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.

WASHINGTON COUNTY MEMORIAL HOSPITAL 300 HEALTH WAY POTOSI, MO 63664 Sept. 11, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and review of video surveillance, the hospital failed to enter into the Emergency Department (ED) log and provide a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#21) of 21 ED patients records reviewed. The hospital's ED average monthly census over the past six months was 1,019.

Findings included:
Review of the hospital's policy titled, "EMTALA GUIDELINES FOR EMERGENCY", undated, showed that:
- An emergency medical condition is any condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future. To include substance abuse symptoms and psychiatric disturbances.
- All patients presenting to Washington County Memorial Hospital's Emergency must be accepted and evaluated regardless of the patient's ability to pay.
- All patients shall receive a medical screening exam that included providing all the necessary testing and on-call services within the capability of the hospital to reach a diagnosis.
- The triage of a patient for managed care contracts without a medical screening exam is not acceptable under EMTALA.
- WCMH (Washington County Memorial Hospital) may not transfer or discharge a patient who may be reasonably at risk to deteriorate from during or after said transfer or discharge.
- WCMH may not transfer patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient.
- Medical screening exams should include at minimum, Emergency Department, (ED) logs, patient triage records, vital signs, history, physical exam, exam of known chronic conditions, necessary testing to rule out medical conditions, notification and use of on-call personnel to diagnose and stabilize as necessary, and complete documentation.

Review of the hospital's policy titled, "Patient Leaving AMA/LWBS/Eloped", undated, showed that if the patient voices the desire to leave prior to being evaluated by the provider the nurse shall:
- Discuss with the patient and/or family the potential complications that may occur.
- Evaluate and address circumstances influencing their desire to leave.
- Notify the provider.
- Complete an AMA form to include possible consequences, including death.
- Complete a left without being seen (LWBS), form and present it to the patient to sign.
-Instruct the patient to follow-up with his/her family physician or return to the ED if his/her condition worsens.
- Document all of the above actions in the chart.

Review of video surveillance dated 08/28/19, showed that at 11:41 PM, Patient #21 and her mother presented to the ED and then exited the ED at 12:10 AM on 08/29/19.

Review of Patient #21's medical record from Hospital B (nearby hospital) showed that Patient #21 (MDS) dated [DATE] at 12:51 AM (approximately thirty minutes after leaving WCMH ED) with a chief complaint of sexual assault. The patient received a MSE and was medically cleared and discharged home on 08/29/19.

Review of the electronic ED log showed no evidence of Patient #21's arrival to the ED that she requested care, or that she left the ED without receiving an examination. There was no medical record on file for Patient #21 and no MSE was completed or documented.

The hospital's failure to enter Patient #21 into the ED log and failure to provide Patient #21 with a MSE could have resulted in possible injury or death to patients who required immediate medical care.

Please refer to A-2405 and A-2406 for details.
VIOLATION: EMERGENCY ROOM LOG Tag No: C2405
Based on interview, record review, policy review, and review of video surveillance the hospital failed to enter into the Emergency Department (ED) log one patient (#21) of 21 patients' medical records reviewed who presented to the hospital's ED seeking care, out of sample selected from March 2019 to September 2019. This failure had the potential to affect all patients who presented to the ED.

Findings included:
Review of the hospital's policy titled, "EMTALA GUIDELINES FOR EMERGENCY", undated, showed that:
- An emergency medical condition is any condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future. To include substance abuse symptoms and psychiatric disturbances.
- All patients presenting to Washington County Memorial Hospital's Emergency must be accepted and evaluated regardless of the patient's ability to pay.
- All patients shall receive a medical screening exam that included providing all the necessary testing and on-call services within the capability of the hospital to reach a diagnosis.
- The triage of a patient for managed care contracts without a medical screening exam is not acceptable under EMTALA.
- WCMH (Washington County Memorial Hospital) may not transfer or discharge a patient who may be reasonably at risk to deteriorate from during or after said transfer or discharge.
- WCMH may not transfer patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient.
- Medical screening exams should include at minimum, Emergency Department, (ED) logs, patient triage records, vital signs, history, physical exam, exam of known chronic conditions, necessary testing to rule out medical conditions, notification and use of on-call personnel to diagnose and stabilize as necessary, and complete documentation.

Review of the hospital's ED memo posting (informal communication memo) undated, showed that EMTALA was very important. Communication included that the hospital must see and must log all patients that present to the ED. And that if a patient refuses to be signed in there must be documentation as to why, and a John or Jane doe chart must be created for documentation purposes.

Review of video surveillance dated 08/28/19, showed that at 11:41 PM, Patient #21 and her mother presented to the ED and then exited the ED at 12:10 AM on 08/29/19.

Review of the electronic ED log showed no evidence of Patient #21's arrival to the ED that she requested care, or that she left the ED without receiving an examination.

During an interview on 09/10/19 at 8:45 AM, Staff F, RN stated that:
- Patients were triaged and given an acuity score of 1-4.
- The assessment determined triage level.
- Patients should always be logged and an MSE should always be performed by a physician.

