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Based on interview and record review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide a triage and medical screening exam (MSE) for 1 patient (P-1) of 20 patients reviewed, resulting in the potential for less than optimal outcomes for all patients seeking emergent care.

See tag 2406: Failure to provide MSE

Based on interview and record review the facility failed to ensure triage and medical screening exam were performed for one (P-1) of twenty (#20) patients reviewed for triage and medical screening exam from a total sample of 20, resulting in potential for less than optimal outcomes for all patients seeking emergent care. Findings include:

Review of ED (Emergency Department) to OB (Obstetric) logbook revealed "OB triage ED" form with P-1 listed on 07/05/2024 at 1154, with symptoms documented as "lost mucus plug", EDC (Estimated date of confinement - Due date) listed as 07/11/2024, disposition listed as "OB", OB Doctor documented as "Muskegon" and ER Doctor information was left blank.

Review of the OB log for the month of July 2024 revealed that P-1 was not on the OB department log.

Review of the facility's electronic medical record system with Staff A and Staff B on 08/27/2024 at 1345, did not reveal any visits or medical record for P-1 in the emergency department, OB department, or any other department in the facility at any time. The facility was unable to produce any documentation that P-1 was provided a medical screening exam by a qualified medical personnel.

In an interview on 08/27/2024 at 1430, Staff A (Vice President of Nursing) stated she had verified that Staff G (ED RN) was the staff member who documented P-1's visit on 07/05/2024 in the ED to OB logbook.

In an interview on 08/28/2024 at 0955, Staff G confirmed she was the nurse working triage on the day P-1 presented to the facility. She vaguely recalled P-1 presenting to the facility. Staff G said P-1 had some concerns about losing her mucus plug but wasn't in imminent labor. Staff G stated she did the initial interview with her and left her with registration staff to be sent to the OB department. Staff G said her job as ED triage is to respond when called by registration for patient presenting with an OB complaint and make sure they are appropriate to go to OB. Her process would be to interview the patient, put her on the OB/ED log, then let registration put her in the registration system and call OB. Staff G stated she was not aware if P-1 went to OB.

In an interview on 08/28/2024 at 1120, Staff F confirmed she was working in the OB department as an RN on 07/05/2024. Staff F stated she did not recall P-1 coming to the department with complaints about losing her mucus plug.

In an interview on 08/28/2024 at 1430, Staff C (Registration Staff) stated when someone presented to the registration desk with OB complaints, the first thing she does is ask how far along they are so she knows who to call OB or ED. Then Staff C said she gets name, date of birth and calls the ED triage nurse who will come and do a quick interview to make determine how urgent the situation is. Every patient who comes in is registered. If the patient goes to OB, they are fully registered, if they go to ED a quick registration is done.

Reivew of facility, "Triage" policy dated 01/2024 revealed, A. All patients who present to the Emergency Department (ED) will be assessed and evaluated by an RN. ED triage will be notified of a patient via registration staff calling for a "Nurse Assessment". 1. The most important key factors required to determine a patients' disposition are: A. Chief complaint and signs/symptoms associated with complaint. B. General appearance. C. Vital signs. D. Allergies E. Patient history including medication.

Review of facility, "EMTALA Compliance" policy dated 01/2024 revealed, Medical Screening Examination. If a person comes to the Hospital and a request is made for their emergency care or, if the person is unable to communicate, a reasonable person would believe that the person is in need of emergency care, then qualified medical personnel will, within the Hospital's capability and capacity, conduct and document an appropriate medical screening examination reasonably calculated to identify an emergency medical condition.