HospitalInspections.org

Based on record review, staff interviews, and policy review, the hospital failed to meet the EMTALA requirements for 1 of 1 patients reviewed (Patient #1) who presented to the Emergency Department with signs and symptoms of a possible emergency medical condition (EMC), including frequent epistaxis (nosebleeds), gingival bleeding, recent transfusion history, lightheadedness, and abnormal vital signs.

The facility did not conduct a comprehensive medical screening examination (MSE) capable of ruling out serious underlying causes such as a hematologic disorder. The facility prematurely discharged the patient home with instructions to follow up with ENT, despite continued symptoms and the availability of further diagnostic services (e.g., CBC, coagulation studies) within the hospital's capabilities.


The findings include:



Record review of the P#1's medical record revealed the patient received limited evaluation with physical exam (while lab work was obtained) however no documentation for PT/ PTT, Factor VIII was in the patient's medical record.While the Patient received nose clamp and oxymetazoline nasal spray, the documentation does not reflect that adequate hemostasis was achieved. Patient was apparently offered nasal tampon, however refused. Patient was subsequently discharged to home with what appeared to be ongoing epistaxis and was instructed to follow up with ENT. It does appear patient independently sought care at another hospital at a later time, however it does not appear that any hospital staff directed the patient to seek care at another hospital.

Based on Record review and interview the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the Emergency Department (including ancillary services) to determine whether an emergency medical condition (EMC) existed for Patient # 1 who presented with recurrent epistaxis, gingival bleeding, dizziness, and a history of recent transfusions.
Key evidence points: Specifically, the facility failed to ensure:

o A coagulation profile was ordered despite ongoing bleeding.
o Clinical documentation revealed differential diagnosis for possible hematologic disorder.


The facility did not conduct a comprehensive medical screening examination (MSE) capable of ruling out serious underlying causes such as a hematologic disorder. The facility prematurely discharged the patient home with instructions to follow up with ENT, despite continued symptoms and the availability of further diagnostic services (e.g., CBC, coagulation studies) within the hospital's capabilities.


The findings include:


Record review of the P#1's medical record revealed the patient received limited evaluation with physical exam (while lab work was obtained) however no documentation for PT/ PTT, Factor VIII was in the patient's medical record.While the Patient received nose clamp and oxymetazoline nasal spray, the documentation does not reflect that adequate hemostasis was achieved. Patient was apparently offered nasal tampon, however refused. Patient was subsequently discharged to home with what appeared to be ongoing epistaxis and was instructed to follow up with ENT. It does appear patient independently sought care at another hospital at a later time, however it does not appear that any hospital staff directed the patient to seek care at another hospital.