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Based on interview and record review, Hospital A (Baylor Scott and White Medical Center McKinney) failed to enforce its policy to ensure compliance with 489.24 (a) (1) (i). The ED (emergency department) did not provide a medical screening exam and any necessary treatment to Patient #1 on 01/04/16. Patient #1 presented to the ED with a complaint of a laceration to his leg. The patient was screened and treated at Hospital B on the same day.

Cross refer to A2406.

Based on interview and record review Hospital A failed to provide a medical screening exam (MSE) to: 1 of 1 (Patient #1) patient. Patient #1 presented to the hospital's ED on 01/04/16 for a laceration of his right leg. After waiting approximately 2 hours the patient left and went to Hospital B where he had an MSE.

Findings included:

A review of Patient #1's Hospital A medical record revealed Patient #1 was a 13-year-old male who presented to Hospital A's ED for a laceration on his leg per the patient's face sheet.

ED Nurse's Notes dated 01/04/16:
At 6:42 PM Patient #1 arrived in the ED.
At 6:42 PM Patient #1 was visited by an Access Service Representative. Patient #1 was moved to the waiting area.
At 8:36 PM Patient #1 was "visited" by an RN (registered nurse). Patient #1 was paged but didn't respond.
At 8:51 PM Patient #1 LWBS (left without being seen). He did not come when he was called by triage.

ED Disposition Summary: No date or time. Outcome: Eloped. Chief Complaint: Laceration to the leg.

Review of the ED Central Patient log revealed Patient #1 arrived to the ED on 01/04/16 at 6:19 PM for a laceration to the leg. Patient #1 LWBS from the ED at 8:52 PM on 01/04/16.

During an interview on 04/04/16 at 10:45 AM Physician #2 said the hospital's ED was a Level 3 Trauma center.

During an interview on 04/04/16 at 11:15 AM with Personnel #5 he said he remembered 01/04/16 because it was such an unusually busy day in the ED. During a review of Patient #1's ED medical record Personnel #5 confirmed Patient #1 didn't receive a medical screening exam on 01/04/16. By the time the patient was called to the back he had left. Any time staff entered the medical record there was a time stamp documented in the chart. It didn't mean that the occurrence happened right at that time but when the staff documented in the medical record.

Hospital A's Medical Screening Exam (MSE) policy in the Emergency Department (ED) dated 01/02/13 reflected on page 1, "...Upon arrival to the ED, patients will receive a MSE in a timely manner as possible based on the patient condition and assigned Triage acuity.

Review of the medical record for Patient #1 Hospital B dated 01/04/16 reflected Patient #1 arrived at Hospital B on 01/04/16 at 9:00 PM. Patient #1's acuity level was placed at ESI 4 (emergency severity index. 1=most urgent, 5=least urgent).

Patient #1 stated he was taking out the garbage and a broken piece of glass cut the outside of his right calf, "bleeding controlled." The laceration sustained to his right leg was clean. Patient #1's pain level was 6 out of 10 on a pain scale (0=no pain/10=extreme pain).

Patient #1's right lower leg laceration was "7.6 to 12.5 cm." The laceration was repaired with sutures using a local anesthetic and antibiotic ointment, and was dressed with 4X4 gauze.

Patient #1 was discharged home ambulatory with his family at 11:30 PM on 01/04/16. Discharge instructions were given and were understood.