HospitalInspections.org

Based on document review and interview, it was determined that 1 of 20 (patient # 1) medical records reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide a medical screening exam.

Findings Include:

1. See findings cited at 42 CFR 489.24, A2406

Based on document review and interview, the facility failed to provide a medical screening exam for one (1) of twenty (20) patients. (Patient # 1)

Findings include:

1. The policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", PolicyStat ID 8637060, indicated the purpose of the policy was to ensure that all individuals seeking attention for a medical condition at the facility receive equitable care. Triage - clinical assessment of the individual's presenting signs and symptoms at the time of the arrival to the hospital, in order to prioritize when the individual would be seen by a physician and/or qualified medical personnel (QMP) which shall include physician assistants, nurse practitioners and registered nurses who function within the scope of their license/certification. Triage is not equivalent to a Medical Screening Exam. This policy was last revised on 01/26/2021.

2. The policy titled, "Emergency Department Triage", no policy number, indicated to establish guidelines for the evaluation and treatment of patients according to their healthcare needs. Patient acuity measured by the quality or state of hemodynamic stability and potential for life, limb or organ threat of a patient's condition. The MSE (medical screening exam) is the determination of whether an emergency medical condition (EMC) exists made by the examining physician or other qualified medical personnel designated by the hospital. Triage is not equivalent to a Medical Screening Exam. This policy was last approved on 02/10/2022.

3. Review of the medical record (MR) for patient # 1 indicated the following:
a. Arrival via ambulance at 2:35 pm.
b. Triage completed at 2:44 pm by P # 2 (Registered Nurse-RN). Patient chief complaint was coughing/vomiting times one (1) week. Blood sugar was 288.
c. Electrocardiogram (EKG) was ordered at 3:01 pm, completed at 3:04 pm, and delivered to provider MS # 1 (Emergency Department-ED/Doctor of Osteopathy-DO) at 3:13 pm.
d. Laboratory Comprehensive Metabolic Panel (CMP) critical Potassium (K+) level 2.6 mmol/L (millimoles per liter) which resulted at 4:02 pm and was communicated/verified to the provider MS # 1 at 4:37 pm. Normal range is 3.5 to 5.5 mmol/L.
e. At 5:55 pm the patient was waiting in the waiting room when a rapid response code blue was called.
f. Time of death was called at 6:22 pm.
g. The MR lacked a medical screening exam.

4. In interview dated 02/06/2023 at approximately 5:07 pm with administrative staff members A # 1 (Director Quality/Patient Safety) and A # 2 (Regulatory Consultant), confirmed the severity of the issue with the patient and indicated the need for staffing changes.