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Based on ED log review, medical record review, policy review, and staff interview, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. This resulted in the failure to provide an appropriate and complete MSE to a patient. Findings include:

Refer to A2406 as it relates to the failure of the hospital to ensure all patients presenting to the hospital for emergency services were provided an MSE.

Failure to ensure all patients presenting to the ED were provided with an appropriate and complete MSE had the potential to negatively affect all patients presenting to the ED.

Based on ED log review, medical record review, policy review, and staff interview, it was determined the hospital failed to ensure an appropriate MSE was conducted for 1 of 4 patients (Patient #8) who's disposition was documented AMA and whose records were reviewed. Failure to conduct a complete MSE had the potential for significant problems to go untreated. Findings include:

A facility policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Guidelines," revised March 2025 stated, "Medical Screening Exam: The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not ... the purpose of the medical screening is to determine if an emergency medical condition exists so that EMTALA is covered."

The ED log was reviewed. It showed Patient #8 presented to the ED on 6/26/25. There was no chief complaint listed. It stated Patient #8 left without being seen.

Patient #8's medical record was reviewed. It included an "Admit-Discharge-Transfer Form," discharge documentation stating Patient #8 left the ED AMA, and a "Refusal of Screening Exam, Treatment, and/or Transfer" form signed by Patient #8. At the time of survey exit, there was no physician note documented in Patient #8's medical record.

Patient #8's record included an "Admit-Discharge-Transfer Form," which stated, "ED Disposition : Left without being seen ... Reason For Leaving: Other: PT [patient] presented to ed with numbness and tingling in all extremities [sic]. [name of office of provider] provider was concerned for a blood clot after thoracic outlet release, [Physician A] at the bedside and was not concerned of a clot, pt then did not want treatment at this time ... ED Physician Notified: [Physician A] ... Comments : Refusal of screening exam paper work completed."

Patient #8 was contacted but did not return a phone call.

The RN who documented the above note was unavailable for interview.

Physician A was unavailable for interview during the EMTALA survey.

Physician A was interviewed by phone on 8/8/25, after the survey exit, beginning at 10:41 AM. When asked if he assessed Patient #8 he said, "I did not." He stated she had tingling in her hands and feet and a clot was unlikely based on just that. He stated he didn't see her but spoke to her at the bedside. He stated Patient #8 determined she did not want to be there and requested to be seen by her PCP. He stated, "If they check in and do the whole visit they have to pay for it," so he requested the visit be cancelled but did not realize the nurse put a note in.

During the interview with Physician A, he stated, he placed a note in Patient #8's chart. The note was requested and received on 8/08/25 11:04 AM. The note was signed on 8/06/25 at 9:21 PM, after the survey exit. It stated, "The patient is a 44 yo [year old] female who initially presented to the ED by recommendation of a medical provider at her work. After talking with her family before my arrival into the room, patient had decided to not be seen and follow up routinely with her primary medical provider. She is complaining of "tingling" sensations in her extremities without localizing neurological concerns or weakness. After a brief discussion about her symptoms, I did encourage her to stay and see if we can determine the cause of her initial concerns. However, the patient has politely refused a medical screening examination or any further work-up at this time. She does understand the potential of possible serious, undiagnosed medical issues if she leaves prior to evaluation. I did offer again to evaluate her and make treatment recommendations based on her initial concerns. However, she felt that her symptoms were not severe and did not require emergent evaluation or treatment. The patient was invited to return to the emergency department at any time if she changes her mind. No ER Physician charge for this patient as she decided to leave prior to examination or any treatment."

It was unclear how Physician A determined a clot was unlikely if he did not assess Patient #8.

The hospital failed to ensure all patients presenting to the ED were provided a complete MSE.