Based on medical record review and interview the facility failed to ensure complete and appropriate care of an upper extremity injury for one of thirty two emergency department patients (Patient #10). Specifically, one of thirty two emergency department patients did not receive an x-ray which resulted in an undiagnosed fracture by the emergency department physician (Patient #10). The findings included: Thirty two electronic medical records were reviewed on March 9, 2015 and March 10, 2015. Patient #10's electronic medical record was reviewed beginning on March 9, 2015 at approximately 10:40 am. A copy of Patient #10 's medical record was requested on March 9, 2015 during the review. A copy of Patient #10 's medical record was received on March 9, 2015 at approximately 3:00 pm. The medical record of Patient #10 was reviewed for a second time on March 9, 2015 beginning at 5:30 pm. Patient #10 was brought to the Emergency Department by rescue squad on January 14, 2015 at approximately 10:16 pm. The Emergency Services paramedic's documentation dated 01/14/2015 at 10:00 pm states "arrived to find the patient (reference to Patient #10) sitting in a chair at the gym. The patient (reference to Patient #10) was throwing a dodge ball with his/her left continuously when he/she suffered significant pain in his/her left upper arm." Documentation by the paramedic states Patient #10 "denied being struck by another person." Documentation by the paramedic indicates Patient #10 did not suffer any loss of consciousness (LOC) or fall. The paramedic's documentation states Patient #10 denied all pain except "humeral pain just above his/her left elbow." Further documentation by the paramedic states no swelling or discoloration of the left upper extremity. The narrative note by the paramedic states Patient #10 complained of 2/10 pain in his/her arm while it was resting in his/her position of comfort (against the chest) however when he/she attempted to move his/her arm it increased the pain to 9/10. No notations by the paramedic indicated a change in the color, pulses, or sensation of Patient #10's left arm. Documentation on the Emergency Medical Services (EMS) Patient Care Report (page 1) states chief complaint "fracture/dislocation." Documented arrival time of Patient #10 to the emergency department on January 14, 2015 is 10:16 pm. Patient #10's triage was performed by Staff #11 at 10:18 pm on January 14, 2015. Documentation in the medical record of Patient #10 dated January 14, 2015 indicates the patient was seen by the emergency department physician at 10:22 pm. Documentation by Staff #11 states Patient #10 received a Triage Emergency Severity Index (ESI) of Level 3. According to the U. S. Department of Health and Human Service Agency for Healthcare Research and Quality Emergency the Emergency Severity Index (ESI) is "a simple to use, five-level triage algorithm that categorizes emergency department patients by evaluating both patient acuity, and the resources needed. ESI levels 3, 4, and 5 are differentiated by the nurse's determination of how many resources are needed to make a patient disposition. Those patients who are expected to need two or more resources are designated as ESI level 3." The triage policy for the facility was requested and received on March 10, 2015 at approximately 8:00 am. A review of the policy titled "Triage" indicates the facility classifies patients into five triage categories "utilizing the Canadian CTAS system to assign acuity" which includes resuscitation, emergent, urgent, less urgent, and non urgent. Of note the facility's electronic medical record lists triage priority scale under the ESI category documentation. Staff #11 was interviewed on March 11, 2015 at 7:15 am. Staff #11 verified he/she was the triage nurse for Patient #10 and cared for Patient #10 while in the emergency department. Staff #11 stated "a priority score of 3 means the doctor needs to see the patient within about ten minutes." Documentation by Staff #11 in Patient #10's electronic medical record states Patient #10 was alert and oriented times three. Documentation by Staff #11 in Patient #10's medical record states Patient #10's "injury occurred 45 minutes ago and he/she was throwing a dodge ball and felt a pop in the left bicep." Further documentation dated January 14, 2015 at 10:24 pm by Staff #11 indicates Patient #10 was complaining of 4/10 pain in the left bicep area. Staff #11 documented "a small knot was present" and Patient #10 "had limited range of motion due to pain." Notation was made by Staff #11 pertaining to the presence of positive pulses in Patient #10's left upper extremity. Documentation of a complete assessment of Patient #10 on January 14, 2015 by Staff #11 was found. Staff #11 documented in the medical record of Patient #10 on January 14, 2015 at 10:24 pm under the "Subjective Assessment" Patient #10 stated he/she was playing dodge ball and went to throw the ball and "felt a huge pop in the arm and it hurts to move it." Documentation by Staff #11 in the electronic medical record of Patient #10 at 10:30 pm on January 14, 2015 under the "Extremity Assessment" notes