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Based on document review and interview, it was determined that in 1 (Patient 31) of 31 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 exam.

Findings Include:

1. See findings cited at 42 CFR 489.24, A2406.

Based on document review and interview, the facility failed to provide an entry on the medical log for 1 of 31 patients that was brought to the facility (Patient 31).

Findings Include:

1. Review of Summary Report indicated that upon arrival at scene, patient 31 was at the clubhouse; had driven "gator type vehicle" into a dry creek bed; patient had no visible injuries but did not remember the incident. The patient arrived at facility ED on 06/28/19 at 6:30 pm after EMS called the ED to verify acceptance of patient. The ED physician P64 asked if patient had been ejected to which they stated patient "went over the front of the vehicle". Upon arrival in the ED, the physician approached the patient at the nurse's station and asked EMS how they got patient out of the vehicle; EMS responded that the patient was at the clubhouse and that by-standers indicated they had picked patient up from the ground. At that time, the ED physician P64 indicated it was a trauma and should have gone to a Trauma I Center. EMS asked physician if they should take to another facility and the response was "yes".

2. Patient was not registered for this encounter. There was no medical record created.

3. Interview on 08/16/19 at 9:10 am with P50 Director of Quality, confirmed an EMTALA violation occurred on 06/28/19 by not providing a facility entry on the emergency log .

Based on document review and interview, the facility failed to provide a medical screening on 1 of 31 patients (Patient 31) arriving at facility ED (Emergency Department).

1. Review of policy titled: Emergency Services Plan for the Provision of Patient Care and Services last approved 03/2019, indicated "All clients seeking medical care who present to the Emergency Department will be triaged by a Registered Nurse (RN)...will receive a medical screening exam by a staff Emergency Department physician".

2. Review of summary of the EMTALA violation, due to complaint from Emergency Medical Services on 07/11/19, indicated Patient 31 was brought to the facility Emergency Department on 06/28/19.

3. Patient 31 did not have a medical record.

4. Patient 31 did not receive a medical screening exam by a staff Emergency Department physician on 06/28/19.

5. Interview on 08/16/19 at 9:10 am with P50 Director of Quality, confirmed on 06/28/19 a medical screening exam was not provided to Patient 31.