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Based on staff interview, video surveillance review, emergency department medical record review, facility policy and procedure review and Medical Staff Bylaws review, the facility failed to provide an appropriate and complete medical screening exam (MSE) by a qualified medical person for one (1) of 20 patients reviewed. Patient #1

Findings Include:

Cross Refer to A2406 for the facility's failure to provide an appropriate medical screening exam (MSE) for patient #1 within the capability of the hospital Emergency Department.
During exit conference on 11/17/2022 at 3:30 p.m. with Chief Operations Officer (COO), Director Performance Improvement, Compliance Officer, Director of Emergency Services, survey findings were discussed. No further documentation was submitted for review.

Based on staff interview, video surveillance review, emergency department medical record review, facility policy and procedure review and Medical Staff Bylaws review, the facility failed to provide an appropriate and complete medical screening exam (MSE) by a qualified medical person and failed to obtain a written and informed refusal of examination or document the reason the facility was unable to obtain for one (1) of 20 patients reviewed. Patient #1.

Findings Include:

Observation of video surveillance of the Emergency Department (ED) on 11/15/2022 at approximately 10:45 a.m. revealed Patient #1 entered the crowed ED at 4:41 p.m. and signed in with the receptionist. Patient #1 was observed walking to the triage area at 4:56 p.m. and returning to waiting area at 5:08 p.m. Patient #1 was observed leaving the waiting room with a staff member at 5:23 p.m. and returning with staff member at 5:29 p.m. and again, leaving with staff member at 5:34 p.m. and returning with staff member at 5:38 p.m. Patient and significant other was observed leaving the emergency department with no return at 7:31 p.m. Video surveillance was consistent with lab collection times and electrocardiogram (EKG) and medical imaging (X-Ray).

Interview on 11/15/2022 at 10:30 a.m. revealed the emergency department manager reviewed the surveillance video and confirms the patient left the ED at 7:31 p.m. after being called for several tests.

Review of ED medical record revealed patient was triaged at 4:56 p.m. with complaints of chest pain and fever for three (3) days, burning on urination, and a history of rheumatoid arthritis. EKG, Chest X-ray, blood work: complete blood count (CBC), Comprehensive Metabolic profile (CMP), Lactic acid, Blood cultures and troponin levels were ordered by provider Physician Assistant (PA) #1.

Review of the ED Care timeline for 11/05/2022 at 4:31 p.m. to 11/05/2022 at 9:26 p.m. revealed ED MSE completed by Physician Assistant #1. ED provider notes dated 11/05/2022 reveal "Initial assessment and exam," completed by provider Physician Assistant #1.

Review of test results order by PA #1 revealed Chest X-ray - small left pleural effusion available at 6:05 p.m., Lactic acid results available at 6:23 p.m., CBC with bandemia of 22 (too many white blood cells, indication of infection) available at 6:53 p.m., CMP results available at 6:53 p.m.

Review of facility policy entitled "Medical Screening in the Emergency Department" revision date 04/04/2018, revealed " ...Guidelines: 1.2 The screening examination concludes when a qualified member of the medical staff determines whether an emergent medical condition exits ...".

Review of the facility "Medical Staff Bylaws," dated January 28, 2021, reveal no documented evidence of a Physician's Assistant as a qualified medical personnel (QMP) to perform a Medical Screening Exam (MSE).

During exit conference on 11/17/2022 at 3:30 p.m. with Chief Operations Officer (COO), Director Performance Improvement, Compliance Officer, Director of Emergency Services, survey findings were discussed. No further documentation was submitted for review.