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Based on observations, review Emergency Room patient medical records, review of facility policies and procedures, review of facility's Medical Staff Bylaws, Medical Staff Rules and Regulations, staff interviews, the facility failed to ensure that an appropriate medical screening examination was provided for patients who presented to the emergency department, regardless of ability to pay, received an appropriate medical screening examination that is within the capability of the hospital ' s emergency department including ancillary services routinely available at the emergency department to determine whether or not an emergency medical condition existed for 36 patients (# ' s 2, 5, 6, 9, 13, 18, 19, 21,22, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) medical records reviewed in a total of 50 sampled patients, required that patient's triaged by the triage nurse as " non-urgent " (Emergency Severity Index levels 4 and 5) were sent to the financial counselor, who informed the patients they were "non-urgent " and if the patient wanted to be examined/evaluated by an emergency department Physician and/or Mid-Level Provider a fee or co-pay was required. The facility failed to have an effective policy in place to ensure that all patients who presented to the emergency department seeking medical care received an appropriate medical screening examination by a qualified medical personnel in the hospital ' s emergency department.
Refer to findings in Tag A-2406.






35180

Based on medical record review, facility Medical Staff Bylaws, facility policies, and staff interviews, the facility failed to ensure that patients in the Labor and Delivery (L&D) Department received an appropriate medical screening examination (MSE) by maintaining an effective policy in place that ensured an examination would be provided by qualified medical personnel. Review of three (3) L&D medical records revealed that a patient (#22) was not provided an examination by qualified medical personnel to determine whether or not an emergency medical condition (EMC) existed. Cross reference 489.24A and 489.24C, Medical Screening Exam.

Based on reviews of the facility ' s Emergency Department- Patient Log Reports, policies and procedures and interviews the facility failed to maintain an Emergency Department Log of each individual who " comes to the emergency department " seeking assistance and whether he or she was refused treatment, was refused treatment, or whether he or she was transferred, admitted, and treated, stabilized and transferred, or discharged for 16 ( # ' s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) of 16 randomly sampled (RS) patients.

The findings are:

The facility ' s policy titled " Emergency Medical Treatment, Stabilization and Treatment Transfer Policy, PRB-6463, effective Date: 02/03/2014 was reviewed. The policy revealed in part, " 2. Documentation Requirements ...e. a central log will be maintained identifying each individual who comes to the hospital seeking treatment ; the information will include whether the individual refused treatment, was refused treatment, or whether the individual was transferred, admitted and treated, stabilized and transferred or discharged.


1. Review of the Emergency Department- Patient Log Report dated 3/1/2015 at DMC (DeKalb Medical Center) revealed that RS patient #1 presented to the ED at 5:03 p.m. The patient's chief complaint was listed as " Pregnancy greater than 20 weeks." The sections titled " Transfer/Discharge To " and " Disposition " were left blank. There was no documentation of a disposition as to whether this patient (#1) was admitted and treated, stabilized and transferred, or discharged on 3/1/2015.

2. Review of the ED-Patient Log Report dated 3/4/2015 to 3/4/2015 at DMC indicated that RS patient #2 presented to the facility ED at 3:27 p.m., with a chief complaint listed as " Seizure. " Further review revealed that RS patient #2 " Disposition " and Transfer/Discharge to sections were left blank. There was no documentation of a disposition as to whether this patient (#2) was admitted and treated, stabilized and transferred, or discharged on 3/4/2015.

3. The ED-Patient Log Report dated 3/5/2015 to 3/5/2015 for RS patient # ' s, 3, 4, 5, 6, 7, and 8 was reviewed. The ED log revealed that RS patient #3 presented to the ED at 11:42 a.m. with a chief complaint of " Respiratory complaints. " There was no documentation/entry of a Disposition for this patient. Further review of the ED log indicated that RS patient #4 arrived to the hospital ' s ED at 12:14 p.m. , no chief complaint was listed the sections titled " Transfer/Discharge to" and "Disposition " were all left blank. Randomly Sampled patient #5 presented to the ED at 12:43 p.m. There was no entry of a "Chief Complaint." The ED log also revealed that there were no entries in the sections titled "Transfer/Discharge To" or "Disposition" , these areas were all left blank. Continued review of the ED log indicated that RS patient #6 presented to the ED at 2:22 p.m. The sections titled "Chief Complaint ", " Disposition " and "Transfer /discharge to " were all left blank. RS patient #7 presented to the ED at 9:38 p.m. with a chief complaint of GI (Gastrointestinal) complaints. There was no entry as to the sections titled "Disposition " or Transfer/Discharge To " RS #8 arrived to the facility ' s ED at 1:18 p.m. The sections titled "Chief complaint " , " Disposition " and "Transfer/Discharge to " were all left blank. There was no entry/documentation of dispositions in the ED log as to whether RS patients # ' s 3, 4, 5, 6, 7, and 8 refused treatment, was refused treatment, or whether RS patient # " s 3, 4, 5, 6, 7 and 8 were transferred, admitted and treated, stabilized and transferred, or discharged on 3/5/2015.

