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Based on findings at A2406 and A2407, the facility failed to ensure compliance with Code of Federal Regulations (CFR) 489.24.

Based on interview, document review, and record review, the facility failed to provide a thorough medical screening exam for 1 of 30 sampled patients (Patient 23). The failure to provide a thorough medical screening exam for this patient had the potential to place the patient at increased risk of further harm or illness.

Findings include:

Patient 23 presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 09/03/2024 with a chief complaint of history of vertigo and falls.

The Emergency Department Physician Notes dated 09/04/2024 at 4:44 PM, revealed Patient 23 became dizzy after walking out of the garage and fell to the ground and was unable to get up. Patient 23 reported sustained burns to buttocks and right arm from the hot pavement.

The Skin Assessment conducted by the attending ED physician revealed the patient had approximately 4 cm (centimeters) cyst and superficial thermal burn to right arm and approximately 3 cm diameter thermal burn to right buttock which was superficial but contained 1 cm area of partial thickness with intact blister. Assessment of the left lower extremity revealed no documentation the patient had incurred thermal burns to the left lower extremity, with no mention the right lower extremity was assessed.

The Medical Decision Making (MDM) section of the ED Physician Notes described the skin examination demonstrated small areas of mostly superficial burns with a single area of partial thickness burn. It was determined the patient did not require to be transferred to a burn center. The final diagnosis did not contain evidence of a single burn diagnosis.

The Discharge Summary dated 09/04/2024, revealed no evidence of prescribed wound treatment, including no evidence of a topical ointment, antibiotic, or wound bandages/gauze to address the two areas of thermal burns sustained from the fall and the inability to get up off the hot ground.

On 04/09/2025 at 12:35 PM, the patient's Attending ED Physician (Physician) confirmed an assessment of the patient's lower extremities was conducted during the medical screening exam (MSE) and acknowledged no discovery of additional thermal burns to the patient's lower extremities. The Physician confirmed no orders for treatments to the thermal burns to the upper arm and buttocks were prescribed. The Physician acknowledged the Lidocaine patch, which was prescribed, was to be applied to the patient's back due to pain.

On 04/09/2025 at 3:10 PM, ED Registered Nurse (Employee 2) confirmed there was no documented evidence of burns on the lower extremities of Patient 23. Employee 2 confirmed there were no treatments ordered that addressed the patient's burns at the time of the ED visit and none prescribed following the patient's discharge.

On 04/10/2025 at 6:30 PM, ED RN (Employee 4) acknowledged her role as a chaperone during the patient's skin assessment. Employee 4 confirmed the Physician conducted a visual examination of the patient's lower extremities during the MSE. Employee 4 acknowledged there was documentation the Physician assessed the left lower extremity of Patient 23, but no documented evidence the right lower extremity was a part of the MSE.

Clinical records were obtained from another local hospital, which revealed Patient 23 was treated in the hospital's ED on 09/05/2024. The ED Physician Record dated 09/05/2024 at 10:53 PM revealed one of the patient's chief complaints were burns from the asphalt with blisters and pain (10/10 pain scale). It was documented in the ED Physician Record that the patient's current skin status was "Warm, burns to lateral aspect right arm, lateral aspect right lower leg, medial aspect left lower leg, right buttocks and lateral hip." The ED Physician Record noted the status of the burns as 1st degree 3% and partial and 2nd degree 3 %.

A third set of partial clinical records were obtained regarding an admission to a local Burn Center following the patient's hospital admission and short engagement at a local outpatient burn clinic, Patient 23 was referred to another local burn clinic. The History and Physical, dated 09/18/2024, revealed the patient was diagnosed with "5% TBSA (Total Body Surface Area) full thickness hot pavement burns to right buttocks to hip and BLE (bilateral lower extremity)". In the Assessment/Plan dated 09/18/2024, Patient 23 was admitted, and surgery was scheduled for 09/19/2024 "due to severity of burn".

A facility policy entitled, Emergency Medical Treatment and Labor Act (EMTALA), revealed that for the hospital to comply with EMTALA, the hospital will provide an individual with an appropriate medical screening examination (MSE) and stabilizing treatment once that individual presents at the hospital and requests an examination.

