HospitalInspections.org

Based on document review and interview, it was determined that in 1 (Patient #1) of 21 medical records (MR) reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide a medical screening examination.

Findings Include:

1. See findings cited at 42 CFR 489.24, Medical Screening Exam (A2406).

Based on document review and interview, the facility failed to ensure a medical screening examination was completed for 1 of 21 patients presenting to the emergency department. (Patient #1)

Findings include;

1. Facility policy titled "EMTALA" (Emergency Medical Treatment and Active Labor Act) last reviewed/revised 3/2020 indicated the following: "...PURPOSE...under the Emergency Medical Treatment and Active Labor Act ("EMTALA"), the Hospital establishes as policy that all patients presenting to the Hospital are entitled to and shall receive a medical screening...Medical Screen/Qualified Medical Personnel (QMP): The Medical Screening Examination is the process to determine with reasonable clinical confidence, whether or not an emergency medical condition exists. The Hospital shall provide an appropriate medical screening examination by QMP, including ancillary services routinely available for the delivery of Emergency Services, to any patient presenting to the Hospital requesting treatment. QMP shall include physicians, physician assistants and nurse practitioners...PROCEDURE...B. Medical Screen...Documentation of the Medical Screen...1. The medical record shall reflect the finding of the medical screening including results of any tests performed and analysis including the determination that a medical emergency does or does not exist..."

2. Review of Patient #1's ambulance run sheet dated 12/22/21 indicated the following: "...was dispatched to location stated for difficulty breathing...Ambulance report was called in via cellphone to (Facility #1). Upon arrival at (Facility #1) crew was met by doctor in ambulance bay prior to unloading pt. Doctor requested to see 12 lead and stated that if there was elevation pt needed to go to a different hospital. Doctor had old EKG available and stated that elevation was new and refused pt. Crew left the hospital and went en route to (Facility #2)..."

3. Facility #1 lacked documentation of medical record information for Patient #1 related to his/her emergency department visit on 12/22/21, which also included a lack of documentation of a medical screening examination for the patient.

4. During an interview on 2/17/22 at 5:24 p.m. with A1 (Chief Nursing Officer), he/she verified the lack of documentation of medical record information for Patient #1 related to his/her emergency department visit on 12/22/21. A1 verified the lack of documentation of a medical screening examination for Patient #1. A1 also verified that MD2 (Doctor of Osteopathic Medicine/Emergency Department Physician) sent Patient #1 to another facility.

5. During an interview on 2/17/22 at 5:30 p.m. with A2 (Corporate Compliance & Risk Officer), he/she verified that MD2 had not completed a medical screening examination on Patient #1 when they presented to the emergency department via an ambulance prior to sending the patient to another facility. A2 verified that once the ambulance pulled onto Facility #1's property, at that point it was a request for a medical screening examination on behalf of the patient.