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Based on policy review, medical record reviews, and interviews, the facility failed to provide a Medical Screening Examination (MSE) for one (#3) patient of 33 patients reviewed. These failures resulted in Patient #3 leaving Hospital A's Emergency Department (ED) on 9/17/2022 after waiting 1 hour and 54 minutes without an MSE being provided. Immediately after leaving the ED at Hospital A, the patient was taken 10.4 miles by family members to Hospital B, a satellite facility of Hospital A, where she was provided an MSE and her Emergency Medical Condition was diagnosed and treated.

The findings included:

Refer to A-2406.

Based on review of the facility policies, review of medical records, and interviews, the facility failed to provide a Medical Screening Examination (MSE) for one (#3) patient of 33 patients reviewed. This failure resulted in Patient #3 leaving Hospital A's Emergency Department (ED) after waiting 1 hour and 54 minutes without an MSE being completed. The patient was immediately transported 10.4 miles by family members to Hospital B, which is a satellite of Hospital A, where she was provided an MSE.

The findings included:

Review of the facility's policy titled "Emergency Screening Stabilization/Transfer/250 Yard Rule and EMTALA" last revised date 3/2019 revealed, "...Any individual who comes to the hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate medical screening performed by a physician or other qualified medical personnel to determine whether or not an emergency medical condition exists..."

Review of facility policy titled, "Emergency Department Scope of Care" last revised date 12/2019 revealed, "...RN [Registered Nurse], LPN [Licensed Practical Nurse], and Physicians perform reassessment when there is a change in the patient's status, or other changes indicated by the patient..."

Review of Hospital A medical records revealed Patient #3 presented at Hospital A's ED on 9/17/2022 at 12:16 PM for complaint of, "...has had n/v [nausea and vomiting] and left flank pain x 2.5 hrs [hours]. Hx [history] of kidney stones..." The patient was triaged by Registered Nurse (RN) #1 on 9/17/2022 at 12:21 PM with vital signs documented as:
Blood Pressure = 134/71 (normal is 100/60 to 119/79)
Pulse = 67 (normal is 60-100)
Respirations = 18 (normal is 12-20)
Temperature = 97.2 (normal is 97.0 to 99.0)
Oxygen Saturation = 99% (normal is 95-100%)

Triage was completed at 12:23 PM and the patient was moved to the ED Waiting room. There was no pain assessment documented and no other vital signs documented. The patient left the ED at 2:10 PM. Review revealed no documentation of the patient was provided an MSE prior to leaving the ED.

Review of Hospital B's medical records revealed Patient #3 presented there on 9/17/2022 at 2:15 PM. Review of the Nurse's Notes dated 9/17/2022 at 2:35 PM revealed, "...Patient c/o [complaining of] left flank pain with hx of kidney stones, n/v since 1000 [10:00 AM]...pt [patient] came from Athens er [Emergency Room] after being told to come here by rn [Registered Nurse], per parent..." Review of the medical record revealed the patient was triaged by an RN at 2:35 PM and the vital signs during triage were:
Pain Scale = 9/10 (zero is no pain, 10 is severe pain)
Blood Pressure = 140/66
Pulse = 67
Respirations = 18
Temperature = 97.0
Oxygen Saturation = 100%
The patient had a MSE by a Medical Doctor (MD) initiated at 2:24 PM. The patient was transported to CT (computerized tomography is an imaging procedure using x-rays). The patient was treated with Ketorolac (a pain medication) 60 milligrams by intramuscular injection and Ondansetron (nausea medication) 4 milligrams by mouth at 3:00 PM on 9/17/2022. Review of the CT Report dated 9/17/2022 at 3:20 PM revealed the patient had a 4 millimeter kidney stone in her left ureter (tube that transports urine from kidney to bladder) as well as multiple non-obstructing kidney stones in both of her kidneys.

