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Based on review of Tri-Town Regional Hospital's EMTALA policies and procedures and interview with the Director of Clinical Services, Tri-Town Regional Hospital failed to have policies and procedures in effect to ensure compliance with the requirements of 42 CFR 489.24

Findings:

The policies and procedures that were reviewd on 8/1/13 are as follows:

Policy# 15-C-1, "EMTALA Transfer", effective 7/15/13
Policy# 15-C-4, "EMTALA Stabilization", effective 7/15/13
Policy #15-C-5, "EMTALA Medical Screening Exam" effective 10/18/10

The policies and procedures were not specific to the services provided at Tri-Town Regional Hospital. Specifically the policies list another separate and distinct hospital in the title of the policies and made reference to this separate and distinct hospital throughout all three of the policies.

Additionally, the policies and procedures make reference to Qualified Medical Personnel (QMP) performing medical screening exams and additional campus sites (Birthing Center, Woman's Health Center, Urgent Care Centers and outpatient Psychiatry).

Tri-Town Reginal Hospital's contract for ED physician coverage states that "every patient presenting himself in the emergency department shall be screened by a physician". QMPs are not utilized at Tri-Town Regional Hospital based on interview with the Director of Clinical Services on 8/1/13. The additional patient care sites mentioned in the policy are not sites specific to the Tri-Town Regional Hospital campus.

During interview on 8/1/13 at 3:15pm with the Director of Clinical Services, it was determined that the three EMTALA policies and procedures were the policies of record.

On 8/7/13, the surveyors contacted Tri-Town Regional Hospital and requested another set of the EMTALA policies and procedures that were given to them during the onsite EMTALA survey on 8/1/13.

The following policies and procedures were received from the Director of Clinical Services on 8/8/13.

Policy IIA - "EMTALA - Duty to Accept", effective 1/1/08
Policy IIC - "EMTALA - Transfer", effective blank
Policy IID - "EMTALA - Stabilization", effective 1/1/08
Policy IIE - "EMTALA - Medical Screnning Exam ", effective 1/1/08

The Director of Clinical Services explained that the first set of EMTALA policies and procedures given to the surveyors on 8/1/13 were the policies and procedures of the other separate and distinct hospital and were not the correct policies and procedures for Tri-Town Regional Hospital.

The second set of EMTALA policies and procedures received on 8/8/13, also make reference to the other separate and distinct hospital, QMPs and areas such as Labor and Delivery. These policies and procedures do not reflect the services and personnel specific to Tri-Town Regional Hospital. Tri-Town Regional Hospital does not use QMPs and does not have Labor and Delivery Services.

Based on interview and record review during an EMTALA survey on 8/1/13, the Tri-Town Regional Hospital failed to perform a medical screening exam on 7/5/13.

Findings:

During interviews on 8/1/13 with three of the staff , Registration Clerk, RN and ED Technician , who were present on 7/5/13, each of them acknowledged that the individual was not examined prior to suggesting that the individual go to the hospital for services that they believed were not routinely performed at their location, specifically a blood transfusion.

The hospital implemented corrective measures prior to the initiation of the survey on 8/1/13.
All Emergency Department Staff, including Medical Staff, were re-educated in relation to EMTALA. This re-education was verified by interview and record review during the EMTALA Survey on 8/1/13.