HospitalInspections.org

Based on medical record review, document review and interviews, in one (1) of (20) records reviewed, the Hospital failed to ensure that a medical screening examination was performed for all patients.

This failure may have placed the patient at risk for harm.

Review of medical record for patient #20 identified the following: this 30-year-old female was brought to the Emergency Department by ambulance on 11/2/16 at 8:41 P.M. following a motor vehicle accident in which she was struck as a pedestrian. Triage assessment on 11/2/16 at 9:08 P.M. noted the patient complained of pain to the right shoulder and right leg, which she rated at seven (7) on a scale of one (1) to (10), ten being the highest level of pain. The patient was unsure of loss of consciousness during the incident. Vital signs at the time of triage were; T 99.8, F, P 82, R 16, R 16, B/P 125/79. A triage classification of Emergency Severity Index, level 3 (Urgent category) was assigned

The medical record documented that the Physician ordered lab work at 9:57 P.M., an x-ray of the shoulder at 9:58 P.M., and a urine drug screen at 10:22 P.M.

A Registered Nurses Note on 11/2/16 at 11:31 PM documented the following: "Patient very combative, verbally abusive, and aggressive towards staff. Patient escorted out by security."

A Physician's Progress note on 11/3/16 at 12:06 A.M. indicated that the "Patient left prior to being seen by a provider. I am completing this note to remove this patient's name from the tracking screen and did not have any personal contact with this patient. Pt was cursing at security and walked out around 11 p.m."

An End of Shift Report from the Security Department dated 11/2/16-11/3/16 at 11:15 p.m. reflected that the patient was escorted out by security at the direction of the Patient Care Coordinator after she was suspected of stealing medical items from the Adult Emergency Room.

There was no documentation in the medical record that the patient had a history and physical examination performed by a physician prior to being escorted out by security staff.

There was no documentation that the patient had an x-ray of the left shoulder performed prior to her departure from the Emergency Department. The urine toxicology test resulted on 11/2/16 at 11:36 PM was positive for cocaine; this was after the patient departed from the Emergency Department.

At interview with Staff B, ED Nurse Manager, on 12/21/16 at 10:30 A.M., he stated that the physician who ordered diagnostic tests never saw the patient.

During interview with Staff A, Emergency Room Associate Medical Director on 12/21/16 at 2:20 PM, staff stated that this patient was disruptive and she attempted to remove items from the Emergency Room. When confronted the patient began to throw things around. The patient stated that she wanted leave; as she left the Emergency Room, security staff followed behind her. Staff A confirmed that this patient was not seen by a physician prior to her departure from the Emergency Department.

There was no documentation in the medical record that the patient expressed the desire to leave the Emergency Department before the completion of a medical screening examination and treatment.