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Based on interview, record review, review of a motor vehicle accident report and policy review, the facility failed to comply with the conditions of participation outlined in §489.20 and related requirements at §489.24: (refer to Appendix V). The facility failed to provide an appropriate MSE within the capacity and capability of the hospital to determine whether or not an emergency medical condition existed for one patient (Patient #15) of 20 sampled patients.

Findings include:

Patient #15 presented to the ED via ambulance on 4/14/24, following a motor vehicle accident. Patient #15's triage assessment contained complaints of pain in the jaw, knee, and pain in both the right and left leg. The ED Physician's examination did not include documented evidence that the hospital provided the necessary testing to rule out whether an emergency medical condition existed, and there was no documented assessment of the patient's tetanus vaccination status. As the patient was being discharged, he complained of inability to bear weight and severe lower leg pain. The patient was placed in a wheelchair, transferred into a cab, and discharged to his home. Upon the patient's arrival, he was unable to ambulate from the cab into his home without extensive assistance. Patient #15 was taken to urgent care later in the afternoon on 4/14/24, evaluated, and diagnosed with a left ankle fracture.

Investigation revealed that there was x-ray and CT imaging available at the time of Patient #15's presentation.

Review of a facility policy, "Emergency Medical Treatment and Labor Act (EMTALA)", dated 12/19/22, showed:

" ...Medical Screening Examination (MSE)- the screening process required to determine with reasonable clinical confidence whether an Emergency Medical Condition exists or a woman is in Labor. Such a screening must be done within the Capability of the Hospital's Dedicated Emergency Department, including on-call physicians. The Medical Screening Examination is an ongoing process that includes continued monitoring based on the individual's needs and must continue until the individual is either stabilized or appropriately transferred.

Based on interview, record review, review of a motor vehicle accident report and policy review, the facility failed to provide an appropriate MSE within the capacity and capability of the hospital for one patient (#15) of 20 sampled patients.

Findings include:

Review of a document, "Motor Vehicle Crash Report", dated 4/14/24, showed patient #15 was unable to maintain his lane and drove into an impact attenuator (a roadway device intended to reduce the damage to structures and vehicles should a collision occur). The vehicle sustained heavy front-end damage and was high centered on the impact attenuator.

Review of patent #15's EMR (electronic medical record) ambulance report, showed patient #15 arrived at the ED via ambulance on 4/14/24 at 3:27 a.m. Patient #15 was involved in a single car motor vehicle accident. Patient #15 stated he was going 60 mph (miles per hour) when he struck a guard rail. He was wearing a seat belt but, his vehicle did not contain an airbag. Patient #15 was noted to have a significant amount of blood on his face, arms and the front of his shirt.

Review of patient #15's EMR, dated 4/14/24, showed patient #15 was triaged at 3:28 a.m. by staff member I. Triage documentation indicated patient #15 was complaining of jaw, knee, and right and left leg pain, with a pain score of 3 out of 10. Patient #15 was seen and examined by staff member L at 3:45 a.m. The physician documented the patient had facial trauma, including a nasal fracture, two lacerations and an avulsion (severe wound where tissue bursts open due to force), as well as a couple superficial abrasions to his knees. At 7:06 a.m., staff member L documented patient #15 was ready for discharge. At 7:15 a.m., the ED adult assessment documented by nursing, showed patient #15 was complaining of knee, head, and left and right leg pain. Patient #15 was discharged at 7:29 a.m. to home, by self, and transported by a private vehicle.

During an interview on 5/21/25 at 7:41 a.m., patient #15 confirmed he had been involved in a motor vehicle accident on 4/14/24. Patient #15 remembered waking up after the accident, was unable to open the car door, and had to crawl into the passenger seat to get out of the vehicle. He was transported to the hospital via ambulance, but remembered few details about the hospital visit until he was being discharged. He stated he remembered telling the nurse that he could not walk and was in a lot of pain. Patient #15 said the nurse got him a wheelchair and told him the hospital was getting him a ride home.

