Based on review of medical records (MR), review of facility documents and interview with staff (EMP), it was determined that the facility failed to ensure on-call physician services were provided for further evaluations and/or treatment necessary to rule out an emergency medical condition for one of 21 medical records reviewed (MR8). Findings include: Review on September 24, 2015, of facilty document "Medical Staff Rules And Regulations," approved March 4, 2015, revealed " I. General Patient Management ... I. EMTALA. An examination to screen for an emergency medical condition as required by the Emergency Medical Treatment and Active Labor Act (EMTALA) must be conducted by a credentialed member of the Medical Staff or the Allied Health Staff, or by House Staff. ... " Review on September 24, 2015, of facility policy "EMTALA (Emergency Medical Treatment and Active Labor Act) Guidelines," revised March 3, 2015, revealed "Purpose: To establish guidelines for the appropriate care and treatment of patients presenting to the Emergency Department consistent with EMTALA regulations. Policy: ... All patients shall receive a medical screening examination that includes providing all necessary testing and on-call services within the capability of the Hospital to reach a diagnosis. ... EMCM may not transfer a or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. ... EMCM will provide an on-call specialty list which includes all specialties privileged at this facility. ...The specialist must respond to the Hospital to render an evaluation and care. ... Medical Screening Exams :Medical Screening Exams should include at a minimum the following ... Physical exam of affected systems and potentially affected systems; ... Necessary testing to rule out emergency medical conditions; Notification and use of on-call personnel to complete previously mentioned guidelines; Notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary ... Emergency Medical Conditions: Emergency medical conditions under COBRA law constitute any condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future. Emergency medical conditions include: Undiagnosed , acute pain which is sufficient to impair normal functioning ... " Review of MR8 revealed that the patient arrived to the ED on April 23, 2015 for paresthesias to left face, left arm and left leg intermittently for the last three days. The patient was assigned an Emergency Severity Index Acuity Level: 2- Emergent. Review of MR8 "ED Physician Record," dated April 23, 2015 and timed 15:17, revealed "History of Present Illness ... patient presents ... with a history of hypertension and smoking who presents with paresthesias to [patient ' s] left face, left arm, and left leg intermittently x3 days. ... Patient also complains of worsening blurry vision. Patient went to [patient ' s] family doctor today and was brought to the ER because of [patient ' s] abnormal symptoms. ... Neurological: ... slightly decreased sensation (to light touch) to L face and L hand compared to R ... Medical Decision Making Rationale: CT abnormal on R frontal lobe- recc MRI brain. Discussed case with neuro. Will get MRI/MRA brain ... Impression and Plan Calls-Consults - 04/23/2015 16:03, [EMP19], phone call, consult, recommends discussed case and CT read- recommends MRI/MRA brain with/without contrast and will try to see in the ED. ... Impression and Plan Calls-Consults- -04/23/2015 19:45, [EMP20], phone call, recommends Spoke with [EMP20] regarding MRI results, feels sx ' s are not from venous abnormality, feels they are likely chronic. State pt can be discharged to home ... " Review of MR8 "Addendum Rad-Lab Results Addendum: Report," dated April 24, 2015 and timed 10:22, revealed " ... Additional Information: Received a call this morning from neuroradiologist ... [Physician] fell [sic] there is a discrepancy in the reading from last night. But there is a concern for possible subacute infarct. I spoke with [EMP20] who had a phone conversation with the practioners in the emergency department last night early the new information [EMP20] felt it was necessary for the patient to return to the emergency department today for further evaluation. I was able to contact the patient I explained to the discrepancy an MRI report and relayed my concern for returning to the emergency department for further evaluation ... " Further review of MR8 revealed that EMP19, the neurologist on-call, indicated " will try to see in the ED. " There was no evidence that EMP19 came to the ED to evaluate the patient. Correspondence received on September 29, 2015, at 5:27PM, indicated that EMP1 and EMP6 discussed the question as to purpose of EMP8 contacting EMP19 and if EMP19 came to the ED to evaluate the patient. EMP1 and EMP6 believed that EMP8 contacted EMP19 "... because of the preliminary signs and symptoms with which the Pateint presented and so the PA [EMP8] could informally discuss the case and ask for advice. Per the documentation in the record, it does not appear that [EMP19] saw the patient in the ED. This is most likely because it was determined that there was no need for an urgent evaluation." The facility failed to ensure on-call physician services were provided for further evaluations and/or treatment necessary to rule out an emergency medical condition.

