HospitalInspections.org

Based on interview, record review and policy review the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#23) of 23 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC).

Findings included:

Review of the hospitals document titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) - Medical Screening Exam (MSE) and Stabilization Policy," dated 07/18/24, showed:
- A MSE was the process required to reach, within reasonable clinical confidence, the point at which it could be determined whether the individual had an EMC.
- The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital.
- A MSE was required when an individual came to the hospital and requested examination or treatment for a medical condition, including when the individual requested medication to resolve or provide stabilizing treatment for a medical condition.

Review of the hospital's undated document titled, "Lafayette Regional Health Center Medical Staff Rules and Regulations," showed:
- The attending practitioner shall be responsible for the preparation of a complete and legible age-specific medical record for each patient.
- The record shall include physical examination findings.
- The history and physical examination shall include all pertinent findings resulting from an assessment of all body systems.

Please refer to 2406 for further details.

Based on interview, record review and policy review the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#23) of 23 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC).

Findings included:

Review of the hospitals document titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) MSE and Stabilization Policy," dated 07/18/24, showed:
- A MSE was the process required to reach, within reasonable clinical confidence, the point at which it could be determined whether the individual had an EMC.
- The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital.
- A MSE was required when an individual came to the hospital and requested examination or treatment for a medical condition, including when the individual requested medication to resolve or provide stabilizing treatment for a medical condition.

Review of the hospital's undated document titled, "Lafayette Regional Health Center Medical Staff Rules and Regulations," showed:
- The attending practitioner was responsible for the preparation of a complete and legible age-specific medical record, for each patient.
- The record shall include physical examination findings.
- The history and physical examination shall include all pertinent findings resulting from an assessment of all body systems.

Review of Patient #23's medical record, dated 03/28/25, showed:
- On 03/28/25 at 6:36 PM, she was a 69-year-old female who presented to the ED with a chief complaint of shaking, dizziness, nausea, and vomiting related to Trazadone (a medication used to treat depression) withdrawal. She had run out of Trazadone two days prior.
- Provider documentation showed the only portion of the physical examination recorded was a review of vital signs (VS, measurements of the body's most basic functions) and "shakiness, sweats, malaise (body weakness or discomfort)."
- At 7:50 PM, she was discharged with a prescription for three Trazadone tablets.

During a telephone interview on 06/30/25 at 9:45 AM, Staff N, ED Medical Director, stated that the physical examination documented for Patient #23 was not to his personal preference or expectations, he would have documented more. However, he would not state that Staff L, ED Physician's, documentation did not meet the requirements of the hospital for the physical exam completed for Patient #23.