HospitalInspections.org

Based on review of policies and procedures and hospital documents and interviews with hospital staff, the hospital failed to follow its policies:

1. Concerning maintenance of a completed central log.
2. Concerning medical screening examination (MSE) to individuals who present to the emergency department. This occurred for one (Patient #1) of twenty-one patients who presented to the hospital with a perceived emergency medical condition.

Findings:

1. Central Log: The hospital's EMTALA - Central Log Policy, with a revision date of May 14, 2013, stipulated, "...PVGH (initials of the hospital) Emergency Room Personnel will maintain a Central Log containing information on each individual who comes to the ED (emergency department) seeking assistance. The Log will document whether the individual refused treatment, left without receiving treatment, or was transferred or discharged ...".

The hospital did not maintain a complete log. Reviewed on 12/17/13, for the dates 06/01 through 12/14/13, the ER log did not contain an entry for Patient #1's 12/08/13 visit.

2. Medical Screening Examination: The hospital Medical Staff by-laws and Rules and Regulations states "...All patients who present to the Emergency Room, will be offered medical screening and stabilizing treatment within the capability of the Hospital and by staff members authorized to provide such treatment ...".

The hospital's EMTALA-Medical Screening Examination and Stabilization Policy, with a revision date of May 14, 2013, states, "... When an individual comes to the Hospital's Emergency Dept (department) and a request is made on his/her behalf for an examination or treatment for a medical condition, or a prudent layperson observer would believe that the individual presented with an emergency medical condition (EMC), an appropriate medical screening examination (MSE), within the capabilities of the Hospital's Emergency Dept (including ancillary services routinely available and the availability of on-call physicians), shall be performed by an individual qualified to perform such examinations to determine whether an EMC exists ..."

On 12/08/2013, Patient #1 presented to the hospital's ED. The hospital did not follow its policy. The patient did not receive a medical screening examination by an authorized staff member.

Based on review of hospital documents and the emergency room (ER) log and interviews with hospital staff, the hospital failed to maintain a complete ER log with the required information.

Findings:

The ER log did not contain an entry for Patient #1's 12/08/13 visit.

On 12/17/13 at 1100, Staff C agreed the patient was brought to the hospital and put on a gurney. She stated the ER staff told her the patient just wanted to "catch the transport" to another hospital. She stated they did not put the patient in the ER log because they did not know Patient #1's name.

Based on review of hospital documents and medical records and interviews with staff and a patient, the hospital failed to provide a medical screening examination by a qualified medical person in order to determine whether an emergency medical condition existed to one of twenty-one patients (Patient #1 of Patients #1 through 5 and 7 through 22) who presented to the hospital requesting examination for a perceived emergency medical condition and whose records were reviewed.

Findings:

Patient #1 presented to the hospital on the evening of 12/08/2013 after a fall with complaints of left hip pain. According to all accounts, when the patient arrived at the hospital, she was placed on a carrier/gurney by ambulance staff.

Documentation from another hospital, the treating facility, recorded Patient #1 arrived at that hospital around 1800. The patient told staff there that she had originally presented to the emergency department (ER) at another hospital, but was not examined.

Hospital staff's written statements, provided to the surveyors on 12/17/13, documented the patient was then transported into the hospital, but was not taken back for a medical screening examination.

On interview on 12/18/13 at 1020, Patient #1 stated she was helped onto a gurney by two males, whom she presumed were hospital staff. She told the staff she had membership for an air ambulance service and requested them to contact the company to transport her to (name removed - treatment hospital). She stated she was told the air service was grounded due to weather conditions. According to Patient #1, one of the male staff stated that he thought the patient had a broken hip and the "hospital could not take care of that." Patient #1 and spouse asked about being taken by ambulance to the other hospital. Patient #1 stated that one staff told them "it would be better" if they went by private vehicle. Patient #1 told the surveyor that no help, other than assistance onto and off the gurney, was provided. Patient #1 told the surveyor that she did not see a physician and no x-ray was taken. Patient #1 told the surveyor that no examination was offered.