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Based on staff interviews, review of the ED Central Log, medical records, policies and procedures, the Professional Staff Bylaws and Rules and Regulations, the Professional Services Agreement, Agreement for ED Coverage, personnel files, credential files, and the receiving facility's medical record for patient #7, it was determined that the facility failed to ensure compliance with CFR 489.24, for one (1) individual (patient #7) of twenty (20) sampled patients.

Findings:

1. Cross refer to A2406 as it relates to failure to provide an appropriate Medical Screening Exam (MSE) for patient #7 on 06/04/2016.

2. Cross refer to A2409 as it relates to failure to ensure that an appropriate transfer was provided for patient #7 on 06/04/2016.

Based on review of the facility's policy, review of Professional Staff Bylaws and Rules and Regulations, review of medical records, and staff interviews, it was determined that the facility failed to generate a medical record for one (1) individual (Patient #7) of twenty (20) sampled patients.

Findings:

Review of the facility's policy entitled Triage Policy and Procedure, number ED.012, approved 05/12/16, revealed the patient may receive a quick registration including name, chief complaint, and DOB (date of birth) prior to triage. There was no documented evidence of a specific policy requiring a medical record to be generated for all individuals who come to the ED requesting treatment for an Emergency Medical Condition (EMC).

Review of Cornerstone Medical Center's Professional Staff Bylaws and Rules and Regulations, approved 05/05/16, revealed in the Medical Records Rules and Regulations that the complete Emergency medical record shall contain the following:
a. Patient identification. When not obtainable, the reason shall be entered in the medical record.
b. Time and means of arrival.
c. Pertinent history of illness or injury and physical findings, including the patient's vital signs.
d. Diagnostic and therapeutic orders.
e. Clinical observations, including results of treatment.
f. Reports of procedures, tests and results.
g. Diagnostic impression.
h. Conclusion at the termination of the evaluation/treatment including final disposition, patient's condition on discharge or transfer, and any instructions given to the patient and/or family for follow-up care.
i. If applicable, emergency care given to the patient prior to arrival.
j. If applicable, the patient's leaving against medical advice.

Review of twenty (20) sampled medical records revealed there was no medical record generated for one (1) individual (patient #7).

During an interview on 06/21/16 at 4:00 p.m. in the Board Room, the Chief Nursing Officer (CNO) and the Chief Operating Officer (COO) confirmed that on 06/04/16 a car drove up to the Emergency Department entrance and staff member (#4) was informed by the driver of the car that the passenger may have been having a stroke. The CNO and COO also confirmed that staff member (#4) told the driver that a nearby hospital (which was in another state) was a stroke hospital and that the driver left without bringing the patient (#7) into the ED. The CNO and COO both agreed that there was no medical record generated for the patient (#7).

Based on review of the facility's policy, review of the Central Log, and staff interviews, it was determined that the facility failed to enter one (1) individual (patient #7) of twenty (20) sampled patients into the central log.

Findings:

Review of the facility's policy entitled EMTALA (Emergency Medical Treatment and Labor Act), number LD.002, effective 05/2016, revealed a central log on each individual who "comes to the emergency department," as defined in §489.24(b), seeking assistance and whether he or she refuses treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. This policy also noted that the Central Log is maintained electronically by Cornerstone's Services department for ED patients.

Review of the facility's Central Log from May 12, 2016 through June 20, 2016 revealed one (1) individual (patient #7) of twenty (20) sampled patients was not entered into the Emergency Department's (ED) Central Log on 6/4/2016 when patient #7 presented to the hospital's property seeking medical assistance..

During an interview on 06/21/16 at 4:00 p.m. in the Board Room, the Chief Nursing Officer (CNO) and the Chief Operating Officer (COO) confirmed that on 06/04/16 a car drove up to the Emergency Department entrance and staff member (#4) was informed by the driver of the car that the passenger may have been having a stroke. The CNO and COO also confirmed that staff member (#4) told the driver that a nearby hospital (which was in another state) was a stroke hospital and that the driver left without bringing the patient (#7) into the ED. The CNO and COO both agreed that the patient (#7) should have been entered into the Central Log.

Based on staff interviews, review of the ED Central Log, medical records, policies and procedures, the Professional Staff Bylaws and Rules and Regulations, the Professional Services Agreement, Agreement for ED Coverage, personnel files, credential files, and the receiving facility's medical record for patient #7, it was determined that the facility failed to provide an appropriate Medical Screening Examination (MSE) within the capability 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 one (1) individual (patient #7) of twenty (20) sampled patients when the patient presented to the ED drive on 06/04/16.

