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Based on hospital policy review, document review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE), monitoring and treatment for 1 of 20 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)..." revised 9/22/2023 revealed, "...Any person who comes to a DED [dedicated emergency department] seeking examination or treatment for any medical condition must be provided an MSE by the hospital's QMP [qualified medical person] to determine if an Emergency Medical Condition exists..."

Review of the hospital's policy titled, "Nursing Assessment in the Emergency Department - Triage - Primary - Ongoing and Disposition..." revised 1/6/2023 revealed, "...Upon arrival of the patient to the treatment area, a medical screening exam will be performed along with ongoing vital signs, assessment, and disposition in accordance to the Emergency Severity Index (ESI)...Triage...All patients will be triaged upon arrival to the ED..."

2. Review of the hospital document titled "ESI Category Description" revealed, "ESI Level 1 - Resuscitation Patients who have conditions that are immediately life threatening and require immediate medical attention, such as cardiac arrest or respiratory failure...ESI Level 2 - Emergency Patients who have potentially life threatening conditions that require rapid medical intervention, such as severe chest pain or stroke..."

Review of the hospital document titled, "Medical Staff Rules and Regulations" revised 7/1/2019 revealed, "...Medical screening examinations, within the capability of the Medical Center, will be performed on all individuals who come to the Medical Center requesting examination or treatment to determine the presence of an emergency medical condition..."

Review of the hospital document titled, "Adult and Pediatric Trauma Activation" revised January 1, 2023 revealed, "...Bravo Trauma Team Criteria Persons who sustain injury with any of the following...Mechanism of Injury...Auto vs [versus] pedestrian/cyclist thrown, run over, or with significant impact...EMS [emergency medical services] provider judgement..."

3. Medical record review revealed Patient #1 was transported to Hospital #1's ED via ambulance on 7/3/2023 at 5:08 PM after getting trapped between a car door and the car moving and dragging Patient #1 down an asphalt driveway approximately 50 to 60 feet. EMS personnel documented the patient had extensive road rash wounds to the right side of the body and the back area as well as a laceration and hematoma to her head. Patient #1 was evaluated by Trauma Surgeon #1 and ED Provider #1 who both documented Patient #1 had extensive road rash wounds to the right side of the body and back area. Trauma Surgeon #1 and ED Provider #1 did not identify or document about the head laceration or hematoma of Patient #1.

The Trauma team completed Computerized Tomography (CT scan - provides a detailed image of the body) scans of the Patient's head, cervical spine, thoracic spine, lumbar spine, chest, abdomen and pelvis as well as a chest x-ray. All scans and x-rays were determined to be within normal limits. There was no documentation Patient #1's head laceration was identified, assessed, cleansed or treated.

Patient #1 was discharged home in stable condition on 7/3/2023 at 7:42 PM with prescriptions for pain medication and muscle relaxer.

4. On 7/3/2023 at 10:42 PM, Patient #1 presented to Hospital #2's ED via private vehicle with complaints of head lacerations, headache, dizziness and nausea. A triage assessment was completed at 10:53 PM which revealed Patient #1 had been seen earlier at Hospital #1 after a car had dragged the Patient down an asphalt driveway. Patient #1 complained that Hospital #1 did not treat the lacerations to her head.

ED Provider #2 evaluated Patient #1's head lacerations reviewed the CT scan results from Hospital #1. ED Provider #2 then used local anesthetics, cleansed the 3 lacerations to Patient #1's head and closed the lacerations with staples.

On 7/4/2023 at 1:44 PM, Patient #1 was discharged home in good condition with diagnoses including a concussion without loss of consciousness and head lacerations. Patient #1 was prescribed Zofran for nausea and Cephalexin to prevent infection in the scalp wounds which had been left untreated and filled with debris for several hours.

5. Review of Hospital #1's July 11, 2023 weekly meetings revealed ED Provider #2 at Hospital #2 had filed an Occurrence report which read, "Patient [Patient #1] was seen as a trauma patient at [Hospital #1] by the trauma team and discharged home after local wound care. Pt returned to ED at [Hospital #2] immediately after discharge (2224 [10:24 PM]) and was found to have undiagnosed scalp lacs [lacerations] with imbedded foreign bodies. Lacs required washout and repair. Pt received 13 staples here in the [Hospital #2] ED. I reviewed the CT images from [Hospital #1] and there are clearly FBs [foreign bodies] present on the CT scan in the posterior scalp area."

