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Based on interview and document review, the hospital failed to maintain compliance with 42 CFR 489.24 with respect to the Emergency Medical Treatment and Labor Act (EMTALA). The lack of compliance constitutes an immediate jeopardy to patient health and safety.

See findings at C-2406: Based on interview and document review, the hospital failed to ensure a timely comprehensive medical screening examination (MSE) was completed for 1 of 20 patients (P1) when P1 presented to the emergency department (ED) with complaints of sexual assault and was not assessed timely or acted upon to ensure a potentially life-threatening emergency medical condition (EMC) did not exist or worsen.

Based on interview and document review, the hospital failed to ensure a timely comprehensive medical screening examination (MSE) was completed for 1 of 20 patients (P1) who presented to the emergency department (ED) and were reviewed for an MSE. P1 presented to the ED with a complaint of sexual assault was not screened to identify any potentially life-threatening emergency medical condition (EMC) did not exist or worsen. This deficient practice resulted in an immediate jeopardy (IJ) for P1.

The IJ began on 7/25/23, at approximately 12:44 a.m. when P1 presented to the ED with a complaint of sexual assault. Medical doctor (MD)-A refused to do a medical screening examination on P1. At 2:55 a.m., per hospital ED logs, P1 left without being seen. P1 was not provided a MSE, nor was she provided a sexual assault nurse examiner exam (SANE). The quality coordinator (QO), vice president of operations (VPO), regional president and chief executive officer (CEO), and chief nursing officer (CNO) were notified of the notified of the IJ finding on 11/16/23, at 11:42 a.m.

Findings include:

The hospital ED record log dated 7/25/23, indicated P1, a 16-year-old female, presented to the ED on 7/25/23 at 12:44 a.m. with a complaint of sexual assault. The ED log also indicated P1 had left the ED prior to being seen.

On 7/25/23 at 2:59 a.m., a Physician Note written by MD-A indicated the facility was not able to complete a medical forensic exam on P1. P1 was informed she would have to travel 1.5 hours (to Sioux Falls, SD) for a sexual assault nurse examiner exam (SANE), and P1 did not want to do that. P1 was told if she changed her mind, she could go to Sioux Falls for the SANE exam anytime within the next 7 days. The note lacked information on why the hospital was not able to complete an MSE on P1.

On 7/25/23 at 10:55 p.m., a progress note indicated P1 had a second visit to the ED which indicated she returned to the ED at that time. P1 did receive an MSE, a SANE exam, was treated and discharged.

On 11/15/23 at 11:09 a.m., registered nurse (RN)-A stated she was the former director of the ED, but no longer worked for the facility. RN-A stated on 7/25/23, at about 2:00 a.m. she received a phone call from RN-B telling her MD-A refused to see P1. RN-A stated she and RN-B reviewed the current policy which indicated anyone aged 13 and under would have to go to Sioux Falls for a SANE exam, but this would not apply to P1 as she was 16. RN-A stated she told RN-B regardless, P1 would still need an MSE. RN-A stated the next morning she reached out to the VP of Operations, who advised her to contact the patient advocate (PA)-A, and see if P1 could come back into the ED. RN-A stated they did not have a phone number to contact P1, and that is why they had to contact PA-A. RN-A stated she did this, and P1 came back into the ED later that evening on 7/25/23.

On 11/15/23 at 12:05 p.m., MD-A was interviewed. MD-A stated he evaluated P1 by watching her on the video camera when she entered the hospital. When asked if this constituted an MSE, MD-A stated, "For this patient, yes." MD-A stated he watched for "guarding" and any signs of injury. MD-A stated he did not do a face-to-face exam on P1, and never went into her room. MD-A stated he did not want to see P1 because it would be a traumatic event for P1 if he had to enter the room more than once. MD-A agreed it would be traumatic for P1 to have to return to the ED at a later time for a MSE and SANE exam.

On 11/15/23 at 12:34 p.m., RN-C stated she triaged P1 and brought her to an exam room. RN-C stated MD-A did not complete an MSE on P1; he never went into P1's room. RN-C stated MD-A did not talk with P1. RN-C stated she printed off the policy for MD-A but was unsure if he read it. RN-A stated MD-A told her he would not see anyone under the age of 18 for a sexual assault exam.

On 11/15/23 at 1:29 p.m., PA-A stated she was contacted to come to the ED as a patient advocate for P1. PA-A stated when P1 was offered to go to Sioux Falls, it was not something she wanted to do. PA-A stated RN-A contacted her later on 7/25/23, to ask if she could contact P1 and convince her to come back to the ED. PA-A stated she was able to do this, and she was with P1 when she returned to the ED at 10:55 p.m. PA-A further stated for a victim of sexual assault, it would be traumatic for that patient to have to return to the ED a second time for a SANE exam.

On 11/15/23 at 1:48 p.m., the chief medical officer (MD)-B stated he was aware of P1 not receiving an MSE the first time she presented at the ED on 7/25/23. MD-B stated he would not consider viewing a patient on the camera to be an acceptable MSE. MD-B stated he would have expected an MSE to have been completed on P1 when she presented to the ED on 7/25/23, at approximately 12:44 a.m.

On 11/15/23 at 2:20 p.m., the Chief Nursing Officer, CNO stated she would have expected MD-A to have completed a MSE on P1 when she presented to the ED on 7/25/23, at approximately 12:44 a.m. The CNO stated the expectation was all patients who presented to the ED received a MSE within 30 min or less. The CNO stated a MSE would include assessing the patient in an exam room, and not by watching a video camera of a patient walking into the hospital's ED. The CNO verifed P1 left the ED on 7/25/23, at approximately 2:44 a.m. without receiving either an MSE or a SANE exam. The CNO stated there had been confusion about the age requirements of patients who presented to the ED that required a SANE exam; however, the current policy in place had been patients under the age of 18 were to have received a SANE exam at the hospital. The CNO stated the hospital contacted the patient advocate, and P1 returned to the ED on 7/25/23, at approximately 10:55 p.m. at which time P1 had received both an MSE and a SANE exam.

The facility policy Emergency Medical Treatment and Labor ACT approved 7/23, directed an MSE will be provided to any individual who presents to the ED. An MSE is defined as an examination within the capability of the ED, including ancillary services routinely available in the ED, to determine with reasonable clinical confidence whether an emergency medical condition exists.

The facility policy Sexual Assault Evidence Procedure approved 5/23, directed the purpose is to obtain evidence from the sexual assault victim who is at least 13 years of age to sustain criminal proceedings against the suspect, to provide physical treatment if necessary, give emotional and psychological support, and to maintain the patient's dignity, safety and privacy.

The IJ was removed on 11/21/23, at 10:52 a.m. when it was verified the hospital had submitted and implemented an acceptable removal plan which included policy review and appropriate education and training of all employees, including emergency department technicians, licensed nurses, mid-level practitioners, and medical doctors. This was verified through interviews, policy review and education transcripts/training attendance records