Based on interview, review of the emergency room (ER) log, and review of facility by-laws and policies, it was determined the facility failed to comply with 42 CFR 489.20(r)(3) in regard to the ER log, as well as 42 CFR 489.24(r) and 42 CFR 489.24(c) in regard to a Medical Screening Exam (MSE), within the capability of the hospital's ER for one (1) of twenty-one (21) sampled patients (Patient #1). The facility failed to follow the policy for Patient Flow, dated September 2015, which stated all patients presenting to the ER will be entered on the ER log and receive an appropriate MSE.

Based on interview, review of the emergency room (ER) Log, review of facility policies and by-laws, and review of the facility's investigation, it was determined the facility failed to enter one (1) of twenty-one (21) sampled patients in the ER log (Patient #1). The findings include: Review of the facility By-Laws, dated November 2014, revealed all patients who presented to the ER were to be entered in the ER Log and receive an MSE. Review of the Patient Flow ER policy, dated September 2015, it was revealed when a patient presented to the ER, the Registration Clerk should enter the patient's name, date of birth, and chief complaint on the ER log. The patient should then be triaged and seen by the Physician or Advanced Nurse Practitioner for an appropriate MSE. Review of the facility's investigation, dated 06/02/16, revealed Patient #1 (MDS) dated [DATE] at approximately 3:10 PM. However, the patient exited the ER after being directed to go to another hospital due to the X-ray equipment being down. Interview with Patient #1, on 06/06/16 at approximately 10:50 AM, revealed he/she (MDS) dated [DATE], and the physician told him/her the X-ray machine was down and he/she would be better off going to another hospital. Patient #1 stated he/she then left without being registered. Review of the ER Log for 05/29/16 (Sunday), revealed there was no documented evidence Unsampled Patient #1 was entered on the ER log. Interview with the ER Registration Clerk, on 06/06/16 at approximately 11:55 AM, revealed, on 05/29/16, Patient #1 presented to the ER and as she was attempting to enter the patient on the ER log, Physician #1 went into the hallway and told the patient the X-ray equipment was down and it would take a long time for him/her to get an X-ray. She stated the patient chose to leave the ER and was not entered on the ER log. Interview with Physician #1, on 06/06/16 at approximately 12:20 PM, revealed, on 05/29/16, Patient #1 reported to the ER stating he/she had been in a motorcycle accident. He revealed he told the patient the X-ray equipment was down and after a visual assessment, the physician told him/her that he/she may want to go to another hospital, and the patient chose to leave at that time. The physician also stated he has received several EMTALA trainings. Interview with the X-Ray Technician, on 06/07/16 at approximately 9:33 AM, revealed she was working on 05/29/16 from 11:30 AM until 7:30 PM. She stated the X-ray reader was down and had been all day that day; however, X-rays were being read from one (1) of the hospital's facilities approximately one (1) mile away. She revealed this caused a delay in patients getting their results. Interview with the Assistant Administrator, on 06/06/16 at approximately 10:50 AM, revealed the ER Registration Clerk reported to him on 05/29/16 that Physician #1 had done something that may be a possible EMTALA violation. He stated the ER Registration Clerk reported to him Patient #1 presented to the ER and Physician #1 told the patient the X-ray equipment was down, and it would take a long time for him/her to get an X-ray, so the patient left the ER and was not entered on the ER log. Interview with the Chief Compliance Officer, on 06/07/16 at approximately 9:00 AM, revealed the Assistant Administrator reported to her, that on 05/29/16, Patient #1 left the ER without being put on the ER log or receiving an MSE because Physician #1 told the patient the X-ray equipment was down and there would be a long wait. She stated the Assistant Administrator revealed he told Physician #1 this was not to be done, and all patients reporting to the ER were to be put on the ER log and receive an MSE.

