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Based on interview and record review, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CFR 489.24, Special Responsibilities of Medicare Hospitals in Emergency Cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements. The facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department when 1 of 20 patients reviewed (Patient #1) presented to the Emergency Department (ED) and did not receive an appropriate medical screening examination when presenting on 11/23/2024.

Refer to 2406.

Based on interview and record review, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department when 1 of 20 patients reviewed (Patient #1) presented to the Emergency Department (ED) and did not receive an appropriate medical screening examination when presenting on 11/23/2024.

Findings were:

Patient #1 presented to the ED complaining of left leg pain from the calf to the knee on 11/23/24 at 1:04 am since the previous day. The patient had a medical history of blood clots, tobacco use, antiphospholipid syndrome, and daily anticoagulant medication. Vital signs on initial triage: blood pressure 134/82, temp 98.4, heart rate 79, Sp O2 100%, respirations 13, pain 10/10.

Per ED Provider Report on 11/23/2024: History of Present Illness, "This is a 45-year-old female patient who presents to the ED with partner at bedside with c/o [complaint of] left leg pain that began occurring yesterday. Patient reports that the pain is mainly in her thigh. Patient states that she has a history of blood clots that she takes Lovenox for. Otherwise, patient does not report any further symptoms or modifying factors with today's visit."

- Physical examination was unremarkable, except to note:
Constitutional: "Mild distress, well-appearing"
Musculoskeletal: "Extremities have no gross deformity, no edema, redness, or swelling. Tenderness to the inner aspect of the left thigh."
Neurologic: "A&O [alert and oriented] x3, normal mentation and speech. Moves all extremities x 4 without motor or sensory deficit."

- Orders completed included:
Lab: Coagulation, D-Dimer 0.86
Medications: Norco 7.5mg-325mg, 1 tab; ketorolac 60mg, intramuscularly
Radiology: Venous doppler study of the left leg ordered for the following morning

- Differential diagnosis: "DVT [deep vein thrombosis], phlebitis, leg pain"

- Medical decision making: "Vital signs within normal limits. Patient presents with left leg pain. Patient does have a 'clotting disorder'. Patient's in-house medical records were reviewed. Social history patient does smoke marijuana and does smoke cigarettes, but does not drink. Patient's D-dimer is elevated at 0.86. Patient is currently taking medications which includes her anticoagulant. Patient to department is given Norco as well as Toradol IM [intramuscularly] for pain control. Patient is set up for an outpatient DVT study. Patient does not need any type of anticoagulant because she is currently taking anticoagulants and that is Lovenox twice a day."

- Diagnosis: "Acute Leg Pain"

- Discharge Summary: "The patient is reevaluated before discharge. They report that their symptoms have improved after ED treatments. I will be providing the patient with a prescription for home symptom management. They are informed of their laboratory findings, provided with strict return precautions for the ED, diagnostic results, treatment and discharge plans, verbalizes agreement with need for outpatient follow-up with PCP [primary care provider]."

On 11/23/24 at 2:20 am, the nurse documented the patient's pain at "8 [out of 10]- Severe Pain".

Patient # 1 was discharged on 11/23/24 at 2:35 am with physician orders: Norco 5mg-325mg for pain and an ECHO study for the left leg the following morning.

Patient # 1 subsequently presented to facility B on 11/23/24 around 10:00 am with continued left leg pain and differential diagnoses were fracture, contusion, sprain, dislocation, DVT, and cellulitis. Patient #1 was admitted as an inpatient on 11/23/24, underwent fasciotomy for compartment syndrome on 11/24/24, and was discharged on 12/6/24.

The physical exam at facility A was not adequate to rule out other potential diagnoses as there was no physical examination to the lower extremities. Without a complete physical exam, along with any additional diagnostic tests, this was an inappropriate medical screening exam for Patient #1.