Based on review of medical records (MR), emergency department (ED) log, facility's policies and procedures, facility's Medical Staff Bylaws Rules and Regulations, and interviews, it was determined the assigned ED physician failed to assess and treat Patient Identifier (PI) # 4, a patient the facility had the capacity and capability to treat. This affected PI # 4, 1 of 25 ED MR reviewed and had the potential to affect all patients seeking medical screening and treatment in the ED. PI # 4 ultimately left the ED because there was no physician onsite to perform a medical screening. Findings include: Facility Policy Subject: emergency room Coverage Date: 8/22/17 "The Georgiana Medical Center emergency room (ER) is organized under the direction and supervision of the medical staff. Supervision by a physician to a nurse practitioner means that the physician is readily available by phone, text and face to face in a timely manner." Facility Policy and Procedure Subject: Guidelines for Patients in ER Date Revised: 9/2008 Policy Number: ER 507.57 Policy: It is the policy of Georgiana Hospital to ensure that all patients receive quality care within the standards set forth for ER patients. Procedure: 1. Assessment: a. All patients will be triaged per a registered nurse (RN) on admission to ensure appropriate care is provided according to condition... d. Assisting patients with needs. e. Assisting physicians with procedures and positioning of patients... Facility Policy and Procedure Subject: Admissions of Patients to emergency room Date Revised: 9/2008 Policy Number: ER 501.40 Policy: To ensure treatment for all persons seeking care in the emergency room . Procedure: 1. Patients who present to the ER will be triaged as emergent or non-emergent and referred to appropriate area for treatment... 2. The ER nurse is responsible for obtaining and recording accurate information on the ER form including: ... 4. Nursing personnel are responsible for notifying the attending physician, recording any verbal orders given on the ER record, and implementing the doctor's orders... 6. Quality Assurance report should be completed and forwarded to the Director of Nursing or the QA Supervisor no later than 24 hours for those patients that have left against medical advice (AMA) or for any unusual occurrences. Facility Policy and Procedure Subject: Standing Order for Emergency or Life Threatening Situation Date Revised: 10/2008 Policy Number: ER 501.40 Policy: It is the policy of Georgiana Hospital to notify the on-call physician on any patient after triage, to notify him/her of the patient, the complaint and condition and initiate any orders given... Title: Georgiana Medical Center Medical Staff Bylaws Rules and Regulations Purpose: The purpose of the organization shall be: 1. To maintain a qualified medical staff whereby each patient admitted to or treated in any of the departments or services of the hospital shall receive quality medical care of the same level as well as other patients in the hospital with the same health problems... Section 6 - Basic Responsibilities of Individual Staff Membership ... The ongoing responsibilities of each member of the Medical Staff include: A. Providing patients with the quality of care meeting the professional standards of the medical staff of the hospital... H. Making appropriate arrangements for coverage for his patients as determined by the medical staff... K. Participating in emergency service coverage or consultation panels as may be determined by the Medical Staff... Rules and Regulations... 19. The hospital and the medical staff shall ensure Emergency Medical Treatment & Labor Act (EMTALA) compliance and Health Insurance Portability and Accountability Act (HIPAA) compliance as required by the CMS (Centers for Medicare & Medicaid) guidelines. 20. The hospital shall evaluate and/or offer treatment to all patients whose conditions warrant such care... Review of PI # 4's ED MR revealed PI # 4 presented to Hospital's ED via personal vehicle on 10/14/18 at 8:30 AM. PI # 4 was triaged by employee identifier (EI) # 3, Registered Nurse (RN) at 8:30 AM. EI # 3 informed PI # 4 that he/she will call the ED physician so that he/she could come to the facility to treat PI # 4. Review of PI # 4's ED MR revealed the physician was contacted at 8:50 AM. PI # 4 asked EI # 3 when was the ED physician going to arrive at the facility and EI # 3 stated the physician said he/she was on her way at 8:50 AM. PI # 4 waited for the ED physician to arrive until 10:11 before he/she decided to leave the ED. EI # 3 asked PI # 4 to sign an AMA form. PI # 4 signed an AMA form. The facility failed to provide a medical screening and treatment for PI # 4. On 10/15/18 PI # 4's AMA event was investigated by EI # 4, RN which revealed the following documentation: " ... Practitioner/Nurse Comments: Pt. (patient) presented to the ER with complaint of abscess under left (L) arm. Pt. had been triaged and awaiting MD (physician). Nurse notified MD X (times) 2 and also informed patient that MD was coming. Pt stated she had to leave to go home to his/her children. ... Description Investigation Brief description of occurrence: Pt had been triaged per RN was awaiting MD (physician) to see her. Had spoken with MD twice stating she/he was on his/her way..." PI # 4 left the ED AMA without having a medical screening and/or treatment because there was no physician onsite in the ED on 10/14/18 from 8:30 AM until 10:11 AM. An interview was conducted on 1/30/19 at 3:00 PM with EI # 3, RN, to determine the process for ED patient screening and treatment response time. EI # 3 stated, if the physician is not present in the ED when a patient presents to the ED, the RN will triage the patient and notify the physician. The physician may give verbal orders for various tests to be done. The physician's general