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Based on hospital policy review, medical record review, physicians and staff interviews the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings included:

The hospital failed to provide a thorough medical screening examination, including ancillary services routinely available, to determine whether an emergency medical condition existed for 1 of 33 Dedicated Emergency Department (DED) records reviewed (Patient [Pt] #3)

~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406.

Based on policy review, medical record reviews and provider and staff interviews, the hospital failed to provide a thorough medical screening examination, including ancillary services routinely available, to determine whether an emergency medical condition existed for 1 of 33 Dedicated Emergency Department (DED) records reviewed (Pt #3)

The findings included:

Review of the EMTALA policy, last revised June 2020, revealed "...When an individual comes to the dedicated emergency department of the hospital and a request is made on the individual's behalf for a medical screening examination....the hospital shall provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available...to determine whether an emergency medical condition exists. ..."

DED record review, on 01/22/2025, revealed Patient [Pt] # 3, a 35-year old, arrived to the DED via private vehicle on 07/22/2024 at 0514 with an arrival complaint of fall. At 0532 the chief complaint was updated to "Leg injury (Pt c/c Fall; pt c/o Rt [right] foot and Lt [left] ankle pain; pt denies LOC [loss of consciousness]; pt states she lost her balance)...." Pain was recorded as a 7 out of 10 [where 0 is no pain and 10 the worst pain]. The pain was noted to be in the right foot and was listed as constant, burning, throbbing. Pt #3 was assigned an acuity of 4 [on a scale of 1-5, where 1 is most severe and 5 is least severe]. An ED Provider Note, date of service 07/22/2024 at 0730 revealed "...Chief Complaint....o Fall o Leg Injury Pt c/c [chief complaint] Fall; pt c/o [complaining of] Rt foot and Lt ankle pain....pt states she lost her balance [space] Patient presents for bilateral ankle pain....Patient states she was on her deck and twisted her ankle going down steps. Patient is able to bear weight but states lateral ankle pain bilaterally....The accident occurred 3 to 5 hours ago....while walking. The pain is at a severity of 9/10...."

Review of the physical exam did not reveal clear documentation of a detailed foot and ankle exam.

Patient #3, per record review, was discharged at 0730 and referred for orthopedic follow-up in one week.

Telephone interview with NP #3, on 01/23/2025 at 1155, revealed the Nurse Practitioner did not recall Pt #3. Interview revealed there were standing orders/ protocols that could be entered by the triage nurse, based on a patient's presenting complaints. NP #3 stated an ankle x-ray would show the foot but further stated if ankle x-rays were entered then the ankles were the areas of most concern. Interview revealed once a provider saw a patient the provider could make a different decision and order additional x-rays if needed. Interview revealed NP #3 "definitely" would have sent Pt #3 back for additional x-rays if there was a concern about the foot.

Telephone interview with MD #5, a Radiologist, on 01/24/2025 at 1130, revealed Pt #3 had "bilateral ankle x-rays." MD #5 stated an ankle x-ray would cover the ankle and about one third to one half of the foot could be seen on that x-ray, but an ankle x-ray was not the ideal way to image a patient if looking for a foot injury.