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Based on review and interview the facility failed to perform an appropriate medical screening examination in the emergency department (ED) to determine if the patient was stable or had an emergency medical condition in 1(#1) of 10 (#1-10) charts reviewed.

The complainant stated that she had been tested for COVID-19 on 12-2-21 at her physicians office and was positive. Patient #1 was given prescriptions and a number to call to schedule antibody infusion. She called to schedule the infusion but was told they were no longer doing infusions at this location. On December 3, 2021, Patient #1 decided to seek treatment at the ED for increasing symptoms that included cough, fatigue, body aches and fever.

Review of patient #1's chart revealed she came to the facility on 12-3-21 at 1600 (4:00PM). The patient was registered by the clerk at 1639 (4:39PM). The chart stated the complaint was "COVID + headache and weakness." The patient signed all the consents for treatment, her driver's license, insurance information, and supplement insurance information were placed in the record. Review of the chart on the "Patient Care Timeline" stated, "17:03 (5:03PM) ED Disposition set to LWBS before triage."

Review of the patient's chart revealed the nurse partially triaged the patient. The nurse had documented that the patient had no medication changes as of 12/3/21. A medical, surgical, family, and tobacco use history was documented. There were no vital signs documented. Review of the chart revealed documentation on 12-3-21 under Disposition, "Pt wants Covid infusion explained infusion could not be given at this time of day. Pt will return tomorrow AM for infusion." There was no signature on who wrote this statement or at what time. The chart stated that a "summary of care document was sent to _____(Staff #10 D.O.)." There was no physician note on the chart that the patient was seen by the physician or triaged out by a physician.

An interview with Staff # 2 was conducted on 4-12-22. Staff #2 confirmed that nurses are not able to triage patients out and the patient should have been seen by a physician.