During an interview on 5/21/25 at 7:53 a.m., staff member K said he remembered receiving report from staff member I and being told patient #15 was, "good to go," for discharge. Staff member K stated he recalled getting patient #15 out of bed and having to assist him to the restroom. Staff member K stated patient #15 was complaining of leg pain and said he could not walk. Staff member K stated he got a walker to assist patient #15 to the restroom and then assisted him to the car with a wheelchair. Staff member K stated he did not look at patient #15' record to determine if the patient's ankle pain was assessed. Staff member K said he assumed everything had been evaluated based on the report provided by the previous nurse, and patient #15 was cleared to be discharged. Staff member K said he should have investigated further but the facility had contacted the cab driver to pick up patient #15, and he had been discharged.

The medical record did not contain evidence that the hospital provided any further appropriate screening to determine the source of the patient's lower extremity pain and inability to walk, or evaluate the patient's tetanus vaccination status. Investigation showed that the hospital had x-ray and CT capabilities at the time the patient presented to the hospital.

During an interview on 5/29/25 at 4:00 p.m., staff member L said he was a physician at the ED who evaluated patient #15. Staff member L stated he was able to review patient #15's ED visit on 4/14/24. Staff member L stated the documentation of a patient's triage assessment was generally available for his review, and he usually quickly reviews the information prior to seeing a patient. Staff member L said, based on his notes, he may not have been aware of patient #15's lower extremity pain, other than patient #15 complained of knee pain and had some minor abrasions over the knees. Staff member L said he should have paid more attention, asked more specific questions, or documented better if the information related to the patient's lower extremity pain was mentioned in the triage notes.

During an interview on 5/21/25 at 7:00 a.m., NF2 stated that when patient #15 arrived at home by cab on 4/14/24 at about 7:30 a.m., patient #15 complained of pain in both of his lower extremities (legs) and was unable to get himself out of the vehicle and walk into the house without significant assistance. NF2 stated she phoned the hospital and asked if patient #15's lower extremities had been evaluated. NF2 stated she informed the nurse over the phone that both lower extremities (legs) were swollen and that patient #15 could not walk. NF2 stated the nurse responded that the lower extremities (legs) had not been evaluated, and the hospital was not aware patient #15 had a concern. NF2 stated that on 4/14/24 at 4:35 p.m., patient #15 was seen in urgent care for pain and inability to bear weight on his left foot and ankle and severe pain to his right heel. NF2 said patient #15 was found to have an ankle fracture. NF2 stated she took patient #15 to an orthopedic clinic for evaluation, and it was determined the ankle fracture did not require surgical intervention.

Record review of patient #15's urgent care record, dated 4/14/24 at 4:35 p.m. showed:
" ... Visual examination of the left foot reveals significant swelling of the foot and ankle. There is bruising over the lateral malleolus (the bony bump on the outside of the ankle joint). Patient is unable to bear weight. ..."

Record review of patient #15's urgent care left ankle x-ray report, dated 4/14/25, showed patient #15 had a left ankle fracture.

Review of patient #15's orthopedic clinic visit, dated 4/16/24, showed patient #15 had nasal bone fractures, bruising on his right heel, a right wrist sprain, swelling in lower extremities, and a left ankle fracture. The plan for care was documented as, "Plan: Ace wrap and boot brace immobilization left with partial weight bearing. Follow-up in 10 days for recheck with standing x-ray of the left ankle. ..." [sic]

During an interview on 5/21/25 at 12:03 p.m., staff member J said the medical director from the ED conducted a review of patient #15's presentation, and a gap in care was identified with a result of "high harm."

Review of a letter addressed to patient #15, dated 8/4/24, showed:
" ...We reviewed your medical records and included the appropriate clinicians to review your care. Our review was completed on the date of this letter. We determined that the ankle fracture was not evaluated at your emergency room visit. ..."

Review of a facility policy, "Emergency Medical Treatment and Labor Act (EMTALA)", with a review date of 1/21/25, showed:
" ...Medical Screening Examination (MSE)- the screening process required to determine with reasonable clinical confidence whether an Emergency Medical Condition exists or a woman is in Labor. Such a screening must be done within the Capability of the Hospital's Dedicated Emergency Department, including on-call physicians. The Medical Screening Examination is an ongoing process that includes continued monitoring based on the individual's needs and must continue until the individual is either stabilized or appropriately transferred.