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Based on observations, interview, and document review, the facility failed to provide a medical screening exam and treatment for 1 of 20 patients (Patient #5). The failure to provide a medical screening exam and treatment for this patient had the potential to place the patient at increased risk of harm or illness.

Findings include:

Patient #5 (P5)

Documented in a facility post-event internal investigation, P5 and spouse entered into the facility's Emergency Department's (ED) Waiting Room on 05/29/2024 at 11:17 PM. Upon entrance, the spouse of P5 approached the ED Registration Window and provided identification cards and was informed by the Admitting Clerk that medical imaging was not available.

A review of the ED Central Log for the month of May 2024, revealed there was no documented evidence P5 was registered during the late evening of 05/29/2024.

A telephonic interview with the ED provider on 11/06/2023 at 9:30 am, revealed at the time P5 was in the ED waiting room between the hours of 11:17 PM and 11:29 PM on 05/29/2024, the ED provider was located in the physician breakroom asleep. The ED provider confirmed not being alerted of the patient's arrival by the RN. The ED provider only became aware of the patient's presence onsite when awakened by the local Fire Chief after midnight on 05/30/2024, accusing the ED provider of not evaluating P5.

In a telephonic interview with the ED Registered Nurse (RN) on 11/06/2024 at 11:06 am, the ED RN acknowledged not placing eyes on P5 while in the waiting room, and only spoke to the spouse of P5 as they were exiting the ED at 11:29 pm on 05/29/2024.

In a face-to-face interview with the Admitting Clerk during the afternoon of 11/06/2024, the Admitting Clerk confirmed telling the spouse of P5, imaging was not available and did not register P5 upon arrival to the ED.

In the facility's internal investigation conducted by Risk Management, it was documented in the report that medical imaging was operational as of 10:15 PM, the evening of 05/29/2024.

On 11/07/2024, a review of the camera footage for 05/29/2024 between P5's arrival at 11:17 PM and departure time of 11:29 PM, P5 remained in the ED waiting room. During the brief stay P5 appeared restless, observed initially sitting in the chair upon arrival then kneeling on the floor hunched over. There was no observable evidence P5 was brought back to the ED from the waiting room and provided a medical screening evaluation (MSE).


Complaint #NV00071832