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Based on record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#13) of 23 Emergency Department (ED) records reviewed. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 3,668.

Findings included:

Review of the hospital's undated policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy," showed that when an individual presents to the ED and requests examination or treatment for a medical condition, the hospital must provide an appropriate MSE by qualified personnel as determined by the board of directors. The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether or not an EMC exists.

Review of the hospital's policy titled, "Rules and Regulations of the Medical Staff," dated 03/18/23, showed that for MSEs, any individual presenting to the ED requesting examination or treatment would receive a MSE to determine if the individual had an EMC as required by federal law. Physicians, registered nurses (RNs), advanced practice registered nurses, physician assistants, and for psychiatric (relating to mental illness) evaluations, mental health coordinators, were authorized to perform a MSE. Only physicians were authorized to certify an unstable patient for transfer. All patients admitted to the ED would be assessed by a RN or physician prior to discharge.

Patient #13 presented to the ED on 08/20/23, with complaints of nausea, vomiting, and difficulty swallowing for the past five days. She had a history of dysphagia (difficulty or discomfort with swallowing). She was triaged (process of determining the priority of a patient's treatment based on the severity of their condition), with vital signs (body temperature, blood pressure, heart rate, and breathing rate) of a temperature of 98.2 degrees Fahrenheit, pulse rate (the number of heart beats per minute) of 112, respirations (inhalation and exhalation of air; breathing) of 12 breaths per minute, blood pressure (BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80) of 123/98, and oxygen saturation (measure of how much oxygen was in blood) of 100%. During the Nurse Practicioner (NP) evaluation, the NP documented the patient voiced she had a condition called Achalasia (rare disorder that makes it difficult for food and liquid to pass from the swallowing tube connecting your mouth and stomach) and often had difficulty swallowing food due to sphincter constriction. During her ED evaluation, the RN documented the patient stated she had not been able to keep any food/water down for five to seven days. No other ancillary testing was done. She was discharged with a prescription for Reglan (a medication used to prevent nausea and vomiting) 10 milligrams (mg, a measure of dosage strength), one tablet by mouth every six hours. She then presented to Hospital E and after completing her MSE, including blood work, the patient was admitted as an inpatient, where she remained until 08/26/23 for dysphagia, nausea, vomiting, and dehydration (a condition caused by excessive loss of water from the body).

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 (#13) of 23 Emergency Department (ED) records reviewed. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 3,668.

Findings included:

Review of the hospital's undated policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy," showed that when an individual presents to the ED and requests examination or treatment for a medical condition, the hospital must provide an appropriate MSE by qualified personnel as determined by the board of directors. The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether or not an EMC exists.

Review of the hospital's policy titled, "Rules and Regulations of the Medical Staff," dated 03/18/23, showed that for MSEs, any individual presenting to the ED requesting examination or treatment would receive a MSE to determine if the individual had an EMC as required by federal law. Physicians, registered nurses (RNs), advanced practice registered nurses, physician assistants, and, for psychiatric (relating to mental illness) evaluations, mental health coordinators, were authorized to perform a MSE. Only physicians were authorized to certify an unstable patient for transfer. All patients admitted to the ED would be assessed by a RN or physician prior to discharge.

Review of Patient #13's medical record from Hospital A, dated 08/20/23, showed the following:
- She was a 27-year-old female who presented to the ED at 10:24 AM, with nausea, vomiting, and difficulty swallowing for the past five days.
- She had a history of dysphagia (difficulty or discomfort with swallowing).
- At 10:25 AM, she was triaged (process of determining the priority of a patient's treatment based on the severity of their condition), with vital signs (body temperature, blood pressure, heart rate, and breathing rate) of a temperature of 98.2 degrees Fahrenheit, pulse (the number of heart beats per minute) of 112, a respiratory rate (inhalation and exhalation of air; breathing) of 12 breaths per minute, blood pressure (BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80) of 123/98, and oxygen saturation (measure of how much oxygen was in blood) of 100%.
- At 10:31 AM, Staff S, Nurse Practitioner (NP), evaluated Patient #13. During the Nurse Practicioner (NP) evaluation, the NP documented the patient voiced she had a condition called Achalasia (rare disorder that makes it difficult for food and liquid to pass from the swallowing tube connecting your mouth and stomach) and often had difficulty swallowing food due to sphincter constriction.
- At 11:06 AM, nursing documentation showed that Patient #13 stated she had not been able to keep any food/water down for five to seven days.
- At 11:26 AM, she was set for discharge and no labs had been ordered.
- At 11:27 AM, she was given a prescription for Reglan (a medication used to prevent nausea and vomiting) 10 milligrams (mg, a measure of dosage strength), one tablet by mouth every six hours.
- At 11:42 AM, Patient #13 was discharged from the ED.

During an interview on 11/08/23 at 11:53 AM, Staff S, NP, stated that she did not recall Patient #13, however, if a patient presented to the ED with nausea, vomiting, and difficulty swallowing, she would assess the patient to see why they had nausea, vomiting, and difficulty swallowing before she put in any orders. If the patient were stable, they would not necessarily get an intravenous (IV, in the vein) and get labs drawn. From the patients chart, the patient's vital signs were stable so she did not present as dehydrated. Patient #13 did not seem to be urgent and had a plan in place for further treatment.

During an interview on 11/07/23 at 1:50 PM, Staff J, ED Assistant Nurse Manager, stated that if a patient presented to the ED with dysphagia, nausea and vomiting, they would typically order basic labs included in the abdominal pain standing orders. Basic labs included a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), a comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions), and a lipase (a test that measured the level of enzymes in your blood).

During an interview on 11/07/23 at 3:07 PM, Staff N, ED RN, stated that he was Patient #13's triage nurse. The patient presented with nausea and vomiting and could not hold down food for a long period of time. After he had the patient triaged, she went to the waiting room for only a short period of time. They did not use standing orders when a patient went back to a room quickly.

During an interview on 11/07/23 at 2:25 PM, Staff L, ED RN, stated that she remembered Patient #13. The patient was taken straight back from triage and hooked up to the machine to monitor her BP and oxygen. The NP went into the room to see the patient. The patient complained of abdominal pain and vomiting. When the ED was slow, ED standing orders were not used. Orders were not put in until after the patient was seen by the provider. The NP ordered the patient Reglan. If the standing orders were not used, labs or IVs were not started until the provider ordered them.

Review of Patient #13's medical record from Hospital E, dated 08/20/23, showed the following:
- She presented to the ED with a chief complaint of nausea and vomiting at 12:46 PM.
- The patient reported a past medical history of dysphagia, had not been able to tolerate anything by mouth for the past five days, and had been to Hospital A earlier that day.
- Blood work results showed a blood glucose (sugar) of 59 (normal range 70-99); chloride (a type of electrolyte in the blood, normal range was 96-106) of 108; carbon dioxide (CO2, a gas produced by exhaling, normal range was 23-29) of 12; red blood cell count (RBC, the number of red cells [oxygen carrying cells] in the blood, normal range was 4.2-5.4) of 5.87; hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body, normal range was 12-16) of 15.9; and hematocrit (a blood test that measures how much of a person's blood was made up of red blood cells, normal range was 36-48) of 49.5.
- On 08/20/23 the patient was admitted with diagnoses that included dysphagia, nausea, vomiting, and dehydration (a condition caused by excessive loss of water from the body), she remained an inpatient until 08/26/23 receiving IV medication, further evaluation and treatment.