Based on interview and record review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide a medical screening exam to one (#1) of twenty patients sampled who presented to the Emergency Department (ED) as determined in the hospital policy and procedure (see A-2406).

Based on interview and record review, the facility failed to maintain a central log for 1 of 20 patients (#1) coming to the hospital emergency department (ED) seeking emergency services resulting in inaccurate documentation of Pt #1's arrival to the emergency department. Findings include: During an interview with registered nurse (RN J) on 11/07/18 at approximately 1410, RN J indicated the ambulance transporting Pt #1 arrived on hospital property on 10/21/18 during the evening hours. RN J said at the time of Pt #1's arrival the ED acuity was very high due to a multiple casualty event. RN J said, while on hospital property, he met briefly with the ambulance driver who indicted Pt #1 was stable. RN J said he diverted the ambulance to another ED. RN J indicated Pt #1's arrival to the ED was not documented into the facility's log. During an interview with Physician C on 11/08/18 at approximately 0950, Physician C said there was no documentation completed in the facility's system regarding Pt #1's arrival on hospital property on 10/21/18, however there was documentation regarding Pt #1 in the record of the hospital that Pt #1 was diverted to. Review of facility's central log for a 6-month period revealed no documented evidence that Patient (Pt) #1 arrived and sought treatment at the facility ED on 10/21/18. Review of facility policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy and Procedure V8" approved 08/17/18 indicated, under documentation section, "3. A central log including name, date, complaint, arrival time, and triage time for all individuals who come to the Emergency Department seeking treatment, including labor and delivery will be maintained for a minimum of eight (8) years.".

Based on interview and record review the facility failed to ensure a medical screening exam (MSE) was performed for 1 of 20 patients (#1) coming to the hospital emergency department (ED) seeking emergency services resulting in the potential for poor outcomes when Patient #1, after entering hospital property via ambulance, was diverted to another hospital emergency department approximately 47 miles away. Findings include: During an interview with ED Director (RN E) on 11/07/18 at approximately 1155, RN E said, on 10/21/18 during the evening hours the ED was placed on diversionary status due to ED resources being fully committed in response to a multiple casualty event. RN E said one patient involved in the event arrived in very critical condition. RN E indicated Pt #1 was a person involved in the same multiple casualty event. RN E said Pt #1 arrived on the property of the facility via ambulance during the time frames the ambulance traffic was being diverted. RN E said the ED charge nurse (RN J) met the ambulance outside the ED and confirmed with the ambulance driver that Pt #1 was in stable condition and RN J diverted the ambulance to another hospital approximately 47 miles away. RN E said there was no evidence that a medical screening examination was performed on Pt #1 when they arrived at the hospital ED. During an interview with RN J on 11/07/18 at approximately 1410, RN J said on 10/21/18 during the evening hours, due to a multiple casualty event, he was instructed by Physician I to divert stable patients from the ED. RN J said during the time frame of the diversion status, Pt #1 arrived via ambulance on hospital property. RN J said he confirmed with the ambulance driver that Pt #1 was in stable condition and diverted the ambulance to another hospital approximately 47 miles away. RN J said he did not assess Pt #1 directly. RN J said Physician I was not aware of Pt #1's arrival via ambulance until hours later. RN J said a medical screening examination was not performed on Pt #1. During an interview with Physician I on 11/07/18 at approximately 1435, Physician I said, on 10/21/18 during the evening hours he placed the ED on diversionary status due to ED staff being fully committed in response to a multiple casualty event. Physician I said he was not aware Pt #1 arrived on hospital property via ambulance until hours after the ambulance was diverted. Physician I said he did not speak with the ambulance driver or directly assess Pt #1. Physician I said if he knew Pt #1 arrived on hospital property via ambulance a medical screening examination would have been completed by an available qualified clinician. Physician I said, on 10/21/18 previous to Pt #1's arrival to the ED, he performed medical screening examinations for other persons involved in the same multiple casualty event. Physician said a medical screening examination was not performed on Pt #1. During an interview with Physician C on 11/07/18 at 1210, Physician C said it was hospital policy to provide a medical screening examination to any person in need of emergency services that arrived on hospital property. Review of facility policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy and Procedure V8" approved 08/17/18 indicated, under policy section, "All individuals who come to the Hospital for examination and treatment of potential emergency medical condition will receive a screening examination ..." and, under definitions, hospital property is defined as, "9. Hospital Property: The entire Hospital campus, including parking lots, sidewalks and driveways ...", and, under examination and treatment, "Any individual who is not already a patient and presents to the hospital or in an ambulance as described in 1 through 3 above will be provided an appropriate medical screening examination to determine if an emergency medical condition exists ...". Review of facility policy titled, "Hospital Diversion in the Emergency Department V3" approved 07/12/17 indicated, under EMTALA responsibilities, " ...If, however, the ambulance staff disregards the hospital's diversion instructions and transports the individual onto hospital property, the individual is considered to have come to the emergency department.".