the mechanism of injury as "change of position/throwing ball." Further documentation states "extremity discomfort and decreased range of motion." Documentation of skin changes, pulses, and sensation of the left upper extremity of Patient #10 by Staff #11 reveal no abnormalities. Documentation by Staff #11 indicates ice and elevation of Patient #10's arm was done per medical doctor (MD) order at 10:35 pm. Documentation by Staff #11 states a left sling and ice was applied per MD order at 10:47 pm. Documentation by Staff #11 at 10:47 pm on January 14, 2015 states Toradol 10 mg by mouth (po) and Oxycodone 5 mg/Tylenol 325 mg tablet po was administered to Patient #10 for pain. Toradol according to Drugs.com is "a nonsteroidal anti-inflammatory drug (NSAIDS). It works by reducing hormones that cause inflammation and pain in the body." Oxycodone and Acetaminophen (Percocet) according to Drugs.com is "a combination medicine used to relieve moderate to severe pain." Percocet is a narcotic. Documentation in the electronic medical record of Patient #10 under HPI (history of present illness) on January 14, 2015 at 10:22 pm by Staff #19 states "arm injury, patient with sudden onset of pain within the belly of the bicep while throwing during a dodge ball match." He/she "felt and heard a pop at the onset of pain. No lump or swelling reported." Documentation by Staff #19 states mechanism of injury "throwing a ball." Staff #19's documentation states Patient #10 reported a pain level of 4/10 in the left arm. Documentation by Staff #19 states "pain exacerbated by flexion/extension at the elbow and movement of the bicep." Further documentation by Staff #19 states no numbness or tingling of Patient #10 ' s left upper extremity. Physical examination documentation by Staff #19 states under the category titled "Arm/shoulder: tender to palpitation within the belly of the bicep. Limited flexion/extension at the elbow due to bicep pain. No palpable mass or deformity. No physical evidence of complete tendon rupture. Shoulder is normal." Documentation by Staff #19 indicates Patient #10's forearm/elbow, wrist, and hand were all normal. No documentation of a small knot noted (previously noted by Staff #11) on the left arm of Patient #10 by Staff #19. Documentation on January 14, 2015 by Staff #19 indicates the medical orders for Patient #10 included ice, elevation, and a sling to the left arm. Medications ordered included Toradol 10 mg po and Percocet for pain. No entry was documented under the title "Clinical Impression" by Staff #19 on January 14, 2015. Documentation by Staff #19 on January 14, 2015 at 10:44 pm was found under "Primary Impression" which states "biceps muscle tear." No documentation was found in Patient #10's electronic medical record the patient had any radiology studies done on January 14, 2015. Documentation by Staff #11 states Patient #10 was discharged at 11:03 pm with discharge instructions and two prescriptions (Toradol and Percocet) for pain. Documentation by Staff #11 indicates Patient #10 was advised to make an appointment to see orthopedics in 3 to 5 days. A copy of Patient #10's discharge instructions was reviewed on March 10, 2015 at approximately 3:00 pm. The discharge instructions were titled "Strain." Staff #11 was interviewed on March 10, 2015 at 7:15 am. Staff #11 verified during interview he/she felt a small knot on Patient #10 ' s left upper arm. Staff #11 stated Patient #10 was having trouble with flexion and extension of his/her left arm. When asked by the surveyor if a patient who fractures an arm will sometimes hear a popping sound Staff #11 stated "yes, fractures will pop." Staff #11 stated not all patients with fractures will complain of a pop. Staff #11 confirmed that Patient #10 did not have any x-rays prior to discharge. Staff #19 was interviewed by speaker phone in the presence of Staff #1 on March 10, 2015 at approximately 5:45 pm. Staff #19 verified he/she provided medical care to Patient #10 on January 14, 2015 in the Emergency Department at the facility named in the complaint. Staff #19 stated Patient #10 had sudden pain in the arm while throwing a ball and heard a pop. Staff #19 stated Patient #10 could move his/her arm and had full range of motion. Staff #19 stated he/she remembered Patient #10 "had pain which was exacerbated with flexion/extension at the elbow." Staff #19 stated the bicep area was tender to palpitation. Staff #19 stated he/she thought the patient (reference to Patient #10) had a bicep muscle tear or strain. Staff #19 stated he/she treated Patient #10 "conservatively but stressed the importance of following up with orthopedics." Staff #19 stated he/she thought about a fracture but Patient #10 was young and healthy and the mechanism of injury was throwing a ball. Staff #19 stated he/she is "generally liberal with obtaining x-rays." Staff #19 verified he/she did not order an x-ray for Patient #10's injured arm on January 14, 2015 while in the emergency department. Eight physician (including Staff #12 and Staff #19) credential files were reviewed on March 10, 2015 at approximately 9:15 am. All necessary documentation was available