Based on medical record review, staff interviews and review of policy and procedures it was determined the facility was not in compliance with 42 CFR 489.24. The facility failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed or any assessment for a minor with a complaint of a Tylenol overdose one (#3) of twenty patients sampled. (see A2407).

Based on medical record review, staff interviews, review of the Emergency Department Log, personnel file review, and review of policy and procedures it was determined the facility failed to inform the person acting on the behalf of the individual of the risks and benefits to the individual of the examination and treatment, and the person acting on behalf of the individual did not consent to examination and treatment for one (#3) of twenty sampled patients. The facility also failed to document a description of the examination and or treatment that was refused for one (#3) of twenty patients sampled. Findings included: Review of the facility policy "Emergency Department Patient-Nursing Assessment and Reassessment", dated 04/2016 and approved by the Chief Clinical Officer stated "All patients attending the Emergency Department are triaged promptly and initially assessed by the triage or designated RN. This assessment will be performed according to age specific and development criteria across the life span. The assessment is recorded on the triage sheet and will include, but is not limited to: Presenting complaint, Allergies, Treatment prior to arrival, Pain, Previous medical history and Vital signs". Review of the facility policy "General Operation-Emergency Services", dated 04/2016 and approved by the Chief Clinical Officer stated "All patients presenting to Emergency Services will be appropriately evaluated to determine their need for treatment based on a systematic triage process". Review of the facility policy "Transfer, Medical Screening and Stabilization (RE: EMTALA and Florida Access to Emergency Services and Care Act Compliance)", dated 03/2017 and approved by the President/Chief Executive Officer page 2 stated "Florida Hospital North Pinellas [FHNP] shall provide emergency services and care within the service capability and service capacity of FHNP when: Any person requests emergency services and care". Page 3 stated "If a patient refuses to consent to a medical screening examination, treatment or transfer, the following steps should be taken to secure the written informed refusal of such examination, treatment and/or transfer from the patient or a person acting on the patient's behalf: 1. The physician treating the patient should give an explanation of the increased medical risks that may be reasonably expected from not being examined, treated or transferred and the medical benefits reasonably expected from the provision of appropriate treatment and/or transfer. 2. The refusal of Evaluation/Stabilizing Treatment/Transfer form should be completed and, if possible, signed by the patient or person acting on the behalf, dated and witnessed and placed in the patient's record. If the patient or person acting on the patient's behalf refuses to consent and will not sign a refusal of consent form, the refusal should be clearly documented in the medical record". A review of the medical record for patient #3 revealed the patient (MDS) dated [DATE] with complaints of an overdose. A review of the facility's face sheet and emergency room EMTALA log documented the patient (MDS) dated [DATE] at 6:17 p.m. with a complaint of an overdose. A detailed review of the medical record revealed a special comment by the nurse stating "Mother chose to take son to hospital [hospital #2] for psych eval [psychiatric evaluation]. Mother states does not want child transferred and would prefer to have child treated at one facility for pedi [pediatric] medical and pedi psych [pediatric psychiatry]. A review of the medical record with the Assistant Director of Emergency Services did not reveal any documented attempts to assess and triage the patient. The medical record did not document any attempts to notify the emergency room physician or charge nurse. There was no documentation in the medical record that the risks and benefits of the medical screening examination and treatment were explained to the patient's mother who was acting on the behalf of patient #3 on 2/16/2017. There was also no documentation in the medical record that Patient #3's mother who was acting on his behalf signed a refusal to consent form on 2/16/2017, as stated in FHNP policy. There was no documentation in medical record of a description of the examination and treatment that was refused on behalf of Patient #3. A telephone interview conducted with Staff [A] on 04/10/2017 at approximately 11:00 a.m. revealed he did not remember the patient exactly but would never tell a patient to go to another facility. A review of Staff [B]'s personnel file on 04/10/2017 at approximately 2:00 p.m. with the Assistant Director of Emergency Services did not document any EMTALA training. An interview with Staff [C] was conducted on 4/10/17. The staff member stated "isn't it ok to tell people when they come in to register we don't have that service? The Risk Manager and Assistant Director of Emergency Services were present during record review and interview and confirmed the above findings. A review of patient #3's medical record from hospital #2 documented the patient arrived at the facility on 02/16/2017 by private vehicle with the parent at 7:08 p.m. with a complaint of "taken many Tylenols, patient seeing things others don't, saying nonsense sayings and confused". The patient was triaged at 7:18 p.m. as ESI level 3-urgent. The assessment documented the patient was awake, confused, pupils dilated and unable to answer questions. The patient's vital signs were documented at 7:19 p.m. as blood pressure 130/73, heart rate 109, respiratory rate 17, with oxygen saturation of 99 percent on room air and temperature of 97.6 degrees Fahrenheit. The Medical Screening Exam (MSE) was initiated at 7:23 p.m. The physician documented "the patient took an unknown quantity of Tylenol PM. He has no evidence of Benadryl toxicity however; he is confused and has an elevated Tylenol level [122]. His other liver function test are normal. The ingestion took place over 4 hours ago...We started the acetylcysteine infusion here and transferred to a children's hospital [hospital #3]. The mother has been informed. I have Baker Acted the patient for involuntary psychiatric hold". The medical record transfer sheet documented the patient was transferred on 02/16/2017 at 10:05 p.m. to a children's hospital [Hospital #3] Intensive Care Unit [ICU].