During a telephone interview on 09/10/19 at 9:30 AM, Staff G, LPN stated that:
- He had been the nurse on duty when patient #21 presented to ED.
- Patient #21 had presented with her mother with an allegation of rape.
- He had begun to attempt to call in a S.A.N.E trained nurse.
- When he had been unable to reach a S.A.N.E trained nurse, he then began contacting other local hospitals to see if they had one available.
- He had communicated to Patient #21 that this may take a while.
- He communicated to Patient #21 that he had located another local ED (hospital B) that had a S.A.N.E nurse on staff at that time.
- He communicated to her that she might have to go by ambulance.
- He had not communicated to her that she could go by personal vehicle if the physician were to have cleared her to do so.
- Patient had refused to be seen at that point and wanted to drive herself to hospital B.
- That Patient #21 was not logged. She had never been checked in, had not been triaged or assessed, and had not been seen by a physician.
- And that he realized he should have logged, registered, triaged, roomed and gotten the physician involved with Patient #21.

During an interview on 09/10/19 at 9:00 AM, Staff A, CNO stated that:
- Hospital process is for all patients that present to the ED to be logged and that Patient #21 had been missed.
- Her expectation was that all patients that presented to the ED were to be logged and should receive a MSE.

During an interview on 09/10/19 at 10:00 AM, Staff H, Medical Director stated that:
- The physicians all had EMTALA training annually via their physician staffing organization.
- His expectation was that every patient that presented should be checked in, logged, and a MSE performed.

During an interview on 09/11/19 at 8:45 AM, Staff I, RN stated that:
- The nurses all received EMTALA training annually.
- She worked the ED department and was S.A.N.E trained.
- Any patient that presents to the ED should be logged.

During a telephone interview on 09/11/19 at 9:10 AM, Staff K, MD, stated that:
- Her expectation would be that the hospital would have S.A.N.E trained nurse coverage, available and on call at all times.
- That there were not too many S.A.N.E trained nurses at that facility.
- Every patient that presented to the ED should be logged and registered, with a MSE.

During a telephone interview on 09/11/19 at 9:31 AM, Staff L, DO, stated that:
- He had performed S.A.N.E exams in the past.
- He would complete a S.A.N.E exam if needed.
- Any patient that presented to the ED should be logged.

During an interview on 09/11/19 at 9:45 AM, Staff B, Director of Quality, stated that:
- The hospital was looking into solutions to ensure S.A.N.E trained staff were available when needed.
- She expected that every patient that presents to the ED to be logged.

During an interview on 09/11/19 at 10:15 AM, Staff D, Interim ED Director stated that:
- Clinical staff had EMTALA training annually.
- All patients that presented to the ED should be logged.

The hospital staff failed to follow their policy and did not document Patient #21 in the ED log after she had presented to the ED with an allegation of sexual assault.
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, policy review and review of video surveillance, the hospital failed to provide a complete Medical Screening Examination (MSE), within its capacity and capability, to determine if an Emergency Medical Condition (EMC) existed for one patient (#21) of 21 patients who presented to the hospital's Emergency Department (ED) seeking care, out of sample selected from March 2019 to September 2019. This failure had the potential to affect all patients who presented to the ED.

Findings included:
Review of the hospital's policy titled, "EMTALA GUIDELINES FOR EMERGENCY", undated, showed that:
- An emergency medical condition is any condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future. To include substance abuse symptoms and psychiatric disturbances.
- All patients presenting to Washington County Memorial Hospital's Emergency must be accepted and evaluated regardless of the patient's ability to pay.
- All patients shall receive a medical screening exam that included providing all the necessary testing and on-call services within the capability of the hospital to reach a diagnosis.
- The triage of a patient for managed care contracts without a medical screening exam is not acceptable under EMTALA.
- WCMH (Washington County Memorial Hospital) may not transfer or discharge a patient who may be reasonably at risk to deteriorate from during or after said transfer or discharge.
- WCMH may not transfer patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient.
- Medical screening exams should include at minimum, Emergency Department, (ED) logs, patient triage records, vital signs, history, physical exam, exam of known chronic conditions, necessary testing to rule out medical conditions, notification and use of on-call personnel to diagnose and stabilize as necessary, and complete documentation.

Review of the hospital's policy titled, "Patient Leaving AMA/LWBS/Eloped", undated, showed that if the patient voices the desire to leave prior to being evaluated by the provider the nurse shall:
- Discuss with the patient and/or family the potential complications that may occur.
- Evaluate and address circumstances influencing their desire to leave.
- Notify the provider.
- Complete an AMA form to include possible consequences, including death.
- Complete a left without being seen (LWBS), form and present it to the patient to sign.
-Instruct the patient to follow-up with his/her family physician or return to the ED if his/her condition worsens.
- Document all of the above actions in the chart.

Review of the hospital's ED memo posting (informal communication memo) undated, showed that EMTALA was very important. Communication included that the hospital must see and complete a MSE by a provider for anyone who presented to the ED, and that if a patient refuses to be signed in or if no medical screening was performed there must be documentation as to why and a John or Jane doe chart must be created for documentation purposes.

