Based on interviews with facility staff, interviews with other observers, review of medical records, and review of facility policies and procedures the facility failed to ensure that it was in compliance with the requirements of Section 1866 (a)(1)(l)(i) and 1867 of the Social Security Act by failing to provide a patient who presented to the hospital with: Findings: 1. The hospital failed to maintain a central log on each individual who "comes to the emergency department" seeking assistance whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged . (See C2405) 2. The hospital failed to provide an appropriate medical screening examination, within the capability of the hospital's emergency department to determine whether or not an emergency condition existed, for an individual who came to the emergency department (Patient 1). (See C2406) 3. The hospital failed to provide either within the capabilities of the staff and facilities available at the hospital further medical examination and treatment for Patient 1 as required to stabilize the medical condition or transfer the individual to another medical facility. (See C2407) 4. The hospital failed to provide certification signed by a physician that based on the information available at the time of transfer the medical benefits expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual. (See C2409)

Based on record review,interviews, and facility policy review, the facility failed to enter one of 30 sampled patients (Patient 1) into the emergency room log, when Patient 1 arrived at the facility emergency room to access medical care. This failure has the potential of not accurately reflecting the time of arrival, medical triaging and disposition of Patient 1. Findings: LN1 was working the Emergency Department (ED) on 10/10/15 and was interviewed on 10/22/15. According to LN 1, Patient 1 was involved in a motorcycle accident going "50-60 miles" an hour. Bystanders on the highway placed patient 1 in the back of their van and drove her to the facility's ED ambulance bay. According to LN 1, she and the Emergency Medical Technician (EMT 1) working in the ED that day went out to the van but were unable to get Patient 1 out of the van as her arm was wedged behind the car seat and she was in "A lot of pain" LN 1 said the patient was complaining of pain in her spine, neck, legs, left knee and the arm which was wedged under the seat. LN 1 said she told EMT 1 to go get the ED physician (EDP). LN 1 stated she went back into the ED to get a gurney and told EDP the patient had been in a motorcycle accident, was in pain and requested EDP to come outside to the ambulance bay and asses the patient. According to LN 1, EDP refused to go outside to assess the patient and instead said EMT 1 had called 911. LN 1 shared EDP stated "I am not going out there." LN1 attempted to get EDP to go outside again due to the patients pain but shared EDP stated "I am not going to give her anything for pain because I don't know if she is stable." According to LN 1 EDP instructed staff not to register the patient because according to EDP "Technically the patient isn't here." During a record review on 10/22/15, the requested emergency room log for 10/10/15, did not reflect Patient 1 as being registered into the log. During an interview with the Admission coordinator (AC1) on 10/23/15 at 4:05 p.m., AC1 recalled the events associated with Patient 1 on 10/10/15. AC1 stated, "Someone came to the desk and said an accident victim was coming in. LN1 told me to register the patient, later LN2 and others (AC1 could not recall who) told me to hold off from registering the patient, so I didn't register the patient." A review of facility policy titled "Transfers-EMTALA, Non EMTALA, SNF, Transfer From and Return for Medical Treatment," dated 11/07/13, indicated in part on pg. 7 of 9 "F. Documentation and Record Keeping, (second bullet) A central log for all individuals who come to the emergency room will be maintained for a minimum of five (5) years. A central log will be kept for every individual seeking emergency treatment in the ED, Labor and Delivery, Pediatrics, etc. The log includes all patients whether he/she refused treatment, was transferred, admitted , stabilized and transferred, or discharged . The log will include disposition of all patients."