Based on review of medical records (MR), review of facility documents, review of credential files (CF) and interview with hospital staff (EMP), it was determined that the facility failed to ensure each patient presenting to the Emergency Department (ED) was provided with an appropriate medical screening examination (MSE), conducted by a qualified medical practioner (QMP), to rule out an emergency medical condition (EMC) for two of 21 medical records reviewed (MR1 and MR8). Findings include: Review on September 24, 2015, of facilty document "Medical Staff Rules And Regulations," approved March 4, 2015, revealed "I. General Patient Management ... I. EMTALA. An examination to screen for an emergency medical condition as required by the Emergency Medical Treatment and Active Labor Act (EMTALA) must be conducted by a credentialed member of the Medical Staff or the Allied Health Staff, or by House Staff. ..." Review on September 24, 2015, of the facility's "Emergency Department Policy and Procedure Manual," revised April 2015, revealed "... Einstein Medical Center Montgomery Emergency Department Scope of Service 2015-2016 ... Services Provided Einstein Medical Center Montgomery (EMCM) provides services to all patients presenting to the Emergency Department on a 24 hour basis. ... Methods Used to Assess and Meet Patient's Care Needs ... All patients are seen by the ED physician or Fast Track provider. ... Scope and Complexity of Patients' Care Needs All patients presenting to the ED, regardless of type and severity of illness or injury, will receive emergency assessment, stabilization and treatment. ... The Appropriateness, Clinical Necessity, and Timeliness of Support Services provided Directly by the Hospital or through referral Contracts Provision of timely, courteous, and expert centered emergency care is dependent upon teamwork of a highly trained staff. ... FY 2016 Goals for Patient Care In order to provide excellent service, the ED staff will commit to: Patients will be seen by a Physician with 15 minutes of arrival. ..." Review on September 24, 2015, of facility policy "EMTALA (Emergency Medical Treatment and Active Labor Act) Guidelines," revised March 3, 2015, revealed "Purpose: To establish guidelines for the appropriate care and treatment of patients presenting to the Emergency Department consistent with EMTALA regulations. Policy: ... All patients shall receive a medical screening examination that includes providing all necessary testing and on-call services within the capability of the Hospital to reach a diagnosis. ... EMCM may not transfer a or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. ... EMCM will provide an on-call specialty list which includes all specialties privileged at this facility. ...The specialist must respond to the Hospital to render an evaluation and care. ... Medical Screening Exams :Medical Screening Exams should include at a minimum the following ... Physical exam of affected systems and potentially affected systems; ... Necessary testing to rule out emergency medical conditions; Notification and use of on-call personnel to complete previously mentioned guidelines; Notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary ... Emergency Medical Conditions: Emergency medical conditions under COBRA law constitute any condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future. Emergency medical conditions include: Undiagnosed , acute pain which is sufficient to impair normal functioning ... " Review of MR1 " ED Triage/Assessment Note, " dated February 26, 2015 and timed 18:38, revealed " ED Triage HPI: Migraine x7 weeks, seeing lights flickering. Pt c/o vomiting. Pt mom called and stated pt had a prescription for 90 Adderall and has 10 left in bottle. Pt denies this. ... Emergency Severity Index Acuity Level: 3- Urgent ... . " Review of MR1 " ED Physician Record, " dated February 26, 2015 and timed 19:50, revealed " History of Present Illness ... patient presents to emergency department complaining of migraines ... Patient states that [patient] is also concerned that [patient] has lost consciousness several times over the last month. [Patient] states that [patient] has seen a cardiologist and has been told that [patient] needs a pacemaker. [Patient] has also seen a neurologist in the past regarding [patient ' s] migraines ... Heart Rate Monitored 120bmp [beats per minute] HI [high] ... Psychiatric: Mood and affect: Anxious, Abnormal/Psychotic thoughts: Tangential, flight of ideas. Medical Decision Making Differential Diagnosis: Migraine, tension headache, seizure, dehydration, anxiety, depression, drug