HospitalInspections.org

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Based on interview, review of hospital policies and procedures, and document review, the hospital failed to implement policies and procedures for the evaluation and treatment of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients receive a comprehensive medical screening examination (MSE) by a qualified medical professional risks poor health outcomes, injury, and death.

Findings included:

The hospital failed to provide evidence that 1 of 25 patients received medical screening examinations when they presented for emergency care.

Cross Reference Tag #2406

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Based on interview, review of hospital policies and procedures, and document review, the hospital failed to implement policies and procedures for the evaluation and treatment of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA) for 1 of 25 patients who presented for emergency care.

Failure to ensure patients receive a comprehensive medical screening examination (MSE) by a qualified medical professional risks poor health outcomes, injury, and death.

Findings included:

1. Review of the hospital policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA), number 14592163, effective date 11/14/23, showed that a physician, advanced registered nurse practitioner (ARNP), or physician's assistant (PA) provides an appropriate medical screening examination to all individuals seeking emergency services.

2. Medical record review for the index patient showed that the patient arrived via ambulance on 07/28/24 at 11:21 PM, with a chief complaint of rectal bleeding and dizziness. The ambulance run sheet showed that the patient had stated that he had been drinking alcohol and smoking marijuana, and had "Mexies" (fentanyl) in his pocket. The ambulance run sheet showed that the patient was alert and oriented to person, place, time, and situation with a heart rate of 102, blood pressure of 149/54, and respiratory rate of 16 at 10:57 PM. Emergency Department (ED) triage notes showed that the patient arrived by ambulance with complaint of rectal bleeding associated with dizziness. Security was notified for a safety search in triage at 11:21 PM, but at 11:22 PM, the patient refused a safety search and was escorted out by security. There was no documentation of a medical screening examination (Patient #18).

3. On 09/05/24 at 1:45 PM, during medical record review, the Director of the ED (Staff #1) verified that there was no documentation of a medical screening examination completed for Patient #18.
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