4. The ED-Patient Log Report dated 3/7/2015 to 3/7/2015 at DMC was reviewed. RS patient #9 presented to the ED at 11:09 a.m. RS patient #10 presented to the ED at 1231 p.m. There was no information or documentation of an entry of the " Chief complaint, " Disposition, " or " Transfer/Discharge to " for RS patient #9 or RS patient # 10. These sections were all left blank. There was no entry on the ED log as to whether these patients were admitted and treated, stabilized and transferred or discharged on 3/7/2015.

5. Review of the ED-Patient Log Report dated 4/7/2015 to 4/7/2015 at DMC revealed that RS patient #11 arrived to the ED at 6:31 p.m., with a chief complaint listed as "Vaginal complaints/OB (Obstetrical) less than 20 wks (weeks). There was no entry of a " Disposition" for this patient . The section titled " Transfer/Discharge To: was left blank. RS #12 presented to the ED on 4/7/2015 at 2:41 p.m. There was no entry on the ED log of a " Chief Complaint " , " Disposition " or "Transfer/Discharge To. " There was no entry in the ED log as to whether RS patients # ' s 11 and 12 were admitted and treated, stabilized and transferred or discharged on 4/7/2015.

6. The ED -Log Report dated 4/10/2015 to 4/10/2015 at DMC was reviewed. RS patient #13 presented to the ED at 2:13 p.m. RS patient #13 ' s Chief complaint was listed as " Other/Revisit. The sections titled " Disposition " and " Transfer/Discharge To " were left blank. There was no entry as to whether RS patient #13 was admitted and treated, stabilized and transferred or discharged on 4/10/2015.

7. The ED-Log dated 4/11/2015 to 4/11/2015 ad DMC revealed that RS patient #14 arrived to the ED at 11:49 a.m. RS #14 ' s Chief Complaint was listed as "Other/Revisit. " There was no entry of a " Disposition " for this patient. There was no entry in the ED log sections " Transfer/Discharge To " as to whether RS patient #14 was admitted and treated, stabilized and transferred or discharged on 4/11/2015.

8. The ED - Patient Log Report for 8/21/2015 at DMC was reviewed. RS patient #15 arrived to the ED at 3:56 p.m., with a Chief complaint of " Syncope." According to the ED Log RS patient #16 walked into the ED at 10:16 a.m. RS patient #16 ' s chief complaint was listed as a " Headache." There was no entry in the sections of the central log of a "Disposition" or "Transfer/Discharge To" as to whether RS patients #'s 15 and 16 were admitted and treated, stabilized and transferred, or discharged on 8/21/2015.

An interview was conducted on 9/18/2015 at 12:30 p.m., with Nurse Manager of Emergency Services and the Director of Patient Relations; both verified the above findings related to the ED log.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that ED Log policy and procedure was followed as evidenced by failing to maintain an accurate and complete central log to include the disposition as to whether or not the individuals refused treatment, was refused treatment , or whether 16 RS ( # ' s 1, 2, 3,4,5,6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) individuals were transferred, admitted and treated, stabilized and transferred or discharged as stated in the facility's policy and procedure.

