A. Based on medical record reviews, observation and interviews, it was determined the hospital failed to comply with 489.24 by delaying the medical screening examination to inquire about each patient's financial status in four (4) of 21 cases reviewed. (patients 11, 18, 19 and 20). This has the potential for patients to have a delay in treatment in the case of a medical emergency. Cross refer to C2408. B. Based on reviews of documents and interview with staff, it was determined the hospital failed to have complete and current policies available in the Emergency Department in order to remain in compliance with the requirements at 489.24. This has the potential for the hospital to have process failures which may result in inadequate care of patients with medical emergencies. Findings include: Based on review of Emergency Department (ED) policies, it was noted there are no policies which specifically refer to the EMTALA (Emergency Medical Treatment and Active Labor Act) requirements. This was discussed with the Director of Nursing/Manager of the ED on 1/28/2015 at 3:00 p.m. and she concurred with the findings. The policy "Triage", last revised 6/2001 includes the statement "Level 3 (semi-urgent) and level 4 (non-urgent) patients may be referred out to the clinic (rural health clinic) or other community healthcare providers for non-urgent care in the manner above." This statement is in direct conflict with the EMTALA regulations which require a medical screening examination to be provided to all patients who present and request treatment and prior to being sent to a lower level of care for a medical screening examination. This policy was discussed with the Director of Nursing/Manager of the ED on 1/29/2015 at 10:40 a.m. and she concurred with the findings. The Director of Nursing/Manager of the ED provided a different "Triage" policy for review at 10:55 a.m. The more recent "Triage" policy was dated 1/2006. These two (2) policies, both with the title "Triage" were discussed with the Director of Nursing/Manager of the ED on 1/29/2015 at 11:20 a.m. It was discussed that the newer policy did not have the language about sending a patient from triage to a lower level of care, i.e. the rural health clinic, and before the medical screening examination was provided by a physician in the ED. She stated the policies given to the surveyors for review were gathered from the ED, and the newer policy was located in the administrative offices. She concurred at that time that the most current policies are not located in the department for the staff to use. The policy "Stabilization Treatment or Transfer", last revised 7/1994, states in total "Once the Hospital determines an individual has an emergency medical condition, the Hospital must then provide appropriate medical care to stabilize the patient, including the full capabilities of the facility, the emergency room Department, and on-call physicians, or if the Hospital is unable to stabilize the patient after exhausting all appropriate avenues given the patient's condition, the Hospital can transfer the patient provided the physician certifies that the transfer is medically indicated and an appropriate transfer to a higher level facility is needed." Although the policy includes language from the requirement for an appropriate transfer, there are no directives to the staff for how that will be accomplished, including all the necessary documentation to ensure appropriate transfers are done. The EMTALA related requirements and hospital policies were discussed with the Director of Nursing/Manager of the ED on 1/28/2015 at 3:00 p.m. and she concurred the policies may not have complete and/or current information in order to ensure the hospital is able to comply with the requirements at 489.24.

Based on medical record reviews, observation and interviews, it was determined the hospital failed to comply with 489.24 by delaying the medical screening examination to inquire about each patient's financial status in four (4) of 21 cases reviewed. (patients 11, 18, 19 and 20). This has the potential for patients to have a delay in treatment in the case of a medical emergency. Findings include: 1. During a tour of the Emergency Department (ED) on 1/27/2015 starting at 10:00 a.m., it was observed the ED has five (5) treatment beds. The ED is located at the back of the hospital. There is a triage room across the hall from the ED. During the tour, the staff Registered Nurse (RN) stated patients are taken to the triage room for a nursing triage assessment. She stated that for patients who are deemed to be a "semi-urgent" or "non-urgent" and are able to ambulate, it is requested the patient walk to the registration area that is located at the front entrance of the hospital to register. She stated the registration process includes the gathering of financial information. She stated the patient then comes back to the ED and is placed in a treatment area and the physician proceeds with the medical screening examination. She stated that the process is followed even if there is a bed available and if the physician is available to perform the medical screening examination prior to the registration process. The Director of Nursing/Manager of the ED was present during some of the discussions about the triage and registration process and she confirmed the patients may be asked for financial information prior to the medical screening examination in the case of a semi-urgent or non-urgent patient who presents to the ED. 2. Review of the record for patient #11 revealed the patient presented and was triaged at 12:45 p.m. on 11/25/2014. The "Classification at Triage" was "semi-urgent". The "Disposition From Triage" was listed as to "Registration". The nurse documented the physician examined the patient at 12:55 p.m. Review of the record for patient #18 revealed the patient presented and was triaged at 7:12 p.m. on 10/28/2014. The "Classification at Triage" was "semi-urgent". The "Disposition From Triage" was listed as to "Registration". The nurse documented the physician examined the patient at 7:40 a.m. Review of the record for patient #19 revealed the patient presented and was triaged at 8:45 a.m. on 9/7/2014. The "Classification at Triage" was "semi-urgent". The "Disposition From Triage" was listed as to "Registration". The nurse documented the physician examined the patient at 9:00 a.m. Review of the record for patient #20 revealed the patient presented and was triaged at 9:15 p.m. on 8/9/2014. The "Classification at Triage" was "semi-urgent". The "Disposition From Triage" was listed as to "Registration". The nurse documented the physician examined the patient at 9:30 p.m. These records were discussed with the Director of Nursing/Manager of the ED on 1/28/2015 at 3:00 p.m. and she concurred with the findings.