Findings:

During an interview on 06/20/16 at 12:00 p.m. in the Board Room, the Chief Nursing Officer (CNO) and the Chief Operating Officer (COO) explained that Cornerstone Medical Center purchased the hospital on 05/12/16 but did not assume the debt from the previous owners, and therefore did not have access to the previous owners documents. The CNO and COO went on to explain that the new owners had assumed the contract for Professional Services and Emergency Department (ED) coverage and a waiver for employee files through the court. In addition, the CNO and the COO confirmed that on 06/09/16 the Chief Executive Officer (CEO) self-reported a possible Emergency Medical Treatment and Labor Act (EMTALA) violation that occurred on 06/04/16.

Review of the facility's Central Log from May 12, 2016 through June 20, 2016 revealed one (1) individual (patient #7) of twenty (20) sampled patients was not entered into the Emergency Department's (ED) Central Log on 6/4/2016; when patient #7 presented to the hospital's property seeking medical assistance..

Review of twenty (20) sampled medical records revealed there was no medical record generated for one (1) individual (patient #7).

Review of the facility's Emergency Department's (ED) policies and procedures included but were not limited to the following:
1. ED Scope of Service, number ED.001, effective 05/2016, revealed the ED had 17 beds and offered emergency care 24 hours a day. This policy noted that the ED would "stabilize and transfer patients in need of services not offered by organization (e.g. [for example] Neurology a specialty service that evaluates and treats disorders of the brain and nervous system)".
2. EMTALA, number LD.002, effective 05/2016, revealed the following:
Under the provisions of §489.24, hospitals with an ED that participates in the Medicare program are required under EMTALA to do the following:
--Provide an appropriate Medical Screening Examination (MSE) to any individual who comes to the ED;
--Not delay the medical screening examination and/or treatment of emergent condition in order to inquire about the individual's insurance or payment status;
3. MSE in the ED, number ED.009, effective 05/16/16, revealed the MSE was to be performed by a physician or an appropriately credentialed mid-level provider.

Review of Cornerstone Medical Center's Professional Staff Bylaws and Rules and Regulations, approved 05/05/16, revealed in the ED Rules and Regulations, section "1. That all patients that present to the ED seeking medical treatment will be provided a MSE by a physician or mid-level provider. The ED physician/mid-level providers on duty is responsible for the degree of evaluation and treatment provided to any patient who presents himself or is brought to the emergency care area. B. Practitioner Responsibility: 6. The Medical center will provide, within the staff and facilities available for such, further medical examination and treatment as may be required to stabilize the patient."

Review of the Professional Services Agreement, Agreement for ED Coverage, entered into on 05/29/15, to be effective 06/01/15, the "Group agrees that all emergency medical services provided pursuant to this Agreement shall be performed in compliance with federal and state law, the Joint Commission ("Joint Commission"), and EMTALA laws.

During an interview on 06/21/16 at 10:00 a.m. in the Board Room, employee (#4) explained that on 06/04/16 he/she was a sitter in the ED assigned to monitor two (2) psychiatric patients. Employee #4 reported that he/she was instructed by the ED Technician/Secretary (employee #1) that a car was parked at the ED entrance and that the sitter needed to go out and see what the people in the car wanted. Employee #4 explained that he/she went out to the car and opened the passenger's car door so that he/she could speak with the people in the car. Employee #4 stated, the driver told me she thought her mother might be having a stroke because the patient (#7) was having tingling in the left arm and left leg. I commented that a nearby hospital (in another state) was a stroke center, I shouldn't have made that comment, I didn't tell her to leave, I said we would help her here but that the other hospital was "more used to treating strokes". Employee #4 said that's when the driver put the car in drive and drove off, stating he/she never got the patient's name and would not even recognize the patient. Employee #4 stated he/she had originally been hired to work the switchboard and had never had EMTALA training prior to that episode but had since received EMTALA training. He/she mentioned several times during the interview that he/she should not have made that comment and felt bad that he/she had made the comment.

During an interview on 06/20/16 at 1:45 p.m. in the Board Room, employee (#1) explained that on 06/04/16 he/she had been working in the ED as an ED Technician/Secretary. He/she stated, I was at the ED nurses' desk when I got a call from Registration Clerk asking for a wheelchair to the ED entrance. The ED Technician/Secretary stated, I asked the sitter (employee #4) who was monitoring two (2) psychiatric patients to take a wheelchair to the ED entrance while I watched the two (2) psychiatric patients. He/she went on to explain that the sitter (employee #4) got a wheelchair and headed to the front entrance, he came back with an empty wheelchair. The ED Technician/Secretary stated he/she had not overheard or seen what went on at the ED entrance. He/she stated that if a patient presents on property requesting treatment for a medical condition and then decide to leave, the staff try to encourage the patient to stay for the MSE and stabilizing treatment as needed. He/she went on to say that if patients refuse treatment the staff try to get the patients to sign an Against Medical Advice (AMA) form. He/she stated EMTALA training had been annually and that he/she had completed an update two (2) to three (3) weeks ago.

