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Based on current policies and procedures, Dedicated Emergency Department (DED) medical record review, the hospital's physician and staff interviews; the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

1. The hospital's DED medical staff failed to provide an appropriate medical screening examination within the capability of the hospital's DED for an individual who presented for evaluation for an emergency medical condition in 1 of 30 sampled patients (Patient #14).

~ Cross refer to §489.24(a) and (c) Medical Screening Exam, Tag A2406.

2. The hospital's DED medical staff failed to provide necessary stabilizing treatment for 1 of 30 sampled patients (Patient #14) presenting to the hospital's DED.

~ Cross refer to §489.24(d) (1-3) Stabilizing Treatment, Tag A2407.

Based on policies and procedures, DED medical record reviews, physician and staff interviews, the hospital's DED medical staff failed to provide an appropriate medical screening examination within the capability of the hospital's DED for an individual who presented for evaluation for an emergency medical condition in 1 of 30 sampled patients (Patient #14).

Findings included:

Review on 12/12/2017 of the hospital's policy "Medical Screening" (Current Effective Date: 03/28/2017) revealed "Purpose: To provide appropriate medical care to patients who present to the Health System and to comply with Emergency Medical Treatment and Active [sic] Labor Act (EMTALA) requirenments related to medical screening examination, treatment, stabilization, and transfer of emergency medical conditions." The policy further revealed "Definitions: Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition or pregnancy with contractions exists. This exam includes appropriate resources routinely available or accessible to _____(Hospital System Name)."

Medical record review on 12/12/2017 for patient #14 revealed the patient was brought to Hospital (A) via emergency medical services (EMS) on 11/10/2017 at 2002 with complaints of motor vehicle accident (MVA) after being involved in a single vehicle accident. Documentation revealed EMS documented the patient's Glascow Coma Score as "14" and had placed a "C-Collar" with head blocks on the patient at the time of transport. Review of the medical record revealed that Hospital (A) was on downtime in their electronic medical records during the initial part of patient #14's arrival and part of the documentation was completed on paper format. Nursing staff documentation at 2002 from Registered Nurse (RN) #1 revealed the patient arrived from EMS after a single vehicle accident with driver unrestrained and in backseat. The documentation revealed ETOH (Alcohol) was present along with laceration of chin, abrasions to abdomen/thighs, and burn to right hand. The RN documented that the patient did not recall the accident and did complain of "neck pain" as well as the patient was in a collar with head blocks. At 2010 the patient was documented as "log rolled" while maintaining c-spine with no pain or tenderness to her back upon palpation. Documentation (Not Timed) revealed that DED Physician #1 completed an "Emergency Physician Record" for the patient with documentation revealing that the patient would not answer him. The physician documented location of pain/injuries to "face, mouth, neck, chest, and abdomen" with recent alcohol use. A laceration was documented as located on the patient's chin with no specific size. Bruising was documented on the patient's abdomen. The patient was described as oriented times 4 with cranial nerves intact. The documentation revealed the patient's treatment including Laboratory Studies, Urinalysis, Drug Screening, Ethanol level, and Radiology Studies. The following were documented results of the studies:

-CT Head and C Spine on 11/10/2017 at 2042. Impression: No acute intracranial abnormality.
No acute abnormality in the cervical spine. Results read by Hospital (A) Radiologist
Physician #1 on 11/10/2017 at 2044.

-Chest X-ray on 11/10/2017 at 2014. Impression: No acute findings. Results read by Hospital
(A) Radiologist Physician #1 on 11/10/2017 at 2047.

-X-ray of Pelvis on 11/10/2017 at 2014. Impression: No acute fracture. Results read by
Hospital (A) Radiologist Physician #1 on 11/10/2017 at 2047.

-CT of Body on 11/10/2017 at 2100. Impression: No evidence for trauma in the chest,
abdomen, pelvis or thoracolumbar spine. Indeterminate high density foci in the esophagus
and stomach. Results read by Hospital (A) Radiologist Physician #2 on 11/10/2017 at 2125.

-Basic Metabolic Panel Laboratory studies revealed Potassium at 2.9 L (3.5-5.1 Range) and
Glucose at 239 H (74-106 range).

The review revealed on 11/10/2017 at 2100 the patient's C - Collar was documented as removed by DED Physician #1. Review at 2104 also revealed the States Highway Patrol Officer was present for a blood sample drawn into kit related to MVC event. The patient began to report pain as "10" on 11/11/2017 at 0005 even after receiving the patient medication "Dilaudid 2 milligrams" (Pain Medication) earlier on 11/10/2017 at 2247 and was again medicated with "Dilaudid 1 milligram" at 0130. On 11/11/2017 at 0030 the patient had lacerations sutured by Hospital (A)'s Trauma team Physician #3) with no complications reported. The patient was also administered the antibiotic "Ancef" while in the DED. The patient was documented as having condition "stable" by DED Physician #1 at 2257 and again at 0122 by DED Physician #2 who took over for DED Physician #1 at their shift change. The patient was documented as discharged home in stable condition on 11/11/2017 at 0140 with discharge instructions along with prescriptions for "Keflex" (Antibiotic) and "Percocet" (Pain Medication) given to the patient's family. The review of the patient's medical record at Hospital (A) revealed there was no evidence of any examination of the patient's jaw, other than to repair the laceration.

