Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in §489.24, related to Emergency Medical Treatment and Labor Act (EMTALA) requirements. Tag A2406 - Medical Screening Exam - Based on interviews and document review, the facility failed to ensure a Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided in 2 of 21 records reviewed (Patients A and #15).

Based on interviews and document review, the facility failed to ensure a Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided in 2 of 21 records reviewed (Patients A and #15). Facility findings: Facility policy: The Admission to the emergency room and EMTALA policy read, all patients presenting to the emergency room will be triaged by the registered nurse (RN) on duty, screened by the qualified medical provider and receive a medical assessment per EMTALA guidelines. A medical screening examination is an ongoing process. Evaluation must be in evidence prior to discharge or transfer. According to the policy the medical screening examination includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an emergency medical condition. 1. The facility failed to ensure patients presenting to the emergency department seeking emergency medical care received a medical screening exam. a. Review of an emergency medical service (EMS) Prehospital Care Report, completed on 1/3/19, showed the ambulance received an emergent call for an elderly male (Patient A) with a fever and weakness. According to the report the patient's oxygen saturation (a measurement of how much oxygen red blood cells are carrying) was "low in the 80s." The patient required oxygen (O2) to be administered at 6 liters for a O2 saturation of 93% (normal is above 92%). The patient's temperature was documented at 101.6 degrees Fahrenheit (normal temperature is 98.6 degrees Fahrenheit). Additionally, the patient complained of pain on inhalation and had some wheezing (a high-pitched whistling sound made while breathing, often associated with difficulty breathing). The report noted the hospital was contacted, advised of the patient's history and vital signs, and the estimated time of arrival. Documentation in the report noted "upon arrival at the hospital once inside" EMS was advised the hospital was full and EMS would have to take the patient to another hospital. EMS "loaded the patient back into the ambulance and diverted" to another hospital approximately 50 miles away. According to the report the patient "said it would be ok." Review of a hospital Incident Report, dated 1/2/19 and completed by Chief Nursing Officer (CNO) #1, documented EMS brought a patient to the emergency department (ED), not aware the hospital was going on divert. According to the report when the ambulance driver "saw how busy" the facility was stated maybe we should go to another hospital. CNO #1 answered "OK if ok [with] the patient." During an interview, on 2/5/19 at 1:06 p.m., CNO #1 stated she was in the ED when EMS arrived on 1/2/19. CNO #1 stated the facility had been extremely busy all day and currently had four patients in the ED. CNO #1 stated she heard the "radio traffic" that EMS was heading towards the hospital and mentioned the hospital probably needed to go on divert. CNO #1 stated she was at the nurses station when the EMS provider came in and they discussed that maybe the patient needed to go to another hospital. CNO #1 stated she was alright with that if the patient was "ok with it." CNO #1 reported "it was a problem with what I said;" the patient should have come in, received a medical screening and the hospital could have transferred him. CNO #1 stated it was extremely busy and she had "never been that overwhelmed." CNO #1 stated "I didn't know how we were going to handle all of this; we don't do that anymore." CNO #1 stated the last EMTALA training she had received was in the summer of 2018 and acknowledged there had been no additional training since the incident on 1/2/19. CNO #1 stated EMTALA "never crossed my mind; I was thinking how long was he going to have to wait." The CNO reported the physician was never made aware an ambulance had arrived at the hospital. On 2/5/19 at 3:30 p.m., Physician #3, who was on duty on 1/2/19, was interviewed. Physician #3 stated she remembered the date of the incident as the facility was nearly full. She stated a few days later she overheard staff talking about a possible situation where the ambulance had come to the facility and was told to turn around. Physician #3 stated she didn't know until then that the ambulance had actually come to the hospital and stated the hospital had to see patients when they were "on your property." b. Review of the Emergency Nursing Record, revealed Patient #15 (MDS) dated [DATE] at 2:29 p.m. According to the triage, the patient's chief complaint was back pain, headaches and a sore throat off and on for one week. Registered Nurse (RN) #6 documented, in the nursing record, the patient was "triaged" over to the "clinic" to be seen by Physician Assistant (PA) #5 at 2:45 p.m. Under the section, titled Disposition, RN #6 documented the patient was "triaged by on-call provider to be seen in the clinic [at] this time." According to the ED Triage Notes, the patient's mother wanted the patient seen related to chronic back pain and headaches for one week as the patient had been missing several days at school. Review of the Discharge Summary, dated 12/13/18 at 2:45 p.m., showed PA #5 documented under Condition, the patient was "Triaged by on call provider to be seen in the clinic. Patient was seen by me for screening medical exam and sent to clinic." However, there was no documentation in the medical record of the medical screening exam, which included an assessment based on the patient's chief complaint, and to determine the presence or absence of an emergency medical condition. On 2/7/19 at 10:28 a.m., CNO #1 stated PA #5 was not available for an interview as she was offsite. On 2/7/19 at 11:14 a.m. Employee #7 presented an unsigned typewritten note, dated 2/7/19, identified as an addendum to Patient #15's ED visit on 12/13/18. Employee #7 stated PA #5 just typed the noted and emailed it to her. Employee #7 stated the note would now become part of the record but stated it had "just been typed up" and wasn't signed as PA #5 was offsite and had emailed it to her. During an interview, on 2/7/19 at 10:51 a.m., Physician #3 reviewed Patient #15's medical record and acknowledged there was no documented medical screening examination (MSE) in the record. Physican #3 stated she would expect to at least see acknowledgment of the patient's nursing triage and vital signs. Additionally, Physician #3 stated there should be objective assessment data reflecting completion of the MSE. Physcian #3 stated the facility utilized a T Sheet (template based documentation) for nursing and the facility should probably utilize one for physicians as well.

