Based on record review and interview the hospital staff failed to ensure compliance with 42 CFR 489.24, in 3 of the 7 required areas (A2405--central log; A2406--medical screening; A2409--Appropriate transfer). Findings include: 1) Interview with "D" reveals Pt 1 was not on ED log because Pt 1 was not registered or seen in the ED. Review of ED log showed Pt 1 was not on ED log dated 8/5/15 (Reference A 2405) 2) Interview on 8/12/15 with "D" reveals "D" did not document a medical screening exam. (Reference A 2406) 3) Interview on 8/12/15 with "D" reveals "D" did not complete a Patient Transfer Form which includes physician certification of benefits outweighing risks of transfer. (Reference A 2409)

Based on record review and and interview staff failed to ensure all patients on hospital property with an emergency medical conditions are documented on an ED central log in 1 of 21 ED MR's reviewed (Pt 1). This could potentially effect all patients on hospital property with an EMC. Findings include: Review of "EMTALA: Screening, Stabilization and Transfer" P/P last revised 10/2012 states the following: "A central log recording each individual who came to each of the medical centers dedicated in Emergency Departments seeking screening or treatment, must be retained for 5 years. The log will include each patient's name and medical record number and indicate whether the individual refused treatment or transfer, was refused treatment, or was transferred prior to stabilization, admitted and treated, stabilized and transferred, or discharged . Review of "First Responder Event Policy" last reviewed 4/2015 states the following: "The policy describes the team of individuals and process that serves as a first response to acute health care events that occur to visitors, outpatients, or employees. Any perceived acute emergency may include, but is not limited to, falls, fainting or any other medical events that require immediate medical assessment within the designated areas inside and surrounding the institution." Team structure and responsibilities include the following: 1. Transport first response team equipment to scene 2. Emergency Department nurse acts as team leader 3. Perform assessment of patient; provide care as needed 4. Use BLS/ACLS standards as needed 5. Assist with transportation of patient to Emergency Department 6. Emergency Department nurse is to complete "First Responder Event Report" Per interview with "B" (Risk manager) on 8/12/15 beginning at 9:00 am, on 8/5/15 at approximately 5:00 am an unknown women entered ED informing staff of a motor vehicle crash in the hospital parking lot. Pt 1 had crashed vehicle into landscaping on curb of hospital parking lot. Per "B" ED staff noticed Pt 1 on the ground outside of car with a lot of blood at the scene so ED staff called a "First Response" and a "Trauma Alert" and responded to the scene to provide treatment. Per interview on 8/12/15 beginning at 9:15 am with "D" (ED Physician), "D" stated Pt 1 was not logged into the ED central log because Pt 1 was never seen in the ED or registered as a patient in the ED. "D" stated Pt 1 was "assessed" and "stabilized" at the scene and transported to a trauma level 1 hospital via ambulance. "D" stated Pt 1 was not brought into ED because in "D's" professional judgement did not want to delay transfer of Pt 1 to a Level 1 Trauma unit for treatment; "D" stated hospital is a Level 4 trauma unit and Pt 1 needed specialized care. Per review on 8/12/15 beginning at 11:30 am of ED central logs from January 2015 to present, on 8/5/2015 Pt 1 was not listed on the ED central log. Per interview on 8/12/2015 beginning at 2:15 pm, "A" (Quality Director) stated staff followed the First Responder Policy and did not feel there was an EMTALA violation. Review on 8/13/15 beginning at 2:30 PM of the Police Department "Incident Report" states the following: "On 8/5/2015 at 5:05 am, officers responded to (hospital) regarding an accident and possible stabbing. On arrival I observed several nurses and doctors waiving me down from the south end of the parking lot on the east side of the hospital. I observed an injured male subject, later identified as (Pt 1) lying on the ground with several medical staff providing treatment. I then made contact with security officer (Q) who was the first person to be notified of this incident. (Q) stated he was in the security office near the ER when an unknown female entered the hospital and advised (Q) about the incident and a 'man down' in the parking lot. (Q) went outside and observed (Pt 1) laying in the parking lot bleeding. (Q) immediately radioed into security office to have ER staff respond to parking lot."