Based on interview, review of patient records, review of the facility's investigation, and review of facility policies and by-laws, it was determined the facility failed to follow the policy and by-laws related to providing a Medical Screening Exam (MSE) for one (1) of twenty-one (21) sampled patients (Patient #1). The findings include: Review of facility By-Laws revealed all patients who present to the ER should be provided an MSE. Review of the Patient Flow ER policy revealed when a patient presented to the ER, the patient should be triaged and seen by the physician or Advanced Nurse Practitioner for an appropriate MSE. Review of the facility's investigation, dated 06/02/16, revealed Patient #1 (MDS) dated [DATE] at approximately 3:10 PM and left the ER after being directed to go to another hospital due to the X-ray equipment being down. Review of Patient Records revealed there was no documented evidence Patient #1, had presented to the ER and/or was provided an MSE. Interview with Patient #1, on 06/06/16 at approximately 10:50 AM, revealed he/she (MDS) dated [DATE], and the physician told him/her the X-ray machine was down and he/she would be better off going to another hospital. Patient #1 stated he/she then left without being registered. Interview with the ER Registration Clerk, on 06/06/16 at approximately 11:55 AM, revealed, on 05/29/16, Patient #1 presented to the ER and as she was attempting to enter the patient on the ER log, Physician #1 went into the hallway and told the patient the X-ray equipment was down and it would take a long time for him/her to get an X-ray. She stated the patient chose to leave the ER without an examination from the physician and she was unable to get the patient's name to enter him/her on the ER log. Interview with Physician #1, on 06/06/16 at approximately 12:20 PM, revealed, on 05/29/16, Patient #1 reported to the ER stating he/she had been in a motorcycle accident. He revealed he told the patient the X-ray equipment was down and after a visual assessment, the physician told him/her that he/she may want to go to another hospital, and the patient chose to leave at that time. The physician also stated he has received several EMTALA trainings. Interview with the X-Ray Technician, on 06/07/16 at approximately 9:33 AM, revealed she was working on 05/29/16 from 11:30 AM until 7:30 PM. She stated the X-ray reader was down and had been all day that day; however, X-rays were being read from one (1) of the hospital's facilities approximately one (1) mile away. She revealed this caused a delay in patients getting their results. Interview with the Assistant Administrator, on 06/06/16 at approximately 10:50 AM, revealed the ER Registration Clerk reported to him on 05/29/16 that Physician #1 had done something that may be a possible EMTALA violation. He stated the ER Registration Clerk reported to him Patient #1 presented to the ER and Physician #1 told the patient the X-ray equipment was down, and it would take a long time for him/her to get an X-ray, so the patient left the ER and did not receive an MSE. Interview with the Chief Compliance Officer, on 06/07/16 at approximately 9:00 AM, revealed the Assistant Administrator reported to her, that on 05/29/16, Patient #1 left the ER without being put on the ER log or receiving an MSE because Physician #1 told the patient the X-ray equipment was down and there would be a long wait. She stated the Assistant Administrator revealed he told Physician #1 this was not to be done, and all patients reporting to the ER were to be put on the ER log and receive an MSE.

Based on interview, review of patient records, and review of facility policies and procedures, it was determined the facility failed to enter one (1) of twenty (20 ) sampled patients (Patient #1) on the emergency room (ER) Log when he/she presented to the ER for treatment. The findings include: Review of the facility policy titled, "Admission Policy", last revised 09/2014, revealed "All patients will be evaluated by a Registered Nurse prior to being seen by a Registration Clerk. All patients will have the appropriate demographic information obtained by a Registration Clerk". Review of policy titled, "EMTALA Guidelines for Emergency Department Services", last revised 09/2014, revealed "An individual that presents to the hospital requesting emergency services shall be triaged by a registered nurse or a paramedic acting within his statutory scope of practice, and in accordance with the hospital's formal operating policies and procedures". Further review of the policy revealed "The hospital must perform a Medical Screening Exam (MSE) to determine if an emergency medical condition (EMC) exists. It is not appropriate to merely "log in" or triage an individual medical condition and not provide an MSE". Review of the ER Log for Tuesday, 04/21/15, revealed Patient #1 was not on the Log. There was no documented evidence Patient #1 had presented on that date. Interview with Patient #1, on 04/30/15 at approximately 10:22, revealed he/she (MDS) dated [DATE] at approximately 2:35 PM with a complaint of leg pain and a concern of a possible blood clot; and at the advice of the staff at his/her Primary Care Physician (PCP)'s office requested an ultrasound. Patient #1 stated Hospital Physician #1 was at the registration desk and told him/her we don't do ultrasounds here except for pregnancy or men's testicles, and you don't fit these categories. Patient #1 stated he/she told Physician #1 his/her problem and Physician #1 replied the PCP's office needs to be informed of our policy. Patient #1 further revealed the physician then told him/her she could give him/her a shot of Coumadin, he/she could go to another area hospital for an ultrasound, or back to her PCP's office to have an ultrasound scheduled. Patient #1 stated he/she chose to return to his/her PCP's office. Interview with Hospital Physician #1, 04/29/15 at approximately 2:05 PM, revealed Patient #1 did present in the ER and was not triaged on 04/21/15. She stated she told Patient #1 ultrasounds were not done through the ER. She revealed she offered to see the patient and told him/her she could get him/her started on Coumadin; he/she could go to his/her PCP to schedule an ultrasound; or he/she could go to another area hospital for an ultrasound. Physician #1 stated she contacted the patient's PCP to get him/her an appointment that day. She reported the Hospital Administrator came to her later and stated the ER does ultrasounds. Interviews on 04/30/14 with Registered Nurse (RN) #2, at approximately 8:35 AM, and RN #5 at approximately 12:20 PM, revealed there was not a dedicated staff person positioned in the ER twenty-four/seven (24/7) as the Registration Clerk. Interview with the Interim Director of Nursing (DON), on 04/29/15 at approximately 7:45 AM, revealed all patients should have appropriate demographic information obtained by the Registration Clerk, as this was how a patient was placed on the ER Log. Additionally, she confirmed Patient #1 was not on the ER Log, dated 04/21/15.

