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CARLISLE REGIONAL MEDICAL CENTER 361 ALEXANDER SPRING ROAD CARLISLE, PA 17015 June 29, 2012
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on review of facility documents, closed medical records (MR) and interviews with staff (EMP), it was determined that Carlisle Regional Medical Center failed to provide an appropriate medical screening examination for one of 28 Emergency Department medical records (MR) reviewed (MR16).

Findings Include:

A review on June 28, 2012, of Carlisle Regional Medical Center's Emergency Department Policy Manual last reviewed September 19, 2011. The following policies were reviewed:

"Emergency Department Physician Responsibilities: ...The Emergency Department physician/physician assistant shall: Provide an emergency medical screening exam (MSE) to all patients coming to the Emergency Department (ED) to determine if an emergency medical condition (EMC) exists ... ."

"Waiver of Medical Screening Exam: Purpose: Establish criteria in which appropriate treatment is given to patients declining a medical screening exam. Policy: All patients will be evaluated by the Triage nurse prior to being seen by an Emergency Department Registration Clerk. All patients are entitled to a Medical Screening Examination. If a patient determines that Medical Screening is not desired, a Medical Screening Waiver form shall be signed by the patient /designee. ... If there are any concerns related to appropriateness of Waiver of Medical Screening exam, the physician on duty in the Emergency Department should act as a resource for decision-making. ... ."

Purpose and Objectives: Purpose: To provide quality care for all patients who arrive at the Emergency Department 24 hours a day regardless of age, race, religion, or ability to pay, as defined by Federal and State laws. All patients will receive an evaluation by the Emergency Department physician/PA ...Objectives: Emergency care shall be delivered in accordance with written Policies and Procedures and Standards of Care. Provide quality care to all patients in accordance with CRMC (Carlisle Regional Medical Center) policy. Provide initial Triage and treatment of all patients ... Provide appropriate discharge and follow-up care ... ."

"Transfer of patient to another facility from the ED: ... Purpose: To establish guidelines based on the EMTALA standards to insure that appropriate care is given to each patient ... Policy: All patients who present to the Emergency Department for care are entitled to a Medical Screening Examination to determine whether a medical emergency condition exists ... If the physician determines that the patient should be transferred to another facility for further care, EMTALA standards must be followed ... Acceptance to the receiving facility must be made physician to physician with documentation of the receiving facility's physician's name ... ."

Review on June 28, 2012 of MR16 revealed the patient presented on June 19, 2012, at 1:17 AM with a "Chief Complaint : Assault/Rape. "A review of MR16 Nurses Notes revealed, "01:40 ED Rounding: spoke with pt and mother concerning no Sexual Assault Forensic Examiner (SAFE) person being on call. Explained that we refer pt to [another hospital] in this case. Asked if pt was injured and she was not. Mother agreed to take pt to [another hospital]. left ambutlatory{sic}. 01:44 ED Rounding: refusal for medical screening not signed. ...Outcome: 07:30 Patient left the ED." Review of MR16 Physician Documentation revealed, "06/19 Patient left the facility before triage: Not evaluated by a provider. ... ."
A review of facility documentation revealed the SAVE On Call Schedule for May 2012, had a hand written notice across the bottom of the paper, "If no one on call, refer to [another hospital]."
A review of the On Call Schedule for June 2012, revealed, "If No one on call ... refer to [another hospital], when RAPE CRISIS or POLICE call in."
An interview was conducted with EMP1 on June 28, 2012 at 11:00 PM. EMP1 stated, "we felt that the patient had not been admitted to the ED and left before the Medical Screening Exam (MSE) could be done. The patient's mother was a nurse and wanted to take the patient where a sexual assault forensic examiner (SAFE) nurse was available. We were acting in the best interest of the patient. We referred the patient to another facility."
An interview was conducted with EMP2 on June 28, 2012, at approximately 11:30 AM. EMP2 stated "the patient wasn't admitted ... I talked with the patient's mother and told her we did not have a SAFE nurse on call. The mother felt she would like the patient treated in a facility with a SAFE nurse. Using the SAFE nurses, who are on call, prevents us from having to tie up the ED doctor and ED nurses for 3 or 4 hours with one patient. I had the ED secretary call [another hospital], when we told the mother and the patient that we did not have a SAFE nurse available."

An interview was conducted with EMP9 on June 29, 2012, at 10:00 AM. EMP8 confirmed that MR16 did not contain documentation that the patient had a MSE or was transferred to a higher level of care.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined that Carlisle Regional Medical Center failed to execute an appropriate transfer for one of 28 Emergency Department medical records (MR) reviewed (MR16).

Findings Include:

A review on June 28, 2012, of Carlisle Regional Medical Center Emergency Department Policy Manual reviewed September 19, 2011. "Transfer of patient to another facility from the ED: ... Purpose: To establish guidelines based on the EMTALA standards to insure that appropriate care is given to each patient ... Policy: All patients who present to the Emergency Department for care are entitled to a Medical Screening Examination to determine whether a medical emergency condition exists ... If the physician determines that the patient should be transferred to another facility for further care, EMTALA standards must be followed ... Acceptance to the receiving facility must be made physician to physician with documentation of the receiving facility's physician's name ... ."

Review on June 28, 2012 of MR16 revealed that the patient presented on June 19, 2012, at 1:17 AM with a "Chief Complaint : Assault/Rape. "A review of MR16 Nurses Notes revealed, "01:40 ED Rounding: spoke with pt and mother concerning no sexual assault forensic examiner (SAFE) person being on call. Explained that we refer pt to [another hospital] in this case. Asked if pt was injured and she was not. Mother agreed to take pt to [another hospital]. left ambutlatory{sic}. 01:44 ED Rounding: refusal for medical screening not signed. ... Outcome: 07:30 Patient left the ED." Review of MR16 Physician Documentation revealed, "06/19 Patient left the facility before triage: Not evaluated by a provider. ... ."
A review of facility documentation revealed the SAFE On Call Schedule for May 2012, had a hand written notice across the bottom of the paper, "If no one on call, refer to [another hospital]."
A review of the On Call Schedule for June 2012, revealed "If No one on call ... refer to [another hospital], when RAPE CRISIS or POLICE call in."
An interview was conducted with EMP1 on June 28, 2012 at 11:00 PM. EMP1 stated, "we felt that the patient had not been admitted to the ED and left before the Medical Screening Exam (MSE) could be done. The patient's mother was a nurse and wanted to take the patient where a sexual assault forensic examiner (SAFE) nurse was available. We were acting in the best interest of the patient. We referred the patient to another facility."
An interview was conducted with EMP2 on June 28, 2012, at approximately 11:30 AM. EMP2 stated "the patient wasn't admitted ... I talked with the patient's mother and told her we did not have a SAFE nurse on call. The mother felt she would like the patient treated in a facility with a SAFE nurse. Using the SAFE nurses, who are on call, prevents us from having to tie up the ED doctor and ED nurses for 3 or 4 hours with one patient. I had the ED secretary call [another hospital], when we told the mother and the patient that we did not have a SAFE nurse available."

An interview was conducted with EMP8 on June 29, 2012, at 10:00 AM. EMP8 confirmed that MR16 did not contain documentation that the patient had a MSE or was transferred to a higher level of care, and that MR16 did not contain a Medical Screening Waiver form. EMP8 confirmed that the facility's transfer policy was not followed, no arrangements for transfer had been made by the physician, there was no accepting physician.