Based on review of twenty-one emergency department records, patient #1's record from hospital #2, review of the hospital's bylaws, and review of the policies and procedures for patients who present to the emergency department, it was determined that in one (patient #1) of twenty-one patients who presented to hospital #1 requesting emergency services, the hospital failed to ensure compliance with 489.24. Patient #1's ED record from hospital #2 and interviews indicated patient #1 had a sudden onset of right back pain and right abdominal pain with nausea and vomiting that started the morning of 11/4/16. Person (K) brought patient #1 to hospital #1 for care during the afternoon of 11/4/16. Patient #1 was not checked in and was not triaged at hospital #1's ED, and as a result, patient #1 did not receive a medical screening examination. Interviews indicated an ED staff person from hospital #1 told patient #1 that there were twelve people ahead of him and waiting to be seen and that the ED was very busy. Interviews revealed that the ED staff person told patient #1 that he did not look sicker than any of the peoople who were waiting and advised patient #1 to leave and go to hospital #2's ED for care. This resulted in an immediate jeopardy to the patient's health and safety. The deficient practice is cited at 42 CFR 489.24, A2406.

Based on review of patient #1's ED record from hospital #2, the 11/4/16 ED log from hospital #1 and interviews, hospital #1 failed to include patient #1's name on the ED's central log when patient #1 came to the ED seeking care for an emergency medical condition and was refused treatment in one of twenty-one patients reviewed (patient #1). Findings include: Review of hospital #1's 11/4/16 ED log did not reveal that patient #1's name was entered on the log when patient #1 visited the ED. Patient #1 was interviewed by phone on 11/15/16, and he stated he was having horrible back pain, abdominal pain and vomiting, and person (K) brought him to hospital #1 for care. A female ED staff person was sitting at the ED admitting desk when he requested care. The staff person told patient #1 that there were twelve people ahead of him waiting to be seen and that the ED was very busy. The ED staff person told patient #1 that he did not look sicker than any of the people who were waiting and advised him to leave and go to hospital #2 for care. Patient #1 said he was not checked in and did not receive a medical screening examination while he was at hospital #1. Patient #1 said he noticed two people waiting to be seen in hospital #1 ' s ED waiting room. Person (K) took patient #1 to hospital #2 for care, and patient #1 stated he received very good care at hospital #2. Nursing assistant (F) was interviewed in person on 11/15/16 and stated she was working in hospital #1's ED/triage area and was sitting at the admitting desk on the afternoon of 11/4/16. She denied the allegation pertaining to patient #1's visit to the ED and stated she would never turn anyone away who requests care at hospital #1's ED. She stated patients do have the option to go to hospital #2's ED for care.

Based on review of patient #1's ED record from hospital #2 and interviews, hospital #1 failed to ensure that each patient who presented to the emergency department received a medical screening examination, to determine whether or not an emergency medical condition existed, in one of twenty-one patients reviewed (patient #1). Findings include: Review of patient #1's 11/4/16 ED record from hospital #2 indicated patient #1 arrived at the ED via car and was accompanied by significant other (K). The record indicated patient #1 stated he had a sudden onset of right back pain and right abdominal pain with nausea and vomiting on the morning of 11/4/16. The patient had a CT scan of the abdomen and pelvis that confirmed the patient had a kidney stone. The patient was having severe pain during the ED visit and was provided narcotic IV pain medication to control the pain. The patient was provided prescriptions for pain and was discharged to home and self care at 4:41 p.m. on 11/4/16. Patient #1 was interviewed by phone on 11/15/16, and he stated he was having horrible back pain, abdominal pain and vomiting, and person (K) brought him to hospital #1 for care. A female ED staff person was sitting at the ED admitting desk when he requested care. The staff person told patient #1 that there were twelve people ahead of him waiting to be seen and that the ED was very busy. The ED staff person told patient #1 that he did not look sicker than any of the people who were waiting and advised him to leave and go to hospital #2 for care. Patient #1 said he was not checked in and did not receive a medical screening examination while he was at hospital #1. Patient #1 said he noticed two people waiting to be seen in hospital #1' s ED. Person (K) took patient #1 to hospital #2 for care, and patient #1 stated he received very good care at hospital #2. Person (K) was interviewed by phone on 11/15/16 and stated she drove patient #1 to hospital #1 on 11/4/16. Patient #1 vomited seven times on the way to the hospital and was in extreme pain and could hardly stand up. An ED staff person who was sitting at the desk at hospital #1 told them the ED was busy and advised them to go to hospital #2 for care. Patient #1 went to the bathroom at hospital #1, and they were at hospital #1 for approximately fifteen minutes. They went to hospital #2 and received immediate care. Patient #1 and person (K) told ED staff at hospital #2 that they were refused care at hospital #1 prior to their arrival at hospital #2. Nurse (I) was interviewed by phone on 11/14/16 and stated patient #1 was having severe pain when he arrived at hospital #2. She stated she triaged patient #1 when he arrived and provided him with IV pain medication. Patient #1 told nurse (I) that he was refused care at hospital #1 prior to coming to hospital #2. Nurse (J) was interviewed by phone on 11/14/16 and stated patient #1 complained of severe pain when he arrived at hospital #2. Patient #1 was provided pain medication immediately. Patient #1 told nurse (J) that he was refused care at hospital #1 and was told by an ED staff person that he did not look sicker than the other people who were waiting to be seen. Patient #1 said hospital #1 advised patient #1 to go to hospital 2 for care because hospital #1's ED was busy, and it would be a two hour wait. Physician (L) was interviewed by phone on 11/16/16 and stated he provided care to patient #1 in hospital #2's ED on 11/4/16. Patient #1 was having severe pain and his condition warranted immediate care which patient #1 received at hospital #2. Patient #1 was given narcotic IV pain medication. Patient #1 told physician (L) that he went to hospital #1's ED before coming to hospital #2. Patient #1 said an ED staff person from hospital #1 advised him to go to hospital #2's ED because hospital #1's ED was very busy. The ED staff person told patient #1 that there were twelve people ahead of him, and it would be a long wait before he was seen. The ED staff person told patient #1 that he did not look sicker than the other people who were waiting to be seen and that he would not be seen before the other people. Nursing assistant (F) was interviewed in person on 11/15/16 and stated she was working in hospital #1's ED/triage area and was sitting at the admitting desk on the afternoon of 11/4/16. She denied the allegation pertaining to patient #1's visit to the ED and stated she would never turn anyone away who requests care at hospital #1's ED. She stated patients do have the option to go to hospital #2's ED for care. The hospital ' s EMTALA policy, dated December 2006, and revised in July 2012, states "when an individual requests an examination or treatment for a medical condition, the hospital will, through a qualified medical professional as defined through the hospital rules and regulations, provide an appropriate medical screening examination to determine whether or not the individual has an emergency medical condition. "