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UPMC MERCY
MEDICAL SCREENING EXAM
Tag No.: A2406
Based on a review of facility documentation, medical records (MR), and employee interviews (EMP), it was determined that the facility failed to follow its policy for providing patients that presented to the Emergency Department a medical screening exam for two of 11medical records reviewed (MR1 and MR2).
Findings include:
Review of facility Medical Staff Rules and Regulations last approved November 3, 2015 revealed " ...EMTALA Medical Screening Examinations, In accordance with the Emergency Medical Treatment and Labor Act (EMTALA), all patients coming to the hospital's emergency department shall receive a medical screening examination (MSE) by Qualified Medical Personnel (QMP). For purposes of the MSE, a QMP at UPMC Mercy is a Physician, Certified Registered Nurse Practitioner (CRNP) or a Physician Assistant (PA) who is practicing within the scope of his or her practice, as defined by the applicable laws and regulations of the Commonwealth of Pennsylvania, and approved at UPMC Mercy."
1. Review of MR1 revealed the patient presented to the ED (Emergency Department) on September 21, 2016, at 12:30 am, had a medical screening exam and was discharged to jail in custody of police at 1:44 am. At 2:58 am, MR1 returned to the ED, had a medical screening exam and was discharged to jail in custody of police at 5:54 am. At 6:05 am, after being tackled and handcuffed by police, MR1 returned to the ED. No documentation of a medical screening exam was found in the medical record for the 6:05 am visit to the ED.
2. Interview with EMP1 at 9:30 am on October 4, 2016, confirmed the above findings.
3. Review of MR2 revealed the patient presented to the ED on September 30, 2016, at 11:00 pm for medical clearance for jail, and at 12:40 am was discharged back to jail with police. No documentation of a medical screening exam was found in the medical record.
4. Interview with EMP1 on October 5, 2016 at 12:15 pm confirmed the above findings and revealed, "It's [documentation of medical screening exam] not there."