The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

GEORGE E WEEMS MEMORIAL HOSPITAL 135 AVE G APALACHICOLA, FL 32320 March 8, 2018
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on review of medical records, policy and procedures, George E Weems Memorial Hospital's written self-report of Emergency Medical Treatment and Labor Act (EMTALA) violation, review of incident reports, incident report review, review of written statement telephone interview, staff interviews, and family member interview, it was determined the facility failed to ensure that an appropriate medical screening examination was provided within the capabilities of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medic al condition exists for 1 (#22) of sampled patients. Refer to findings in Tag A 2406.
VIOLATION: EMERGENCY ROOM LOG Tag No: C2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of hospital policies and procedures, George E Weems Memorial Hospital's written self-report of Emergency Medical Treatment and Active Labor Act (EMTALA) violation, review of incident reports, review of the Emergency Department central log; and staff interviews and family written telephone interview, the hospital failed to ensure that each individual seeking care from the emergency department was added to the central log for 1 of 22 patients sampled. (Patient #22)

Findings include:

On 3/5/2018, during a state licensure survey, a review of incident reports for a six month period was conducted. An incident report, dated 2/5/2018, completed by an Emergency Department (ED) registration clerk (Employee I) documented that a grandmother (MDS) dated [DATE] at approximately 2:00 PM with her [AGE] year old grandson (Patient #22) wanting the child checked for influenza. The report did not include the patient's name, but stated "[AGE] year old boy not registered." The grandmother was told by Employee I that the child's mother needed to be contacted for consent to treat. The grandmother stated she could not reach the mother to get consent. Employee I asked the nursing staff if they could see the child and was told that parental consent was required. When the clerk told the grandmother that parental consent was required to see the child, the grandmother left the ED and stated, "we hope the grandson won't die because he was refused treatment."

The report was completed on 2/5/2018 at 3:20PM and was submitted to the facility's Licensed Health Care Risk Manager (LHCRM). The incident review documented that the LHCRM signed the report at 6:00PM, spoke with the nurses involved, and instructed the nurses that they needed to talk with the family, not the registration clerk. The report failed to document that there was any investigation, analysis or corrective actions. The LHCRM, who also serves as the Director of Nursing, went out on an unexpected extended leave of absence shortly afterwards and was not available for interview at the time of the survey.

A review of the ED registry failed to include a [AGE] year old presenting for treatment on 2/5/2018 (photo evidence obtained).

On 3/5/2018 at approximately 1:20 PM, in an interview with the Admissions Director (Employee H), revealed that all patients seeking care are included in the control register.

On 3/5/2018 at approximately 2:55 PM, the Field Office Manager (FOM) was called and informed of findings related to a child presenting to ED and not entered in the control log or receiving a medical screening exam.

On 3/5/2018 at approximately 3:05 PM, an interview was conducted with an emergency department clerk (Employee J) and the Admissions Director (Employee H). Employee J confirmed that EMTALA training is conducted annually and went on to state that it is common practice not to register a minor in the emergency department control log until parental consent is obtained. She went on to describe that she doesn't usually have a problem getting parents on the phone for consent.
Employee H confirmed that the sign located next to the registration window states that everyone must be seen and stated this does seem like an EMTALA violation, but it has never been addressed with her; and that there were times when a parent couldn't be reached and that patients were not entered into the log on those occasions.

On 3/6/2018 at approximately 10:20 AM, an interview was conducted with the Chief Executive Officer (Employee R), who is also the acting Risk Manager designee. The CEO confirmed the information in the incident report to be correct. The CEO also confirmed that the child (Patient #22) was not entered into the control log.

On 3/7/2018 at approximately 4:30PM, the Human Resources Director (Employee K) provided a written statement of a phone conversation that she had with the grandmother of patient #22. The grandmother confirmed that she brought patient #22 to the hospital on [DATE] and was refused treatment due to lack of parental consent. The grandmother further stated that if it had been explained that the ED was busy and it might take a little time to see her grandson, she would have waited. The grandmother confirmed the name and date of birth of patient #22 and that the child was seen at another ED on 2/6/2018. The name of the child was compared to the ED registry log for 2/5/2018 and confirmed that patient #22 was not entered on the registry.

On 3/7/2018 at approximately 4:40PM, an interview was conducted with an admissions specialist (Employee M). Employee M was asked to verbalize the process for a patient who presents with a minor child without parental consent. Employee M replied, "are we going by today's policy or before today?" The director of admissions was present at the registration window and had just finished providing training on the process of registering patients. Employee M was asked to explain what the process would have been on 2/5/2018 if someone presented seeking care for a minor child. Employee M explained that she would have asked the person if they could consent for the child. If the person said they were not the parent, then she would have asked them to call a parent and get consent. If the person stated they could not get a parent by phone and didn't have parental right to consent, then she would get the nurse for further guidance. She stated that she would not have put any information into the register, but she "would do that now."

