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Based on a review of CAH Medical Staff Bylaws Rules and Regulations, review of clinical records, and staff interview, it was determined that the CAH failed to ensure an appropriate medical screening examination was provided to 6 of 21 (Pt. #6, 9, 10, 11, 20, 21) medical records reviewed of patients who presented to the ED.
Please refer to C-2406.

Based on a review of CAH Medical Staff By-Laws Rules and Regulations, review of clinical records, and staff interview, it was determined that the CAH failed to provide appropriate medical screening examinations to 6 of 21 (Pt. #6, 9, 10, 11, 20, 21) medical records reviewed of patients who presented to the ED.
Findings include:

1. The CAH Medical Staff By-Laws Rules and Regulations reviewed 8/21/12 titled; "Accountability & Responsibility of Physician for E.R. Patient Care" was reviewed on 3/12/13. Under "I. PROCEDURE 2.0 Medical Screening Requirement" indicated "If any individual comes to the hospital and a request is made on the individual's behalf for examination or treatment for a medical condition, an appropriate medical screening shall be performed by a Physician, Physician Assistant, Nurse Practitioner a Registered Nurse or other qualified nurse with appropriate training, in order to determine whether or not an emergency medical condition exists,...."

2. During an interview with the ED Supervisor on 3/12/13 at 1:30 PM, the Supervisor stated the RN triages and assesses patients. If the RN feels it is not a true emergency, the RN discusses with the Physician or PA on call in the ED. If the Physician or PA feels it is non-emergent they call the Clinic and to see if the Clinic can see the patient. If so, the patient is walked to the Clinic by the RN. A copy of the ED nursing assessment is given to the Clinic. The Supervisor stated that only Physicians or PAs perform the MSE. The RN's have not had any special training to do the MSE at this time. The Supervisor stated this process is fairly new only the past few months.

3. During an interview with the Chief of Staff/ED Director on 3/12/13 at 4:30 PM, the Director explained his definition of MSE. The Director stated a MSE consists of a history and physical, vital signs in order to determine diagnosis and treatment. The Director confirmed the process of the triaging patients to the Clinic. The Director confirmed that only the Physicians and PAs are doing the MSE. Presently, the RNs do not have special training to do the MSE.

4. The medical record of Pt. #6 was reviewed on 3/11/13. Documentation indicated Pt. #6 presented to the ED on 2/4/13 at 0838. A RN performed triage and nursing assessment at 0845. Pt. #6 indicated chief complaint of Fever, Headache and Sore Throat. Documentation in the "Nursing Notes" indicated "triaged to clinic" at 0845. There was no documentation to indicate an MSE was conducted to determine if a EMC existed. A copy of the Clinic record was obtained on 3/12/13 indicating Pt. # 6 was assessed and treated for Influenza Type B positive.

5. The medical record of Pt. #9 was reviewed on 3/11/13. Documentation indicated Pt. #9 presented to the ED on 2/18/13 at 0905. A RN performed triage and nursing assessment at 0915. Pt. #9 indicated chief complaint of Sore Throat and Sore on Chin. Documentation in the "Nursing Notes" indicated "triaged to clinic" at 0915. There was no documentation to indicate a MSE was conducted to determine if an EMC existed. A copy of the Clinic record was obtained on 3/12/13 indicating Pt. # 9 was assessed and treated for a Skin Lesion and Asthma.

6. The medical record of Pt. #10 was reviewed on 3/11/13. Documentation indicated Pt. #10 presented to the ED on 12/12/12 at 0920. A RN performed triage and nursing assessment at 0930. Pt. #10 indicated chief complaint of Right Elbow Pain without injury. Documentation in the "Nursing Notes" indicated "triaged to (name of PA's) office" at 0930. There was no documentation to indicate a MSE was conducted to determine if an EMC existed. A copy of the Clinic record was obtained on 3/12/13 indicating Pt. # 10 was assessed and treated for Right Elbow Pain.

7. The medical record of Pt. #11 was reviewed on 3/11/13. Documentation indicated Pt. #11 presented to the ED on 12/18/12 at 1234. A RN performed triage and nursing assessment at 1320. Pt. #11 indicated chief complaint of Vomiting and Fever. Documentation in the "Nursing Notes" indicated "triaged to (name of Physician's) office" at 1320. There was no documentation to indicate a MSE was conducted to determine if an EMC existed. A copy of the Clinic record was obtained on 3/12/13 indicating Pt. # 11 was assessed and treated for a Urinary Tract Infection.

8. The medical record of Pt. #20 was reviewed on 3/11/13. Documentation indicated Pt. #20 presented to the ED on 10/31/12 at 1002. A RN performed triage and nursing assessment at 1010. Pt. #20 indicated chief complaint of G-tube Pain and Itching. Documentation in the "Nursing Notes" indicated "triaged to (name of PA's) office" at 1040. There was no documentation to indicate a MSE was conducted to determine if an EMC existed. A copy of the Clinic record was obtained on 3/12/13 indicating Pt. # 20 was assessed and treated for Dermatitis Peri G-Tube.

9. The medical record of Pt. #21 was reviewed on 3/11/13. Documentation indicated Pt. #21 presented to the ED on 11/29/12 at 0643. A RN performed triage and nursing assessment at 0655. Pt. #21 indicated a chief complaint of Cough and Congestion. Documentation indicated a Pain assessment of "10" with a scale of 1-10, 10 being most severe. Documentation in the "Nursing Notes" indicated "triaged to (name of PA's) office" at 0750. There was no documentation to indicate a MSE was conducted to determine if an EMC existed. A copy of the Clinic record was obtained on 3/12/13 indicating Pt. # 21 was assessed and treated for Bronchitis.

10. During an interview with the ED Supervisor on 3/12/13 at 1:30 PM, the Supervisor stated the MSE is not completed before being sent to the Clinic.