During an interview on 06/21/16 at 9:15 a.m. in the Board Room, employee (#3) explained that on 06/04/16 he/she had been working as the ED Charge Nurse (CN). The CN stated he/she had not been made aware of the situation until two (2) days later. He/she stated, had I been made aware of the situation I would have had the triage nurse or another clinical staff member go out and bring the patient into the ED to receive a MSE, stabilizing treatment, and an appropriate transfer or discharge. The CN stated he/she had received EMTALA training annually for the past 15 years and an update since this occurrence.

During an interview on 06/21/16 at 8:45 a.m. in the Board Room, the ED Medical Director (#5) confirmed that after being notified of the episode that occurred on 06/04/16 he/she spoke with the ED physician (#7) that was on duty that day. The ED Medical Director (#5) explained that the ED physician (#8) had not been made aware of the episode until after the fact. The ED Medical Director (#5) said that the ED physician (#7) was aware of the EMTALA requirements and that all of the facility's contracted ED physicians received EMTALA training at least annually. The ED Medical Director (#5) went on to explain that the facility did not have an operating Intensive Care Unit (ICU) at the present but that the ED could treat stroke patients. He/she stated that the ED physicians could evaluate and stabilize stroke patients, that a computerized tomography (CT) scan (specialized x-ray) could be performed to rule out an acute intercranial hemorraghe (sudden onset of bleeding inside the skull), that the National Institute of Health Stroke Score (NIHSS) could be performed, and that a call could be made to a facility for a neurologist (Neurology specialist), and that appropriate transfer arrangements could be made. In addition, the ED Medical Director (#5) said that in the event a stroke patient needed tissue plasminogen activator (TPA - used to breakdown a blood clot) the facility could administer the TPA or if outside the window for administering the TPA the facility could control the patient's blood pressure and administer Aspirin (blood thinner) if there were no contraindications, prior to transferring the patient.

Review of four (4) personnel files and three (3) credential files revealed evidence of EMTALA training between 02/01/16 and 06/10/16.

During an interview on 06/21/16 at 4:00 p.m. in the Board Room, the Chief Nursing Officer (CNO) and the Chief Operating Officer (COO) confirmed that on 06/04/16 a car drove up to the Emergency Department entrance and staff member (#4) was informed by the driver of the car that the passenger may have been having a stroke. The CNO and COO also confirmed that staff member (#4) told the driver that a nearby hospital (which was in another state) was a stroke hospital and that the driver left without bringing the patient (#7) into the ED. The CNO and COO both agreed that the patient (#7) should have received a MSE. The CNO and COO explained that on 06/06/16 the receiving facility's Risk Manager (RM) called Cornerstone Medical Center's RM to report the 06/04/16 episode. The CNO and COO stated they were notified of by their RM and that they in turn notified the facility's CEO who notified the state (Department of Community Health's Healthcare Facility Regulation Department). The CNO and COO explained that an internal investigation was launched which included interviewing all involved ED staff and that they identified a need for additional EMTALA education which was provided to the ED staff on 06/08/16. The CNO and COO stated there had also been some 1:1 training for the staff member (#4) involved in the episode. In addition, the CNO and COO stated the facility was in the process of completing a Root Cause Analysis, that the EMTALA policy had been revised and was scheduled for approval during the next week, that EMTALA training would continue to be provided to all staff annually, and that new employees would have 30 days from the date of hire to complete the EMTALA training. The CNO and COO provided a copy of the EMTALA revision and evidence that 90 out of 104 hospital employees had received EMTALA training since the 06/04/16 occurrence for a total of 86.54% of the facility's staff. Documentation revealed this staff included the following staff members: Administration, Admitting, Central Monitoring, Clinical Resources, Education, ED, Chemistry, Human Resources, Medical Surgical Unit, Respiratory Therapists, Security, Sitters, and others.