for review. All physician credentials were up to date. Documentation in Patient #10's medical record dated January 19, 2015 from the follow-up visit to the orthopedic specialist was reviewed on March 10, 2015. The documentation by Staff #7 under the section titled "Brief History" states "He/she (reference to Patient #10) was playing dodge ball a couple of days ago and he/she threw the dodge ball and felt a pop in his/her arm. He/she went to the hospital. No x-rays were taken. He/she was diagnosed with a biceps tendon tear and sent to me for follow up in a sling." Documentation of Patient #10's physical examination by Staff #7 states he/she "has a notable amount of bruising over the medial side of the arm and the antecubital fossa (triangular cavity of the elbow that contains a tendon of the biceps, the median nerve, and the brachial artery). His/her arm is grossly swollen." Documentation by Staff #7 reveals x-rays were obtained of Patient #10's left arm during the orthopedic follow up office visit on January 19, 2015. Documentation by Staff #7 states x-rays including AP (anterior/posterior) and lateral of elbow as well as AP and lateral of the humeral (long bone in the arm) shaft were obtained. Documentation by Staff #7 states he/she "has got a distal third humeral shaft spiral fracture with some displacement and slight varus (bent inward) angualtion." According to Orthopedics One.com "humeral shaft fractures are defined as fractures in which the major fracture line occurs distal to the insertion of the pectoralis major (anterior chest muscle) and proximal to the supracondylar ridge (either of two ridges above the condyle of the humerus). The fracture is usually described as open or closed, by the location within the humeral shaft (proximal, middle, or distal third) and overall character of the fracture pattern (transverse, oblique, or spiral)." According to Wheeless ' Textbook of Orthopedics "torsion force will result in a spiral fracture." Documentation by Staff #7 indicates the treatments discussed with Patient #10 and his/her parents were Sarmiento bracing (a brace used to immobilize humeral shaft fractures) or open reduction and internal fixation (a type of surgery used to fix broken bones). Documentation by Staff #7 on January 19, 2015 indicated Patient #10 elected to have the open reduction and internal fixation (ORIF) because of the "long bracing period of time." Further documentation by Staff #7 indicated the surgical procedure would be scheduled as soon as possible. Staff #7 stated he/she "needs to ice this and use the compression sleeve as much as possible." A copy of the electronic medical record of Patient #10 dated January 27, 2015 was received and reviewed on March 9, 2015. Documentation by Staff #7 indicates Patient #10 underwent surgery on January 27, 2015 for an Open Reduction Internal Fixation (ORIF) of the left humeral shaft fracture. Documentation by Staff #7 in the section titled "Description of the Procedure" states "I placed 2 lag screws across the fracture securing the anatomic reduction. I slid a long Synthes (type of orthopedic trauma hardware) posterolateral locking plate, underneath the proximal radial nerve (large nerve in the arm). The radial nerve expansion was very broad across the posterior aspect of the humerus and almost parallel to the shaft of the bone, so that actually traversed quite a distance from proximal to distal along the humeral shaft. This caused me to use a much longer plate than I normally would with 3 cortical screws proximal to the fracture site and multiple cortical and locking screws distal to the fracture site." Documentation by Staff #7 in Patient #10's electronic medical record indicates Patient #10 was discharged on [DATE]. Discharge plan documented by Staff #7 states he/she "will be in a sling for comfort." Documentation by Staff #7 states Patient #10 "will be in a compression sleeve to control edema and immediately begin range of motion exercises." Further documentation by Staff #7 states a follow up appointment for Patient #10 on Friday or Monday (no dates recorded) to put him/her on the edema (swelling) control sleeve and glove. Staff #7 was interviewed via speaker phone on March 10, 2015 at approximately 10:45 am. Staff #1, Staff #6, Staff #3, and Staff #12 were present during the interview. Staff #7 confirmed he/she cared for Patient #10 during the follow up orthopedic visit on January 19, 2015. Staff #7 stated he/she remembered Patient #10 (called patient by name). Staff #7 stated Patient #10 had been to the emergency department (reference to facility named in the complaint) with an injury to the arm. Initially, Staff #7 stated the injury was sustained he/she thought playing baseball but later stated he/she remembered it was dodge ball. Staff #7 stated Patient #10 reported no x-rays were done while in the emergency department. Staff #7 stated Patient #10's left arm was "very swollen and had a lot of bruising" on January 19, 2015. Staff #7 stated he/she ordered x-rays (4 views) and a left humeral shaft fracture was found. Staff #7 stated "this was a fracture that was missed. X-rays should have been