Based on record review and staff and physician interviews it was determined the hospital failed to comply with Section 484.24(f). The hospital failed to accept a patient from a transferring hospital who potentially required the specialized services of the medical staff who was on call at the time of the request. Emergency Department (ED) records and staff interview from the transferring hospital revealed Patient #1 (MDS) dated [DATE] at approximately 9:46 AM, with a laceration to the left forearm that resulted in arterial bleeding. A medical screening examination (MSE) determined the patient required the services of a vascular surgeon. Staff interviews and review of the specialty physician on-call log revealed the transferring hospital did not have a vascular surgeon available. The transferring hospital records revealed a request was made on 05/18/17 at approximately 10:54 AM, of the on-call vascular surgeon at Hospital B to accept Patient #1. Interviews with the ED staff at the transferring hospital and the vascular surgeon revealed this person refused to accept the transfer of Patient #1 related to past disputes between the vascular surgeon and the transferring hospital. After consultation with the Chief Medical Officer and CNO, the vascular surgeon agreed to accept Patient #1 and the transferring hospital was notified at approximately 12:48 PM. However, at that time the patient had already been transferred to another hospital who had agreed to accept the patient. (Refer to A-2411)

Based on record reviews and staff interviews, it was determined the hospital failed to ensure an on-call specialty physician agreed to accept an appropriate transfer from a referring hospital of a patient who required specialized vascular services. This was found for one of 23 patients in the selected sample (Patient #1). On 09/12/17 at 2:45 PM an interview with the Compliance Officer (CO) from Hospital A was conducted. The CO stated on 05/18/17 at approximately 9:46 AM Patient #1 presented to Hospital A's ED with a laceration injury to the left arm. Patient #1 received a MSE from a physician assistant (PA) and physician who noted arterial damage and determined the services of a vascular surgeon were required. As Hospital A had no vascular surgeon available, Hospital B's on-call vascular surgeon was contacted on 05/18/17 at approximately 10:54 AM. The vascular surgeon refused to accept the transfer of Patient #1 related to past disputes with Hospital A. Various telephone calls were made to Hospital B's administrative staff and at 12:48 PM Hospital A received a call from the CNO at Hospital B stating that the vascular surgeon had agreed to accept Patient #1. However, after the initial refusal by the surgeon to accept Patient #1, Hospital A contacted Hospital C who agreed to accept the patient. Patient #1 had been transferred to Hospital C on 05/18/17 at 12:20 PM. On 09/11/17 at 3:12 PM, an interview was conducted with the vascular surgeon who was on call at Hospital B on 05/18/17. The surgeon stated sometime around midday on 05/18/17, he received a call that had been routed to him by his office. The caller identified themselves as a practitioner from the ED at Hospital A. The caller stated their ED had received a patient with a vascular injury to the arm and requested the surgeon accept the patient's transfer to Hospital B. The surgeon stated the call was confusing because such requests normally came through a transfer call center. The surgeon told the caller that Hospital A usually transferred such cases to hospitals out of state because of past disagreements between the surgeon and Hospital A. The surgeon informed the caller he would not accept the transfer unless the patient was at risk of serious injury. According to the surgeon, he was involved in a short procedure after the call took place. At the conclusion of the procedure, the Chief Medical Officer (CMO) and CNO were waiting to speak with him. After they explained to the surgeon that his/her refusal to accept the patient was a possible EMTALA violation, he agreed to accept the patient. He later learned the patient had been accepted at another hospital. The surgeon stated he had not received any formal EMTALA training. An interview was conducted with the CMO on 09/13/17 at 8:50 AM. This person stated he accompanied the CNO at her request to discuss the transfer with the vascular surgeon. The CMO stated the vascular surgeon was located in the "special procedures" area performing a minor procedure. The CMO and CNO had to wait approximately 15-20 minutes for the surgeon to complete the procedure before speaking with him. In