Based on observations, review Emergency Room patient medical records, review of facility policies and procedures, review of facility's Medical Staff Bylaws, Medical Staff Rules and Regulations, staff interviews, the facility failed to ensure that an appropriate medical screening examination was provided for patients who presented to the emergency department (ED), regardless of ability to pay, received an appropriate medical screening examination (MSE) that is within the capability of the hospital 's emergency department including ancillary services routinely available at the emergency department to determine whether or not an emergency medical condition existed for 36 patients (#'s 2, 5, 6, 9, 13, 18, 19, 21,22, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) medical records reviewed in a total of 50 sampled patients required, that patient's triaged by the triage nurse as "non-urgent" were sent to the financial counselor, who informed the patients they were "non-urgent" and if the patient wanted to be examined/evaluated by an emergency department Physician and/or Mid-Level Provider a fee or co-pay was required. The facility failed to have an effective policy in place to ensure that all patients who presented to the emergency department, seeking medical care, received an appropriate medical screening examination by a qualified medical personnel in the hospital's emergency department. ((Emergency severity Index is a 5 level Emergency Department triage Algorithm based on the acuity of the patient's health care problems and the number resources their care is anticipated to require. Level 1 -most severe, Level 4- Less Urgent and Level 5- Non-Urgent).



Findings include:


OBSERVATION

An observational tour was conducted on 9/3/2015 at 10:00 a.m. It was observed at the outside walls of the receptionist area where patients registered, signs were seen on the left and right side of the walls that stated in part, " Welcome to DeKalb Medical Emergency Department. . . Payment Is Collected At The Time Of Service. . . Services May Be rendered By A Nurse Practitioner Or A physician's Assistant. "



MEDICAL RECORD REVIEWS

1. Patient #2, a 31 year old, who presented to the ER on 9/1/15 at 7:47 PM. Review of the ER (emergency room) -Triage notes revealed the patients Chief Complaint: was " Skin /Rash. " The section titled "Chief Complaints Comments" : revealed in part, " Patient states rash and itching x 3 weeks ...has been taking Claritin and hydrocortisone otc (over the counter) without relief. " The patient was triaged on 9/1/15 at 8:18 PM, and assigned an ESI level 5. Triage notes revealed the patient had no pain, and was screened as " No " for recent travel, no TB, exposure, and no history of previous Blood transfusion. Triage vital signs were: Temperature (T) -99; Pulse (P)-80; Respirations (R )-16; Blood Pressure (B/P): 122/89; and Oxygen saturation (oxygen saturation-measurement of oxygen the blood is carrying as a percentage)100% on Room Air. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel in the emergency department (ED). There was also no documentation in the medical record to indicate treatment or follow-up instructions had been provided to the patient. The patient's discharge disposition was documented as " Referred Out. " Further review revealed that Disposition VS were to be completed on " ALL " patients. There was no documentation in the medical record to indicate that Disposition VS were performed. The facility failed to ensure that an appropriate medical screening examination was performed by a Qualified Medical Personnel in the ED for patient #2 on 9/1/2015.

2. Patient #5, 57 year old, who presented to the ER on 3/2/15. The patient was triaged on 3/2/15 at 6:50 PM, and assigned an ESI level 5. .Review of the ER -Triage notes revealed the patients Chief Complaint was listed as " Headache. " The section titled " Chief Complaint Comments: " revealed the patient had complaints of headache for one (1) week, and blood pressure of 149/70 at work. Triage notes revealed the patient stated that he/she had been under a lot to stress. Patient #5 reported that when he/she had phoned his/ her health plan, they informed him/her that his/her blood pressure was critically high, and instructed him/her to go to the emergency room. The Patient ' s triage vital signs at 6:58 PM were: (T) 97.5; (P)-81; (R)-20; B/P 144/86 (normal BP 120/80); and oxygen saturation of 100% on room air. The pain was assessed as 7/10 (Pain scale 0-10, 0-no pain at all and 10-worst imaginable pain). A review of the document in the medical record titled " Emergency Department Chart " for Patient #5, was reviewed. There was no documentation of a history and physical, review of body systems, physical examination, Interventions, or procedures ordered, and no diagnosis was listed; the entire document was blank. There was no documentation in the medical record to indicate that an appropriate medical screening examination was provided by a qualified medical personnel in the ED. There was no documentation in the medical record regarding the patient ' s concern of his/her headache or complaint of elevated blood pressure. Review of the Discharge Assessment section revealed that Patient #5 ' s Discharge Disposition was " Referred Out. " Further review revealed that Disposition VS were to be completed on " ALL " patients. There was no documentation in the medical record to indicate that Disposition VS were performed. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel for patient #5 on 3/2/2015.


