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Based on interview, record review and policy review, the hospital failed to provide an appropriate medical screening exam (MSE) within the available capabilities of the hospital, sufficient to determine whether or not an emergency medical condition (EMC) exists for one patient (#2) of 20 Emergency Department (ED) records reviewed.

Findings included:

Review of the hospitals policy titled, "Emergency Medical Treatment and Labor Act Guidelines for Emergency Department Services (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)," revised 01/26/22, showed:
- All patients received a MSE which included necessary testing and on-call services within the capability of the hospital to reach a diagnosis.
- MSE referred to the process required to reach the point at which it could be determined whether the individual had an EMC and would be suitable based on the presenting symptoms.
- EMC was a medical condition with such severity (to include severe pain, pregnancy, and active labor) such that the absence of immediate medical attention could place the individual's health at risk.
- A MSE included vital signs (VS, measurements of the body's most basic functions); history and physical exam of affected systems and potentially affected systems; necessary testing to rule out EMCs; notification and use of on-call staff to complete guidelines; notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary; and repeat VS upon discharge.
- EMCs included undiagnosed, acute pain which was sufficient to impair normal functioning.
- The hospital may not discharge a patient who may be at risk to deteriorate from, during or after said discharge.

Please refer to A-2406 for further details.

Based on interview, record review and policy review, the hospital failed to provide an appropriate medical screening exam (MSE) sufficient to determine whether or not an emergency medical condition (EMC) exists for one patient (#2) of 20 Emergency Department (ED) records reviewed.

Findings included:

Review of the hospitals policy titled, "Emergency Medical Treatment and Labor Act Guidelines for Emergency Department Services," revised 01/26/22, showed:
- All patients received a MSE which included necessary testing and on-call services within the capability of the hospital to reach a diagnosis.
- MSE referred to the process required to reach the point at which it could be determined whether the individual had an EMC and would be suitable based on the presenting symptoms.
- EMC was a medical condition with such severity (to include severe pain, pregnancy, and active labor) such that the absence of immediate medical attention could place the individual's health at risk.
- A MSE included vital signs (VS, measurements of the body's most basic functions); history and physical exam of affected systems and potentially affected systems; necessary testing to rule out EMCs; notification and use of on-call staff to complete guidelines; notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary; and repeat VS upon discharge.
- EMCs included undiagnosed, acute pain which was sufficient to impair normal functioning.
- The hospital may not discharge a patient who may be at risk to deteriorate from, during or after said discharge.

Review of Patient #2's medical record showed:
- On 01/21/25 at 1:24 PM, a 37-year-old female presented to the hospital at six weeks pregnant with a chief complaint of nausea, abdominal cramping, lightheadedness, and diarrhea that had begun at 9:30 AM. She reported a brown discharge to her outpatient clinic Obstetrician/Gynecologist (OB/GYN, a specialty physician focused on women's health and delivering babies) the previous day.
- At 1:27 PM, medical record documentation showed her blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) was 115/54 or "low", as documented on page 6, where the QMP and hospital characterized her diastolic BP as being low, showing knowledge of her hypotension, and her pulse (normal pulse/heartbeats for adults range from 60 to 100 per minute) was 88 BPM. No other VS were obtained. Her pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) score was five out of 10, for her abdominal, chest and neck pain. It was described as dull and aching, no other pain assessments were completed.
- At 1:33 PM, provider documentation showed Patient #2 felt achy on the sides of her abdomen and to her neck. She had been so dizzy that she was only comfortable laying on the bathroom floor. She was advised by her outpatient OB/GYN to call their office if she had any red vaginal discharge after she reported the brown vaginal discharge the previous day. She had no vaginal bleeding. Staff H, NP, documented in the medical record on page 6 that Patient #2's medical decision-making differential diagnosis included "vaginal bleeding, pelvic pain, ectopic pregnancy [a serious condition in which a pregnancy implants outside the uterus and is associated with risk of rupture, which can cause severe bleeding, low blood pressure, shock, organ dysfunction, serious impairment of bodily functions, loss of future reproductive function and fertility, and death, among other risks], urinary tract infection [UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra], and discomfort of pregnancy".
- A qualitative human chorionic gonadotropin (HCG, a hormone produced in the body during pregnancy) was positive.
- The medical record did not contain any evidence that the hospital provided any further appropriate screening to determine whether Patient #2's signs and symptoms were a manifestation of ectopic pregnancy.
- At 2:42 PM, she was discharged.

During an interview on 03/04/25 at 8:37 AM, Staff K, OB/GYN, reviewed Patient #2's medical record. He would have preferred for the ED provider to have called an OB provider to consult for this patient because he would have recommended a Quantitative HCG instead of a Qualitative hCG because it would have shown more specific detail. This would have provided more information. He would have recommended a conversation with an OB/GYN provider because there were other possibilities that were not explored.

During an interview on 03/03/25 at 2:17 PM, Staff H, Nurse Practitioner, stated she had taken care of Patient #2 on 01/21/25. She could have called the US staff in to perform an exam. The on-call US staff would have responded to the hospital within 60 minutes.

Review of Patient #2's Hospital B medical record showed:
- On 01/21/25 at 9:06 PM, she presented with a chief complaint of abdominal pain. Her VS included a BP of 88/53 and a pulse of 81 BPM.
- At 9:17 PM, physician documentation showed she had reported dark discharge and abdominal pain to her OB/GYN earlier in the day.
- At 9:25 PM, an ultrasound was completed and showed an ectopic pregnancy and a small amount of hemorrhagic (excessive blood) fluid.
- The recommendation was to admit her for surgical intervention for a presumed ruptured ectopic pregnancy.
- On 01/22/25 at 12:18 AM, she was admitted.
- At 1:32 AM, an operative note showed she had a ruptured ectopic pregnancy, and her left fallopian tube (two slender, muscular tubes that connect the ovaries [small glands located on either side of the uterus] to the uterus) had a significant number of adherent clots (clumps that occur when blood hardens from a liquid to a solid). Her left fallopian tube and the ectopic pregnancy were removed.