taken." Staff #7 stated this type of injury is somewhat "unusual but have seen a handful of these types of injuries." Staff #7 stated after being asked by the surveyor if x-rays were taken the night of the injury would the treatment be different for Patient #10. Staff #7 stated "no the treatment would have been the same. No harm was done to the patient. No difference in the treatment but x-rays should have been taken. This was a misdiagnosis, thinking it was a bicep tear. A bicep tear would be an unusual injury for a patient of his/her age." Staff #12 was interviewed on March 10, 2015 at approximately 10:25 am. Staff #12 confirmed he/she spoke with Patient #10 and explained why Staff #19 did not do an x-ray. Staff #12 confirmed he/she "waived part of the bill." Staff #12 stated he/she spoke directly with Staff #19 after reviewing the medical record of Patient #10. Staff #12 stated it made more sense to him/her after speaking with Staff #19 pertaining to why no x-ray was taken. Staff #12 stated Patient #10 was a young healthy patient who had a non traumatic injury to the arm and although had pain had full range of motion. Staff #12 was asked by the surveyor if a torn bicep is a common injury in a 21 year old. Staff #12 stated "it is not a common injury in a 21 year old." Staff #12 was asked by the surveyor about the significance of the popping Patient #10 described to the emergency department staff. Staff #12 stated popping is a common complaint with orthopedic injuries in general. Staff #12 stated popping can happen for a lot of reasons. Staff #12 stated "the popping is more suspicious for a fracture." Staff #12 confirmed the emergency department has a "Long Bone Fracture Protocol" which is used for obvious fractures and pertains to pain management. A copy of the protocol was requested and reviewed on March 10, 2015. Staff #12 stated the decision to x-ray is determined by the physician based on physical examination, mechanism of injury, history, pain, and range of motion. Documentation by Staff #12 to Staff #14 on February 27, 2015 pertaining to the complaint states he/she (reference to Patient #10) "had no blunt trauma of any kind and full painless range of motion at every joint in the affected arm" which lead to no imaging by the emergency department medical doctor. According to the Mayo Clinic.com normal range of motion is defined as "the full movement potential of a joint, usually its range of flexion and extension." Documentation by the paramedic on January 14, 2015 stated Patient #10 had 9/10 pain when moving left arm. Documentation by Staff #11 on January 14, 2015 at 10:24 pm stated Patient #10's left arm "had limited range of motion." Documentation by Staff #19 on January 14, 2015 at 10:22 pm states "limited flexion/extension at the elbow due to bicep pain. Pain in the left arm exacerbated by flexion/extension at the elbow and movement of the bicep."

Based on clinical record review, facility document review, staff and other involved personnel interviews, the facility staff failed to ensure compliance with EMTALA requirements at 42 CFR ?489.24, Special responsibilities of Medicare hospitals in emergency cases. The findings include: The facility staff failed to ensure an appropriate MSE (Medical Screening examination) and necessary stabilizing treatment were provided to Patient #21, who had been brought to the emergency department (ED) by a "family member/significant other" and requested assistance for the patient. The family member/significant other came into the ED and stated the "patient" was out in the car and had been psychotic and was in need of help. According to investigation/interviews, the family member of Patient #21 was "encouraged" to seek medical assistance elsewhere by the on-duty Emergency Department Physician. Further detailed information is found within this report, specifically at: 42 CFR ?489.24 (a) (1) (i) (C-2406) 42 CFR ?489.24 (d) (1) (i) (C-2407)

Based on staff interview, facility document review, and in the course of complaint investigation, it was determined the facility staff failed to ensure an appropriate medical examination (MSE) was provided for one of 21 (twenty one) patients, Patient #21,who had been brought to the emergency department (ED) by a "family member/significant other" and requested assistance for the Patient. The family member/significant other came into the ED and stated the "patient" was out in the car and had been psychotic and was in need of help. The findings included: A "self reported" event was received by the RO (Regional Office) of 1/26/15 and forwarded to the SA (State Agency) for further investigation. According to the report, on 1/5/15, a "male family member" presented to the freestanding ED and approached the registration desk. The "family member" stated to the Registrar that he had a "female patient" in his vehicle who was psychotic and manic. He stated the patient had been this way for a week and her physician recommended she be taken to the ED. The family member questioned whether he could move his car to the ambulance entrance and escort the patient though that entrance. The family member indicated