Based on Medical Staff Rules and Regulations, clinical record review and interview, it was determined the facility failed to assure Emergency Department (ED) physician's orders for discharge were signed and dated for 14 (#12 through #20, and #23 through #27) of 16 ( #12-#27) ED patients and physician's orders for admission, diagnostic studies, and medications were dated and timed for 5 (#13, #14, #16, #22 and #24) of 16 (#12-#27) ED patients. Failure to sign, date, and time physician's orders did not ensure medical staff were following the facility Rules and Regulations and did not ensure staff knew the time frame for the orders. The failed practice had the potential to affect Patients #12 through #20 and #22 through #27. Findings follow: A. Review of the Medical Staff Rules and Regulations received on 11/08/18 showed all clinical entries in the patient's medical record were to be accurately dated, timed, and authenticated. B. Review of the discharge orders for Patients #12 through #20 and #23 through #27 did not show a dated signature. C. Review of the ED orders for Patient #13, #14, #16, #22 and #24 showed ER orders for admission, diagnostic studies, and medications were not dated or timed. D. During an interview with the Chief Nursing Officer at 2:25 PM on 11/07/18 the findings in B and C were verified. Based on policy review, review of Crash Cart Check Records, and interview, it was determined the facility failed to ensure three of three (Trauma #1, Trauma #2, and Cardiac) crash carts were checked every shift. Failure to check crash carts every shift did not ensure all components of the crash cart were in working order in the event of an emergency and had the likelihood to affect any patient needing services involving the crash cart. Findings follow. A. Review of policy titled, "Crash Carts - Inspection, Maintenance, and Exchange" showed, "The crash cart shall be checked each shift by licensed nursing personnel to: a) Verify the integrity of the locks. b) Assure that all equipment on the top and sides of the crash cart is available. c) Assure functioning of monitor/defibrillator." B. Review of Crash Cart Check Records for 06/01/18 through 11/04/18 showed the following: 1) Trauma #1 was not checked for 48 shifts. 2) Trauma #2 was not checked for 46 shifts. 3) Cardiac was not checked for 34 shifts. C. During an interview on 11/05/18 at 10:00 AM, the emergency room Manager confirmed the crash cart checks had not been done.

Based on review of the emergency room (ER) Daily Log, Medical Staff Rules and Regulations review, policy and procedure review, and interview, it was determined the facility failed to accurately and completely record Patient #1's ER presentation into the ER Log. Failure to enter Patient #1's name into the ER Log did not allow the facility to track Patient #1's presentation and treatment. The failed practice affected Patient #1 on 04/26/17. Findings follow. A. Review of policy titled "Admission of Patient to Emergency Department, EMTALA Regulations" stated, "All patients must be logged in and a permanent record produced." B. Review of Medical Staff Rules and Regulations stated under "General Rules Regarding Emergency Services: An appropriate medical record shall be kept for every patient receiving emergency service and be incorporated into the patient's hospital record, if such exists. The record shall include: Adequate patient identification; Information concerning the time of the patient's arrival, means of arrival and by who transported ...". C. Review of the ER Log revealed Patient #1 (MDS) dated [DATE] at 1729. Review of the clinical record of Patient #1 revealed he left, and returned to the ER at 1915. The ER Log revealed no evidence of Patient #1's second presentation to the ER.

Based on clinical record review, policy review, ER log review, and interview, it was determined the facility failed to ensure Patient #1 received an appropriate and timely medical screening exam (MSE) for one of two visits to the Emergency Department (ED) on 04/26/17. Failure to provide a timely MSE did not ensure the facility was aware of whether or not Patient #1 had an emergency medical condition, which caused a delay in treatment. The failed practice affected Patient #1 on 04/26/17. Findings follow. Patient #1 first (MDS) dated [DATE] at 1732, with complaints of nausea and vomiting. The patient was triaged and had an extended wait in the waiting room. The patient's spouse went up to admissions several times, to see when the patient was going to be seen. Licensed Practical Nurse #1 was interviewed on 05/24/17 from 0926-0936 and confirmed the patient had been triaged on the prior shift and stated "the physician was not notified the patient was in the ED, because he had not been brought back and put into a room. The medical screening exam is done when the Patient is taken back to a room." The patient's spouse called 911 from the waiting room because she was trying to get her husband into the ED to be seen faster. Since 911 refused to come to the waiting room, the patient and spouse then left the ED and called 911 from outside the facility. The patient and spouse walked down the street so he could be picked up by EMS. The patient was returned to the same ED by EMS. Per the patient's medical record, documentation of the patient's second visit started at 1918. For the first visit, there is no medical record for review except for triage notes. There is no documentation to support the patient was evaluated or re-evaluated while in the ED waiting to be seen if there was a long wait. The patient did not receive an appropriate and timely medical screening exam during the first presentation. During the second visit, the patient was being treated, but went into a cardiac arrest. CPR was unsuccessful and the wife discontinued their efforts at 2251, and the patient expired. Review of policy titled "Admission of Patient to Emergency Department, EMTALA Regulations" stated, "C. A physician, nurse practitioner or physician assistant must do a medical screening on each patient to determine if an emergency exists. If no emergency exists, EMTALA is not involved. D. The medical screening must use all resources of the hospital, as deemed necessary, from laboratory, radiology, and even consultation to decide if an emergency exists. E. Treatment and management must then follow. F. EMTALA involves all of the above and also the stabilization and transfer, if necessary, of the patient."