Review of the facility's Emergency Medical Treatment and labor ACT (EMTALA) Policy and Procedure (P&P), dated January 2018, documented the purpose of a Central Log is to track the care provided to each patient that presents to the facility seeking care for an emergency situation. The procedure documented a log entry is made at the first point of contact; and usually initiated on patient presentation to the ER and is completed after the medical screening and/or necessary treatment and stabilization to address the emergency medical condition is completed. The log contains a minimum: (1) Name of the individual presented to the facility seeking care for an emergency condition. (2) whether the individual was treated and released, treated and admitted , stabilized and transferred and/or refused treatment/ (3) Treating physician or Qualified Medical Provider (4) Date and time of presentation.

The facility failed to ensure that their Central Log Policy and Procedure was followed as evidenced by failing to enter Patient #22 on the Central log on 2/5/2018, when he was brought to the ED by his grandmother seeking medical assistance.
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on review of medical records, policy and procedures, George E Weems Memorial Hospital's written self-report of Emergency Medical Treatment and Labor Act (EMTALA) violation, review of incident reports, incident report review, review of written statement telephone interview, staff interviews, and family member interview, it was determined the facility failed to ensure that an appropriate medical screening examination was provided within the capabilities of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 22 sampled patients (#22).

Findings include:

On 3/5/2018, during a state licensure survey, a review of incident reports for a six month period was reviewed. An incident report, dated 2/5/2018, completed by an Emergency Department (ED) registration clerk (Employee I) stated that a grandmother (MDS) dated [DATE] at approximately 2:00PM seeking care for her [AGE] year old grandson (Patient #22) wanting the child checked for influenza. The report did not include the patient's name, but stated "[AGE] year old boy not registered." The grandmother was told by Employee I that the child's mother needed to be contacted for consent to treat. The grandmother stated she could not reach the mother to get consent. Employee I asked the nursing staff if they could see the child and was told that parental consent was required. When the clerk told the grandmother that parental consent was required to see the child, the grandmother left the ED and stated, "we hope the grandson won't die because he was refused treatment."

The report was completed on 2/5/2018 at 3:20PM and was submitted to the facility's Licensed Health Care Risk Manager (LHCRM). The incident review documented that the LHCRM signed the report at 6:00PM, spoke with the nurses involved, and instructed the nurses that they needed to talk with the family, not the registration clerk.

A review of the ED registry failed to include a [AGE] year old presenting for treatment on 2/5/2018 (photo evidence obtained). On 3/5/2018 at approximately 1:20PM, in an interview with the Admissions Director (Employee H), revealed that all patients seeking care are included in the control register. She further stated that they would have to get consent from a child's parent in order to provide treatment. She also stated that the ED clerks would not make a decision as to whether a patient could be treated. Employee H reviewed the incident report and called the clerk (Employee I) on the phone. She returned and stated that the clerk (Employee I) confirmed she asked the nurses twice to see the child and then informed the surveyors that the clerk was on the phone and available for an interview. A telephone interview took place on 3/5/2018 at approximately 1:30PM with the Employee I who confirmed the documentation on the incident report to be accurate. She further explained that she did not ask the grandmother for her name or the child's name, but that she got the grandmother's name from another patient who was present after she left. She confirmed that she attempted twice to have the nurses talk with the grandmother.

On 3/5/2018 at approximately 2:30PM upon request, the Administrative Assistant (Employee G) provided a policy and procedure (P&P) titled ER Triage with a most recent revision date of 10/22/2007. The policy stated all patients who present to the emergency department requesting care or having a request made on their behalf will be medically screened by a qualified medical provider as soon as possible. Policy documented that "triage, medical screening, and/or treatment will be provided without regard to race, ethnicity, religion, national origin, citizenship, age, sex, creed or ability to pay." The policy further stated that consent for treatment and demographic information necessary to provide patient care, including name, date of birth, age, etc., may be collected upon arrival to the emergency department but will not impede the triage and medical screening process.

On 3/5/2018 at approximately 2:55PM, the Field Office Manager (FOM) was called and informed of findings related to a child presenting to ED and not entered in the control log or receiving a medical screening exam.

On 3/5/2018 at approximately 3:30PM, an interview was conducted with a nurse working in the ED on 2/5/2018 (Employee E). The nurse confirmed the information on the incident report to be correct. She stated that she saw the child on video surveillance holding his head up and did not appear in distress. She further stated that nursing administration had indicated on multiple occasions that unless an apparent emergency was present, no child would be seen without parental consent.

On 3/5/2018 at approximately 4:00PM, an interview was conducted with the ED physician on duty (Employee O) who stated that parental consent is required in order to provide treatment unless it is an emergency. He further stated that nursing could determine based on observation of the child if an emergency condition existed.

