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Based on policy review, medical record review, and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings included:

1. The hospital failed to ensure a thorough medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) existed for one of 27 sampled Emergency Department (ED) patients (Patient #4).

~ Cross refer to Medical Screening Exam - Tag A2406.

Based on policy reviews, medical record reviews and physician interviews, the hospital failed to ensure a thorough medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) existed for one of 27 sampled Emergency Department (ED) patients (Patient #4).

The findings included:

Review of the facility's EMTALA (Emergency Medical Treatment and Labor Act) Policy effective 11/2022 revealed, "... Any individual who "comes to the emergency department" will be offered a Medical Screening Examination by this hospital. ... All patients shall receive a Medical Screening Examination, based on patient acuity, the overall demands of the emergency department and the capabilities of the institution. ..."

Closed DED record review conducted on 07/18/2023 revealed Patient #4 was a 37-year-old female who presented to Hospital A's DED via private vehicle on 12/13/2020 at 0035 with a chief complaint of headache. Review of triage notes recorded at 0051 revealed BP 185/116, P 99, R 16, T 97.4 and SpO2 98% with a pain level of 1 in her head. The patient was triaged as a level 3 at 0052. Nursing notes at 0053 documented a chief complaint of eye drainage bilaterally for a couple of weeks, and headache for over a week. Notes revealed the patient was seen in the DED recently for the same and was requesting a head CT (Computerized Tomography) to rule out aneurysm. Notes at 0336 recorded BP 144/98, P 101, R 18 and SpO2 97%. Review of the physician's (MD #4) medical screening examination revealed the exam started at 0608. Notes recorded, "Patient reports chronic headaches since car accident in January with progressive increase in frequency and severity over the last few months and especially few weeks. She has had a 10/10 headache almost constantly for the last 10-14 days with short periods of relief; aspirin and oxycodone have only helped minimally and briefly. The pain is mostly on the left side, usually in the front but sometimes on the side, and feels like "something is chewing on my brain", a sharp, throbbing pain. Headache is associated with nausea, light-headedness, sensitivity to light and sound, occasional blurry vision, and confusion. The headaches are made worse with stress and seem associated with high blood pressure and bending over. Patient is frustrated because she has been told several times to see neurology but has no insurance and is not sure how to access this. ..." Review of systems recorded the patient had congestion, photophobia, eye discharge, visual disturbance, syncope, light-headedness, headache, and confusion. Review of the physician's medical decision making revealed, " ... MDM: 37yrs Female presenting with acute worsening of chronic headaches and intractable headache for over a week. Patient's exam was unremarkable and she is not having concerning neurological symptoms. Patient had negative CT head in September so another one today in the setting of similar headache and no new symptoms is not indicated. In depth conversation had with patient and family about need to establish with PCP (primary care provider) and see neurology if possible for additional evaluation as well as management of other chronic issues such as HTN (hypertension). Patient was added to ECU Family Medicine appointment book for 12/21 and expectation that she come for that appointment was explained. She was discharged home with 30 days of fioricet (pain medication) and Amitriptyline (medication for neuropathic pain) for likely migraine. ..." The physician recorded an impression of Migraine, cluster headaches, tension headaches, hypertensive headache, less likely IIH (increased pressure around the brain), acute intracranial pathology. Review of the physician's notes recorded a plan to discharge the patient. Review revealed prescriptions, an appointment to establish with a primary care provider was scheduled, and after visit instructions were provided. The patient departed the DED on 12/13/2020 at 0814.

An interview was requested with MD #4 who was the resident that performed the MSE on Patient #4 on 12/13/2020. MD #4 no longer worked at the facility and was not available for interview.

Telephone interview conducted on 07/20/2023 at 1240 with MD #1 (attending DED physician for Patient #4 on the 09/17/2020 and 12/13/2020 visits) revealed he did not remember Patient #4. Interview revealed MD #1 had access to Patient #4's DED records. MD #1 stated the patient "came in for chronic headaches. She had a normal neurological exam. There was no indication for stroke symptoms and/or stroke exam. She had elevated blood pressure and was poorly controlled. She didn't have great access to primary care and that was a primary care responsibility to manage. We don't manage blood pressure just because it was elevated. Her blood pressure would not jump out as needing intervention. We made multiple attempts to get her to a neurologist. It was not an unusual blood pressure for what we see on a routine basis. I cannot find anything that we could have done to change her outcome. Not sure a head CT would have changed it. Old strokes would not have changed the management. She had a normal neuro exam and multiple referrals to neuro. There was no indication for a head CT."

In summary, Patient #4 was complaining of worsening headaches, vision changes, nausea and ongoing worsening symptoms post previous head trauma. The standard of care with worsening headaches is to image (CT scan). Patient #4 had been attempting to get an outpatient neuro evaluation unsuccessfully and returned to the DED seeking assistance with symptoms. Her symptoms had been occurring for 3 months post trauma. The patient had a history of severe hypertension and presented with notably elevated blood pressure. She had been unable to establish outpatient care with neurology as previously referred or a primary care provider for management of her blood pressure. Given the nature of her worsening headaches, failure to obtain outpatient care and setting of severe elevated blood pressure, a head CT was warranted.