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Based on review of medical records, Medical Staff Rules and Regulations, policy and procedures and interviews with staff it was determined that the facility failed to ensure that one patient (P) (P#1) of 20 sampled patients received a complete medical screening examination. Specifically, P#1 arrived at the Emergency Department (ED) by ambulance on 2/23/24 at 12:53 a.m. with complaints of difficulty breathing and pain. P#1 had been in a house fire and had been extracted through a window. The medical screening examination failed to include a musculoskeletal examination and failed to note a wound to P#1's left foot and was therefore incomplete and inappropriate.

Findings included:

Cross refer to A2406 as it relates to the facility's failure to ensure that a complete, appropriate medical screening examination was conducted for P#1.

Based on review of medical records, Medical Staff Rules and Regulations, and hospital policy and procedures, it was determined that the facility failed to ensure that one patient (P) (P#1) of 20 sampled patients received a complete medical screening examination within the capacity and capability of the facility. Specifically, P#1 arrived at the Emergency Department (ED) by ambulance on 2/23/24 at 12:53 a.m. with complaints of difficulty breathing and pain. P#1 had been in a house fire and had been extracted through a window. The medical screening examination failed to include a musculoskeletal examination and failed to note a wound to P#1's left foot and was therefore incomplete and inappropriate.

Findings included:

A review of P#1's medical record revealed that she was triaged at 12:59 a.m. Triage notes indicated that bleeding was noted from a surgical wound to the left foot. A Medical Screening Exam (MSE) was initiated at 1:16 a.m. The MSE did not include a musculoskeletal exam nor documentation of the wound to the left foot as noted in a nursing note.

Review of an ED Assessment on 2/23/24 at 1:38 a.m. by RN CC revealed that P#1 was involved in a house fire with smoke inhalation. P#1 had a bleeding surgical wound on her left food from being pulled out of the window by a neighbor and an officer. P#1 complained of shortness of breath and pain overall. P#1 was alert and oriented.

Review of an ED Progress Note by RN FF on 2/23/24 at 5:15 p.m. revealed that RN FF spoke to P#1's daughter at the bedside and another family member on the phone. Review of an ED Progress Note by RN EE on 2/23/24 at 8:30 p.m. revealed that P#1 was moved to the Clinical Decision Unit (CDU) exam room 21 for the night at the request of the administrator on call, until resource management could become involved and find a resolution to the patient's current living situation. Review of an ED Progress Note by the Registered Nurse (RN) DD on 2/24/24 at 10:36 a.m. revealed that family members approached the front desk and said P#1 had developed chest pain. P#1 would be moved back to the ED for reevaluation.

Review of the Medical Staff Rules and Regulations, adopted by the health system on 2/26/20, revealed that a Medical Screening in the Emergency Department (ED) would be performed by qualified registered nurses, certified nurse practitioners, physician assistants, and physicians. If the screening was performed by a qualified registered nurse, certified nurse practitioner, or physician assistant, the screening would be performed according to established policy with the physician readily available for personal supervision except for life-threatening situations. Patients determined to have an emergency medical condition would be evaluated by an emergency medicine physician.

Review of the "EMTALA - Medical Screening Examination and Stabilization Policy," Version 1, reviewed 11/1/21, revealed it was the policy of the health system that when an individual came to the dedicated emergency department (DED) requesting examination or treatment for a medical condition, an appropriate medical screening examination (MSE) within the capabilities of the hospital's DED would be performed by an individual qualified to perform such examination. The determination of whether an individual was stable or not was not based on the clinical outcome of the individual's medical condition. An individual was considered stable when the physician determined that the condition that caused the individual to seek care in the ED was resolved although the underlying medical condition may have persisted.