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Based on interview, document review, policy review and medical record review, it was determined that the hospital failed to comply with 42 CFR 489.24 and the related provisions at 42 CFR 489.20.

Findings include:

The hospital does not maintain a central log that documents all patients who present to the emergency department, as evidenced for Patient #1.
See Tag #A-2405

Patient #1 was not provided with a medical screen examination in the emergency department to determine if an emergency medical condition existed.
See Tag #A-2406

There is lack of physician documentation related to ongoing medical examinations provided to Patient #24 in order to stabilize her emergency medical condition.
See Tag #A-2407

The hospital does not ensure that the risks of transfer specific to the patient's medical condition are documented, as evidenced for 9 of 20 emergency department patients who were transferred to another acute facility.
See Tag #A-2409

Based on interview, document review and policy review, the hospital does not maintain a central log that documents all patients who present to the emergency department (ED), as evidenced for Patient #1.

Findings include:

Interview on 9/30/13 at 9:15 AM with Nurse Manager of Risk Management and Corporate Compliance Staff #1 and ED Nurse Manager Staff #2 revealed Patient #1 signed in at registration, was brought to triage, but she was not entered into the log, did not see a physician and no medical record was generated for her while she was present at the facility on 9/20/13.

Review on 9/30/13 of the Emergency Department Patient log dated 9/20/13 revealed no evidence of Patient #1's presentation to the facility.

Review on 10/1/13 of policy "EMTALA: Screening, Stabilization and Transfers" (dated 12/18/12) revealed a central log will record each individual who came to the ED seeking screening or treatment and must be maintained for at least 10 years. The log will include each name, medical record number (if available) and indicate whether the individual refused treatment or transfer, denied treatment, treated, admitted, transferred or was discharged.

Based on interview, document review and policy review, Patient #1 was not provided with a medical screen examination in the emergency department (ED) to determine if an emergency medical condition (EMC) existed.

Findings include:

Interview on 9/30/13 at 9:15 AM with Nurse Manager of Risk Management and Corporate Compliance Staff #1 and ED Nurse Manager Staff #2 revealed Patient #1 signed in at registration on 9/20/13, was brought to triage, but did not see a physician or other medical provider. No medical record was generated for her visit to the facility on 9/20/13.

Review on 9/30/13 of the Quality Management Investigation form and the Quality Assurance incident complaint form dated 9/24/13 revealed Patient #1's father phoned the facility stating that Patient #1 presented to the facility on 9/20/13 between 8:30 and 9:00 PM with the complaint of pregnancy and "spotting". Triage ED Registered Nurse Staff #7 took vital signs and advised them that the blood was old, not fresh, spotting was normal and if it got worse to go to another specified hospital where they have obstetrics (OB) on call. Patient #1 was not examined by Staff #7 and never saw a doctor.

Review on 9/30/13 of the facility's EMTALA investigation interview conducted on 9/26/13 at 1:00 PM with Staff #7 revealed she was the triage nurse from 11:00 AM to 11:00 PM on 9/20/13. She was made aware by the registration clerk that Patient #1 presented with bleeding and was pregnant. In triage, Patient #1 stated she was two months pregnant and was having bleeding with dark spots, but denied cramping or passing clots. Staff #7 believed the "dark spots" were old blood, although no physical examination was performed. Patient #1 asked what she should do and Staff #7 told her she could stay, but if she didn't want to, she should call her doctor or return to the hospital immediately if she felt uncomfortable, having heavy bleeding or was cramping. She told Patient #1 she could go to another specified hospital, as obstetrics on-call was available there and the service was not offered at this hospital. Patient #1 left the hospital shortly thereafter.

Review on 10/1/13 of policy "EMTALA: Screening, Stabilization and Transfers" (dated 12/18/12) revealed the following:
- It is the policy of the hospital to provide an appropriate medical screening examination (MSE) to individuals presenting to its ED requesting examination or treatment of an emergency medical condition or are in labor, and if one exists, provide the necessary stabilizing treatment within the capacity of the hospital.
- If an individual waiting for an MSE decides to leave without examination, the following steps should be taken if possible: explain the importance of the MSE to rule out an EMC that needs treatment, inform the individual of the risks of not having an MSE, ask the individual to sign the "Against Medical Advice" form and document the above information and/or refusal to sign the AMA form in the medical record.

