HospitalInspections.org

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Based on interview and document review, the hospital failed to implement their policies and procedures for evaluation and treatment of a patient that presented for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional and stabliizing treatment prior to transfer or discharge risks poor health outcomes, injury and death.

Findings included:

The hospital failed to ensure that a patient received a medical screening exam before they left the emergency department (ED).

Cross Reference: Tag C 2406
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Based on interview and document review, the hospital failed to implement its policy under Emergency Medical Treatment and Labor Act (EMTALA) to provide a medical screening exam to a patient that presented to the emergency department (ED) for 1 of 21 patient records reviewed (Patient #1).

Failue to implement their policy put patients at risk for poor outcomes when a medical screening exam is not completed that may reveal a medical emergency that requires care and treatment.

Findings included:

1. Document review of the hospital policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)," revised 10/23, showed that all patients that presented to the ED were to be given a medical screening exam to rule out a medical emergency.

2. On 05/21/24 at 10:30 AM, the investigator interviewed the ED registration specialist (Staff #5). Staff #5 stated that in April a patient came into the ED complaining of kidney pain. The ED physician on duty came out and told the paitent the CT scan machine was not working. The physician did not offer a medical screening exam (MSE). The patient left the ED before Staff #5 could get their name.

3. On 05/21/24 at 11:30 AM, the investigator interviewed the ED physician on duty (Staff #7). Staff #7 remembered telling a patient with flank pain that the hospital CT scan was not working. The patient left the ED without getting a MSE. Staff #7 stated that the patient should have received a MSE and if warranted, transferred to another hospital after the MSE.

4. On 05/21/24 at 1:30 PM, the investigator interviewed Patient #1. Patient #1 stated that on 04/21/24, they came to the hospital to get help for pain for their kidney stones. Patient #1 stated they were told by the ED physician the CT scan was not working. The patient was not offered a MSE and left with their family member. The pain intensified on the way to another hospital and 911 was called. The fire department ambulance came and transported the patient from their car on the side of the road to another hospital for care.

5. Document review of Emergency Response records showed that on 04/21/24 they/them (Patient #1) was picked up from their car on the side of the road by the local fire department. Patient #1 was on their way to the hospital when the pain increased causing the patient to pass out. The patient was transported to the another hospital by ambulance.

6. On 05/21/24 at 2:00 PM, the investigator interviewed the Manager of Quality/Risk & Regulatory (Staff #11). Staff #11 verified the investigator's findings. Staff #11 stated that all patients presenting to the ED were to receive a MSE to rule out a medical emergency. Staff #11 stated that on 04/21/24 the ED staff self-reported that a patient had not been given a MSE. There was no name of the patient as the patient had left the ED before a name could be obtained.

7. Document review of the ED visit where Patient #1 was transported showed the patient was treated and released for a kidney stone on 04/21/24.