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Based on document review and interview, it was determined that 1 of 27 (Patient 13) medical record review of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide a medical screening exam.

Findings Include:

1. See findings cited at 42 CFR 489.24, A2406.

Based on document review and interview , the facility failed to provide a medical screening exam on 1 of 27 patients (Patient 13) presenting to the emergency Department for medical care.

Findings Include:

1. Review of policy titled: Emergency Medical Treatment and Active Labor Act (EMTALA) (PolicyStat ID: 8637060) last approved 01/2021, indicated that all patients presenting to the ED will receive a MSE (Medical Screening Exam) required to determine wether or not an Emergency Medical Condition exists. "Triage is not equivalent to a Medical Screening Exam.

2. Review of policy titled: Emergency Department Triage (PolicyStat ID: 5614677) last approved 10/2018 indicated facility uses a five level triage instrument that categorizes emergency department patients by both acuity and expected resources needed (ESI (Emergency Severity Index) - Agency for Research, Healthcare and Quality, Version 4).

3. Review of the ESI Index indicated that ESI Level 2 is defined as "Patient is in a high risk situation, is disoriented, in severe pain, or vitals are in danger zone."

4. Review of Patient 13's medical record indicated presentation to the ED on 07/19/21 at 3:26 pm with complaint of increased shortness of breath. The Quick Triage Note indicated Patient arrived by car and in wheelchair. Vital signs were blood pressure of 144/90, respiratory rate of 16, heart rate of 117, temperature orally is 98.6 degrees and oxygen saturation (O2) 94% on room air. Elsewhere on the form indicated O2 was 96% on 4 liters of oxygen. Patient had EKG (electrocardiogram). Patient's pain level was 7 out of 10 and ESI level of 2. Note indicated Patient left without being seen at 7:30 pm indicating it was ridiculous to wait and wasn't waiting any longer...released to self, upright and alert.

5. Interview:
Interview on 07/29/21 with P51 (Director of Quality) at 3:24 pm confirmed that Patient 13 did not receive a MSE, was triaged at an acuity level of 2 and waited 4 hours to be seen before leaving.