discussing the issue, the vascular surgeon questioned why he was obligated to accept the patient because Hospital A had a vascular surgeon on staff. When the CMO and CNO explained the vascular surgeon at hospital A was not available, the vascular surgeon agreed to accept the patient. The CMO stated new members of the medical staff receive EMTALA training as part of their orientation, but this was not part of an ongoing program. A telephone interview was conducted on 09/12/17 at 2:55 PM, with the PA who was involved in the MSE of Patient #1 at Hospital A. The PA stated on 05/18/17 she examined the injury to Patient #1 and consulted with the ED physician and an orthopaedic surgeon. It was determined the patient required the services of a vascular surgeon and the only vascular surgeon on staff at Hospital A was not on-call. She contacted the on-call surgeon at Hospital B after having the unit secretary place the call. The surgeon stated it was an "inappropriate" call related to the surgeon being denied privileges at Hospital A by the administrator. The surgeon refused to accept the transfer on that basis. Review of Hospital A medical records for Patient #1 revealed this person (MDS) dated [DATE] at approximately 9:46 AM. The chief complaint was listed as "Vascular injury of left arm, initial encounter, laceration of left arm with complication, foreign body (FB) in soft tissue". ED physician notes on 05/18/17 at 11:34 AM, documented "pulsing blood loss" related to a vascular injury. The physician documented Patient #1 had "good" radial and ulnar pulses. On 05/08/17 at 11:30 AM, the PA documented the presence of a vascular injury and foreign body to the left arm. Bleeding was controlled with a pressure dressing. The PA documented that the general surgeon on-call (this was later determined to be an orthopaedic surgeon) was contacted and recommended the patient be transferred to a facility with a vascular surgeon. The PA documented the vascular surgeon at Hospital B was contacted but refused to accept the patient due to "political reasons". The PA documented Hospital C was contacted and agreed to accept the patient. Physician certification documented the patient's condition as stable at the time of transfer which was listed as 12:20 PM. The medical records from Hospital C for Patient #1 were obtained and reviewed. The ED physician note for 05/18/17 at 2:00 PM, noted a 6 cm long by 3 cm wide by 3 cm deep laceration to the proximal dorsum of the left forearm with "scant arteriole bleeding". The record documented the services of a plastic surgeon was obtained. A history and physical and procedure note by the plastic surgeon documented a 2 cm glass shard was removed from Patient #1's left arm. The wound was then irrigated with normal saline and closed with surgical sutures. The patient was discharged home with antibiotic and narcotic prescriptions . There was no documentation of consultation with a vascular surgeon. Review of medical staff bylaws for Hospital B revealed the section titled "Emergency Services". This section stated active medical staff were responsible for emergency call for their respective specialties. Physicians were responsible to respond within 30 minutes of being contacted in an emergency.

Based on staff interviews and record review it was determined the hospital failed to provide necessary stabilization treatment to a patient who was experiencing acute psychosis along with homicidal ideation. The facility failed to provide treatment to stabilize the patient to ensure these acute psychiatric symptoms would not deteriorate. This was found for one (1) of twenty (20) sampled patients (Patient #1). The findings include: Review of the Emergency Department (ED) record for Patient #1 revealed this person (MDS) dated [DATE] at 11:42 AM. An initial screening by a Licensed Professional Counselor (LPC) described the patient's presenting symptoms of driving down a road the wrong way, screaming, yelling and expressing the belief that people were trying to kill him/her. The LPC documented that the patient's belief (his/her behavior) was caused by a medication reaction. The patient denied any past psychiatric history or treatment. Review of ED record Physician Notes, dated 04/19/16 at 12:22 PM, revealed the ED Physician documented the patient to be fearful, delusional and paranoid. The patient stated to the ED physician a similar event happened the previous year and he/she was concerned the symptoms were caused by a medication reaction. Review of the ED record (Registered Nurse) note for 04/19/16 at 12:09 PM revealed Registered Nurse (RN) #6 documented while the