3. Patient #6, 25 year old, who presented to the ER on 3/2/15 with complaints of nausea, vomiting and diarrhea for 4 days, which stopped two (2) days ago; now with cramping, bloating, and abdominal pain. The patient was triaged on 3/2/15 at 9:45 AM, and assigned an ESI level 4. Vital signs on triage were: (T) 98.9; (P) - 82; (R)-18; P-106 (normal- 60-100); B/P-147/86; and oxygen saturation of 95% on room air. The Pain scale was assessed as 5/10. Review of the document in the medical record titled "Emergency Department Chart" revealed there was no documentation of a history and physical, review of body systems, or physical examination was performed. There were no interventions or procedures ordered. No diagnosis was listed, this form was left blank. There was no documented evidence in the medical record that a medical screening examination had been performed by a qualified medical personnel in the ED; and indicated that no treatment had been provided for the patient. Review of the Discharge Assessment section revealed that Patient #6 ' s Discharge Disposition was " Referred Out. " Further review revealed that Disposition VS were to be completed on " ALL " patients. There was no documentation in the medical record to indicate that Disposition VS were performed. The facility failed to ensure that an appropriate medical screening examination was performed by a Qualified Medical Personnel for patient #6 on 3/2/2015.



4. Patient #9, a 40 year old, was triaged on 3/7/15 at 12:14 AM, and assigned an ESI level 4. Review of the section titled " Chief Complaint Comments " revealed in part, " Presents to the ER c/o (complaint/of) left eye irritation x two (2) days. Also c/o of painful urination x three (3) days. " Vital signs on triage were: (P)-63; (R)-16; B/P140/83; (T) - 98.3; and oxygen saturation of 97% on room air. The Pain scale was assessed as 5/10. A review of the document in the medical record titled " Emergency Department Chart " for Patient #9, was reviewed. There was no documentation of a history and physical, review of body systems, physical examination, Interventions, or procedures were ordered, and no diagnosis were listed; the entire document was blank. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel in the ED. There was no documentation in the medical record to indicate that treatment had been provided to address the patient ' s complaint of pain for his/her complaint of painful urination. Review of the Discharge assessment revealed the patient ' s discharge disposition was documented as " Referred Out. " Further review revealed that Disposition VS were to be completed on " ALL " patients. There was no documentation in the medical record to indicate that Disposition VS were performed. The facility failed to ensure that an appropriate medical screening examination was performed by a Qualified Medical Personnel for patient #9 on 3/7/2015.



5. Patient #13, a 40 year old, who presented to the ER on 4/7/15. The patient was triaged on 4/7/15 at 11:02 AM, and assigned an ESI level 5. Review of the ER triage notes titled, " Chief Complaints Section " revealed in part, " Pt. Presents with c/o something just don' t feel right, Pt states that he wants to be checked for STD ' s (Sexually transmitted diseases-generally acquired by sexual contact-organisms that cause STD may pass from person to person in blood, semen, and other body fluids). Pt. states he wants to be checked for STD ' s. Pt denies any penile discharge. Urinary issues, abdominal pain, nausea or vomiting. Pt states it " it just feels warm down there " pt. was point (sic) at groin area. " The patient ' s Vital signs on triage were: (T) 97.6; (P)-90; (R)-17; B/P-141/95, and oxygen saturation of 98% on room air. The patient ' s pain was documented as zero. Review of the " Emergency Department Chart " for patient #13 was reviewed. There was no documentation of a history and physical, review of body systems, physical examination, interventions and no diagnosis was listed; the document was blank. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel in the ED. There was no urinalysis or STD evaluation ordered. There was no documentation that treatment had been provided for the patient. Review of the Discharge assessment revealed that patient #13 ' s discharge disposition was documented as " Referred Out. " Further review revealed that Disposition VS were to be completed on " ALL " patients. There was no documentation in the medical record to indicate that Disposition VS were performed. The facility failed to ensure that an appropriate medical screening examination was performed by a Qualified Medical Personnel for patient #13 on 4/7/2015.



