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Based on interview and record review, the facility failed to complete a comprehensive medical screening exam for 1 (P-1) of 37 patients reviewed for EMTALA requirements resulting in unrecognized, unmet patient needs and poor patient outcomes. Findings include:

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A-2406 Failure to complete a comprehensive medical screening exam

Based on interview and record review, the facility failed to perform a comprehensive medical screening exam for 1 (P-1) of 37 patients reviewed resulting in unrecognized, unmet patient needs and poor patient outcomes. Findings include:

Review of the medical record for P-1 revealed he was a 13-year-old male who presented to Facility B, an acute care hospital within the same healthcare system, on 2/22/2024 with a chief complaint of a headache. It was noted that P-1 had been seen at the local children's hospital (Facility A) on 2/19/2025 and 2/21/2025 for a headache as well. A CT scan (computerized tomography-"cat scan") was ordered at the 2/19/2025 visit and resulted with "No acute intracranial abnormality."

Triage notes indicated the mother reported P-1 was "unable to get out of bed d/t (due to) intensity of h/a (headache); ct scan at (Facility A) x 2 days ago; endorses nausea, weakness, and lightheadedness." P-1 rated his pain 9/10. Triage assigned him an ESI (Emergency Severity Index-a five-level triage algorithm used in the emergency department to quickly assess and prioritize patients based on the severity of their condition and the resources needed for their care) acuity level 4 (Non-urgent. Patient only needs one resource to be treated and discharged.)

During an interview on 4/29/2025 at 1109, Confidential Informant #1 stated P-1 lost the ability to walk at home and his older brother had to carry him around the house and help him to the bathroom and was brought to Facility B. Confidential Informant #1 stated when the facility asked why P-1 was there, the mom told them it was because (Facility A) was not doing anything (to help P-1).

Review of provider notes from Physician Assistant (PA) Staff I revealed the provider was aware P-1 had been seen twice before at Facility A for a headache and had a negative CT scan of the head. P-1 had not received the Depakote that had been previously prescribed for the patient by neurology at Facility A nor had he followed up with the neurologist as instructed as the discharge paperwork had been misplaced. The notes stated, "Complains of a headache not able to sleep. No reported fevers falls injuries no chills coughing wheezing chest pain shortness of breath no major abdominal pain there has been nausea vomiting per patient (sic). No swelling edema numbness or tingling no recent weight loss (sic)."

Under the "Review of Systems" portion of the provider notes, the constitutional, eyes, respiratory, cardiovascular, genitourinary, musculoskeletal, endo/heme/allergy, psychiatric/behavioral sections were all listed as "negative." The gastrointestinal was positive for nausea and vomiting the neurological section was positive for headaches.

Physical exam revealed under constitutional, "General: He is not in acute distress." The neurological section stated, "Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline."

No mention was made in the provider notes regarding P-1's inability to walk or having weakness as was mentioned in the triage notes. No further neurological exam was done after a third admission for the same problem in three days. No labs or further imaging were obtained. No further consults were placed.

P-1 was given Benadryl, Reglan, Toradol, Depakote, and a liter of normal saline while in the ED. His pain decreased to 6/10. A diagnosis of "Acute nonintractable headache, unspecified headache type" was given. In the ED course portion of the provider notes, PA Staff I stated, "Do not feel any further imaging at this time as needed (sic). Patient will be discharged stable... Patient will be discharged stable and improved."

On 5/1/2025 at 1024, PA Staff I stated during interview P-1 had come in for a headache, was seen twice previously at Facility A, had a CT scan that was unremarkable, neurology had been consulted and had recommended Depakote. He presented at Facility B with headache, nausea/vomiting, and insomnia. Staff I stated mom had lost the discharge papers and script that had been given to her from Facility A and had come in "for another script." He stated P-1 "looked good" and was "non-toxic." He gave a "migraine cocktail" and on re-examination, P-1 was "resting comfortably and looked much improved." Staff I also stated "the discharge papers were a big thing. I really stressed the importance of seeing neurology and getting the medications that had been prescribed."