As directed by the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site allegation survey was conducted at this facility from 10/17/17 to 10/18/17 to determine compliance with Emergency Medical Treatment And Labor Act (EMTALA) under the Responsibilities of Medicare Participating Hospitals in Emergency Cases, 42 CFR 489.20(l) and 42 CFR 489.24(a). The facility's failure to enter into the Emergency Department (ED) log one patient who presented to the ED and failure to provide a medical screening examination within the capability and capacity of the hospital, could have resulted in possible injury or death to patients who required immediate medical care. Please refer to the 2567 for details.

Based on interview, record review and review of video surveillance, the Hospital failed to enter into the Emergency Department (ED) log one patient (#24) of 24 patients' medical records reviewed, who presented to the ED. This failure had the potential to affect all patients who presented to the ED. Findings included: 1. Review of the Hospital's policy titled, "Registration Log," revised 11/2016, showed the directive for staff that all individuals seeking care in the ED shall be logged into the control register, and this information was to be entered into the electronic medical record (EMR) databank/log (ED log) without exception. 2. Review of the Hospital's undated education materials titled, "The Joint Commission: EMTALA," showed that staff would document every patient who presented to the ED along with information about the treatment of each patient's emergency condition. 3. Review of video surveillance dated 10/13/17, showed the following: - On 10/13/17 at 9:47:03 AM, an ambulance appeared into camera's view of the ED's ambulance bay with Patient #24 (identified by the facility); - At 9:47:20 AM, EMS personnel exited the ambulance and entered the ED; - At 9:48 AM, EMS personnel on camera view appeared to be talking to Staff I, Registered Nurse (RN); and - At 9:51 AM, Ambulance drove out of the ambulance bay, and out of the camera's view. During an interview on 10/18/17 at 8:35 AM, Staff I, RN, stated that: - She remembered Patient #24 and the events on 10/13/17; - She had taken report from the EMS; - EMS ambulance arrived to the ambulance bay, on Hannibal Regional Hospital's property; - She told EMS to divert to Hospital B; - She never retrieved the name or date of birth, and/or entered Patient #24 into the ED log. During an interview on 10/17/17 at 8:45 AM, Staff E, ED Unit Clerk, stated that registration personnel were responsible for "checking in" all patients who presented to the ED for emergency care, which placed the patients on the ED log. During an interview on 10/18/17 at 8:45 AM, Staff L, Director of the ED, stated that any patient that presents to the ED and/or on hospital grounds, should have been entered into the ED log. Review of the ED log, dated 10/13/17 showed no evidence of Patient #24's arrival to the ED, that he requested care or that he left the ED without receiving an examination based on staff I's suggestion.

Based on interview, review of Emergency Department (ED) logs, Medical Records, review of Video Surveillance, and Policy review the hospital failed to provide a medical screening examination (MSE) within its capabilities and capacity to determine whether an emergency medical condition (EMC) existed for one patient (#24) of 24 ED records reviewed from May 2017 through October 2017. Findings included: 1. Review of the Hospital's policy titled, "Emergency Medical Screening Examination (EMTALA)," dated 12/18/16, showed the directives for staff to perform a MSE: - The purpose was to ensure that all patients have access to and received a medical screening examination and stabilization of emergency medical conditions, and to provide expectations and guidance for care of the patient; - Any individual who presents to the hospital and who requests the examination of, or treatment for, an emergency medical condition, shall be provided a medical screening examination (MSE) and when necessary, stabilizing treatment, within the capabilities of the Hospital; and - Physicians who were on-call (and, if appropriate, backup contacts) will need to provide the treatment necessary to stabilize an individual with an EMC after the initial MSE had been performed. 2. Review of the video surveillance dated 10/13/17 showed the following: - On 10/13/17 at 9:47:03 AM, an ambulance arrived into camera's view to the ED's ambulance bay with Patient #24 (identified by the facility); - At 9:47:20 AM, Emergency Medical Services (EMS) personnel exited the ambulance and entered the ED; - At 9:48 AM, EMS personnel on camera view appeared to be talking to Staff I, Registered Nurse RN; - At 9:51 AM, The ambulance exited the camera's view and the ambulance bay; and - From 9:47 AM through 9:51 AM, Patient #24 remained in the ambulance, and no ED personnel, including a physician enter the camera's view or entered the ambulance. 