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Based on review of medical records (MR) and facility documentation, it was determined the facility failed to comply with §489.24 by failed to provide further medical examination and treatment to ensure an emergency medical condition (EMC) was stabilized prior to discharge to rule out an EMC (Refer to A 2407).

Cross Reference:
489.24(a) & 489.24(c) Medical Screening Exam

Based on interview and record review, the facility failed to provide further medical examination and treatment to ensure an EMC was stabilized prior to discharge for one (1) out of twenty (20) medical records reviewed (MR1).

Findings include:

Review of facility policy, titled "Emergency Medical Treatment and Labor Act (EMTALA) Policy", reviewed June 2020, revealed: "... Procedure: 1. General Requirements: A. When an individual, including an infant or minor, comes by him/herself or with another person to Medical Center Property or Premises, and a request is made on the individual's behalf for a medical examination or treatment or a prudent layperson observer would conclude from the individual's appearance a need for examination or treatment of a medical condition, Medical Center or a department thereof must provide an appropriate Medical Screening Examination within the capability of Medical Center's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists ... C. 2. Medical Center is obligated to perform the Medical Screening Examination to determine if an emergency medical condition exists. It is not appropriate to merely "log in" a patient and not provide a Medical Screening Examination. 3. Medical Center must provide screening and stabilizing treatment within the scope of its abilities, as needed, to the individuals with emergency medical conditions who come to Medical Center for examination and treatment. 4. Individuals coming to the emergency department must be provided a Medical Screening Examination beyond triage. Triage is not equivalent to a Medical Screening Examination ... 6. Depending on the patient's presenting symptoms, the Medical Screening Examination may range from a simple process involving only a brief history & physical examination to a complex process that also involves performing ancillary studies and procedures including, but not limited to, lumbar puncture, clinical laboratory test, CT [computed tomography] scans and other diagnostic tests and procedures. 7. A Medical Screening Examination is not an isolated event but an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized ..."

A review of the facility's website - https://www.st-marys.org/centers-services/ - revealed the facility provides the following medical services, not limited to, but including: Laboratory services, Emergency Department, Intensive Care Unit, Hospitalist, medical/surgical services, and radiology service.

A medical record review was conducted for MR1. The patient presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 07/01/23 at 1:42 p.m. with a complaint of decreased level of consciousness (LOC). Vital signs were noted as: blood pressure (BP) 87/75, heart rate 80, respirations 20, and temperature of 98 degrees Fahrenheit. Patient 1 was accompanied by a Health Service Worker (HSW) from the outside facility.

A "Provider Note" by Physician 1, dated 7/1/23, states "[Patient 1] presented to the ED from [other facility] for evaluation of decreased responsiveness. A physical examination revealed the patient was awake and alert, but somewhat drowsy appearing and very pale, with stable vital signs. An EKG was completed but no interpretation was documented. Differential diagnoses included: ACS [acute coronary syndrome], sepsis, pneumonia, AKI [acute kidney injury], UTI [urinary tract infection], metabolic derangement, symptomatic anemia, and pancreatitis. Final diagnostic impression dehydration."

A "Nurse Free Text" note by Registered Nurse (RN) 2 on 07/01/23 at 3:41 p.m. states: "Critical Results Chloride 116 [states Physician 1's name] notified."


A "Nurse Free Text" note by RN 2 on 07/01/23 at 9:33 p.m. states in part the patient left the ED via EMS on 07/01/23 at 10:32 p.m., and vital signs during Patient 1's stay were noted as: 1:47 p.m.: BP 90/58; 3:40 p.m.: BP 93/63, pulse 95; 6:05 p.m.: pulse 99, respirations 15, BP 100/59; discharge: BP: 103/68, heart rate 93, respirations 16. There was no documented evidence in the medical record the patient refused any treatment.

There was no documented evidence the hospital identified the cause of a hemoglobin level of 7.3 (low), hematocrit 24.4 (low), Red Blood Count (RBC) 2.68 (low), White Blood Count (WBC) 13.2 (high), Chloride serum 116 (high), potassium 5.3 (low), Lactic Acid 3.1 (high), Ammonia 44 (high), Chloride 116 (high), Tropinin 43 (high), low blood pressure, and high pulse rate, and the provider failed to complete an appropriate MSE to identify the reason of decreased and elevated lab values, low blood pressure, high pulse rate and differential diagnosis of Acute Coronary Syndrome (ACS), sepsis, pneumonia, Acute Kidney Injury (AKI), metabolic derangement, symptomatic anemia, and pancreatitis in a patient who presented to the ED with complaints of syncope, unresponsiveness, and cyanosis.