Based on interviews and record review the facility failed to ensure patients requiring a higher or specialized level of care were transferred appropriately pursuant to EMTALA (Emergency Medical Treatment and Labor Act) in 2 of 11 medical records reviewed in which patients where transferred out of the facility (Patient #7 and #12). Findings include: Facility policy: The policy, Emergency Department Transfer of Patients read, documentation of patient stabilization had been prepared by a physician or qualified medical person in consultation with a physician. The policy also read, the transferring hospital should document its communication with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer. The receiving facility must ensure it has available space and qualified personnel for the treatment of the individual, and has agreed to accept the transfer of the individual and to provide appropriate medical treatment. The policy, Admission to the emergency room read, the provider shall determine whether the patient had an emergency medical condition and if necessary, stabilize the patient and/or admit the patient or initiate a transfer under medical necessity. The policy, Transfer of Patients: For a Patient Being Transferred to Another Health Care Facility read, the primary care provider was responsible to notify the receiving primary care provider and institution. The policy also read, the facility must copy appropriate medical records and complete patient transfer forms and orders, including a nursing summery and a care plan for the receiving facility. 1. The facility failed to ensure the receiving facility agreed to accept the patients for transfer and provide available documentation including patient consents. a. Patient #7 (MDS) dated [DATE] at 12:37 p.m. with contractions. The patient was documented to be 40 weeks and three days pregnant with her fourth child. At 12:44 p.m. Patient #7 was examined by Physician #4 and according to emergency department provider assessment the patient was experiencing contractions two to three minutes apart with no loss of fluid or bleeding. At 12:49 p.m. Physician #4 documented Patient #7 needed to be transferred to a different facility (Facility B) for further labor and delivery care and that delivery was not imminent at that time. At 12:54 p.m., according to the prehospital report the patient was transported out of the facility by ambulance to Facility B. Further documentation revealed RN #11 told the emergency medical technician (EMT) to take the patient prior to all paperwork being completed and she would have paperwork completed upon the EMT's return to the facility. b. On 5/15/18 at 12:46 p.m. an interview was conducted with Physician #4 who had cared for Patient #7 on 4/8/18. Physician #4 stated the appropriate process for transferring a patient out of the facility included calling the receiving facility to confirm they had available beds, obtaining acceptance of the patient by a physician, giving report and filling out the proper paperwork to transport the patient. Physician #4 stated after he examined Patient #7, he determined the patient needed to be transferred to a facility with appropriate obstetrics care and ordered the transport team to take the patient to a different facility. Physician #4 stated, the emergency transport service crew were at the patient's bedside, ready to take the patient at that time. Physician #4 stated he did not call the receiving facility until approximately 20 minutes after the patient left and no paperwork was filled out or completed prior to transfer. c. On 5/15/18 at 3:59 p.m. an interview was conducted with Registered Nurse #11 who cared for Patient # 7 on 4/8/18. RN #11 stated she called report to Facility B and spoke with a registered nurse in the emergency department and the labor and delivery department after Patient #7 left the facility. RN #11 stated paperwork sent with the patient typically included the consent, any nursing documentation, vital signs and any testing completed (lab and radiology). RN #11 stated it was important to send as much information to the receiving facility so they could get the full picture of what was occurring with the patient. RN #11 stated Physician #4 did not fill out paperwork and sign the consent for transfer until 4:30 p.m. on 4/8/18. This was 4 hours after the patient left the facility. RN #11 was unsure what paperwork had been sent with the patient and was unsure if any paperwork had been faxed by the unit clerk after it had