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Based on review of hospital policies, medical record reviews, Emergency Department (ED) logs, ED census reports, video review, and interviews, it was determined the hospital failed to ensure a patient who presented to the ED for emergency care received a Medical Screening Examination.

This affected one of twenty patiens reviewed including Patient Identifier # 1, and had the potential to affect all patients presenting to this ED.

Findings include:

Refer to A 2406 for findings.

Based on review of hospital policy, medical record (MR) review, review of the Medical & Dental Staff Rules and Regulations, review of Emergency Department (ED) census report, video recordings and, ED Logs reviews, and interviews with staff, it was determined the hospital failed to ensure a patient presenting to the ED for emergent care received an appropriate Medical Screening Examination (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed.

This affected one (1)of twenty (20) MR reviewed including Patient Identifier (PI) # 1, and had the potential to affect all patients presenting to the ED with complaints of abdominal pain, nausea, vomiting, and diarrhea.

Findings include:

Hospital Policy: Medical & Dental Staff Rules and Regulations

Approved: 7/24/23

... 11.3 A ... MSE will be conducted on every patient who comes to the Hospital...requesting emergency examination or treatment of an emergency medical condition...

Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA) Policy.

Policy Number: None Listed.

Revised: 5/17/24

Purpose: To set forth guidelines for UAB (University of Alabama Birmingham) Hospital to comply with the Emergency Medical Treatment Act...

Policy:

...B. Emergency Department Medical Screening Examination (MSE).

1. UAB Hospital shall provide a MSE for every person who comes to the Hospital Campus and makes a request for examination of treatment of an Emergency Medical Condition.

...3. Within the capability of UAB Hospital, the MSE shall determine whether or not an Emergency Medical Condition exists...

1. PI # 1 presented to the ED on 6/24/24 at 6:26 AM with complaints including abdominal pain, nausea, vomiting, and diarrhea.

Review of the Triage assessment dated 6/24/24 at 6:41 AM revealed Employee Identifier (EI) # 9, Registered Nurse (RN), documented PI # 1 had been seen at the ED for the same complaint three times in the month of June. The vital signs documented included a blood pressure of 148/91, heart rate of 88, respirations of 16, and a temperature of 97.7. EI # 9 assigned a Tracking Acuity of three.

Review of the Nurse Assessment dated 6/24/24 at 7:14 AM revealed EI # 8, RN, documented PI # 1 was informed he/she "needed a driver present to receive narcotics, patient has been here (for the) past two days and told the same, patient stated (spouse) dropped (him/her) off and would be back. RN repeated (spouse) must be present. Patient got up (and) ambulated out of ED lobby...Patient walked to parked car in handicap spot in front of ED, got in driver's side and drove away."

Further review of the MR revealed no documentation of a MSE and no documentation of an order for narcotics.

There was no documentation PI # 1 signed a refusal of treatment or a refusal to sign.

An interview was conducted on 7/10/24 at 1:15 PM with EI # 11, Doctor of Osteopathic Medicine, who confirmed he/she was working on the morning of 6/24/24 when PI # 1 presented to the ED but did not see PI # 1. EI # 11 further stated no MSE was performed, and no narcotics were ordered.

An interview was conducted on 7/10/24 at 1:45 PM with EI # 8, who stated he/she had seen PI # 1 in the ED many times before and told PI # 1 he/she had to have a driver before any medications were given. EI # 8 confirmed PI # 1 did not see the provider and did not have any medications ordered.

An interview was conducted on 7/10/24 at 2:15 PM with EI # 9, who stated he/she remembered PI # 1 coming to the ED on 6/24/24, but did not remember much other than he/she documented the triage assessment.

A Zoom meeting was conducted on 7/11/24 at 8:15 AM with EI # 1, Chief Executive Officer, who stated PI # 1 presented to the ED on 6/24/24, signed in, and had vital signs taken at the registration desk by the technician. EI # 1 stated PI # 1 was not seen by the triage nurse who documented the assessment obtained from the registration documentation.

A review of the video recordings conducted on 7/11/24 at 9:00 AM revealed the following:

On 6/24/24 at 6:25 AM, PI # 1 entered the ED entrance.

At 6:26 AM, PI # 1 walked to the Registration Desk.

At 6:28 AM, the Registration technician performed a blood pressure assessment on PI # 1.

At 6:30 AM, PI # 1 sat in a chair in the ED waiting room. No other patients were visible in the ED waiting room.

At 6:54 AM, a staff member, identified by EI # 2, Director of Highlands ED, as EI # 8, was seen addressing PI # 1 in the ED waiting area.

At 6:55 AM, PI # 1 exited the ED.

There were no video recordings of PI # 1 entering the triage area, no video of EI # 9 performing a triage assessment, and no video of PI # 1 entering the patient treatment area to have a MSE performed.

Review of the 6/24/24 ED bed census report revealed the ED had 10 patients at 6:00 AM with 14 open beds and at 7:00 AM the ED had 10 patients with 14 open beds.

An interview was conducted on 7/11/24 at 2:28 PM with EI # 2, who confirmed the hospital failed to ensure a MSE was performed on a patient presenting with abdominal pain and confirmed the ED had beds available and was sufficiently staffed with RNs and Providers on 6/24/24.

The facility failed to ensure that their policy and procedure, and Medical and Dental Staff Rules and Regulations were followed as evidenced by failing to ensure that an appropriate medical screening examination was provided that was within the capability (sufficiently staffed with RNs and ED Providers) and capacity (ED open beds available) of the hospital's emergency department including ancillary services routinely available to the ED to determine whether or not an emergency medical condition existed for patient #1 on 6/24/2024.