Medical record review for patient #14 revealed that the patient presented to another acute care hospital (B) on 11/14/2017 (four days later) at 1228 with complaint of "Generalized Body Aches." The revealed the patient was medically screened by Hospital (B)'s DED Physician #3 who documented the patient had been involved in a MVA on Friday, seen outside hospital, had unknown workup, and a large laceration which was repaired under chin. The physician also documented the patient had been in accident earlier at Hospital (A). The physician revealed that on 11/14/2017 the patient began having extreme pain and soreness to left side of her body and to face. The patient was described as tearful in triage with moaning. The patient reported her pain as constant with no new trauma. The patient's treatment while in the DED at Hospital (B) revealed she received IV fluids, pain medications along X-Rays of Left Shoulder that revealed no fracture reported. A CT Scan of the head was done for the patient that was negative. Another CT scan of the patient's cervical spine was taken with results revealing a "C5 left lamina fracture mildly displaced uncomplicated" as well as C-scan facial that revealed a "left mandible fracture." The DED Physician #3 documented that the hospital's on-call neurosurgeon recommended a cervical collar and he would see the patient in 1-2 weeks. The documentation also revealed that an oral surgeon was contacted and that he would see the patient the following day and was recommended to continue her antibiotics as well as a soft diet. The patient was discharged home at 1622.

Interview on 12/13/2017 at 0930 with DED Physician #1 revealed that he was the DED physician that was assigned to see patient #14 on 11/10/2017 at Hospital (A). The interview revealed the patient presented after having a MVC and was described as alert and oriented but refused to answer his questions. The physician also revealed he remembered the patient having large lacerations to her chin and after review of his notes he confirmed that the patient had CT scans and Radiology Studies that was negative. The testing was ordered on arrival according to the interview. The patient was reported to be able to talk and move. The interview also revealed the patient ' s laceration was sutured by the Trauma Team physician. The physician stated that the patient's trauma from MVC resulted in the patient's potassium being low but that it was an expected shift. The physician also revealed that patient was stable until he left duty and DED Physician #2 took over the care. The physician reported the patient was stable in his medical opinion. The physician revealed that he did not order any CT specific to the face area and he felt he provided an appropriate trauma workup. The physician also revealed the hospital and his physician group provides EMTALA training.

Interview on 12/13/2017 at 0942 with DED Physician #2 via telephone revealed that he remembered patient #14 as a result of taking over physician care from DED Physician #1 on 11/10/2017. The interview revealed "The patient was signed out from Dr.__ (DED Physician #1), gave report and I did not have to do much." The interview revealed the patient had already had all of the tests ordered and completed and the patient was waiting for the Trauma Team to come suture her lacerations. The interview revealed the patient was stable for discharge.

On 12/13/2017 an interview was requested with DED RN #1 who was unable to be interviewed due to being off of work and unavailable for interview.

Interview on 12/13/2017 at 1238 with Radiologist #1 at Hospital (A) revealed that after reviewing report for patient #14, there was no mandible or jaw area involved in the ordered CT testing ordered for 11/10/2017. The interview revealed the mandible would have to be for a CT of the face to cover that area. The interview also revealed that the CT scans were all read by a Radiologist at the hospital. The interview also revealed that he was not able to answer to whether or not an ordered CT of the Cervical Spine could have a fracture that was missed on the scan.

Interview on 12/14/2017 at 1517 with the DED Physician #3 at Hospital (B) via telephone revealed that he was the DED physician who provided the medical screening examination for patient #14. The interview revealed the patient presented and reported that she had been in a car wreck earlier and had pain on face. The interview revealed that the patient could not remember what tests she had at previous hospital and was in so much pain that he made choice to work her up as new instead of delaying care to wait for record retrieval. The interview revealed that the patient ' s lacerations looked good, but she was reporting pain in face so he ordered CT of Face and CT of cervical spine that both come back with fractures. The patient was discharged home after consultation with neurosurgeon and oral surgeon recommending discharge home. The physician indicated he did not remember anything specific about the patient and got his information from review of his documentation.

In summary, Patient #14 presented to Hospital (A) on 11/10/2017 via EMS following a MVC with treatment consisting of laboratory studies, radiological studies, medications and laceration repair. The patient received a chest x-ray along with CT scans of the body, cervical spine and head that call were read as negative. No evidence of an examination of the patient's jaw by the medical staff at Hospital (A) was found, despite documentation that patient #14"s location of pain/injuries were facial and mouth. Interview with the DED Physician performing the examination revealed that he felt the patient received a trauma workup and that the patient was in stable condition for discharge. The patient was administered pain medications and antibiotics in the DED as well as prescription medications before being discharged home on the morning of 11/11/2017. Approximately three days later on 11/14/2017, the patient presented to Hospital (B)'s DED with complaints involving "extreme pain" in her face area and body that began earlier in the morning. According to the DED Physician performing the screening examination at Hospital (B), the patient was unable to state what tests were completed at Hospital (A) in the first visit and he made a decision based on the patient's condition and time factors to go ahead and work the patient up again as new complaints. The patient received an X-ray of left shoulder and CT scans for Face and Cervical Spine that revealed fractures of the cervical spine and left mandible. The physician at Hospital (B) in consultation with a neurosurgeon and oral surgeon discharged the patient home with follow up appointments. The patient was treated with pain medications and discharged home on 11/14/2017.