Based on medical record review, staff interview and document review it was determined the facility failed to provide an appropriate medical screening exam for one (1) of twenty (20) medical records reviewed who presented to the Labor and Delivery Unit and requested treatment (Patient #1). This failure has the potential for all patients who come to the hospital for emergency treatment to recieve substandard care (See tag A-2407 and A-2409).

Based on medical record review, staff interview and document review it was determined the facility failed to transfer a patient with an emergency medical condition to another facility that offers psychiatric care in one (1) of twenty (20) medical records reviewed who presented to the Labor and Delivery Unit and requested treatment (Patient #1). This failure has the potential for all psychiatric patients who have an emergency medical condition who come to the hospital for emergency treatment to receive substandard care. 1. Review of the medical record for Patient #1 revealed the patient was brought to the hospital by the Emergency Medical Services (EMS) on 10/05/17 at 5:28 p.m. at the request of the police for complaints of pregnancy and abdominal pain. The patient was diagnosed with a thirty-three (33) week intrauterine pregnancy and delusions. Registered Nurse #1 documented in part on 10/05/17 at 6:44 p.m., "est gest age is 33 wks. Patient cleared with pregnancy to be taken to another facility for mental health and drug detox. The patient threatened every nurse on unit that she would "hurt you, whip your ass, kick your face off"... The patient's family stated she is dangerous. The patient was escorted off the unit by security and Beckley police department to meet EMS in parking lot to be taken to Beckley Appalachian Regional Hospital (BARH)." It further revealed no documentation for a transfer to another hospital had been attempted by Physician #1 or the midwife who cared for the patient. Further review revealed no documentation of the physician speaking to another hospital for a transfer for an emergency medical condition. 2. A telephone interview was conducted on 10/16/17 at 3:10 p.m.with the security officer/Beckley police. When asked if he remembered the patient, he stated, "Yes". When asked to explain how he came to take the patient to the parking lot. he stated, in part, "She was discharged and when we got to the parking lot she threatened to kill me and she had threatened harm to the nurses on the unit and she was given a choice to go to get help or go to jail and she said she couldn't go to jail she'd get help, so I called EMS and they pulled into the Krogers parking lot and took her to BARH." When asked if she was a transfer or a discharge he stated, "A discharge." 3. An interview was conducted with the Labor and Delivery (L&D) midwife on 10/17/17 at 8:10 a.m. When asked if she remembered the patient she said, "Yes". She stated that due to a police officer being at the nurse's station she thought the patient was in police custody. She stated the police officer had a gun and she was not going to stop him from taking the patient into custody and risk getting arrested. She reported she did not have EMTALA training. 4. An interview was conducted with the Obstetrics Physician on 10/17/17 at 12:30 p.m. When asked if he remembered the patient, he said, "Yes". He stated a Beckley Police officer accompanied the patient to the L&D floor, (she wasn't brought up by EMS) and she came to L&D by blue transport chair and staff. He reported he did not see EMS staff at all and he assumed the patient was under arrest or a possible involuntary commitment hold. He stated if the police had not been there the patient wouldn't have been discharged ; she would have been sent back to the Emergency Department because she wasn't okay to go home. He stated, "This is definitely an EMTALA violation." During the interview the Chief Medical Staff of Obstetrics arrived to sit in on the interview with the permission of the Obstetrics physician. She concurred with his findings this was an EMTALA. 5. Review of the policy titled, "Medical Screening", last reviewed 04/16 states, in part: "The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED) or when an individual request emergency medical care on hospital property other than in a DED. If an Emergency Medical Condition (EMC) is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer." 6. An interview was conducted on 10/17/17 with the Director of Quality at approximately 1:20 p.m.and she concurred with the above findings.

