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Tag No.: C0271
A. Based on CAH policy, review of medical records and interview, it was determined that in 1 of 10
(Pt. #2) patients presenting to the Emergency Department, the hospital failed to ensure that the emergency medical screening exam is provided in accordance with written policy.
Findings include:
1. The CAH policy titled, "Triage and Medical Screening of Emergency Department Patients," under procedure 4. b. "the Emergency Department physician will do a hands on medical screening of the patient."
2. The medical record of Pt. #2 was reviewed on survey date 1/12/10. Documentation on the Physician Medical Screening Examination Record failed to indicate a "hands on" assessment was performed by the physician.
3. During an interview with the Chief Nursing Officer on 1/14/10 at 11:30 am, the above finding was confirmed.