Based on interview, record review and review of facility policy and procedures, the facility failed to have one of 30 sampled patients (Patient 1) medically screened by an emergency room physician. This failure delayed the rendering of emergency medical services for Patient 1. Findings: LN1 was working the Emergency Department (ED) on 10/10/15 and was interviewed on 10/22/15. According to LN 1, Patient 1 was involved in a motorcycle accident going "50-60 miles" an hour. Bystanders on the highway placed patient 1 in the back of their van and drove her to the facility's ED ambulance bay. According to LN 1, she and the Emergency Medical Technician (EMT 1) working in the ED that day went out to the van but were unable to get Patient 1 out of the van as her arm was wedged behind the car seat and she was in "A lot of pain" LN 1 said the patient was complaining of pain in her spine, neck, legs, left knee and the arm which was wedged under the seat. LN 1 said she told EMT 1 to go get the ED physician (EDP). LN 1 stated she went back into the ED to get a gurney and told EDP the patient had been in a motorcycle accident, was in pain and requested EDP to come outside to the ambulance bay and asses the patient. According to LN 1, EDP refused to go outside to assess the patient and instead said EMT 1 had called 911. LN 1 shared EDP stated "I am not going out there." LN1 attempted to get EDP to go outside again due to the patients pain but shared EDP stated "I am not going to give her anything for pain because I don't know if she is stable." According to LN 1 EDP instructed staff not to register the patient because according to EDP "Technically the patient isn't here." EMT 1 was interviewed on 10/23/15 at 2:00 p.m. According to EMT1, on 10/10/15, sometime after 4 p.m., she overheard a request for help to get a patient out of a car in the ambulance bay (Patient 1). EMT 1 took a wheelchair out to the van to help the bystanders get the patient out of the car and into the emergency department (ED). EMT1 stated, "The patient was crying in pain, and complaining of pain in her lower back and one knee, the patient said she could not sit up." EMT 1 shared he had seen LN1 go out to the ambulance bay to see the patient and recalled LN1 had requested EDP to assess the patient more than once but was refused. During an interview with LN2 on 10/28/15 at 8:40a.m., LN2 indicated that on 10/10/15 she received a call from LN1 who indicated there was a trauma case in the ED bay and EDP would not see the patient. LN2 recalled going to the ED and requesting EDP to see the patient. According to LN2, she and the EDP went out to the ambulance bay and watched the fire department but EDP offered no advice or assessment. During an interview with Fire Department Staff (FD1) on 10/28/15 at 5 p.m., FD 1 recalled the events of 10/10/15 and Patient 1. According to FD1, the initial call was hospital needs assistance with transferring a patient out of the car. FD 1 said when he arrived on the scene a mini-van was parked in the ambulance bay outside of the ED, there were civilian bystanders who directed me to the van. FD 1 recalled there was no hospital staff in attendance, but he saw several staff just looking out of the ED window. FD 1 recalled getting the patient onto a spinal board (a devise used primarily in pre-hospital trauma care, designed to provide rigid support during movement of a patient with suspected spinal or limb injuries) and about 2-5 minutes into the call, two ED staff members came out of the ED they were like "looky-loos." FD 1 recalled asking the staff if the FD should bring the patient into the ED but got no response. According to FD1 the patient was not seen at the facility but rather transferred to a nearby trauma center. During an interview with the EDP on 11/23/15 at 8:30 a.m., EDP acknowledged standing approximately 6-8 feet away from the van with LN 2. EDP shared the patient was awake and alert, but that EDP did not speak with or assess the patient. According to EDP she felt the patient met the criteria for a direct transfer to the trauma center. The EDP acknowledged she did not medically screen or asses Patient 1, nor did she direct the ED staff to move the patient into the ED or direct the fire department staff or ambulance staff to move the patient into the ED. The EDP stated "I don't know what happened, I know what should have happened." On 10/22/15, a review of the records for Patient 1 was requested. There was no record of an emergency department visit for Patient 1 on 10/10/15 at the facility. A review of facility policy titled "Transfers-EMTALA, Non EMTALA, SNF, Transfer From and Return for Medical Treatment," dated 11/07/13, indicated in part on pg 4 of 9 "VII. EMTALA Transfers, Procedures: A. Medical Screening Examination, 1. All individuals on hospital property seeking examination of treatment will be provided a medical screening examination to determine if an emergency medical condition exists. The medical screening will be performed within the capacity and capabilities of the hospital, including ancillary services, resources routinely available, and on-call providers as may be indicated. The physician or qualified medical person shall determine if an emergency medical condition exists."

