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Based on record review, interview, and policy review, the hospital failed to perform a medical screening examination (MSE) for one patient (Patients (P)1) of 20 Emergency Department (ED) records reviewed when the patient presented to the ED on 04/23/23 seeking care. This failure had the potential to harm all patients who present to the ED and request an exam.

Findings include:

Review of the nursing notes dated 04/23/23 at 10:09 PM located in the medical record revealed,"[P1] is a 19 y.o. [sex] with a past medical history of anxiety and depression, who presents to the emergency department for evaluation of fall. Patient was riding a motorized skateboard this evening down a hill and tried to slow down and flew off of it. [He/she] was not wearing a helmet and may have hit [his/her] head. +LOC. [He/she] remembers waking up and someone calling EMS. On EMS arrival patient was initially confused. [He/she] states this only lasted a few seconds and [he/she] states [he/she] quickly came back to baseline. [He/she] endorses just abrasions over the right face, left elbow and right leg without any pain in these areas."

Review of the physical examination documented by MD2 located in the medical record dated 04/23/23 at 10:09 PM revealed, " ...Head: Normocephalic, + superficial abrasions over the right face with hematoma over the right forehead..."

Review of the medical record revealed a "Medical Decision Making" documented by MD2 that revealed, :"4/23/2023 10:32 PM-Medical Decision Making: Medical Decision-Making (P1) is a 19 y.o. male with a past medical history of anxiety and depression, who presents to the emergency department for evaluation of fall off of a motorized skateboard with +LOC. On arrival normal vitals, blood pressure here is 163/80. Primary exam negative for acute life threat...According to Canadian CT head rules, patient does not require a CT of his head at this time. Although patient has abrasions over his face and hematoma over his right forehead, he has no significant tenderness in these areas, and I have low suspicion for facial fracture. Patient does not require further work-up at this time...At this time, he may have a concussion, and I have given referral to the concussion at work."

Cross Refer to 2406.

Based on observation and staff interview, the facility failed to post in the emergency department (ED) or in a place or places likely to be noticed by all individuals entering the ED, and individuals waiting for examination and treatment in areas other than traditional ED an EMTALA (Emergency Medical Treatment and Labor Act) sign specifying the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor.

Findings include:

During a tour of the ED on 11/04/24 at 1:55 PM with the ED Nurse Manager (EDNM2), observation failed to identify EMTALA signage in the patient entrance to the ED. Upon entering the ED waiting area, observation did not reveal EMTALA information was posted. Interview at the time EDNM2 stated the sign used to be on the wall in the ED waiting room. After some looking the EMTALA sign was found behind a vertical electronic signboard. EDNM2 had to remove the vertical electronic signboard before the EMTALA sign could be visualized. EDNM2 confirmed the EMTALA sign was completely covered by the signboard and was not visible to patients coming into the ED.

Based on record review, interview, and policy review, the hospital failed to perform a medical screening examination (MSE) for one patient (Patients (P)1) of 20 Emergency Department (ED) records reviewed when the patient presented to the ED on 04/23/23 seeking care. This failure had the potential to harm all patients who present to the ED and request an exam.

Findings include:

Review of the policy titled, "EMTALA Compliance, Including Patient Transfers (Emergency Medical Treatment and Labor Act) (GC Market)" dated 10/28/24 revealed, " ... 'Emergency Medical Condition' or 'EMC' means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
o Placing the health of the individual (or, in the case of a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
o Serious impairment to bodily functions.
o Serious dysfunction of any bodily organ or part.
'Medical Screening Exam' or 'MSE' means examinations, tests, studies, monitoring, and procedures that are appropriate given the individual's presenting signs and symptoms and reasonably calculated to determine if an EMC is present, including ancillary services routinely available to the emergency department ...'Stable' or 'Stabilized' means that no material deterioration of the individual's condition is likely, within a reasonable medical probability, to result from or occur during the transfer of the individual. In other words, the EMC that caused the individual to seek care is Stable, even though the underlying condition may still exist ..."

Review of the "Canadian CT Head Rule" revealed, " ...CT of head is only required for minor head injury patients with any one of these findings ...dangerous mechanism (pedestrian occupant ejected fall from elevation.) ..."

Review of P1's medical record revealed P1 arrived at the hospital ED on 04/23/23 at 9:34 PM with a chief complaint of falling. P1 was triaged at 9:46 PM.
Review of the nursing note dated 04/23/23 at 9:46 PM located in the medical record revealed," Chief Complaint: Trauma (Riding skateboard this evening without helmet, crashed on concrete, - helmet. + LOC [loss of consciousness], initially confused on EMS [Emergency Medical Services] arrival and hypertensive @ 200/100 [blood pressure]. GCS [Glasgow Coma Scale- a clinical tool that measures a patient's level of consciousness by assessing their eye, verbal, and motor responses also used to guide medical care and monitor patients after a brain injury, such as a car accident] was 15, Trauma cleared, and c-collar [cervical collar] removed on arrival to ED."

