Intakes: TN 491 Based on facility policy, training records, medical record review and interview, the facility failed to remove the IV (intravenous needle) for 1 of 1 (Patient # 4) sampled ED (Emergency Department) patients reviewed with an IV access. The findings included: 1. Review of the facility policy, "Peripheral Intravenous Catheter Guidelines" revealed, "E. DOCUMENTATION: Document details related to peripheral venous access: ... Discontinuation ..." Review of an In-service and Training Record dated May, 2017 revealed, "Please insure that you are removing IV's prior to patient's being discharged -this must also be documented on the depart form." 2. Medical record review for Patient #4 revealed on 5/17/17 at 19:50 (7:50 PM) an INT (Intermittent Needle Therapy) was placed in the left antecubital with a 20 gauge needle. Blood work was drawn and a CT (Computerized Tomography) soft tissue neck with contrast was performed. There was a prominent mental lymph node present measuring 8 mm (millimeters). The patient was discharged home at 21:34 (9:34 PM) on PO (by mouth) antibiotics and Ibuprofen with directions to see her PCP (Primary Care Physician) in the AM. There was no documentation the INT had been discontinued prior to her leaving the ED. Medical record review for Patient #4 revealed on 5/19/17 at 1:55 PM the patient returned to Hospital #1's ED and was triaged with chief complaint of "was seen here 2 days ago in fast track and was discharged home with an INT in her left arm, went to [Hospital #2] and had it removed. C/o [complaint of] left forearm pain where the INT was, ...Musculoskeletal: Normal ROM [range of motion], Proximal upper extremity: Left, AC [antecubital] region with mild soft tissue swelling and [DIAGNOSES REDACTED] noted. No red streaking or warmth. Radial pulse 3+ ..." Review of the ED Providers note dated 5/19/17 at 3:31 PM revealed, " ...The patient presents with left, arm pain. The onset was 2 days ago. Location: Left arm. The character of symptoms is pain and redness. The degree of pain is moderate. The degree of swelling is minimal ..." Review of the Radiology results revealed, "Findings ...There is superficial venous thrombosis/thrombophlebitis involving a subcutaneous vein on the medial aspect of the elbow at the recent IV site ..." 3. In an interview on 6/23/17 at 1:27 PM via telephone, RN #1 stated, "There was no documentation the INT was taken out. She [Patient #4] called on 5/19/17 and stated she had left with the IV in, went to [Hospital #2] and had it removed. On 5/19/17, the Outcome Coordinator talked to her and she complained of her arm hurting. She returned to our ED, was seen and given prescriptions for antibiotics ..."

Based on hospital Emergency Medical Treatment and Labor Act (EMTALA) policy, facility training logs, medical record review and interview, the facility failed to provide continuing monitoring according to the patients' needs after the Medical Screening Exam (MSE) was initiated for 3 of 23 (Patient's #4, 23, and 5) sampled patients and failed to provide a MSE to determine if an Emergency Medical Condition (EMC) existed for 3 of 23 (Patient's #3, 22 and 23) sampled patients. The facility failed to post signs at the ambulance entrances specifying the rights of patients related to EMTALA and failed to ensure the physician certification was completed for 4 of 6 (Patient's #8, 9, 10 and 14) sampled patients transferred to another hospital. Refer to findings in deficiencies A-2402, A-2406 and A-2409.

Based on policy review, observation and interview, the facility failed to post the required signage specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment of emergency medical conditions at 2 of 2 ambulance entrances. The findings included: Review of the facility policy, "Screening, Stabilization, Treatment and Transfer of Individuals in Need of Emergency Medical Services - EMTALA" revealed, "... Posting Signs: The Hospital should post conspicuously, in the dedicated emergency department(s) and in a place(s) likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency department (e.g., entrance, admitting area, waiting room, treatment area), a sign(s) (in a form specified by the U.S. Secretary of Health & Human Services) specifying the rights of individuals under EMTALA with respect to examination and treatment of emergency medical conditions and women in labor. The sign should be written in clear and simple terms and language that can be understood by the population served by the Hospital. The sign should also state that the Hospital participates in the Medicaid program..." During tour of the Emergency Department (ED) on 3/7/16 at 9:53 AM observations revealed there were no EMTALA signage posted by the two ambulance entrances which specified the rights of individuals under section 1867 of the Act with respect to examination and treatment for an emergency medical condition or information indicating whether or not the hospital participates in the Medicaid program under a State plan approved under Title XIX. During an interview in the hallway of the ED, the ED Clinical Director was questioned about the required signage and the ED Clinical Director verified there were no signs at either of the two ambulance entrances.

