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Based on record review and interviews, the facility did not provide a complete medical screening exam (MSE) for 1 of 20 patients (Patient # 3), in that, there was no documentation that a medical screening examination was completed on Patient #3 who presented to the Emergency Department (ED) on 04/10/11 for the second time with the new complaint of loss of consciousness (LOC). LOC was not addressed by Personnel # 8 who was assigned to perform Patient #3's MSE.

Findings Included:

Medical Record # 2 for Patient #3 timed 3:36 PM to 4:11 PM (according to Disposition Information in medical record) included that Patient #3's Chief Complaint was LOC (Loss of Consciousness)/Vomiting/Abdominal Pain. Patient #3's medical record (MR) did not contain an MSE of body systems, and had no reference to his new complaint of a "loss of consciousness." There were no ED "T-sheets" with manual documentation of any clinical details found on an exam by Personnel #8.

In an interview at 5:15 PM on 12/28/11 with the ED Director (Personnel # 3), she verified the absence of the manual ED "T-sheets," used to document the clinical MSE, in Patient # 3's second ED medical record for 04/10/11.

In telephone interviews with both the PA (Personnel # 8) at 11:15 AM on 12/29/11 and the ED Team Leader (Personnel # 5) at 12:35 PM on 12/29/11, they each confirmed they had not been aware of the new chief complaint of a "loss of consciousness" by Patient # 3, and therefore, had not been addressed by a MSE.

No clinical documentation was in the record to affirm that a MSE had been performed.

Cross refer to A2406.

Based on interview and record review, the facility did not maintain a central log on each individual who came to the emergency department seeking assistance, in that, 1 of 20 patients (Patient # 3) was not listed in the computerized ED Log for his 2nd visit on the same day (04/10/11).

Review of the 2 Emergency Department (ED) Medical Records (MR's) for Patient # 3 on 04/10/11 confirmed he had presented to the ED twice on that day, and noted the following:

Medical Record # 1:
- 7:08 AM to 10:41 AM (according to Disposition Information in MR).
- Discharge Disposition: ER (Emergency Room) Discharge - Home.
Medical Record # 2:
- 3:36 PM to 4:11 PM (according to Disposition Information in MR).
- Discharge Disposition: Discharge -Due to error, with a computer discharge time (4:11 PM).

Review of the ED Central Log for the 2 ED visits for Patient # 3 on 04/10/11, revealed that his first visit was documented in the log, and did have a discharge disposition of "home."

The ED Central Log had no record of Patient # 3's second visit on 04/10/11, even though the facility had a medical record documenting the patient's 2nd visit on that day. Therefore, the facility had not maintained the ED Central Log to reflect all aspects required to be contained in the log, which included discharge disposition.

In a telephone interview at approximately 4:00 PM on 12/29/11 with the Director of Regulatory & Accreditation (Personnel # 1), she confirmed that the ED Patient Log did not have a record of Patient # 3's second visit to the ED on 04/10/11.

Based on record review and interviews, the facility did not provide a complete medical screening exam (MSE) for 1 of 20 patients (Patient # 3), in that, there was no documentation that a medical screening examination was completed on Patient #3 who presented to the Emergency Department (ED) on 04/10/11 for the second time with the new complaint of loss of consciousness (LOC). LOC was not addressed by Personnel # 8 who was assigned to perform Patient #3's MSE.

Findings Included:

Review of the 2 ED medical records (MR's) for Patient # 3, dated 04/10/11, revealed the following:

Medical Record # 1:
- 7:08 AM to 10:41 AM (according to Disposition Information in MR).
- Chief Complaint: Abdominal Pain.
- Treatment: Computer documentation date & time stamped a MSE at 9:06 AM on
04/10/11, by a Family Nurse Practitioner (FNP)(Personnel # 9), which was used as a
"Rounding Timer," and contained no clinical details. Included in Patient # 3's MR was a
detailed MSE of body systems that had been manually documented on the ED "T-sheets"
by the FNP. She ordered extensive blood and urine labwork, all with negative results,
except the urine drug screen that was positive for marijuana, barbiturates, and opiates.
Patient # 3 was treated with a bolus of intravenous (IV) fluid, and received an non-opioid
analgesic, and an antiemetic. He was discharged with prescriptions for abdominal cramps,
a gastric acid blocker, an antiemetic, and an anti-hypertensive.
- Discharge Instructions: Included to "follow up at Urgent Care Center or your primary care
doctor...take bentyl (Dicyclomine) for pain...stop smoking...return for any new or worsening
symptoms...Phenergan (Promethazine) may make you sleepy...stay on bland diet."
- Discharge Disposition: ER (Emergency Room) Discharge - Home.
- Primary Diagnosis: Abdominal Pain.
- Secondary Diagnosis: Marijuana Abuse.