The receiving hospital's medical record for patient #7 was reviewed. Documentation revealed the 87 year old patient presented to the receiving facility's ED by private owned vehicle on 06/04/16 with complaints of left arm and leg weakness. Physician notes revealed the patient lived at a Skilled Nursing Facility (SNF) in Georgia and that earlier that day a family member witnessed the patient walking with a walker when the patient's suddenly had left arm and leg weakness. The physician further noted that the patient had a history of three (3) previous strokes. The physician further noted that the patient had not loss consciousness and had no slurred speech. Initial treatment included blood work, the NIHSS evaluation, a CT scan, and the administration of TPA TPA-Tissue Plasinogen Activator- a substance that is sometimes given to patients within three hours of a stroke to dissolve clots within the brain). Documentation revealed the patient was admitted to the ICU. On 06/09/16, the patient's physician noted that the family refused rehabilitation for the left arm and leg weakness, and the patient was discharged back to the SNF in stable condition.

Based on staff interviews, review of the ED Central Log, medical records, policies and procedures, the Professional Staff Bylaws and Rules and Regulations, the Professional Services Agreement, Agreement for ED Coverage, personnel files, credential files, and the receiving facility's medical record for patient #7, it was determined that the facility failed to provide an appropriate transfer for one (1) individual (patient #7) of twenty (20) sampled patients, when the patient presented to the ED drive 06/04/16.

Findings:

Cross refer to A2406 as it relates to failure to provide an appropriate Medical Screening Examination (MSE) and appropriate transfer for patient #7 who presented with an emergency medical condition.

Review of the facility's Emergency Department's (ED) policies and procedures included but were not limited to the following:
1. ED Scope of Service, number ED.001, effective 05/2016, revealed the ED had 17 beds and offered emergency care 24 hours a day. This policy noted that the ED would "stabilize and transfer patients in need of services not offered by organization (e.g. [for example] Neurology a specialty service that evaluates and treats disorders of the brain and nervous system)".
2. EMTALA, number LD.002, effective 05/2016, revealed the following:
Under the provisions of §489.24, hospitals with an ED that participates in the Medicare program are required under EMTALA to do the following:
--Provide an appropriate Medical Screening Examination (MSE) to any individual who comes to the ED;
--Provide necessary stabilizing treatment to an individual with an Emergency Medical Condition (EMC) or an individual in labor;
--Provide an appropriate transfer of the individual if either the individual requests the transfer or the hospital does not have the capability or capacity to provide the treatment necessary to stabilize the EMC (or the capability or capacity to admit the individual);
--Not delay the medical screening examination and/or treatment of emergent condition in order to inquire about the individual's insurance or payment status;
--Obtain or attempt to obtain written and informed refusal of examination, treatment, or an appropriate transfer in the case of an individual who refuses examination, treatment, or transfer.
This policy also revealed a central log on each individual who "comes to the emergency department," as defined in §489.24(b), seeking assistance and whether he or she refuses treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. This policy further revealed that an EMTALA obligation may be triggered if an individual presents within 250 yards of the hospital and a requests for examination or treatment of an EMC was made by the individual or a prudent layperson.
3. Patient Transfer to Outside Facilities, number CC.017, effective 05/2016, revealed every patient would be provided with an appropriate MSE, and necessary stabilizing treatment within the hospital's capability for emergency medical treatment and labor. An appropriate transfer of the patient will be conducted if the hospital does not have the capability or capacity to provide the treatment necessary to stabilize the EMC.
--Patients may require transfer to another facility when"
a. Needed services are not available.
b. Requested by the attending physician (or ED physician) and patient agrees.
c. Requested by the patient or family in situations where the patient is unable to make such a request for himself (herself).
This policy required the patient and/or others as outlined in the facility's Informed Consent Policy to give their informed consent for the transfer after being informed of the risks versus the benefits of the transfer. The policy also required the facility to obtain an accepting physician, acceptance by the receiving facility, and noted that the patient was to be transferred when considered sufficiently stabilized for transport. In the event that the patient was not stabilized the physician was required to attest that the medical benefits of the transfer outweighed the risk to the individual and in the case of labor to the unborn child. In addition, the transfer form was required to be completed, nurse to nurse report documented, pertinent portions of the medical record sent with the patient, and mode of transportation documented. The facility failed to ensure that their policies and procedures regarding appropriate transfer of individuals were followed.

During an interview on 06/21/16 at 4:00 p.m. in the Board Room, the Chief Nursing Officer (CNO) and the Chief Operating Officer (COO) confirmed that on 06/04/16 a car drove up to the Emergency Department entrance and staff member (#4) was informed by the driver of the car that the passenger may have been having a stroke. The CNO and COO also confirmed that staff member (#4) told the driver that a nearby hospital (which was in another state) was a stroke hospital and that the driver left without bringing the patient (#7) into the ED. The CNO and COO both agreed that the patient (#7) was not appropriately transferred to the receiving facility. The facility failed to ensure that on 5/14/2016 patient #7 was appropriately transferred as stated in the hospital's policies and procedures.