Based on hospital EMTALA policy, medical record review and interview, the hospital failed to provide continued monitoring according to the patients' needs after the MSE was initiated to determine if an EMC existed for 3 of 23 (Patient's #4, 23 and 5) and failed to provide a Medical Screening Exam (MSE) to determine if an Emergency Medical Condition (EMC) existed for 3 of 23 (Patient's #3, 21 and 22) sampled patients who presented to the hospital's Dedicated Emergency Department (DED) seeking care. The failure to provide continued monitoring to determine if an EMC existed resulted in Patient #4 leaving the facility and being admitted to a second facility for surgery. The findings included: 1. Review of Hospital #1's policy, " Policy: Screening, Stabilization, Treatment and Transfer of Individuals in Need of Emergency Medical Services - EMTALA revealed, "Purpose: The purpose of this Policy is to establish guidelines by which [Name of Hospital] will comply with federal requirements relating to the Emergency Medical Treatment and Labor Act ("EMTALA"), the Tennessee State Hospital Licensure and the Mississippi Department of Health requirements for Emergency Services ... Definitions: ... c. "Comes to the emergency department" or "Comes to the Hospital" or Presents" means that the individual, who is not a patient: 1. Arrives at a Hospital's dedicated emergency department [DED] and requests examination or treatment for an emergency medical condition, or has such a request made on his or her behalf. (In the absence of such a request by or on behalf of the individual, a request on behalf of the individual should be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition.); ... j. "Medical screening examination" or "MSE" means the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. A MSE is not an isolated event. It is an ongoing process that begins but does not end with triage ... The medical record must reflect continued monitoring according to the individual's needs until it is determined whether or not the individual (and the unborn child, if applicable) has an EMC and, if he/she does, until he/she is stabilized or appropriately transferred. There should be evidence of this ongoing monitoring prior to discharge or transfer ... C. Stabilization and Reassessment: Once the Hospital provides the MSE and determines that the individual has an EMC, and provides to that individual treatment to stabilize the EMC, the Hospital generally has satisfied its EMTALA responsibilities with respect to that individual. However, depending on the medical condition, the Hospital may be required to continue to reassess the patient (and document the reassessments) to ensure the patient remains stable ... Q. Patient Leaving Hospital against Medical Advice or Without being seen (AMA or LWBS) If an individual attempts to leave the Hospital AMA or LWBS, personnel should reasonable attempt to obtain the individual's signature on the AMA form and should attempt to inform the individual of the risk of not waiting to be examined by a physician, without physically touching the individual if possible. Hospital personnel should appropriately document in the medical record or on the Patient Refusal of Medical Treatment and/or Leaving Hospital Against Medical Advice Form that the patient was advised of the risks but left AMA/LWBS ..." 2. Medical record review revealed Patient #4 was an 8 month old baby who was brought to Hospital #1's DED by her mother on 2/23/17 at 9:05 PM with a chief complaint of fever and abscess to vaginal area. A MSE was initiated at 9:11 PM by Nurse Practitioner (NP) #1 prior to triage. Review of the History of Present Illness revealed, "The patient presents with fever and abscess to left labia area. Patient is with mother and says she noticed it today after playing outside. The onset was 1 days ago. The course/duration of symptoms is constant and worsening. Location: Left labia. The character of symptoms is pain, swelling and redness. The degree of onset was minimal. The degree of present is minimal. Risk factors consist of none. Therapy today: none. Associated symptoms: none. Additional history: none ... Skin: lesion(s): left labia, primary abscess, characteristics (edematous, raised, tender) ...Plan: Condition: stable ... Disposition: Patient care transitioned to: to main ed [ED] for further evaluation ...." There was no documentation the patient was transferred to the main ED for care. The patient was triaged by RN #1 at 9:15 PM. The patient's temperature was 102.7 F degrees orally. There was no documentation where the patient was placed after the triage was completed. At 9:31 PM, Nurse #1 administered 