Based on document review and interview, it was determined for 2 of 22 clinical records reviewed, (Pt. #1 and #8) the Hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The Hospital failed to provide a medical screening examination. Refer to tag A 2406. 2. The Hospital failed to ensure transfer requirements were completed prior to transfering a patient to receiving hospital. Refer to A 2409.

Based on document review and interview, it was determined that for 1(Pt #1) of 22 sampled patients who presented in the Emergency Department (ED), the Hospital failed to provide a medical screening examination (MSE). Findings include: 1. The Medical Staff Bylaws (revised 2/2015) indicated "4.3 A. 14 b.The initial medical screening examinations for persons presenting in the Emergency Department may be performed by a physician member of the Medical Staff or House Staff or by a physician assistant, advanced practice nurse or any other qualified practitioner within his or her credentials... " 2. The policy entitled " Triage " (Revised 11/2015) indicated " Goals H ...Patient should be reassessed at appropriate intervals while waiting to be taken to the treatment area. Any significant symptoms should be reassessed for change and acuity category change as indicated. " 3. Pt #1 was a [AGE] year old male that arrived to the Emergency Department (ED) via ambulance on 2/23/16 at 5:57 PM for medical evaluation. Pt #1's chief compliant was diarrhea and back pain. Pt #1's vital signs were as follows: Temperature 98.4 Fahrenheit, pulse 93, espiration 18, blood pressure 106/78, pulse oximetry (oxygen level in the blood) 97% . A pain score of 10 (with 10 being the worst pain) was documented with the triage at 5:57 PM, and Pt #1 was moved to the waiting room. Pt #1's ESI (Emergency Severity Index) score upon arrival was a 3 (urgent). After triage, it was changed to a score of 4 (non-urgent). Pt #1's clinical record indicated the Registered Nurse (E #4) was assigned to reassess patients while waiting for medical examination. E #4 called Pt #1 for a reassessment on two different occasions, 8:33 PM and 11:15 PM and documented "no response" from Pt #1. On 2/24/16 at 2:41 AM the Registered Nurse (E#5) documented Pt #1 left without being seen (LWBS). 4. On 3/2/16 at approximately at 10:00 AM the Registered Nurse (E #2) was interviewed. E #2 stated it was not clear based on documentation why Pt #1's acuity status changed from a level 3 (urgent) to a 4 (non-urgent) with abdominal pain level at a 10 (worst pain). E #2 stated based on the patient's clinical presentation, Pt #1 should have remained at level 3 after triage. E #2 further stated the triage nurse should have notified the physician of the patient's pain score of 10; and also have notified the assigned nurse, to perform reassessment of Pt #1's pain level, while waiting for medical evaluation. 5.. On 3/2/16 at approximately 1:00 PM the Medical Director of the Emergency Department (MD #1) was interviewed. MD #1 stated it is the expectation that every patient who that presents to the ED receives a Medical Screen Examination (MSE). MD #1 stated it is the physician's responsibility to identify and assess patients for any life threatening situation. 6.. On 3/2/16 at approximately 1:15 PM the Director of Emergency Services (E #3) was interviewed. E # 3 stated the triage nurse should have alerted the physician of Pt #1's pain level. E #3 stated the physician should have been alerted for patients who presented with pain level at 10 for them (physician) to evaluate the case.

Based on document review and interview, it was determined that for 1 of 2 (Pt. #8), clinical records reviewed for transfers to another hospital, the Hospital failed to ensure an appropriate transfer. Findings include: 1. On 3/1/16 at approximately 2:00 PM, the clinical record of Pt. #8 was reviewed. Pt. #8 was a [AGE] year old male who presented to the emergency department (ED) on 10/14/15 with a chief complaint of altered mental status change. The clinical record indicated Pt. #8 was transferred to another hospital on [DATE] at 6:20 PM. A nurse's note on 10/14/15 at 6:20 PM indicated, "(Ambulance) has arrived for pt (Pt #8), pt stable at this time for transfer." 2. On 3/2/16 at approximately 10:00 AM, the Director of Regulatory Compliance stated that Pt. #8's transfer form for 10/14/15 could not be located in Pt #8 chart. The Director presented a preprinted form entitled "Interfacility Patient Transfer Form" and stated this form is required to be completed when a patient is transferred. This form includes the following information: determination of stability, physician certification, patient consent, and the receiving physician of the other hospital. 3. On 3/2/16 at approximately 1:00 PM, the Director of Regulatory Compliance reviewed Pt #8's clinical record, and stated the required information was not in the record: acceptance of the receiving physician at the other Hospital, patient's consent to transfer or the physician certification that patient was stable to transfer. 4. On 3/2/16 at approximately 1:30 PM, an interview was conducted with the ED Medical Director (MD #1). MD #1 stated the expectation is prior to each patient that is transferred the transfer forms are completed and included in the patient's clinical record.