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.

SHANDS LAKE SHORE REGIONAL MEDICAL CENTER 368 NE FRANKLIN ST LAKE CITY, FL 32055 Dec. 15, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Reference 2406 Based on interview, record review and policy review the hospital failed to ensure the EMTALA(Emergency Medical Treatment and Labor Act) policies and procedures were followed by failing to provide a medical screening for one (#1) of 26 patients presenting to the facility..
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, review of the facility's Policy and Procedures, and interview, the facility failed to ensure that Patient 1 (#1) of 26 sampled residents was seen and received a Medical Screening Examination (MSE) by the physician, and there was a delay in medical screening by requesting financial payment from the patient when the patient presented to the emergency room requesting care. Failure for the patient to be seen and receive a medical screen by the physician has the potential for the patient not having their needs meet.

Findings:

Review of the emergency room log revealed that patient #1, (MDS) dated [DATE] at 12:09 PM with the complaint of acute lower back pain. He works lifting boxes, stocking at at a retail store. Prior to presenting to the ER, the patient had taken Ibuprofen 200 mg without relief. His primary nurse in the emergency room (ER) was Registered Nurse #A (RN#A). The patient was triaged by RN #A at 12:20 PM. At 2:20 PM the nurse's note states that patient #1 had lower back pain for 3 to 4 days. Nursing note's stated that he complained of pain in his left subscapular area, lumbar area, right and low back, and that his pain was 10 out of 10 on a pain scale, (10 being the worst pain). He was on no medications at home, and his mother present had stated that he had recently diagnosed with Scolosis.

Review of the Physician Documentation revealed that the physician documented that he visited patient #1 on 11/06/2014 at 12:36 PM while he was sitting in a chair the hallway of the emergency room in Chair #3 (C3). at 1:23 PM the physician documented patient medically screened, and at 1:24 wrote for his Emergency Department (ED) course: patients symptoms ongoing, nothing acute. Discussed MSE and nature of the disease. Declined further treatment at this point.
DISPENSED MEDICATIONS: No medications were administered. Next documentation was at 1:24 PM the physician documented that a medical screening examination had been done and that patient #1 was discharged .
The medical record did not reflect continued monitoring according to patient #1's needs. And there was not any ongoing monitoring prior to discharge of the patient.

Further review of the log revealed that the patient had left on 11/06/2014 at 1:25 PM, and according to interviews Chief Nursing Officer (CNO), with his primary care nurse, and the registration clerk staff revealed that patient #1 left without being seen by the physician.

Interview on 12/15/2014 at 11:30 AM with the Facility's Risk Manager (RM) he stated " in the eyes of Emergency Medical Treatment and Labor Act (EMTALA) for MSE, the ER physician failed to do a MSE."
When this surveyor asked when and how he had become aware of this event and if he had done an investigation, he stated " the Chief Nursing Officer (CNO) had received a call from patient #1's mother 3 days after he left the facility, and voiced a complaint/grievance about her son not being seen in the emergency room ." The mother had stated to the CNO that she took her son (patient #1) to another acute care hospital where he was seen by a physician, X-rays were done, and he was given a prescription for pain medications.

Telephone interview was conducted on 12/15/2014 at 2:00 PM with the registration clerk that was present on registration on 11/06/2014 and observed patient #1. The registration clerk stated that on 11/06/2014 he asked patient #1 if he had insurance, and patient #1 replied that he worked at a retail store and had private health insurance. The clerk stated that he could not verify the insurance with his employer , and he didn't have his insurance card with him. The clerk stated when he was asked by the physician who patient #1's insurance with, the clerk told the physician that there was not any insurance verified, and the physician stated " Then he is going to have to be private pay, and he is going to have to pay to be seen. He must come up with at least half of the payment.

Interview on 12/15/2014 at 2:40 PM with the Chief Nursing Officer (CNO) revealed that after his investigations and interviews with patient #1's emergency room primary nurse and the registration clerk, that he confirmed that the emergency room physician never touched or examined patient #1. Therefore he did not conduct a MSE. And that emergency room physician had stated that he would not see patient #1, and because of no insurance, the physician did not touch, nor talk to the patient, after initial contact. Improper and false documentation. He further stated that this is improper and false documentation of a MSE, and that a physician cannot refuse care based on a patient's ability to pay. And that patient #1 went to another facility for the care that he did not receive here because of this physician.