3. During a telephone interview on 10/18/17 at 5:00 PM, EMS personnel stated that: - She remembered Patient #24 and the events on 10/13/17; - She transported Patient #24 to Hannibal Regional Hospital's ambulance bay; - Upon arrival to the hospital, she spoke with a nurse that directed her to take Patient #24 to Hospital B, because they did not have a Urologist (a physician that focus on diseases of the urinary tract) on call; - She never removed Patient #24 from the ambulance; and - No physician or any staff approached the ambulance to examine Patient #24. 4. During an interview on 10/18/17 at 8:35 AM, Staff I, RN, stated that: - She remembered Patient #24 and the events on 10/13/17; - She had taken report from the EMS; - The report was that Patient #24 had suprapubic catheter (sterile tube inserted through the abdomen into bladder) problems; - She looked at the on call list, and saw there was no Urologist on call; - She spoke with ED Physician H, who directed her to divert the ambulance to Hospital B; - She had given the directions to divert (go to another hospital) to Hospital B to dispatch, but never spoke to the ambulance crew; - EMS ambulance arrived to the ambulance bay, on Hannibal Regional Hospital's property; - She told EMS to divert to Hospital B; - She never told the physician that Patient #24 had arrived on hospital property; and - No physician or any staff had went out to the ambulance bay. 5. During a telephone interview on 10/17/17 at 1:30 PM, Staff H, ED Physician, stated that: - He has the knowledge to treat or attempt to stabilize any medical condition that presents to the ED; - He remembered Patient #24 and the events on 10/13/17; - He was the only physician working in the ED at the time of the event; - He was unaware that the patient arrived at the hospital; - He never examined Patient #24; and - Once Patient #24 arrived on the hospital's property, the patient should have received an examination and treatment. 6. Review of Hospital B's ED Physician's note dated 10/13/17, showed the following: - An [AGE] year old man, who was a resident of a Nursing Home; - Had urinary retention (unable to release urine), that was managed with suprapubic (inserted through abdomen into bladder) catheter; - He was transferred (by EMS) from a nursing home to Hannibal Regional Hospital, then on to Hospital B; and - Patient #24 was admitted to Hospital B. During an interview on 10/18/17 at 8:45 AM, Staff L, Director of the ED, stated that: - She remembered Patient #24 and the events on 10/13/17; - On 10/13/17, Hannibal Regional Hospital was not at any time on a full diversion, or incapable of providing care to any ambulance that requested examination of their patients; - Patient # 24 did not receive a MSE from a physician; and - Staff I, RN, should have not let the ambulance leave the hospital grounds, without the physician examining the patient. During a telephone interview on 10/18/17 at 9:15 AM, Staff O, ED Medical Director, stated that an ED Physician has the knowledge to treat and/or the ability to attempt to stabilize any medical condition that presents to the ED. If a patient's request that we examine them, it was the hospital's responsibility to see that patient.

Based on interview and review of Emergency Department (ED) logs, 72 Hour Return logs, Medical Records, Staffing and Physician On-Call Schedules, the facility failed to provide a sufficient medical screening examination within its capacity and capability for one patient (#19) of 20 patient records reviewed, who presented to the hospital ED for emergency care. The patient presented to the hospital and was found to have an elevated Creatine Kinase, Plasma (CPK, enzyme found in brain, skeletal muscles and the heart. An elevated level could be associated with heart attacks, when the heart muscle is damaged, or in conditions that produce damage to the skeletal muscles or brain) level. The facility did not recheck the CPK before they discharged the patient. The facility also failed to ensure patients were informed of their rights when Patient Rights signage was not posted in one of two ED entrances and in the psychiatric safe room. The average monthly census over the past six months was 1,749. The facility census was 54. The hospital had the capacity and capability to complete a medical screening examination to include further assessment of the patient's abnormal lab work to ensure that the patient was not suffering from a medical emergency. Please refer to A2402 and A2406 for details.