Based on medical record review, staff interview and document review it was determined the facility failed to transfer a patient with an emergency medical condition to another facility that offers psychiatric care in one (1) of twenty (20) medical records reviewed who presented to the Labor and Delivery Unit and requested treatment (Patient #1). This failure has the potential for all psyciatric patients who have an emergency medical condition who come to the hospital for emergency treatment to receive substandard care. 1. Review of the medical record for Patient #1 revealed the patient was brought to the hospital by the Emergency Medical Services (EMS) on 10/05/17 at 5:28 p.m. at the request of the police for complaints of pregnancy and abdominal pain. The patient was diagnosed with a thirty-three (33) week intrauterine pregnancy and delusions. Registered Nurse #1 documented in part on 10/05/17 at 6:44 p.m., "est gest age is 33 wks. Patient cleared with pregnancy to be taken to another facility for mental health and drug detox. The patient threatened every nurse on unit that she would "hurt you, whip your ass, kick your face off"... The patient's family states she is dangerous. The patient was escorted off the unit by security and Beckley police department to meet EMS in the parking lot to be taken to Beckley Appalachian Regional Hospital (BARH)." It further revealed no transfer to another hospital had been attempted by Physician #1 or the midwife who cared for the patient. 2. A telephone interview was conducted on 10/16/17 at 3:10 p.m. with security the officer/Beckley police. When asked if he remembered the patient, he stated, "Yes". When asked to explain how he came to take the patient to the parking lot he stated in part, "She was discharged and when we got to the parking lot she threatened to kill me and she had threatened harm to the nurses on the unit and she was given a choice to go to get help or go to jail and she said she couldn't go to jail she'd get help, so I called EMS and they pulled into the Krogers parking lot and took her to BARH." When asked if she was a transfer or a discharge, he stated, "A discharge." 3. An interview was conducted with the Labor and Delivery (L&D) midwife on 10/17/17 at 8:10 a.m. When asked if she remembered the patient she said, "Yes". She stated that due to a police officer being at the nurse's station she thought the patient was in police custody. She stated the police officer had a gun and she was not going to stop him from taking the patient into custody and risk getting arrested. She reported she did not have EMTALA training. 4. An interview was conducted on 10/17/17 at 8:45 a.m. with the L&D charge nurse. When asked if she remembered Patient #1, she stated,. "Yes". When asked if she made a phone call to another hospital to see if they accepted pregnant psychiatric patients she stated, in part, "Yes, the mother wanted the patient to recieve help and I called BARH to see if they would take a pregnant psychiatric patient and talked to the supervisor and he told me they don't take pregnant women and they did not have any psychiatric beds available." When asked if she had a physician's order to begin a transfer request, she stated, "No". 5. A tour of the L&D unit was conducted on 10/17/17 at 9:55 a.m. with the Director of L&D. The patient was in an observation room directly in front of the nursing station. An interview was conducted during the tour with Registered Nurse #2. When asked if there was ever any talk about a transfer to another hospital, she said., "No, we thought she was in custody. The police escorted her out of the hospital and it was our understanding he was going to take her to BARH." When asked to describe the patient's behavior and if the physician was aware of the patient's behavior, she stated, in part, "She was delusional and yelling and threatening us and thrashing around and she was hard to monitor (the baby) ... the physician was at the desk he knew what she was acting like ... it took about 5-6 nurses to take care of her." The Director of L&D concurred with the findings. 5. An interview was conducted with the Obstetrics Physician on 10/17/17 at 12:30 p.m. When asked if he remembered the patient, he said, "Yes". He stated a Beckley Police officer accompanied the patient to the L&D floor (she wasn't brought up by EMS) and she came to L&D by blue transport chair and staff. He reported he did not see EMS staff at all and he assumed the patient was under arrest or possible involuntary commitment hold. He stated if the police had not been there the patient wouldn't have been discharged ; she would have been sent back to the Emergency Department because she wasn't okay to go home. He stated "This is definitely an EMTALA violation." During the interview the Chief Medical Staff of Obstetrics arrived to sit in on the interview with the permission of the Obstetrics physician. She concurred with his findings this was an EMTALA. 6. Review of the policy titled, "Medical Screening", last reviewed 04/2016, revealed it states, in part:: "The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED) or when an individual request emergency medical care on hospital property other than in a DED. If an Emergency Medical Condition (EMC) is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer." 7. An interview was conducted on 10/17/17 at approximately 1:20 p.m.with the Director of Quality, she concurred with the above findings.

