HospitalInspections.org

Based on document review and interview, the facility failed to ensure documentation indicating an MSE (Medical Screening Exam) was completed on 1 of 22 patients (patient 22) that presented to the facility Emergency Department.

Findings include:

1. See findings cited at 489.24(1) Medical Screening Exam A2406.

Based on document review and interview, the facility staff failed to ensure documentation indicating an MSE (Medical Screening Exam) was completed in 1 of 22 patient (patient 22) medical records reviewed.

Findings include:

1. Facility policy titled, "Patient Rights and Responsibilities", Policy Number: 100.10, last revised 8/25/15, under Policy: Patient Rights: 3. Patients or their representatives have the right to consent or refuse treatment after being adequately informed of the benefits, risks, and alternatives to treatment.

2. F1 (Critical Access Facility) ED (Emergency Department) Log indicated a patient left without being treated (LWOT) who presented to the ED at approximately 3:00 pm on 11/07/24 with complaint of pregnancy pain and twin gestation at 31 weeks. The ED log lacked patient identifiers or reason patient left.

3. P22 presented to F2 (Acute Care Facility), arrived by EMS (Emergency Medical Services) at approximately 3:52 pm on 11/07/24, where patient received a MSE, fetal monitoring, and was discharged in self-care at approximately 8:20 pm.

4. Review of Incident Report dated 11/07/24 indicated P22 presented to F1 at approximately 3:00 pm where N2 (Registered Nurse) recommended patient see his/her own provider. N2 note indicated patient LWOT. N2 note lacked documentation of informing P22 of risk/benefits to remain at F1 for a MSE.

5. In interview on 1/07/25 at approximately 11:17 am to 11:31 am, N2 confirmed the documentation in the Incident Report on 11/07/24 regarding ED encounter with P22 who then left without being treated.

6. In telephone interview on 1/08/25 at approximately 1:04 pm to 1:15 pm, P22 confirmed he/she had presented to F1 in the afternoon of 11/07/24 complaining of pregnancy pain. P22 confirmed he/she was told by F1 staff there were no Obstetricians onsite and the nurse suggested patient see his/her own provider. P22 did not recall F1 staff explaining the risks/benefits of staying at F1 versus seeking treatment elsewhere. P22 indicated he/she felt discouraged to remain at F1, left F1, and sought treatment at F2.