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RIVERVIEW HEALTH
COMPLIANCE WITH 489.24
Tag No.: A2400
Based on document review and interview, the facility failed to complete a medical screening exam for 1 of 24 medical records reviewed.
Findings Include:
1. See findings cited at 42 CFR 489.24 (1), A2406.
EMERGENCY ROOM LOG
Tag No.: A2405
Based on document review and interview, the facility failed to keep a log of each individual presenting to the F1 emergency department for medical care on 5/29/2023.
Findings Include:
1. Review of F1 emergency department (ED) log and F1 "Event Summary with all Tasks" document dated 6/1/2023, did not indicate P24 was recorded seeking medical treatment on 5/29/2023, but does indicate the patient did present to the F1 emergency department in observable distress.
3. On 7/12/2023 at 1500 hours, S1, Clinical Quality and Compliance Coordinator confirmed that P24 was not recorded on the (ED) log on 5/29/2023.
4. On 7/12/2023 at 1350 hours S4, Director Organizational Improvement, confirmed the additional Emergency Medical Treatment and Labor Act (EMTALA) training was initiated on 6/5/2023 for all emergency, registration, and security staff. This training focused on registration, emergency medical assessment, and transfer responsibilities. Roles for clinical and ancillary and supporting staff were clarified.
MEDICAL SCREENING EXAM
Tag No.: A2406
Based on document review and interview, the facility failed to provide a medical screening exam to 1 of 24 emergency medical records reviewed. (P24).
Findings Include:
1. F1 policy, "Emergency Medical Treatment and Transfer," HPP.112, effective 01/06/2021, that indicates that the facility will perform an appropriate medical screening examination to all persons who come to the emergency center and request (or has a request made on the person's behalf, or absent a request, would cause a prudent layperson observer to believe based on the person's appearance or behavior that the person needs) an examination or treatment for a medical condition by a physician or other qualified medical professional to determine if an emergency medical condition exists.
2. Review of F1 emergency department (ED) log and F1 "Event Summary with all Tasks" document dated 6/1/2023, did not indicate P24 was recorded seeking medical treatment or receiving a medical screening exam on 5/29/2023.
3. On 7/12/2023 at 1500 hours, S1, Clinical Quality and Compliance Coordinator confirmed that P24 was not recorded on the (ED) log, and did not have a medical screening exam conducted on 5/29/2023.