Based on review of documents and interview it was determined the entry in the emergency room Daily Log for Patient #21 who presented to the emergency room (ER) for treatment on 10-05-16 was not complete. Incomplete information on the emergency room Daily Log prevented the patient's care being accurately assessed for treatment. This failed practice affected Patient #21 that was named in the Self Report and had the potential to affect all patients that presented to the emergency room requesting emergency treatment. Findings follow: A. Review of the emergency room Daily Log October 2016 did reveal the name of Patient #21 which was the minor Patient named in the Self Report. Review of the emergency room Daily Log revealed Patient #21 presented on [DATE] to the emergency room and a medical record number was generated at that time. There was no disposition listed for Patient #21 nor was there documentation of why Patient #21 presented to the emergency room . B. On 12-01-16 at 1215 the Surveyor talked with the Administrator and requested the medical record for Patient #21 that presented to the emergency room . The Administrator on 12-02-16 at 1345 stated there was no medical record for Patient #21 available for review it had been deleted.

Based on review of policies and procedures, Medical Staff Bylaws, Emergency Daily Log, interview and Self Report, it was determined Patient #21 presented on [DATE] requesting emergency services and did not receive a medical screening exam. Failure to conduct a medical screening exam did not give the physician enough information to determine if an emergency medical condition existed. This failed practice affected Patient #21 and had the likelihood of affecting any patient that presented to the emergency room requesting emergency services. Findings follow: A. Patient #21 presented on [DATE]. There was no medical record for the Surveyor to review to determine if a medical screening exam was conducted. B. Review of the Medical Staff Bylaws on 11-30-16 at 1215 revealed no documentation who could perform a medical screening exam. The Director of Quality and the Chief Nursing Officer verified at 1440 on 11-30-16 there was no evidence in the Medical Staff Bylaws of who could perform the medical screening exam, however a policy titled "Admission of Patient to Emergency Department" Number: ER-A8.0 II. Policy: C. reflected A physician must do a medical screening on each patient to determine if an emergency exists ...". C. Review of the Emergency Daily Log revealed Patient #21 presented at 2347 on 10-05-16. emergency room physician documented on the Daily Log as Dr. (Named). The Self Report that was submitted regarding Patient #21 revealed an interview by the Chief Nursing Officer, conducted 10-13-16, with the emergency room Physician on duty. The emergency room physician "was interviewed and asked if he recalled Patient #21 coming into the emergency room . He said "I do not."... D. The Self Report submitted by the Facility revealed an interview conducted by the Chief Nursing Officer, with the nurse on duty when Patient #21 presented, on 10-13-16 which stated "...I spoke with the patient's (Patient #21) mother and informed her of options of going to (Named) hospital or being treated here. I did state several times that we would be glad to treat here. The mother and grandmother then decided to take the patient (Patient #21) elsewhere...". E. The Surveyor requested the medical record for Patient #21. The Administrator on 12-02-16 at 1530 verified there was no medical record available for review. There was no evidence a medical screening exam was provided to Patient #21.

Based on clinical record review and interview, it was determined the Facility failed to fully disclose the risks and benefits of transfer specific to the condition of transferred patients. Failure to fully disclose the risks and benefits did not allow four (Patients #3, #4, #6 and #14) of four (Patients #3, #4, #6 and #14) transferred patients to make an informed decision regarding the need for the transfer along with associated risks and benefits particular to the patient's medical condition. The failed practice was likely to affect Patients #3, #4, #6 and #14. Findings follow: A. Review of the clinical records of Patients #3, #4, #6 and #14 revealed no evidence of the risks and benefits specific to the condition for which the patient was being transferred. For example: 1) Patient #3 presented 09-30-16 at 0929 with laceration to the fourth and fifth finger of left hand. Review of a form (no name) in the clinical revealed "Risks of transfer - worsening of condition. Benefits of transfer- orthopedic care". 2) Patient #4 presented 08-23-16 at 2225 with right lower quadrant pain. Review of a form (no name) in the clinical record revealed "Risks of transfer - motor vehicle accident. Benefits of transfer- pediatric surgeon". 3) Patient #6 presented 11-02-16 at 2238 with gun shot wound. Review of a form (no name) in the clinical record revealed "Risks of transfer - worsening of condition. Benefits of transfer - eval (evaluation) and treatment of gsw (gun shot wound)". 4) Patient #14 presented 11-26-16 at 1805 with red irritated area on back. Review of a form (no name) in clinical record revealed "Risks of transfer- worsening of condition. Benefits of transfer- surgical cover". B. The above findings were verified by the emergency room Nurse Manager at 1220 on 08/02/16.