Medical Record # 2:
- 3:36 PM to 4:11 PM (according to Disposition Information in MR).
- Chief Complaint: LOC (Loss of Consciousness)/Vomiting/Abdominal Pain.
- Nursing Assessment: The Triage nurse (Personnel # 6) documented in a note at 4:00 PM, a
"Chief Complaint: Abd (abdominal) pain," and that patient had complained of "generalized
weakness and syncopal episode at home, denies hitting head...," but she had not included
the new complaint of "loss of consciousness" on this return ED visit that day.
- Nursing Reassessment: The ED Team Leader (Personnel # 5) noted at 4:09 PM that
"Pt (patient) seen by MD (doctor) today...pt dc' d (discharged) home...went to (another
hospital)...now back again...spoke with prior treating MD - pt does not have emergent
condition and needs to get meds filled...does not (need) to sign back in."
Personnel # 5 noted at 4:10 PM she "explained discharge instruction with pt again."
- Discharge Disposition: Discharge - Due to error, with computer discharge time of 4:11 PM.
- Treatment: Computer documentation date & time stamped a MSE at 4:32 PM on
04/10/11, by a Physician Assistant (PA)(Personnel # 8), which was used as a "Rounding
Timer," and contained no clinical details. Patient # 3's MR did not contain a detailed MSE
of body systems, and had no reference to his new complaint of a "loss of consciousness,"
as there were no ED "T-sheets" with manual documentation of any clinical details found on
an exam by the PA, and no orders for treatment was written.
- At 4:53 PM, the last documentation in the MR, noted by the PA, was that the patient was
"waiting for Treatment/Bed," which was 42 minutes after the computer discharge time of
4:11 PM.
- Post Disposition: At 4:54 PM the physician (Personnel # 10) who had seen Patient # 3 at
an earlier visit this day, documented in the computer MR that he had ordered Promethazine
(Phenergan) suppositories, as needed for nausea/vomiting, and noted "prescription printed
post-discharge." This order occurred 43 minutes after Patient # 3 had been discharged
from the computer system at 4:11 PM.
- Discharge Instructions: None found in this 2nd MR on 04/10/11.
- Primary Diagnosis: Blank (according to Disposition Information in MR).
- Secondary Diagnosis: Blank (according to Disposition Information in MR).

In an interview at 5:15 PM on 12/28/11 with the ED Director (Personnel # 3), she verified the absence of the manual ED "T-sheets," used to document the clinical MSE, in Patient # 3's second ED medical record for 04/10/11.

In a telephone interview at 11:15 AM on 12/29/11 with the PA (Personnel # 8), when asked if he had performed a MSE on Patient # 3, he said "yes," and that "it was a stable, normal exam." When asked if he had assessed the patient for a "loss of consciousness," he said that "he didn't know that was part of why the patient was in the ED," and that "he thought the patient was there for abdominal pain." When asked if he had documented his assessment on the manual "T-Sheets" used in the ED, he said "yes," and when he was informed that the T-Sheets were not in the medical record, he said "they get lost, and he didn't know what happened to them." When asked about computerized documentation, he stated that "the computer only records the time he actually sees the patient." When asked if the Team Leader (Personnel # 5) had told him not to do the MSE, he said "he did not remember her saying that."

In a telephone interview at 12:35 PM on 12/29/11 with the ED Team Leader (Personnel # 5), when asked if she remembered if the PA (Personnel # 8), had done a medical screening exam on Patient # 3, she said "yes, he did." When asked if the patient's loss of consciousness after leaving the ED earlier that day had been addressed, she said she "didn't know if she knew about the LOC." When informed the record did not include the T-Sheets where the PA's assessment would be documented, she said "she had no idea what could have happened to them." She stated that both the PA (Personnel # 8), and the Patient Advocate (Personnel # 7), had called her because the patient's mother (grandmother) was irate. When asked if she had told the PA not to do a MSE, she said "no." She stated that the mother said that the patient could not keep down the medication prescribed for him that morning, and she had obtained a suppository form of Phenergan for him from the prior MD who had seen him (Personnel # 10). She also said that the mother had refused that prescription and they had left. She stated that "the patient had not been refused a MSE."

No clinical documentation was in the record to affirm that a MSE had been performed.