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METHODIST RICHARDSON MEDICAL CENTER
COMPLIANCE WITH 489.24
Tag No.: A2400
Based on record review and interview, the facility failed to ensure compliance with § 42 CFR 489.24 Emergency Medical Treatment and Labor Act (EMTALA), in that,
~ the facility failed to ensure a medical screening examination (MSE) for all patients presenting for treatment, in that, 1 of 20 patients (Patient #1) did not have a documented MSE for her 5/05/2023 visit.
Cross reference Tag A-2406
MEDICAL SCREENING EXAM
Tag No.: A2406
Based on record review and interview, the facility failed to ensure a medical screening examination (MSE) for all patients presenting for treatment, in that, 1 of 20 patients (Patient #1) did not have a documented MSE for her 5/05/2023 visit.
Findings
Patient #1's record reflected, "5/5/2023 Arrival 03:27 via Ambulance Acuity: Urgent
Arrival Complaint: SOB (shortness of breath)...Chief Complaint: Abdominal Pain...SOB...Nurse Notes: 0327 Pt arrives by EMS (ambulance)...after leaving ER about a hour ago. Pt c/o SOB (complaint/shortness of breath) and abdominal pain...0412 Dr. (Personnel #6) at bedside...07:16 Discharge."
There was no documented MSE by a provider.
The patient had an ED Visit on 5/4/2023 with arrival of 21:03 and discharged at 01:00 (5/05/2023). This MSE was documented. The patient returned/came back to the ED via ambulance on 5/05/2023 at 03:27.
Subsequently, the patient went to another hospital on 5/05/2023 at 10:02. The patient was taken for emergent caesarean section, and hematoma evacuation due to concern for a catastrophic obstetrical complication. The infant delivered and required immediate CPR with ultimate demise.
During record review and interview on 6/29/23 ending at 11:16 AM, Personnel #2, #3, and #4 were present. Personnel #4 navigated the Epic chart and confirmed there was no provider note (MSE) for the 5/05/2023 return visit where the patient came back via ambulance. Personnel #2 called Personnel #5 on the phone and asked if she could locate a physician evaluation of the patient brought in by ambulance on 5/5. Personnel #5 stated No, I don't see one. They were asked if they had any questions. Personnel #2 stated No ma'am.