Review of video surveillance dated 08/28/19, showed that at 11:41 PM, Patient #21 and her mother presented to the ED and then exited the ED at 12:10 AM on 08/29/19.

Review of Patient #21's medical record from Hospital B (nearby hospital) showed that Patient #21 (MDS) dated [DATE] at 12:51 AM (approximately thirty minutes after leaving WCMH ED) with a chief complaint of sexual assault. The patient received a MSE and was medically cleared and discharged home on 08/29/19.

Review of the electronic ED log showed no evidence of Patient #21's arrival to the ED that she requested care, or that she left the ED without receiving an MSE.

During an interview on 09/10/19 at 8:45 AM, Staff F, RN stated that:
- Patients were triaged and given an acuity score of 1-4.
- The assessment determined triage level.
- Patients should always be logged and an MSE should always be performed by a physician.

During a telephone interview on 09/10/19 at 9:30 AM, Staff G, LPN stated that:
- He had been the nurse on duty when patient #21 presented to ED.
- Patient #21 had presented with her mother with an allegation of rape.
- He had begun to attempt to call in a S.A.N.E trained nurse.
- When he had been unable to reach a S.A.N.E trained nurse, he then began contacting other local hospitals to see if they had one available.
- He had communicated to Patient #21 that this may take a while.
- He communicated to Patient #21 that he had located another local ED (hospital B) that had a S.A.N.E nurse on staff at that time.
- He communicated to her that she might have to go by ambulance.
- He had not communicated to her that she could go by personal vehicle if the physician were to have cleared her to do so.
- Patient had refused to be seen at that point and wanted to drive herself to hospital B.
- That there had not been LWBS or AMA paperwork had completed.
- That Patient #21 did not receive a MSE. She had never been checked in, had not been triaged or assessed, and had not been seen by a physician.
- And that he realized he should have logged, registered, triaged, roomed and gotten the physician involved with Patient #21.

During an interview on 09/10/19 at 9:00 AM, Staff A, CNO stated that:
- Hospital process is for all patients that present to the ED to have a MSE and that Patient #21 had been missed.
- They did not have any S.A.N.E trained nurses that were on an on-call schedule for after hours.
- Her expectation was that all patients that presented to the ED were to receive a MSE.

During an interview on 09/10/19 at 10:00 AM, Staff H, Medical Director stated that:
- The physicians all had EMTALA training annually via their physician staffing organization.
- His expectation was that every patient that presented should be checked in and logged.
- Anyone that presented to the ED should have an MSE performed.

During an interview on 09/11/19 at 8:45 AM, Staff I, RN stated that:
- The nurses all received EMTALA training annually.
- She worked the ED department and was S.A.N.E trained.
- She thought any RN could perform the S.A.N.E exam, but they would need to know what they were doing.
- Physicians can complete the S.A.N.E exams.
- There were a total of 4 nurses that were S.A.N.E trained, including her, and none of them were on an on-call schedule or took call after hours.
- Every patient that presented to the ED should have a MSE.

During a telephone interview on 09/11/19 at 09:00 AM, Staff J, DO, stated that:
- Physicians received EMTALA training annually.
- Anyone that presented to the ED should be registered and logged.
- All patients who presented to the ED should be screened and medically cleared with a MSE before transferring.

During a telephone interview on 09/11/19 at 9:10 AM, Staff K, MD, stated that:
- Her expectation would be that the hospital would have S.A.N.E trained nurse coverage, available and on call at all times.
- That there were not too many S.A.N.E trained nurses at that facility.
- She had been told by the hospital administration that physicians should perform the S.A.N.E exams if a nurse was not available to perform the exam.
- She was often the only provider and did not feel physicians completing the S.A.N.E exams was a desirable or safe practice.
- Every patient that presented to the ED should be logged and registered, with a MSE.

During a telephone interview on 09/11/19 at 9:31 AM, Staff L, DO, stated that:
- He had performed S.A.N.E exams in the past.
- He would complete a S.A.N.E exam if needed.
- Any patient that presented to the ED should have a MSE.
- MSE's were completed to rule out medical first, and then they should consider completing a BHA when warranted.

During an interview on 09/11/19 at 9:45 AM, Staff B, Director of Quality, stated that:
- The hospital was looking into solutions to ensure S.A.N.E trained staff were available when needed.
- Any patient that presented to the ED should be registered and logged.
- She expected a MSE to be completed on every patient that presented to the ED.

During an interview on 09/11/19 at 10:15 AM, Staff D, Interim ED Director stated that:
- Clinical staff had EMTALA training annually.
- All patients that presented to the ED should be registered and logged.
- All patients that presented to the ED should have an MSE.

The hospital did not have any documentation of Patient #21's presentation to the ED, treatment, refusal (if warranted), or an MSE.

The hospital staff failed to follow their policy and did not complete an MSE on Patient #21 after she had presented to the ED with an alleged sexual assault.