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Based on record review and interview, the facility's emergency room staff failed to conduct a Medical Screen Examination which included monitoring of the patient's vital signs in 1 of 21 sampled patients who presented to the facility's emergency room requesting care and services. Patient #1

Findings:

Review of the Patient #1's emergency room clinical record, revealed the patient was brought to the facility's emergency room on 06/04/2022 by a family member (mother). The patient arrived in the emergency room at 2039 p.m. with chief complaint of "vomiting X 6 today. NB NB, Decreased UOP 3 wet diapers today."

A Medical Screen Examination was conducted at 2041 p.m. and completed at 2047 p.m. by an advanced medical practitioner, with the following documentation:

"Medical Screening Exam General MSE
Emergency Medical Condition. EMC Does Not Exist.
Patient Decision: Patient declines care in the EC. Risk / benefits of examination and treatment explained to patient/ surrogate.
TCH urgent care MSE.
Appropriate mental status. No respiratory distress, well profused yes. No significant medical condition. Chief complaint within scope of UCC yes. "

The Patient's emergency room record revealed no documented vital signs, done during the Medical Screening Examination of the patient, or the reason documented, it was determined the patient did not have an emergency medical condition.

ED Disposition: LWBS 8.47 p.m.: Comment "Recommended UC, mother became upset as she believed she would be sent back down to the ER. Told her she was more welcome to check in here; however, mother declined as I was recommending UC."

The record revealed the patient was given an option to be seen in the urgent care center which is not affiliated with the hospital's provider number or continue treatment in the emergency room.

Further review of the record revealed a discharge medication list for Amoxicillin PO susp 400 ms /5 ml, which was started on 5/27/2022 with end date of 6/23/2022.
The record revealed a follow-up call was made from the facility on 06/05/2022 at 1040 to the telephone number provided during admission.
" LWBS Follow up"

Interviewed Facility's Director of Clinical Services (A)
Interview on 7/25/2022 at 11.08 a.m. with Facility's Director of Clinical Services (A) revealed, she said the facility has an urgent care which is located on the second floor of the facility. This facility does not operate under the same provider number as the hospital, and it has a different leadership structure. She said patients who are medically screened in the facility's emergency room and do not have an emergency medical condition are given an option to be seen in the urgent care facility or continue care in the facility's emergency room. She said this model works especially well with the increase in patients' volume, but sometimes patients become confused when given the choice, between receiving care in the urgent care and the emergency room. She said the patients are not charged for the service received in the emergency room if transferred to urgent care.

Interviewed Assistant Clinical Director Emergency Room (B)
Interview on 07/25/2022 at 11:35 a.m. with the Facility's Assistant Clinical Director Emergency Room revealed she stated, "It's not a part of routine medical screen to do vital signs on patients." She said if the staff have additional information, they have the ability to do so. But staff use visualization and history taken during the medical screening of patients.

Interviewed Registered Nurse (Practitioner (G)
Interview via the telephone on 07/25/2022 at 1:24 p.m. with Registered Nurse Practitioner (G) revealed, while working in the emergency room on 06/04/2022 a two years old female presented to the emergency room with chief complaint of having six episodes of non -bilious, non- bloody vomitus X 1 day. The mother reported the patient had decreased urinary output x 3 wet diapers.

He said prior to entering the emergency room the patient was screened by screeners for elevated temperature, then he saw the patient, and conducted a Medical Screen Examination. He said the patient's mother explained the condition to him, and he looked to make sure the patient was hydrated by checking the patient's pulse and capillary refill. He said he checked the pulse during the Medical Screen Examination, but this was not documented. He then told the patient's mother that the patient met the criteria to be seen in the urgent care center because based on his evaluation the patient did not have an emergency medical condition, but was in the scope that the urgent care facility could treat.

He said the patient's mother was "a little upset" and told him that she believed that if she was sent to the urgent care center, she would be sent back to the emergency room.
He also told her that she was welcome to be treated in the emergency room. He said he had the patient's chart and was about to check the patient into the emergency room, when the patient's mother left with the child. She told him; she would go somewhere else. He said he did not know if the facility had further contact with the patient.

Interviewed Emergency Room Physician (J).
An interview was conducted on 7/26/2022 at 7.55 a.m. with Facility's Emergency Room Physician (J). The Physician was currently evaluating patients in the emergency room. He revealed he has been working in the facility's emergency room for approximately 2 years. He said Medical Screen Examination are done on all patients who enter the facility's emergency room requesting service. He said once the patient is screened then a determination is made whether service meets criteria for urgent care. The family is given an option to continue care in the emergency room or go to the urgent care center.

Interviewed Emergency Room Registered Nurse (F)
During an interview on 07/26/2022 at 8:30 a.m. with Registered Nurse (F) revealed she does medical screening of patients daily. She said the process includes the following:
The patient presents to the registration window and is asked to complete a simple form with their name, date of birth and reason for the visit. She then does a quick assessment of the patient which includes listening to the lung. She said no vital signs are done at this time. The patient then goes to the other window where they are provided with HIPPA forms. She said between the hours of 11.00 p.m. - 11.00 a.m. patients are given an option to be treated in the emergency room or the urgent care center, if during the medical screen it is determined that the patient does not have an emergency medical condition.

Reviewed Facility's Procedure on Medical Screening exam
Review of the Facility's current Procedure on Medical Screening Exam EC Procedure, #1357, directs staff as follows: Procedure Statement:
"A Medical Screening Examination (MSE) is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition. The MSE must be conducted by an individual who is determined qualified by hospital rules and regulations or bylaws to be a Qualified Medical Personnel (QMP). The Medical Screening Examination is an ongoing process that ranges from a simple process involving only a brief history and physical examination to a complex process involving ancillary studies and procedures, depending on the individual's presentation."