140 mg of Tylenol by mouth to the patient. The next temperature recorded at 12:26 AM on 2/24/17 was 37.9 (100.2 F) rectally. There was no documentation of interventions for this temperature. There was no documentation where the patient was when the Tylenol was administered or where the patient was at 12:26 AM when the rectal temperature was taken. The ED Departure Form dated 2/24/17 at 3:44 AM revealed the patient left the DED Against Medical Advice (AMA). There was no signed AMA form in the record. There were no further assessments or documentation on the baby from 12:26 AM through 3:44 AM. During an interview in the conference room on 3/2/17 at 2:10 PM, the Chief Nursing Officer (CNO) stated, "Pt triaged, sent to non-acute [Fast-Track], they sent baby back to main ED. We went on diversion; we were holding 2 IMU [Intermediate Care] and 4 ICU patients in the ED. Went on diversion at 19:30 [7:30 PM] and tried to come off at 12:30 AM but did not come off until later ...I would expect documentation out there [waiting room] VS [vital signs] every 2 hours if in waiting room ... even if on diversion, should still do VS ..." During an interview in the conference room on 3/6/17 at 9:01 AM, the CNO stated, "[Patient #4] never went to Fast Track [non-acute]. I reviewed her record and thought because of the NP, she went to Fast Track but she never did." During an interview in the Fast Track treatment area on 3/6/17 at 9:22 AM, NP #1 stated, "I'm familiar with this case. [Patient #4]. I did the MSE in the main ED in triage. We examined the patient. She had a labial abscess. We medicated her for fever and sent her back to the waiting room. I did not have any other contact with her. If pts still in waiting, they do re-vitals. She was red, swollen [labia]; baby did not look in distress. Sent to waiting room, when a room available, to main ED. I'm not sure who was responsible for re-vitals, nurse or tech. If a concern, staff will say something but mostly will talk to doctor in main ED. No concerns with this patient." During an interview via telephone on 3/6/17 at 10:00 AM the DED Medical Director stated he had been ED Medical Director for 12 years at Hospital #1. He stated when a patient came to the ED they are triaged and a MSE was performed. The Medical Director staed if the patient is sent back out to the waiting room then vital signs should be re-taken while waiting to be seen. During an interview via telephone on 3/6/17 at 10:11 AM, Nurse #1 stated that triage was based on the chief complaint and that they would use their protocol. Nurse #1 stated they would get a full set of vital signs and if vital signs were abnormal they would send the patient to the acute main ED. The nurse stated Patient #4 had a fever of 102.7 degrees F and a swollen labia. The nurse stated the ED physician was notified because of the patient's age and Tylenol was administered to the patient. The nurse stated the next time she assessed the patient was at 12:26 AM and the patient's temperature was still elevated at 100.7 degrees F. The nurse stated she looked at the patient's labia at that time but didn't document what it looked like. The nurse stated she didn't see the patient after the 12:26 AM check. Review of Hospital #2's medical record for Patient #4 revealed the patient arrived at the hospital DED on 2/24/17 at 2:37 AM with chief complaint of fever and a labia abscess. The patient was triaged at 2:41 AM. An MSE was initiated at 2:47 AM which revealed, "...skin: Warm, dry, pink, Lesion(s): L [left] labia abscess (1.5 x [by] 4.0 cm [centimeter] area of [DIAGNOSES REDACTED] with 1 cm x 4 cm area of induration. Very tender. Small "bug bite" seen on inferior aspect of labia; no drainage. No fluctuance) ...." On 2/24/17 at 3:42 AM documentation revealed, "...Admitting Resident, phone call, Accepted patient. Plan for IV [intravenous] fluids, IV abx [antibiotics], NPO [nothing by mouth] while awaiting surgical consult in AM for possible intervention. Reexamination/Reevaluation: Time: 2/24/17 3:28 AM course: Informed on plan to admit with IV Clindamycin, NPO, and MIVF [maintenance intravenous fluid] for possible surgical intervention in the AM. Will obtain CBC [complete blood count], BMP [basic metabolic profile], and blood culture ..." The admission diagnoses was left labial abscess, fever and tachycardia. The patient had surgical consult on 2/24/17 which revealed, "...History of Present Illness ...The day prior to consultation, mother picked her up from daycare and noticed some redness and swelling on a diaper change. She was also noted to have some fevers at home as high as 99 degrees. It just appeared really swollen to