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Based on record review, interview with staff, and review of policy and procedures, the facility failed to ensure compliance with EMTALA Regulations 489.20 and 489.24 in that the facility failed to provide a medical screening exam and stabilizing medical treatment for 1 of 20 patients whose record was reviewed.

See findings:

The hospital failed to provide a medical screening exam. See A2406.

Based on record review, patient interview and facility staff interviews, review of EMTALA policies and procedures, the hospital failed to ensure that 1 of 20 sampled patients (Patient #1), who came into the Emergency Department requesting medical treatment, had an appropriate medical screening exam to rule out emergency medical conditions.

Findings include:

As indicated in the medical records pt. #1 presented to the emergency department (ED) of the hospital on 01/13/2012 complaining of back pain. A dictated note by the hospital's ED Physician's Assistant (PA) B, stated the following; "This is a 27 year old who is currently approximately 6 months pregnant who is brought into the ER because of right lower back pain that radiates down the back of her leg. Patient stated that she wanted to see her primary care provider (PCP), [. . .] but her boyfriend brought her here. She denies any chills, fevers, sweats, nausea, vomiting, diarrhea, or abdominal pain. No vaginal discharge or contractions." PA B (credentialed and qualified in emergency medicine) stated per interview on 01/19/2012 at 1:10 PM that he made the determination after a medical screening exam that pt. #1's condition was not emergent and contacted her PCP per her request. Stabilizing treatment of pt.#1's condition was not deemed necessary. PA B's emergency physician record dated 01/13/2012 indicates a very limited review of patient #1's disposition which fails to indicate the severity of pain or its onset. PA B failed to contact an OB physician to examine patient #1 as dictated by hospital policy.

Per interview by phone with MD A (the complainant) on 01/19/2010 at 1215 he stated he was not contacted directly by anyone at the hospital. He also expressed concern that pt. #1 was in pain at the hospital and did not receive treatment.

Per interview with PA B on 01/19/2012 at 1:10 PM pt. #1 requested to see her primary care physician (PCP) and have him treat her pain. Before discharging pt. #1 PA B stated he contacted her PCP and spoke to staff who agreed to see patient #1 as soon as she got there. PA B stated he did not consider pt. #1's condition to be emergent or even urgent. He stated that the transfer forms were only completed as an afterthought and he had initially treated the case as discharged.

Per interview with patient #1 on 02/20/2012 at 11:50 AM she arrived at the ED complaining of intense pain and could barely walk. She stated that the ED RN performed a cursory exam which consisted of pressing on her abdomen and the bottom of her feet. she also stated that she was never offered anything for her pain and was not seen by anyone except the ED RN who reported his findings to the PA. Patient #1 stated that she did not request to be sent to her primary care physician but instead was sent by the ED's PA.

Per interview with hospital CEO C on 01/19/2012 at 4:00 PM it is expected that a thorough medical screening exam be done of every patient presenting with an emergency medical condition.