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Based on policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking medical treatment were provided an appropriate medical screening examination (MSE) for 1 of 20 (Patient #2) sampled patients.

The findings include:

1. Review of the "Screening, Stabilization, Treatment and Transfer of Individuals in Need of Emergency Medical Services - EMTALA" policy (revised 3/2021) revealed, "...f. 'Medical screening examination' ('MSE') means the process 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. A MSE is not an isolated event. It is an ongoing process that begins but does not end with triage..."

2. Medical record review revealed Patient #2 presented to the ED on 2/17/22 at 1:14 PM with chief complaint of lower back pain since 2/13/22. A MSE was initiated at 1:45. A CT (computerized tomography) scan at 5:05 PM revealed a 12 millimeter kidney stone. The Urologist on call was contacted at 6:00 PM. The Urologist inquired about Patient #2's pain control and stated he would see Patient #2 in the office in 1-2 weeks. The Urologist did not come to the ED and examine Patient #2.

Refer to A2406

Based on policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking medical treatment were provided an appropriate and ongoing medical screening examination (MSE) for 1 of 20 (Patient #2) sampled patients.

The findings included:

1. Review of the "Screening, Stabilization, Treatment and Transfer of Individuals in Need of Emergency Medical Services - EMTALA" policy (revised 3/2021) revealed, "...d. '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 either: placing the health of the individual...in serious jeopardy, or serious impairment to bodily functions or Serious dysfunction of any bodily organ or part...f. 'Medical screening examination' ('MSE') means the process 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. A MSE is not an isolated event. It is an ongoing process that begins but does not end with triage...If the Individual is experiencing an EMC, then Hospital should provide to an individual such further medical examination and treatment as required to stabilize the EMC, within the capability of the Hospital..."

2. Medical record review revealed Patient #2 presented to the ED on 2/17/22 at 1:14 PM. A triage assessment at 1:30 PM documented the chief complaint for Patient #2 was lower back pain since 2/13/22. The triage assessment revealed Patient #2's pain level rating was a 7, and relaxation techniques were implemented.

A MSE was initiated on 2/17/22 at 1:45 PM by Physician's Assistant (PA) #1. A CT (computerized tomography) scan was performed at 5:05 PM with the following results: Left obstructive Uropathy secondary to a 12 millimeter stone at the left Ureteropelvic Junction, nonobstructing left nephrolithiasis (kidney stone), Diverticulosis and enlarged prostate gland.

A continuing MSE on 2/17/22 at 6:15 PM by Physician #1 revealed Urologist #1 was contacted at 6:00 PM with recommendation to discuss with on call physician, who would come to the ED to see Patient #2.

A "Calls-Consults" note on 2/17/22 at 7:00 PM documented, "[Urologist #1] recommends ensure pain control, will see as outpt [outpatient] in 1-2 wks [weeks]"

Patient #2 was discharged from the ED on 2/17/22 at 7:13 PM in "stable" condition.

There was no documentation Patient #2 was assessed by a Urologist while in the ED.

In an interview on 3/9/22 at 9:10 AM, Physician #1 verified he spoke with the Urologist on call two times. The Urologist initially told Physician #1 he would come to the ED to see Patient #2. Physician #1 stated the Urologist called him back and stated he would not make it to the ED, but would contact Patient #2 the next day to set up an appointment.