HospitalInspections.org

Based on document review and interview, the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The hospital failed to conduct an appropriate medical screening examination, including a complete triage assessment, and examination by a qualified medical practitioner (QMP) determined by the hospitals' medical Staff by-Laws to
determine whether or not an emergency medical condition existed.See A-2406.

2. The hospital failed to ensure that an appropriate transfer was performed. See A-2409.

Based on document review and interview, it was determined that for 9 of 20 records (Pt. #1, #3, #4, #5, #6, #7, #9, #10, & #20) reviewed for individuals who presented to the Emergency Department (ED), the hospital failed to ensure that the correct disposition was documented on the ED Centralized Log, as required.

Findings include:

1. The hospital's policy titled, "EMTALA: Emergency Medical Treatment and Labor Act" (Last Approved 4/2021) was reviewed and included, "Central Log 1. Hospital shall maintain a Central Log of all individuals who come to the ACC (Acute Care Clinic) or are transferred to Hospital for a potential emergency medical condition. The log shall identify the individual by name and other identifying information as well as whether the individual ... was transferred, admitted and treated, stabilized and transferred, or discharged from Hospital."

2. The clinical record of Pt. 1 was reviewed. Pt. #1 presented to the ED, on 03/11/2025 at 1:53 PM, with a chief complaint of constipation/abdominal pain. The clinical record lacked documentation of the patient's disposition.

3. The clinical record of Pt. #3 was reviewed. Pt. #3 presented to the ED, on 03/21/2025 at 10:00 PM, with a chief complaint of wound on hand. The clinical record did not include the patient's disposition.

4. The clinical record of Pt. #4 was reviewed. Pt. #4 presented to the ED, on 04/20/2025 at 7:36 PM, with a chief complaint of emesis (vomiting) and diarrhea. The clinical record indicated that the patient was referred to higher level of care, however the patient was discharged to home and instructed to follow up with their primary physician.

5. The clinical record of Pt. #5 was reviewed. Pt. #5 presented to the ED, on 05/10/2025 at 10:44 AM, with a chief complaint of skin abrasion. The clinical record lacked documentation of the patient's disposition.

6. The clinical record of Pt. #6 was reviewed. Pt. #6 presented to the ED on 6/2/2025 at 12:48 AM, with a chief complaint of right flank pain. The clinical record did not have documentation of patient disposition.

7. The clinical record of Pt. #7 was reviewed. Pt. #7 presented to the ED on 6/19/25 at 2:20 PM, with a chief complaint of earache. The clinical record did not have documentation of the patient's disposition.

8. The clinical record of Pt. #9 was reviewed. Pt. #9 presented to the ED on 7/9/25 at 8:00 pm, with a chief complaint muscle pain and sore legs. For Pt. #9, the clinical record did not have documentation of patient disposition.

9. The clinical record of Pt. #10 was reviewed. Pt. #10 presented to the ED on 8/10/25 at 7:45 pm with a chief complaint constipation and inability to pass bowels. The clinical record did not have documentation of a patient disposition.

10. The clinical record of Pt. #20 was reviewed. Pt. #20 presented to the ED on 5/10/25 at 1:37 PM with a chief finger pain. The clinical record indicated that Pt. #20 was categorized as non-emergent condition and was referred to a higher level of care, however the record did not indicate where Pt. #20 was referred to.

11. The hospital's ED Logs dated 02/19/2025 through 08/16/2025 was reviewed. The log did not indicate a disposition for Pt. #1, #3 - #7, #9, #10, & #20.

12. An interview with the Chief Medical Officer (MD#1) was conducted on 8/21/2025 at approximately 12:20 PM. MD#1 stated that the ED Log and clinical records should include the disposition of patients, whether transferred for higher level of care or discharged to home.

Based on document review and interview, of 10 (Pt. #1, #2, #3, #5, #6, #7, #8, #9, #10, and #20) of 20 clinical records reviewed for patients seeking emergency medical services, the hospital failed to conduct an appropriate medical screening examination, including a complete triage assessment, and examination by a qualified medical practitioner (QMP) determined by the hospitals' medical Staff by-Laws to determine whether or not an emergency medical condition existed.