Based on document review, record review and staff interview it was determined the facility failed to ensure the Emergency Department (ED) staff provided care per the facility's policies and procedures. This deficient practice was identified in six (6) of twenty (20) medical records reviewed (patients #1, 15, 16, 17, 19 and 20). This failure has the potential to negatively impact the care given to all patients in an emergency situation. Findings include: 1. Review of facility policy titled "Triage, NUR-SPP-95-8070", approved 4/13, revealed it states, in part: "Triage is not a medical screening...The medical screening is completed by the physician, physician assistant or nurse practitioner." 2. Review of facility policy titled "CO 008, Assessment-Reassessment", last reviewed 3/31/16, revealed it states, in part: "To ensure patients who enter the Emergency Department seeking care and attention will receive an assessment and reassessment regardless of the location in the Emergency Department...All efforts made will be to gain access to a qualified medical provider. Should there be a delay, the triage nurse will communicate any concerns to the provider and charge nurse for evaluation in obtaining orders while waiting...All patients waiting greater than one (1) hour- regardless of location in the Emergency Department-will be reassessed at least hourly or more often as indicated following the Rapid Initial (Triage) Assessment." 3. Review of facility policy titled "Medical Screening, NUR-SPP-04-8098, NUR-SPP-05-6105", approved 11/11, revealed it states, in part: "Leaving Dedicated Emergency Department (DED) after Triage but before an Medical Screening Examination (MSE)...If an individual presents to the DED and requests services for a medical condition, is triaged and then indicates a desire to leave prior to the MSE ("LPMSE"), the facility should use its best efforts to:..offer the individual further medical examination and treatment as may be required to identify and stabilize an Emergency Medical Condition (EMC);...discuss with the individual the risks and benefits involved in leaving prior to the medical screening and document same;...take all reasonable steps to secure the individual's written informed consent to refuse or withdraw from such examination and treatment by having the individual sign the Refusal of MSE and/or Consent to Treatment form, if possible;...document the individual's refusal of MSE or the attempts to locate the individual if he or she left without notifying someone." 4. Review of patient #1's medical record revealed a sixty-nine (69) year old female who (MDS) dated [DATE] at 11:24 p.m. with complaints of an elevated blood sugar of six hundred (600). The patient was triaged by RN #1 at 11:33 p.m. Laboratory orders were initiated in triage for an Abdominal protocol and an acetone. The patient was given a priority level three (3) and placed in the ED waiting area. At 12:51 a.m. on 3/1/17 the laboratory called a critical value result, for Glucose five hundred seventy-seven (577), to the ED Licensed Practical Nurse (LPN) who documented the physician was notified (Doctor of Osteopathic Medicine; DO #1). The patient left the facility at 2:46 a.m. on 3/1/17. Further review of the medical record revealed there was no documentation of repeat vital signs, repeat glucose level, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance. 5. Review of patient #15's medical record revealed a forty-two (42) year old male who (MDS) dated [DATE] at 5:12 p.m. with complaints of chest pain. The patient was triaged at 5:14 p.m. and Cardiac Protocol orders were initiated in triage. Blood work was obtained and a chest X-ray and electrocardiogram (EKG) were completed. The patient was given a priority level three (3) and placed in the ED waiting area. The patient left the facility at 9:07 p.m. on 2/28/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance. 6. Review of patient #16's medical record revealed a forty-two (42) year old male who (MDS) dated [DATE] at 3:43 p.m. with complaints of chest pain. The patient was triaged at 3:49 p.m. and Cardiac Protocol orders were initiated in triage. Blood work was obtained and a chest X-ray and EKG were completed. The patient was given a priority level three (3) and placed in the ED waiting area. The patient left the facility at 7:55 p.m. on 2/28/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance. 7. Review of patient #17's medical record revealed a twenty-six year (26) old female who (MDS) dated [DATE] at 5:09 a.m. with complaints of swelling to the left hand/fingers. The patient was triaged at 5:18 a.m., given a priority level four (4) and was placed in the ED waiting area. The patient left the facility at 9:37 a.m. on 4/1/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance. 8. Review of patient #19's medical record revealed a seventy-eight (78) year old male who (MDS) dated [DATE] at 7:08 p.m. with complaints of shortness of breath. The patient was triaged by RN #1 at 7:20 p.m. Documentation revealed the patient had a history of Congestive heart failure (CHF), cardiac, pacemaker and hypertension. Cardiac orders were initiated in triage. Blood work was obtained and an EKG was completed. The patient was given a priority level three (3) and placed in the ED waiting area. The patient left the facility at 9:04 p.m. on 2/28/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance. 9. Review of patient #20's medical record revealed a fifty-six (56) year old female who (MDS) dated [DATE] at 10:23 p.m. with complaints of chest pain. The patient was triaged by RN #1 at 10:26 p.m. Cardiac orders were initiated in triage. Blood work was obtained and a chest X-ray and EKG were completed. The patient was given a priority level three (3) and placed in the ED waiting area. The patient left the facility at 2:31 a.m. on 3/1/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance. 10. An interview was conducted on 4/3/17 at 11:12 a.m. with the RN Director of Emergency Services. When asked how often vital signs are reassessed, she replied, "Every two (2) hours." 11. An interview was conducted on 4/3/17 at 11:20 a.m. with RN #3 (ED Charge Nurse). When asked how often vital signs are reassessed, she replied, "Vital signs are repeated every two (2) hours by the ED Tech or the triage nurse. 12. An interview was conducted on 4/4/17 at 9:07 a.m. with the LPN. When asked how often vital signs are reassessed, she replied, "Each nurse does their own vital signs every two (2) hours unless the patient is critical." 13. A telephone interview was conducted on 4/4/17 at 8:10 a.m. with RN #2 (ED Charge Nurse). When asked how often vital signs are reassessed, she replied, "Repeat vital signs are done every two (2) hours; that's the expectation." 14. A telephone interview was conducted on 4/5/17 at 1:41 p.m. with RN #1 (Triage Nurse). When asked how often vital signs are reassessed, she replied, "Every two (2) hours if we can." She also stated, "I do reassess patients and make them a higher level if necessary."

