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Based on policy review, medical record reviews, and physician interviews, the hospital failed to comply with 42 CFR §489.24.

The findings included:

The hospital failed to ensure an appropriate medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) by failing to show evidence of discussion of the risks of refusing the medical screening to 1 of 20 sampled patients who presented to the DED requesting care and left without being seen. (Patients #9)

~cross refer to §489.24(a) & §489.24(c), Appropriate Medical Screening Exam - Tag A2406

Based on policy review, medical record review and physician interview, the hospital staff failed to document discussion of the risks of refusing a medical screening examination and the benefits of staying to complete the medical screening examination for 1 of 20 sampled patients that presented to the hospital's Dedicated Emergency Department (DED) (Patient #9, visit #2).

The findings included:

Review of the facility policy, (named health system) Emergency Medical Treatment and Labor Act (EMTALA), revised 01/2022, revealed, " ... Definitions: ... Medical Screening Exam (MSE): A process of sufficient scope required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC (emergency medical condition) or not. The MSE shall be reasonable calculated to identify critical medical conditions that may be afflicting a symptomatic individual and shall be consistent among individuals presenting with the same complaints or symptoms ... Refusal of Examination: ...if the (named health system) hospital offers to examine or treat an individual who presents for emergency care or evaluation of contractions and explains to the individual the risks and benefits of such examination and/or treatment and/or non-treatment, and the individual voluntarily withdraws his or her request for such examination and/or treatment, (named facility) must document specific information in the individual ' s medical record ... (named facility) shall take all reasonable steps to obtain a written informed refusal of the examination or treatment. If the individual leaves the hospital before staff can obtain a written informed refusal form the individual before the individual leaves, document staff ' s inability to obtain the written for in the individual ' s medical record ..."

Visit #2
Closed medical record review of Patient #9 revealed a 57-year-old female who presented to the DED on 10/31/2022 at 1905 with complaints of being involved in a MVC (motor vehicle collision). Review of Triage Vital Signs at 1932 revealed the following: Temperature - 99F, Blood Pressure -119/70, Pulse - 85, Respirations - 16, Pulse Oximetry - 100% on Room Air, Pain - 10/10 (acute pain). Review of the ED Triage Note dated 10/31/2022 at 2000 revealed, " ...mvc on Saturday and she was seen then and had xray done. Pt stated she felt she heard a "pop or crack" on her left side ribs (leaning over) and now pt states pain and sh (sic) (shortness) of breath has worsened. 100% on ra (room air) in triage. No noted distress. Review revealed orders for x-rays of the chest at 2009 and CT of the chest at 2010. Patient #9 ' s x-ray imaging began at 2035 and resulted at 2102. Review revealed that the CT scan was not completed. Review of ED Notes dated 10/31/2022 at 2146 revealed, "Patient approached this RN and stated they wished to leave. This RN reviewed the patient ' s chart and notified the patient of their plan of care. Patient encouraged to stay in order to complete their care. Patient declined. This RN removed patient's armband, IV Intravenous line for medication administration), and patient exited through main ED door in no acute distress. Charge RN notified." Patient #9 left the DED at 2147 and was discharged from the system as left without being seen at 2354.

Interview on 03/08/2023 at 0928 with MD #4 revealed that she provided oversight for the Radiology Department. Interview revealed that each radiologist used a free form format for the reading of x-rays. Interview revealed that it was common practice to only mention explicit abnormalities, so the absence of a broken bone on the report meant that the bones were normal. Interview revealed that when the radiologist noted important or emergent findings, the ordering provider was notified provider to provider. Interview revealed that a CT scan is more sensitive to finding fractures than an x-ray due to artifact or obscuring due to body types. Interview revealed that a non-displaced rib fracture would be difficult to find on a plain x-ray film.

Interview on 03/08/2023 at 1120 with MD #3 revealed that he read the x-ray from Patient #9 ' s 10/29/2022 DED visit. Interview revealed that MD #3 had over 25 years of radiology experience and used standardized templates for his readings. Interview revealed that MD #3 reviewed everything on the film, but for brevity, it is not included in the dictation. Interview revealed that MD #3 included the pertinent findings and called the ordering physician to relay any abnormal findings. Interview revealed MD #3 reviewed the images from Patient #9 ' s DED visits and did not see any fractures in the ribs. Interview revealed that a CT scan of the chest was far more superior to the chest x-ray in diagnosing fractures.

Interview on 03/08/2023 at 1205 with MD #1 revealed that he was the treating provider of Patient #9 ' s 10/29/2022 DED visit. Interview revealed that MD #1 did not recall Patient #9 specifically, but reviewed the medical record prior to interview. Interview revealed that Patient #9 had complaints of chest tenderness and that x-rays were ordered. Interview revealed that both MD #1 and MD #3 read the x-rays as negative for fractures. Interview revealed that Patient #9 was diagnosed with a chest wall contusion and sent home with pain medication. Interview revealed that Patient #9 left before being seen by a medical provider on 10/31/2022 (Visit #2). Interview revealed that with Patient #9 ' s continued complaints of pain and the "pop/crack" complaint would warrant a higher level of radiology like a CT scan, which was not completed prior to Patient #9 ' s facility departure. Interview revealed that the treatment for a non-displaced fracture was similar to treatment for the chest wall contusion and would require analgesics/anti-inflammatory medications. Interview revealed that non-displaced rib fractures would heal on their own. Interview revealed that displaced rib fractures would warrant consultation from orthopedics depending on severity.

In summary, Patient #9 returned to the DED on 10/31/2022 seeking evaluation of pain and shortness of breath following a motor vehicle collision. A medical screening examination was not started and the patient notified DED staff that she was leaving. The staff failed to document risks of leaving and Patient #9's refusal of an examination. DED staff failed to follow the hospital's EMTALA policy.