patient was driving the wrong way down the street, the patient had been screaming, honking the horn and blinking the lights. On 04/19/16 at 12:39 PM, the patient was given an intravenous injection of Lorazepam (anti-anxiety drug) after stating he/she felt threatened and screaming, "Don't kill [patient's spouse]." On 04/19/16 at 4:40 PM, the patient stated, "We will be married 22 years in a couple of days. Too bad we won't make it till then." When asked by the staff what the patient meant, he/she stated "We'll be dead!" Further review revealed on 04/19/16 at 4:53 PM, Patient #1 became "violent" with staff and other patients, ran into the hallway and stated "They killed (him/her)! They're going to kill you. I am not crazy! They are going to kill you too!" The patient was mechanically restrained in a restraint chair and on 04/19/16 at 5:50 PM, was given an intramuscular injection of Ziprasidone (anti-psychotic drug). On 04/19/16 at 6:15 PM, the patient was removed from the restraint chair and returned to bed. The ED Physician completed the paperwork for Patient #1 to be evaluated by a local mental health professional for possible involuntary hospitalization to a regional state psychiatric hospital. However, when the mental health professional arrived the evaluation could not be completed because the patient was sleeping. The mental health professional was again called at 2:38 AM, on 04/20/16. The ED staff was informed by the mental health professional the evaluation could not be performed unless the ED Physician repeated the evaluation paperwork. Review of the Nursing and ED Physician Notes revealed the physician decided to wait for the hospital staff psychiatrist to evaluate the patient later that morning. According to a document titled, "Psychiatric Consultation Evaluation" by an Advanced Practice Registered Nurse (APRN) dated 04/20/16 at 10:19 AM, the APRN documented the patient's symptoms prior to and following his/her arrival at the ED. The patient again stated similar symptoms occurred in the past related to a medication allergy. The APRN documented the patient to be alert and oriented. Patient #1 also denied any psychosis. After consultation with the staff psychiatrist it was determined Patient #1 was not homicidal, suicidal or psychotic. The psychiatrist decided the patient was not a candidate for voluntary or involuntary hospitalization . Arrangements were made for outpatient treatment and Patient #1 was discharged from the ED on 04/20/16 at 12:25 PM. An interview was conducted with the LPC on 04/06/17 at 8:23 AM. The LPC stated on 04/19/16 he/she was the intake therapist for the ED. Part of her responsibilities was to gather information from the patient and consult with the psychiatrist for possible inpatient hospitalization . Patient #1 was not appropriate for admission to the hospital's psychiatric unit because of his/her aggressive behavior. The LPC stated he/she left the hospital on [DATE] at approximately 11:30 PM and he/she did not know why Patient #1 was not transferred to the state psychiatric hospital. Interview with the APRN on 04/10/17 at 10:37 AM stated when he/she spoke with Patient #1 the patient was alert, oriented and did not exhibit any delusional or psychotic behavior. The APRN conferred with the hospital psychiatrist who decided Patient #1 did not meet inpatient criteria. The patient was discharged after making arrangements for outpatient treatment. Following these interviews, it could not be determined that, other then the administration of antipsychotic and antianxiety medications, the facility continued to provide stabilization treatment to ensure Patient #1's condition would not deteriorate following discharge. Although the medical record documented the severity of the patient's symptoms it failed to describe what interventions were taken to prevent further deterioration other then the one time dose of antipsychotic medication. A subsequent ED record dated 07/01/16, revealed Patient #1 was returned to the ED by law enforcement after shooting his/her spouse and another bystander. The ED physician documented the patient as combative and aggressive with disorganized thought processes and homicidal ideas. The patient stated he/she was "a child of God." Further review of the medical record revealed the patient's symptoms were severe enough to warrant intravenous administration of Lorazepam (anti-anxiety drug), Haloperidol (anti-psychotic drug) and intramuscular injection of Ketamine (general anesthetic). The physician's final impression was 1.) Homicidal Ideation, 2.) Psychosis, unspecified psychosis type and 3.) Elevated serum creatinine.

