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Based on a review of facility documentation, medical records and staff interview, the Department determined that the administrator failed to ensure that a medical record for two patients was established & maintained. This deficient practice poses the risk of patient treatment not being accurate, timely and continuity of care being compromised.

Findings include:

Policy #PI005 titled "EMTALA", last revised: July 12, 2022 revealed, "...Destiny Springs Healthcare shall provide a medical screening examination to any individual who comes to the Emergency Department...."

Facility documentation titled "EMTALA & Patient Flow" revealed, "...We must provide an MSE to EVERYONE who presents at our 'dedicated emergency department'..."

Facility document titled "EMTALA Log" identified the following patients and corresponding information:

Patient #11: November 1, 2024, Arrival: 2251, Car/Vehicle, Psych Emergency: No, Departure: 2320 Disposition: "911 called pt transferred to ER. SI and detox and No more information"

Patient #14: November 3, 2024, Consents Sent: 0940, Walk-in, Comments: "PENDING N2N Pt was released back to her GH Pending Consents"

Patient #11, and Patient #14 medical record were requested on November 13, 2024 and on November 15, 2024. None were provided.

Interview with Employee #2 and Employee #12 on November 15, 2024, confirmed that a medical records were not available to review for Patient #11 and #14.

Based on review of policies and procedures, medical records, facility documents, and staff interview, the Department determined that the administrator failed to ensure medical screening examinations (MSE) were completed according to facility policy to determine if an emergency medical condition existed. This deficient practice poses a risk to the health and safety of patients if life-threatening or potentially life-threatening conditions are not recognized and treated upon admission.

Findings include:

Policy #PI005 titled "EMTALA", last revised: July 12, 2022 revealed, "...Destiny Springs Healthcare shall provide a medical screening examination to any individual who comes to the Emergency Department...."

Facility documentation titled "EMTALA & Patient Flow" revealed, "...We must provide an MSE to EVERYONE who presents at our 'dedicated emergency department'..."

Facility document titled "EMTALA Log" identified the following patients and corresponding information:

Patient #1 ' s medical record revealed, "...Pt ' s MSE completed by day shift RN ..." A request was made for documentation of the MSE completed by the RN. None was provided. No other documentation of a completed MSE was revealed in the medical record.

Patient #11: November 1, 2024, Arrival: 2251, Car/Vehicle, Psych Emergency: No, Departure: 2320 Disposition: "911 called pt transferred to ER. SI and detox and No more information"

Patient #14: November 3, 2024, Consents Sent: 0940, Walk-in, Comments: "PENDING N2N Pt was released back to her GH Pending Consents"

Patient #1, Patient #11, and Patient #14 Medical Screening Exams were requested on November 13, 2024 and on November 15, 2024. None were provided.

Interview with Employee #2 and Employee #12 on November 15, 2024, confirmed that a MSE were not available to review for Patient #1, #11 and #14.