the patient became agitated in the presence of law enforcement and there were deputies present in the ED at that time. The Registrar stepped away from the desk and spoke with the ED physician who stated to the registrar the ED was not a psychiatric facility and to inform the family member of this fact. The registrar refused to do this, so the physician stated he/she would speak with the family. The ED physician entered the waiting area and spoke with the family member. The physician claimed he/she offered to see the patient but the family member declined and said he would take her to another facility. The patient was never entered into the ED logs. The patient left the ED without an appropriate MSE (Medical screening examination) and stabilizing treatment. On 2/2/15 at 12:00 p.m., the survey team entered the facility in order to conduct the investigation of the reported event. A tour of the ED was conducted. Staff member #4 was interviewed concerning treatment of patients and EMTALA regulations and stated he/she was aware of the circumstances of the reported incident, when interviewed as to whether he/she had knowledge of any EMTALA violations at this facility. Staff #4 stated he/she had been informed about the incident on the day it occurred and had reported it to his/her supervisor. Staff #4 stated that, "Every patient is treated here no matter what. We should not turn patients away or discourage them from receiving care...We do not know who the patient was. We did not get a name. The family member did not give that information and did not sign in..." On 2/2/15 at 1:50 p.m., Staff #5 was interviewed. Staff #5 stated he/she had been informed of the concern by one of his/her staff "right after it happened". Staff #5 stated it was reported to the "supervisor". At 3:00 p.m. on 2/2/15, the surveyor interviewed Staff # 6, who was the registrar on duty at the time Patient #21 arrived to the ED. Staff #6 stated, "A gentleman came in and said he had a female out in his car that had been psychotic for two weeks and he didn't know what to do with her, that her doctor said to bring her to the emergency room . He said she had a fear of law enforcement and there were two sheriffs in the ED at that time, so he wanted to know if he could bring her through the ambulance entrance. I went back to ask and there was no one at the nurses station except for (name of physician) and I asked him/her about it. He/she said that I should tell the gentleman that we were not a psychiatric facility and that he should take her (the patient) somewhere else. I told him I absolutely would do no such thing, that it was not right and also I could loose my job. He/she then said he/she would go out and talk with him. When I went back out the man was not there, but he came back in and said he had gone to the car and given her some medication to calm her so he could get her to come in. (Name of physician) came out and I heard him/her tell the gentleman that we were not a psych facility and that he should take her (the patient) somewhere else. The man told him/her that she (the patient) had been recently seen at (another hospital) and had been a patient there so (name of physician) told him he (the family member) should take her (the patient) back there. He (the physician) told the man he would be happy to see her (the patient) here but that it would take too much time because she would have to be transferred anyway and it would be easier if he(the family member) took her himself. There was another registrar present at that time. (Name of physician) then turned around and said. "Are you ladies alright with that?" I didn't say anything. I just looked at him/her because he/she knew I wasn't alright with it...I went to the charge nurse and told him/her what happened and he/she said it needed to be reported so he/she reported to his/her supervisor and I reported to mine...after this happened, and administration started asking questions, the doctor (name of physician) was still working and he/she would not speak to me or even look at me. It upset me because I was afraid he/she may retaliate..." On 2/2/15 at 3:20 p.m., the survey team was informed by Staff # 1 and 3 that the physician was no longer employed by the hospital. Staff #3 stated, "This was brought to my attention by (Staff #1) because he/she had contacted the director of risk and then contacted me...I did not reach out to the registrar, but did reach out to (name of physician)...