mother and she decided to take her to the emergency department. She did present to an outside hospital [Hospital #1] and was waiting for a while and so it prolonged her presentation to [name of Hospital #2], after having not been seen. When she arrived at [name of Hospital #2], the pediatric team was consulted for her cellulitis. They gave her Clindamycin. She had a white count of 24.6 [normal 6-14] and temperature maximum of 39.3 [102.7 F] and they were concerned for an abscess so the pediatric surgery team was called ..." Review of Hospital #2's surgical report revealed Patient #4 had an incision and drainage of the abscess on 2/25/17 and was discharged home on 2/26/17 with a diagnoses of [DIAGNOSES REDACTED] 3. Medical record review revealed Patient #23 was a [AGE] year old male who arrived at Hospital #1 on 2/23/17 at 2:51 PM via private vehicle with a chief complaint of left facial numbness for 24 hours. The patient was triaged at 3:02 PM and the nurse documented the patient was in no acute distress. The patient reported head pain at 7 on a scale from 1-10, with 10 being the greatest. He reported the pain was constant and aching with gradual onset. His vital signs were recorded by the Triage nurse at 3:02: BP- 136/83, Pulse rate- 70, Oxygen saturation- 97%, temperature- 98.2. The MSE was initiated at 3:05 PM by NP #1. The NP documented, "The patient presents with chest pain, left arm pain and numbness, denies SOB [shortness of breath]. The onset was one day ago. The course/duration of symptoms is constant and worsening. Location: left. The character of symptoms is pain and numbness. The degree at onset was moderate. The degree at present is moderate. Risk factors consist of none. Therapy today: none. Associated symptoms: chest pain ..." A magnesium, lipase, GFR, Troponin, Complete Metabolic Profile, and Complete Blood Count, Amylase level and electrocardiogram were ordered at 3:14 PM. The lab results revealed an elevated glucose, creatinine and protein with Alkaline Phosphatase levels lower than normal. The diagnosis was [DIAGNOSES REDACTED]"Patient care transitioned to: main ed for further evaluation." There was no documented evidence of the time Patient #23 was sent back to the main DED waiting room to be seen in the main DED. There was no documentation Patient #23 was reassessed during his wait time in the main DED waiting room (after MSE was initiated at 3:05 PM but actual time was not documented when the patient was sent back to the waiting room) until a second set of vital signs were documented at 9:29 PM. The patient's MSE was initiated at 3:05 PM and not seen again until 10:42 PM. ED Physician #4 evaluated Patient #23 in the main DED on 2/23/17 at 10:42 PM for Paresthesia. ED Physician #4 documented, "The patient presents with left upper extremity paresthesia. The onset was 2/23/17 at 5:30 AM... Location: Left upper extremity. The character of symptoms is paralyzed and numbness. The degree at present is none. ...Associated symptoms: chest pain, headache, nausea and denies vomiting ..." A follow up Electrocardiogram was completed at 11:32 PM with first degree atrioventricular block [AVB] w/interval change. A computerized tomography [CT] of the brain without contrast was ordered at 10:51 PM due to numbness and tingling. The CT results documented no finding to suggest a recent hemorrhage, no midline shift and the paranasal sinuses and mastoid air cells were clear. At 2:53 AM Patient #23 was re-examined by ED Physician #4 who documented diagnoses of [DIAGNOSES REDACTED] Review of the History and Physical report for Patient #23's hospital admission 2/23/17 documented, "REASON FOR ADMISSION: Chest pain. Left-sided weakness ...This is a [AGE] year old African American male ...the patient woke up yesterday morning with left-sided weakness, pain and tightness. He also describes some left face tightness and numbness. He also had some left hand numbness. His symptoms were associated with some head ache ...IMPRESSION/PLAN:1. Atypical left-sided chest pain ...2. Left sided weakness, resolved, possible transient ischemic attack ..." Review of the facility grievance log revealed Patient #23 voiced a complaint on 2/24/17, regarding his treatment in the DED on 2/23/17. The complaint documented, "According to him [Patient #23] he presented to the ED with stroke-like symptoms around 3:00 PM yesterday but he was not seen by the physician until 9:00 PM. He also claimed he was hurting so bad and he had to resort to taking the med from his neurologist while he was waiting ...