Based on policy review, medical record review and interview, there is lack of physician documentation related to ongoing medical examinations provided to Patient #24 in order to stabilize her emergency medical condition.

Findings include:

Review on 10/1/13 of policy "EMTALA: Screening, Stabilization and Transfers" (dated 12/18/12) revealed any woman in active labor is considered unstable for the purposes of EMTALA (Emergency Medical Treatment and Labor Act). The physician must ensure that the evaluations/assessments included in the MSE (medical screening examination) are documented in the patient's medical record. In addition, the physician must determine and clearly document whether the patient has an EMC (emergency medical condition) in the patient's medical record.

Review on 10/1/13 of the emergency department (ED) medical record dated 6/5/13 for Patient #24 revealed the following:
- ED Physician record indicates Patient #24 was seen on arrival at 4:30 AM by ED Physician Staff #8 for labor pains. She was full term and scheduled for a C-Section on 6/20/13. She had a history of seizure and was on Lamictal. Blood pressure was 130/92, pulse 88, temperature 98 and pulse oximetry 99%. FHS (fetal heart sounds) were 140. A pelvic exam showed water discharge, dilation and at full term. At 4:30 AM, Patient #24's OB (obstetric) physician was contacted, who gave instructions to send Patient #24 to another specified hospital with obstetrics service. At 4:45 AM, the OB physician at the other facility was contacted, but he could not come. Facility Medical Director Staff #16 was called and is on his way.
- The Physician Certification of Transfer and Informed Consent to Transfer form documented that an MSE was performed, the EMC was stabilized and a higher level of care was required for active labor, but it did not indicate risks specific to Patient #24's medical condition. Patient #1 was transfered by ambulance at 6:35 AM. See Tag #A-2409.
- No further documentation of ongoing medical examinations and/or treatment by either Staff #8 or 16 was found in the medical record.

During telephone interview on 10/3/13 at 10:45 AM, Staff #16 indicated he should have done a medical record entry on Patient #24 and there could have been more documentation by Staff #8.

Based on medical record review, policy review, document review and interview, the hospital does not ensure that the risks of transfer specific to the patient's medical condition are documented, as evidenced for 9 of 20 emergency department (ED) patients who were transferred to another acute facility. (Patients #2, 4, 8, 9, 10, 11, 15, 22 and 24)

Findings include:

Medical record review on 9/30/13 revealed no evidence that the risks of transfer specific to the patient condition was listed and/or discussed with the patient for the following patients:
- On 9/25/13, Patient #2 was being transferred due to hypotension and general weakness.
- On 9/22/13, Patient #4 was being transferred due to acute appendicitis.
- On 9/13/13, Patient #8 was being transferred due to an acute abdomen.
- On 9/7/13, Patient #9 was being transferred due to cardiac arrest.
- On 9/7/13, Patient #10 was being transferred due to a renal stone.
- On 8/29/13, Patient #11 was being transferred due to esophageal food impaction.
- On 9/1/13, Patient #15 was being transferred due to a pneumothorax.
- On 8/7/13, Patient #22 was being transferred due to STEMI (ST elevation myocardial infarction).
- On 6/5/13, Patient #24 was being transferred due to active labor.

Review on 10/1/13 of policy "EMTALA: Screening, Stabilization and Transfers" (dated 12/18/12) revealed a physician must certify the medical benefits from transfer outweigh the risks and describe the reasons for and the potential risks and benefits by completing the applicable areas on the Patient Transfer Physician Certification form.

Review on 10/1/13 of the Physician Certification of Transfer and Informed Consent to Transfer form revealed the following:
- Section IV - Risks vs. Benefits section includes an area for the physician to write at least one risk of transfer specific to the patient's current condition.
- Section VIII - Patient Consent to Transfer section has two options/check-off boxes for the patient to select:
1. to indicate whether they consent to transfer, have been informed of the risks of transfer versus the benefits, understand risks and consent to transfer.
2. patient refusal to transfer.
There is another area (box) in this section for the patient/representative to sign.

These findings were verified with Nurse Manager of Risk Management and Corporate Compliance Staff #1 and ED Medical Director Staff #12 on 10/1/13.