On 3/6/2018 at approximately 10:20 AM, an interview was conducted with the Chief Executive Officer (Employee R), who is also the acting Risk Manager designee. The CEO confirmed the information in the incident report to be correct.

3/6/2017 at approximately 1:35PM the FOM contacted the survey team and instructed them to proceed with an EMTALA investigation.

A review of the facility self-report dated 3/6/2018 documented the following: On 2/5/2018 at 2 p.m., a [AGE] year old male presented at the Emergency Department in the company of his grandmother. The grandmother requested that the [AGE] year old male be checked for the flu. The admission clerk told the grandmother that the hospital would need to contact the child's mother for consent to treat. The grandmother said she didn't know where the child's mother was and that the mother didn't want to give her custody of the [AGE] year old child. The clerk consulted the ED nurses who said the child could not be treated without the mother's consent. The child left the facility with his grandmother without receiving a medical screening.

On 3/6/2018 at approximately 3:49PM, the ED Physician Director (Employee L) was interviewed and stated that everyone is supposed to get a medical screening regardless of consent and he doesn't know why anyone stated that they have to have consent to get seen.

On 3/6/2018 at approximately 4:50PM, a nurse working in the ED (Employee A) on the date of the incident was interviewed. This nurse is currently the interim Director of Nursing. This nurse confirmed the information on the incident report to be correct and stated that she remembered telling the clerk (Employee I) to try to get parental consent.

On 3/7/2018 at approximately 4:30PM, the Human Resources Director (Employee K) provided a written statement of a 3/7/18 phone conversation that she had with the grandmother of patient #22. The grandmother confirmed that she brought patient #22 to the hospital on [DATE] and was refused treatment due to lack of parental consent. The grandmother further stated that if it had been explained that the ED was busy and it might take a little time to see her grandson, she would have waited. The grandmother confirmed the name and date of birth of patient #22 and that the child was seen at another ED on 2/6/2018. The name of the child was compared to the ED registry log for 2/5/2018 and confirmed that patient #22 was not entered on the registry.

On 3/7/2018 at approximately 4:40PM, an interview was conducted with an admissions specialist (Employee M). Employee M was asked to verbalize the process for a patient who presents with a minor child without parental consent. Employee M replied, "are we going by today's policy or before today?" The director of admissions was present at the registration window and had just finished providing training on the process of registering patients. Employee M was asked to explain what the process would have been on 2/5/2018 if someone presented seeking care for a minor child. Employee M explained that she would have asked the person if they could consent for the child. If the person said they were not the parent, then she would have asked them to call a parent and get consent. If the person stated they could not get a parent by phone and didn't have parental right to consent, then she would get the nurse for further guidance. She stated that she would not have put any information into the register, but she "would do that now." Employee M stated that she has "always been told" that she had to have legal guardian consent to treat a child. She would tell the nurse that someone was there wanting to get a child seen, but that "pretty much all the nurses would tell me to get consent." When asked if people usually get upset or leave when told the facility has to have parental consent, Employee M responded that "some people get upset, but most understand." Employee M was asked what she would do in the scenario of a grandparent presenting with a visibly ill child and requesting care. Employee M responded that it would be the same process of requesting parental consent and further elaborated, "I've always been told if you don't have parental consent we can't see the child." Employee M was asked if she thinks the doctors know that the process is to get consent before seeing a child and the clerk responded that she isn't sure, but the doctors are sitting near the nurses when the conversations take place. Employee M stated that she was re-educated today and the new process requires everyone to be registered no matter what and don't ask for parental consent right away and if "we need to call mom, they (the nurses) will let us know." When describing the new process, Employee M described that the person will be asked for a name and date of birth of the patient, register the patient, ask about consent, but let the person know that the patient will be seen and ask to call parent for consent if possible. When asked if she thinks it is an EMTALA violation to not see a child without consent, Employee M said yes, but she was "doing what she was told to do."

On 3/8/2018 at approximately 8:30AM, an ED record for patient #22 was obtained from a local hospital which confirmed that patient #22, a [AGE] year old male, was seen for symptoms related to influenza on 2/6/2018.

Review of facility's Emergency Medical Treatment and Labor Act (EMTALA) Policy and Procedure (P&P), review date of 1/2018, documented the purpose is to ensure all individuals with potential emergency conditions, who present to a part of the hospital or premises, receive an appropriate medical screening examination and any necessary treatment and stabilization, as appropriate. The procedure for Medical Screening Exam (MSE) documented all patients presenting to Weems Memorial Hospital property or premises, requesting emergency services will receive an appropriate medical screening examination (MSE).

The facility failed to ensure that their policies and procedures were followed as evidenced by failing to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's ED to determine whether or not an emergency medical condition existed for Patient #22 on 2/5/2018.