Complaint NV00073503

Based on interview, document review, and record review, the facility failed to provide stabilizing treatment for 1 of 30 sampled patients (Patient 23). The failure to provide stabilizing treatment for this patient had the potential to place the patient at increased risk of further harm or illness.

Findings include:

Patient 23 presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 09/03/2024 with a chief complaint of history of vertigo and falls.

The Emergency Department Physician Notes dated 09/04/2024 at 4:44 PM, revealed Patient 23 became dizzy after walking out of the garage and fell to the ground and was unable to get up. Patient 23 reported sustained burns to buttocks and right arm from the hot pavement.

The Skin Assessment conducted by the attending ED physician revealed the patient had approximately 4 cm (centimeters) cyst and superficial thermal burn to right arm and approximately 3 cm diameter thermal burn to right buttock which was superficial but contained 1 cm area of partial thickness with intact blister. Assessment of the left lower extremity revealed no documentation the patient had incurred thermal burns to the left lower extremity, with no mention the right lower extremity was assessed.

The Medical Decision Making (MDM) section of the ED Physician Notes described the skin examination demonstrated small areas of mostly superficial burns with a single area of partial thickness burn. It was determined the patient did not require to be transferred to a burn center. The final diagnosis did not contain evidence of a single burn diagnosis.

The Discharge Summary dated 09/04/2024, revealed no evidence of prescribed wound treatment, including no evidence of a topical ointment, antibiotic, or wound bandages/gauze to address the two areas of thermal burns sustained from the fall and the inability to get up off the hot ground.

On 04/09/2025 at 12:35 PM, the patient's Attending ED Physician (Physician) confirmed an assessment of the patient's lower extremities was conducted during the medical screening exam (MSE) and acknowledged no discovery of additional thermal burns to the patient's lower extremities. The Physician confirmed no orders for treatments to the thermal burns to the upper arm and buttocks were prescribed. The Physician acknowledged the Lidocaine patch, which was prescribed, was to be applied to the patient's back due to pain.

On 04/09/2025 at 3:10 PM, ED Registered Nurse (Employee 2) confirmed there was no documented evidence of burns on the lower extremities of patient 23. Employee 2 confirmed there were no treatments ordered that addressed the patient's burns at the time of the ED visit and none prescribed following the patient's discharge.

On 04/10/2025 at 6:30 PM, ED RN (Employee 4) acknowledged her role as a chaperone during the patient's skin assessment. Employee 4 confirmed the Physician conducted a visual examination of the patient's lower extremities during the MSE. Employee 4 acknowledged there was documentation the Physician assessed the left lower extremity of Patient 23, but no documented evidence the right lower extremity was a part of the MSE.

Clinical records were obtained from another local hospital, which revealed Patient 23 was treated in the hospital's ED on 09/05/2024. The ED Physician Record dated 09/05/2024 at 10:53 PM revealed one of the patient's chief complaints were burns from the asphalt with blisters and pain (10/10 pain scale). It was documented in the ED Physician Record that the patient's current skin status was "Warm, burns to lateral aspect right arm, lateral aspect right lower leg, medial aspect left lower leg, right buttocks and lateral hip." The ED Physician Record noted the status of the burns as 1st degree 3% and partial and 2nd degree 3 %.

A third set of partial clinical records were obtained regarding an admission to a local Burn Center following the patient's hospital admission and short engagement at a local outpatient burn clinic, Patient 23 was referred to another local burn clinic. The History and Physical, dated 09/18/2024, revealed the patient was diagnosed with "5% TBSA (Total Body Surface Area) full thickness hot pavement burns to right buttocks to hip and BLE (bilateral lower extremity)". In the Assessment/Plan dated 09/18/2024, Patient 23 was admitted, and surgery was scheduled for 09/19/2024 "due to severity of burn".

A facility policy entitled, Emergency Medical Treatment and Labor Act (EMTALA), revealed that for the hospital to comply with EMTALA, the hospital will provide an individual with an appropriate medical screening examination (MSE) and stabilizing treatment once that individual presents at the hospital and requests an examination.

Complaint NV00073503