[Patient #23] reported ED wait times were horrible with no staff checking to see if your condition had changed. He reported right facial tightness and a severe headache. While waiting to be triaged he started having chest pain around 6 PM. He informed the staff. [Patient #23] reported his biggest concern was he was not able to get the medical attention from the ED staff when experiencing a change in his medical attention..." During an interview in the hospital conference room on 3/6/17 at 11:55 AM, the CNO was asked if it was acceptable for a patient to be sent back to the main DED waiting room for 6 hours without a reassessment or vital signs recorded. She stated it was not appropriate, but if there was no beds available and no hallway beds, the patient would return to the waiting room but the goal was to monitor the patient while in the waiting area. During an interview in the hospital conference room on 3/6/17 at 12:50 PM, the CNO and Nurse #4 verified the vitals documented for Patient #23 in the DED were at 3:02 PM during triage and again at 9:29 PM, 6 hours and 27 minutes apart. 4. Medical record review revealed Patient #5 was a 4 year old who was brought by his mother to Hospital #1's DED on 2/7/17 at 3:22 PM with chief complaint of nausea and vomiting for 3 days and asthma. Triage was initiated on arrival. Additional assessment note at triage was the patient was positive for nausea and vomiting. The patient's chief complaint was nausea and vomiting at bedtime which started 3 days ago. The Physical exam revealed, "General: alert, mild distress ... Plan: Condition: stable ... Patient waiting to be called to room when available." There was a prolonged wait in the waitin room and it is documented that they left without treatment. No MSE was completed. The patient was treated at 1522 and seen by the ARNP at 1527 and not called to be treated untill 2215. This caused a delay in receiving an appropriate medical screening exam and stabilizing care. There was no reassessment or vital signs documented from 3:22 PM until the patient was called to be seen at 10:15 PM, 6 hours and 53 minutes later. At 10:15 PM, the nurse documented, "First call from waiting room/no answer." At 10:33 PM, the nurse documented, "Second call from waiting room/no answer." There was no documentation a "No Answer" form was completed During an interview in the conference room on 3/2/17 at 2:42 PM, the Director of Risk Management verified that there was no further documentation of VS or continued patient monitoring from 3:22 PM to 10:15 PM for Patient #5. 5. Medical record review revealed Patient #3 was an [AGE] year old child who was brought to Hospital #1's DED on 2/20/17 at 5:34 PM with chief complaint of diarrhea and anorexia for four days. The patient was triaged at 6:24 PM. At 10:00 PM, RN #3 documented, "ED Depart [department]: LWBS [Left Without Being Seen]." There was no documentation the patient was reassessed or monitored by the staff from 6:24 PM until it was discovered the patient had left the facility at 10:00 PM (3 hours and 36 minutes). There was no documentation the staff called the patient's name 3 times or a "No Answer" form was completed. 6. Medical record review revealed Patient #21 was a [AGE] year old male who came to Hospital #1's DED on 2/23/17 at 11:02 PM with chief complaint of left arm and hand numbness. Triage was initiated at 11:11 PM with EKG and blood work ordered. At 2:42 AM on 2/24/17 the nurse documented the patient LWBS. There was no documentation of reassessment or vitals signs performed from 11:02 PM until 2:42 AM (3 hours and 42 minutes), when it was discovered the patient had left. There was no documentation a "No Answer" form was completed. 7. Medical record review revealed Patient #22 was a [AGE] year old male who came to Hospital #1's DED on 2/23/17 at 11:20 PM with chief complaint of chemical exposure. The patient was triaged at 11:23 PM with chief complaint of abdominal pain. Vital signs were taken with blood pressure of 153/89 and pulse 111. At 3:10 AM on 2/24/17, RN #2 documented the patient had LWBS. There was no documentation the patient was re-checked by the staff from 11:23 PM until it was discovered the patient had left the facility at 3:10 AM (3 hours and 43 minutes later). There was no documentation the staff called the patient's name 3 times or a "No Answer" form was completed. 8. During an interview in the conference room on 3/2/17 at 1:18 PM, the Director of Risk Management stated the LWBS protocol was to call the patient back three times. During an interview in the DED on 3/6/17 at 9:30 AM, the ED Clinical Director stated, "We call patients back 3 times every 5 minutes, but usually longer because they may be in the bathroom. There's a "No Answer" form that is supposed to be filled out."

