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Based on interview and record review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide a triage and medical screening exam (MSE) for 1 patient (P-1) of 20 patients reviewed, resulting in the potential for less than optimal outcomes for all patients seeking emergent care.

See tag
A-2406: Failure to provide MSE

Based on interview and record review, the facility failed to document information on the Emergency Department's central log for 1 (P-1) of 20 patients reviewed for fulfillment of Emergency Medical Treatment and Labor Act requirements, resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings incllude:

On 10/10/2024 at 1350, review of the discharge log for the past 8 months (03/2024-present) revealed no evidence of P-1 being registered as a patient at the facility with-in the dates reviewed as alleged in the complaint to the State Agency (SA). Review of the ED centralized log revealed no evidence of P-1 presenting to the facility's ED for services, on or around the alleged date (04/30/2024).

On 10/11/2024 at 0905, Chief Nursing Officer, Staff C, was queried as to her expectation of staff when a patient seeks ED services to which she stated, "Anytime a patient goes to the emergency room, requesting care, they should be placed on the central log, registered and have a screening done."

Review of policy: Emergency Medical Treatment and Active Labor Act (EMTALA) last revised 4/4/2022
(page 11 of 13), L. Centralized Log:: 1. All applicable [affiliated] hospital Emergency Centers and Labor and Delivery, shall maintain logs that identify the individuals who have presented for such services.
2. The logs shall include whether the individual refused treatment, were refused treatment, were
treated, were admitted, were stabilized, were transferred or were discharged.

Based on record review and interview, the facility failed to perform a medical screening exam for 1 (P-1) of 20 patients reviewed for fulfillment of Emergency Medical Treatment and Labor Act requirements, resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include:

On 10/10/2024 at 1350, review of the discharge log for the past 8 months (03/2024-present) revealed no evidence of P-1 being registered as a patient at the facility with-in the dates reviewed as alleged in the complaint to the State Agency (SA). One finding for P-1 was found dated June of 2023 and did not have the same events.

On 10/10/2024 at 0945, during an interview with the director of ED, Staff F, it was confirmed that "all patients seeking treatment must be triaged and documentation of the events must be completed."

On 10/11/2024 at 0905, Chief Nursing Officer, Staff C, was queried as to her expectation of staff when a patient seeks ED services to which she stated, "Anytime a patient goes to the emergency room, requesting care, they should be registered and have a screening done."

On 10/11/2024 at 1053, an interview was conducted with ED physician Staff L, who indicated that he was very familiar with P-1 due to previous behavior issues, and confirmed there was an incident where P-1 arrived to the ED and was only evaluated in the lobby. Staff L was queried if there was any documentation related to this visit, Staff L stated, "No I did not put the evaluation in writing. I should have had the documents [MSE] in place."

Facility policy titled "Emergency Medical Treatment and Active Labor Act" effective 04/04/2022, last revised: 04/04/2022 states,
Department."

III. GENERAL INFORMATION:

A. The emergency department is required to provide an appropriate Medical Screening Examination (MSE) to any individual (including an infant born alive, at any stage of development) who "comes to the emergency department." The MSE must be performed within the capability of the emergency department including ancillary services routinely available to the department. The MSE shall be conducted in a reasonable manner to evaluate whether an Emergency Medical Condition (EMC)exists. If it is determined that an EMC exists, the hospital must provide stabilizing treatment. The MSE must be provided regardless of the individual's ability to pay.

B. EMTALA requires hospital emergency departments do the following:
1. Provide an appropriate MSE to any individual who "comes to the emergency department."