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Based on review of facility policy, medical record review, and interviews the facility failed to provide a complete medical screening evaluation for one (1) patient (#11) who presented with left shoulder pain of 34 patient's reviewed.

The findings included:

Refer to A-2406

Based on review of facility policy, medical record review, and interviews the facility failed to provide a complete and ongoing medical screening evaluation for one (1) patient (#11) who presented with left shoulder pain of 34 patients reviewed.

The findings included:

Review of facility policy, Emergency Medical Treatment & Active Labor Act (EMTALA) Guidelines, last revised 12/2019, showed "...Medical Screening Examination [MSE] is defined as the process to reach, with reasonable clinical confidence, the point in which it can be determined whether the individual has an emergency medical condition [EMC] or not. An MSE is an ongoing process that begins with triage...the emergency department record shall accurately reflect the individual's triage, assessment, and treatment until such time he/she is admitted, discharged, or appropriately transferred. Documentation should include continued monitoring according to the patient's needs throughout the patient's stay and prior to discharge or transfer..."

Medical record review of a Provider in Triage note dated 10/1/2021 at 9:30 PM showed "...59-year-old male patient presents via private vehicle unaccompanied with chief complaint of left shoulder pain. Patient presented to local urgent care and was sent here for evaluation of cardiac workup. Patient states earlier today he had sharp anterior left shoulder pain that radiated into his neck. Patient denies chest pain but states he has baseline shortness of breath. Patient states he had loss of movement of his left arm with severe pain that was 10 out 10...states he took 2 Tylenol (over-the-counter pain medication) and 1 Aspirin (anti-inflammatory medication), and his pain is now 1 out of 10 on a pain scale...states he had history of decreased lung function secondary to COVID 19. On exam patient has minimal tenderness palpation over the anterior left shoulder..."

Medical record review of an ED Nursing triage record dated 10/1/2021 at 9:35 PM showed the patient presented with an episode of "severe left shoulder pain", he was unable to move the arm where the pain was relieved by Tylenol, Aspirin, and Benadryl (antihistamine medication). The patient had been evaluated at an urgent care center which had referred the patient to the ED for further evaluation. His vital signs were as follows: Pulse 87, Blood Pressure 160/94, Respirations 16, Pulse Oximeter 94% on room air, and Temperature 98.2 degrees Fahrenheit (F). He was triaged with an Emergency Severity Index (ESI) score of a 3 indicating urgent but non emergent needs.

Medical record review of an ED Physicians Record dated 10/2/2021 at 7:30 AM showed the patient presented with left shoulder pain and was initially with inability to move the left arm. The pain was relieved by Tylenol, Aspirin, and Benadryl. He was sent to the ED from an urgent care facility for further evaluation. The progress note showed "...patient was monitored in the ED for 11 hours, cardiac work-up Troponin negative. EKG without any signs of ischemia, no pain..."

Medical record review of the Discharge Documentation showed the patient was discharged home on 10/2/2021 at 7:33 AM with diagnosis of left shoulder pain. His vital signs were as follows: Pulse 92, Blood Pressure 138/78, and Respirations 16. He was given discharge instructions related to shoulder pain, follow up with the Primary Care Physician, and return to the ED as needed

During an interview on 2/1/2022 at 2:50 PM, Registered Nurse (RN) #1 stated she called the patient on 10/4/2021 for a follow-up call related to the patient's admission on 10/1/2021. The patient had multiple complaints related to his wait in the ED on 10/1/2021. All patients who present to the ED were triaged by a nurse and assigned an appropriate ESI score related to the clinical presentation. Some patients who present by EMS may be triaged and then sent back to the waiting room depending on bed availability and clinical presentation. There was an ED technician at the front who was an Emergency Medical Technician (EMT) or a paramedic who can see the patients at all times and the triage nurse can see the patients in the ED waiting room..."

In summary, the medical record review showed the patient did not receive continuous telemetry monitoring while he was in the waiting room during the cardiac workup. There was no documentation of vital signs or assessments for the patient while waiting in the ED waiting room from the initial vital signs on 10/1/2021 at 9:35 PM and the discharge vital signs on 10/2/2021 at 7:30 AM.