HospitalInspections.org

Based on a review of facility policy and documents, and staff interviews (EMP), it was determined the facility failed to provide an appropriate medical screening examination within the capability of the hospital's Emergency Department.

Findings include:

Review of Southwest Regional Medical Center ' s Rules and Regulations. ... " 6.1(a) Screening: (1) Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition."

Review of the facility's policy "EMTALA - Definitions and General Requirements" dated April 1, 2011, revealed "The Facility with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development who ' comes to the emergency department ' an appropriate Medical Screening Examination (MSE) within the capability of the facility's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) exists regardless of the individual's ability to pay."

A review of a facility document dated February 5, 2015, indicated a patient presented to ED and triaged with a complaint of eye pain. Patient verbalized being seen at a nearby hospital ED and was told to follow up with the eye clinic. Patient did not follow up with the eye clinic due to cost. As a result, patient presented to ED and requested to be seen. Nursing staff discussed patient ' s situation with the ED physician. Nursing staff " did not want to bring any more burden on the patient, financially " therefore called a local eye doctor and scheduled an appointment for the patient. Patient then signed LWOT (left without treatment) paperwork and went to the eye clinic. The document also indicated that the ED physician believed it would have been unethical to complete a medical screening examination in an attempt to collect an emergency department fee when the patient had no insurance and did not have the money to pay, which patient made facility aware.

During an interview on February 13, 2015, at approximately 8:45 AM, EMP11 confirmed the above findings. When asked if there was a medical record for the patient, EMP11 stated, " No there is not, he never came into the back."

During an interview on February 13, 2015, at approximately 9:15 AM, EMP2 stated, " There is not a medical record, there was a quick reg. (registration) and the nursing documentation that they left before treatment."

Review of a " Complaint Statement and Statement Summary " dated February 2, 2015, indicated that a female and child presented to the ED registration window. The female requested that the child be seen for a cough. It was explained that the female was not the child ' s parent, but the appointed caregiver assigned by Children and Youth Services (CYS). The female had no records or information regarding the child. The ED staff called Children and Youth Services who suggested that the female and child be seen at another local hospital ED for treatment as that hospital had the child ' s records. The female and child left the ED without being seen.


During an interview on February 12, 2015, at approximately 9:15 AM, EMP1 stated, " A foster mother came in with a child to be checked. ... CYS was called and stated the child was from [another county] and to take the child to [nearby hospital]. The nurse relayed the message and the foster mother left with the child to take the child to [nearby hospital]. They were never seen by a physician."

During an interview on February 13, 2015, at approximately 9:00 AM, EMP2 stated, "There is no medical record for that incident. They were never seen."

Based on a review of facility policy and documents, and staff interviews (EMP), it was determined the facility failed to provide an appropriate medical screening examination within the capability of the hospital's Emergency Department.

Findings include:

Review of Southwest Regional Medical Center ' s Rules and Regulations. ... " 6.1(a) Screening: (1) Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition."

Review of the facility's policy "EMTALA - Definitions and General Requirements" dated April 1, 2011, revealed "The Facility with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development who ' comes to the emergency department ' an appropriate Medical Screening Examination (MSE) within the capability of the facility's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) exists regardless of the individual's ability to pay."

A review of a facility document dated February 5, 2015, indicated a patient presented to ED and triaged with a complaint of eye pain. Patient verbalized being seen at a nearby hospital ED and was told to follow up with the eye clinic. Patient did not follow up with the eye clinic due to cost. As a result, patient presented to ED and requested to be seen. Nursing staff discussed patient ' s situation with the ED physician. Nursing staff " did not want to bring any more burden on the patient, financially " therefore called a local eye doctor and scheduled an appointment for the patient. Patient then signed LWOT (left without treatment) paperwork and went to the eye clinic. The document also indicated that the ED physician believed it would have been unethical to complete a medical screening examination in an attempt to collect an emergency department fee when the patient had no insurance and did not have the money to pay, which patient made facility aware.

During an interview on February 13, 2015, at approximately 8:45 AM, EMP11 confirmed the above findings. When asked if there was a medical record for the patient, EMP11 stated, " No there is not, he never came into the back."

During an interview on February 13, 2015, at approximately 9:15 AM, EMP2 stated, " There is not a medical record, there was a quick reg. (registration) and the nursing documentation that they left before treatment."

Review of a " Complaint Statement and Statement Summary " dated February 2, 2015, indicated that a female and child presented to the ED registration window. The female requested that the child be seen for a cough. It was explained that the female was not the child ' s parent, but the appointed caregiver assigned by Children and Youth Services (CYS). The female had no records or information regarding the child. The ED staff called Children and Youth Services who suggested that the female and child be seen at another local hospital ED for treatment as that hospital had the child ' s records. The female and child left the ED without being seen.


During an interview on February 12, 2015, at approximately 9:15 AM, EMP1 stated, " A foster mother came in with a child to be checked. ... CYS was called and stated the child was from [another county] and to take the child to [nearby hospital]. The nurse relayed the message and the foster mother left with the child to take the child to [nearby hospital]. They were never seen by a physician."

During an interview on February 13, 2015, at approximately 9:00 AM, EMP2 stated, "There is no medical record for that incident. They were never seen."