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Based on facility policy review, document review, medical record review and interview, the facility failed to ensure each patient who presented to the Emergency Department (ED) was documented on the ED central log and received an appropriate medical screening exam (MSE) to determine if an emergency medical condition existed.

The findings included:

1. The facility failed to ensure each patient who presented to the ED seeking treatment was documented on the hospital's ED central log for 1 of 21 (Patient #21) sampled patients who presented to the hospital's ED.
Refer to A2405

2. The facility failed to ensure all patients presenting to the ED received an appropriate MSE to determine if a emergency medical condition existed for 1 of 21 (Patient #21) sampled patients.
Refer to A2406.

Based on review of the hospital's Emergency Department (ED) Central log, the hospital's ED policies, facility documents and interview, the hospital failed to ensure that each patient who presented to the ED seeking treatment was documented on the hospital's ED central log for 1 of 21 (Patient #21) sampled patients who presented to the hospital's emergency department seeking treatment.

The findings included:

1. Review of Hospital #1's "Emergency Room Policy" revealed, "...A record of every patient treated in the Emergency Room will be entered in the Emergency Room Log Book..."

Review of Hospital #1's ED policy "Emergency Screening, Stabilization, and Transfer," revealed "...1. SCREENING PROCEDURES: Whenever an individual comes to the hospital Emergency Department requesting an examination or treatment... The screening is to be recorded in the patient's medical record and in the Emergency Department's Register or Log Book..."

2. Review of the contracted ED physician's document titled "COBRA/EMTALA [Consilidated Omnibus Budget Reconciliation Act/Emergency Medical Treatment and Active Labor Act]" under the heading "THE '20 Commandments' of COBRA/EMTALA" revealed, "...1. THOU SHALL: Log in every patient who presents, together with complaint/diagnosis and disposition." The document was signed by Physician #1 on 8/3/15.

3. Review of the hospital's ED central log dated 11/13/15 revealed no documentation that Patient #21 had presented to the hospital's ED seeking treatment.

4. During an interview in the break room on 1/5/15 at 2:15 PM, the Registration Clerk for Hospital #1 verified that she was present on 11/13/15 when Patient #21 presented to the ED seeking treatment for visual disturbances. The Registration Clerk verified she had not placed Patient #21 on the ED central log. When asked who's responsibility it was to place patients on the ED central log, the Registration Clerk stated, "The registration person's." The Registration Clerk stated that patients are not placed on the ED log until registration is complete. She stated that Patient #21 had been completely registered and that she had to get someone in medical records to take her registration out of the computer so she would not be charged for a visit.

Based on policy review, facility document review, medical record review and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) received an appropriate medical screening examination (MSE) to determine if a medical emergency existed for 1 of 21 (Patient #21) sampled patients presenting themselves to the ED seeking emergency care.

Failure by the hospital to conduct appropriate medical screening resulted in an IMMEDIATE AND SERIOUS threat to the health and safety of Patient #21 and to all patients seeking treatment in the hospital's ED.

The findings included:

1. Review of Hospital #1's policy "Emergency Screening, Stabilization, and Transfer" revealed, ...Whenever an individual comes to the hospital Emergency Department requesting an examination or treatment, the individual shall be screened without delay to determine whether an emergency medical condition exists: as follows:1. Prompt Examination: The patient shall be examined promptly utilizing all appropriate screening resources of the Emergency Department and hospital ancillary services...3. Definition of 'Emergency Medical Condition': The screening shall be conducted to determine whether the individual has an 'Emergency Medical Condition', which is defined under federal law as: A. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in-- Placing the health of the individual in serious jeopardy, OR Serious impairment to bodily functions, OR Serious dysfunction of any bodily organ part...4. Questionable Medical Condition: If there is any doubt as to the existence of an emergency medical condition as defined above, it shall be presumed that the patient has an emergency medical condition..."