6. Interviews were conducted on 8/27/2024 with Hospital #1's Director of Risk Management, The Trauma Program Manager, and the Chief Medical Officer. All parties interviewed verified Hospital #1 failed to identify and treat Patient #1's head lacerations and Hospital #1's Radiologist failed to include the presence of foreign bodies imbedded in Patient #1's scalp on his final report of the head CT.

Cross Refer to A2406.

Based on hospital policy review, document review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE), monitoring and treatment for 1 of 20 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)..." revised 9/22/2023 revealed, "...Definitions...Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected in...Placing the health of the individual...in serious jeopardy...Serious impairment of bodily functions...Serious dysfunction of any bodily organ or part...Medical Screening Examination (MSE): An examination performed by a Qualified Medical Personnel (QMP) to reach with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition does or does not exist...It is the policy of each [Corporate Hospital Owner] hospital to provide an appropriate MSE, including ancillary services routinely available to the emergency department, within its Capability to...All individuals who present to a DED [dedicated emergency department] for examination or treatment of Any medical condition, whether or not emergent...The MSE must be used to determine whether an Emergency Medical Condition exists...Procedure...Any person who comes to a DED seeking examination or treatment for Any medical condition must be provided an MSE by the hospital's QMP to determine if an Emergency Medical Condition exists...If it is determined that an Emergency Medical Condition exists...the QMP shall do everything within the Capacity and Capability of the facility and staff to Stabilize the patient..."

Review of the hospital's policy titled, "Nursing Assessment in the Emergency Department - Triage - Primary - Ongoing and Disposition..." revised 1/6/2023 revealed, "...All patients presenting to the ED [Emergency Department] will receive a brief assessment by qualified licensed team members who will then coordinate and facilitate entrance into the appropriate treatment area...Upon arrival of the patient to the treatment area, a medical screening exam will be performed along with ongoing vital signs, assessment, and disposition in accordance to the Emergency Severity Index (ESI)...Triage...All patients will be triaged upon arrival to the ED...Patients will be triaged using the 3-Level Acuity System (Emergent, Urgent, Non-Urgent)...Initial assessment will be based on the ESI 5-Level System..."

2. Review of the hospital document titled ESI Category Description" revealed, "ESI Level 1 - Resuscitation Patients who have conditions that are immediately life threatening and require immediate medical attention, such as cardiac arrest or respiratory failure...ESI Level 2 - Emergency Patients who have potentially life threatening conditions that require rapid medical intervention, such as severe chest pain or stroke..."

Review of the hospital document titled, "Medical Staff Rules and Regulations" revised 7/1/2019 revealed, "...Emergency services and care will be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care...Medical screening examinations, within the capability of the Medical Center, will be performed on all individuals who come to the Medical Center requesting examination or treatment to determine the presence of an emergency medical condition..."

Review of the hospital document titled, "Adult and Pediatric Trauma Activation" revised January 1, 2023 revealed, "...Bravo Trauma Team Criteria Persons who sustain injury with any of the following...GCS [Glasco coma scale] 9-13...Injury Patterns...Suspected spinal injury with new motor or sensory loss...Chest wall instability, deformity...Two or more proximal long bone fractures...Crushed, degloved, pulseless or mangled extremity...Active bleeding requiring a tourniquet or wound packing with continuous pressure Mechanism of Injury...Auto vs [versus] pedestrian/cyclist thrown, run over, or with significant impact...EMS provider judgement..."

3. Review of the Emergency Medical Services (EMS) documentation dated 7/3/2023 revealed, EMS was dispatched to Patient #1's home at 4:27 PM and was on the scene with Patient #1 at 4:34 PM. The report further revealed, "...MVC [motor vehicle collision] that injured a pedestrian. O/A [on arrival] found 29 y/o [year old]...sitting on the curb. Pt [Patient #1] had extreme amount of road rash on her R [right] shoulder all the way down her back with abrasions and road rash noted on R [right] side and R hip. Pt clothes were shredded. Pt also had a hematoma to the back of her head and a lac [laceration] noted there also. Pt stated that she was trying to get something out of her car, and it was out of gear and she got stuck between the door and the side of the car and she was drug approx [approximately] 50 ft. [feet]. Pt stated that she had no loss of conc [consciousness], neck or back pain...Pt with no blood from ears-nose-mouth...Trauma alert done via radio with a 10 min [minute] eta [estimated time of arrival]...established a INT [intermittent needle therapy]...Pt tx [transferred] routine to [Hospital #1]. Pt report given via radio with a 5 min eta [estimated time of arrival]. Pt placed in T1 [trauma room #1] in bed via 4 man sheet draw. Pt and report given to Trauma team and RN [registered nurse] for further treatment and exam..."