6. Patient # 18, a 49 year old, who presented to the ER on 3/3/15. The patient was triaged on 3/3/15 at 10:18 AM, and assigned an ESI level 4. Review of the ER triage note titled, " Initial screening " revealed in part, " Chief Complaint: Extremity pain/injury Chief Complaints Comments: ...R (right) knee swollen and intermittently painful. Pt. reports feels stiff. Pt. has hx (history): Loss sensation in in toes r/t (related/to) Saphenous Harvest for L (left) leg. Pt. hx: Arthritis, HIV. " The patient ' s Vital signs on triage were: (T) 98.2; (P)-72; Resp.-16; B/P- 142/81, and oxygen saturation of 98% on room air. The patient ' s pain was assessed as " O No Pain. " Review of the " Emergency Department Chart " for patient #18 was reviewed. There was no documentation of a history and physical, review of body systems, physical examination, interventions, or procedures ordered, and no diagnosis was listed. The " Emergency Department Chart " form was blank. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel. There was no indication in the medical record that treatment or follow-up care instructions were provided. The ED Discharge Assessment section of the medical record was reviewed. The patient's discharge disposition was documented as " Referred Out. " Additionally, " Vital Signs (Must be completed on ALL patients): " There was no documentation in the medical record to indicate that DC disposition vital signs were performed. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel for patient #18 on 3/3/2015.

7. Patient # 19, a 54 year old, who presented to the ER on 3/3/15. The patient was triaged on 3/3/15 at 12:43 PM, and assigned an ESI level 5. Review of the ER Triage noted, titled , " Initial Screening " stated in part, Chief Complaint: Extremity pain/Injury: Chief Complaint Comments: Pt. reports Lt (left) foot pain. States just left (name of another hospital) 30 min. (minutes) ago. They gave her an IV (intravenous) and pain meds. Pt. stated then left and came here. No obvious deformity, drainage, or open wounds to foot. Nad (no acute distress)." Vital signs on triage were: (T) 97.8; (P)-96; Resp-16; B/P- 110/74; and, oxygen saturation of 96% on room air. The patient ' s pain was assessed as 7/10. The Medical Screening Form, which was completed by the triage RN, noted the Referral Status as Referred to Provider for MSE due to patient complaints of pain greater than 7/10 and/or the presence of clinical signs suggestive of acute pain or distress. Despite the triage nurse documenting to refer patient #19 to the provider for a medical screening examination, there was no documentation that the provider was notified to evaluate the patient. Review of the "Emergency Department Chart " for patient #19 was reviewed. There was no documentation of a history and physical, review of body systems, physical examination, interventions, or that procedures were ordered, and no diagnosis was listed. The "Emergency Department Chart " form was blank. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel. There was no indication in the medical record that the patient ' s pain was addressed. The ED Discharge Assessment section of the medical record was reviewed. The patient's discharge disposition was documented as " Referred Out. " Additionally, " Vital Signs (Must be completed on ALL patients): " There was no documentation in the medical record to indicate that DC disposition vital signs were performed. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel for patient #19 on 3/3/2015. During interview with the Clinical Risk Manager on 9/15/2015 at 2:00 PM verified that Patient #19 was not seen by a physician as requested by the ED Triage RN. The facility also failed to ensure that their policy regarding medical screening examinations for ESI level 4 and 5 were followed as evidenced by failing to ensure that a medical screening examination was provided by the physician or mid-level provider for Patient #19.




8. Patient # 21, a 24 year old, who presented to the ER on 8/21/15. The patient was triaged on 8/21/15 at 4:12 PM and assigned an ESI level 4. Review of the ED triages notes revealed the patient the patient complained of a " Sore Throat and H/A (headache) for past few days, no respiratory distress was present. The Vital signs on triage were: (T) 98.2; (P)-93; Resp-18; B/P- 128/89; and oxygen saturation 100% on room air. The patient ' s pain was assessed as 4/10. Review of the " Emergency Department Chart " for patient #21, revealed no evidence of a history and physical, review of systems, physical examination, no interventions or procedures were ordered. There was no diagnosis listed, the form was blank. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel. There was no indication in the medical record that treatment for the patient ' s complaint of sore throat and headache were addressed. There was no documentation that in the medical record to indicate the patient's throat was assessed by the triage nurse. The ED Discharge Assessment section of the medical record was reviewed. The patient's discharge disposition was documented as " Referred Out, " and that " Vital Signs (Must be completed on ALL patients): " There was no documentation in the medical record to indicate that DC disposition vital signs were performed. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel for patient #21 on 8/21/2015.