been completed by Physician #4. d. Similar findings were found in Patient #12's medical record. On review of Patient #12's medical record, the patient (MDS) dated [DATE] at 10:50 a.m. Patient #12 was triaged with a primary and secondary assessment were completed at 10:56 a.m. by Registered Nurse (RN) #1. RN #1 documented Patient #12's chief complaint as suicidal with a specific plan. At 11:14 a.m., the physician documented, on the ED Provider Assessment, that Patient #12 was brought in by ambulance with a history of bipolar, schizophrenia, anxiety, depression, post traumatic stress disorder and a recent admission to a psychiatric facility for suicidal ideation's and with worsening suicidal ideation's. The patient was seen at a clinic yesterday, 11/20/17, and was noted to "currently struggle with suicidal ideation." At 11:41 a.m., RN #1 documented under the nursing assessment notes, Patient #12 was suicidal with a plan to overdose on her medications and complained of increased depression, anxiety and sadness. At 1:10 p.m., on the vitals signs flow sheet, it was documented Patient #12 took pills approximately 10-15 minutes ago. Review of the Emergency Nursing Record revealed RN #1 documented the patient came up to the nurses station and said she took approximately 60 pills about 15 minutes ago. At 2:35 p.m., a crisis evaluation was conducted. In the crisis evaluation, the crisis clinician documented Patient #12 was in need of stabilization inpatient treatment at a involuntary facility. At 6:42 p.m., RN # 1 documented the patient was being transferred under the care of the receiving facility physician and report to the RN at the receiving facility had been completed. RN #1 further documented all documents were ready for transport. Review of Patient #12's record revealed no documentation that the physician caring for Patient #12 communicated with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer. This was in contrast to facility policy. On 5/15/18 at 1:31 p.m., an interview was conducted with the Chief Medical Officer (CMO) #6. CMO #6 stated the facility policy was to call the receiving facility to ensure the receiving facility had the capability and capacity to care for the patient who was needing to be transferred. The physician then spoke to the receiving physician who accepted the patient called a "doc to doc." This was all required prior to the patient being transported. CMO #6 stated it was important for the doc to doc communication to be completed to ensure a safe handoff of patient care because the most dangerous part of transporting patients was when the patient was outside the facility and have access to less resources. CMO #6 stated receiving acceptance of a patient and then providing a doc to doc allows for the receiving team to prepare for the patient and identify if any changes in the patient's condition had occurred while in transient. CMO #6 on review of Patient #12's medical record confirmed there was no documentation on when the doc to doc had occurred and no documentation of what paperwork had been sent with the patient prior to being transported. CMO #6 stated the physician consent for transfer should always be completed and sent with the patient prior to being transported.

Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. FINDINGS 1. The facility failed to meet the following requirements under the EMTALA regulations: Tag C240 - Posting of Signs - Based on observation and interview, the facility failed to have a posting clearly describing patients' rights under section 1867 of the Act and the participation of the facility in the Medicaid program under a State plan approved under Title XIX, at all places likely to be seen by individuals entering the facility seeking emergency medical treatment. Tag C2406 - Medical Screening Examination (MSE) - Based on interviews and document review the facility failed to determine and document who was qualified to perform an initial medical screening examinations and receive approval by the governing body of the hospital. This failure resulted in 20 of 20 patients who presented to the emergency department, to receive an MSE by an individual(s) who had not been determined by the facility as qualified to perform MSE's (Patient #1 - #20). Tag C2409 - Appropriate Transfer - Based on interviews and record review the facility failed to ensure 2 of 11 patients, requiring a higher or specialized level of care, were transferred appropriately pursuant to EMTALA requirements (Patient #7 and #12).