Based on document review, record review and staff interview it was determined the hospital failed to ensure the Emergency Department (ED) kept a current ED log (see tag A 2405) and the ED failed to provide an appropriate medical screening exam (see tag A 2406).

Based on document review, record review and staff interview it was determined the Emergency Department (ED) staff failed to repeat vital signs and a reassessment per facilty policies and procedures and failed to provide a Medical Screening Examination for all patients presenting to the ED for treatment. This deficient practice was identified in six (6) of twenty (20) medical records reviewed (patients #1, 15, 16, 17, 19 and 20). This failure has the potential to adversely affect the health status and condition of all patients. Findings include: 1. Review of facility policy titled "Triage, NUR-SPP-95-8070", approved 4/13, revealed it states, in part: "Triage is not a medical screening...The medical screening is completed by the physician, physician assistant or nurse practitioner." 2. Review of facility policy titled "CO 008, Assessment-Reassessment", last reviewed 3/31/16, revealed it states, in part: "To ensure patients who enter the Emergency Department seeking care and attention will receive an assessment and reassessment regardless of the location in the Emergency Department...All efforts made will be to gain access to a qualified medical provider. Should there be a delay, the triage nurse will communicate any concerns to the provider and charge nurse for evaluation in obtaining orders while waiting...All patients waiting greater than one (1) hour-regardless of location in the Emergency Department-will be reassessed at least hourly or more often as indicated following the Rapid Initial (Triage) Assessment." 3. Review of facility policy titled "Medical Screening, NUR-SPP-04-8098, NUR-SPP-05-6105", approved 11/11, revealed it states, in part: "Leaving Dedicated Emergency Department (DED) after Triage but before an Medical Screening Examination (MSE)...If an individual presents to the DED and requests services for a medical condition, is triaged and then indicates a desire to leave prior to the MSE ("LPMSE"), the facility should use its best efforts to:..offer the individual further medical examination and treatment as may be required to identify and stabilize an Emergency Medical Condition (EMC);...discuss with the individual the risks and benefits involved in leaving prior to the medical screening and document same;...take all reasonable steps to secure the individual's written informed consent to refuse or withdraw from such examination and treatment by having the individual sign the Refusal of MSE and/or Consent to Treatment form, if possible;...document the individual's refusal of MSE or the attempts to locate the individual if he or she left without notifying someone." 4. Review of patient #1's medical record revealed a sixty-nine (69) year old female who (MDS) dated [DATE] at 11:24 p.m. with complaints of an elevated blood sugar of six hundred (600). The patient was triaged by Registered Nurse (RN) #1 at 11:33 p.m. Laboratory orders were initiated in triage for an Abdominal protocol and an acetone. The patient was given a priority level three (3) and placed in the ED waiting area. At 12:51 a.m. on 3/1/17 the laboratory called a critical value result, for Glucose five hundred seventy-seven (577), to the ED Licensed Practical Nurse (LPN) who documented the physician was notified (Doctor of Osteopathic Medicine; DO #1). The patient left the facility at 2:46 a.m. on 3/1/17. Further review of the medical record revealed there was no documentation of repeat vital signs, repeat glucose level, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance. 5. Review of patient #15's medical record revealed a forty-two (42) year old male who (MDS) dated [DATE] at 5:12 p.m. with complaints of chest pain. The patient was triaged at 5:14 p.m. and Cardiac Protocol orders were initiated in triage. Blood work was obtained and a chest X-ray and electrocardiogram (EKG) were completed. The patient was given a priority level three (3) and placed in the ED waiting area. The patient left the facility at 9:07 p.m. on 2/28/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance. 6. Review of patient #16's medical record revealed a forty-two (42) year old male who (MDS) dated [DATE] at 3:43 p.m. with complaints of chest pain. The patient was triaged at 3:49 p.m. and Cardiac Protocol orders were initiated in triage. Blood work was obtained and a chest X-ray and EKG were completed. The patient was given a priority level three (3) and placed