but the Physician continued to see other patients out of the triage sequence. RN #1 stated Patient #1's family members left the facility with the patient at approximately 3:45 AM and told the facility's House Supervisor they would take the child to another hospital.

A review of additional medical records revealed ED Physician #1 assessed three patients (Patients #4, #5, and #6) on 01/05/13 that had been triaged after Patient #1 and were determined to be at the same acuity level as Patient #1 (Level 3). As noted above, according to facility policy, patients with the same acuity level should be triaged and medically screened according to their time of arrival. However, based on record review, the ED Physician failed to ensure patients who presented to the ED were assessed in sequence of their acuity level.

A telephone interview conducted on 01/09/13 at 9:00 AM with ED Physician #1 revealed he was working in the facility's ED on 01/05/13 when Patient #1 presented to the ED seeking medical treatment. After reviewing the medical record, the ED Physician confirmed Patient #1 did not receive a medical screening. The ED Physician stated, "I don't understand how any of this transpired." The Physician acknowledged the ED had a computerized system for staff to follow the triage time for each patient; however, the Physician stated he had not known about Patient #1 and did not know the family members of the patient were upset because the patient had not been seen by the Physician. The ED Physician stated he was still trying to get adjusted to the hospital's system of triage program and levels.

2. Documentation in the medical record of Patient #6 revealed the patient (MDS) dated [DATE] at approximately 9:50 PM with complaints of fever and abscess on the buttock and received a triage assessment at 9:50 PM on 01/05/13. Even though ED Physician #1 requested a culture be obtained of the patient's abscess, there was no documented evidence that the Physician conducted a medical screening of Patient #6. Documentation revealed Patient #6 was transferred to the medical floor and underwent a surgical procedure on the following day, 01/06/13, related to the abscess on the buttock.

Interview with ED Physician #1 on 01/10/13 at 12:40 PM revealed Patient #6 had been in the ED from 9:50 PM until 4:44 AM and a phone call was made to admit the patient to the services of a Pediatrician. The ED Physician acknowledged a medical screening for Patient #6 was never documented. The ED Physician stated, "It was a busy night and unfortunately I didn't have time to document what I had done."

Patient #6 had already been discharged from the facility therefore an interview with the family was not conducted.