Based on a review of medical records (MR), facility documentation and staff interview (EMP), it was determined that Kane Community Hospital failed to ensure that every individual presenting to the Emergency Department seeking treatment was documented on the Emergency Department (ED) electronic Log for one of 51 patients (PT1). Findings: Kane Community Hospital, An Affiliate of UPMC Hamot ... Policy No: 1207 ... Title: Patient Log ... dated April 2016. " PURPOSE: To provide a policy on the maintenance of the patient Log of Emergency Department patients. POLICY: A Patient Log of all patients who presents to the Emergency Department for treatment shall be maintained. Data input into the Log will be the responsibility of the Registration and Emergency Department Staff. These records will be maintained for at least three years. The Patient Log can be accessed by selecting 'reports' icon on the ED dashboard and selecting the Patient Log Report ... ." 1. An interview was conducted with EMP9 on August 4, at approximately 2:00 PM. "... The Registration staff leave at 9:00 PM so at night if a patient comes to the ED, they will ring the bell and one of us will go out and let them in and get the patient's name, date of birth, and chief complaint. Do a quick reg. If they have not been here before, we will give them a form to fill out. We would administer emergency care if needed. We would copy their insurance cards later ... I was working a Friday night a couple of weeks ago and we were really busy. It was after 11:00 PM and the bell rang. When I opened the door there was a man holding a child. He stated that the child was just molested and needs to be seen right away. I told him that we were full, and he would have to wait. The child was awake and alert, the man was upset and said he was going to take the child to ... Hospital and left. It all happened so fast, I didn't get their name or any information before they left." 2. A review of the Emergency Department electronic Log dated June 1, 2016 through July 31, 2016, revealed no documented evidence that the patient to which this complaint was related was identified on the Log.

Based on a review of medical records (MR), facility documentation, and interview with staff (EMP), it was determined that Kane Community Hospital failed to ensure that each patient presenting to the Emergency Department for treatment was provided with an appropriate medical screening examination (MSE) by a physician, or other qualified medical personnel, and failed to define those personnel qualified to perform a MSE in their Medical Staff Bylaws or Rules and Regulations for one of 51 medical records reviewed (MR1). Findings: Facility policy entitled Patients Presenting to the Emergency Department, dated April 2016. "... Purpose: To establish guidelines on patients presenting to the Emergency Department at Kane Community Hospital. Policy: All patients presenting to the Emergency Department requesting examination or treatment from illness or injury will be provided an appropriate medical screening exam within the capability of this hospital. No patients will be refused care on the basis of religion, creed, disability, gender, color, national origin, sexual preference, financial status, or ability to pay for services. Procedure: All patients will be afforded a medical screening examination to determine whether an emergency medical condition exists, and will include an appropriate medical history, physical examination, appropriate diagnostic testing, consulting with pertinent on-call physicians or other health care providers, and reassessing the patient prior to discharge or transfer. This process must be clearly and completely documented in the patient's medical record. Medical screening or treatment will not be delayed to obtain registration or insurance information. the medical screening examination may only be performed by a person qualified to perform such exams as established in Medical Staff Bylaws ... ." Kane Community Hospital, kch, An affiliate of UPMC Hamot, Department of Emergency Medicine. Policy Title: Sexual Assault, Care of the Victim Issued Under: Emergency Department ... Last Review: January 31, 2013. "Purpose: To provide guidelines to: 1. Care for the immediate medical and psychological needs of alleged sexual assault victims and their families in a professional and empathetic manner ... Procedure: 1. The patient shall be given an ESI 2 Triage priority and removed from the ED Waiting area into a private location upon arrival to the ED. During Triage the nurse should ascertain a brief Chief Complaint as well as any injuries requiring immediate medical attention. 2. Medical stabilization always precedes forensic examination ... All patients who present to the Emergency Department for an unscheduled forensic examination related to sexual assault must have a screening examination by the attending physician ... ." 1. An interview was conducted with EMP9 on August 4, at approximately 2:00 PM. "... The Registration staff leave at 9:00 PM so at night if a patient comes to the ED, they will ring the bell and one of us will go out and let them in and get the patient's name, date of birth, and chief complaint. Do a quick reg. If they have not been here before, we will give them a form to fill out. We would administer emergency care if needed. We would copy their insurance cards later ... I was working a Friday night a couple of weeks ago and we were really busy. It was after 11:00 PM and the bell rang. When I opened the door there was a man holding a child. He stated that the child was just molested and needs to be seen right away. I told him that we were full, and he would have to wait. The child was awake and alert, and seemed to be in distress, the man was upset and said he was going to take the child to ... Hospital and left. It all happened so fast, I didn't get their name or any information before they left. We like to use the Triage area for sexual assault patients because that is where we store the rape kits, but we already had a patient in there." 2. A telephone interview was conducted with EMP12 on August 5, 2016, at 9:08 AM. "I did not know that a parent with a child who had been assaulted patient presented to the Emergency Department. If I would have known I would have tried to track them down. I would have taken steps to contact Children and Youth Services. I do not recall hearing any discussion about the child presenting or about the police calling for the rape kit." 3. An interview was conducted with EMP6 on August 3, 2016, at approximately 1:41 PM. "We have limited specialties, for example we have Orthopedics and General Surgery. Nothing in our Bylaws or the Rules and Regulations define who can perform a medical screening exam. It's not ringing a bell. We wouldn't need to define that because we don't use any mid levels anyway." 4. During a review by the survey team, of the Medical Staff Bylaws of Kane Community Hospital ... Approved by Medical Staff on August 8, 2000. Approved by Board of Directors April 24, 2001. Revised: November 2015, it was noted that the Bylaws failed to define those personnel qualified to perform a medical screening exam (MSE).