Based on record reviews and interviews, the hospital failed to meet §489.24(c) Medical Screening Exam as evidenced by: 1) Failing to ensure there was documented evidence that each patient presenting to the emergency department (ED) was provided an appropriate medical screening examination (MSE) as evidenced by failure to have an appropriate MSE documented by the ED physician for 17 (#3, #8, #10, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33) of 33 (#1 - #33) ED patient records reviewed for a MSE ( see findings in tag A2406). 2) Failing to ensure that nurse practitioners who performed MSEs in the ED were privileged by the Medical Staff and Governing Body to perform such examinations as evidenced by having 1 (S13) of 3 (S13, S14, S15) nurse practitioners (NP) who performed MSEs in the ED not privileged to do so (see findings in tag A2406). 3) Failing to ensure that the on-call ENT (Ear, Nose, Throat) physician presented to the Emergency Department (ED) to provide treatment to a patient having active epistaxis (nose bleed) on 01/27/15 for 1 (#7) of 6 (#3, #7, #9, #12, #13, #19) ED patient records reviewed of patients who presented to the ED with nose bleed from a total sample of 33 (#1 - #33) patients (see findings in tag A2404).

Based on record reviews and interviews, the hospital failed to ensure that the on-call ENT (Ear, Nose, Throat) physician presented to the Emergency Department (ED) to provide treatment to a patient having active epistaxis (nose bleed) on 01/27/15 for 1 (#7) of 6 (#3, #7, #9, #12, #13, #19) ED patient records reviewed of patients who presented to the ED with nose bleed from a total sample of 33 (#1 - #33) patients. Findings: Review of Patient #7's ED record of 01/27/15 revealed he (MDS) dated [DATE] at 10:26 p.m. with a chief complaint of Nose Bleed. He was triaged as Emergent by S7RN. S8LPN documented that Patient #7 complained of severe nose bleed for 10 minutes, facial trauma 3 days ago, and was awaiting ENT surgery on Friday 01/30/15. S5ED Physician documented in Patient #7's ED record on 01/27/15 at 10:54 p.m. that Patient #7 was a [AGE] year old male who had a nasal fracture 4 days ago and was seen for a nose bleed yesterday, transferred to Hospital A since Opelousas General Health System had no ENT on-call, had an appointment soon for re-evaluation, and was bleeding profusely from both nares, the right greater than the left. Further review revealed that at 10:58 p.m. S5ED Physician documented Patient #7 was bleeding from the right and left nares, had active epistaxis during the exam, had active bleeding with blood being swallowed as well, and no single site of bleeding was identified. At 10:51 p.m. S5ED documented that Patient #7 required posterior packing with balloon to control posterior bleeding and anterior packing to control anterior bleeding. Some oozing was noted post procedure, and continued monitoring will occur to observe for recurrence of bleeding. Review of Patient #7's "Nursing Continuation Notes", documented by S8LPN (Licensed Practical Nurse) on 01/27/15 at 11:00 p.m., revealed that "S6Physician, ENT on call contacted for S5ED Physician. She states that we must call pt.'s (patient's) ENT, S18Physician at Hospital A. S18Physician at Hospital A's answering service contacted, S19Physician at Hospital A on call being paged." Review of Patient #7's "Disposition" revealed he was transferred to Hospital A. Review of his "Discharge Summary" revealed that S5ED Physician documented that he discussed Patient #7's transfer with S19Physician at Hospital A who accepted the transfer. Review of Patient #7's ED record for 01/27/15 revealed no documented evidence that S5ED Physician had discussed Patient #7's condition with S6Physician who was on-call for ENT on 01/27/15. Review of Patient #7's "Patient Transfer Summary - Important Legal Notice", signed by Patient #7's wife on 01/27/15 at 11:00 p.m., revealed the reason for transfer was noted to be "Patient-initiated request for transfer." Further review revealed the "Benefits Of Transfer" had a hand-written note of "pt requested transfer." Review of the "Unassigned Call Schedule For January 2015" revealed S6Physician was on-call for ENT on 01/27/15. In an interview on 02/05/15 at 8:35 a.m., S5ED Physician indicated that he had treated Patient #7 during his ED visit on 01/27/15. He further indicated that he didn't "recall a lot" but remembered both Patient #7 and his wife. S5ED Physician indicated that Patient #7 had requested to be transferred to Hospital A, because he had been seen by someone there before this visit. S5ED Physician indicated that he didn't get good results after having placed both tampons into Patient #7's nose, and he (Patient #7) was still having bleeding. He indicated that he "thought he put somewhere in here but I guess not" the discussion he had with Patient #7 about the transfer. When asked if he spoke with S6Physician (ENT on call), he indicated that he didn't know who S6Physician was. When told she was the ENT on call on 01/27/15, S5ED Physician indicated we "don't have ENT here", and after a brief pause he indicated "you mean at main campus?" He indicated that he didn't remember if he spoke with S6Physician that night, but Patient #7 was saying he didn't want to go there (Main Campus of Opelousas General Health System). He further indicated that Patient #7 said they were heading to Hospital A, but he didn't think they could make it there with the amount of bleeding he was having. S5ED Physician