Based on observation and interview, the facility failed to have posted, at all places likely to be seen by individuals entering the facility seeking emergency medical treatment, a posting clearly describing patients' rights under section 1867 of the Act and the participation of the facility in the Medicaid program under a State plan approved under Title XIX. Findings include: 1. The facility failed to post notification of patient rights, under EMTALA, in all places that individuals seeking emergency medical treatment might note when entering the facility. a. On 05/14/18 at 1:10 p.m., a tour of the facility was conducted with the chief nursing officer (CNO #3). Observations of the main entrance included a welcome sign with visiting hours. No posting was noted which described patients' rights under EMTALA. Further touring of the hospital revealed an ambulance bay on the West side of the building. CNO #3 stated the entrance was used to bring patients in and out of the hospital by ambulance as well as patients who could present to this entrance seeking emergency services. Observation of the door and surrounding area at the hospital's ambulance bay did not contain any signage describing patients' rights under EMTALA. The hospital's waiting room was observed. No signage describing patients' rights under EMTALA were noted. Observation of the facility's Emergency Department (ED) was conducted. A posting was noted on the ED entrance door which described patient rights under EMTALA and included the facility participated in Medicare and Medicaid. b. On 05/16/18 at 4:44 p.m., an interview was conducted with CNO # 3 who stated patient notification of their rights under EMTALA was important; patients had the right to know they could not be denied care even if they lacked insurance or the ability to pay. She also added that adhering to EMTALA was the law and the right thing to do. The CNO confirmed three entrances into the facility, housing the ED, and only one entrance contained an EMTALA posting notifying patients of their rights. CNO #3 confirmed it would be possible for individuals entering the main entrance to the facility and the ambulance bay seeking emergency medical treatment to not see the EMTALA posting.

Based on interviews and document review the facility failed to determine and document who was qualified to perform an initial medical screening examinations and receive approval by the governing body of the hospital. This failure resulted in 20 of 20 patients who presented to the emergency department, to receive an MSE by an individual(s) who had not been determined by the facility as qualified to perform MSE's (Patient #1 - #20). Findings include: References: Medical staff bylaws from 8/26/08 state basic qualifications for membership on the medical staff are a practioner must demonstrate compliance with all the basic qualifications in order to have an application for medical staff membership accepted for review. The practioner must: qualify under Colorado law to practice with an out-of-state license or be licensed as follows: Physician must be licensed to practice medicine by the Colorado State Board of Medicine; Dentist must be licensed by the Colorado State Board of Dentistry; Certified Registered Nurse Anesthetist; Nurse practioner by the Colorado Board of Nursing, Physician Assistants by the Colorado State Board of Medicine, podiatrist must be licensed to practice podiatry by the Colorado State Board of Podiatry, Clinical Psychologists eligible for Medical staff membership must be licensed to practice by the appropriate Colorado State licensing authority. 1. The facility failed to identify who was a designated qualified medical professional (QMP) within the facility, document those individual(s) and then receive approval by the governing body. a. Patient #1 (MDS) dated [DATE] at 5:28 p.m. with a complaint of abdominal pain. At 5:41 p.m., the patient was seen by Physician #9 and received an MSE. Patient #2 (MDS) dated [DATE] at 10:15 a.m. with a complaint of back pain. At 10:35 a.m., the patient was seen by Chief Medical Officer (CMO #6) and received an MSE. Patient #3 (MDS) dated [DATE] at 3:00 p.m. for left sided numbness. The patient was seen by Physician #9 at 3:28 p.m. and received an MSE. Similar findings were found in medical record review for Patient's #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #20. b. On 5/15/18 at 4:00 p.m. an interview was conducted with the chief executive officer (CEO #7). CEO #7 stated the medical staff bylaws indicated who the facility designated as a qualified medical professional. CEO #7 reviewed the facility medical staff by laws, dated August 26, 2008, and indicated a section titled basic qualifications which stated a practitioner must demonstrate compliance with all the basic qualification in order to have an application for medical staff membership accepted for review. Listed where physicians, dentists, certified registered nurse anesthetist, physician assistants, podiatrists and clinical psychologists. On review of the medical staff bylaws there was no documentation Physician #9 and CMO #6 were designated QMPs to perform an MSE. Further review of the entire bylaws revealed no documentation of any individual(s) who the facility had designated as a QMP to perform an initial MSE and received approved by the governing body. c. A review of the facility medical staff meeting minutes from 5/1/17 to 4/17/18 also revealed no documentation of whom the facility had designated as a QMP to perform an MSE at the facility. d. On 5/21/18 at 3:05 p.m., an interview was conducted with Physician Assistant (PA) #8, who was on call for the emergency department. PA #8 reviewed the medical staff bylaws and facility policy, emergency room standards with CNO #3 and CEO #7 and confirmed there was no documentation which identified who the facility had designated as a QMP to do an initial MSE.