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Based on record review and interview, the hospital failed to provide an appropriate medical screening examination to an individual who presented to the emergency department (ED) for 1 of 20 individuals that presented to the emergency department over the previous six months. (Patient identifier is #1)

Findings include:

Interview on 3/25/21 at 11:00 a.m. with Patient #1 revealed that Patient #1 went to the ED because they were afraid they were having a reaction to a new medication. Patient #1 stated they felt "funny", their face was twitching, and it felt like their throat was tightening. Patient #1 stated they registered at the front desk and waited about 20 minutes and a nurse came out to the waiting room and said there would be a wait and that Patient #1 could go to their already scheduled physician appointment in the adjacent building. The patient decided to leave and go to their physician appointment but was nervous and upset because they thought they were having a reaction. Patient #1 was seen by their physician.

Review on 3/30/21 of dedicated emergency department logs from October 2020 to present revealed Patient #1 was admitted to the ED on 3/10/21 and "Left Before Being Treated".

Review on 3/30/21 of Patient #1's medical record revealed Patient #1 presented on 3/10/21 at 3:45 p.m. and their discharge disposition was "Left Before Being Treated" at 4:07 p.m. Further review revealed that there was no record of Patient #1 being triaged or receiving a MSE (Medical Screening Examination) to determine if an emergency medical condition existed.

Interview on 3/30/21 at 10:30 a.m. with Staff C (ED Manager) during tour of the ED revealed that all patients who register at the ED are triaged, if the patient has a physician appointment in the adjacent medical office building, they may choose to be seen there instead of in the ED.

Interview on 3/30/21 at 1:15 p.m. with Staff B (Vice President, Patient Care Services) revealed that the hospital calls all patients that leave the ED before receiving a MSE. Staff B had talked to Patient #1 who according to Staff B was upset that they had been in the waiting room alone while waiting to be seen.

Interview on 3/30/21 at 1:45 p.m. with Staff A (Registered Nurse) revealed that Staff A talked with Patient #1 in the ED waiting room on 3/10/21 before Patient #1 left. Staff A stated they reminded Patient #1 that they had an appointment with their physician and that Patient #1 had decided not to wait to be seen at the ED and decided to go to their previously scheduled physician appointment. Staff A stated that Patient #1 was not triaged and did not receive a MSE but did not appear to be in distress.

Review on 3/30/21 of the hospital's policy titled "Emergency Medical Treatment and Labor Act EMTALA" revealed the following: "Individuals coming to the emergency department must be provided an MSE [Medical Screening Examination] beyond triage."; "At a minimum, the MSE must assess the following: Chief complaint, high acuity, high risk, true emergency. Vital signs - grossly abnormal. Metal Status - Evidence of abnormalities. General appearance - Patient looks sick, patient's skin looks perfused, patient shows signs of dehydration. Ability to walk- Patients who cannot walk are high risk for true emergency medical conditions. The MSE also must consist of a focused physical examination (i.e. an examination appropriate to the organ system referred to in the chief complaint)."; and "Patients will be assigned a triage category by the triage nurse. There are four (4) triage categories:...Category IV (non-emergent): The patient's presentation provides no reason to think they have an emergency medical condition or at risk for developing one. For such patients it is appropriate to either schedule an appointment with a physician or recognize that Physician care is not required. Disorders are chronic, minor or self-limiting. Case examples include, but are not limited to, medical refill, acne, mild adult upper respiratory tract symptoms, mild sore throat, blood pressure check, and lumps and bumps. Note: Patients classified as Category IV will still require MSE if they request treatment or evaluation."

Based on interview and record review, the hospital failed to provide stabilization treatment to a possible medication reaction for 1 of 20 sampled patients (Patient #1).

Findings include:

Interview on 3/25/21 at 11:00 a.m. with Patient #1 revealed that Patient #1 went to the ED because they were afraid they were having a reaction to a new medication. Patient #1 stated they felt "funny", their face was twitching, and it felt like their throat was tightening. Patient #1 stated they registered at the front desk and waited about 20 minutes and a nurse came out to the waiting room and said there would be a wait and that Patient #1 could go to their already scheduled physician appointment in the adjacent building. The patient decided to leave and go to their physician appointment but was nervous and upset because they thought they were having a reaction.

Review on 3/30/21 of dedicated emergency department logs from October 2020 to presented revealed Patient #1 was admitted to the ED on 3/10/21 and "Left Before Being Treated".

Review on 3/30/21 of Patient #1's medical record revealed Patient #1 present on 3/10/21 at 3:45 p.m. and their discharge disposition was "Left Before Being Treated" at 4:07 p.m. Further review revealed that there was no record of Patient #1 being triaged or receiving a MSE (Medical Screening Examination) to determine if an emergency medical condition existed.

Interview on 3/30/21 at 1:45 p.m. with Staff A (Registered Nurse) revealed that Staff A talked with Patient #1 in the ED waiting room on 3/10/21 before Patient #1 left. Staff A stated that Patient #1 had decided not to wait to be seen at the ED and decided to go to their previously scheduled physician appointment in the adjacent building.