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Based on record review and interview, facility staff failed to provide an emergency medical screening exam sufficient to rule out an emergency medical condition for 1 of 20 patients reviewed (Patient #1), in a total sample of 20 patients.

Findings include:

The facility staff failed to complete a full medical screening exam for 1 of 20 patients (Patient #1) who presented to the Emergency Department. See Tag A-2406.

Based on record review and interview, facility staff failed to provide an emergency medical screening exam sufficient to rule out an emergency medical condition for 1 of 20 patients reviewed (Patient #1), in a total sample of 20 patients.

Findings include:

Review of Patient #1's medical record revealed Patient #1 presented to the Emergency Department (ED) on 10/13/2024 at 6:59 PM with complaints of lower abdominal pain. Patient #1's ED Narrator event log (timeline) pre-arrival documentation dated 10/13/2023 at 7:02 PM reveals, "Triage information...Patient arrives with c/o (complaint of) lower abdominal pain that started last night accompanied by nausea and multiple vomiting ...Other Complaints/Symptoms: Denies chest pain, diff (difficulty) breathing, urinary symptoms and blood in stools or urine."

Patient #1's event log dated 10/13/2023 at 7:05 PM, reveals, "Pain score: 7 (on 0-10 scale with 10 being highest); Pain Type: Acute Pain; Pain Location: Abdomen; Pain Descriptors: Aching; Pain Frequency: Continuous; Associative Factors ...Nausea, Vomiting."

Per the "ED Provider Note" authored by ED Physician Assistant J and dated 10/13/2023 at 7:31 PM, "...reports starting yesterday evening, began developing concerns of lower abdominal discomfort. ...uncertain if she may have pulled something in her abdominal wall. ...states in the middle of the night she started with new onset nausea and vomiting and estimates ...about 9 episodes of vomiting activity. ...states her abdomen was not causing her any significant pain immediately however, the more activity she began to do the more her pain returned. ...continues to report nausea but has not had recurrent vomiting. ...did not have a bowel movement today but did have diarrhea yesterday. Denies any dysuria (pain with urination) or hematuria (bloody urine) symptoms. Denies a prior history of abdominal surgeries. (Patient #1) did not take anything for pain today. No obvious recent fevers. No other concerns..."

Patient #1's medical records indicates that a urine specimen was collected 10/13/2023 with results indicating, "...Specimen...Clean catch urine: Epithelial (surface cells from skin, blood vessels, urinary tract or organs) cells: 3-5! (Reference range 0-2/HPF (high powered field)), Urine WBCs (white blood cells): Too numerous to count! (Reference range 0-2/HPF), Urine Bacteria 2+! (Reference range None seen/HPF) ...Laboratory results for "WBC (white blood cell) count (an indicator for infection) 10.0 (Reference range 4.0-11.0) ...'Positive' for Nitrites, 'Moderate' for Leukocytes and 'Trace' for Urine Blood. Normal results for these values are "Negative."

Review of Patient #1's ED Summary and Plan revealed, "...Differential diagnoses considered today include diverticulitis (inflammation of a diverticulum, especially in the colon), viral gastroenteritis (stomach flu), cystitis (inflammation of the bladder), dehydration, electrolyte disturbance (necessary minerals in blood), ureterolithiasis (kidney stone stuck in the ureter), less worried for but possible appendicitis (inflammation of the appendix)...Urinalysis appeared concerning for infection with positive nitrites (sign of possible urinary tract infection), moderate leukocyte esterase (sign of infection or inflammation in the urinary tract), many WBCs and 2+ bacteria. Urine was sent for culture. Medical chart review demonstrates (Patient #1) has not had a prior urine culture completed. Based on (Patient #1's) allergy list, will place (Patient #1) on Macrobid (antibiotic) for treatment of urinary tract infection. Recommend pushing fluids. (Patient #1) was given a prescription for Zofran to help with nausea symptoms. Follow-up instructions discussed. Instructions provided..."

There is no documented re-assessment of pain, nausea or vomiting after the triage note at 7:05 PM. There is no documentation in the medical record of the provider having assessed the patient for clinical signs and symptoms of a urinary tract infection after the urinalysis results.

There is no documentation of reassessment for resolution of patient #1's presenting symptoms prior to discharge on 10/13/2023. The medical screening examination was not sufficient to exclude additional emergency medical conditions contributing to the patient's presentation of abdominal pain, nausea and vomiting.

A review of Patient #1's medical record for ED visit of 10/14/2023 revealed Patient #1 was readmitted to the ED on 10/14/2023 at 5:34 PM with complaints of vomiting, nausea and worsening abdominal pain. A CT (computed tomography) scan of the abdomen was ordered revealing small bowel obstruction with umbilical herniation. Patient #1 was admitted as an inpatient per surgical consult recommendation.