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Based on medical record (MR) review, policy and procedure review, facility administrative document review and staff interview, it was determined that in 3 (PT101, PT102 and PT103) of 20 MRs reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to maintain a list of physicians on call for duty for emergency services, failed to provide a medical screening exam, failed to provide stabilizing treatment and failed to meet the requirements of an appropriate transfer.

Findings include:

1. See findings cited at 42 CFR 489.24(j), A2404, 489.24(r) and 489.24(c), A2406, 489.24(d)(1-3), A2407 and 489.24(e)(1)-(2), A2409.

Based on ambulance record review, facility document review and staff interview, the facility failed to maintain a medical record (MR) for 3 (PT101, PT102 and PT103) of 10 emergency department (ED) patients transferred to another acute care facility.

Findings include:

1. Review of #T1's ambulance service Patient Care Reports dated 05/17/12 for PT101 with complaint of broken right leg, 05/11/12 for PT102 with complaint of chest pain and 05/17/12 for PT103 with complaint of chest pain indicated those patients had been transported from F1's ED to other acute care facilities.

2. Review of ED medical record listing for transfers and leaving against medical advice for April and May 2012 and ED log for PT101, PT102 and PT103 for the month of May 2012 indicated there were no medical records generated for PT101, PT102 and PT103.

3. At 1515 on 05/24/12, interview with S1 indicated the patients had presented to the ED and there were no medical records for PT101, PT102 and PT103.

Based on facility administrative documentation and staff interview, the facility failed to ensure a list of emergency department (ED) physicians who were on call for duty to provide evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition or provide a medical screening exam to all persons presenting and requesting treatment in the ED when an ED physician was not scheduled to staff the ED.

Findings include:

1. At 1345 on 05/24/12, interview with S1 indicated the facility's previously contracted ED physicians gave five-day notice and no longer provided service as of 04/13/12. From 04/13-27/12, the hospital ED was under diversion. They notified the ambulance services. The community/general public/other facilities were not notified. If a patient came to the ED, they went to registration, the nurse was notified for visual assessment. The patient was told there was no MD in ED and instructed to go to a family physician, urgent care or another facility. They also had the option of the hospital trying to get the patient in to see one of two family practitioners who have offices on the hospital campus or an internist with a nearby office. If the patient appeared to be a medical emergency, they were placed on a stretcher and given oxygen and either 911 or EMS was called. No medical records, no ED log entries or any other type of documentation was generated, as they were not considered patients. Three new contracted ED physicians began providing services on 04/27/12.

2. Review of May 2012 (May 1-24) ED physician schedule indicated lack of 24/7 on duty/on call coverage for 7 of 24 days under the new contracted physicians:
05/01/12-no coverage for 7 hours, 5PM to 8PM and 4AM to 8AM (05/02)
05/03/12-no coverage for 4 hours, 8AM to 12PM
05/05/12-no coverage for 3 hours, 8AM to 11AM
05/08/12-no coverage for 2 hours, 8AM to 9AM and 7PM to 8PM
05/10/12-no coverage for 12 hours, 8PM to 8AM (05/10-11)
05/12/12-no coverage for 11 hours, 8AM to 11AM and 8PM to 8AM (05/12-13)
05/19/12-no coverage for 3 hours, 8AM to 11AM
05/24/12, date of survey, schedule indicated 24-hour coverage, however, physician left at noon, leaving no coverage for the ED at least until survey exit at 5:30PM.

3. Review of the Independent Contractor Agreement for the 3 (MD1, MD2, MD3) ED physicians indicated "Hours to be Worked. Contractor will be available for a minimum of 12-24 hour shifts in the Emergency Room at SCRH as scheduled".


4. Review of the Medical Staff Rules and Regulations, page 22, Article V, 5.2(f), "Emergency Department Call, All members of the Active and Provisional Staff shall participate in the on-call back-up to the Emergency Department".

