HospitalInspections.org

Based on record review and interview the facility failed to ensure 1 patient (#14) who presented to the Emergency Department (ED) was provided with a medical screening exam (MSE) by a qualified provider to determine if a medical emergency existed. In addition the facility failed to provide a disposition for patient #14. Findings:

Review of the ED Activity Log on 9/4-5/14 revealed Patient #14 presented to the ED on 8/31/14 with a diagnosis of "burn". Review of the electronic medical record revealed the Patient presented to the ED at 2:43 pm and the record stated, "Registered in error". There was no documentation of a triage time; no physician note; no nursing note; no discharge note or disposition; and no documentation of an MSE being done.

During an interview and review of Patient #14's medical record, on 9/4/14 at 2:40 pm, the Director of ED was asked if the Patient had an MSE when he presented to the ED. She stated that Patient #14 was not triaged or seen in the ED and did not know what happened to him.

Review of the facility's policy "Emergency Medical Services and Emergency Medical Treatment and Labor Act (EMS/EMTALA) Definitions Procedure #713-01 Reference Policy: EMS/EMTALA Policy #713 A", revised 10/13, revealed "...Medical Screening Examination means the process required to determine within reasonable clinical confidence whether an individual has an Emergency Medical Condition."

Review of the facility's policy "EMS/EMTALA General Procedure #713-02" , revised 10/25/13, revealed "...This procedure applies to all individuals, even if they are not eligible for or cannot pay for other direct health care services, who: come to the Emergency Department and request or appear to need examination or treatment for a medical condition of any kind...A physician or qualified medical personnel will provide Medical Screening Examination to an individual to determine within reasonable clinical confidence whether the individual has an Emergency Medical Condition..."