Telephone interview was conducted on 12/15/2014 at 3:30 PM with patient #1's emergency room primary nurse (RN #A) on 11/06/2014. She stated that day patient #1's physician stated that he was coming to do a MSE for patient #1, that it was not a medical emergency, and that he was going to require payment if he wanted to be seen. RN #A saw patient #1 and his mother leaving, they were upset, they got up from the chair in the hallway (C3) and left the building. He was never placed in a room to be examined by the physician. RN #A stated " I don't think the physician treated, assessed or did a MSE. I never saw him do anything with the patient."

After patient #1 left this facility (Shands at lake Shore) on 11/06//2014 at 1:25 PM, he arrived at another 2nd emergency room (ER) at another acute care hospital 1:36 PM. Review of the ER record at the second hospital for patient #1 revealed that he was triaged at 1:42 PM, presenting with the same complaint of Lumbar (part of back between the thorax and pelvis) pain, with a pain level of 8 out of 10. At the 2nd emergency room facility, patient #1 at 1:44 PM, he was place in a room and seen by a physician at 1:44 PM who did a Medical Screening Examination (MSE), and ordered a X-ray of the lumbar spine, which revealed Levoscoliosis of the lumbar spine with measurements of 18 degrees as reviewed by the radiologist at 2:59 PM.

Patient #1's physician at the 2nd emergency room at another acute care hospital had written for prescriptions given to him for pain of Motrin, Robaxin, Flexeril, and to follow up with his health Department or Primary Care Physician (PCP). He was discharge that same day of 11/06/2014 at 3:22 PM.

Review of the facility's Policy and Procedures titled Subject: EMTALA- Medical Screening/Stabilization- revised September, 2013 revealed the following:
Medical Screening Examination Requirements
Hospitals are obligated to perform the Medical Screening Examination to determine if an Emergency Medical Condition exists.
Medicare participating Hospitals that provide emergency services must provide a Medical Screening Examination to any individual regardless of diagnosis, FINANCIAL status, race, color, national origin, handicap, ABILITY TO PAY, or other protected category.
The Medical Screening Examination includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of a Emergency Medical Condition.
VIOLATION: DELAY IN EXAMINATION OR TREATMENT Tag No: A2408
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of grievances, review of the facility's Policy and Procedures, and interview revealed that the facility failed follow reasonable registration processes for one (#1) of twenty six patients reviewed, that discouraged this patient to remain for further evaluation.

Findings:

Review of the emergency room log revealed that patient #1, (MDS) dated [DATE] at 12:09 PM with the complaint of acute lower back pain. He works lifting boxes, stocking at retail store. Prior to presenting to the ER, the patient had taken Ibuprofen 200 mg without relief. His primary nurse in the emergency room (ER) was Registered Nurse #A (RN#A). The patient was triaged by RN #A at 12:20 PM. At 2:20 PM the nurse's note states that patient #1 had lower back pain for 3 to 4 days. Nursing note's stated that he complained of pain in his left subscapular area, lumbar area, right and low back, and that his pain was 10 out of 10 on a pain scale, (10 being the worst pain). He was on no medications at home, and his mother present had stated that he had recently diagnosed with Scolosis.

Review of the Physician Documentation revealed that the physician documented that he visited patient #1 on 11/06/2014 at 12:36 PM while he was sitting in a chair the hallway of the emergency room in Chair #3 (C3). at 1:23 PM the physician documented patient medically screened, and at 1:24 wrote for his Emergency Department (ED) course: patients symptoms ongoing, nothing acute. Discussed MSE and nature of the disease. Declined further treatment at this point.
DISPENSED MEDICATIONS: No medications were administered. Next documentation was at 1:24 PM the physician documented that a medical screening examination had been done and that patient #1 was discharged .
The medical record did not reflect continued monitoring according to patient #1's needs. And there was not any ongoing monitoring prior to discharge of the patient.