in the ED waiting area. The patient left the facility at 7:55 p.m. on 2/28/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance. 7. Review of patient #17's medical record revealed a twenty-six year (26) old female who (MDS) dated [DATE] at 5:09 a.m. with complaints of swelling to the left hand/fingers. The patient was triaged at 5:18 a.m., given a priority level four (4) and placed in the ED waiting area. The patient left the facility at 9:37 a.m. on 4/1/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance. 8. Review of patient #19's medical record revealed a seventy-eight (78) year old male who (MDS) dated [DATE] at 7:08 p.m. with complaints of shortness of breath. The patient was triaged by RN #1 at 7:20 p.m. Documentation revealed the patient had a history of Congestive heart failure (CHF), cardiac, pacemaker and hypertension. Cardiac orders were initiated in triage. Blood work was obtained and an EKG was completed. The patient was given a priority level three (3) and placed in the ED waiting area. The patient left the facility at 9:04 p.m. on 2/28/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance. 9. Review of patient #20's medical record revealed a fifty-six (56) year old female who (MDS) dated [DATE] at 10:23 p.m. with complaints of chest pain. The patient was triaged by RN #1 at 10:26 p.m. Cardiac orders were initiated in triage. Blood work was obtained and a chest X-ray and EKG were completed. The patient was given a priority level three (3) and placed in the ED waiting area. The patient left the facility at 2:31 a.m. on 3/1/17. Further review of the medical record revealed there was no documentation of repeat vital signs, documentation of any further assessment or a medical screening examination. These findings were confirmed on 4/5/17 at 3:45 p.m. with the RN Director of Emergency Services and the Director of Quality and Regulatory Compliance. 10. An interview was conducted on 4/3/17 at 11:12 a.m. with the RN Director of Emergency Services. When asked how often vital signs are reassessed, she replied, "Every two (2) hours." 11. An interview was conducted on 4/3/17 at 11:20 a.m. with RN #3 (ED Charge Nurse). When asked how often vital signs are reassessed, she replied, "Vital signs are repeated every two (2) hours by the ED Tech or the triage nurse." 12. An interview was conducted on 4/4/17 at 9:07 a.m. with the LPN. When asked how often vital signs are reassessed, she replied, "Each nurse does their own vital signs every two (2) hours unless the patient is critical." 13. A telephone interview was conducted on 4/4/17 at 8:10 a.m. with RN #2 (ED Charge Nurse). When asked how often vital signs are reassessed, she replied, "Repeat vital signs are done every two (2) hours; that's the expectation." 14. A telephone interview was conducted on 4/5/17 at 1:41 p.m. with RN #1 (Triage Nurse). When asked how often vital signs are reassessed, she replied, "Every two (2) hours if we can." She also stated, "I do reassess patients and make them a higher level if necessary." 15. A telephone interview was conducted on 4/4/17 at 11:28 a.m. with DO #1. When asked if it was normal protocol to leave a patient with a critical lab value in the waiting room, he replied, "We would not look at just the critical lab value and we would try to make a space as soon as possible to bring them back." 16. A telephone interview was conducted on 4/4/17 at 3:02 p.m. with DO #2. When asked if it was normal protocol to leave a patient with a critical lab value in the waiting room, he replied, "It is not normal. It varies person to person on the lab value and the condition of the patient. A critical lab value does not indicate a critical patient."

Based on document review and staff interview it was determined the Emergency Department (ED) staff failed to accurately complete ED documentation. This failure has the potential to negatively affect the prompt care and disposition of all patients. Findings include: 1. Review of the ED Central Log Book from 10/1/16 through 3/31/17 revealed incomplete documentation as follows: October 2016 had ten (10) days of incomplete documentation; November 2016 had three (3) days of incomplete documentation; December 2016 had fourteen (14) days of incomplete documentation; January 2017 had thirteen (13) days of incomplete documentation; February 2017 had fifteen (15) days of incomplete documentation; and, March 2017 had four (4) days of incomplete documentation. 2. The above findings were reviewed on 4/5/17 at 3:40 p.m. with the Registered Nurse Director of Emergency Services and the Director of Quality and Regulatory Compliance; both confirmed the findings.