5. At 1345 on 05/24/12, interview with S1 indicated there is not always 24/7 ED coverage with the current contracted ED physicians. S1 also indicated he/she was unsure the dates the schedule reflected full coverage by physicians was accurate.

Based on document review, policy and procedure review and staff interview, the facility failed to maintain a central log on each individual who comes to the emergency department, seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 3 (PT101, PT102 and PT103) of 20 individuals presenting to the Emergency Department (ED).

Findings include:

1. Review of #T1's ambulance service Patient Care Reports dated 05/17/12 for PT101 with complaint of broken right leg, 05/11/12 for PT102 with complaint of chest pain and 05/17/12 for PT103 with complaint of chest pain indicated those patients had been transported from F1's ED to other acute care facilities.

2. Review of the ED central log for May 9-24/12 indicated PT101 and PT102 had not been entered upon presentation to the ED. PT103's entry lacked patient number, medical record number, ED doctor and discharge status.

3. Review of policy titled EMTALA Guidelines for the Emergency Department, last reviewed 04/11, page 2, "Medical Screening Exams: Medical Screening Exam should include at the minimum the following; Emergency Department log entry including disposition of patient"...

4. At 1515 on 05/24/12, interview with S1 indicated PT102 had presented to the ED on 05/11/12 and had not been entered on the central log, PT101 had presented to the ED on 05/17/12 and had not been entered on the central log and PT103 had presented to the ED on 05/17/12 and had been entered on the central log, but was lacking patient number, medical record number, ED doctor and patient discharge status. S1 also indicated that after the contracted physician group left, the hospital was on diversion from 04/13-27/2012. They notified the ambulance services, however, the community and other facilities were not notified. Patients who presented to the ED during this time were not entered into the ED log. An ED log was not kept and the number of patients presenting is unknown.

Based on medical record review, document review and staff interview, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for 3 (PT101, PT102 and 103) of 20 individuals who presented to the Emergency Department.

Findings include:

1. Review of #T1's ambulance service Patient Care Reports dated 05/17/12 for PT101 with complaint of broken right leg, 05/11/12 for PT102 with complaint of chest pain and 05/17/12 for PT103 with complaint of chest pain indicated those patients had been transported from F1's ED to other acute care facilities.

2. There were no medical records or documentation to indicate a medical screening exam was provided for PT101, PT102 and PT103 or that the patients refused care at the time of presentation to F1's emergency department.

3. Review of policy titled EMTALA Guidelines for the Emergency Department, last reviewed 04/2011, page 1, Policy: third paragraph, "All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis".

4. At 1515 on 05/24/12, interview with S1 indicated the patients had presented to the ED on 05/11/12 and 05/17/12 and PT101, PT102 and PT103 had not received a medical screening exam. S1 also indicated that after the contracted physician group left, the hospital was on diversion from 04/13-27/2012. They notified the ambulance services, however, the community and other facilities were not notified. Patients who presented to the ED during this time frame and during the time frames there were no physicians available during May of 2012 were not provided a medical screening exam. The number of patients presenting is unknown.

Based on medical record review, document review and staff interview, the facility failed to ensure stabilizing treatment was provided to 3 (PT101, PT102 and PT103) of 20 patients presenting to the Emergency Department (ED).

Findings include:

1. Review of #T1's ambulance service Patient Care Reports dated 05/17/12 for PT101 with complaint of broken right leg, 05/11/12 for PT102 with complaint of chest pain and 05/17/12 for PT103 with complaint of chest pain indicated those patients had been transported from F1's ED to other acute care facilities.

2. Review of ED medical record listing for transfers and leaving against medical advice for April and May 2012 and ED log for PT101, PT102 and PT103 for the month of May 2012 indicated there were no medical records for PT101, PT102 and PT103.