4. Review of the medical record revealed Patient #1 presented to Hospital #1's ED via ambulance and was placed in ED Trauma Room #1 on 7/3/2023 at 5:08 PM with arrival complaint motor vehicle collision.

Review of the ED Trauma Flowsheet revealed, "...Mechanism of Injury...Pt dragged by car door down driveway...B/P [blood pressure] 140/90...HR [heart rate 112]...chin black substance around nose...Rt shoulder abrasion - mid clavicle to bicep...... Scalp: Normal...Nursing Observations...pt states she was trying to get something out of her car reaching in drivers door, the car was not in park and Pt caught between door jamb + [and] door, driveway is asphalt and 50-60 ft downhill. Pt denies LOC [loss of consciousness] the car did not run over Pt. Multiple abrasions noted on Rt side + back of Pt...1710 [5:10 PM] C-collar applied to Pt...sent to CT [computerized tomography - shows a detailed image of the body] scan. No active bleeding noted, large abrasions noted...1740 [5:40 PM] Pt returned from CT scan..."

There was no documentation ED Trauma staff identified or assessed Patient #1's head lacerations and hematoma as documented in the EMS report.

On 7/3/2023 at 5:10 PM, Trauma Surgeon #1 documented, "...29 year old female [Patient #1] s/p [status post] dragged by own vehicle after getting out of it thinking it was in park on a hill and it began rolling and she was stuck hanging out the door and was reportedly dragged 50-60 feet down an asphalt driveway...EMS reports the pt did not have LOC [loss of consciousness] and the vehicle did not run over the patient. She [Patient #1] presents with moderate amount of road rash on her right side...Glasgow Coma Score...15..." CT scans of the Patient's Head, C- spine, thoracic (T) spine, lumbar (L) spine, chest, abdomen and pelvis were completed as well as a portable chest x-ray. Trauma Surgeon #1 documented, "...CT head - no acute abnormalities noted...Physical Exam...She [Patient #1] is not in acute distress...Head: Normocephalic. Right Ear: External ear normal. Left Ear: External ear normal. Ears: Comments: Dried blood behind ears, no blood in external canals Nose...Blackened abrasion nare and chin...Skin...extensive road rash right side including right upper shoulder extending posteriorly extends from clavicle to bicep and to scapula posteriorly. Road rash multiple sites including right flank, mid-thigh, lateral knee, calf, lateral ankle and dorsal right ...2-4th toes...She is alert and oriented...Procedures: Conscious sedation with local abrasion wash out...Problems/issues covered today include: right arm, right sided back, right hip abrasions..."
There was no documentation Trauma Surgeon #1 identified, assessed, or treated Patient #1's head lacerations and hematoma.

The Trauma Nurse Triage Note dated and signed on 7/3/2023 at 5:38 PM revealed, "...Pt was dragged by her car door when it rolled down her driveway about 50-60 feet. pt states she was caught between door and door jam. Pt has multiple abrasions over her back and right side, arm and rt leg..." There was no documentation of Patient #1's head laceration and/or hematoma as documented in the EMS report.

Review of the CT Head Without Contrast (Final Result) read by Radiologist #1 at Hospital #1 dated 7/3/2023 at 6:07 PM revealed, "...Impression: No significant acute intracranial abnormalities are identified..."

Review of a Procedures note written by ED Provider #1 on 7/3/2023 at 7:19 PM revealed, "...Procedure: Conscious Sedation for wound debridement Attending surgeon: [Trauma Surgeon #1]...Indication for procedure: large amount of abrasions right arm, right flank, right leg...Sedation: Ketamine 50mg [milligrams]...After written consent was obtained, the patient was placed on room air. Medications for sedation and analgesia were administered by nursing...After completion of the procedure, patient awoke from sedation without complication. Telemetry and continuous pulse ox [oximetry] were monitored throughout the duration of the procedure and vital signs remained stable. The attending physician, Attending Surgeon [Trauma Surgeon #1] was present for all critical portions of the procedure..." There was no documentation Patient #1's head lacerations were identified, assessed, and/or treated during the procedure.

