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Based on observation, record review, and interview, facility A failed to comply with 489.24 and provide a complete medical screening examination (MSE) for one of 20 patients (Patient #1) whose records were reviewed.

Hospital A failed to provide an appropriate medical screening for Patient # 1 to determine the presence of an emergency medical condition. On 04/28/2024 Patient #1 arrived at Hospital A in her own vehicle. Patient # 1's chief complaint was excessive vaginal bleeding and requested an examination. Patient #1 was discharged from Facility A with a diagnosis of Menorrhagia [heavy menstrual bleeding] with irregular cycle. Patient (pt) #1 left Facility A on 04/28/2024 at 1:20 AM and presented at Facility B on 04/28 2024 at 4:31 AM. A pelvic exam was completed at Facility B and Patient #1 was diagnosed with a vaginal laceration and a correction was performed.

Refer to A2406

Based on record review and interviews, Facility A failed to complete a medical screening examination (MSE) for one of 20 patients (Patient #1) whose records were reviewed. Patient #1 presented to Facility A with a chief complaint of excessive vaginal bleeding. Patient #1 was discharged from Facility A with a diagnosis of Menorrhagia [heavy menstrual bleeding] with irregular cycle.
Patient (pt) #1 left Facility A on 04/28/2024 at 1:20 AM and presented at Facility B on 04/28 2024 at 4:31 AM. A pelvic exam was completed at Facility B and Patient #1 was diagnosed with a vaginal laceration and a correction was performed to treat Patient # 1 in the Emergency Department.

The findings include:

Patient # 1, Facility A Chart review:
A review of the document titled "ED Provider Note" by Staff # 1, MD-ED, Attending on 04/28/2024 at 1:22 AM revealed the following:
"Chief Complaint:
Pt reports she woke @ 2300 to void and noticed she passed 10cm clot, was having [abdominal] abd cramping and has been filling a super tampon every 10min. Pt reports abd pain to be cramping pain to lower abd rates 3/10. Pt denies dizziness.
History Of Present Illness:
Vaginal bleeding x 6 days. Reports normal regular cycle 28 days in
length that stopped after starting duloxetine last month so she stopped the duloxetine.
Initially started spotting 6 days ago so thought her period was starting. Approximately 3 hours prior to arrival passed a blood clot and has required tampon changing every hour. Patient states the bleeding has caused her anxiety." ...
..."Medical Decision Making:
Labs interpreted by me. No previous for comparison. CBC unremarkable
Chemistry unremarkable hCG negative
Urinalysis with hematuria consistent with vaginal bleeding contamination...."
"...
Pt reassessed. Reviewed results. Pt feels improved and comfortable going home. Blood pressure
improved."
"...IMPRESSION
Heavy and frequent menstrual cycle perhaps triggered by recent duloxetine use. No evidence of
significant blood loss and not pregnant. Appropriate for outpatient follow-up.
Antibiotics considered but not thought to be appropriate given the lack of evidence currently of
any bacterial source of infection.
Advanced imaging considered to include CT and ultrasound however given the lack of evidence during
ED evaluation they are not thought to be currently indicated.
The patient and I had a discussion in layman's terms which include shared decision making and
expressed understanding of the condition, diagnosis, treatment, and agreed with the plan.
Strong precautions were discussed, including study limitations , and was advised to return to the
nearest emergency department if any changes occurred or concerns arise regarding their condition.
The patient was counseled about ongoing non-emergent medical problems and have recommended close follow-up with their primary care provider. This includes incidental findings on labs and/or radiographic studies done in the ED and any pending results.
The test results were reviewed, and the patient's questions were answered. The patient feels
better, is well appearing, without increased work of breathing, or oxygen requirement."

A review of the documentation "vital signs" revealed the following:
"Temperature: 37.1 °C (Oral) Heart Rate: 100 (Peripheral) Respirations: 20 per minute
Blood Pressure: 157/124 SpO2: 98% Height: 175.26 cm Weight: 110.22 kg BMI: 35.88 Pain Score: 3. Oxygen Therapy: Room air."

A review of the document titled "discharge order" by Staff # 1, MD-ED on 04/28/2024 at 3:39 AM revealed
Patient # 1 was diagnosed with menorrhagia with irregular cycle. Patient # 1 did not receive a complete examination while at Facility A. No pelvic exam by a physician was documented.

A review of the document titled "Disposition Documentation/Discharge" by Staff # 3, RN-ED on 04/28/2024 at 3:46 AM revealed Patient # 1's disposition was noted as satisfactory and the patient was discharged to home with self/family care. The patient was ambulatory and discharge transportation was noted as a private vehicle. ED Discharge Comments were: "Pt is tearful and reports she doesn't [doesn't] think she is having a heavy period and feels the dr is "blowing her off". Discussion that her blood levels are normal and pt should follow up with OBGYN or PCP. Pt reports plan to go to GRMC for 2nd opinion."