Based on observation, interview and policy review the facility failed to ensure patients were informed of their rights when Patient Rights signage was not posted in one of two Emergency Department (ED), entrances and for one (#19) psychiatric safe room (an exam room designated as a safe environment that was free of medical equipment that the patient could use to harm himself or others) of one psychiatric safe rooms observed. These failures had the potential to affect all patients who presented to the ED for emergency care. The average monthly census over the past six months was 1,749. The facility census was 54. Findings included: 1. Record review of the facility's policy titled, "Emergency Medical Screening Examinations," dated 05/22/14, showed that signage was to be in all areas where patients may be awaiting treatment for Emergency Medical Conditions, (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in serious impairment to any bodily function and/or serious dysfunction of any bodily organ or part), signs will be posted specifying the rights of individuals pursuant to the Emergency Medical Treatment and Labor Act, (EMTALA) regulatory requirements. 2. Observation and subsequent interview on 05/17/16 at 12:10 PM showed no signage located in the ambulance entrance into the ED. Staff F, Registered Nurse, (RN), ED Director, stated that this entrance was used for patients that arrived to the ED by ambulance and also for patients that were brought in by law enforcement. She stated that some of these patients brought in by law enforcement may be placed in a regular ED examination room and some may be placed in the psychiatric safe room. 3. Observation and subsequent interview on 05/17/16 at 12:14 PM showed an exam room (#18) that was free of medical equipment inside the room. Staff F, RN, stated that this was designated as the psychiatric safe room. Room #18 had no Patient Rights signage inside or outside the room. During an interview on 05/18/16 at 8:45 AM, Staff F, verified that there was no EMTALA signage in the ambulance entrance or in the psychiatric safe room.

Based on interview, record review, and policy review, the facility failed to provide a medical screening exam sufficient to determine the presence of a medical emergency within the facility's capacity and capability for one patient (#19) of 20 Emergency Department (ED) patient records reviewed by not re-assessing the patient's blood Creatine Kinase, Plasma (CPK, enzyme found in brain, skeletal muscles and the heart. An elevated level could be associated with heart attacks, when the heart muscle is damaged, or in conditions that produce damage to the skeletal muscles or brain) level prior to discharge. This lack of reassessment had the potential to affect all patients who presented to the ED. The average monthly census over the past six months was 1,749. The facility census was 54. Findings included: 1. Record review of the facility's policy titled, "Emergency Medical Screening Examinations," dated 05/22/14, showed the following: - Any individual who presented to the facility and who requested the examination of, or treatment for, an emergency medical condition shall be provided a medical screening and, when necessary, stabilizing treatment, within the capabilities of the facility. - An Emergency Medical Condition (EMC) was a medical condition that manifested itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment of bodily functions, serious dysfunction of any bodily organ or part. - A Medical Screening Exam (MSE) consists of whatever forms of evaluation required to reasonably determine whether or not an EMC exists. This may include a history and physical examination, but might also include imaging, testing, lengthy observations, or even hospitalization . 2. Record review of the ED Triage (process of determining the priority of a patients' treatment based on the severity of their condition) Assessment performed by Staff K, Registered Nurse, (RN), on 05/07/16 at 11:05 AM showed: -The patient presented to the ED, in a wheelchair, accompanied by law enforcement through the ambulance entrance. - Patient was found by police by the railroad tracks looking for gold 30 minutes prior to his arrival to the ED. - Temperature 99.5 (normal 98.6); - Heart rate 127 beats per minute (normal 60-100 beats per minute); - Respirations 18 (within normal range); and - Blood pressure 132/95 (normal 120/80). 3. Review of ED Nurse Assessment performed by Staff K, RN, on 05/07/16 at 11:39 AM showed the patients chief complaint was mental health evaluation. The patient was anxious, agitated, hostile, combative and loud. 4. Review of the MSE, performed by Staff I, Doctor of Osteopathy, (DO), ED Medical Director, on 05/07/16 at 11:15 AM showed: - Patient was not coherent with staff but informed social services that he was panning for gold. - Uncooperative with any treatment or exam, fighting to get out of law enforcement hand cuffs; - Appeared unkept and disheveled; - Abrasions to both knees but no other obvious injuries - Verbally rambled and spoke about the Hippocratic Oath (an oath historically taken by physicians); and - Was afraid of needles. 