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Based on facility policy, medical record review, and interview, the hospital failed to ensure all patients presenting to the hospital's Dedicated Emergency Department (DED) seeking medical treatment were provided an appropriate medical screening examination (MSE) for 1 of 20 (Patients #1) sampled patients.

The findings included:

Medical record review revealed Patient #1 presented to the Hospital #1 ED on 10/6/2021 at 10:51 PM with a chief complaint that he was wrestling with his kids prior to arrival and felt like was going to pass out and felt like he was seizing (possible seizure). Patient #1 reported he was awake the whole time, but his arms and legs were shaking.

Patient #1 left the DED on 10/7/2021 at 1:00 AM without being seen by a medical provider and without receiving a medical screening examination.

Refer to A 2406

Based on policy review, medical record review, and interview, the facility failed to ensure an individual who presented to the emergency department was provided with an appropriate medical screening examination within the capability of the hospital's emergency department (ED) for 1 of 20 (Patient #1) sampled patients.

The findings included:

1. Review of the facility policy, "Medical Screening Examination," revealed, "...[Hospital #1] shall provide an appropriate medical screening examination 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 exists...under the following circumstances...an individual comes by him or herself or with another person to the hospital's Emergency Department, and a request is made on the individual's behalf for examination or treatment of an emergency medical condition... Who May Perform the Medical Screening Examination?... A medical screening examination will be performed by a qualified medical professional with appropriate privileges, as determined by the Medical Executive and approved by the Board... The hospital shall ensure that: 1) an Emergency Department physician on duty is responsible for the general care of all patients presenting to the Emergency Department; and 2) the responsibility remains with the Emergency Department physician until the patient's private physician, hospitalist or an on-call specialist assumes that responsibility, or the patient is discharged... Refusal of Screening Exam If a patient withdraws his or her request for examination or treatment or refuses further examination or treatment, an appropriately trained individual from the Emergency Department staff will discuss the medical issues related to a voluntary withdrawal. In the discussion, the Emergency Department staff member will... offer the patient further medical examination and treatment as may be required to identify and stabilize an emergency medical condition... inform the patient of the benefits of the examination and treatment, and or the risks of withdrawal prior to receiving the examination and treatment... take all reasonable steps to secure the individual's written informed refusal of such examination and treatment or appropriate transfer; and complete a Refusal to Permit Further Care... describe, in the medical record, the examination and treatment or transfer that was refused or the request for treatment that was withdrawn... If the patient refuses to sign the form, the written document should indicate that the person has been informed of the risks and benefits of the examination and/or treatment but refused to sign the form..."

2. Medical record review revealed Patient #1 was a 43-year-old male who presented to the Hospital #1 ED on 10/6/2021 at 10:51 PM with a chief complaint that he was wrestling with his kids prior to arrival and felt like was going to pass out and felt like he was seizing (possible seizure). Patient #1 reported he was awake the whole time, but his arms and legs were shaking.

Patient #1 had a medical history of Diabetes Mellitus Type 1 and a surgical history of Incarcerated Umbilical Hernia Repair on 6/8/2017. Patient #1's blood glucose was 136 during triage. Patient #1 was triaged at 11:01 PM with an acuity of 3-Urgent and vital signs were documented as: temperature 97.9 degrees Fahrenheit, pulse rate 79, respiratory rate 20, blood pressure (BP) 153/96, and oxygen saturation 96% on room air. Patient #1 reported he felt normal during triage. Patient #1 was assessed in triage as awake, alert, and oriented.

An electrocardiograph (EKG) was obtained on Patient #1 on 10/7/2021 at 12:10 AM (1 hour 19 minutes after arrival to the ED) which showed sinus rhythm with possible left atrial enlargement and borderline left axis deviation.

A late-entry nursing note for 10/7/2021 at 12:55 AM documented, "Pt's (patient's) wife upset, yelling and cursing at staff in hallway and in pt's room. Pt's wife states, they 'are just going home'... Pt was nonverbal during the whole incident. After wife quit yelling, I did directly ask the patient, 'You are the patient. Do you want to go home?' Pt responded with, 'Yes I do' all the while looking at the floor and not making eye contact. Pt and his wife left ambulatory from ER. Pt had not been seen per ER provider prior to leaving the ER."

An ER discharge summary dated 10/7/2021 at 1:00 AM (2 hours 9 minutes after arrival to the ED) revealed Patient #1 left without being seen by a medical provider and without receiving a medical screening examination. The patient's vitals signs at 1:00 AM are documented as BP 119/76, pulse rate 69, respiratory rate 17 and oxygen saturation 96%. There was no documentation any Emergency Department staff offered further medical examination and treatment or tried to obtain written refusal from the patient prior to leaving the facility. There was no documentation the Emergency Department staff informed the patient of the risks of leaving the hospital without being seen by a provider.

3. During an interview on 4/5/2022 at 12:54 PM when asked if she would expect the ED staff to get an EKG on a patient who presented with seizures, the Clinical Coordinator stated, " ...seizures is not one [symptom] I would think about doing [performing an EKG] right off the bat..." The Clinical Coordinator stated she would expect ED staff to perform an EKG immediately on patients who presented with palpitations or tachycardia along with seizure activity.

During an interview on 4/5/2022 at 12:58 PM, when asked how urgent should ED staff obtain an EKG for a patient who presented with reported seizure activity, the ED Medical Director stated, " ...not at all quickly ..." The Medical Director stated he would expect the ED staff to get an EKG quickly if a patient had a seizure and passed out or had some sort of arrythmia. The Medical Director reviewed the medical record for Patient #1 and stated the ED staff would get an EKG at some time during the visit, but it was not urgent to perform it quickly.

During an interview on 4/5/2022 at 11:30 PM, Registered Nurse (RN) #1 stated she remembered triaging Patient #1. RN #1 stated Patient #1 reported he felt shaky prior to arrival but felt normal during triage. RN #1 stated Patient #1 denied any pain and denied losing consciousness. RN #1 stated Patient #1's spouse asked about an EKG, but Patient #1's condition did not warrant an immediate EKG. RN #1 stated Patient #1 was brought back to a room, and an EKG was performed to appease the spouse. RN #1 stated the EKG was given to the physician (uncertain which physician). RN #1 stated she would get an immediate EKG for a patient who presented with chest pain, syncopal episode where the patient would lose consciousness, respiratory distress, or other abnormal symptoms. RN #1 stated she did not remember Patient #1 reporting anything about a cardiac history.