2. Review of the contracted ED physician's document signed by Physician #1 on 8/3/15 titled "COBRA/EMTALA [Consilidated Omnibus Budget Reconciliation Act/Emergency Medical Treatment and Active Labor Act]" under the heading THE '20 Commandments' of COBRA/EMTALA revealed, "1. THOU SHALL: Log in every patient who presents, together with complaint/diagnosis and disposition. A patient who presents when they enter into a dedicated emergency department of the hospital...seeking care or under circumstances when a reasonable layperson would conclude that the patient required care or evaluation for am emergency medical condition...2. THOU SHALL: Provide a medical screening examination (MSE) by physicians IN THE HOSPITAL OR DEDICATED EMERGENCY DEPARTMENT SITE, beyond triage, to all patients regardless of acuity who present as specified in #1 above. The MSE is an on-going process sufficient to reach a definitive exclusion of legally defines emergency medical conditions and is NOT a fixed point in the evaluation that allows termination of services or redirection of the patient to there sites.

3. Review of a Hospital #1 event report dated 11/15/15 and completed by RN #1 revealed, "...Date of Event 11/13/15/Time 11 AM ?...Pt [Patient #21] came into ER stating could not see, then stated could not see shapes, since the night before. Did NOT refuse to see her. Got an appointment with eye doctor. Was told to come anytime to ER, come back, if needed...[Patient #21] her husband and her sister's husband came to ER. [Patient #21] stated she could not see, also stated she could not see images, could not see since night before. [Physician #1] in ER, this nurse [RN #1]. Stated we would be glad to see her, but wondered if an eye doctor could tell more about eyes. Husband stated- What about a CT [computerized axial tomography] scan? Stated I'm not sure. Optometrist #1 called and stated come over and would be seen. Also stated, this nurse, come back to ER if needed. Did not refuse to see her. [Patient #21] also stated had not taken any pain pills in awhile. And we hugged..."

4. Review of Hospital #1's Patient Care Committee Meeting minutes dated 12/15/15 revealed, "...Patient Incident-...Patient presented to ER [Emergency Room] reporting that she was unable to see clearly. Nursing reports an appointment was made with the patients' optometrist. The patient reported she was refused treatment..."

5. Review of Hospital #1's ED central log dated 11/13/15 revealed no documentation that Patient #21 had presented to the ED seeking treatment. There was no medical record for Patient #21 for a date of service 11/13/15.

During an interview in the break room on 1/5/16 at 2:20 PM, the Registration Clerk stated that she had registered Patient #21 on 11/13/15 when she presented with complaints of vision problems. She stated, "She [Patient #21] didn't make it to the log but she was completely registered ...I had to call Medical Records to have her taken out of the system so she wouldn't be charged [for the ED visit] ..."

During a telephone interview on 1/5/16 at 3:55 PM, a Business Office representative verified she had received a call from the Registration Clerk on 11/13/15, asking her to remove Patient #21 from the system because the patient had been registered but was not treated in the ED.

6. Review of Patient #21's ED medical record from Hospital #2 dated 11/13/15 revealed the patient presented to the ED via ambulance at 2:02 PM with complaints of blurred vision since the night prior. The patient received a MSE at 2:05 PM that documented, "58 yo [year old] female with complaints of blurred vision for the past two days which is getting worse. no fever or chills. patient seen at [Hospital #1] this morning and was sent to an eye doctor and has not gotten better so she came here. patient with generalized 'pain' which she says is chronic and she takes chronic pain medicine. She says that she can see some blurred shapes but is unable to watch TV and she is not able to move around because she keep falling.

Review of nursing ED notes dated 11/13/15 at 2:29 PM revealed, "PATIENT STATES THAT SHE HAS HAD BLURRED VISION SINCE 8 AM THIS MORNING. PATIENT STATES, 'I CAN SEE A BIG BLOB.' PATIENT STATES SHE HAS HAD BLURRED VISION SINCE LAST NIGHT. SHE WENT TO [HOSPITAL #1] TODAY AND DID NOT THINK THAT SHE GOT WHAT SHE NEEDED THERE SO CAME INTO [HOSPITAL #2] ER. PATIENT STATES THAT SHE WENT TO THE EYE DOCTOR AND THEY DID NOT FIND ANYTHING WRONG WITH HER EYES..."

A Computerized Tomopraghpy (CT) of the head was completed at 3:07 PM and documented, "Findings are most consistent with posterior reversible encephalopathy syndrome..."

