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Based on document review and staff interview, it was determined the hospital failed to:

a. include EMTALA requirements in the medical staff by-laws, rules and regulations;

b. evaluate adherence to EMTALA requirements through the QAPI process;

c. develop and implement hospital policies and procedures related to EMTALA requirements;

d. provide an appropriate medical screening examination. See Tag A 2406.


Findings:

On 04/19/13, the medical staff by-laws were reviewed. There were no rules and regulations for EMTALA requirements. The CEO acknowledged the medical staff by-laws did not address EMTALA requirements.

Medical staff credentialing and education files were reviewed.

There was no documentation of EMTALA training. The CEO stated there was no documented physician training on EMTALA requirements. She provided a memorandum from the emergency room physician contractor to the ER physicians dated 04/19/13. The memo addressed EMTALA requirements.

The ER manager stated there was no EMTALA training for ER staff.

The hospital had no current approved and implemented QAPI program or plan. QAPI meeting minutes for 2012 and 2013 had no documentation EMTALA requirements were evaluated by the hospital.

The ER manager and the CEO stated there were no hospital policies and procedures regarding EMTALA requirements including:

~retention of medical records for patients transferred
~ER physician on-call policies
~ER log requirements
~appropriate medical screening examination
~provision of necessary stabilizing treatment
~transfer policies that meet all the EMTALA requirements
~prohibition of delay in medical screening and treatment
~EMTALA whistleblower protection.

Based on clinical record review, documents review and staff interviews, it was determined that this hospital failed to perform an appropriate medical screening examination for 27 of 28 patients reviewed.

Findings:

On 04/19/2013, the clinical records of 28 emergency department patients were reviewed. All clinical records had various forms with missing information including lack of documentation of medical history, physical examinations, diagnostic tests and procedures performed, and the results of those tests and procedures. All clinical records reviewed did not have evidence of on-going monitoring and assessments of patients throughout their stay in the emergency department. The clinical records showed inconsistent patient assessments prior to discharge or transfer. The clinical records failed to show the patients' responses to interventions provided.

The clinical record of patient #5 (female of child bearing age) showed that the patient was brought by ambulance to the emergency department of this hospital on 01/02/2013 at 14:52 PM. The patient complained of severe abdominal pain, rated by the patient as "10" on a 1 - 10 scale, 10 being the most severe. The triage nurse documented that the patient had "sudden onset of abd (abdominal) pain, unknown last menstral (sic) period. pt (patient) a&o (alert & oriented) X3 pt (patient) very demanding."

The patient's vital signs were recorded by the triage nurse as:
blood pressure - 103/65,
pulse - 118,
respirations - 22,
temperature - 97.6.

The urine specimen for pregnancy test collected on 01/02/2013 at 17:45 PM. The laboratory report at 18:03 PM showed "positive" for pregnancy. There was no documentation of assessment done by the emergency department physician (staff F) of the patient's medical history including pregnancy status or menstrual history. There was no evidence that a physician performed an appropriate medical screening examination to determine the etiology of the patient's abdominal pain. There was no indication that the physician performed basic examination and tests such as pelvic examination, ultra sound, and serum human chorionic gonadotropin (HCG) pregnancy test to determine whether ectopic pregnancy was the etiology of the continued severe abdominal pain.

When the care of the patient was handed off to another emergency department physician (staff G), no further assessment was performed to determine the etiology of the patient's continued abdominal pain.

On 04/19/2013 at 14:15 PM, the emergency department manager was asked if the clinical record showed an appropriate medical screening examination on the patient's presenting symptomatologies. She informed the surveyor that there was a problem with the documentation. She stated that she and the administrator were aware of the deficiencies in the clinical record. She stated that the hospital did not have a policy regarding medical screening evaluation requirements.

On 04/22/2013 at 14:30 PM, staff E informed the surveyor that the patient was loud, uncooperative and cursing the technicians the CT Scan room. She informed the surveyor that the patient was in too much pain to lie flat and lie still for the procedure. The procedure was not done and the patient was returned to the emergency department.

On 04/23/13 at 10:55 AM, staff H, one of two registered nurse working at the emergency room at the time the patient #5 presentment, informed the surveyor that she provided care to the patient. She stated that she did not do an assessment of patient #5.

On 04/24/13 at 10:50 AM, spoke with the surveyor by telephone and stated that she only triaged patient #5. She did not perform an assessment of the patient.

Based on review of the clinical records and interviews with staff, attempts were made to have patient #5 discharged against medical advice (AMA). An AMA form was presented by staff H to the patient to be signed and requested two police officers, who were present at the emergency department, to witness. Staff H did not have the AMA form signed because she believed that the patient was unable to make informed consent because of medications that the patient had been given. The surveyor asked if patient #5 requested to leave AMA and she responded that she didn't think so. During the process, the police officers saw two bottles of narcotics in her purse labeled with another person's name and informed patient #5 that she will be arrested for it. The emergency physician stated that patient #5 was medically stable for discharge without completing rudimental tests or examinations to determine the etiology of the continued severe abdominal pain of patient #5.

A serum drug screen laboratory test was performed on 01/02/2013 at 18:03 PM which showed "negative."

The police officers took patient #5 to jail after the physician provided medical clearance.

Patient #5 was brought back to the emergency department of this hospital by ambulance from the jail on 01/02/2013 at 23:00 PM. On arrival, patient #5 was unresponsive with no respirations and was asystole. Patient #5 was pronounced dead at 23:05 PM on 01/02/2013.