Based on staff interviews and record review it was determined the hospital failed to provide an appropriate medical screening examination for one (1) of twenty (20) sampled patients (Patient #1), who presented to the hospital with psychotic symptoms. Patient #1 presented to the Emergency Department (ED) on 04/19/16 with delusional and homicidal behaviors. The patient expressed the belief that this behavior was caused by a medication reaction. The hospital staff failed to fully screen the patient to determine the root cause of Patient #1's behavior. The findings include: Review of the Emergency Department record for Patient #1 revealed the patient (MDS) dated [DATE] at 11:42 AM. An initial screening by a Licensed Professional Counselor (LPC) described the patient's presenting symptoms of driving down a road the wrong way, screaming, yelling and expressing the belief that people were trying to kill him/her. The LPC documented the patient believed his/her behavior was caused by a medication reaction. The patient denied any past psychiatric history or treatment. Review of Patient #1's medical record revealed on 04/19/16 at 12:22 PM, the ED Physician documented the patient was fearful, delusional and paranoid. The patient stated a similar event happened the previous year and he/she was concerned that his/her present symptoms were caused by a medication reaction. Further review of the medical record revealed on 04/19/16 at 12:09 PM, Registered Nurse (RN) #6 documented while driving the wrong way down the street, Patient #1 had been screaming, honking the horn and blinking the lights. On 04/19/16 at 12:39 PM, the patient was given an intravenous injection of Lorazepam (antianxiety drug) after stating that he/she felt threatened and was screaming, "Don't kill [Patient #1's spouse]." On 04/19/16 at 4:40 PM, the patient stated, "We will be married 22 years in a couple of days. Too bad we won't make it till then." When asked by the staff what he/she meant, Patient #1 stated, "We'll be dead!" On 04/19/16 at 4:53 PM, Patient #1 became "violent" with staff and other patients. He/she (Patient #1) ran into the hallway and stated, "They killed (him/her)! They're going to kill you. I am not crazy! They are going to kill you too!" The patient was mechanically restrained in a restraint chair. On 04/19/16 at 5:50 PM, Patient #1 was given an intramuscular injection of Ziprasidone (antipsychotic drug). On 04/19/16 at 6:15 PM, the patient was removed from the restraint chair and returned to bed. The ED Physician completed the paperwork for Patient #1 to be evaluated by a local mental health professional for possible involuntary hospitalization to a regional state psychiatric hospital. However, when the mental health professional arrived, the evaluation could not be completed because the patient was sleeping. The mental health professional was again called at 2:38 AM, on 04/20/16. The ED staff was informed by the mental health professional that the evaluation could not be performed unless the ED Physician repeated the evaluation paperwork. Review of the Nursing and ED Physician Notes revealed the physician decided to wait for the hospital staff psychiatrist to evaluate the patient later that morning. According to the document, "Psychiatric Consultation Evaluation" by an Advanced Practice Registered Nurse (APRN) dated 04/20/16 at 10:19 AM, the APRN documented the patient's symptoms prior to and following his/her arrival at the ED. The patient again stated similar symptoms occurred in the past related to a medication allergy. The APRN documented the patient to be alert and oriented. Patient #1 also denied any psychosis. After consultation with the staff psychiatrist, it was determined Patient #1 was not homicidal, suicidal or psychotic. Thus, it was decided the patient was not a candidate for voluntary or involuntary hospitalization . Arrangements were made for outpatient treatment and Patient #1 was discharged from the ED on 04/20/16 at 12:25 PM. Interview was conducted with the LPC on 04/06/17 at 8:23 AM. The LPC stated on 04/19/16 he/she was the intake therapist for the ED. Part of his/her responsibilities as the intake therapist was to gather information from the patient and consult with the psychiatrist for possible inpatient hospitalization . The LPC stated Patient #1 was not appropriate for admission to the hospital's psychiatric unit because of his/her aggressive behavior. Further interview with the LPC revealed he/she left the hospital on [DATE] at approximately 11:30 PM and he/she did not know why Patient #1 was not transferred to the state psychiatric hospital. Interview with the APRN, on 04/10/17 at 10:37 AM, revealed when he/she spoke with Patient #1, the patient was alert, oriented and did not exhibit any delusional or psychotic behaviors. The APRN conferred with the hospital psychiatrist, who decided Patient #1 did not meet inpatient criteria. The APRN stated Patient #1 was discharged after arrangements were made for outpatient treatment. Following these interviews, it could not be determined that the medical screening examinations fully explored the circumstances and details of the patient's reported past medication reactions. The interviews failed to verify that the practitioners attempted to independently verify Patient #1's statement that he/she had no previous psychiatric history or treatment. Review of the medical record documentation from these practitioners, as well as from the ED Physician, and other staff notes also failed to provide this information. The medical record documentation and staff interviews also failed to fully explain the patient's psychotic behavior prior to his/her arrival in the ED. Review of an ED record dated 07/01/16, revealed Patient #1 was returned to the ED by law enforcement after shooting his/her spouse and another bystander. The ED Physician documented the patient's behaviors as combative and aggressive with disorganized thought processes and homicidal ideas. Further review revealed the patient stated he/she was "a child of God". On this occasion, the physician documented the patient had a psychiatric history that included hospitalization at a state hospital.