5. Review of laboratory results reported on 05/07/16 at 12:05 AM showed: - CPK level of 3,574 (normal range is 45-235); - Carbon dioxide (a gas produced by exhaling) level of 14 (normal range 22-32, a low level could indicate hyperventilation, alcohol overdose, dehydration, severe malnutrition, liver or kidney disease, heart attack, hyperthyroidism or uncontrolled diabetes). - Ketones in the urine above 80 (ketonuria, presence of ketones in the urine could indicate starvation or diabetes). 6. Review of Vital Signs on 05/07/16 at 1:50 PM showed: - Heart rate 110; - Respirations 18; and - Blood pressure 146/86. 7. Review of treatment plan documented by Staff I, DO, showed: - Patient had abnormal lab findings of ketonuria, elevated CPK, and decreased carbon dioxide; - Electrocardiogram (EKG, test that checks for problems with the electrical activity of your heart) showed Sinus Tachycardia (rapid heart rate above 100 beats per minute); - Patient was hydrated with three liters of intravenous (IV, within the vein) fluids secondary to his elevated CPK level which was related to dehydration as well as his uncooperativeness, combativeness and "fighting" with staff; - Patient was calm after he received medications but remained uncooperative and incoherent; - Patient was acutely psychotic; - Patient was stable for discharge; and - Patient was discharged to custody of law enforcement at 2:55 PM. 8. Review of five affidavits in the medical record documented patient # 14 was "was walking down Mark Twain Ave early sat. morning 5-7-16 stumbling and almost falling down"; not "acting right"; "fell off a wall"; "saying sentences that did not make sense"; and was a "danger to himself and others around him." The patient was not stable for discharge as he continued to have an elevated heart rate, respirations and blood pressure, and remained acutely psychotic posing a danger to self and others. His CPK was not re-tested so his level at discharge was unknown and there were no details pertaining to his fall off a wall (how far he fell or whether he hit his head) documented in the medical record. During a telephone interview on 05/18/16 at 10:04 AM, Staff I, DO, stated that: - The patient was very afraid of needles and threw himself onto the floor when staff attempted to draw blood; - Required medication to calm him down so that they could draw blood; - Social services had talked with patient's family and patient had no history of this type of behavior; - Patient received three liters of fluids due to elevated CPK level and that he appeared clinically dehydrated; - Patient was coated in mud, appeared dry and unclean; - She did not order a repeat CPK level or any other repeat blood tests due to his fear of needles and she felt he would not allow it. She felt he "looked" better and was more cooperative and calm; - Patient was stable and was discharged to custody of law enforcement; and - She was aware that law enforcement had a signed 96 hour hold from a judge to take the patient to Hospital B for inpatient psychiatric treatment. During an interview on 05/18/16 at 2:40 PM, Staff E, Medical Doctor, (MD), Chief Medical Officer stated that: - If a mental health patient needed medical care they were able to admit them to either the Intensive Care Unit or medical floor until they were stable; - The patient was young so the fluids he received should have helped his condition; and - He felt that the MSE was appropriate for the patients presenting signs and symptoms. During an interview on 05/18/16 at 8:45 AM, Staff K, RN, stated that the patient: - Could transfer from the wheelchair to the bed but was unsteady; - Required "seven people to hold him down" to obtain blood draw; - CPK level was elevated (abnormal) but was not rechecked prior to discharge due to the patient's fear of needles; and - Was very combative and uncooperative upon arrival but much calmer at discharge. 8. Record review of the patient's medical record from Hospital B dated 05/07/16 showed that the patient presented to their facility with law enforcement with a signed 96 hour hold by a judge with Hospital B listed as the facility to take the patient to for inpatient psychiatric treatment. Hospital B did not medically clear the patient for admission for inpatient treatment and transferred him to Hospital C. The patient was admitted at Hospital C for medical treatment with a diagnosis of an elevated CPK with the need for IV fluids, telemetry (heart) monitoring, and lab work. Hannibal Regional Hospital did not determine if Patient #19 had an EMC as they failed to re-check his CPK level for continued abnormality prior to his discharge. This failure resulted in the patient's admission to another facility and a delay in the care of his psychiatric issues.