Findings include:

1. The hospital's policy titled "EMTALA: Emergency Medical Treatment and Labor Act" (Last Approved 4/2021) was reviewed and included, " ..."Medical Screening Examination" or "MSE" - The process required to reach, with reasonable certainty, the point at which it can be determined whether the individual has an emergency medical condition, including the use of necessary available testing resources ... [In general, a proper MSE should generally include: log entry with disposition, triage record, recording of vital signs, oral history, physical examination, use of on-call physicians as needed, discharge or transfer vital signs, and adequate documentation ..."

2. On 8/22/2025, the hospital's Medical Staff By-Laws (Approved 11/9/2015) did not indicate who can perform a medical screening examination.

3. On 8/22/2025, the hospital's Medical Staff By-Laws (Approved 07/29/2025) included, "Section 8 - Medical Screening Exams. Qualified medical personnel performing medical screening exams in the Acute Care Clinic may include registered nurses and APNs (Advance Practice Nurse) ..."

4. The clinical record of Pt. #1 was reviewed. Pt. #1 presented to the Emergency Department (ED), on 02/20/2025 at 5:07 PM, with a chief complaint of fever. The clinical record lacked documentation of a complete MSE (Medical Screening Examination). The medical record did not include documentation of a vital signs, such as respirations, oxygen saturation level, temperature, or a review of systems.

5. The clinical record of Pt. #2 was reviewed. Pt. #2 presented to the ED, on 03/11/2025 at 1:53 PM, with a chief complaint of constipation/abdominal pain. The clinical record lacked documentation of a complete MSE. The record did not include documentation of vital signs such as respirations, blood pressure, oxygen saturation, temperature, and review of systems.

6. The clinical record of Pt. #3 was reviewed. Pt. #3 presented to the ED, on 03/21/2025 at 10:00 PM, with a chief complaint of wound on hand. The clinical record lacked documentation of a complete MSE, vital signs or a pain assessment.

7. The clinical record of Pt. #5 was reviewed. Pt. #5 presented to the ED, on 05/10/2025 at 10:44 AM, with a chief complaint of skin abrasion. The clinical record lack documentation of a complete MSE, vital signs, pain assessments and review of systems.

8. The clinical record of Pt. #6 was reviewed. Pt. #6 presented to the ED on 6/2/2025 at 12:48 AM, with a chief complaint of right flank pain. There was no documentation of vital signs or a pain assessment.

9. The clinical record of Pt. #7 was reviewed. Pt. #7 presented to the ED on 6/19/25 at 2:20 PM, with a chief complaint of earache. The clinical record lacked a complete medical screening examination (MSE). The only vital sign documented was a temperature of 98.6 F (Fahrenheit) (normal temperature 97 F to 99 F). There were no other vital signs nor pain assessment documented.

10. The clinical record of Pt. #8 was reviewed. Pt. #8 presented to the ED on 6/21/25 at 7:35 PM, with a chief complaint of a rash. The clinical record lacked a complete medical screening examination (MSE). The only vital sign documented was a temperature of 37.1 C. There were no other vital signs nor pain assessment documented.

11. The clinical record of Pt. #9 was reviewed. Pt. #9 presented to the ED on 7/9/25 at 8:00 PM, with a chief complaint muscle pain and sore legs. The clinical record lacked documentation of a complete MSE. The only vital signs documented were oxygen saturation of 99.1% (reference range (95% to 100%) on room air and temperature of 36.6 C (Celsius) (reference range 36.5 C to 37.5 C). There was no documentation of a pain assessment documented.

12. The clinical record of Pt. #10 was reviewed. Pt. #10 presented to the ED on 8/10/25 at 7:45 PM with a chief complaint constipation and inability to pass bowels. The clinical record lacked a complete medical screening examination (MSE). The record only included a temperature of 37.3 C. No other vital signs nor pain assessment were documented.

13. The clinical record of Pt. #20 was reviewed. Pt. #20 presented to the ED on 5/10/25 at 1:37 PM with a chief complaint of finger pain. The clinical record lacked a complete medical screening examination (MSE). The record did not include vital signs, pain assessment or review of systems.