Review of a nurses note at 5:24 PM documented, "PATIENT TO BE TRANSFERRED TO [HOSPITAL #3] Patient STATES THAT SHE IS STILL HAVING BLURRED VISION. PATIENT UNABLE TO DISTINGUISH NUMBER OF FINGERS HELD UP BY NURSE AT 6 INCHES WITH LEFT EYE, RIGHT EYE AND BILATERAL EYES.

Patient #21 was transferred by ambulance on 11/13/15 at 5:46 PM to Hospital #3 to obtain a higher level of care by neurology services. The patient was documented as "Stable for transfer."

7. Review of Patient #21's medical record from Hospital #3 revealed she arrived 11/13/15 at 7:05 PM by ambulance. The history and physical (H&P) revealed a chief complaint of blurred vision. The H&P documented Patient #21 had a 2 day history of blurred vision, which appeared worse overnight. The patient described associated headaches, mild focal deficit on the right, as well as some sensitivity to light. CT of the head essentially was consistent with posterior reversible encephalopathy syndrome. She was transferred to Hospital #3 for neurology evaluation. The plan included inpatient admission, modified Cerebral Vascular Accident order sets and Magnetic Resonance Imaging (MRI) with and without contrast.

Review of Patient #21's discharge summary from Hospital #3 revealed a stay of 11/13/15 - 11/16/15. The final diagnoses included Subacute isochrones bilateral posterior artery ischemic stroke, Congenital hypoplasia of bilateral v4s and basilar artery with occluded P2-3s, Visual Changes, and Hypertension. A CT of the head showed subacute isochrones bilateral Posterior Cerebral Artery (PCA) ischemic stroke. National Institute of Health Stroke Score (NIHSS) was 3/42 (which indicates a minor stroke). A CT Angiogram (CTA) of the neck and brain showed congenital hypoplasia of bilateral v4s and basilar artery with occluded P2-3s. Lower extremity venous duplex was negative for Deep Vein Thrombosis. A 2-D echo showed an ejection fraction of 55 - 60%. No etiology for her stroke had been found. MRI of the brain noted a distribution of overall appearance, posterior cortical and subcortical flair and T2 hyperintense signal abnormality consistent with posterior reversible encephalopathic syndrome.

8. During an interview in the break room on 1/5/16 at 10:05 AM the Director of Nursing (DON) was asked about the patient referenced in the Patient Care Minutes dated 12/15/15. The DON stated a patient with vision problems came to the ER and reported she was refused treatment. The DON identified the patient as Patient #21. The DON was asked why Patient #21 was not on the ED log and why there was no refusal of treatment documented. The DON stated, "Those are excellent questions, I just don't have an answer for you..." The DON stated RN #1 called an eye doctor and made an appointment for Patient #21. She verified the patient did not receive an MSE. When asked about any follow up treatment Patient #21 received, the DON stated after the eye appointment Patient #21 went to another facility where she was told she was having mini strokes. The DON further stated she was concerned first of all for Patient #21, was upset by the family's reaction and was upset that the hospital had allowed the situation to be created.

During an interview in the break room on 1/5/16 at 10:45 AM, RN #1 verified she was working in the ED on 11/13/15, when Patient #21 presented with complaints of vision problems. She stated, Patient #21 "came in with her husband and a brother in law...Physician #1 was around the corner." She further stated Patient #21 complained of not being able to see, and Patient #21's husband reported the onset was the night before. RN #1 stated, "I spoke with Physician #1 and we got her an appointment with an eye doctor. I advised her to come back if she needed to..." RN #1 stated Patient #21 nor her husband talked with Physician #1. When asked if Patient #21 had ever presented to the ED with blurred vision or dizziness, RN #1 stated "Dizzy but not blurred vision." When asked if she and Physician #1 discussed Patient #21's care after the appointment was made with an optometrist, RN #1 stated, "Not that I can remember". RN #1 verified that she documented the hospital event report dated 11/15/15. When asked if the patient said she wanted to be seen in the ED, RN #1 stated, "That is what they [Patient #21 and her spouse] implied by coming in [to ED]." When asked if the patient requested to be sent to an Optometrist, RN #1 stated, "No." RN #1 verified that it was her and Physician #1 who suggested the patient see an eye doctor. When asked why she felt the patient needed to see an eye doctor instead of being medically screened in the ED, RN #1 stated,"I guess her vision loss since the night before..." RN #1 stated she told Physician #1 Patient #21 was experiencing vision problems and Physician #1 stated she might be better served by an eye doctor.

