Based on interview and record review, the hospital failed to abide by the provider's agreement that required a hospital to comply with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements, citing 1 of 1 patient (Patient #6) that presented in the emergency department on 10/01/17 and then was transferred to a local facility. Cross Refer to Tag 2406

Based on interview and record review, the hospital failed to provide an appropriate medical screening examination of 1 of 1 patient (Patient #6) who presented in the emergency room on [DATE]. A radiologist conducted a "CT scan" of the facial bones, listed multiple findings, and noted that a follow-up ophthalmology consultation was recommended for further evaluation. The ophthalmologist on-call (Physician #5) was notified of the findings and did not examine Patient #6. Findings included: Patient #6 presented in the emergency department (ED) on 10/01/17 at 1:31 PM via ambulance. The chief complaint was "The patient was hit in the right eye with a golf ball." Patient #6 was transferred to the facility from their sister hospital. The ED physician saw Patient #6 at 1:32 PM. The physician noted the patient was "hit with his own golf ball around 11:00 AM while playing golf." Patient #6 "complained pressure to the right eye, and had no vision out of the right eye." Patient #6 "reported he could not open his eyelid on his own." The "triage BP (blood pressure) was 161/99." The pain level was "8" of a pain scale of 10. The Physical Examination of the eye included "2 x 1/2 cm laceration of the lower lid, rupture globe, mild bleeding from the globe, globe appears to be deformed, no light perception, hemorrhage from globe." The "Differential Diagnosis: Open globe fracture." The "CT Facial Bones W/O IV Contrast impression: 1. Fracture of the floor the right orbit. 2. Fracture of the medial floor of the right orbit and lamina papyracea. 3. Right cheek and orbital soft tissue edema. 4. Hemorrhage in the right maxillary sinus and in many of the right ethmoid air cells. 5. Marked deformity of the right globe...the finding is consistent with a ruptured right globe...consistent with hemorrhage in the vitreous and aqueous. Follow-up ophthalmology consultation is recommended for further evaluation." On 10/01/17 at 2:08 PM the ED physician noted "Discussed patient's case with Physician #5 who is on-call...and wants to transfer patient...At 3:10 PM call with Physician/local hospital who will accept the patient..." The ED disposition was "transfer to acute care hospital." In an interview with Physician #4 the attending ED physician on 01/16/18 at 11:22 AM and 01/18/18 at 2:05 PM, Physician #5 stated he took care of Patient #6 on 10/01/17. Patient #6 had a ruptured globe and was transferred from their sister hospital. Physician #4 consulted with Physician #5 who was the ophthalmology on-call that day [10/01/17]. Physician #5 was informed of the findings. Physician #5 told Physician #4 that he needed another ophthalmologist to work on Patient #6 and that he was the only ophthalmologist that worked in the hospital. Physician #4 was told by Physician #5 that Patient #6 needed to be transferred to this particular local hospital, but this hospital did not have ophthalmology services. Physician #5 transferred Patient #6 to a different local hospital that had available ophthalmology services. Physician #4 was asked if he requested Physician #5 to come to the ED to physically assess the patient. Physician #4 replied "no." Physician #4 stated he thoroughly explained Patient #6's medical condition to Physician #5. In an interview with Physician #5 on 01/16/18 at 1:12 PM via telephone he stated he recalled the case. The ED physician told him a detailed description of the patient's injury and reviewed the patient's CT scan which he could access in the computer. Physician #5 stated with all the information he gathered, he told the ED physician that this was beyond his skill sets and could not manage the patient's care. This would require a complicated wound closure that required 2 eye surgeons. The patient's tissue disruption was extensive in the posterior globe. The patient needed a higher level of care..."I knew my limitation; I could not tackle the patient's condition."

Based on record review and interview, the facility failed to include on the emergency room log the information of Patient #1 who was pregnant and came to the emergency department seeking treatment. Findings included: On 1/15/2017 at approximately 11:00 PM, Patient #1's husband came into the emergency department and stated that his wife's water had broken and she was in labor. He inquired about their status as a hospital and if they had a labor and delivery department. The hospital staff failed to provide triage or medical screening examination for this patient. The patient was not listed on the emergency room log. On 1/31/2017 at approximately 2:30 PM, Personnel #1 was asked if Patient #1 was listed on the emergency room log. Personnel #1 answered, "No."

Based on record review, tour and interview, the facility failed to perform a medical screening exam on 1 of 1 patient (Patient #1), in that, Patient #1's husband entered the emergency department and stated his wife was in labor and her water had broken. He stated they needed a hospital and a labor and delivery department. Personnel #4 advised the husband that they were not a hospital and that they did not have a labor and delivery department. Findings include: There was not a medical record for Patient #1 who came to the emergency department as she was in labor and her water had broken. No medical record was documented. A telephone interview was conducted with Personnel #4 on the afternoon of 1/31/2017. Personnel #4 stated that the husband came into the emergency department and stated that his wife was in labor and her water had broken. Personnel #4 stated they were not a hospital and did not have a Labor and Delivery. Personnel #4 stated that she told the husband they could have their baby in the emergency department ..."but it would not be the best experience." The husband hurried from the emergency department back to his car that was parked at the front entrance to the emergency department and drove to Hospital B. Hospital B was 8.2 miles away from the free standing emergency center. When Patient #1 arrived at Hospital B, the husband ran in and told the staff that his wife was in labor. A doctor and licensed nurse went out to the car in the parking lot to attend to Patient #1. Patient #1 was in the back seat of the vehicle and was in the process of delivery of the baby. The staff assisted with the delivery in the vehicle and quickly brought Patient #1 and infant into the hospital where they were evaluated, treated and admitted . Both Patient #1 and infant had a normal post-natal course and were discharged in stable condition. Policy: Medical Screening Examinations and Patient Transfers Effective Date: 08/23/2016 states: " ...Any person who comes to Hospital Emergency Department (ED) and request an examination or treatment for a medical condition shall receive an appropriate Medical Screening Examination by a physician or other Qualified Medical Person as defined in Section 5.0 within the Capability of the ED, including ancillary services routinely available to the ED to determine whether or not the person has an Emergency Medical Condition. Any woman who comes to the Labor and Delivery Department and requests an examination or treatment for her pregnancy shall receive an appropriate Medical Screening Examination by a physician on the medical staff or other Qualified Medical Personnel, including ancillary services. Persons present on the hospital campus (but outside the ED or Labor and Delivery) If any person who arrives on the hospital campus (as defined in Section 5.0 below), and the person, or someone on his behalf, asks for an exam or treatment for what may be or appears to be an Emergency Medical Condition (as defined in Section 5.0). Hospital's medical emergency response team will be called. The medical emergency response team will stabilize the person within its Capability and transport the person to the ED for an appropriate Medical Screening Examination in accordance with this policy." The free standing ED had not delivered any babies at their facility, however while on tour of the facility, we were shown the OB/GYN room that had an OB tray and an isolette for the baby. When questioned about having a birth at the center, Personnel #2 stated that in any other patient with an emergency medical condition, they would stabilize and transfer the patient and if it was a delivery that was impending, they would deliver the baby and as soon as stabilized they would transfer to the appropriate facility.

Based on record review and interview, the hospital failed to ensure compliance with 489.24 (a) Medical Screening Exam, in that 1 of 1 patient (Patient #1) came to the emergency department on 1/15/2017 and was not provided a medical screening examination and was not documented on the central log. Cross refer to A2405 and A2406