Based on record review and staff interviews it was determined the facility failed to comply with Section 484.24(a). The facility failed to provide an appropriate medical screening examination for one (1) of twenty (20) sampled patients (Patient #1) that was comprehensive enough to determine whether an emergency medical condition existed. The facility also failed to comply with Section 484.24(d) by failing to provide further treatment to ensure the patient's condition was stabilized and his/her condition did not further deteriorate. On 04/19/16, Patient #1 presented at the Emergency Department with psychotic symptoms and homicidal ideation. The patient was discharged from the facility twenty-four (24) hours later. On 07/01/16, Patient #1 shot and killed his/her spouse and wounded a bystander who survived. Cross Reference to: A-2406 - The facility failed to provide an appropriate medical screening examination to the extent necessary to determine if an emergency medical condition existed for Patient #1. Cross Reference to: A-2407 - The facility failed to provide further medical examination and treatment necessary to stabilize the medical condition for Patient #1.

This STANDARD is not met as evidenced by: Based on interview, record review, review of the facility's policy, and review of facility "Medical Staff Rules and Regulations", it was determined the facility failed to have an effective system in place to ensure one (1) of twenty-four (24) sampled patients (Patient #1), who presented to the Emergency Department (ED) received an appropriate Medical Screening Exam (MSE) to determine whether or not an emergency medical condition existed. The findings include: Review of the facility's Medical Staff Rules and Regulations, last revised February 2012, revealed qualified medical personnel would perform a MSE for all persons that present to the ED. Review of the facility's policy titled, "Medical Screening Exam", start date 03/01/13, last review date 12/01/16, revealed the purpose was to establish and define the rights of all patients to the access of a MSE regardless of ability to pay for services. Review of the facility's policy titled, "Credit and Collection", approval date 11/18/16, revealed payment is not to be collected from patients until after a MSE and treatment has been provided (related to the ED). Review of the medical record revealed Patient #1 arrived at the ED, on 10/05/16 at 6:59 PM, with a complaint of chest pain. Record review revealed Patient #1 was triaged and an electrocardiogram (EKG) was completed by Registered Nurse (RN) #1 at 7:15 PM. Review of the EKG results revealed no abnormalities. Patient #1 was assigned to the Rapid Medical Exam (RME) Room #5 at 7:18 PM. Further review of the medical record revealed registration was completed at 7:36 PM by ED Registration Clerk #1. Interview with RN #1, on 12/01/16 at 2:54 PM, revealed Patient #1 was triaged, then assigned a room because of his/her complaint of chest pain. Further interview with RN #1 revealed the EKG was normal. She stated the registration process was completed once the patient was seen by a provider and assigned a room. Interview with ED Registration Clerk #1, on 12/01/16 at 1:25 PM, revealed, after completing the registration process, she informed Patient #1 he/she had a co-pay and asked how he/she wanted to pay. Further interview with Registration Clerk #1 revealed Patient #1 replied, "I can't believe a hospital is asking for money." She stated she informed Patient #1 a copay did not have to be paid at that time; however, Patient #1 left the ED without receiving a MSE. Interview with the Advanced Practice Registered Nurse (APRN), on 12/01/16 at 3:30 PM, revealed as she entered Patient #1's room to perform a MSE, the patient was leaving the exam room. Further interview with the APRN revealed Patient #1 stated, "I can't believe a hospital is asking for money." The APRN revealed she informed the patient that a co-pay did not have to be collected at the present time; however, Patient #1 declined a MSE and left the ED. Interview with the Chief Nursing Officer (CNO), on 12/01/16 at 2:10 PM, revealed registration staff were supposed to collect co-pays after triage initially. Further interview revealed the following changes have occurred with the registration process, effective 11/01/16: when someone presents to the ED for care/treatment, there will be a quick registration process. This process consists of obtaining his or her name, date of birth, phone number, and the complaint to minimize delay in treatment. The CNO revealed the patient will then be triaged and have a MSE. After that, the registration process may be completed and the patient will be informed of the copay. Further interview revealed patients will be seen regardless of the ability to pay. Additionally, anyone who leaves the ED without being seen or against medical advice, the ED Nurse Manager will do a follow up with the patient to ensure services are still available at the facility and attempt to reconnect with the patient. Prior to the investigation by Office of Inspector General (OIG), the facility self-reported the incident after conducting an internal investigation. Based on the facility's investigation, the allegation was substantiated and was corrected. **The facility implemented the following actions to correct the deficient practice: 1. Obtain for review a copy of Lourdes medical staff by-laws detailing the Medical Screening Exam (MSE). 