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Based on review of Emergency Department (ED), facility ED Central Logs, Medical Staff Bylaws/Rules and Regulations, facility policies and procedures, physician, staff interviews, and Emergency Medical Techinican/Paramedic it was determined that the facility failed to ensure compliance with 42 CFR Part 489.24.

Findings were:

Cross refer to A2405 as it relates to failure to maintain documentation in the facility's central log of each patient who presented to the Emergency Department.

Cross refer to A2406 as it relates to failure to provide an appropriate Medical Screening Exam (MSE).

Cross refer to A2407 as it relates to failure to provide an appropriate stabilizing treatment.

Cross refer to A2409 as it relates to failure to affect an appropriate transfer.

Based on review of the facility's Medical Staff Bylaws/Rules and Regulations, Emergency Department (ED) Central logs, medical records, and staff interviews, it was determined that the facility failed to ensure that a medical record was created and completed for one (1) patient (#6) of twenty (20) sampled patients.

Review of the facility's Medical Staff Bylaws/Rules and Regulations, revision date of August 2011, page 41, F. item #2, revealed that an appropriate medical record would be kept for every patient receiving emergency service and be filed within the medical records department. Continued review revealed that on page 42, item #3, each medical record shall be signed by the Practitioner in attendance that is responsible for its accuracy.

Review of facility policy, entitled "EMTALA (Emergency Medical Treatment & Active Labor Act), revised May 2009, page 4, item 14, revealed all records pertaining to EMTALA management of an individual, including medical records, refusal or treatment records/Against Medical Advice( AMA) discharge forms, and logs will be maintained for a period of not less than thirty (30) years.

Review of the facility's ED Central Logs, dating from February 24, 2013 through February 27, 2013, revealed no evidence of patient #6 presenting to the ED.

Interview on March 6, 2013 at 9:30 a.m. the Licensed Practical Nurse (LPN) #2, who was on duty in the ED the night of February 26, 2013, when Emergency Medical Services (EMS) presented patient #6, to the ED driveway, revealed that there was no medical record.

LPN #2, continued to reveal the ED staff heard on the scanner that EMS was in route to their facility. LPN #2 and the ED physician #2, were outside waiting when EMS pulled up under the awning over the ED entrance. The EMS staff reported at that time that the patient's vital signs were stable and the patient had an open airway. The EMS staff were advised to proceed to the next closest acute care facility.

LPN #2, stated that the patient was not examined and that there was no documentation regarding the patient and that no medical record was initiated.

Based on review of facility policies and procedures including "EMTALA Emergency Medical Treatment & Active Labor Act (EMTALA) Management and Compliance, Registration and Consent for Treatment, Emergency Department (ED) Central Log, ER Daily Log Book", physician and staff interviews, it was determined that the facility failed to ensure that each patient who presented to the facility's ED seeking assistance was recorded in the Central Log for one patient (#6) of the twenty (20) sampled patients.

Findings include:

Review of facility policy entitled, "EMTALA Emergency Medical Treatment & Active Labor Act (EMTALA) Management and Compliance", revised May 2009, page 4, item 13, revealed the facility will maintain a central log on each individual refused treatment, was transferred, admitted, treated, stabilized or discharged.

Review of facility policy entitled "Registration and Consent for Treatment", effective August 2007, revealed that the purpose of the policy was to ensure that each patient is registered properly and consents for treatment were obtained. The policy indicated that all patients seen in the ED were to be appropriately logged in the ED Central Log with a brief description of the presenting problem, intervention, and the attending provider.

Review of the facility policy entitled, "ER Daily Log Book", effective August 2007, revealed the "Policy Statement" to include the policy is to provide guidelines for all nursing personnel to follow when a patient is treated, transferred, signs out Against Medical Advice, or is discharged. The ER daily log is a factual legal book.

Review of the facility's ED Central Logs from February 24, 2013 to February 27, 2013 failed to provide evidence that patient #6 had presented on the facility's property for evaluation and/or treatment in the ED.

Interview on March 6, 2013 at 9:00 a.m. with Licensed Practical Nurse #2, who was the ED nurse on duty the night of February 26, 2013, when Emergency Medical System presented patient #6, to the ED driveway, confirmed that the patient was not entered in the facility's ED central log and/or the ER daily log.

Based on reviews of medical records, facility policy and procedure, "EMTALA (Emergency Medical Treatment & Active Labor Act) Management and Compliance,Medical Staff Bylaws/Rules and Regulations and Medical Staff meeting minutes, and physician, staff and EMT/P interviews, it was determined that the facility failed to provide a Medical Screening Examination (MSE) that was within the capability and capacity of the hospital for one (patient #6) of twenty (20) sampled patients.

