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Based on staff interview, medical record review and facility policy review, the hospital failed to comply with CFR 489.24 by not providing an appropriate Medical Screening Exam for Patient #1.

Findings Include:

Refer to C2406 for detail findings.

Based on staff interview, medical record review and facility policy review, the hospital failed to comply with CFR 489.24 by not providing an appropriate Medical Screening Exam for Patient #1.

Findings Include:

During an interview on 03/08/2022 at 2:45 p.m., the Director of Nursing (DON) for facility #1 revealed she recently took the role of the DON. She revealed the granddaughter (whom was not at the facility) of the patient posted a negative comment on Facebook concerning the patients recent Emergency Department (ED) visit and discharge. When Patient #1 left this facility the patients daughter took her to another facility the next day with a gastrointestinal (GI) bleed. The patient was admitted to the second facility (Hospital #2) and stayed several days to be discharged and admitted back to us (Hospital #1 - Tallahatchie General Hospital)for a few days in a swing bed. The DON confirmed that ED physician ordered a Computed Tomography (CT) scan of the brain for Patient #1 and no other labs or tests. DON confirmed Patient #1 was admitted to Hospital #2 on 01/27/2022 and was discharged on 02/04/2022. She was then admitted back to Hospital #1 on 02/04/2022 and discharged on 02/24/2022.

During an interview on 03/09/2022 at 3:00 p.m., Registered Nurse (RN) #1 confirmed being familiar with Patient #1 and recalls that the family found her unconscious sitting on the toilet at home, was very drowsy on arrival and ED Physician #1 was working. RN #1 revealed in his experience most patients presenting to the ED with symptoms of a stroke usually are ordered a Urinalysis (UA), Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and a computed Tomography (CT) of the Brain. RN#1 confirmed ED Physician ordered a CT of the brain only.

During an interview on 03/09/2022 at 4:08 p.m., ED Physician #1 stated he believed Patient #1 "had a vasovagal response while straining on the toilet. I see and treat this often. I do not know if I would do any labs, just a CT of the Brain." When asked by state agency if he would order a prothrombin time (PT), international normalized ratio (INR), ED Physician #1 replied he would only order these if the patient was on blood thinners and especially the new ones.

Medical record review of Patient #1 revealed the ED "Clinical Report-Nurses ...Triage Assessment ...01/26/2022 ...21:19 (9:19 p.m.) ... ...Triage ...Acuity: LEVEL 3 ....Pt. came in on 100% non-rebreather per EMS ... patient confused to time, person, and place ...FSBS (Finger Stick Blood Sugar) 347 ...she has had altered mental status, trouble walking and difficulty breathing ... No loss of consciousness...No dizziness, neck pain, extremity pain, back pain, or limited ROM present ... Glasgow COMA SCALE: 15, eyes open-spontaneous (4) ... best verbal response-oriented (5) ... best motor response-obeys commands ...22:12 (10:12 p.m.)...(RN #1 signature) ... ...21:31(9:31 p.m.) ...01/26/2022 ... blood pressure (BP) 112/84, HR 88, respirations 20 ....Temp: unable to obtain due to patient condition ...History ...PAST MEDICAL HISTORY ...Stroke...No history of diabetes mellitus ...No history of dementia ... PHYSICAL ASSESSMENT ...the patient is disoriented to place and time ...not to person ...NURSING PROGRESS NOTES ...Patient ready for evaluation-chart flagged and ED physician notified-22:13 (10:13 p.m.) 01/26/2022 ...DISPOSITION/DISCHARGE ...Departure time:23:45 (11:45 p.m. 01/26/2022 ... Discharge instructions provided and reviewed with the patient and family (Daughter). Verbalized understanding (Daughter) ....The patient was discharged by the physician ...She left in a wheelchair and via private vehicle ...Family member driving (Daughter) ...00:31 ...01/27/2022...(RN #1 signature) ...00:28 (12:28 a.m. 01/27/2022 ...BP 94/56 ...HR 88 ...RR 20 ...O2 SAT 99%...00:31 (12:31 a.m.. 01/27/2022."
Medical record review of "Emergency Department Visit Overview ...01/26/2022 ...PAST MEDICAL HISTORY ...Anemia ...Cerebrovascular Accident ... Dementia ... Depression ... Heart Disease ...Hypertension, Colon Resection ..."

Medical record review of "Clinical Report- Physicians/Mid Levels ...HISTORY OF PRESENT ILLNESS ...Chief Complaint: CHANGED MENTAL STATUS ....This started today, unknown when patient was last known well and is now gone ...The patient has been confused ...The patient was not found unresponsive ...No history of chronic dementia ...She has had one recent fall ...Neuro: Alert ...Oriented x 3 ...Mood/affect normal ...Speech normal ...No motor deficit ...No sensory deficit ...LABS,-RAYS AND EKG ...Laboratory Tests ...Laboratory test have been ordered with results reviewed and considered in the medical decision making process ... CT Head/Brain w/o Contrast ...There is moderate generalized atrophy with chronic white matter changes ...no apparent infarction, mass, hemorrhage, edema, hyperdense vessels ...PROGRESS AND PROCEDURES ...Disposition: Discharged ...CLINICAL IMPRESSION ...Single Acute Transient Ischemic Attack consistent with vertebra-basilar artery syndrome ... (electronically signed by (ED Physician #1)...01/26/2022 23:08 (11:08 p.m.)..."

Medical record review revealed Patient #1 had a CT scan of the brain at 10:25 p.m. on 01/26/2022 and revealed moderate atrophy and some chronic white matter changes. No acute processes.

Review of Hospital #2's medical history listed for Patient #1 revealed Cancer, Colon Cancer, Depression, Gastrointestinal Reflux Disease, Hiatal Hernia, Esophageal reflux with bleeding, Hyperlipidemia, Hypertension, Osteoporosis, and Parkinson disease.

Review of Patient #1's ED records (date 01/27/2022) from Hospital #2 revealed diagnosis includes Sepsis, GI Bleed, leukocytosis, lactic acidosis, acute kidney injury, elevated BUN, positive hemoccult. Patient was admitted to the facility. Patient was discharge 02/04/2022.

Review of facility policy entitled Emergency Medical Treatment and Labor Act "(EMTALA)" (revised 10/2020) revealed, " ... is the policy of the Emergency Department at (Hospital #1) to establish a uniform process for the adherence of all EMTALA rules and regulations ... Any individual with a medical condition that presents to the ED shall receive a medical screening exam (MSE) that is appropriate for their medical condition...".