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Based on observation, record review, and interview the facility failed to have organized systems and policies in place to ensue emergency care services were available to persons seeking emergency services at the facility based on their scope of practice. This failed practice had the potential to adversely affect any person that come to the facility seeking emergency care.

Findings:

During a complaint investigation on 10/14/11 at the facility the following observation was made at 8:35 am:

A sign written in bold red letters on the double glass doors at the facility ' s entrance stating "No Emergency Services provided" . The Director of Clinical Services verified the notice on the door by reading what was written there.

Review of the facility ' s policy and procedure for Emergency Services presented to the Surveyor revealed the following information:
The policy was titled " Unauthorized Patient Presence (Emergency Patient) " revised 06-2011 and documented the following information:


" Purpose is to provide stabilizing care for the emergent patient or intervention for the non urgent emergent patient until patient transfer via " 911 ambulance, if required " .

" On-call physician is neither required nor obligated to come to the facility following an unauthorized patient presentation " .

"It is unnecessary to have the patient sign an AMA form if they elect not to accept treatment or transfer. "

" A standard Memorandum of Transfer is not required for and emergency transfer via 911 ambulances " .

The facility ' s policy/procedure did not address personnel to respond to emergency service needs including their roles and responsibilities.

There was no on call physicians assigned to respond to patients seeking emergency services at the facility or to instruct staff in emergency care decisions.

There were no medical records developed for patients that might have entered the facility seeking emergency care. The facility had no systems in place to identify individuals seeking emergency care, and to record the facility ' s intervention and the disposition of those individuals.

During an interview at the facility on 10/14/11 at 11:25 am with the Director of Clinical Services she stated there was an emergency treatment room however the facility was not sure to what extent they should be involved in the provision of emergency services to patients who were not already admitted to the facility.

According to the Director of Clinical Services the thinking was to call 911 and provide the basics until they arrive. She further stated the facility had a easonable scope for practice because there was trained staff , an Intensive Care Unit (ICU),physician services for the greater part of each day, and the capability to intubate patients.