9. Patient # 22, a 59 year old, who presented to the ER on 4/5/15 and triaged at 10:12 AM. The patient was assigned an ESI level 4. The section of the ER-triage note section titled, " Initial Screening " revealed in part, " Respiratory Complaints: Chief Complaint Comments: Pt. C/O productive cough x 2 months. Says she has been coughing up white sputum. Pt. says she was treated with penicillin (an antibiotic) but symptoms never resolved. " The Vital signs on triage were: (T) 98; (P)-95; Resp-18; B/P- 120/58; oxygen saturation 97% on room air. The pain was assesses as 0/10. Review of the " Emergency Department Chart " for patient #22 was reviewed. There was no documentation of a history and physical, review of body systems, physical examination, interventions, or that a chest x-ray was ordered. There was no diagnosis listed. The " Emergency Department Chart " form was blank. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel in the ED; and, indicated that no treatment had been provided to the patient. There was no documentation in the medical record that Patient #22's lungs were assessed by the triage nurse. The ED Discharge Assessment section of the medical record was reviewed. The patient's discharge disposition was documented as " Referred Out. " Additionally, " Vital Signs (Must be completed on ALL patients): " There was no documentation in the medical record to indicate that DC disposition vital signs were performed. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel for patient #22 on 4/5/2015.



10. Patient # 24, a 23 year old, who presented to the ER on 4/10/15. The patient was triaged on 4/10/15 at 3:16 PM, and assigned an ESI level 4. Review of the ER-triage in the section titled " Chief Complaints Comments " revealed in part, " Pt. to triage c/o back spasms for the past 2 days. Pt denies injury ...ambulatory to triage with steady gait moving all extremities without difficulty. " The vital signs on triage were: (T) 97.8; (P)-79; Resp. -18; B/P- 108/56; and oxygen saturation 100% on room air. The patient ' s pain was assessed as 7/10. Review of the " Emergency Department Chart " for patient #24 was reviewed. There was no documentation of a history and physical, review of body systems, physical examination, interventions, or procedures ordered, and no diagnosis was listed. The " Emergency Department Chart " form was blank. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel in the ED; and no treatment had been provided to the patient. The ED Discharge Assessment section of the medical record was reviewed. The patient's discharge disposition was documented as " Referred Out. " Additionally, " Vital Signs (Must be completed on ALL patients): " There was no documentation in the medical record to indicate that DC disposition vital signs were performed. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel for patient #24 on 4/10/2015.



11. Patient # 25, a 22 year old, who presented to the ER on 4/9/15. The patient was triaged 4/9/15 at 4:47 PM, and assigned an ESI level 4. The section of the ER-Triage note section titled, " Chief Complaint: GU (genitourinary-reproductive organs and urinary system) revealed in part, " Chief Complaint Comments: Presents to the ER c/o of painful urination and penile discharge x 2 days." The patient's pain was assessed as 4/10. The Vital signs on triage were: (T)-97.2; (P)-87; Resp.-16; B/P- 165/74, oxygen saturation 100% on room air. Review of the " Emergency Department Chart " for patient #25 was reviewed. There was no documentation of a history and physical, review of body systems, physical examination, interventions, or procedures ordered, and no diagnosis was listed. The " Emergency Department Chart " form was left blank. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel. The medical record also indicated that no urinalysis or STD testing and or evaluation was offered or provided to the patient. The ED Discharge Assessment section of the medical record was reviewed. The patient's discharge disposition was documented as " Referred Out. " Additionally, " Vital Signs (Must be completed on ALL patients): " There was no documentation in the medical record to indicate that DC disposition vital signs were completed. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel for patient #25 on 4/9/2015.






