Based on interview and review of Emergency Department (ED) logs, Medical Records, and video surveillance, the facility failed to enter one patient (#31) into the ED log of 31 patients' records reviewed, and failed to provide a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) within its capacity and capability for two patients (#31 and #30) of 31 ED records reviewed from July 2016 through January 2017. The facility had the capacity to provide a MSE to Patients #30 and 31 to determine if they had an emergency medical condition, and had the capability to provide stabilizing treatment or arrange an appropriate transfer to a higher level of care if the required treatment exceeded the facility's capabilities. Please see the citations at A2406 for further details.

Based on interview, record review and review of video surveillance, the facility failed to enter into the Emergency Department (ED) log one patient (#31) of 31 patients' medical records reviewed, who presented to the ED. This failure had the potential to affect all patients who presented to the ED. The ED sees approximately 2825 patients per month. The facility census was 134. Findings included: 1. Record review of the facility's policy titled, "Emergency Medical Treatment and Active Labor Act - EMTALA Requirements," revised 07/08/2015, showed that when a patient makes the first point of contact at the Emergency Department (ED), all patients are asked their name and date of birth, and this information is entered into the electronic medical record (EMR) databank/log (ED log) 2. Review of video surveillance dated 12/17/16 showed that at 9:29 PM, a patient (identified by facility staff as Patient #31) presented to the ED in the area outside the ambulance bay in an ambulance and spoke with a staff member (identified by facility staff as ED Physician F), who then exited the area at 9:37 PM. 3. Review of the ED log, dated 12/17/16 showed no evidence of Patient #31's arrival to the ED. During an interview on 01/12/17 at 4:00 PM, Staff A, Accreditation and Licensure, stated that there was no entry of Patient #31's name in the log because she was not treated in the ED.

Based on interview, record review, and video surveillance, the hospital failed to provide a medical screening examination (MSE) to determine the presence of a medical or psychiatric emergency condition (EMC) within its capacity and capability, for two patients (#31 and #30) of 31 patients' Emergency Department (ED) records reviewed July 2016 through January 2017. Th hospital's failure had the potential to affect all patients who presented to the ED. The ED sees approximately 2825 patients per month. The facility census was 134. Findings included: 1. Review of the facility's policy titled, Emergency Medical Treatment and Labor Act - EMTALA Requirements," reviewed 07/08/15 showed that all patient's presenting to the ED requesting medical care and treatment must be provided a medical screening exam. This would include anyone who presents to the ED and requests examination or treatment for a medical condition, has such a request made on his or her behalf, or a prudent layperson observer would believe, based on the individuals's appearance or behavior, that the individual needs examination or treatment for a medical condition, or is in an ambulance on hospital property for examination and treatment of a medical condition. 2. Review of video surveillance provided by the facility dated 12/17/16 showed that patient (#31) was brought to the hospital by ambulance. Further review of the video showed that ED Physician F climbed into the ambulance at 9:27 PM and exited the ambulance at 9:37 PM. During an interview on 01/10/17 at 6:05 PM, ED Physician F, stated that on 12/17/16 he had been notified by the facility staff that an ambulance was in route from Hospital A to Hospital C with a seven year old patient with possible peritonitis (inflammation of the peritoneum - a silk-like membrane that lines the inner abdominal wall and covers the organs within the abdomen). The ambulance was diverting to Mercy Hospital due to severe weather conditions. In a radio call with the EMS (Emergency Medical Services) crew, ED Physician F stated that he told the EMS crew that Mercy Hospital Jefferson did not have the capability to care for a child and they should continue to Hospital C. He stated that the crew told him that the child was stable. He stated that he told them that he had traveled the roads two hours earlier and that the roads were clear. He also stated that he was outside the ED checking the weather when the ambulance pulled into the area next to the ambulance bay and talked with the crew through the window and then he entered the ambulance and talked with the patient, mother and crew. He stated that the patient was in no distress and there was no request for a medical screening examination of the patient. 