On 7/3/2023 at 7:42 PM, Patient #1 was discharged home.

There was no documentation in the medical record to indicate Patient #1's head laceration was identified and/or treated by any of the ED Trauma team at Hospital #1.

5. On 7/3/2023 at 10:42 PM, Patient #1 presented to Hospital #2's ED via private vehicle just 2 hours and 42 minutes after she was discharged from Hospital #1. A triage assessment was completed at 10:57 PM and revealed, "Pt was seen at [Hospital #1] as she had been dragged by her car, but they did not see that she had lacerations on her head in two places and still debris - she had head CT already and was cleared..." The patient was assigned an ESI level 4.

Review of Hospital #2's ED Provider Note written by ED Provider #2 on 7/4/2023 at 1:44 AM revealed, "...29-year-old female who presents with complaint of head laceration. States she was dragged by her car rolling down the driveway earlier today and sustained multiple abrasions and minor injuries. She was seen at [Hospital #1] initially immediately after this event, had head CT which was negative and received care for multiple abrasions to the trunk and extremities. She was discharged without examination of the scalp which has multiple deep lacerations which have bled significantly. She presented here for evaluation and treatment of these lacerations. She also endorses headaches, dizziness, nausea...Physical Exam...Three lacerations noted to scalp. 2 cm [centimeters] to right lateral scalp, 3 cm to occiput...right lateral scalp which is packed with gravel...Lac Repair...7/4/2023 3:46 AM...Anesthesia method: Local infiltration...Lidocaine...Scalp location: Left parietal, occipital, right parietal, Wound length (cm): 2 cm, 3 cm, 3 cm...wound explored through full range of motion and entire depth of wound visualized Contaminated: yes...Area cleansed with : chlorhexidine and saline Amount of cleaning: Extensive...Visualized foreign bodies/material removed: yes (Multiple rocks/gravel)...Skin Repair...Staples Number of staples: 13...Medical Decision Making Patient was seen in ED for complaint of head laceration, was seen at [Hospital #1] earlier and medically cleared, however was not treated for head lac. Lacerations to scalp were anesthetized with local infiltration, thoroughly irrigated and washed with saline and chlohexidine, and closed via staples...Prescribed Zofran for nausea, also prescribed antibiotics as lacerations had been left untreated for several hours and were packed with gravel and grit. Also provided patient care instructions for likely concussion based off of patient's symptoms...Concussion without loss of consciousness, subsequent encounter...Laceration of scalp..."

6. Review of a Hospital #1 weekly meeting dated July 11, 2023 revealed Hospital #2's ED Provider #2 filed an Occurrence report which read, "Patient [Patient #1] was seen as a trauma patient at [Hospital #1] by the trauma team and discharged home after local wound care [to the arm]. Pt returned to ED at [Hospital #2] immediately after discharge (2224 [10:24 PM]) and was found to have undiagnosed scalp lacs with imbedded foreign bodies. Lacs required washout and repair. Pt received 13 staples here in the [Hospital #2] ED. I reviewed the CT images from [Hospital #1] and there are clearly FBs [foreign bodies] present on the CT scan in the posterior scalp area."

7. During an interview on 8/27/2024 at 3:05 PM, Hospital #1's Director of Risk Management (DRM) verified ED Provider #2 from Hospital #2 reported the incident involving untreated lacerations to Patient #1 which was then investigated by Hospital #1. The DRM continued and stated in viewing the Head CT images, the "picture shows imbedded gravel but it was not documented by Hospital #1's Radiologist. The DRM stated, "It [the head lacerations with imbedded debris] was a complete miss on our part..."

During an interview on 8/27/2024 at 3:30 PM, Hospital #1's Trauma Program Manager (TPM) verified she was aware of the incident with Patient #1 and assisted with the investigation. The TPM stated during the meeting held to investigate and discuss the incident, "we pulled up the head CT; debris was noted, but it was not documented..." The TPM continued and stated there was no documentation of Patient #1's head lacerations found in the medical record.

During an interview on 8/27/2024 at 4:50 PM, Hospital #1's Chief Medical Officer (CMO) verified the Radiologist for Hospital #1 failed to document all findings visible in Patient #1's head CT. The CMO continued and stated there was a missed diagnosis of Patient #1's head laceration and the "Attending Trauma Surgeon [Trauma Surgeon #1] is ultimately responsible for the Residents [physicians in training] involved."