HospitalInspections.org

Based on review of facility policy and procedure, facility documents, medical record request and employee interview, the Department determined the administrator failed to ensure a medical screening exam (MSE) was completed for a patient referred to the facility for an emergency medical condition. This deficient practice poses a potential risk to the health and safety of a patient if life-threatening or potentially life threatening conditions are not recognized and stabilizing treatment provided.

Findings include:

Facility policy #12197131, titled "...Intake Sheet-Accepting Referrals," last approved 08/2022, revealed "...POLICY: ...The Intake Department staff shall complete a Triage Assessment Form for each caller inquiring or seeking assessment for inpatient care...PROCEDURE: ...A copy, fax, or email of completed Triage Assessment Form for patients being admitted to the hospital shall be sent to the nursing station and admitting staff as well as uploaded into the Wellsky document storage. Nursing staff shall review information on the Intake Sheets and incorporate it into the nursing assessment of the patient...."

Facility policy #12508324, titled "EMTALA,' last approved 10/2022, revealed "...POLICY: A hospital with specialized capabilities or facilities (including, but not limited to burn units, shock-trauma units, neonatal intensive care units, dedicated behavioral health units, or regional referral centers in rural areas) shall accept from a transferring hospital an appropriate transfer of an individual with an emergency medical condition (EMC) who requires specialized capabilities if the receiving hospital has the capacity to treat the individual...The transfer of an individual shall not consider age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state or local law..."

Facility document titled "Referrals" had the following patients, referral dates, "Disposition Comment" and "Facility Reason Status" noted:

Patient #42: 08/18/2024 "Pt is legally blind requires 1:1" and "Not Medically Approved"
Patient #43: 08/19/2024 "Full Transgender/Private Room" and "Other"

Facility medical records for Patients #42 and #43, including MSE and Triage Assessment Form were requested. None were provided.

Employees #2 and #8 confirmed during a joint interview on September 13, 2024, both patients #42 and #43 were referred to the facility due to psychiatric emergency, that neither patient was accepted and that no medical records, including MSEs or Triage Assessment Form, for either patient were available for review at the time of the survey.