HospitalInspections.org

Based on staff interview and document review, it was determined the facility failed to provide an appropriate medical screening exam (MSE) to determine whether an emergency medical condition (EMC) existed in one of twenty records cases in the survey sample (Patient [P] 3).
Cross Reference:
CFR(s): 489.24(a) & 489.24(c) Medical Screening Exam

Based on staff interview and document review, it was determined that the facility failed to maintain an accurate central log of each individual who comes to the emergency department (ED). Specifically, the facility failed to document Patient #3, who was refused treatment, on the central log.

Findings:

Review of the facility policy titled "EMTALA – Compliance with the Emergency Medical Treatment and Labor Act" dated December 2021, revealed " ... Each INOVA Dedicated Emergency Department shall maintain a central log (i.e. a triage sign in sheet) that includes the name of each individual who presents to the Dedicated Emergency Department seeking medical attention. The following information shall also be maintained in the central log: a. whether the individual refused treatment; b. whether the individual was refused treatment; or c. whether the individual was: i. transferred, treated and admitted; ii. Stabilized and transferred; or iii. discharged."

Review of the facility ' s central log from November 1, 2023, through December 26, 2023, identified it did not contain any patients that were refused treatment including P3 who presented November 29, 2023. This was confirmed in an interview with Staff Member (SM) 4, nurse.

Based on staff interview and document review, it was determined the facility failed to provide an appropriate MSE to determine whether an EMC existed in one of twenty cases reviewed in the survey sample (P3).

Findings:

Review of the facility policy titled "EMTALA - Compliance with the Emergency Medical Treatment and Labor Act" dated December 2021, revealed "An appropriate Medical Screening Examination, within the capability of the facility, shall be provided to any individual who (i) comes to an INOVA dedicated emergency department requested, or for whom a request is made, examination or treatment for a medical condition; or (ii) is on INOVA Hospital Property other than in a Dedicated Emergency Department and who requests, or for whom a request is made for an emergency medical condition.."

Review of P3 ' s ambulance trip record dated November 29, 2023, at 11:10 PM revealed the medic "arrived on grounds at Alexandria Hospital. Paramedic [name] went into Alexandria Hospital ED to speak with ER (emergency room) doctor ... [upon return to the ambulance] stated MD (medical doctor) would not accept patient or evaluate injuries was told to leave hospital and go to [name of other hospital]."

Interview with SM3, emergency room physician, on December 27, 2023, at 11:10 AM confirmed that they told the paramedic to "take the patient to another hospital" after EMS arrived onsite and that Patient #3 did not receive an MSE prior to leaving the facility.

Interview with SM1 and SM2 (Hospital Administration) on December 27, 2023, at 11:15 AM confirmed that a medical screening exam was not performed on P3 prior to directing EMS to take the patient to another hospital. Both SM1 and SM2 indicated that P3 should have received an MSE.