Based upon interview, medical record review and document review, the facility did not comply with all of the provisions for maintaining a central log, conducting a medical screening exam and obtaining physician certification for transfer. Please reference findings under Tags 2405, 2407 and 2409.

Based on document review and interview, the facility failed to ensure that all individuals presenting to the Emergency Department (ED) are entered into the central log for 1 of 22 patients (Patient A). This failure could result in a patient not receiving a medical screening exam. Findings include: Review on 9/10/15 of Policy #24.0086.4 " ED Patient Record " revealed all patients entering the ED will have a record completed and will be seen by a physician. Review on 9/10/15 of the EMTALA Refresher Self-Study Course used for orientation and educational updates revealed that every person presenting to the ED must be logged in. Interview on 9/9/15 at 11:00am with Staff #3, ED Registration Clerk revealed everyone who comes to the ED is logged into the central log. The registration clerk receives the patient and enters their name and date of birth in the log. Review on 9/9/15 of the Quality Assurance Event report dated 8/23/15 revealed the patient, who (MDS) dated [DATE], was not logged into the central log. Review on 9/9/15 of the phone recording between the Emergency Medical Services dispatcher and Staff # 13, ED RN revealed the patient was never registered and no face sheet was generated. Interview on 9/9/15 at 3:54pm with Staff # 2, Quality Coordinator confirmed the patient was not registered/logged in to their system. Review on 9/10/15 of the ED log for 8/23/15 revealed the patient was not entered into the log.

Based on interview, policy review and document review, the hospital did not document a medical screening exam for 1 of 22 patients who presented to the Emergency Department (Patient A). A lack of a documented medical screening exam could result in an emergency medical condition not being identified and treated. Findings Include: Review on 9/10/15 of Policy #24.0086.4 " ED Patient Record " revealed all patients entering the ED will have a record completed and will be seen by a physician. Review on 9/9/15 of the Quality Assurance Event report dated 8/23/15 revealed the patient was sent to the ED from a nursing home (NH) on 8/23/15 with a MOLST (Medical Orders for Life Sustaining Treatment) form signed by the patient indicating DNR/DNI (Do not resuscitiate/Do not intubate). On arrival, the ED physician asked the patient if he wanted to be seen by a doctor, be treated, and have x-rays and tests done. The patient replied no and verbal consent for refusal of treatment was obtained, following which the patient was returned to the NH. The ED physician stated the patient was competent to make this decision and able to understand the questions with appropriate answers given. The patient was not logged in and no nursing or provider documentation was found. A leave before being seen (LBS) form was found, but does not indicate that any screening/assessment was performed, what treatment was offered or why the patient refused to be seen. Interview on 9/9/15 at 3:54pm with Staff # 2, Quality Coordinator revealed the Physician came out to see if the patient was competent to refuse care. The patient had a MOLST form. The patient was not registered/logged in to their system. The patient signed out against medical advice and was sent back to the nursing home. No medical record was generated. Review on 9/10/15 of Policy #24.0005.3 " Discharge of Patient ' s Leaving AMA " revealed the registered nurse (RN) should attempt to have the patient sign the " Departure Against Medical Advice " form and place it on the patient record. The RN/Physician (MD)/Physician Assistant (PA) should assess and document the patient's competency to sign out against medical advice (AMA). PA/RN/MD should provide discharge instructions. Review on 9/10/15 of the Medical Bylaws, Rules and Regulations revealed if a patient desires to leave against the advice of the Attending Staff member, the patient will be requested to sign a release. A notation of the incident must be made in the patient ' s medical record including the advice given and the refusal to comply.

Based on medical record review, policy review and interview, the facility failed to ensure that a physician is consulted prior to transfer to a higher level of care in 5 of 5 patient transfers (Patient I,K,N,O,S). This failure to consult with a physician could result in a transfer of an individual in which the risks outweigh the benefits. Findings Include: Review on 9/10/15 of the ED medical records for Patients I dated 9/4/15, Patient K dated 8/31/15, Patient N dated 8/30/15, Patient O dated 8/26/15 and Patient S dated 8/24/15 revealed they were transferred to other facilities on the authorization of a Physician Assistant. (PA). No documentation, including physician countersignature, was found indicating the PA consulted with a physician prior to the patient transfers. Review of the Medical Staff Bylaws, Rules and Regulations on 9/10/15 indicate a patient shall be transferred to another medical facility only upon the order of the Attending Staff Member and only after the patient is considered sufficiently stabilized for transfer. PA duties include for every case, medical orders written must be counter-signed by the supervising MD/DO. Review of Policy #24.0023 " Mid-level Coverage in ED " indicates all ED records, data summaries, progress notes, directions or other information entered into the medical record by a mid-level shall be counter-signed by the onsite supervising physician within 24 hours.