Based on observation, record review, policy review, and interviews the hospital failed to follow their provider agreement when they did not comply with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements to provide an appropriate medical screening exam (MSE) to any individual who comes to the emergency department (ED) to determine whether they have an emergency medical condition for 3 of 20 records reviewed (Patient 1, 12, and 13). Failure to comply with their special responsibilities of Medicare hospitals in emergency cases puts all patients who present to the ED seeking medical care at risk for worsening of their condition or even death. Findings Include: Document review of the hospital's policy titled, Medical Screening Examinations for Emergency Department, approved on 02/28/17, showed, Purpose: When any individual comes to the emergency department of the hospital and a request for examination or treatment is made by the individual or by someone on the individual's behalf, such patient should be provided with an appropriate medical screening examination within the capability of the hospital's emergency department, in order to determine whether or not an emergency medical condition (EMC) exists. All MSE's should be performed in the hospital by a qualified medical provider (QMP). Sumner Regional Medical Center recognizes a QMP as the following: Physician, Physician assistant, Advance registered nurse practitioner. Registered nurse, licensed practical nurse, or medical intensive care technician (MICT) of who must be under physician direction. In the latter two instances, the physician must make the determination of whether an EMC exists, based on the information provided by the nurse or MICT. Document review of the hospital's policy titled, Transfer of Patients, approved on 11/11/14 included, Emergency Department dismissal to the Physician's Clinic: A patient dismissed from the emergency department with instructions to go directly to physician office, should have a copy of the ED record with age, name, signs and symptoms, physician transferring, physician receiving facility, and any treatments or medications. The medical screening exam should be completed by a qualified medical provider. 1. Patient #1 (age 19 months) (MDS) dated [DATE] at 07:59 AM with their mother for a fever. The record lacked a medical screening examination (MSE) performed by a qualified medical provider (QMP). 2. Patient #12 presented to the Emergency Department (ED) on 06/21/18 at 07:50 AM for complaint of drainage from the left ear. The medical record lacked documentation of an MSE by a QMP. 3. Patient #13 (5 years old) presented to the Emergency Department (ED) on 06/21/18 at 07:49 AM for complaint of fever. The medical record lacked documentation of an MSE by a QMP. Refer to A - 2406 for further details.

Based on observation, interviews, and record reviews the hospital failed to complete a Medical Screening Exam (MSE) for 3 of 20 patients (Patient 1, 12, and 13) presenting to the Emergency Department (ED) seeking medical treatment. The hospital's failure to ensure that all patients presenting to the ED receive an MSE places all patients at risk for worsening of their condition or even death. . Findings Include: 1. Review of Patient #1's medical record showed a [AGE] year old that (MDS) dated [DATE] at 07:59 AM with their mother for a fever. The medical record lacked documentation of an exam of the affected system, a History and physical (H & P), any treatments or vital signs. The Nurses Progress note on 10/26/17 at 10:40AM read, "patient over to clinic without being seen by DR". The record lacked a medical screening examination (MSE) performed by a qualified medical provider (QMP). 2. Review of Patient #12's medical record showed they presented to the Emergency Department (ED) on 06/21/18 at 07:50 AM for a complaint of drainage from the left ear. Documentation at 08:12 AM by Staff C, Registered Nurse (RN) showed the patient came to the ED with their son. The patient voiced they had drainage coming from the left ear the last two days, had taken Claritin (an antihistamine) without relief, and has had tubes in both ears since the age of three years old. Documentation at 08:12AM by Staff C included vital signs. The RN documented ear with clear drainage, tube visible. At 08:27AM, the RN notified Staff D, Advanced Practice Registered Nurse (APRN) of the patient #12. The APRN directed the patient to go to clinic. The medical record showed the patient walked out with their son at 08:29 AM and the patient left prior to Dr. exam. The discharge information read, "Discharge Disposition: discharged to Other Inst-Outpatient", and discharge location to facility G (The Rural Health Clinic operated by the Physician's Group which covers the ED during day-time hours). 3. Review of Patient #13's medical record showed a five year old that presented to the Emergency Department (ED) on 06/21/18 at 07:49 AM with their mother for a complaint of a fever. Documentation at 08:07 AM by Staff C, Registered Nurse (RN) showed mom voiced concerns that the patient had a fever since noon yesterday (06/20/18) with the highest at 103 degrees Fahrenheit (normal 98.6). Mom gave the patient Tylenol and that reduced the fever, but the patient also vomited, was tired, and had a decrease in his appetite. Documentation of the admission vital signs include; temperature 99.1 Fahrenheit, respiratory rate 20, pulse 121 beats per minute (normal pulse for 5 -6 year old 75-115). The RN documented patient without cough, runny nose, or diarrhea. At 08:27 AM, the RN notified Staff D, APRN about Patient #13. The APRN directed the patient to be seen in the clinic. The medical record showed on 06/21/18 at 08:29 AM the patient out of the ED with mom and the patient left prior to Dr. exam. The discharge information read, "Discharge Disposition: discharged to Other Inst-Outpatient and Discharge Location to facility G. Documentation on 06/21/18 at 09:00AM by the RN in the "ED Assistance Summary" read "left without being seen". The record lacked a MSE performed by a QMP. During an interview on 08/28/18 at 11:30 AM, Staff D, Advanced Practice Registered Nurse (APRN) stated that she is one of the mid-levels who take call for the ED during working hours Monday through Friday for an 8:00 AM-6:00 PM shift. Staff D stated that if a patient would like to be seen in the ED "I'm happy to see them". She stated that if an assessment had been done, and they are stable, she thought it was the patient's preference where they wanted to be seen in the ED or the clinic, "I guess." Staff D stated that she has not received any EMTALA training. Staff D further stated that all of the nurses from the hospital have called about patients in the ED and wanted to know if she wanted to see them in the clinic. Staff D stated that she had received communication to have patients leave the ED and be seen in the clinic. During an interview on 08/29/18 at 8:00 AM, Staff C, RN stated that it looked like I triaged the patients (12 and 13) and then talked to Staff D. They went to the clinic after that. I took their vital signs and asked mom what brought them in today. Staff C stated that Staff D will sometimes ask, "Do you think they can be seen in the clinic?" Staff C stated that she had sent patients to the clinic to be seen there instead of the provider seeing them in the ED. During an interview on 08/28/18 at 8:50 AM, Staff B, Assistant Chief Nursing Officer (ACNO), stated that the ED provider collaborated with the hospital nursing staff to determine the patient's condition."We don't have any training for nurses to be a QMP and to do the MSE." We have always called the nurses initial assessment a triage. Staff B felt that the mid-levels are getting pressure from their physicians to see patients in the clinic. She stated about a year ago she was yelled at by a physician regarding this practice. There is a history of great conflict with this Physician's group.