3. Review of the "Prehospital Care Report" dated 12/17/16 from the ambulance service showed Patient #31 was en route to Hospital C when it diverted to Mercy Hospital Jefferson due to "extreme slick road conditions from ice, freezing rain and snow." Contact was made by radio with the physician at Mercy Hospital Jefferson who advised crew to continue to Hospital C as he would not see the patient. The decision was made to divert to Mercy Hospital Jefferson where the ED physician stepped into the ambulance and again stated that he would not see the patient and that if roads became worse, they could divert to Hospital D, which was "along the way." During an interview on 01/18/18 at 9:55 AM, Paramedic O, stated that the ambulance diverted to Mercy Hospital Jefferson due to safety concerns related to the severe weather conditions. He stated that he had spoken to ED physician F by radio and that he was told to continue to Hospital C. He stated that he diverted to Mercy Hospital Jefferson and that the physician (ED Physician F) came out to and stepped into the ambulance where he again told them that he would not see the patient because there were no Pediatric surgical services available and he could not do anything for her. During an interview on 01/18/17 at 3:51 PM, the mother of patient # 31 stated that the roads were icy and slick and the ambulance had slipped off the road twice and had called the Highway Patrol for help (who called a salt truck) and she was afraid the ambulance would have a wreck. She stated that she overheard the paramedic's conversation with the physician at Mercy Hospital Jefferson and that he directed them to continue to Hospital C because he was unable to take the patient because they didn't have a pediatric surgeon. It was decided that they would go to Mercy Hospital Jefferson and once there, the physician came into the ambulance and again stated that they couldn't take the patient because they did not have a pediatric physician. She stated that she asked the physician if he could give her daughter something to keep her comfortable for the night until the roads were better in the morning. She stated that Physician F again told them to continue to Hospital C. 4. Review of Patient #31's ED record from Hospital C, showed the patient was admitted on [DATE] at 11:00 PM with an unstabilized emergency medical condition. 5. Review of a closed medical record showed that Patient #30 (MDS) dated [DATE] at 9:39 PM accompanied by his mother after having ingested a bunch of pills and self inflicting multiple cuts to his arms. Review of the ED provider notes dated 12/08/16 at 7:39 PM showed that ED Physician J documentated that the patient had taken approximately 30 (mother stated 80-90) Ibuprofen 200 mg tablets (used to reduce fever and treat pain) in an attempt to kill himself and that he had superficial cut to both of his wrists using a razor blade. Further documentation showed that patient # 30 had a history of bipolar disorder in addition to ADHD (attention-deficit/hyperactivity disorder, a brain disorder marked by an ongoing pattern of inattention and/or hyperactivity). ED Physician J documented that patient # 30 initially stated that he wanted to kill himself and then later stated that the next time he would use a gun. The patient later reported to the psychiatric intake coordinator that he only said those things in an attempt to shock and scare his parents. Further documentation showed patient # 30 stated that he took Ibuprofen knowing that they would not actually kill him rather than taking his Adderall (medication to treat ADHD) or other medications. Review of the laboratory results showed that patient # 30 tested positive for Marijuana and Amphetamines (Adderall) and had a non toxic level of Ibuprofen. Review of the Physical Exam showed multiple parallel superficial lacerations to both forearms. No active bleeding. No full thickness injuries. Review of the facility's "Patient Care Timeline" dated 12/08/16 at 11:58 PM showed the patient was discharged from the ED. Review of the Behavioral Health Intake Coordinator's documentation titled "Progress Notes", dated 12/08/16 at 11:42 PM stated that the patient had presented to the ED after consuming 20 tablets of Ibuprofen and cuts on both arms with a razor blade. After the patient and parents were informed that the ingestion was not toxic; the patient yelled that the next time he would use a gun. Therefore, a psychiatric evaluation was requested. The patient denied Suicidal Ideation, Homicidal Ideation and Psychosis. When separated from his parents, his demeanor changed significantly and he was smiling and laughing. He stated that he wanted to "hurt them" (his parents) and show them he was upset. During a telephone interview on 01/12/17 at 9:30 AM, Behavioral Health Intake Coordinator K, stated that he assessed the patient and there was a great deal of difference in the patient's presentation when the parents were present. He stated that the patient said he was mad and wanted to scare them. The patient stated that if he really wanted to kill himself he would have taken an overdose of Adderall or shot himself (the documentation showed a gun in the home and parents reported it was secure). Behavioral Health Intake Coordinator K stated that he nearly always offered to find a bed for a behavioral health patient if the family felt they couldn't keep their family safe. During a telephone interview on 01/19/17 at 9:46 AM, the mother of Patient #30 stated that the Behavioral Health Intake Coordinator assessed her son and said that he had behaved in the way that he did to "get back at us." She said Staff K stated that her son needed inpatient or intensive out patient care but did not believe that he was a danger to himself or others. She stated that he said "we would just sit in the ED all night waiting for a bed" and that if the circumstances changed we should go to another facility who could admit him if we felt he wasn't safe. She stated that the next day her son continued to decline and was admitted to Hospital D for treatment of his psychiatric emergency. Review of the medical record from Hospital D showed that Patient # 30 was admitted less than 24 hours after discharge from Mercy Hospital Jefferson for treatment of an emergency psychiatric condition on 12/09/16 at 2:46 PM. .