Based on policy review, hospital training materials, medical record review and interview, the hospital failed to ensure patients who required transfer to a higher level of care had documentation of the mode of transportation, reason for transfer, informed consent to transfer and were informed of their risks and benefits, for 1 of 6 (Patient #8) sampled patients who were transferred and failed to ensure the physician certification was fully completed for 4 of 6 (Patient #8, 9, 10 and 14) sampled patients who were transferred. The findings included: 1. Review of the hospital's policy "Screening, Stabilization, Treatment and Transfer of Individuals in Need of Emergency Medical Services- EMTALA" revealed, "The purpose of this policy is to establish guidelines by which [Name of Hospital] will comply with federal requirements relating to Emergency Medical treatment and Labor Act...F. Transfer of Patients...An Individual Who Has An Emergency Medical Condition When it is determined that the individual has and EMC [emergency medical condition], the Hospital should: Within the capability of the staff and facilities available at the Hospital, stabilize the individual to the point where the individual is either stable for discharge or stable for transfer (as defined by EMTALA); or If an individual has a EMC that has not been stabilized, the individual should be transferred only if the transfer is carried out as set forth below. The unstable individual may be transferred: (1) If the transfer is an appropriate transfer (meaning all of the following conditions (a) through (d) are met:...(c) The Hospital should send the receiving facility copies of pertinent records available at the time of transfer (e.g...and a copy of the completed Interfacility Transfer Form (which includes the physician certification and or the patient's request for transfer)...(2) And, the Individual Requests the Transfer; The individual may be transferred if the individual or the person acting on the individual's behalf is first informed of the risks and benefits of the transfer...(3) And the physican or QMP [Qualified Medical Professional] certifies transfer...The individual may be transferred if a physician...has documented on the 'Physician Certification' section of the Interfacility Transfer Form that the medical benefits expected from transfer outweigh the risks..." Review of the hospital's EMTALA training materials pages 17-21, revealed, "...When can the ED [Emergency Department] transfer an unstable patient?...1. Patient/legal representative gives an informed consent to be transferred after being told of the risks and Hospital's obligations; and (2) Physician certifies benefit of transfer outweighs the risk to patient...Interfacility Transfer Process When transferring a patient to another facility, the Interfacility Transfer form must be completed Page 1 of the form must be verified by a physician- This section of the form includes: diagnosis, information about the accepting facility/physician, mode of transportation, level of response, reason for transfer, risk of transfer or transport and the physician certification...Page 2 of the form includes- Patient informed consent (to be signed by the patient or patient representative)...ALL Elements of the Interfacility Transfer form...must be completed before the patient departs the ED if time allows..." 2. Medical record review for Patient #8 revealed a 2 year old female presented to Hospital #1's DED on 2/2/17 at 12:24 AM after a motor vehicle crash (MVC). Patient #8 was not restrained, and was found in the floor board of the car after the head on MVC collision. Triage was performed at 12:33 AM and the nurse documented Patient #8 was very lethargic. A MSE was initiated at 12:23 AM by ED Physician #1. Labs were completed, a chest X ray was completed with no fractures identified, and a Computerized Tomography (CT) scan was completed with no acute traumatic findings. A nursing note dated 2/2/17 at 3:43 AM revealed, "Patient appears lethargic, doesn't want to keep her eyes open. pt has vomited on the bed and on the floor. vomit is a mixture of frank blood and dark blood. Vomit appears mucusy [mucous filled], and slimy. [ED Physician #1] notified about my concern and when I asked if we are going to transfer to [Hospital #2], [ED Physician #1] stated he was going to discharge home and the blood was from a cut on the lip. [named house Supervisor] notified about the situation." The Impression and plan by Physican #1 documented a diagnosis of MVC with patient condition guarded. Patient #8 was transferred to Hospital #2 for further evaluation at 4:01 AM. Review of the "INTERFACILITY TRANSFER FORM" completed by ED Physician #1 did not document the mode of transfer, the reason for transfer, the risk of the transfer, or the physician certification that Patient's #8 was stable or not stable for transfer. Patient #8's parental informed consent or refusal, which verified they were informed of the risks and benefits, was not documented on Page 2 of the form. 3. Medical record review for Patient #9 revealed an 8 month old male presented to Hospital #1's DED on 2/1/17 at 9:30 AM for a burn to the right forearm from a flat iron. Triage was performed at 9:41 AM with a blister noted to the right forearm. The MSE was initiated at 10:12 AM by Nurse Practitioner #2. The burn was assessed and described as a rectangular 3 centimeter (cm) wide 4 cm long second degree burn with blistering along the edges. Nurse Practitioner #2 consulted with the ED Medical Director regarding Patient #9 who instructed her to send the patient to Hospital #2 for further evaluation. Review of the "INTERFACILITY TRANSFER FORM" completed by the ED Medical Director did not document the physician certification that Patient #9 was stable or not stable for transfer. 