3. There were no documents indicating refusal of exams or treatment.

4. Review of the Medical Staff Rules and Regulations, page 20, Article V, 5.1(b), "Stabilization, (1) Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge..." and (4), "If a patient refuses to accept the proposed stabilizing treatment, the Emergency Department Physician, after informing the patient of the risks and benefits of the proposed treatment and the risks and benefits of the individual's refusal of the proposed treatment, shall take all reasonable steps to have the individual sign a form indicating he/she has refused the treatment. The Emergency Department Physician shall document the patient's refusal in the patient's chart, which refusal shall be witnessed by the Emergency Department supervisor".

5. At 1515 on 05/24/12, interview with S1 indicated PT102 had presented to the ED on 05/11/12 and PT101 and PT103 on 05/17/12 and had not received exam or treatment and confirmed there was no documentation of refusal of exam or treatment.

Based on document review, medical record review and staff interview, the facility failed to follow its policy/procedure on patient transfers to another facility and failed to provide an appropriate transfer for 3 (PT101, PT102 and PT103) of 3 Emergency Department (ED) patients transferred from F1 to another acute care facility by ambulance service (T1) in that the facility lacked documentation of medical treatment that minimizes the risks to the individuals' health, lacked documentation of a written request for transfer, lacked documentation of a signed physician certification which included risks and benefits, lacked any evidence that the required medical record (MR) information was sent to the receiving facility and lacked documentation of contact with the receiving facility.

Findings include:

1. Review of ambulance service (T1) Patient Care Reports for PT101, PT102 and PT103 indicated these patients had been transported from F1's ED to other acute care facilities.

2. T1 ambulance report for 05/11/12 for PT102 indicated chest pain, emergent transport and atrial fibrillation per cardiac monitor. Arrived at F3 at 2200.

3. T1 ambulance report for 05/17/12 for PT101 indicated broken right leg and transport under basic life support. Arrived at F2 at 1354.

4. Medical record at F2 indicated PT101 was admitted and had intramedullary pinning performed on 05/18/12.

5. T1 ambulance report for 05/17/12 for PT103 indicated chest pain, emergent transport, unable to read cardiac monitor. Arrived at F3 at 1330.

6. There was no documentation of a written request for transfer, of a signed physician certification which included risks and benefits, no evidence that the required MR information was sent to the receiving facility or that the receiving facility was contacted for PT101, PT102 and PT103.

7. Review of the Medical Staff Rules and Regulations, page 21, Article V, 5.1(c), "Transfer, (1) The Emergency Department Physician shall obtain the consent of the receiving hospital facility before the transfer of an individual. Said person shall also make arrangements for the patient transfer with the receiving hospital. (2) The condition of each transferred individual shall be documented in the medical records by the physician responsible for providing the medical screening examination and stabilizing treatment. (3) Upon transfer, the Emergency Department shall provide appropriate medical records...informed written consent or transfer certification". (4) The Emergency Department Physician must inform the patient (or the patient's representative) of the risks and benefits of the proposed transfer".

8. Review of policy titled EMTALA Guidelines for the Emergency Department, last reviewed 04/11, page 1, Policy, sixth paragraph, "[F1] may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge". Page 2, beginning with first paragraph, "[F1] may not transfer patients who are potentially unstable...If a patient is to be transferred...the following guidelines must be followed: a physicians certification...patients request...receiving hospital must give acceptance in advance...must be documented in the medical records..."

9. At 1600 on 05/24/12, interview with S1 and S4 confirmed PT102 had presented to the ED on 05/11/12 and PT101 and PT103 on 05/17/12 and had not been transferred per policy. PT 102 and PT103 complained of chest pain and had been placed on a stretcher and oxygen and EMS called for transport. PT101 had fallen, thought leg was broken, came to F1. F1 instructed no MD in house and not to move out of car. S5 was called, as was patient's family physician and S5 ordered an xray. When S4 went to tell family/patient, family/patient had left. They had gone to S5's office, who sent them back to F1 for xray. In-house radiologist read xray and called S5, who instructed T1 to transport patient to F2. S1 and S4 confirmed there was no ED record.

10. Interview with S13-14 (F3) on 05/24/12 at 1115 indicated PT102 and PT103 had been transported to F3 via ambulance without any type of notice from F1.