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.

Based on observation, record review and interview, the facility failed to ensure compliance with Emergency Medical Treatment and Active Labor Act (EMTALA) regulations in 3 of 11 required areas (Sign Posting, Log Maintenance, and Appropriate Medical Screening).

Findings include:

The facility failed to ensure signage is legible and posted in the entrance to the Emergency Department. See tag C2402.

Facility staff failed to maintain an accurate, complete log of all patients presenting to the Emergency Department. See tag C2405.

The facility failed to provide an appropriate medical screening examination for all patients presenting to the Emergency Department. See tag C2406.
Based on observation and interview, the facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signs are placed in all lobbies and treatment areas in1 of 3 observed areas (main vestibule entrance to the Emergency Department).

Findings include:

Per observation on 9/9/2019 at 9:30AM, there are no EMTALA signs in the vestibule entrance to the Emergency Department (ED). Patients enter into a small area, ring a bell to alert their arrival, and wait for the designated ED Registered Nurse to unlock the door for them to enter the ED. Director of Nursing A on 9/9/2019 at 9:35AM pointed to a small sign, approximately 15 feet away from the vestibule area, through a glass door and hanging 8 feet up on a wall behind the ED registration and stated "we have the EMTALA sign there." Director A was in agreement that it is difficult if not impossible to read from the vestibule waiting area and that a sign should also be posted in the vestibule.
Based on review, observation and interview, the facility failed to maintain an accurate, complete log of patients presenting to the Emergency Department (ED).

In interview with ED Manager G on 9/10/2019 at 8:30AM when asked about expectations for documentation in the ED log stated, "it is expected that every column is documented on for each patient presenting to the ED. It is the nurses responsibility to assure it is complete and accurate." Questioned regarding error correction in the log, ED Manager G stated that, "the ED follows the facility policy for error correction." Review of facility policy titled "Paper error documentation" last reviewed 11/8/2018, revealed "when an error is present within a paper document, a single line is to be drawn through the error and initialed."

Review of the ED Log with ED Manager G on 9/10/2019 at 8:30AM revealed the following:
675 entries dating from 2/24/2019-9/6/2019. The paper log had the following 13 columns: date admitted , time, AM or PM, patient's name, address, age, sex, admitted by, service of Dr., nature of injury, services rendered, amount, and disposition of case. ED Manager G stated that the column titled "amount" was used to enter the discharge time.


Out of a total sample of 675 entries 21 had discharge times missing on; 2/20, 2/22, 3/27, 3/7, 3/31, 4/1 (2 patients), 4/14, 4/29, 5/21, 5/22, 5/25, 6/1, 6/10, 6/19, 7/20, 7/25, 7/26, 8/6, 8/30 ( 2 patients);
disposition was missing on 8 entries on; 3/7, 5/2, 5/22 (2 patients), 6/1, 7/26, 8/6, and 8/30; address was missing on 11 entries on 4/8, 5/10, 5/25, 6/1, 6/4, 6/17, 6/23, 6/27, 7/7, 7/20, and 8/6; age was missing on 4 entries on 4/29, 8/16, 8/25, and 8/30; services rendered was missing on 3 entries on 3/7, 7/25, and 7/26; the date of service was missing on 2 entries on 4/24 and 8/30; the time of admission was missing on 2 entries on 4/24; the nature of injury was missing on 2 entries on 3/7 and 5/22; two missing entries for service of Dr. on 3/7 and 8/6, and one missing entry for admitted by on 3/7.

Out of a total sample of 49 error corrections revealed during review of the ED Log from 2/24/2019-9/6/2019 46 were not corrected according to facility policy. These included cross outs, write overs, and scribbles on the following dates; 2/24, 3/2, 3/3, 3/17, 3/20, 3/21 (2 entries), 4/4 (2 entries), 4/11, 4/12, 4/13, 4/17, 4/19, 4/20, 5/7, 5/25 (2 entries), 5/26, 5/29, 6/3, 6/4, 6/5, 6/9, 6/10, 6/15, 6/25, 6/29, 7/1, 7/3, 7/6, 7/7 (2 entries), 7/12 (2 entries), 7/13 (2 entries), 7/22, 7/31, 8/7, 8/9, 8/12 (2 entries), 8/25, 8/19, and 8/31.

The above findings were confirmed with ED Manager G on 9/10/2019 at 8:30AM.

Review of medical record for Patient #10 revealed a 4/23/2019 ED visit with an arrival time of 1:40PM for hallucinations from meth (methamphetamine, a strong and highly addictive drug that affects the central nervous system). The patient received a medical screening exam and labs were drawn. The ED log documents that the patient left AMA at 2:45PM. The medical record contained a nurses note dated 4/24/2019 at 2:10AM that revealed a return visit for a complaint of "bleeding from my anus." This visit is not documented in the ED Log. The patient did not receive a medical screening exam and was discharged to home to follow up with the physician the following day. See Tag C-2406 for cite on the lack of medical screening.

ED Manager G confirmed in interview on 9/10/2019 that the second visit should have been entered in the log.
Based on interview and medical record review the facility failed to provide a medical screening exam in 1 of a total sample of 22 records reviewed (Patient #10).


Review of Patient #10's medical record revealed admission to the Emergency Department (ED) on 4/23/2019 at 1:40PM requesting treatment for a meth (methamphetamine, a strong and highly addictive drug that affects the central nervous system). Nurses notes document that ED Physician I was present when the patient arrived. The emergency room Report in medical record documented by ED Physician I revealed the patient was seen by ED Physician I at 1:40PM, received a physical exam, had blood pressure, pulse, respirations and oxygen saturation taken and had labs drawn. Nurses notes document at 4:45PM that the patient went out for a cigarette and did not return to the ED. A nurses note in the 4/23/2019 medical record documented a return visit to the ED on 4/24/2019 at 2:10AM with a complaint of "bleeding out of her anus." The nurses note documented a call at 2:20AM to the on-call physician (ED Physician H) who instructed the nurse to tell the patient "I am willing to assess him/her for treatment if he/she would like to come back in the morning to the clinic." There was no documentation of vital signs, physical assessment or a screening exam performed in the medical record. Nurses notes document at 2:25AM, "pt and boyfriend leave out the ER door and state they will be back in the morning." In interview with ED Manager G on 9/10/2019 at 8:22AM Manager G agreed that a medical screening exam was not done and "should have been." Review of facility policy "ED Medical Screening" last reviewed 11/8/2018 revealed under the heading Medical Screening Exam, "any person requesting emergency services, who presents to facility that provides emergency services must receive a medical screening exam (MSE). The purpose of the MSE is to identify whether an emergency condition exists. This has been delegated to the ER Registered Nurse by the medical staff. See bylaw."