Findings include:

Review of facility policy entitled "EMTALA (Emergency Medical Treatment & Active Labor Act) Management and Compliance", effective May 2009/ revised May 20, 2009, revealed that the "Purpose" of the policy was to provide appropriate resources and personnel to accept persons presenting with a request for treatment or an emergent medical condition or perceived emergency medical condition, and that a proper MSE is conducted.

The "Policy" section revealed that the facility EMTALA obligations apply to the Emergency Department (ED), main hospital campus as well as all hospital property located within two-hundred-fifty (250) yards of the main hospital buildings. Continued review revealed the facility will provide MSE and care to any individual when a request is made by the individual, or by someone else on their behalf, or is implied given the circumstances, for screening and/or treatment for a potential emergency condition. For purposes of this policy, "emergency care" is defined as "a MSE by a physician or designated qualified medical provider and stabilization of any current emergency medical condition(s).

Review of the the facility's Medical Staff Bylaws/Rules and Regulations, last revised August 2011, revealed that a MSE would be provided by a qualified medical provider for any individual presenting to the hospital's ED requesting treatment, or when a request was made on their behalf, for a potential Emergency Medical Condition or, in the absence of communication, displaying signs and/or symptoms indicative of a potential emergency condition. The Bylaws indicated that qualified medical providers were designated as a physician, physician assistant, nurse practitioner or a designated registered nurse.

Interview on March 6, 2013 at 10:20 p.m. with Emergency Medical Technician/Paramedic (EMT/P), and review of a written statement by the interviewee, who was on duty on February 26, 2013, and cared for patient #6, revealed, that a local nursing facility had dispatched a call for assistance/transport of a patient #6, who had pulled a tracheotomy tube out, (a tracheotomy tube-is a tube in the trachea that provides a method for breathing) and the opening in the trachea/stoma was actively bleeding. The EMT/P revealed that upon arrival to the nursing facility and entering the patient's room, while at bedside that patient began to cough and coughed up a clotted blood estimated to be about thirty centimeters (30 cc). The nursing facility staff placed a towel over the patients trachea/stoma, to catch any further blood that might be coughed out. The EMT/P stated, that a telephone call was made to Lower Oconee Hospital Emergency Department, and advised the ED that the patient had just coughed up the blood, and that the patient needed to be seen at the ED prior to the longer transport time to the next closest acute care facility. The EMT/P stated the nurse who answered the telephone call, stated it would be alright if EMS brought the patient to the ED at Lower Oconee. The EMT/P stated that enroute to the Lower Oconee ED, a radio call was made to the ED, with one minute and half estimated time of arrival. As EMS pulled into the awning covering the ED ramp, the ED physician and ED nurse, met the ambulance. The ED walked to the back of the ambulance, received a update status of the patient, including that the patient seemed stable, but had coughed up blood approximately 30 cc, then the ED physician advised the EMT/P to transport the patient to the closest next acute care facility.

Interview on March 6, 2013 at 9:30 a.m. with the Licensed Practical Nurse LPN #2, who was on duty in the ED the night of February 26, 2013, when EMS arrived in the ED driveway while transporting patient #6, revealed the ED physician #2 had advised the staff to divert stable EMS patients with a bleeding problem to the next closest facility. The LPN #2 reported that they heard a call dispatched on the scanner to the local nursing home. A patient that had pulled out a tracheotomy tube and was bleeding from the neck area.
Continued interview revealed, that when the ambulance arrived at the facility, thy LPN #2 and ED physician #2, met the ambulance in the driveway. The LPN stated the EMT/P confirmed that the patient's vital signs were stable and that the patient had an open airway with no risk of aspiration. The LPN stated the ambulance attendant also confirmed that they had functional suction equipment available in the ambulance. The interviewee reported that the EMT/P was advised to proceed to the next nearest acute care facility (approximately 15 minutes from this facility). The interviewee stated that patient #6 was not examined by the physician and that a MSE had not been performed.