12. Patient # 26, a 49 year old, who presented to the ER on 4/9/15. The patient was triaged 4/9/15 at 8:45 AM, and assigned an ESI level 5. Review of the ER-Triage note revealed the patient complained of a tooth abscess and tooth irritation for two (2) weeks, no pain. The Vital signs on triage were: (T)-98.3; (P)-99; Resp.-(16); B/P- 156/80, and 97% oxygen saturation, on room air. Review of the " Emergency Department Chart, revealed no documentation of a history and physical, review of systems, Physical examination, or that interventions were ordered, the form was left blank. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel in the ED. There was no documentation in the medical record to indicate that treatment or follow-up care instructions were provided for the patient's complaint of tooth irritation/possible abscess. The ED Discharge Assessment section of the medical record was reviewed. The patient's discharge disposition was documented as " Referred Out. " Additionally, " Vital Signs (Must be completed on ALL patients): " There was no documentation in the medical record to indicate that DC disposition vital signs were performed. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel for patient #26 on 4/9/2015.





13. Patient # 27, a 30 year old, who presented to the ER on 4/9/15. The patient was triaged 4/9/15 at 8:11 AM, and assigned an ESI level 5. The ER-Triage notes revealed the patient walked in "Chief Complaints: Skin/Rash/Abscess. Chief Complaint Comments: Pt. presents to ER c/o rash to right side of neck for one x (1) week. " The Vital signs on triage were: (T)-97.3; (P)-75; Resp. -16; B/P-134/92; and 98% oxygen saturation on room air. The patient ' s pain was assessed as 7/10. The " Emergency Department Chart " for patient #27 was reviewed. There was no documentation of a history and physical, Review of Systems, or that a Physical examination was completed. The form was left blank. The patient ' s pain was not addressed. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel in the ED; and indicated that no treatment had been provided to the patient. The ED Discharge Assessment section of the medical record was reviewed. The patient's discharge disposition was documented as " Referred Out. " Additionally, " Vital Signs (Must be completed on ALL patients): " There was no documentation in the medical record to indicate that DC disposition vital signs were performed. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel for patient #27 on 4/9/2015.



14. Patient # 28, a 23 year old, who presented to the ER on 4/9/15. The patient was triaged 4/9/15 at 8:11 AM, and assigned an ESI level 5. Review of the ER-Triage notes revealed the patient presented to the ER requesting an STD check after sexual partner's condom broke while having intercourse that morning. " The Vital signs on triage were: (T)-98.5; (P)-66; Resp. 16; B/ 147/65, 100% oxygen saturation on room air, and no pain. Review of the " Emergency Department Chart " for patient #28 was reviewed. There was no documentation of a history and physical, review of body systems, physical examination, interventions, or procedures were ordered, and no diagnosis was listed. The " Emergency Department Chart " form was left blank. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel in the ED. The medical record also indicated that no urinalysis or STD testing or evaluation was offered or provided to the patient. The ED Discharge Assessment section of the medical record was reviewed. The patient's discharge disposition was documented as " Referred Out. " Additionally, " Vital Signs (Must be completed on ALL patients): " There was no documentation in the medical record to indicate that DC disposition vital signs were performed. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel for patient #28 on 4/9/2015.



15. Patient # 29, a 23 year old, who presented to the ER on 3/1/15. The patient was triaged 3/1/15 at 12:50 AM, and assigned an ESI level 4. A review of the ER-Triage notes revealed the patient reported pain in left arm, was in MVC (Motor vehicle Collision) two (2) yrs. (years)ago. The patient ' s pain was assessed as 4/10. " The Vital signs on triage were: (T)- 97.9; (P)-83; Resp-16 ; B/P- 127/58; and 97% oxygen saturation on room air. Review of the " Emergency Department Chart " for patient #29 was reviewed. There was no documentation of a history and physical, review of body systems, physical examination, interventions, or procedures ordered, and no diagnosis was listed. The " Emergency Department Chart " form was left blank. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel in the ED. The ED Discharge Assessment section of the medical record was reviewed. The patient's discharge disposition was documented as " Referred Out. " Additionally, " Vital Signs (Must be completed on ALL patients): " There was no documentation in the medical record to indicate that DC disposition vital signs were performed. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel for patient #29 on 3/1/2015.