indicated that Patient #7 didn't want to be transferred to Main Campus. When asked about S6Physician coming to see Patient #7 at the off-site campus, S5ED Physician indicated he wasn't aware that happens (the on-call physician coming to the off-site campus to see ED patients). He further indicated the patient was sent to main Campus if they needed to be seen by an on-call physician. S5ED Physician confirmed that Patient #7 did have an emergency medical condition. In an interview on 02/05/15 at 8:55 a.m., S6Physician indicated that S5ED Physician did not speak with her about Patient #7 on 01/27/15. She indicated that a man spoke with her, and she didn't remember where he was calling from. She further indicated that she "felt like it was a nurse but it could be a clerk." S6Physician indicated the caller told her Patient #7 was in the ED with a nose bleed and was having surgery with S18Physician of Hospital A on Friday and was asked if she was taking call for S18Physician of Hospital A. She further indicated that she was not taking call for S18Physician of Hospital A, and no one asked if she would come to see Patient #7. She further indicated that the ED physician did not speak with her. S6Physician indicated she is in a solo practice and covers on-call 5 days a month for unassigned patients. She further indicated it is usually always a physician who calls her. She further indicated that the off-site campus didn't usually have ENT emergencies, because the hospital did not have an operating room. She further indicated that if an ENT emergency presented to the ED at the off-site campus, the off-site ED would send the patient by ambulance to the Main Campus ED. S6Physician indicated she would come to see a patient in the ED at the off-site campus if the patient didn't need surgery and if the staff said they had the equipment (such as sutures) needed to provide care. In an interview on 02/05/15 at 10:00 a.m., S8LPN indicated he remembered Patient #7 who walked into the ED with a Tupperware container in one hand that was more than half full of blood and a towel in the other hand. He further indicated that Patient #7 was actively bleeding. He indicated that Patient #7 was put in an exam room upon his arrival. S8LPN indicated that he called S6Physician for S5ED Physician after another nurse had asked S5ED Physician if he wanted them (the nurses) to call the ENT on-call. S8LPN indicated he placed the call to S6Physician, but he didn't remember if he specifically identified himself, but "I can't see myself calling a doctor in the middle of the night and not." S8LPN indicated he didn't remember what was actually said during the phone call, but he remembered the outcome of the call was that S6Physician recommended we call the ENT that Patient #7 had seen before. He further indicated that S5ED Physician did not speak with S6Physician. S8LPN indicated that upon Patient #7's arrival to the ED, he remembers Patient #7's wife saying that they were on their way to Hospital A but only stopped at Opelousas General health System, because Patient #7 felt like he couldn't make it to Hospital A. He further indicated that as he finished the call with S6Physician and before he could say anything that was recommended by S6Physician, the other ED nurses told him that Patient #7 and his wife were requesting to go to Hospital A.

Based on record reviews and interviews, the hospital failed to ensure: 1) There was documented evidence that each patient presenting to the emergency department (ED) was provided an appropriate medical screening examination (MSE) as evidenced by failure to have an appropriate MSE documented by the ED physician for 17 (#3, #8, #10, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33) of 33 (#1 - #33) ED patient records reviewed for a MSE and 2) Nurse practitioners who performed MSEs in the ED were privileged by the Medical Staff and Governing Body to perform such examinations as evidenced by having 1 (S13) of 3 (S13, S14, S15) nurse practitioners (NP) who performed MSEs in the ED not privileged to do so. Findings: 1) There was documented evidence that each patient presenting to the ED was provided an appropriate MSE: Review of the hospital policy titled "EMTALA (Emergency Medical Treatment And Labor Act) Policy & ER (and emergency room ) Call, document MS13 presented as a current policy by S2DON (Director of Nursing), revealed that any individual who comes to the hospital's ED requesting examination or treatment shall be provided with an appropriate medical screening examination. The medical screening examination shall include ancillary services routinely available to the ED and must be similar for patients presenting with similar symptoms. Further review revealed the purpose of the MSE is to determine if an individual is experiencing an emergency medical condition. If an individual presents to the ED and requests doctor-ordered care or treatment and the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform a screening examination appropriate to determine that the individual does not have an emergency medical condition. An ED physician shall be responsible for the general care of all patients presenting to the ED until the patient's private physician, or an on-call physician, assumes that responsibility or the patient is discharged or transferred. Review of Patient #30's ED record revealed she (MDS) dated [DATE]. Further review revealed no documented evidence that a MSE was performed by S12ED Physician. Review of the