Interview on March 6, 2013 at 9:00 a.m. with the ED physician #2, who was on duty February 26, 2013, when patient #6 was transported by EMS into the ED driveway confirmed that he/she advised the ED staff that if a patient being transported to the facility was stable but required blood work then they should be diverted to the next closest acute care facility. The physician stated that they heard on the scanner that EMS was picking up patient #6 from the local nursing home. The patient was bleeding after having pulled out a tracheotomy tube. The interviewee communicated with EMS and advised them to proceed to the next closest acute care facility if the patient had an intact airway and stable vital signs.
Continued interview revealed, that when the EMS ambulance pulled under the emergency overhang, the physician reported that he/she ran out to advise them that the facility had no working equipment available to assess the level of the patient's bleeding. ED physician #2, confirmed there was no MSE completed and that the patient was transported by EMS to the next closest acute care facility. The ED physician added that he/she reported the incident immediately to the Risk Manager. The interviewee stated remembering about an EMTALA case of "Powers versus Arlington", in which a facility was cited for an EMTALA violation when proper blood tests were not performed to determine a possible emergent condition.
The ED physician acknowledged that the equipment was broken to perform blood tests. In addition, there was no open operating room available if it was needed to replace the tracheotomy tube. The interviewee acknowledged that the decision was made in the patient's best interest to divert the patient to the nearby acute care facility. The interviewee added that they identified that the situation could have been handled better. Continued interview revealed that a meeting was held with the interviewee, the ED Medical Director and the Risk Manager. The interviewee stated that additional training and discussion related to EMTALA and Diversion Policy were provided on February 26, 2013. The physician reported that additional training and discussion was scheduled to be completed on March 12, 2013.

Interview on March 6, 2013 at 10:55 a.m. with the ED Medical Director revealed, an awareness of patient #6, who had been brought to the ED by EMS after the patient pulled out a tracheotomy tube. The ED Medical Director acknowledged that facility staff needed to assess a patient and complete an MSE if a patient present within 250 yards of hospital property. The interviewee was aware that, even if placed on diversion, the facility must assess and manage the care of a patient brought on to the facility's property. The interviewee reported that EMTALA training CD(Compact Disc) had been provided to all of the other physicians for review. Review of the facility's Medical Staff Meeting Minutes of February 23, 2013, revealed the facility policies related to diversion status in the ED and EMTALA policies were reviewed including a MSE of all patients presenting to the ED. Facility documentation was reviewed which confirmed that all ED staff had received updated training on the facility's ED Diversion Policy later the same day that patient #6 arrived on the ED property.

Review of the medical record from the receiving facility revealed that patietn#6 was admitted to the second ED. The patient was evaluated by the ED nurse and received a medical screening examination by the ED physician. The facility staff at the receiving hospital contacted the nursing home staff to determine the size trach tube that had been pulled out. Further review revealed that a new trach tube was inserted by the respiratory staff without complications.

The facility failed to ensure that their policy and procedures were followed as evidenced by: failing to ensure that on 2/26/2013 that patient #6 received a medical screening examination when he/she presented to the hospital via ambulance seeking medical treatment, which was within the capability and capacity of the hospital.

Based on review of facility policy and procedure titled, "EMTALA (Emergency Medical Treatment & Active Labor Act) Management and Compliance, and physician, staff and Emergency Medical Technician/Paramedic (EMT/P)interviews, it was determined that the facility failed to provide stabilizing treatment that was within its capability and capacity for one (1) patient (#6) of twenty (20) sampled patients.

Findings include:

Review of facility policy entitled "EMTALA (Emergency Medical Treatment & Active Labor Act) Management and Compliance", effective May 2009, page 1. . . To ensure that all persons presenting with an actual emergency medical condition are properly assessed and stabilized, and either admitted or transferred, per EMTALA requirements, to an appropriate medical receiving facility."

Interview on March 6, 2012 as conducted at 9:30 a.m. with Licensed Practical Nurse (LPN) #2, who was on duty in the ED on February 26, 2013, the night that the EMS arrived in the ED driveway while transporting patient #6, revealed that when the ambulance arrived at the facility, LPN #2 and the ED physician #2 met the ambulance in the driveway. The LPN #2 reported that the ambulance attendant was advised to proceed to the next nearest acute care facility (approximately 15 minutes from this facility). The LPN #2 stated that patient #6 was not examined by the ED physician #2 or LPN #2.

Interview on March 6, 2013 at 9:00 a.m. with ED physician #2, who was on duty in the ED on February 26, 2013, the night that the EMS arrived in the ED driveway while transporting patient #6, revealed the physician heard on the scanner that EMS was picking up patient #6, from the local nursing home. The patient was bleeding after having pulled out a tracheotomy (trach) tube. The interviewee communicated with EMS and advised them to proceed to the next closest facility if the patient had an intact airway and stable vital signs. When the EMS ambulance pulled under the emergency overhang the physician reported that he/she ran out to advise them that the facility had no working equipment available to assess the level of the patient's bleeding. The ED physician #2, confirmed that there was no MSE conducted. The facility failed to provide stabilizing treatment that was within the capability and capacity of the hospital for patient #6 on 2/26/2013.