(name of physician) is no longer providing services for any of our facilities. The CMO (Chief Medical Officer) in conjunction with the CEO (Chief Executive Officer) made that decision...we will be doing education and haven't set a date for it yet but it will be in addition to the required annual EMTALA training. It will be done in forty-five days..." Staff #3 also stated the other registrar who was present at the time the incident occurred was "off on leave" and not available, however the "other registrar" first "sided with the doctor" when interviewed, and then "changed his/her story that he/she was not able to hear because the physician had his/her back to him/her"... At 4:00 p.m. on 2/2/15 the surveyors further interviewed Staff #4. Staff #4 stated, "It was a (race) female with a history of bipolar having a severe manic episode. The gentleman who brought her was visibly upset and panicked. We had the police here for another patient who was agitated and because the nurses were tied up so (name of physician) went out and talked with the gentleman. After I was told what happened, I called (name of supervisor/director). I have been concerned that this would happen with this particular physician and I have voiced some concern regarding his/her attitude before this...my experience with (name of physician) was that I felt very frequently he/she would walk into a room and tell a patient reasons why they should be anywhere but here...I saw that happening a lot, but he/she never said he/she would not care for them and in fact, gave excellent care...but would say to staff, "I am not a dermatologist etcetera, but I am happy to see him/her..." On 2/3/15 at 12:30 p.m., the surveyors inquired as to the corrective plan - removal measures outlined in the letter to CMS dated 1/26/15. Staff # 3 stated "some" of the removal measures had not been implemented as of yet. The surveyors inquired as to the status of each removal measure and were informed as follows: A. The actions of the ED Physician were reported to the Peer review Committee for review..."We just had Peer review on 1/28/15, but this was not discussed. It will be discussed at the 3/28/15 meeting..." B. The ED Physician was counseled...(This was completed according to evidence from the Medical Director and interview 2/3/15 12:50 p.m.) C. (Initials of hospital) ED staff members at all of our campuses were educated on EMTALA requirements..."This is not implemented yet. We are still working on the education part..." (Physician re-education was documented by ED Medical Staff meeting January 22, and Med Exec meeting minutes January 21, 2015.) D. (Initials of hospital) ED staff members were re-educated on procedures for escalating EMTALA questions to their supervisors. "This is not completed yet..." E. (Initials of hospital) reviewed with ED staff members the response plan for patients that were outside the ED but on hospital property within 250 yards of the main building and present for en emergency medical condition. "This is not completed yet..." Staff # 3 stated that she would be working on a plan of action for the above issues and it would be submitted "by the end of March." On 2/3/15 at 12:50 p.m., the surveyors interviewed the Medical Director (Staff # 7) for the facility. Staff #7 stated, "I was informed the next day, I believe, and when I found out about it was the first time I spoke to (name of physician), however, we had many conversations about this...I did an EMTALA review with all of the physicians...they were either present in person or on the conference call...there is required annual training through (name of physician group) but secondary to this incident we bolstered the training..." The survey team reviewed a document dated 1/22/15, "(Name of physician group) ED Meeting Minutes". This document evidenced "EMTALA Review (presented by Staff #7) Detailed discussion of definitions and interpretation of law, focusing specifically on: EMTALA definition, EMTALA and ambulances, Central log, Emergency Medical Condition, Prudent layperson Observer, Hospital Property, Medical Screening Exam, Qualified Medical Personnel, and "Comes to the Emergency Department". Case reviewed and group discussion of possible outcomes, options for management. Online EMTALA training for all providers required yearly." The "Medical Executive Committee" meeting minutes for 1/21/15 were reviewed. The minutes documented, "Ethics and Compliance Committee Update: (name of director) presented an update on EMTALA. It was noted: EMTALA REQUIREMENTS: Individuals must be evaluated and provided with medical support services and/or transfer arrangements that rare consistent with the capability of the institution and the well-being of the patient; Hospitals must have a list of physicians who are on-call to provide treatment necessary to stabilize an individual with an emergency medical condition; Hospital must have privileged physicians with skill sets to provide care that is consistent with the services it provides; Medical Executive Committee must review on-call schedule and make recommendations to CEO when formal changes are to be made or when legal or operational issues arise..." The facility policy on EMTALA was also reviewed. The policy stated, in part: "EMTALA- Definitions and General Requirements: PURPOSE: To require, in conjunction with state-specific policies, that a hospital with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to any individual, including every infant who is born alive, at any stage of development who comes to the Emergency Department and requests such an examination as required by the Emergency Medical Treatment and Labor Act (EMTALA) 42 U.S.C. Section 1395dd and all Federal regulations and interpretive guidelines promulgated thereunder. POLICY: The hospital with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development