Based on record review and interview staff failed to ensure all patients on hospital property with an emergency medical condition receive a medical screening exam in 1 of 21 ED cases reviewed (Pt 1). This could potentially effect all patient receiving treatment in the ED. Findings Include: Review of the "EMTALA: Screening, Stabilization, and Transfer" facility P/P last revised 10/2012 states the following: A Physician must perform and document a MSE (medical screening exam) for individuals presenting to an area on Medical Center property that is not a Dedicated Emergency Department (including a parking lot) and the individual or a a person acting on the individual's behalf requests examination or treatment for what may be and EMC, or a prudent layperson observer would believe, based on the individuals appearance or behavior, that the individual needs an emergency examination or treatment. Review of the Police Department "Incident Report" states the following: "On 8/5/2015 at 5:05 am, officers responded to (hospital) regarding an accident and possible stabbing. On arrival I observed several nurses and doctors waiving me down from the south end of the parking lot on the east side of the hospital. I observed an injured male subject, later identified as (Pt 1) lying on the ground with several medical staff providing treatment. I then made contact with security officer (Q) who was the first person to be notified of this incident. (Q) stated he was in the security office near the ER when an unknown female entered the hospital and advised (Q) about the incident and a 'man down' in the parking lot. (Q) went outside and observed (Pt 1) laying in the parking lot bleeding. (Q) immediately radioed into security office to have ER staff respond to parking lot." Per interview with "B" (Risk manager) on 8/12/15 beginning at 9:00 am, on 8/5/15 at approximately 5:00 am an unknown women entered ED informing staff of a motor vehicle crash in the hospital parking lot. Pt 1 had crashed vehicle into landscaping on curb of hospital parking lot. Per "B" ED staff noticed Pt 1 on the ground outside of car with a lot of blood at the scene so ED staff called a "First Response" and a "Trauma Alert" and responded to the scene to provide treatment for Pt 1. Review of ambulance run sheet "Prehospital Care Report" states the following: (8/5/2015) At 5:15 am the patient was found supine position on the ground in the hospital parking lot near the parking lot entrance at the southeast corner of the hospital. The initial assessment revealed Pt 1 had a GCS (Glascow Coma Scale) of 13 blood sugar of 96, pulse 151 and Respiratory rate of 26. Pt 1 was in the care of hospital staff who responded that Pt 1 sustained a 2 inch laceration to the right anticubital which resulted in a arterial bleed, and severe blood loss. Per interview on 8/12/15 beginning at 9:15 am with "D" (ED Physician), "D" stated no documentation was completed for medical screening exam. "D" stated after finding Pt 1 on the ground Pt 1 was not taken into the hospital and registered in the ED. "D" stated 911 was called and "D" "assessed" Pt 1's ABC's (airway, breathing, and circulation), Per "D" Pt 1 was talking and alert during the assessment; "D" did not document this assessment. Per interview with "D" Pt 1 was transported to a Level 1 Trauma unit with Paramedic/EMT via ambulance. "D" stated Pt 1 was not brought into ED; in "D's" professional judgement did not want to delay transfer of Pt 1 to a Level 1 Trauma unit for treatment. "D" stated hospital is a Level 4 trauma unit and Pt 1 needed specialized care. Per interview on 8/12/2015 beginning at 2:15 pm, "A" (Quality Director) stated staff followed the First Responder Policy and did not feel this was an EMTALA violation.

Based on record review and interview staff failed to develop treatment documentation to send to the recieving hospital and ensure all patients with an emergency medical condition receive appropriate transfers in 1 of 21 ED cases reviewed (Pt 1). This could effect all patients receiving treatment in the ED. Findings Include: Review of "EMTALA: Screening, Stabilization, and Transfer" P/P last revised 10/2012 states the following: A physician must certify that the medical benefits expected from Transfer outweigh the risks and describe the reasons for and the potential risks and benefits of the Transfer by completing the applicable areas on the "Patient Transfer Form". Medical Center staff should document any communication with the receiving facility including the date and time of the Transfer request and the name of the person accepting the Transfer in the patient's medical record. The Medical Center staff should send the receiving medical facility copies of all pertinent medical records including available history, records related to the patients EMC, observations of signs and symptoms, preliminary diagnosis, treatment provided, and copy of the completed "Patient Transfer Form". Per interview with "B" (Risk manager) on 8/12/15 beginning at 9:00 am, on 8/5/15 at approximately 5:00 am an unknown women entered ED informing staff of a motor vehicle crash in the hospital parking lot. Pt 1 had crashed vehicle into landscaping on curb of hospital parking lot. Per "B" ED staff noticed Pt 1 on the ground outside of car with a lot of blood at the scene so ED staff called a "First Response" and a "Trauma Alert" and responded to the scene to provide treatment for Pt 1. Review of ambulance run sheet "Prehospital Care Report" states the following: (8/5/2015) At 5:15 am the patient was found supine position on the ground in the hospital parking lot near the parking lot entrance at the southeast corner of the hospital. The initial assessment revealed Pt 1 had a GCS (Glascow Coma Scale) of 13 blood sugar of 96, pulse 151 and Respiratory rate of 26. Pt 1 was in the care of hospital staff who responded that Pt 1 sustained a 2 inch laceration to the right anticubital which resulted in a arterial bleed, and severe blood loss. Per interview with "D" (ED Physician) on 8/12/15 beginning at 9:15 am, "D" stated "D" did not complete "Patient Transfer Form" with Physician Certification in regards to Pt 1's benefits outweighing the risks of transfer to Level 1 Trauma hospital. "D" stated after finding Pt 1 on the ground in hospital parking lot, Pt 1 was not taken into the hospital and registered in the ED. "D" stated 911 was called and "D" "assessed" Pt 1's ABC's (airway, breathing, and circulation), Per "D" Pt 1 was talking and alert during the assessment; "D" did not document this assessment. Per interview with "D" Pt 1 was transported to a Level 1 Trauma unit with Paramedic/EMT via ambulance. "D" stated Pt 1 was not brought into ED; in "D's" professional judgement did not want to delay transfer of Pt 1 to a Level 1 Trauma unit for treatment. "D" stated hospital is a Level 4 trauma unit and Pt 1 needed specialized care. Per "D" hospital staff did not send any medical records to the receiving facility to provide pertinent information in regards to Pt 1's EMC.