2. Obtain for review a copy of Patient Access Policy "Credit and Collections". 3. Retrain ER Registration staff to ensure MSE is completed before completing the registration process. 4. Ensure ED Registration staff and ED staff complete the EMTALA training online via I-Learn no later than 11/01/16. 5. Patient Access management provided face-to-face training on Credit and Collections policy specifically addressing ED patients to complete the registration process after a MSE is complete. ** The State Survey Agency validated the facility's plan of action was implemented by: 1. The Nurse Manager of the ED revealed she was the responsible person to review the facility's medical staff by-laws (date unknown), regarding the "Medical Screening Exam". The review, dated 12/01/16, revealed no revisions to the policy. Interview with the Nurse Manager of the ED, on 12/01/16 at 2:15 PM, revealed there were no changes implemented to the "Medical Screening Exam" policy. Interview revealed the policy mandates a MSE is performed by a physician before the registration process is completed. Further interview revealed that has always been the facility's policy. Interview with the CNO, on 12/01/16 at 2:10 PM, revealed when someone presented to the ED for care/treatment, there would be a quick registration process. The process consisted of obtaining his/her name, date of birth, phone number, and the complaint to minimize delay in treatment. The CNO revealed the patient would then be triaged and have a MSE. Further interview revealed the changes occurred with the registration process on 11/01/16. 2. Review of the Patient Access policy "Credit and Collections" dated 11/18/16, related to the ED revealed payment would not be collected from patients until after a MSE and treatment was provided. Interview (post survey) with ED Registration Clerk #1, on 12/20/16 at 6:14 PM, revealed she attended in-service training in October 2016 conducted by the Patient Access Director/Manager, regarding the hospital's change in collection of copays at the time of registration. Interview with the Patient Access Director, on 12/02/16 at 11:15 AM, revealed she was responsible to review the facility's policy, "Credit and Collections" dated 11/18/16. She revealed she was responsible to ensure registration staff in the out-patient areas were re-trained regarding collection of copays. Further interview revealed the facilty's policy related to ED registration was no collection of fees/copays from the patient until the patient has been seen by a provider and the MSE has been completed. Further interview revealed all registration and ED staff were mandated to have EMTALA training yearly. 3. Interview (post survey) with ED Registration Clerk #1, on 12/20/16 at 6:14 PM, revealed staff were mandated to complete the EMTALA web based training through I-LEARN and pass the posttest to ensure training was completed. Interview (post survey) with RN #1, on 12/21/16 at 3:30 PM, revealed he was in-serviced regarding changes to the ED registration process by the ED Nurse Manager in October 2016. Further interview revealed changes to the registration process from a Triage Nurse's prospective were, "after a patient presenting to the ED was triaged, it was the Triage Nurse's responsibility to let the assigned Provider know the patient was ready for a MSE." Additional interview revealed the registration process would not be completed until the patient had a MSE. Copays were not collected prior to a patient being examined by a Physician, APRN, or PA. He revealed triage by an RN was not a MSE. Interview (post survey) with the APRN, on 12/20/16 at 5:30 PM, revealed she was educated on changes in the ED registration process in October 2016 via an email she received from the ED Medical Director. She revealed education consisted of ensuring patients in the ED received a MSE prior to the registration process. The APRN revealed she also had to complete a mandatory EMTALA course through I-LEARN web training before November 2016, take a posttest after completing the training, and pass the competency with a score of 90% or greater. She revealed she e-signed an attestation acknowledgement upon completing the course, and emailed a copy of the posttest certificate to the ED Medical Director. 4. Interview with ED Registration Clerk #2, on 12/01/16 at 1:55 PM, revealed she completed mandatory EMTALA web training in October 2016. Interview revealed after completion of the EMTALA course, her supervisor, the Patient Access Director/Manager, viewed the staff's certificate of completion of the EMTALA training. Post survey interview with the Patient Access Director, on 12/20/16 at 5:30 PM, revealed registration staff were re-trained 10/25/16 through 10/26/16 on the hospital's changes regarding the collection of copays during the registration process. Further interview revealed changes to the registration process started 11/01/16. Additional interview revealed registration staff were mandated and completed EMTALA training in the I-LEARN computer web based training with completion verified by her and the Patient Access Manager.

