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Based on medical record review, review of facility policies and Medical Staff Bylaws, it was determined the facility failed to provide an appropriate medical screening examination, that was within the capability of the hospital's emergency department, including ancillary services routinely available in the emergency department, to determine whether or not an emergency medical condition existed for an individual for one of seventeen (17) medical records reviewed (# 2). Refer to findings in tag A-2406.

2406
Based on medical record review, review of facility policies and Medical Staff Bylaws, it was determined the facility failed to provide an appropriate medical screening examination, that was within the capability of the hospital's emergency department, including ancillary services routinely available in the emergency department, to determine whether or not an emergency medical condition existed for an individual for one of seventeen (17) medical records reviewed (# 2).

Findings include:

Policies and Procedures/Medical Staff By- Laws

Review of facility policy titled Pediatric Patients in the Emergency Department, activation and last review date 6/21/12, revealed that ER physicians would be credentialed to provide emergency medical care for pediatric patients. Additionally, the ED Medical Director and ED Department Director would equip the ED for the evaluation and treatment of pediatric emergency medical conditions.

Review of facility policy titled EMTALA-Medical Screening, Treatment and Related Issues, activated 1/22/16, last reviewed 1/22/16, revealed Medical Screening Examination: 1. Medical Screening Examination or (MSE) means the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not the patient has an emergency medical condition. An MSE is not an isolated event, it is an ongoing process that begins but does not end with Triage. Triage entails the clinical assessment of the individual's presenting signs and symptoms, in order to prioritize when the individual will be seen by a physician or other QMP. (Qualified Medical Personnel). All individuals coming to the Emergency Department should be provided an MSE appropriate to the individual's presenting signs and symptoms, as well as the capability and capacity of the Hospital.

Review of the facility's Medical Staff Bylaws, Medical Screening Examination and Stabilizing Treatment, revealed that all patient who went to the facility and requested examination or treatment for a medical condition would be provided with a medical screening examination (MSE) to determine if the patient has an emergency medical condition. The following persons are qualified to perform a MSE: In the facility's Emergency Department a MSE would be performed by a physician, or by a physician's assistant or advanced practice nurse in accordance with approved clinical guidelines/protocols.


Medical Record Review

Review of medical record #2 revealed the seventeen (17) month old patient was brought to the ER on 1/5/16 at 7:08 PM with complaint of head laceration. The patient was triaged at 7:12 PM, and assigned an emergency severity index (ESI) level 3 (urgent). Triage notes revealed a bruise to the left forehead and laceration. The patient had bumped his/her head on the corner of a wall while running at home the same day. The patient was alert. Vital signs were: (Tympanic Temperature) 95(Low); (Pulse)-94; (Respiration) 25; and 94% oxygen saturation on room air, pain score 10. No immunization status was documented.

At 7:19 PM, the triage nurse documented in part, "Pt (patient arrives bruise to L (left) forehead and laceration PTA (prior to arriving) s/p (status/post) bumping heal on corner of wall while running at home today."
At 7:27 PM, an RN noted that the parent decided to take patient to a hospital for children. The hospital's address was provided; "patient comfortable with family".
At 7:28 PM, and RN documented that a MSE (Medical Screening Examination) had been done by the NP (Nurse Practitioner) #1, who advised to go to a children's hospital, parent agreed and left with patient in her arms with directions. The medical record showed no evidence that a physical examination was provided by the NP for this patient's head injury or laceration sustained. There was no documentation in the medical record by the NP that an appropriate medical screening examination was performed.
The patient was discharged from the Emergency Department at 7:30 PM on 1/5/2016, and referred to another hospital.

Interview:
Interview with the PA on 5/4/16 at 11:15 AM revealed confirmation that he/she was on duty the day patient #2 was brought to the ER, but did not recall the patient, or examining the patient. The PA explained that the standard was that the nurse calls the patient to the triage area and obtains the patient's history and vital signs. In the midst of that, the provider entered to perform a focused MSE, including mental status and appearance. If, after the triage and focused examination, the patient wishes to leave, a full examination is not performed. The PA added that a note is typically written, and he/she did not advise patients to go to any particular hospital. He /she also stated that the hospital did not have pediatric unit, nor an on-call pediatrician.


The facility failed to ensure that their EMTALA policy and procedure and Medical Staff Bylaws related to Medical Screening Examination were followed as evidenced by failing to ensure that an appropriate MSE was provided by the NP for patient #2 on 1/5/2016; in order to determine whether or not an emergency medical condition existed when the 17 month old (#2) presented to the emergency department with his/her mother who was seeking an evaluation for his/her medical condition.