Review of the nursing notes dated 04/23/23 at 10:09 PM located in the medical record revealed,"[P1] is a 19 y.o. [sex] with a past medical history of anxiety and depression, who presents to the emergency department for evaluation of fall. Patient was riding a motorized skateboard this evening down a hill and tried to slow down and flew off of it. [He/she] was not wearing a helmet and may have hit [his/her] head. +LOC. [He/she] remembers waking up and someone calling EMS. On EMS arrival patient was initially confused. [He/she] states this only lasted a few seconds and [he/she] states [he/she] quickly came back to baseline. [He/she] endorses just abrasions over the right face, left elbow and right leg without any pain in these areas."

P1 received ibuprofen (Motrin) 800 milligrams (mg) per physician orders at 9:55 PM. There was no pain assessment related to this medication administration in the medical record.

Review of the physical examination documented by MD2 located in the medical record dated 04/23/23 at 10:09 PM revealed, " ...Head: Normocephalic, + superficial abrasions over the right face with hematoma over the right forehead..."

Review of the medical record revealed a "Medical Decision Making" documented by MD2 that revealed, :"4/23/2023 10:32 PM-Medical Decision Making: Medical Decision-Making
(P1) is a 19 y.o. male with a past medical history of anxiety and depression, who presents to the emergency department for evaluation of fall off of a motorized skateboard with +LOC. On arrival normal vitals, blood pressure here is 163/80. Primary exam negative for acute life threat...According to Canadian CT head rules, patient does not require a CT of his head at this time. Although patient has abrasions over his face and hematoma over his right forehead, he has no significant tenderness in these areas, and I have low suspicion for facial fracture. Patient does not require further work-up at this time...At this time, he may have a concussion, and I have given referral to the concussion at work."

Review of the medical record revealed P1 was discharged from the facility on 04/23/23 at 10:59 PM.

The ED attending physician documented the following attestation in P1's medical record,
"4/24/23 at 6:27 PM I have seen the patient concurrently with the resident. I agree with their history, physical, medical decision making, and plan as documented."

During an interview with MD1 on 11/07/24 at 9:15 AM MD1 stated he/she had reviewed P1's medical record to refresh his/her memory. He/she was attending at the time and the resident (MD2) saw the patient. There was some question about the history, whether the patient actually lost consciousness or not. P1 was doing well. We discussed whether P1 needed a CT (computed tomography, - a type of x-ray that produces detailed images of the inside of the body, often used to diagnose head injuries. CT can identify evidence of bleeding, swelling, or skull fractures) or not, and MD2 elected not to perform a CT. We discharged P1 when it was determined that he/she needed no further evaluation. When asked if he/she or his/her resident made the right call in not doing the CT, MD1 stated that in retrospect the MD2 applied her clinical judgement using the Canadian head CT rule (a medical scale used to determine if a patient with a minor head injury needs a CT scan of their head) and that was what informed her decision. MD1 stated he was aware of what subsequently happened to P1 but that "in real time, right in front of us, we had a patient that looked good in front of us and met the criteria per MD2's application of the Canadian head CT rule." MD2 stated the ED does not CT everyone that comes in with a head injury, and the rule is designed to limit unnecessary radiation exposure. MD1 stated in retrospect, would have done a CT knowing what happened with a bad outcome. MD1 reiterated that P1 looked good, and we did not think he needed the head CT. When asked what the criteria is used for determining whether to perform a head CT, MD1 stated a lot of it is based on "clinical gestalt," but criteria include if there was an abnormal neurological examination, if there was a very high-risk mechanism (i.e. the cause of the accident), if there was persistent vomiting, if the wound looks bad, coupled with the history and physical exam findings. MD1 stated part of the ED's general discharge instructions would be to return to the ED if the patient experiences persistent vomiting.

During an interview on 11/07/24 at 9:45 AM, the Accreditation Liaison stated MD2 was no longer employed by the facility.

During an interview on 11/07/24 at 4:17 PM, Family Member (FM) stated he/she received a call on a Sunday night around 8:00 PM that P1 was taken to the facility's ED by a friend from P1's college campus. FM was unable to reach the hospital ED before P1 was discharged and had returned to the college campus. FM was at the dormitory entrance when P1 arrived in a car driven by a friend. When P1 got out of the car he/she was disoriented, had a huge gash on the head, looked awful, and started immediately vomiting. P1 almost fell when trying to walk toward FM, and FM had to grab him/her to prevent a fall. FM stated P1 reported he/she started vomiting on the trip back from the hospital to the campus. FM stated when driving from the campus to their home, P1 was very disoriented and vomited several times. FM stated P1 was not getting any better, so FM brought P1 to Hospital 2's ED. While at Hospital 2, P1 had a CT scan done that revealed brain hemorrhaging and fractures. P1 was transferred to the hospital (Intensive Care Unit) for a few days and then discharged to home with therapy.