Based on a review of Emergency Medical Services Documents, Emergency Department (ED) logs, Medical Records, Medical Staff ByLaws, Medical Staff Rules and Regulations, Medical Staff credentialing files, On-Call Schedules and interviews, it was determined the facility failed to: - Ensure one patient (#13) out of 20 patient ED charts reviewed, received an appropriate medical screening exam (MSE) to rule out an emergency medical condition (EMC), refer to A-2406 for example. - Ensure one patient (#19) out of 20 patient ED charts reviewed received an appropriate transfer, refer to A-2409 for example.

Based on interview and record review, the facility failed to ensure a patient received a complete Medical Screening Exam (MSE) within the facility's capacity and capabilities to determine if an Emergency Medical Condition (EMC) existed for one (#13) patient out of 20 Emergency Department (ED) medical charts reviewed. The average patients seen in the ED over the past six months was 89.5. Findings included: 1. Record review of Patient #13's discharged ED medical chart showed the following: - The "History of Present Illness" dated 03/23/15 at 4:05 PM showed Staff D, Registered Nurse (RN), Nurse Practitioner (NP), documented that the patient arrived to the ED from the nursing home with complaints of inability to void for 24 hours and abdominal pain. A bladder scan showed the patient had 660 milliliters (ml) of urine in her bladder. A Foley catheter (tube placed into the bladder used to drain urine) was inserted and drained 675ml of urine. A urine sample was obtained for analysis. Laboratory test were ordered and the patient was discharged back to the nursing home in stable condition at 4:51 PM with a primary diagnosis of urinary retention. - The ED Visit Notes showed Staff O, Paramedic, documented at 4:38 PM that Staff C, Laboratory Technician (Lab Tech), arrived to draw labs. At 5:12 PM the patient was discharged back to the nursing home with labs pending. - The patient's laboratory results dated [DATE] at 6:01 PM showed eight lab tests returned with critical values. Staff C, Lab Tech, documented that he reported the patient's critical lab values on 03/23/15 at 6:01 PM to Staff O, Paramedic. 2. Record review of Patient #13's second ED visit showed the following: - She presented the second time to the ED on 03/23/15 at 6:33 PM with complaints of revisit to the ED for abnormal labs. - The History of Present Illness dated 03/23/15 at 6:35 PM showed Staff E, ED Physician, documented the patient came back to the ED for evaluation for abnormal labs. Labs came back showing critical values related to kidney function and Potassium (mineral crucial for life and necessary for the heart, kidneys and other organs to work normal). - The patient was transferred at 6:35 PM with primary diagnosis of renal failure with hyperkalemia (abnormally high levels of potassium in the blood). 3. Interviews showed the following: - During a telephone interview on 03/26/15 at 9:30 AM, Staff C, Laboratory Technician, stated that with critical lab results, lab staff are to call the physician, RN, or EMT (Emergency Medical Technician). Staff C stated that since Patient #13 was an ED patient he called the paramedic to report the critical lab values. Staff C drew the patient's lab specimens, ran the tests and confirmed the critical lab values. - On 03/26/15 at 9:45 AM, Staff I, Laboratory Director, stated that on 03/23/15 at approximately 5:30 PM, she told Staff C to repeat the labs. Once verified, laboratory staff would call the ED. - On 03/26/15 at 9:50 AM, Staff D, RN, NP, stated that: -Since her shift ended at 5:00 PM she did not see Patient #13's lab results. - The patient had a history of chronic renal insufficiency. - The patient did not present with any acute issues and when the Foley catheter was inserted the patient's bladder drained 675ml of urine. - The patient was discharged back to the nursing home because she thought the problem was resolved when the catheter was inserted, returned urine and she would receive constant nursing care. - The patient was very familiar to her and between her and the patient's primary care physician they see the patient almost monthly. - When she left the facility, she knew that the lab results would be called to her and she would see the patient's lab results the next day. - If the lab results came back at critical levels, she would have been called if she was on-call. - Staff E, ED Physician, was at the hospital so he was informed of the patient's critical lab values. - Normally she would not discharge a patient until lab results are back but because she knew the patient she felt it was ok to let her go back to the nursing home. - The patient would be seen by her the next day since she was making rounds at the nursing home this week. -On 03/26/15 at 10:46 AM, Staff E, ED Physician, stated that: - The expectation for patients are to stay in the ED until lab results have returned unless the lab was one that had to be sent out. - It is not common practice to let a patient leave the ED to return to the nursing home and the disposition should be made after lab results returned. - Normally he received end of the shift report from the off going shift but did not receive any report from Staff D, RN, NP, about Patient #13. - Staff notified him that the patient's labs returned critical. - After he received the critical lab results, EMS went to the nursing home and brought the patient back to the ED. - During her ED visit the patient had normal mental status function and showed no signs or symptoms of deterioration and he felt like the patient was stable for transfer and he instructed EMS to notify him with any concerns during transport. - On 03/26/15 at 11:55 AM, Staff F, RN, stated that: - Normally a patient will stay in the ED until lab results are returned. - At times if lab is going to take awhile, the patient may be discharged before lab result are available