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Based on review of facility documents and staff interview (EMP) it was determined the facility failed to comply with 489.24 related to Medical Screening Examination.

Findings include:

The review of facility documentation, Emergency Department (ED) logs and medical records revealed the facility failed to provide a medical screening examination to a patient that presented to the Emergency Department in 1 of 21 medical records reviewed.

Interview with EMP1 on January 3, 2023, revealed the patient was registered upon presenting to the Emergency Department (ED), however the patient requested a caesarean section saying they were 4 days overdue and did not have a provider in the area. The ED staff called the Obstetrics Department and the patient was referred to an OB/GYN provider's office. EMP 1 confirmed that a Medical Screening Examination was not provided to the patient and there was no medical record for the visit.

Cross referenced:
§489.24 (a) & 489.24 (b) - Medical Screening Exam

Based on review of facility documentation, Emergency Department (ED) logs, medical records and staff interview (EMP) it was determined the facility failed to provide a medical screening examination to a patient that presented to the Emergency Department in 1 of 21 medical records reviewed.

Findings include:

Review of facility documents on January 3, 2023, revealed the patient presented to the Emergency Department on December 5, 2022. The patient was registered. The patient requested a caesarean section since patient was 4 days overdue and did not have a provider in the area. ED tech contacted the Obstetrics Department and the patient was referred to an OB/GYN provider's office. Patient left the Hosptial and was not given a medical screening examination.

Review of ED logs on January 3, 2023, revealed that patient was registered on the log on December 5, 2022, and then removed after the referral to the OB/GYN office was made. This action removed the patient from the list of patients to be seen, but the name remained visible on the list with no further action taken.

Request for patient's MR revealed no record recorded for the Emergency Room visit on December 5, 2022.

A review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" Dated: April 3, 2021, revealed "...II. Purpose: This policy sets forth the system hospitals' requirements under EMTALA, including guidelines for providing the appropriate setting (department) for conducting medical screening ...PROCEDURE ...If an individual seeking emergency medical care comes to the hospital campus, a QMP (Qualified Medical Provider) shall offer a Medical Screening Exam. If an individual seeking emergency medical care comes to any other portion of the hospital campus, including on- campus clinics, sidewalks, driveways, and parking lots, and requests emergency medical care, a QMP will offer a Medical Screening Exam to that person in an appropriate clinical care environment. Upon entering the clinical care environment, an individual will be registered within the electronic health record and entered into the electronic log. ..."

Interview with EMP1 on January 3, 2023, confirmed that the patient was registered upon presenting to the Emergency Department (ED), however a Medical Screening Examination was not provided to the patient and there was no medical record for the visit.