Based on document review and interview, it was determined that the Hospital failed to ensure compliance with A 2406. This potentially affected all patients presenting to the Emergency Department (ED) with emergency medical conditions. Findings include: 1. The Hospital failed to ensure the patient received a medical screening exam, (A-2406).

Based on document review and interview, it was determined for 1 of 6 patients (Pt #1) who presented to the Hospital's ED between 10:10 pm on 1/28/16 and 2:27 am on 1/29/16, the Hospital failed to ensure a medical screening exam (MSE) was completed based on highest acuity. Findings include: 1. The Hospital's policy entitled, "Triage Assessment of Patients by Emergency Severity Index (ESI) Policy" (revised 2/12/15) was reviewed on 2/8/16 at approximately 2:00 pm and required, "...To determine patient acuity; To identify severity of illness or injury; To ensure patients with highest acuity are seen first..." 2. The clinical record for Pt #1 was reviewed on 2/8/16 at approximately 11:00 am. Pt #1 was a [AGE] year old male who presented to the Hospital's emergency department (ED) via ambulance on 1/28/16 at 10:10 pm with a complaint of abdominal pain. The ED nurse's (E #1) triage note dated and timed 1/28/16 at 10:15 pm included, " ...pt states L [left] lower abd [abdomen] cramping started 1 hour ago, complains of N/V [nausea/vomiting] ...Numeric Rating at Rest: 10=Worst possible pain ... " Pt #1' s triage vital signs were documented as follows: heart rate-79, blood pressure-138/74, respirations-15, and temperature-98.3. Based on triage assessment, E #1 assigned an acuity level (ESI) of 3 - urgent to Pt #1. Pt #1's clinical record included an ED clinical summary completed by the ED charge nurse (E #2) which included, " ...ED Departure Time: 01/29/2016 02:27:00 [2:27am-more than 4 hours after triage). The clinical record lacked documentation of the location of Pt #1 following triage. The ED log indicated Pt #1 left after triage, and lacked a medical screening exam (MSE). 3. The ED log was reviewed from 01/28/16 to 01/29/16. During Pt #1 ' s time in the waiting area after triage at 10:15 pm through departure on 01/29/16 at 2:27 am, 7 patients arrived, received treatment, and were discharged . Five of the seven patients were assigned a lower acuity level of 4 (less urgent) and included the following: [AGE] year old male via ambulance with back pain (ESI-4); [AGE] year old male with nausea/vomiting (ESI-4); [AGE] year old male with rash (ESI-4); [AGE] year old male with left ear impacted cerumen, emotional stress reaction (ESI-4); [AGE] year old male with left ankle injury (ESI-4). 4. On 02/08/16 at approximately 1:40 pm, the triage notes for these 7 patients were reviewed on the computer with the ED Manager (E #4). When this surveyor asked why patients with a lower acuity ESI received MSEs before those with a higher acuity ESI, E #4 stated that the patients are seen based on their presenting symptoms, as well as the anticipated length of stay. Therefore, the patient with severe back pain might not have been unable to sit in an upright position in the waiting room. A patient with active vomiting would not be appropriate to put in the waiting area. Patients with conditions that can be treated in a shorter amount of time might be seen and discharged before a patient with a longer anticipated length of stay would be brought back to a room. 5. On 2/9/16 at approximately 11:00 am, an interview was conducted with the ED Medical Director (MD #1). MD #1 stated patients are seen in order of severity based on airway, vital signs, and presenting symptoms.

Based on document review, and interview, it was determined that the Hospital failed to ensure compliance with A 2404. This potentially affected all patients presenting to the Emergency Department (ED) with orthopedic injuries. Findings include: 1. The Hospital failed to ensure all physician speciality services were available via an on-call system in the ED.

Based on document review and interview, it was determined that in the Emergency Department (ED) the Hospital failed to ensure all physician speciality services were available via an on-call system. This potentially affected all patients presenting to the Emergency Department (ED) with orthopedic injuries. Findings include: 1. On 10/1/15 the Hospital's ED on call list of Hospital speciality's was reviewed. The list failed to include Orthopedic Surgery as a service that was on call to the ED. 2. The Hospital's By-Laws and Rules and Regulations, dated December 2014 were reviewed on 10/1/15. The Rules and Regulations required, "Article VI Emergency Medical Screening, Treatment, Transfer & On-Call Roster Policy...6.2...6.2(d) The rotation call list, containing the names and phone numbers of the on-call physicians shall be posted in the Emergency Department." 3. The Hospital's "Patient Care Scope of Services," for the Emergency Department (revised 3/2014), reviewed on 10/1/15, required, "Types of Patients...Patient care in the Emergency Department is focused around a patient population...The most common types of illnesses seen are...orthopedic..." 4. The Hospital's application to the Joint Commission (dated 10/31/14) included orthopedic surgery as a service provided by the Hospital. 5. The Hospital's "2015 Plan for the Provision of Patient Care," was reviewed on 10/1/15. The Plan included, "MetroSouth Medical Center provides the community with an extensive range of healthcare services including but not limited to...Orthopedics." 6. The Hospital's active physician roster was reviewed on 10/1/15. The roster included 8 orthopedic surgeons on staff at the Hospital. The personnel files of the orthopedic surgeons were reviewed on 10/2/15. Of the 8 surgeons 7 (MD #3, 4, 5, 7, 8, 9 and 10) were credentialed in the "Core Privileges". MD #6 was credentialed in "hand" procedures only. 7. The Hospital's "Clinical Privileges in Orthopedic Surgery," (revised 2015) was reviewed on 10/2/15. The Core Privileges included, "Admit, perform history and physical...provide surgical and non-surgical care to patient..." 8. On 10/1/15 at approximately 8:15 AM the ED physician (MD#1) on duty 9/26/15 from 11:00 AM to 11:00 PM was interviewed. MD#1 stated there is not an "on-call schedule for orthopedics in the ER." MD#1 stated the orthopedic physicians are not required to be on-call. 9. The Hospital's Orthopedic Surgery core procedures dated 7/30/08 was reviewed on 10/2/15. The Orthopedic Surgery privileges included, "Note this list is a sampling of procedures included in the orthopedic surgery core...not intended to be all encompassing...Closed reduction of fractures and dislocations of the peripheral skeleton...open and closed reductions of fractures, open reduction and internal fixation of fractures and dislocations of the peripheral skeleton..." 10. On 10/2/15 at approximately 1:10 PM the Interim Chief Executive Officer stated the Hospital does have an on-call list for the physicians, however "yes it is a fact, it does not include orthopedic specialty."