only if the patient is stable or if the patient refused to wait on the lab results. - When critical labs are reported to staff they are to notify either the physician on-call or the FNP (Family Nurse Practitioner) and staff would follow whatever orders they would give. - The patient at discharge seemed to be doing better and she did report relief of her abdominal pain after insertion of the Foley catheter. - She felt comfortable with the patient going back to the nursing home before lab results had been returned and the patient was as stable as she always was. - The patient verbalized she felt a lot better at discharge. - When the patient returned to the ED, she had a change in condition and experienced slowed slurred speech. - She felt like the patient did receive an appropriate MSE to rule out an EMC and the patient was stable at the time of transfer to the receiving medical facility (second ED visit). - On 03/26/15 at 1:10 PM, Staff A, RN, Chief Nursing Officer (CNO), stated that she expected patients that presented to the ED to wait until labs have returned before they are discharged . - During a telephone interview on 03/30/15 at 2:34 PM, Staff N, EMT (Emergency Medical Technician), stated that: - He was working in the ED when Patient #13 (MDS) dated [DATE]. - The patient presented due to not being able to void for approximately 24 hours and abdominal pain. - A Foley catheter was inserted and Staff F, RN, performed a bladder scan. - He was very familiar with the patient and she has been in the ED and hospital many times. - The patient reported that she felt better after the Foley catheter had been inserted with immediate return of 400ml of urine. ED staff clamped the Foley for approximately 10 minutes and then unclamped it and another 275ml of urine returned. - At approximately 5:12 PM the patient was transported back to the nursing home that is attached to the facility because lab reported it would take approximately two hours for results to return. - Since the lab was going to take approximately two hours for results to return and the patient reported feeling better, Staff D, RN, NP, decided to discharge the patient back to the nursing home where she would have constant nursing observation. - Staff D was going to follow up with the patient the next day and give her the lab results. - As a rule patients are not discharged from the ED until test (labs/X-Ray) results have returned. - When the patient's lab results came back critical, the lab reported the critical results to ED staff. - ED staff notified Staff D, RN, NP, and Staff E, ED Physician, of the critical lab values. - Staff E relieved Staff D at the end of her shift. - Staff E and Staff D discussed on the phone the patient's critical lab results and it was decided the patient should be brought back to the ED. - During a telephone interview on 03/30/15 at 3:20 PM, Staff O, Paramedic, stated that: - It is not typical for patients to be discharged before lab/X-Ray results have returned and this was the first time a patient had been discharged without known lab results. - She and Staff N took the patient back to the nursing home. - Staff C, Lab Technician, called the ED with critical lab results and she informed Staff E, ED Physician, of the patient's critical lab results. - Staff E, ED Physician, instructed for the patient to be returned to the ED and he would come into the ED and evaluate her.

Based on findings from document review and interview, the facility's Emergency Department (ED) failed to ensure that one patient (#19) out of 20 ED medical charts reviewed received an appropriate transfer to another medical facility. This failure had the potential to place all patients transferred to another medical facility at risk. The facility's ED transferred an average of 5.5 patients over the past six months. Findings included: 1. Record review of the facility's policy titled, "Patient Transfer (EMTALA-Emergency Medical And Labor Act)," dated 08/2014, showed the following direction for staff: - Physician certification is required for all transfers. This certification is required from the treating physician ordering the transfer and prior to the patient's transfer. - If the treating physician is not physically present at the time of transfer, another physician can sign the certification as long as that physician is in agreement with the certification and the treating physician subsequently, countersigns the certification. 2. Record review of Patient #19's discharged ED medical record showed the following: -She (MDS) dated [DATE] at 11:41 PM accompanied by the local police and EMS (Emergency Medical Services) with complaints of overdose of Valium (medication used to treat anxiety). -The "Physician Assessment and Certification" dated 10/15/14 at 3:02 PM showed the patient would be transferred by qualified personnel (local police) and transportation equipment as required, including the use of necessary and medically appropriate support measures. - The transfer form showed the reason for transfer was for a psychiatric evaluation. - Staff L, Registered Nurse (RN), Family Nurse Practitioner (FNP), signed and dated both the line for the qualified medical personnel and the on-call physician on the certification transfer form. - Staff L, RN, FNP, did not document that she notified neither the ED on-call physician nor the patient's primary care physician of the transfer. 3. As of 03/26/15 neither the ED physician nor the patient's primary care physician (PCP) had countersigned the Physician Assessment and Certification form for the patient to be transferred to the receiving psychiatric facility. 4. During an interview on 03/26/15 at 5:00 PM, Staff L, RN, FNP, stated that the Medical-Surgical staff had asked her to fill out the transfer form and she did not recall if she consulted with the ED physician or the patient's primary care physician prior to the patient being transferred to the receiving facility.