Interview on March 6, 2013 at 9:00 a.m. room with EMT/P involved with the transportation of patient #6 from the local nursing home, confirmed that they were dispatched to the local nursing home to transport a patient who had pulled out a trach tube and was actively bleeding. The EMT/P reported the patient was transported to Lower Oconee ED and was met on the ramp by the ED physician and ED nurse. The interviewee observed the ED physician walked to the back of the ambulance and looked in then asked about the patient's condition. The interviewee reported that the patient did not appear to be in respiratory distress at that time and seemed fairly stable. The interviewee reviewed with the physician that the patient had previously coughed up the clotted blood. The EMT/P reported that the ED physician advised them to transport the patient to next closest acute care facility. The interviewee stated that the ED physician at Lower Oconee Hospital did not examine the patient prior to the patient being transported to the next closest acute care facility.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure stabilizing treatment was provided for patient #6 on 2/26/2013 when he/she presented to the hospital's property.

Based on review of facility policies and procedures including, "EMTALA (Emergency Medical Treatment & Active Labor Act) Management and Compliance", physician, staff and Emergency Medical Technician/Paramedic (EMT/P) interviews, it was determined that the facility failed to ensure an appropriate transfer was effected by failing to provide medical treatment that was with the capability and capacity of the hospital for one (patient #6) of 20 sampled patients.

Findings were:

Review of facility policy entitled "EMTALA (Emergency Medical Treatment & Active Labor Act) Management and Compliance", effective May 2009, page 1, "Purpose:" . . .To ensure that all persons presenting with an actual emergency medical condition are properly assessed and stabilized, and either admitted or transferred, per EMTALA requirements, to an appropriate medical receiving facility.

Review of the hospital's "Transfer Policy" revised August 2012, revealed in part, "RESPONSIBILITY: . . 1. In the event the physician deems it necessary to transfer a patient, he/she must explain the risks and benefits of the transfer to the patient or patient's representative. The patient's consent or refusal to be transferred must be documented in writing on he appropriate area of the transfer form; 2. The physician, the physician assistant, or nurse practitioner must sign a certificate of transfer that includes a summary of risks and benefits of the transfer;3. Nursing will be responsible for completing the appropriate forms. Information that must be documented includes a summary of the risks and benefits of the transfer; 4. Nursing will be responsible for completing the appropriate form in its entirety; 5. The transferring physician, the physician assistant. or Nurse Practitioner will be responsible for obtaining and documenting the accepting physician and facility that is receiving the patient; 6. The transfer form, ER record, ...will be copied and sent with the patient to the receiving facility."


Interview on March 6, 2013 at 9:30 a.m. with Licensed Practical Nurse (LPN) #2, who was on duty on February 26, 2013, in the ED the night that the EMS arrived in the ED driveway while transporting patient #6. The interviewee reported that the EMT/P was advised to proceed to the next nearest acute care facility approximately fifteen (15) minutes away from Lower Oconee Community Hospital. The LPN stated that after the ambulance left with the patient, a telephone call to the closest facility to inform them of the patient's pending arrival. The interviewee stated that patient #6 was not examined by the ED physician. The LPN also reported that there was no documentation of the patient being at the facility or on the property.

Interview on March 6, 2013 at 9:00 a.m. with ED physician #2 who was on duty the day, March 26, 2013, patient #6 was transported by EMS into the ED driveway. The ED physician #2 confirmed the statement of LPN #2, including there was no MSE and no stabilizing treatment given to patient #6. The physician reported that the patient was transported by EMS to the next closest acute care facility. The facility failed to ensure that medical treatment was provided on 2/26/2013 for patient #6, which was within the capability and capacity of the hospital. As this resulted in an inappropriate transfer for patient #6 on 2/26/2013.

Interview on March 6, 2013 at 9:00 a.m. with the Emergency Medical Technician/Paramedic (EMT/P) involved with the transportation of patient #6 from the local nursing home. The interviewee confirmed that they were dispatched to the local nursing home to transport a patient who had pulled out a trach tube and was actively bleeding. Prior to reaching the nursing home, they received a message over the radio to contact Lower Oconee Hospital ED. The EMT/P reported the ED physician advised them to transport the patient to the next closest acute care facility and the ED nurse was to notify the facility of the patient's pending arrival. The interviewee stated that the ED physician at Lower Oconee Hospital did not examine the patient prior to the patient being transported to the next closest acute care facility. The EMT/P reported that a call was the receiving facility enroute to give a patient report. The patient was transported to the receiving facility where the patient was received in their ED.

There was no documented evidence that the facility's ED physician had obtained nor documented the accepting physician and facility that was approximately 15 minutes away, as indicated by LPN #2. There was no documentation that the risk and benefits of the transfer was explained failed to the patient. Additionally there was no documented evidence that a transfer form or or other appropriate forms were completed by the nursing staff as indicated in the facility's policy. The facility failed to ensure that their Transfer Policy was followed for patient #6 on 2/26/2013.