Based on interview, review of patient records, and review of facility policy and procedure, it was determined the facility failed to comply with their policy to ensure one (1) of twenty (20) sampled patients (Patient #1), was given a Medical Screening Exam (MSE) when he/she presented to the emergency room (ER). The findings include: Review of policy titled, "EMTALA Guidelines for Emergency Department Services", last revised September 2014, revealed "An individual that presents to the hospital requesting emergency services shall be triaged by a registered nurse or a paramedic acting within his statutory scope of practice, and in accordance with the hospital's formal operating policies and procedures". Further review revealed "The hospital must perform a Medical Screening Exam (MSE) to determine if an emergency medical condition (EMC) exists". Review of patient records, revealed there was no documented medical record for Patient #1 verifying he/she (MDS) dated [DATE] and an appropriate MSE had been completed. Interview with Patient #1, on 04/30/15 at approximately 10:22, revealed he/she (MDS) dated [DATE] at approximately 2:35 PM with a complaint of leg pain and a concern of a possible blood clot and was told by staff at his/her Primary Care Physician (PCP)'s office to go to the hospital and request an ultrasound. Patient #1 stated Hospital Physician #1 told him/her the hospital does not do ultrasounds except for pregnancy or men's testicles, and she/he did not fit these categories. Patient #1 revealed he/she told Hospital Physician #1 his/her problem and Hospital Physician #1 replied the PCP's office needed to be informed of the hospital's policy. Patient #1 stated the physician told him/her they could give him/her a shot of Coumadin, he/she could go to another area hospital for an ultrasound, or back to her PCP's office to have an ultrasound scheduled. Patient #1 stated he/she chose to return to his/her PCP's office. Interview with Hospital Physician #1, on 04/29/15 at approximately 2:05 PM, revealed she was at the registration desk when Patient #1 arrived. She stated Patient #1 (MDS) dated [DATE] and he/she was not triaged and an appropriate MSE was not completed. She stated she told Patient #1 ultrasounds were not done through the ER. She further revealed she did offer to see the patient and told him/her she could get him/her started on Coumadin, he/she could go to his/her PCP to schedule an ultrasound or he/she could go to another area hospital for an ultrasound. Hospital Physician #1 reported she contacted the patient's PCP to get him/her an appointment that day, but Patient #1 chose to go to his/her PCP and not be seen in the ER. Additionally, Hospital Physician #1 stated the hospital Ultrasound Policy states ultrasounds were done through the ER for [DIAGNOSES REDACTED] and ovarian or testicular torsion; however, review of the hospital policy titled, "Emergency Ultrasound Procedures", dated 10/14, revealed the policy addressed emergency after hours procedures that would require an Ultrasound Technologist to be called in after hours and on weekends. This policy stated the patient must present with a sudden onset of testicular pain which could possible indicate Testicular Torsion or the patient must present with pain in the exact location of the ovaries which could possible indicate Ovarian Torsion. Further review revealed there was no documented evidence an ultrasound could not be obtained during normal business hours Monday through Friday. Interview with the Director of Nursing (DON), on 04/29/15 at approximately 7:45 AM, revealed Patient #1 presented to the ER, was not listed on the ER Log and there was no MSE completed.

Based on interview, review of patient records and review of facility policies, it was determined the facility failed to comply with 42 CFR 489.20(r)(c) and 489.24(c) in regard to providing an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department (ER) for one (1) of twenty (20) sampled patients (Patient #1). The facility failed to follow their policies for EMTALA Guidelines for Emergency Department Services, last revised September 2014, regarding the emergency room (ER) Log, triage, and an appropriate Medical Screening Exam (MSE). Additionally the facility failed to follow the Admission Policy which states, "All patients will be evaluated by a Registered Nurse prior to being seen by a Registration Clerk. All patients will have the appropriate demographic information obtained by a Registration Clerk". Hosptal staff failed to triage, conduct a MSE and obtain demographic information which would of resulted in the patient being placed on the ER log, when she (MDS) dated [DATE] with complaints of leg pain and a concern of a blood clot. Refer to C-2405 and C-2406.