response time to see a non-emergent patient is within an hour or an hour and a half. The physicians' general response time for emergent cases is immediately (within 5 minutes). The surveyor asked EI # 3, what the physician said on 10/14/18 concerning his/her arrival time to ED to see PI # 4. EI # 3 stated the physician told her/him that he/she would be there in a "little while." The surveyor asked EI # 3, if the physician has not arrived within the expected 45 minutes to an hour what would be the facility's protocol? EI # 3 stated if the physician has not arrived within 45 minutes to an hour the physician would be called again to follow up. The surveyor asked EI # 3 did you make a follow up call concerning PI # 4 awaiting services in the ED. EI # 3 stated the physician was contacted X 2 and she/he stated she/he was on the way. The surveyor asked EI # 3 if he/she know how far the physician would have to travel to the ED. EI # 3 stated the physician lives about a block and a half from the hospital. An interview was conducted on 1/30/19 at 3:20 PM with EI # 4, RN. The surveyor asked EI # 4 what the expected response time is for the ED physicians to see a patient presenting with a non-emergent case. EI # 4 stated within a 30 minute window. The surveyor asked EI # 4 what the expected response time is for the ED physicians to see a patient in an emergent case. EI # 4 stated, immediately (within 15 minutes). Review of the AMA investigation conducted on 10/15/18 revealed "follow-up: Pt. stated she/he will follow up with her/his primary physician." The surveyor asked EI # 4 if he/she followed up with the patient during his/her investigation dated 10/15/18 and EI # 4 stated, "No." An interview was conducted on 1/31/19 at 8:38 AM with EI # 5, Chief of Staff. The surveyor asked EI # 5, about the facility's process for notifying the ED physicians of patient arrival and need for screening and treatment and the physicians' expected response time to non-emergent and emergent cases. EI # 5 stated, from 8 AM - 5 PM the registration clerk will call the nurse and the nurse will notify the physician. If the patient looks seriously ill the nurse will call and say immediate. The response time frame for non-emergent depends on the RN assessment and what the patient looks like. I may order labs before I arrive. It may be 2 to 3 hours to have all ordered test results and then I will see the patient. The surveyor asked EI # 5, what is the response time for emergent cases? EI # 5 stated, I live 5 minutes away and I will see the patient usually within 10 to 15 minutes of being notified by the RN. EI # 5 also stated, "We follow the state licensure guidelines to see patients within 30 minutes." A telephone interview was conducted on 1/31/19 at 7:54 AM with PI # 4, who verified he/she went to the ED on 10/14/18 at 8:30 AM. The surveyor asked PI # 4 can he/she recall what took place during his/her ED visit. PI # 4 stated, "Yes." PI # 4 stated, "I went to the ED to be treated for an abscess under my left arm and I was in severe pain. The nurse told me that the doctor was not at the hospital but he/she was on the way. I asked the nurse, how long will it take for the doctor to come and the nurse stated, this one (physician) is usually late. I stayed almost 2 hours. They usually are late when I come to the ED but not this late. I told the nurse I was going to leave because the doctor was taking too long to come and I was in too much pain to just be sitting in the ED. The nurse asked me to sign an AMA form and I did. I asked the nurse if I was going to be billed for the ED visit and she/he said yes because they took vital signs. I was going to go to Evergreen Hospital but I decided to apply a hot rag to the abscess site after I spoke with my grandmother. The abscess erupted the same day and the pain resolved. I did not seek further treatment." A telephone interview was conducted on 2/1/19 at 9:04 AM with EI # 6, Physician covering ED on 10/14/19. The surveyor asked EI # 6, what is the expected timeframe for nursing staff to contact the ED physician once a patient presents to the ED. EI # 6 stated, the nurse will work up the patient and then call the doctor (they would call right away). The surveyor asked EI # 6, what is the general response time for an ED physician to see emergent patients. EI # 6 stated, there is no set timeframe. We try to see patients as fast as we can (I try to see non-emergent cases within 20 to 25 minutes). EI # 6 stated I see emergent cases right away. The surveyor asked EI # 6, if he/she recalled why it took from 8:50 AM until 10:15 AM for you to arrive to the ED on 10/14/19? EI # 6 stated, on the weekend I generally round on patients at Georgiana Medical Center. The surveyor asked EI # 6 if he/she was in the hospital on [DATE] at 8:30 AM until 10:11 AM. EI # 6 did not answer the question. EI # 6 stated, "If it was an emergency I would have been there." It wasn't clear what was meant by non-emergent and emergent patients as they are all in the emergency room . It was determined through review of PI # 4's MR, ED log, staff interviews, and patient interview, the facility had the capacity and capability to screen and treat PI # 4. PI # 4 did not receive medical screening and treatment because the ED physician was not in the ED. On 2/1/18 at 11:13 AM an interview was conducted with EI # 7, Chief Executive Officer. The surveyor asked EI # 7 who is qualified to perform medical screening examinations? EI # 7 stated, "The physician is the qualified screening person for the ED." On 2/1/19 a review of the facility's policies and procedures, and Medical Staff Bylaws, and Rules and Regulations revealed there was no documentation of who was authorized to perform a medical screening examination, and/or a specific response timeframe for ED physicians to respond in order to see patients.