Based on interviews, medical record review, and document review, it was determined the facility's staff failed to ensure the freestanding Emergency Department (ED) adopted and enforced a policy to provide a medical screening exam and medical treatment as defined by EMTALA requirements. 42 CFR §489.20 (l) of the provider's agreement, and §489.24(b), to comply with §489.24. Please see A-2406 and A-2407 for additional information.

Based on observations, medical record reviews, document review and staff interviews, the facility staff failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, to determine whether or not an emergency medical condition existed for 1 of 21 patients reviewed. (Patient #1). This involved three of four staff members present in the dedicated emergency department (ED). (Staff #7, #8 and #9). The findings include: On 11/18/15 at 12:30, during a tour of the freestanding ED (Emergency Department), the desk receptionist (Staff #4) was questioned, and was aware of the EMTALA requirements when questioned. At 12:50 p.m. on 11/18/15, Staff #2 (ED Charge Nurse) recalled the following information about a patient who presented on November 12th around 3:30 p.m. The nurse stated Staff #8, the receptionist, told the nurse a patient was in the waiting room sent by her doctor to be "admitted for observation". Staff #2 told the receptionist that this ED did not have the capability to admit patients. Further, if he/she wants to be seen for admission, she/he can be seen at a hospital of the patient's choosing. The receptionist then told Patient #1 what Staff #2 reported. Staff #2 said Patient #1 decided to leave. Staff #2 said she was not seen by the doctor nor any nursing staff, so that was why there was no chart. There was no medical record at this ED, as the patient was not logged in or registered. On 11/18/15 at 3:35 p.m. Staff #8 was interviewed at the facility. He/she stated on November 12th at around 3:30 p.m. Patient #1 came up to the desk and said he/she was having "mini-stroke" symptoms. Patient #1 had a paper from an evaluation by a nurse at the patient's work where he/she wrote down the symptoms. The nurse at patient's work called a Neurologist, and the physician told the nurse the patient needed to be seen at an ED and placed under observation. Staff #8 said he/she went back and told the charge nurse (Staff #7) what the patient said. Staff #8 then told the surveyor that he/she was told that the freestanding ED did not have the capability to admit, and to tell the patient to go to another ED where the patient could be admitted . Staff #8 informed the surveyor, he/she returned and told Patient #1 the ED staff could see the patient, but if Patient #1 wanted to save the co-pay from this visit, he/she could go to the hospital of his/her choosing. Staff #8 stated, "I did not see [him/her] as an emergency. The patient was coherent and did not slur her/his words. Patient #1 told the receptionist he/she had just recently seen the Neurologist, and had a history of TIA (Trans Ischemic Attack). Staff #8 stated he/she told the patient we would be glad to see her, but he/she was determined to go after I talked to him/her about the co-pays. Staff #8 admitted she had no medical training. Patient #1 stayed in the waiting room for quite awhile playing with her baby and waiting for his/her spouse to return. When the spouse came back about 5:00 p.m., Patient #1left the ED. Patient #1 was not logged in nor had any triage or medical screening exam. When the surveyor asked Staff #8 if he/she knew about EMTALA regulations regarding all patients getting a medical screening exam despite payment or insurance. Staff #8 said, "I am just hearing about it now. I have only worked here for a few weeks." Staff #8's personnel file orientation documented she/he had EMTALA training 11/8/15. All of the other nursing staff and physicians in the ED were most recently trained on 3/8/15.

Based on staff interviews, medical record reviews, and document review, the facility staff failed to provide reasonable steps for further medical examination and any stabilizing treatment which may have been needed. This practice affected 1 of 21 patients in the survey sample, (Patient #1). The findings include: Patient #1 arrived at the freestanding Emergency Department (ED) on 11/12/15 at approximately 3:30 p.m. The surveyor interviewed the ED Charge Nurse (Staff #2) on 11/18/15 at 12:50 p.m. and was informed of the following. The patient arrived at the ED and told the receptionist, Staff #8, that the patient's physician had instructed the patient to go to the ED and to be "admitted for observation". The receptionist told the nurse of the patient saying he/she was to be admitted for observation. Staff #2 then told the receptionist that this ED did not have the capability to admit patients. Further, if the patient wanted to be seen for admission, the patient could be seen at a hospital of his/her choosing. The receptionist then told Patient #1 what Staff #2 had said about not being able to admit the patient at this facility. Staff #2 said the patient apparently decided to leave the facility. Staff #2 said Patient #1 was not seen by a physician nor any nursing staff. There was no medical record for Patient #1 at this ED, as the patient was not logged in or registered. On 11/18/15 at 3:35 p.m. the surveyor interviewed Staff #8, the receptionist on duty at the time of Patient #1's arrival to the ED. According to the receptionist, Patient #1 stayed in the ED waiting room from approximately 3:30 p.m. until 5:00 p.m., waiting for his/her spouse to arrive and take the patient to a different ED. Staff #8 told the surveyor that "I did not see [him/her] as an emergency. He/she was coherent and did not slur [his/her] words." In the interview, the receptionist informed the surveyor that Patient #1 had informed him/her of a history of TIAs (transichemic attacks - mini strokes). The hospital's policy on EMTALA read, in part, "...Then the individual will be provided necessary stabilizing treatment, within the capability of the facility, or an appropriate transfer as defined by and required by EMTALA. Establishing treatment shall be applied in a non-discriminatory manner (e.g., no different level of care because of diagnosis, financial status, race, or insurance status, disease, or handicap)." The ED failed to provide a medical screening exam (MSE) and therefore failed to determine if Patient #1 required stabilizing treatment. Please refer to A-2406 for additional information.