16. Patient # 30, a 26 year old, who presented to the ER on 3/4/15. The patient was triaged on 3/4/15 at 11:39 PM, and assigned an ESI level 5. Review of the ER- Triage notes revealed the patient complained of seasonal allergies acting up, and wants prescription to be filled, and no complaint of pain. The Vital signs on triage were: (T)-98.6; (P)-70; Resp.-16; B/P- 148/78; and 100% oxygen saturation on room air. Review of the " Emergency Department Chart " for patient #30 was reviewed. Review of this form revealed no documentation that a history and physical, review of systems, physical examination or interventions were ordered, the form was left blank. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel in the ED. The record also indicated that no treatment, or follow-up plans had been provided to the patient. Review of the ED Discharge Assessment of the medical record revealed that Patient #30 was " Referred Out. " Further review revealed that " Vital Signs (Must be completed on ALL patients): " There was no documented evidence to indicate that DC disposition vital signs were completed. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel for patient #30 on 3/4/2015.




17. Patient # 31, a 38 year old, who presented to the ER on 2/2/15. The patient was triaged 2/2/15 at 7:54 PM, and assigned an ESI level 4. The ER-Triage notes revealed the patient complained of burning on urination, and this started today. The Vital signs on triage were: (T) -98.6; (P) -70; Resp.-16; B/P- 147/75; 98% oxygen saturation on room air. The pain assessment was documented as 0/10. Review of the " Emergency Department Chart " revealed no documentation of a history and physical, review of systems, physical examination and no interventions or procedures (i.e., urinalysis for c/o dysuria) were ordered. There was no diagnosis listed, the form was left blank. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel in the ED; and that no treatment was provided for the patient. The ED Discharge Assessment section of the medical record was reviewed. The patient's discharge disposition was documented as " Referred Out. " Additionally, " Vital Signs (Must be completed on ALL patients): " There was no documentation in the medical record to indicate that DC disposition vital signs were done. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel for patient #31 on 2/2/15.


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18. Patient # 32 ' s, ambulance report (Pre-Hospital Care Report) dated 2/8/2015 (at pt. side 5:24 P.M.) was reviewed. The report specified, in part, " History of Present Illness: ... Pt. stated Complaint: Chief Complaint Category: neck pain... cause of injury ...MVC (motor vehicle collision) ...Patient position in Vehicle/seat in vehicle: Driver. " The patient ' s Vital signs at 5:31 p.m., B/P 118/60; (P) 75; Resp. -16 and pain scales assessment of 2/10. The patient was awake alert and oriented. Review of the report revealed in part, " Responded to street intersection or MVC with injuries. Pt 29 yr. old ...complaint of soreness to right side of ...neck .restrained ...and was side swiped by another car.. ..Pt assessment, pt. assisted to ambulance bench seat, Pt transported to DeKalb Med (Medical) Ctr (Center)." The medical record from DeKalb Medical was reviewed. Patient #32 presented to the ER on 2/8/2015 and was triaged on 2/8/15 at 6:23 PM, and assigned an ESI level 4. Review of the ER- Triage notes revealed the patient stated he/she was the restrained driver involved in MVC approximately one (1) hour ago, complained of neck pain; ambulating without difficulty and moves all extremities. Denies head or back pain. The patient ' s pain was assessed in the ED as 5/10. The vital signs on triage were: (T)-97.9; (P)-61; Resp.-16; B/P- 109/59; 98% oxygen saturation on room air. The Emergency Department Chart " form for patient #32 was reviewed. There was no documentation on this form that indicated that a history and physical, review of systems, physical examination had been performed. There were no noted interventions or procedures ordered. No diagnosis was listed on this form, which was left blank. The patient ' s pain was not addressed. The medical record failed to reveal evidence that a medical screening examination had been performed by a qualified medical personnel. The medical record did not indicate that treatment had been provided for the patient. Review of the ED Discharge Assessment revealed that Patient #32 was " Referred Out. " There was no indication that the patient ' s complaint of pain was re-assessed prior to discharge from the ED. Further review revealed that " Vital Signs (Must be completed on ALL patients): " There was no documented evidence to indicate that DC disposition vital signs were completed. The facility failed to ensure that an appropriate medical screening examination was provided by a Qualified Medical Personnel for patient #32 on 2/8/2015.




19. Patient # 33, a 23 year old, who presented to the ER on 2/11/15. The patient was triaged 2/11/15 at 1:49 PM, and assigned an ESI level 4. The ER -Triage notes revealed the patient complained of shoulder pain after a car accident today, and rates pain as 4/10. The vital signs on triage were: (T) - 99; (P)-83; Resp-16; B/P-150/95, oxygen saturation 98% on ro