who comes to the Emergency Department an appropriate Medical Screening Examination (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) exists, regardless of the individuals ability to pay. The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED), when an individual requests emergency medical care of hospital property, other than in a DED, or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made..." The policy "Dealing with and Reporting Misconduct" was reviewed and documented: We rely on you to report potential misconduct so that we may take corrective action and implement changes to prevent a similar violation from occurring...REPORTING CHANNELS: Your Supervisor, Human Resources Department, Facility Ethics and Compliance Officer, The Ethics Line..." "Behavioral Health, Guidelines for Patient Care Management" was reviewed and documented in part: "Patients with emotional or behavioral disorders present with special needs. According to the scope of care and service (name of hospital) does provide inpatient and outpatient behavioral health treatment and care, Should a patient present to (name of facility) with a behavioral health disorder, processes will be implemented to facilitate patient safety, stabilize the patient and provide for a safe disposition...A. Emergency Department Guidelines: 1. Any patient, including patients with behavioral health (psychiatric) conditions who present to the Emergency Department or hospital grounds for treatment must be provided with an appropriate medical screening examination to determine of the patient is suffering from an emergency medical condition. triage is NOT the equivalent of a medical screening examination...." The survey team discussed the concerns related to the patient not being provided with an MSE or stabilizing treatment and that there was no identification of the patient for follow-up, on 2/3/15 at 3:00 p.m.

Based on staff interview, facility document review, and in the course of a complaint investigations, it was determined the facility staff failed to ensure stabilizing treatment was provided for one of 21 (twenty one) patients, Patient #21, who was brought to the emergency department (ED) by a "family member/significant other" and requested assistance for the Patient. The family member/significant other came into the ED and stated the "patient" was out in the car and had been psychotic and was in need of help. The findings included: On 2/2/15 at 12:00 p.m., the survey team entered the facility in order to conduct the investigation of an event where a caregiver/patient reportedly arrived at the emergency department, requesting assistance. Reportedly a physician suggested the patient be taken to a different hospital, this was suggested prior to the patient being examined (medical screening exam) or stabilizing treatment provided. A tour of the ED was conducted. Staff member #4 was interviewed concerning treatment of patients and EMTALA regulations and stated he/she was aware of the circumstances of the reported event, when interviewed as to whether he/she had knowledge of any EMTALA violations at this facility. Staff #4 stated he/she had been informed about the incident on the day it occurred and had reported it to his/her supervisor. Staff #4 stated that, "Every patient is treated here no matter what. We should not turn patients away or discourage them from receiving care...We do not know who the patient was. We did not get a name. The family member did not give that information and did not sign in..." On 2/2/15 at 1:50 p.m., Staff #5 was interviewed. Staff #5 stated he/she had been informed of the concern by one of his/her staff "right after it happened". Staff #5 stated it was reported to the "supervisor". At 3:00 p.m. on 2/2/15, the surveyor interviewed Staff # 6, who was the registrar on duty at the time of the incident. Staff #6 stated, "A gentleman came in and said he had a female out in his car that had been psychotic for two weeks and he didn't know what to do with her, that her doctor said to bring her to the emergency room . He said she had a fear of law enforcement and there were two sheriffs in the ED at that time, so he wanted to know if he could bring her through the ambulance entrance. I went back to ask and there was no one at the nurses station except for (name of physician) and I asked him/her about it. He said that I should tell the gentleman that we were not a psychiatric facility and that he (the family member) should take her (the patient) somewhere else. I told him/her I absolutely would do no such thing, that it was not right and also I could loose my job. He/she (the physician) then said he/she would go out and talk with him. When I went back out the man was not there, but he came back in and said he had gone to the car and given her some medication to calm her so he could get her to come in. (Name of physician) came out and I heard him/her tell the gentleman that we were not a psych facility and that he should take her somewhere else. The man told him/her (the physician) that she (the patient) had been recently seen at (another hospital) and had been