Based on interviews, record reviews and review of facility policy and procedures, the facility failed to have patient 1 evaluated and stabilized by an emergency room physician prior to Patient 1 transferring to another facility. This failure had the potential of delaying emergency medical services and stabilization of Patient 1. Findings: LN1 was working the Emergency Department (ED) on 10/10/15 and was interviewed on 10/22/15. According to LN 1, Patient 1 was involved in a motorcycle accident going "50-60 miles" an hour. Bystanders on the highway placed patient 1 in the back of their van and drove her to the facility's ED ambulance bay. According to LN 1, she and the Emergency Medical Technician (EMT 1) working in the ED that day went out to the van but were unable to get Patient 1 out of the van as her arm was wedged behind the car seat and she was in "A lot of pain" LN 1 said the patient was complaining of pain in her spine, neck, legs, left knee and the arm which was wedged under the seat. LN 1 said she told EMT 1 to go get the ED physician (EDP). LN 1 stated she went back into the ED to get a gurney and told EDP the patient had been in a motorcycle accident, was in pain and requested EDP to come outside to the ambulance bay and asses the patient. According to LN 1, EDP refused to go outside to assess the patient and instead said EMT 1 had called 911. LN 1 shared EDP stated "I am not going out there." LN1 attempted to get EDP to go outside again due to the patients pain but shared EDP stated "I am not going to give her anything for pain because I don't know if she is stable." According to LN 1 EDP instructed staff not to register the patient because according to EDP "Technically the patient isn't here." During an interview with the EDP on 11/23/15 at 8:30 a.m., EDP acknowledged standing approximately 6-8 feet away from the van with LN 2. EDP shared the patient was awake and alert, but EDP did not speak with or assess the patient. According to EDP she felt the patient met the criteria for a direct transfer to the trauma center. The EDP acknowledged she did not medically screen, assess, or treat Patient 1, nor did she direct the ED staff to move the patient into the ED or direct the fire department staff or ambulance staff to move the patient into the ED for screening and stabilizing treatment. The ED Physician stated "I don't know what happened, I know what should have happened." A review of facility policy titled "Transfers-EMTALA, Non EMTALA, SNF, Transfer From and Return for Medical Treatment," dated 11/07/13, indicated in part on pg 2 of 9 "IV. EMTALA Definitions Stabilize: To provide medical treatment of the emergency medical condition necessary for a physician to assure, within reasonable clinical confidence and medical probability, that no material deterioration of the condition or reasonably foreseeable harm is likely to result from, or occur during transfer of the individual from the facility...." Page 3 of 9 of the same policy under "VI Responsibilities of the Transferring Physician and Hospital #1. The transferring physician must determine whether the patient is "medically fit" to transfer. State and federal law required that before a patient is transferred to another facility, the patient must be sufficiently stabilized to be safely transported. The transferring physician is responsible for determining whether the patient's condition will allow transfer."

Based on record review, interview and review of facility policies, the facility failed to obtain physician signed certification of risk and benefits of transfer to another facility for eight (Patient 6,7,11,12,20,21,24,and 26) of 30 patients sampled. This failure did not ensure risks and benefits were explained to the patients' at transfer. Findings: The facility policy and procedure titled, "Transfers- EMTALA-Non-EMTALA-SNF,Transfer from and Return for Medical Treatment" dated 11/7/13, pg. 4 of 9 indicates in part, "A patient with an emergency medical condition may be transferred only upon a transfer request or physician certification..... Physician Certification: A physician has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh any increase risks to the patient and in the case of labor to the unborn child from effecting the transfer. The physician should complete and sign the "Physician Certification" form as close to the time of transfer as possible.................." During a record review on 11/30/15 starting at 8a.m., the transfer records for sampled Patient's 6,7,11,12,20,21,24,and 26 did not contain physician signed certification of risk and benefits documentation for transferring to another hospital on the transfer forms. Sampled Patient 11 lacked a transfer form and the corresponding documentation of the risk and benefits to transferring to another hospital. During an interview with the QIM, on 11/30/15 starting at 8 a.m., she acknowledged the missing documentation of the physician signed certification of risk and benefits of transferring to another hospital for sampled Patient's 6,7,11,12,20,21,24,and 26.