Based on review of emergency department (ED) logs, patient and staff interviews, and medical record review, the facility failed to provide an appropriate medical screening examination for 1 of 15 sample patients (#1) who presented to the ED. The findings were: Refer to A2406 for details concerning the facility's failure to perform an appropriate medical screening examination for 1 patient currently receiving anticoagulation therapy who presented to the ED with signs and symptoms of adverse effects of anticoagulation therapy.

Based on review of the ED log, staff and patient interviews, and review of facility policies, the facility failed to maintain an ED log on every individual who came to the ED seeking assistance. The findings were: 1. During an interview on 7/3/18 at 11:30 AM patient #1 stated on 6/16/18 s/he went to the ED about 5 AM after s/he reinjured his/her shoulder at work. The patient waited, but did not receive treatment at the ED and ended up going to another hospital's ED. The following concerns were identified: a. Review of the ED log on 7/2/18 at 2:30 PM revealed patient #1 was not on the ED log for 6/16/18 (or for any days in June 2018). b. Interview with RN #1, who was the patient's co-worker, on 7/3/18 at 2:56 PM confirmed the patient went to the ED on 6/16/18. c. Interviews with RN #2 on 7/3/18 at 8:35 AM, RN #3 on 7/3/18 at 9:45 AM, and RN #4 on 7/2/18 at 4:30 PM confirmed the patient came to the ED. d. During an interview on 7/3/18 at 8:35 AM RN #2 stated he was working when the patient arrived. He confirmed he did not register the patient, nor put him/her in the ED log. e. On 7/2/18 at 2:01 PM the interim CEO verified the patient did not show up on the ED log. f. Review of the facility's "EMTALA" policy (dated 8/29/17) showed "...Centralized Log. 9.1. All SBHCHD departments/facilities where a patient presents for emergency services or receives an MSE, including the Emergency Department, shall maintain logs that identify the patients who have presented for such services..." g. During an interview on 7/3/18 at 10:05 AM the CNO stated staff in the ED should have registered and logged the patient in the ED log.

Based on review of the ED log, patient and staff interviews, medical record review, and policy review, the facility failed to provide a MSE to 1 of 21 sample patients (#1) who presented to the ED. The findings were: 1. During an interview on 7/3/18 at 11:30 AM patient #1 stated s/he came to the ED on 6/16/18 about 5 AM after reinjuring his/her shoulder at work. The patient stated his/her pain level was "over 10" when asked to rate his/her pain from 0 to 10, with 10 being the highest level of pain. S/he stated the nurse working (RN #2) in the ED told him/her that the physician had just left the ED, and "he wasn't going to call the physician for shoulder pain." The patient stated s/he wasn't registered and did not receive any triage or assessment. S/he further stated s/he waited in the waiting room for about another hour when another nurse came up to him/her and asked if s/he wanted the physician to be called. The patient stated s/he was told it it could be awhile before the physician would get there, and suggested the patient might want to go to a different hospital. The patient stated s/he told the nurse s/he would just go to the ED in a different hospital. The patient stated s/he left without receiving a MSE. 2. Review of the ED log on 7/2/18 at 2:30 PM showed the patient was not on the log for 6/16/18. 3. An interview with RN #1, who was the patient's co-worker at the nursing home, on 7/3/18 at 2:56 PM revealed the patient injured his/her shoulder at work, and she told the patient to go to the ED at about 5:30 AM on 6/16/18. She stated the patient came back and said s/he was leaving because s/he couldn't see the physician. RN #1 stated she called the ED and spoke to RN #2, who told her the physician had a bad night, had just left, and he wasn't going to call him back for shoulder pain. RN #1 stated that wasn't acceptable and said the patient needed to be seen there because the ED visit might be related to worker's compensation. RN #2 told RN #1 to send the patient back to the ED. RN #1 stated s/he assumed the ED had seen the patient after s/he went back. 4. During an interview on 7/3/18 at 8:55 AM RN #2 stated he was working when the patient came to the ED at about 5:15 AM. He stated the patient had apparently reinjured his/her shoulder while working. He stated the patient said s/he would rather be seen at a different hospital, so s/he left. RN #2 stated he received a phone call from the nurse at the patient's place of employment who called upset and said the patient needed to be seen. He said the patient returned to the ED and he told him/her the physician had just left and he would be back in a little while. He stated he didn't register him/her or put the patient in the ED log. He stated normally he would register a patient, but s/he had stated s/he would prefer to go to a different hospital. When asked why the patient was waiting in the ED if s/he didn't want to be seen, he replied "the nurse at the [patient's place of employment] told [him/her] [s/he] needed to be seen in this ED...[s/he] was confused...[s/he] never said [s/he] wanted to have the physician see [him/her]." He stated the patient was still there when he went to count medications with another nurse at about 5:45 AM. 5. On 7/2/18 at 4:30 PM RN #4 stated she came on shift at the ED at about 5:45 AM that day and the patient was in the waiting room. She stated RN #2 told her the patient came from his/her place of employment with a hurt shoulder and he had told him/her it was going to be a little bit of a wait. The RN stated she and RN #2 then went to count medications and while they were doing that, the patient left. She stated RN #3 had spoken to the patient. She stated a few hours later a physician from another hospital called and asked if they had refused to see the patient. 6. During an interview on 7/3/18 at 9:45 AM RN #3 stated she came on shift that day at about 6 AM. She stated she talked with the patient, who was in the ED waiting room. She said the patient told her s/he had been there awhile. RN #3 says she asked the patient if s/he wanted to be seen and s/he said yes. She says she told the patient they would need to call the physician to come in, and he would have 20 minutes to respond. She says the patient stated s/he did not want to wait, and said she would go to a different ED. 7. Review of the ED report from another hospital in the area dated 6/16/18 showed the patient arrived there at 6:59 AM. The patient's chief complaint was "left shoulder pain 9/10 post injury lifting a resident." The ED report further noted "[S/he] went to the ER at South Big Horn and waited an hour before they said it would be even longer and suggested [s/he] come to the ER in [another city]." The ED report showed the patient received two injections for "strain of rhomboid muscle" and "muscle spasm." 8. Review of the facility's policy "EMTALA" (dated 8/29/17) showed "...All patients who come to SBHCHD for emergency medical treatment shall receive an appropriate Medical Screening Examination (MSE). " 9. During an interview on 7/2/18 at 2:01 PM the interim CEO confirmed he was aware of the situation with patient #1 and stated the RN involved had been counseled. He stated he was not sure why the RN didn't register or log the patient. 10. On 7/3/18 at 10:05 AM the CNO stated the facility had not conducted their own investigation yet, but had already scheduled EMTALA training for staff. When asked what should have happened, she replied that the patient should have been registered and received a MSE.