a patient there so (name of physician) told him (the family member) he should take her (the patient) back there. He/she (the physician) told the man he/she would be happy to see her (the patient) here but that it would take too much time because she would have to be transferred anyway and it would be easier if he (the family member) took her himself. There was another registrar present at that time. (Name of physician) then turned around and said, "Are you ladies alright with that?" I didn't say anything. I just looked at him/her because he/she knew I wasn't alright with it...I went to the charge nurse and told him/her what happened and he/she said it needed to be reported so she reported to her supervisor and I reported to mine...after this happened, and administration started asking questions, the doctor (name of physician) was still working and he/she would not speak to me or even look at me. It upset me because I was afraid he may retaliate..." On 2/2/15 at 3:20 p.m., the survey team was informed by Staff # 1 and 3 that the physician was no longer employed by the hospital. At 4:00 p.m. on 2/2/15 the surveyors further interviewed Staff #4. Staff #4 stated, "It was a white female with a history of bipolar having a severe manic episode. The gentleman who brought her was visibly upset and panicked. We had the police here for another patient who was agitated and because the nurses were tied up so (name of physician) went out and talked with the gentleman. After I was told what happened, I called (name of supervisor/director). I have been concerned that this would happen with this particular physician and I have voiced some concern regarding his attitude before this...my experience with (name of physician) was that I felt very frequently he/she would walk into a room and tell a patient reasons why they should be anywhere but here...I saw that happening a lot, but he/she never said he/she would not care for them and in fact, gave excellent care...but would say to staff, "I am not a dermatologist etcetera, but I am happy to see him/.her..." On 2/3/15 at 12:30 p.m., the surveyors inquired as to the removal measures outlined in the letter to CMS (Centers for Medicare Medicaid Services) dated 1/26/15. Staff # 3 stated "some" of the removal measures had not been implemented as of yet. Staff # 3 stated that she would be working on a plan of action for the above issues and it would be submitted "by the end of March." On 2/3/15 at 12:50 p.m., the surveyors interviewed the Medical Director (Staff # 7) for the facility. Staff #7 stated, "I was informed the next day, I believe, and when I found out about it was the first time I spoke to (name of physician), however, we had many conversations about this...I did an EMTALA review with all of the physicians...they were either present in person or on the conference call...there is required annual training through (name of physicians group) but secondary to this incident we bolstered the training..." The "Medical Executive Committee" meeting minutes for 1/21/15 were reviewed. The minutes documented, "Ethics and Compliance Committee Update: (name of director) presented an update on EMTALA. It was noted: EMTALA REQUIREMENTS: Individuals must be evaluated and provided with medical support services and/or transfer arrangements that rare consistent with the capability of the institution and the well-being of the patient; Hospitals must have a list of physicians who are on-call to provide treatment necessary to stabilize an individual with an emergency medical condition; Hospital must have privileged physicians with skill sets to provide care that is consistent with the services it provides; Medical Executive Committee must review on-call schedule and make recommendations to CEO when formal changes are to be made or when legal or operational issues arise..." The facility policy on EMTALA was also reviewed. The policy stated, in part: "EMTALA- Definitions and General Requirements: PURPOSE: To require, in conjunction with state-specific policies, that a hospital with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to any individual, including every infant who is born alive, at any stage of development who comes to the Emergency Department and requests such an examination as required by the Emergency Medical Treatment and Labor Act (EMTALA) 42 U.S.C. Section 1395dd and all Federal regulations and interpretive guidelines promulgated thereunder. POLICY: The hospital with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development who comes to the Emergency Department an appropriate Medical Screening Examination (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) exists, regardless of the individuals ability to pay. The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED), when an individual requests emergency medical care of hospital property, other than in a DED, or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made..." The survey team discussed the concerns related to the patient not being provided with an MSE or stabilizing treatment and that there was no identification of the patient for follow-up on 2/3/15 at 3:00 p.m.