Further review of the log revealed that the patient had left on 11/06/2014 at 1:25 PM, and according to interviews Chief Nursing Officer (CNO), with his primary care nurse, and the registration clerk staff revealed that patient #1 left without being seen by the physician.

Interview on 12/15/2014 at 11:30 AM with the Facility's Risk Manager (RM) he stated " in the eyes of Emergency Medical Treatment and Labor Act (EMTALA) for MSE, the ER physician failed to do a MSE."
When this surveyor asked when and how he had become aware of this event and if he had done an investigation, he stated " the Chief Nursing Officer (CNO) had received a call from patient #1's mother 3 days after he left the facility, and voiced a complaint/grievance about her son not being seen in the emergency room ." The mother had stated to the CNO that she took her son (patient #1) to Lake City Medical Center, where he was seen by a physician, X-rays were done, and he was given a prescription for pain medications.

Telephone interview was conducted on 12/15/2014 at 2:00 PM with the registration clerk that was present on registration at 11/06/2014 and observed patient #1. The registration clerk stated that on 11/06/2014 he asked patient #1 if he had insurance, and patient #1 replied that he worked at a retail store and had private health insurance. The clerk stated that he could not verify the insurance with his employer, and he didn't have his insurance card with him. The clerk stated when he was asked by the physician who patient #1's insurance with, the clerk told the physician that there was not any insurance verified, and the physician stated " Then he is going to have to be private pay, and he is going to have to pay to be seen. He must come up with at least half of the payment.

Telephone interview was conducted on 12/15/2014 at 3:30 PM with patient #1's emergency room primary nurse (RN #A) on 11/06/2014. She stated that day patient #1's physician stated that he was coming to do a MSE for patient #1, that it was not a medical emergency, and that he was going to require payment if he wanted to be seen. RN #A saw patient #1 and his mother leaving, they were upset, they got up from the chair in the hallway (C3) and left the building. He was never placed in a room to be examined by the physician. RN #A stated " I don't think the physician treated, assessed or did a MSE. I never saw him do anything with the patient."

Interview on 12/15/2014 at 2:40 PM with the Chief Nursing Officer (CNO) revealed that after his investigations and interviews with patient #1's emergency room primary nurse and the registration clerk, that he confirmed that the emergency room physician never touched or examined patient #1. Therefore he did not conduct a MSE. And that emergency room physician had stated that he would not see patient #1, and because of no insurance, the physician did not touch, nor talk to the patient, after initial contact. Improper and false documentation. He further stated that this is improper and false documentation of a MSE, and that a physician cannot refuse care based on a patient's ability to pay. And that patient #1 went to another facility for the care that he did not receive here because of this physician.


After patient #1 left this facility (Shands at lake Shore) on 11/06//2014 at 1:25 PM, he arrived at another 2nd emergency room (ER) at Lake City Medical Center 1:36 PM. Review of the ER record at Lake City Medical Center for patient #1 revealed that he was triaged at 1:42 PM, presenting with the same complaint of Lumbar (part of back between the thorax and pelvis) pain, with a pain level of 8 out of 10. At the 2nd emergency room facility, patient #1 at 1:44 PM, he was place in a room and seen by a physician at 1:44 PM who did a Medical Screening Examination (MSE), and ordered a X-ray of the lumbar spine, which revealed Levoscoliosis of the lumbar spine with measurements of 18 degrees as reviewed by the radiologist at 2:59 PM.

Patient #1's physician at the 2nd emergency room at Lake City Medical Center had written for prescriptions given to him for pain of Motrin, Robaxin, Flexeril, and to follow up with his health Department or Primary Care Physician (PCP). He was discharge that same day of 11/06/2014 at 3:22 PM.


Review of the facility's Policy and Procedures titled Subject: EMTALA- Medical Screening/Stabilization- revised September, 2013 revealed the following:
Medical Screening Examination Requirements
Hospitals are obligated to perform the Medical Screening Examination to determine if an Emergency Medical Condition exists.
Medicare participating Hospitals that provide emergency services must provide a Medical Screening Examination to any individual regardless of diagnosis, FINANCIAL status, race, color, national origin, handicap, ABILITY TO PAY, or other protected category.
The Medical Screening Examination includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of a Emergency Medical Condition.