Telephone interview with Patient #3's mother on 10/13/2022 at 8:43 AM revealed the patient was having severe abdominal pain, nausea, and vomiting when she took the patient by private car to the ED at Hospital A around noon on 9/17/2022. The patient was triaged quickly by a nurse and then sent to the waiting room; "...we were told she would be next to be seen...". The mother stated there were multiple patients observed coming in and being triaged and Patient #3 was waiting in the ER for over two hours. The patient's condition worsened while waiting and the patient laid down on the floor just outside of the triage room. The mother stated she went into the triage room 3 times and asked for someone to assist the patient. "...I told them she was getting worse and that she had passed out...no one ever came to check her or take her vital signs..." She stated finally an employee came out and gave her a wash cloth. The mother stated she later learned this employee was a registration clerk. The registration clerk told the mother, "...I just checked the [hospital B] ED and they only have one patient. They said you can go there and get treated right now..." The mother stated she asked, "...So you want me to leave here and go to another ER..." The mother stated the registration clerk told her, "...if you need to be treated right now, you need to go there..." The mother told the registration clerk she would take the patient to Hospital B. The patient and mother were not advised by any ED staff to wait at Hospital A to be examined and treated. The patient and mother were not asked to sign any discharge papers, Refusal of Treatment forms, or Leaving Against Medical Advice forms. The mother assisted the patient into a wheelchair, put her in her car, and immediately drove her to Hospital B. The ED staff at Hospital B had not been notified Patient #3 was on her way and were surprised to learn she had been told to come there. The patient was quickly examined by a physician and treatment was provided. The patient was discharged home after being diagnosed with kidney stones and provided treatment for her severe pain. The mother had notified the ED manager of the incident by telephone a few days after the incident.

Patient #3 was interviewed by telephone on 10/13/2022 at 9:20 AM. Patient #3 stated she remembered being very sick and being in severe pain when she was taken by her mother to the ED at Hospital A. The patient stated she was unconscious for much of her stay at the ED on 9/17/2022, but remembers being in severe pain and having nausea and vomiting frequently. She remembers one of the ED employees telling her mother, "...you should just take her to [Hospital B]..." The patient did not remember her trip to Hospital B or how she got there, just remembered regaining consciousness while she was at Hospital B. The patient was treated at Hospital B and felt better when discharged home later that day.

Registered Nurse (RN) #1 was interviewed by telephone on 10/12/2022 at 11:40 AM. RN #1 stated she remembered Patient #3 and stated she appeared very sick and in severe pain when she arrived. RN #1 stated the ED at Hospital A was very busy that night, all of the rooms were filled with patients, and she had no place to lay Patient #3 down. RN #1 stated there were no spaces in the hallways or elsewhere for a stretcher, and there were no stretchers available as they all had patients in them already. RN #1 stated she would have taken Patient #3 back right away if she had space. RN #1 stated she saw the patient sitting on the floor outside of triage, and she spoke to the patient. RN #1 stated the patient was not unconscious and asked her "...how much longer will it be..." RN #1 stated she told the patient she would take her back as soon as she had room for her. RN #1 stated she was too busy to recheck the patient's vital signs. RN #1 stated she did not speak with the patient or her mother before she left the ED. RN #1 stated the patient left without telling her or any of the other ED nurses, and she was not aware the patient had left until later. RN #1 stated the patient did not have a MSE by a physician or other provider while in the ED at Hospital A on 9/17/2022. RN #1 stated the patient left without telling staff so she was not able to get a Leaving Against Medical Advice or Refusal of Treatment form signed by the patient or her mother.

Registration Clerk #1 was interviewed by telephone on 10/12/2022 at 11:59 AM. The clerk stated she remembered Patient #3. She stated the ED was very busy that night and Patient #3 was in the lobby 1.5 to 2 hours waiting to be seen and treated. She saw the patient was lying on the floor outside of triage. The mother came to registration multiple times and asked for assistance. The clerk stated, "...we told her there was nothing we could do...". The clerk stated, "...I went out and checked on her...she was not unconscious, and she spoke to me when I asked her questions...she was not blue anywhere...I spoke to her and her mother and I apologized for the wait..." The clerk brought the patient an emesis basin and a wet washcloth. The clerk said, "...I felt bad for them. She was really sick...I showed the mother an app [phone app] that she could check the wait times here and at [Hospital B]...I did not tell her to go to [Hospital B]...later the mother left without telling us where she was going...I offered to help her with the wheelchair but she refused..." The clerk did not advise the patient to remain at Hospital A.

Interview with the ED Director in the Quality Assurance office on 10/12/2022 at 1:00 AM revealed Patient #3 did not have an MSE documented in the medical record. Continued interview revealed there was no Leaving Against Medical Advice or Refusal of MSE forms completed in the medical record.