ED records for Patients #8, #25, #26, #27, and #32 revealed they (MDS) dated [DATE]. Further review revealed there was no documented evidence that a MSE was performed by S10ED Physician. Review of the ED records for Patients #28, #29, and #31 revealed they (MDS) dated [DATE]. Further review revealed there was no documented evidence that a MSE was performed by S10ED Physician. Review of the ED records for Patients #10, #24, and #33 revealed they (MDS) dated [DATE]. Further review revealed there was no documented evidence that a MSE was performed by S10ED Physician. Review of the ED records for Patients #3, #20, #21, #22, and #23 revealed they (MDS) dated [DATE]. Further review revealed no documented evidence that a MSE was performed by S10ED Physician. Review of the ED records of Patients #3, #20, #22, and #23, presented by S2DON on 02/05/15, revealed that S10ED Physician had documented their physical examinations on 02/05/15, 4 days after the patients had presented to the ED. Review of Patient #21's ED record presented by S2DON on 02/05/15 and with documentation of "Chart Status: Interim" revealed no documented evidence of a MSE. Review of Patient #21's ED chart presented later in the day by S2DON with the documentation of "Chart Status: Final" revealed the MSE was included in the record. In an interview on 02/05/15 at 11:15 a.m. with S2DON and S3ED Director present, both S2DON and S3ED Director indicated that the ED record is not able to be seen until it had been signed electronically by the ED physician. They further indicated that the ED record doesn't enter the HPF (Horizon Patient Folder) system until the ED physician completes the ED record. In an interview on 02/05/15 at 11:20 a.m., S9Project Manager IT (Information Technology) confirmed that the patient's ED record isn't able to be printed until the physician has completed the record. She further indicated that this process was to assure that the chart is complete before it "makes it to a permanent record." She indicated that S2DON, S3ED Director, or any staff member in the ED or Medical Records could access the record from HEC (Horizon Emergency Care), but they would only see what's been documented up to the time they're viewing it on the computer screen and would not be able to print the record in the event the record was requested by a physician or another facility. In a telephone interview on 02/05/15 at 1:30 p.m., S10ED Physician indicated that all of her ED records were completed until her recent "4 day run" when they were very busy in the ED. She indicated that the process in ED is "patient satisfaction driven especially now." When asked what she meant by this statement, S10ED Physician indicated that one of the questions on the patient satisfaction survey is "Were you seen in a timely fashion?" She further indicated that there was only one physician with two nurses in the ED at the off-site campus. S10ED Physician indicated that she does a complete exam, but when she's busy, such as having 12 patients with her being the only physician, she keeps hand-written notes during her patient visits. She further indicated that when she lets the patient leave, she has the diagnosis and the prescriptions given to the patient documented in the ED record, and then she goes back later and documents the complete note. When asked how familiar she was with the EMTALA regulations, S10ED Physician indicated, "I don't understand what you're asking." She was then asked if she knew what EMTALA means, she indicated, "I know you can't transfer a patient if you provide the service." When asked if she had ever discussed with anyone in Administration or leadership the difficulty she was having in performing her job while meeting patient satisfaction expectations, S10ED Physician indicated, "No, I tend to not, tend to try to work within the system." In an interview on 02/05/15 at 2:20 p.m., when asked how the hospital complies with ensuring that each ED patient receives a MSE, S2DON indicated that they set the expectation with the physician, and the nurses are there to see that it's done. She further indicated that she was not aware that MSEs were not being documented at the time of each ED patient visit. She confirmed that she was not aware that the hospital had incomplete ED records until it was identified by the surveyor. In an interview on 02/05/15 at 4:15 p.m., S2DON presented the Medical Staff Rules and Regulations. She indicated that the physician was required to countersign the ED records documented by the nurse practitioners, and these records would be considered incomplete until the physician had signed them. In an interview on 02/06/15 at 10:15 a.m., S2DON confirmed that no one at the hospital was aware there was a problem with incomplete MSEs until it was identified by the surveyor. 2) Nurse practitioners who performed MSEs in the ED were privileged by the Medical Staff and Governing Body to perform such examinations: Review of the credentialing file of S13ED NP revealed she was approved by the Governing Body as an Allied Health Staff from 04/16/14 through 04/16/16. Review of her request for privileges revealed no documented evidence that S13ED NP had requested or been approved to conduct MSEs. In an interview on 02/06/15 at 11:30 a.m., S2DON confirmed that S13ED NP was one of three NPs who conducted MSEs in the ED at the main campus. She further confirmed that S13ED NP had not requested and had not been approved through the credentialing process to perform MSEs.