Patient # 1, Facility B Chart review:

A review of the document titled " Emergency Department Note Signed" by Staff #B 2, MD-ED on 04/28/2024 at 5:26 AM revealed the following:
"I inherited the patient at 0800 from Staff # B6 . Patient was seen and examined by the on-call obstetrician and her vaginal laceration was repaired. Patient's blood pressure has been elevated here in the ED. I spoke with the patient regarding this. She reports that she has had a stressful night and she typically has elevated blood pressure readings when she sees physicians. She reports she has a long history of ventricular tachycardia and takes metoprolol as needed for palpitations. She claims that she does check her blood pressure regularly at home and it is within normal limits. I offered the patient a pocket prescription for blood pressure medicine if her blood pressure remains elevated and she reports that she gets good results with the metoprolol when she feels symptoms.
Patient received a single dose of doxycycline here in the ED per OB/GYN's recommendation.
All laboratory /radiologic findings were discussed, and all questions were answered. Patient is in stable condition, and will be discharged home with instructions for pelvic rest for 2 weeks. The patient does not have a primary care provider on file with us today. Patient was provided a list of local primary providers to contact to establish care." ...
... "Final Diagnosis: Vaginal bleeding, vaginal laceration, whitecoat syndrome without diagnosis of hypertension."

A review of the document titled "Progress Note Signed" by Staff # B3, MD-ED on 04/28/2024 at 8:53 AM revealed the following:
"HPI: 37 yo G2P2[pregnant twice, birthed twice] presents to the ER with vaginal bleeding that began tonight. She reports that her last menstrual period (LMP) was 4/22 and lasted for 3 days. She stopped bleeding completely by thursday. Last night around 11pm she strained for a BM and noticed blood from vagina at that time. She went to shower and began bleeding copiously soaking pads in moments. She went to loal [local] ER 45 min away from here where they checked blood counts and discharged her in stable condition, She did not have pelvic exam at that time. Negative urine pregnancy test (UPT) (patient s/p BTL[post bilateral tubal ligation]. She then soaked through her tampon/pad/ clothing on the way home and presented to our ER.
Patient reports history of heart condition, and vascular condition for which she is currently undergoing work up. She denies recent intercourse or other vaginal trauma other than tampon placement." ...

... " Exam:
revealed a right vaginal sidewall laceration that extended to the posterior vagina. There was no bleeding from the cervical as [assessment], NO visible masses. Majority of laceration had clotting and was becoming homeostatic, however posterior edge was bleeding briskly. On bimanual examination there were no masses palpated in the vagina, bulging on the left sidewall.
PROCEDURE:
The area was injected with 2% lidocaine (6cc). It was then repaired with 3-0 vicryl on CT-1 in running locking fashion. Good homeostasis was achieved. There was some mild oozing form suture points and monsels solution was applied to assist with homeostasis which was readily achieved."

A review of a document titled "Nurse Note: by Staff # B4 RN-ED on 04/28/24 at 10:00 revealed the following:
"Patient discharged home in stable condition with all personal belongings. Patient given discharge instructions and verbalized understanding of those instructions, physician referral and follow-up. Patient ambulatory out of this ER with even and steady gait."


Policy Facility A:

A review of the policy titled "14801375, EMTALA (Emergency Medical Treatment and Active Labor Act) ER and for those Patients that Present Outside the Traditional ER" revealed the following: page 2
"Employees of [Facility A] are responsible to ensure a patient and/or visitor that requests emergency treatment and/or exhibits an emergent condition receives the appropriate medical treatment."
Patient # 1 went to Facility A to seek treatment for vaginal bleeding and pain.

Interviews Facility A:

An interview with Patient # 1, Complainant on 06/03/2024 at approximately 4:30 PM revealed the following:
Surveyor: After going over your complaint, is there anything you would like to add?
Complainant: No, I still get very upset when I think about driving to Seguin in the middle of the night. I can't believe he [doctor] didn't believe me. I was told this happened because I have CRPS [complex regional pain syndrome].
Surveyor: Do you want to remain anonymous?
Complainant: No, I have talked to so many people at the hospital about this.

An interview with Staff # 2, MD, ED Medical Director on 06/04/2024 at approximately 12:45 PM via phone revealed the following:
Surveyor: Did, Staff # 1, MD-ED, Attending preform a vaginal exam for Patient # 1?
Staff # 2, ED Medical Director: I have reviewed the chart and if he did an exam, it was not documented. You would have to ask him.
Surveyor: What would your process look like for a female with chief complaint of heavy vaginal bleeding?
Staff # 2, ED Medical Director: I would look at the vital signs to see if she were hypertensive, this would rule out hemorrhagic shock. I would order labs to ensure values do not show a loss of blood. If all indicators were showed the patient was stable, I would discharge her home or complete a pelvic exam. "I can't say I would always do an exam." If the patient had requested a pelvic exam, I would find a chaperone and do the exam.

An interview with Staff # 3, RN-ED on 06/04/2024 at approximately 1:00 PM revealed the following:
Surveyor: Do you remember Patient # 1?
Staff # 3, RN-ED: Yes, I do. She came in with vaginal bleeding, there was no mention of trauma. I saw she had used the restroom a few times. Staff # 4, RN-ED was in the bathroom with her and I asked, "how does it look?" Her response was something like "it's not much." The patient was not bleeding to the point blood was coming through her clothes. The patient said she was going to another facility at discharge. I didn't know what to say. I said, "then you should do that."