abuse. Rationale: Patient ... with a reported history of migraines and several syncopal episodes who presents to the emergency department tachycardic and complaining of headache. History difficult to obtain, as patient has tangential thought processes and flight of ideas. Denies suicidal ideation. Physical exam significant for tachycardia ... Will check labs and EKG [electrocardiogram] ... Cardiology: Electrocardiogram (Order): 02/26/2015 20:06 EST, Stat ... " Review of MR1 " ED Nursing Record, " dated February 26, 2015 and timed 20:40, revealed that the ED tech did not arrive until 20:40 to complete the STAT order for the EKG. Upon arrival the ED tech noted that the patient was no longer in the room and " appears to have left. " Interview on September 24, 2015, at 11:30 AM, with EMP6 indicated that a STAT order for an EKG would mean that it is done almost immediately after it is ordered. Review of MR1"Discharge Plan", dated February 26, 2015 and timed 21:06, revealed "Notes: Patient eloped from the ED prior to EKG, IV placement, or evaluation by ED attending." Further review of MR1 revealed that the medical screening examination was performed by EMP7, a resident physician. Interview on September 24, 2015, at 11:40 AM, with EMP6 revealed that resident physicians provide medical screening examinations to patients coming to the ED. EMP6 indicated that the resident physician will then review the plan with the attending to get approval. The attending is required to co-sign resident charts which is documented under the " teaching-supervisory addendum " in the medical record. Review of CF2 revealed that EMP7 was not privileged, designated or approved by the governing body as a qualified medical practioner (QMP) to perform MSE in accordance with EMTALA. Review of MR1 revealed that this patient did not receive an appropriate MSE, that was conducted by a QMP, to rule out an EMC in accordance with EMTALA. Review of MR8 revealed that the patient arrived to the ED on April 23, 2015 for paresthesias to left face, left arm and left leg intermittently for the last three days. The patient was assigned an Emergency Severity Index Acuity Level: 2- Emergent. Review of MR8 " ED Physician Record, " dated April 23, 2015 and timed 15:17, revealed " History of Present Illness ... patient presents ... with a history of hypertension and smoking who presents with paresthesias to [patient ' s] left face, left arm, and left leg intermittently x3 days. ... Patient also complains of worsening blurry vision. Patient went to [patient ' s] family doctor today and was brought to the ER because of [patient ' s] abnormal symptoms. ... Neurological: ... slightly decreased sensation (to light touch) to L face and L hand compared to R ... Medical Decision Making Rationale: CT abnormal on R frontal lobe- recc MRI brain. Discussed case with neuro. Will get MRI/MRA brain ... Impression and Plan Calls-Consults - 04/23/2015 16:03, [EMP19], phone call, consult, recommends discussed case and CT read- recommends MRI/MRA brain with/without contrast and will try to see in the ED. ... Impression and Plan Calls-Consults- -04/23/2015 19:45, [EMP20], phone call, recommends Spoke with [EMP20] regarding MRI results, feels sx ' s are not from venous abnormality, feels they are likely chronic. State pt can be discharged to home ... " Review of MR8 revealed "... Addendum Rad-Lab Results Addendum: Report: 04/24/2015 10:22, Additional Information: Received a call this morning from neuroradiologist ... [Physician] fell [sic] there is a discrepancy in the reading from last night. But there is a concern for possible subacute infarct. I spoke with [EMP20] who had a phone conversation with the practioners in the emergency department last night early the new information [EMP20] felt it was necessary for the patient to return to the emergency department today for further evaluation. I was able to contact the patient I explained to the discrepancy an MRI report and relayed my concern for returning to the emergency department for further evaluation ... " Review of MR8 revealed that the patient received a medical screening examination by EMP8 and then care was transferred to EMP9. Review of CF3 revealed that EMP8 was not privileged, designated or approved by the governing body as a QMP to perform MSE in accordance with EMTALA. Review of CF4 revealed that EMP9 was not privileged, designated or approved by the governing body as a QMP to perform MSE in accordance with EMTALA. Review of MR8 revealed that this patient did not receive an appropriate MSE, that was conducted by a QMP in accordance with EMTALA.