4. Medical record review for Patient #10 revealed a 3 year old male presented to Hospital #1's DED on 10/23/16 at 10:12 AM with complaints of fever and swelling in left side of neck/ lymph area. Triage was performed at 10:17 AM. The MSE was initiated at 10:35 AM by Nurse Practitioner #3. Nurse Practitioner #3 consulted with ED Physician #2 who recommended sending the patient to Hospital #2 for further evaluation and possible CT scan. Review of the "INTERFACILITY TRANSFER FORM" completed by ED Physician #2 did not document the physician certification that Patient #10 was stable or not stable for transfer. The transfer form did not indicate what services were needed at facility number 2 and not available at facility number one. 5. Medical record review for Patient #14 revealed a 4 year old male presented to Hospital #1's DED on 12/8/16 at 5:20 PM with complaint of throat pain and fever. Triage was performed at 5:43 PM. The MSE was initiated at 6:05 PM by ED Physician #3. Labs and a Strep screen was completed. Results were documented as positive Strep, elevated white blood cells and a low number of Absolute Lymphs. A CT of the soft neck tissue was performed with enlargement of the palatine and adenoid tonsils with out abscess, bilateral cervical lymphadenopathy, likely reactive and Mild mucosal thickening in the paranasal sinuses documented. ED Physician #3 consulted with ED Physican #2. Patient #14 was transferred to Hospital #2 for further evaluation via ambulance. Review of the "INTERFACILITY TRANSFER FORM" completed by ED Physician #3 did not document the physician certification that Patient #14 was stable or not stable for transfer. 6. During a telephone interview on 3/6/17 at 10:00 AM, the ED Medical Director stated the physicians were trained on EMTALA every year. He further stated he expected the ED Physician's to fully complete the Interfacility Transfer form because it was required.

Intakes: TN 297 Initial Comments: An investigation of a possible EMTALA was initiated on 09/14/2015 and concluded on 09/16/2015. EMTALA investigative guidelines and procedures were followed. As a result of the investigation, deficient practice was identified at 42CFR 489.24 (A2405), "Maintain a Central Log " on patients who come to the Emergency Department. A 90 day termination notice was sent by overnight mail to the hospital Administrator on October 21, 2015 with a termination date of January 19, 2016 for complaint numbered NC . Based on review of the hospital's Emergency Department (ED) Central log, the Emergency Medical Services (EMS) ambulance report, the hospital's ED policy and interview, the hospital failed to ensure that each patient who presented to the hospital's ED was documented on the hospital's ED central log for 1 of 3 (Patient #1) sampled patients who had presented to the hospital's emergency department but left prior to the Medical Screening Examination (MSE). The findings included: 1. Review of the hospital's, "EMTALA" policy revealed, "...Central Log...The Hospital should maintain a Central Log on each individual who 'comes to the emergency department, '...seeking assistance...' 2. Review of the Hospital #1's ED central log dated 8/29/15 revealed no documentation that Patient #1 had presented to the hospital's ED seeking care. 3. Review of Hospital #2 ED Triage Form revealed Patient #1 was triaged 8/29/15 at 5:56 AM with chief complaint of "... abdominal pain all night. was at [Hospital #1] and left. Has had bowel obstruction in the past and thinks he does again..." Patient #1 was admitted to Hospital #2's Inpatient Telemetry Unit at 8/29/15 at 8:40 AM. 4. Review of the EMS ambulance Report dated 8/29/15 revealed Patient #1 was transported to and arrived at the Hospital #1's ED at approximately 1:47 AM. 5. Review of the hospital's security video of 8/29/15 at 1:48 AM revealed EMS unit arrived on the hospital's property and later left the hospital's property. 6. During an interview in the conference room on 9/14/15 at 2:10 PM the Director of Quality/Performance Improvement & System Regulatory verified Patient #1 was not on Hospital #1's ED central log. The Director stated when a patient leaves the ED, a depart form is completed. When the depart form is completed, it causes the patient information to print on the central log. He further stated, "... I know we have to have a log but I don't think there is a regulation that says it has to be 100% accurate..."