Based on interview, review of the emergency room (ER) log, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure one (1) of twenty (20) sampled patients (Patient #1) who presented to the ER seeking assistance as defined in §489.24(b), was included on the ER log. The findings include: Review of the facility's policy titled, "Obstetrical Patient in ED", dated 08/29/16, revealed patients presenting to the ER who are equal to or greater than twenty (20) weeks with an obstetrical complaint will be sent directly to Labor and Delivery. There was no mention of the patient being added to the ER log. Review of ER specific policies revealed no policy which mentioned the ER log. Interview with Registrar #1, on 10/14/16 at approximately 8:12 AM, and review of Registrar #1's Safe Care Report, dated 08/28/16, revealed Patient #1, who was thirty-eight (38) weeks pregnant, (MDS) dated [DATE] (Saturday) complaining of possible contractions. Registrar #1 reported she asked Registrar #2 to call up to Labor and Delivery for a bed while she tried to register Patient #1. She stated Patient #1 talked to a nurse on the phone and left the hospital without being added to the ER log. Review of the ER log, dated 08/27/16, revealed Patient #1 was not included. Interview with Registrar #2, on 10/14/16 at approximately 8:35 AM, revealed she contacted the Labor and Delivery department when Patient #1 arrived at the ER. She stated the nurse requested to speak to the patient on the phone and the patient left the facility without being added to the ER log. She stated she overheard Patient #1 state the nurse advised her to go to her regular physician because if they admitted her, the patient's regular physician did not have privileges at the hospital and would not be able to see her. Interview with the Registrar Supervisor, on 10/14/16 at approximately 9:20 AM, revealed when pregnant women present to the ER with contractions, the registrar calls Labor and Delivery. She stated if the patient goes to Labor and Delivery, the patient is not added to the ER log. She revealed all types of patients enter through the ER entrance. She stated when any pregnant patient who is twenty (20) weeks or more pregnant enters the ER, regardless of complaint, the registrar tells the Charge Nurse and the Charge Nurse calls Labor and Delivery. She revealed the Charge Nurse and the Labor and Delivery Nurse determine if the patient is seen in the ER or taken to Labor and Delivery. If the patient is taken to Labor and Delivery, the patient is registered in the Labor and Delivery department and not on the ER log. Interview with Registered Nurse (RN) #1, on 10/13/16 and 10/14/16 at 9:40 AM, revealed a patient presenting to the ER who is 20 weeks or greater pregnant will be sent to the Labor and Delivery department for a medical screening exam and will not be put on the ER log. She stated the facility's policy was revised because of the facility's investigation. She revealed the policy now calls for the registrar to contact an ER nurse to call Labor and Delivery for a patient presenting to the ER who is 20 weeks pregnant or greater and they will decide where the patient will be seen. The policy revision does not make provisions for a patient who is 20 weeks or greater into their pregnancy to be put on the ER log. Review of the facility's communications, investigations, and action plans revealed the facility has placed interventions in place and the facility is currently in compliance with 42 CFR 489.20 and 489.24, Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

Based on interview, record review, review of the facility's policy, and review of the facility's Medical Staff Rules and Regulations, it was determined the facility failed to have an effective system in place to ensure one (1) of twenty (20) sampled patients (Patient #1) who presented to the emergency room (ER) received an appropriate Medical Screening Examination (MSE) to determine whether or not an emergency medical condition exists. The findings include: Review of the facility Emergency Services Medical Staff Rules and Regulations, last revised February 2012, revealed qualified medical personnel would perform a Medical Screening Examination (MSE) for all persons that present to/at the Emergency department. In the case of the pregnant patient who is having contractions or other acute symptoms of sufficient severity related to the pregnancy, the MSE will be completed by a Registered Nurse (RN) of the Maternal Child Department using protocols and procedures approved by the medical staff of the Maternal/Child Committee. Review of the facility's policy titled, "Medical Screening Exam", with policy start date of 03/01/15, revealed, pregnancy with contractions, over twenty (20) week gestation are triaged to the Obstetrics (OB) Department for evaluation and screening by an experienced OB nurse. Interview with Registrar #1, on 10/14/16 at approximately 8:12 AM, and review of Registrar #1's Safe Care Report, dated 08/28/16, revealed Patient #1, who was thirty-eight (38) weeks pregnant, (MDS) dated [DATE] (Saturday) complaining