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Based on review of medical records, staff interview, and review of facility documents, it was determined the facility failed to ensure all patients receive stabilizing treatment when presenting to the Emergency Department (ED).

Cross reference: 489.24(d)(1-3) Stabilizing Treatment

Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure that all patients seeking emergency treatment received a medical screening examination (MSE) from a qualified provider in one of 22 medical records reviewed (Patient (P)2).

Findings include:

Facility policy titled, "Emergency Medical Treatment and Active Labor Act" last revised January 2024 stated, " ...Procedure ... 3. Medical Screening Examination (MSE) A. ...staff will provide all patients with a Medical Screening Examination. This examination shall be performed by a physician or other practitioner (e.g., Nurse Practitioner, Physician's Assistant) deemed qualified to perform such examination pursuant to state law and the acute care hospitals Rules and Regulations .... C. Staff will ensure that the Medical Screening Examination is performed in accordance with the patient's identified needs and with the acute care hospital's capabilities ..."

On 12/11/24 at 11:25 AM, a review of P2's medical record for an Emergency Department (ED) visit from 12/7/24 was reviewed. On 12/7/24 at 12:10 AM, P2 presented to the ED with a chief complaint of foot pain. The medical record indicated that P2 was seen by a provider on 12/7/24 at 1:59 AM. P2's medical record lacked evidence of an MSE, or a provider note. This finding was confirmed with Staff (S)18, Nursing Informaticist, on 12/13/24 at 10:44 AM.

On 12/13/24 at 12:30 PM, the above findings were reviewed and confirmed with S1, Director of Risk Management.