14. On 8/20/2025 at approximately 12:00 PM, an interview was conducted with the Pediatric Hospitalist (MD#3). MD#3 stated that for all patients who present to the Hospital for medical assistance, an MSE should be completed. The MSE should include at least the vital signs (blood pressure, temperature, respiratory rate, pulse rate), a complete physical assessment (head to toe examination).

15. On 8/20/2025 at approximately 1:52 PM, an interview was conducted with the Chief Medical Officer (MD#1). MD#1 stated that during change of leadership of the hospital sometime in May 2025, MD#1 performed audits of charts involving EMTALA compliance and identified issues with Medical Screening Examination. MD#1 stated that for all patients presenting in the ED requesting for medical assistance, an MSE should be performed.

16. On 08/21/2025 at approximately 2:30 PM, an interview was conducted with the Chief Executive Officer (E #2). E #2 stated that the hospital's Medical Staff By-Laws approved 11/9/2015, did not include who can perform medical screening examinations in the ED. The current By-Laws approved 07/29/2025, were updated to include who can perform MSE, which includes RNs, APNs, and Physicians.

Based on document review and interview, for 1 (Pt. #13) of 3 patients seeking medical evaluation and transferred, the Hospital failed to ensure that an appropriate transfer was performed.

Findings include:

1. The hospital's policy titled "EMTALA: Emergency Medical Treatment and Labor Act" (Last Approved 4/2021) included: "...Appropriate Transfer - A transfer is appropriate if: Hospital provides medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child; The transferring physician or designee has contacted the receiving facility and documented that the receiving facility has available space and qualified personnel for treatment of the individual and has agreed to accept the individual and to provide appropriate medical treatment; Hospital provides copies of all medical records related to the emergency medical condition that the individual has presented that are available at the time of the transfer...; The transfer is carried out by qualified personnel and transportation equipment, including necessary and medically appropriate life support measures..."

2. The clinical record of Pt. #13 was reviewed. Pt. #13 presented to the Emergency Department (ED) on 4/07/2025 at 2150 (9:20 PM), with a chief complaint of breathing difficulty. The clinical record included:

-ACC (Acute Care Coordinator) documentation dated 4/7/2025 at 10:11PM included Chief Complaint Difficulty breathing ...Brief History and focused exam ...in no apparent distress. Mom stated wants (Pt. #13) checked out ...Mom wants 911 called, (physician) assessed the child, called 911 they arrived at 2220 (10:30 PM) taken to (Outside hospital/OSH) for further evaluation ...Triaged and transferred to high level of care ..."

- The "Non Patient Documentation Tool" completed on 4/7/2025 at 10:28 PM, by the physician indicated "Pt. #13 (pediatric) observed ambulating, running, laughing in no distress ...lungs clear ...due to reported respiratory event, unresponsive event, called 9111 for evaluation. Handoff completed with EMS (ambulance)" The clinical record did not indicate that the receiving facility was contacted to ensure they had available space, qualified personnel to provide appropriate medical treatment and that they could accept the patient.

3. On 8/20/2025 at approximately 9:47 AM, an interview was conducted with the Administrative Nurse Coordinator (E#6). E#6 stated that when a patient needs to be transferred, the hospital will utilize the service of an ambulance provider. For patients with conditions beyond the capability of the hospital, E#6 stated that they will call 911. E#6 stated that for transfers, transfer documentation is completed and a physician-to-physician report or nurse to nurse report is done. E#6 stated that the transfer documentation includes a certification by the physician of the need for transfer. E#6 added that their process to comply with EMTALA was changed about a week before July 4 of this year.

4. On 8/21/2025 at approximately 12:20 PM, an interview was conducted with the Chief Medical Officer (MD#1). MD#1 stated that minor patients that present to the hospital with request for medical assistance and needs a higher level of care will be transferred in accordance with their transfer protocol and agreement. MD#1 stated that these patients should be transferred following their transfer protocol (utilize an ambulance provider, providing report to receiving hospital, completion of transfer documentation). MD#1 stated that for adult non-patients who present for medical assistance, these cases would not be within their scope of practice so these patients would be stabilized based on their capability and 911 called to transport the patient to a facility capable of caring for the patient.