of possible contractions. Registrar #1 stated she asked Registrar #2 to call up to Labor and Delivery for a bed while she tried to register Patient #1. She stated Patient #1 talked to a nurse on the phone and left the hospital without receiving a MSE. She stated she did not believe this was right and filled out a Safe Care Report. Interview with Registrar #2, on 10/14/16 at approximately 8:35 AM, revealed when Patient #1 arrived at the ER, she contacted the Labor and Delivery department. She stated the nurse requested to speak to the patient on the phone and the patient left the facility without receiving a MSE. She revealed she overheard Patient #1 state the nurse advised her to go to her regular physician because it they admitted her, the patient's regular physician did not have privileges at the hospital and would not be able to see her. She also reported she completed a Safe Care Report. Review of RN #7's Safe Care Report, dated 08/27/16, revealed she received a call from the ER registration stating there was a thirty-eight (38) week pregnant patient in the ER who wanted to be checked to see if she was in labor. RN #7 reported she asked to speak to the patient and the patient stated she was having contractions every ten (10) minutes and felt heavy in the pelvis area. RN #7 revealed the patient stated her OB physician was in Murray so she told the patient if she was in active labor, she would be admitted and they would have to obtain her records from Murray. RN #7 reported she told the patient if she needed to be checked out here, the hospital would evaluate her, but it would be at the risk of having to keep her, and a physician who was not familiar with her history would assume her care. RN #7 reported the patient stated she would go to Murray (45 minutes away) where her physician was. Interview with the Registrar Supervisor, on 10/14/16 at approximately 9:20 AM, revealed when pregnant women present to the ER with contractions, the registrar calls Labor and Delivery. She stated all types of patients enter through the ER entrance. She revealed when any patient who is twenty (20) weeks or more pregnant enters the ER, regardless of complaint, the registrar tells the Charge Nurse and the Charge Nurse calls Labor and Delivery. The Charge Nurse and the Labor and Delivery Nurse determine if the patient is seen in the ER or taken to Labor and Delivery without a MSE in the ER. Interview with RN #1, on 10/13/16 and 10/14/16 at 9:40 AM, revealed a patient presenting to the ER who is twenty (20) weeks or greater pregnant will be sent to the Labor and Delivery department for a MSE. She stated the policy was revised because of the facility's investigation and now calls for the registrar to contact an ER nurse, who then calls Labor and Delivery, and they will decide where the patient will be seen without conducting a MSE in the ER. She further stated Patient #1 left the ER, and did not receive a MSE. Interview with the Clinical Manager of Maternal Child Services, on 10/13/16 at 2:55 PM, revealed she had informed RN #7 when someone presented to the ER that he/she has to be seen, and Patient #1 met the criteria to be seen in the ER department. She stated that RN #7 did not think this was an EMTALA violation; however, she stated "I explained it was". Interview with the Administrator on call for 08/27/16, on 10/14/16 at 1:11 PM, revealed he was informed of the situation regarding RN #7. The facility discovered the deficiency and put an effective Plan of Correction (POC) into effect prior to the survey. The facility implemented the following actions to correct the deficient practice: 1. The RN (#7) in the Obstetrics (OB) Department was terminated on 09/07/16. 2. The ER policy regarding pregnant patients presenting to the ER was revised on 09/16/16. 3. The ER staff were re-educated on EMTALA and the revised policy. The State Survey Agency validated the facility's plan of action was carried out as follows: 1. Interview with the Chief Nursing Officer (CNO), on 10/13/16 at approximately 9:40 AM, revealed the RN in the Obstetrics Department (OB) was terminated based on the facility's investigation. Interview with the Director of Human Resources, on 10/13/16 at approximately 11:45 AM, revealed the RN in the OB was terminated on 09/07/16. 2. Review of the facility's policy, Obstetrical Patient in the ED, dated 09/16/16, stated, "Obstetrical (OB) patients presenting to the Emergency Department (ED) will be provided care based on current medical condition and in consideration of her gestational age. Patients presenting with pregnancy equal to or greater than twenty (20) weeks and an obstetrical complaint will be sent to Labor and Delivery to undergo a Medical Screening Exam (MSE). Patients with non-obstetrical complaints will undergo a Medical Screening Examination (MSE) in the Emergency Department". 3. Interviews with Registrar #1, Registrar #2, RN #5, RN #6, the Patient Access Director, and the CNO, confirmed they had been re-educated on EMTALA and the revised policy regarding pregnant patients presenting to the ER.