During an interview in the break room on 1/5/16 at 2:20 PM, the Registration Clerk verified she was working when Patient #21 presented to the ED on 11/13/15. The Registration Clerk stated Patient #21 presented to the ED with her husband who stated Patient #21 could not see. The Registration Clerk stated RN #1 told Patient #21 and her husband, "We can't do anything for her eyes." The Registration Clerk stated the husband asked RN #1 if they were refusing to see his wife and RN #1 replied, "I just don't know what we can do for her." The Registration Clerk stated, "I felt like she should have been treated..." The Registration Clerk verified the ED Physician did not see Patient #21, there was only interaction with RN #1. She stated Patient #21 had never been to the ED with vision complaints to her knowledge. When asked about how Patient #21's husband responded, the Registration Clerk stated, "He wanted her treated...he brought her up here for treatment." She stated she heard Patient #21's husband ask if a CT scan could be done and RN #1 replied "A CT wouldn't show up anything." The Registration Clerk stated after the patient left the ED, RN #1 said we probably should have went ahead and seen her.

During an interview in the break room on 1/5/16 at 2:55 PM, the DON stated she spoke with RN #1 after the incident and asked her to write up what happened. The DON stated she did not have a discussion with Physician #1 regarding the incident because she felt it was the Medical Directors place to review with his staff. When asked if she and the Medical Director had discussed the incident, the DON stated, "I honestly can't recall..." The DON was asked about any discussion of the incident in the Patient Care Committee Meeting on 12/15/15. The DON stated, "The incident was read by [Medical Director]...I think it was pretty much in agreement it was not handled in the best way...and that it wouldn't happen again..." When asked if Physician #1 had participated in the EMTALA training that she provided to staff in November 2015, she stated he had not. She further stated only 3 of the 12 contracted ED physicians had attended the EMTALA training she provided. When asked if the Medical Director had provided training to the ED physicians, the DON stated, "I don't know." When asked how the Interim Administrator had been involved in the investigation, the DON stated, "...has not been involved, he has his plate full managing two hospitals..."

During a telephone interview on 1/5/16 at 3:10 PM, Physician #1 verified he was working the ED on 11/13/15 when Patient #21 presented. Physician #1 stated, "This [Patient #21] patient is well known to the medical and nursing staff...she came in around 8:00 AM and complained she couldn't see since the night before...we suggested perhaps get an appointment with an eye doctor." When asked what happened to the patient after she was seen by the Optometrist, Physician #1 stated he heard she was told to return to the ED to let somebody else treat her. Physician #1 stated, "...[we] felt like [we] were doing the right thing...we did not check her in [log her into ED system]. He further stated he did not lay eyes on Patient #21 but RN #1 had explained to him her presenting complaint of vision problems.

During a telephone interview on 1/5/16 at 4:15 PM, Optometrist #1 stated he did not examine Patient #21 on 11/13/15, but his associate, Optometrist #2 did. Optometrist #1 stated he could review the record over the telephone with the survey team. Optometrist #1 stated, "She [Patient #21] was referred due to acute vision loss. Optometrist #2 did an internal and an external exam and could find nothing abnormal." He further stated Patient #21 couldn't count fingers until she was within a foot away. He stated Optometrist #2 documented, "Suggested patient go back to physician for a CT scan." Optometrist #1 again stated Patient #21 could count fingers at one foot and she had no visual field. Optometrist #1 stated he had examined Patient #21 in June 2015 and at that time he documented she had 20/80 and 20/60 vision, with decreased vision only from cataracts.

During a telephone interview on 1/6/16 at 10:59 AM, Patient #21 confirmed she did not have a MSE at Hospital #1 on 11/13/15. She stated Hospital #1 mad an appointment for her to see the optometrist. Patient #21 stated the optometrist examined her and told her she needed to be seen by a doctor. She stated she returned home, then went to Hospital #2's ED via ambulance. She stated Hosptial #2 transferred her to Hospital #3 via ambulance where she was admitted.