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Based on review of facility policies and patient (MR#1) emergency treatment record as well as same patient emergency treatment record (MR#22) at a second facility on the following day, interview with staff and patient. The requirement of having an appropriate medical screening was not met which also led to delay in stabilizing treatment.

Findings:

A. Policy:
1) "Use of the Emergency Department" states: All patients will receive a medical screening exam by an emergency provider before being admitted to or discharged from the Emergency Department ....."

Review of Medical Staff Bylaws, page 25-26, Section 14 states:"

2) ....Patients registered in the Emergency Department shall receive a medical screening examination prior to discharge ... ....

3) Reviewed Social Security Act Section 1867 Medical Screen Requirement states:

"In the case of a hospital that has a hospital emergency department. If an individual (whether or not eligible for benefits under this title) comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, to determine whether or not an emergency medical condition (within the subsection (e) (1)) exists.


In review of the treatment record of patient (MR#1) the emergency department did not provide evidence of an appropriate medical screening and stabilizing treatment.

B. Review of Patient (MR#1) Emergency treatment record:

On March 29, 2018, Reviewed the medical record of patient MR#1, 54 year old male who visited the emergency room at Christus Spohn Hospital - Corpus Christi South on March 10, 2018 at 11:28 am, triaged at 11:31 am. The event history states a provider assessment was conducted at 11:32 am. The patient was discharged at 1:32pm, the patient was placed in a room at 1:42 pm, the patient treated and discharged at 1:42 pm, the patient registered at 1:54 pm, and patient discharged at 2:25 pm on March 10, 2018.

The chief complaint was the patient fell off ladder. The initial comments:
"54-year-old male who is otherwise healthy reports to the emergency department after falling off of a ladder. He does not recall what number step he was on or how many runs of the ladder he was on when he fell off. The patient states that he was cutting a tree limb when the tree limb fell and knocked him off the ladder. He states he landed with his entire weight on his left shoulder. Patient is sitting in triage alert awake and oriented x 3 ambulatory into triage without assistance and he is sitting with his arm extended held in a 95 degree angle. He denies any other injury. Denies headache, no head injury, no at neck pain, no neck injury. He denies loss of consciousness. He denies numbness or tingling in his extremities.

The patient pain level was 8 on a 1-10 pain scale. The patient was triaged and a primary assessment was done by primary nurse, RN at 2:20 pm (2 hours, 51 minutes after triage was begun) March 10, 2018. Musculoskeletal assessment conducted by same showed Wound location modifier left; Wound location Shoulder. Discharge Assessment by same nurse, RN at 2:59 pm on March 10, 2018.

The patient was given Norflex injection 60 mg IM and a Toradol Inj 60mg IM at 2:20 pm on March 10, 2018 in the left gluteal. Both ordered by provider at 11:39 am and administered by primary assessment nurse, RN.

Radiology: Complete Shoulder ordered at 11:36 am on March 10, 2018 by medical provider, time of exam 11:36 am. Impression: Normal Shoulder.

Under Physical Exam: It only states: Vital Signs initial conducted at 11:31 am on March 10, 2018 which was within normal limit. The last vital documented is at same time, same result as initial. No discharge vital conducted.

There was no evidence that a hands on physical examination was conducted by provider on March 29, 2018 the date of review of this record.

Clinical Impression: Primary: Muscle Spasm, Additional Impression: Left shoulder pain

Disposition: Discharge home, self-care, Improved. Follow up with Primary Care physician.

Prescription written for Ibuprofen (Motrin) 600 Mg tab orally three times a day and Orphenadrine Citrate (Norflex, Flexor) 100 mg Tabcr 100 Mg orally twice a day by provider documentation shows the order written at 11:43 am on March 10, 2018.

Discharge Instruction: Additional Instructions:

"Please keep your appointment for your scheduled MRI. You have been prescribed a pain medication and muscle relaxer for your symptoms. Your urine was negative for infection. Immediately return to the emergency department if symptoms worsen, or if any new concerning symptoms develop. Take medications as prescribed."

Note: Unsure of what scheduled MRI appointment the provider is referring to and there was no physical evidence of a urine test or any laboratory exams that were conducted on this patient.

An addendum to this emergency treatment record was added after March 29, 2018's on-site investigation. The addendum was added on March 31, 2018 and provided to the investigator for review on April 6, 2018.

The addendum shows that a medical screening was done:

States:

"PE: Gen: Alert, NAD; Head: NC, AT, PERRL, EOMI, Normal lids/conjunctiva; ENT B TML WNL, normal hearing, patient oropharynx without erythema/exudate, uvula midline; Neck +supple, no tenderness/meningismus/JVD, +trachea midline; Pulm: Bilateral BS, Normal resp effort, no wheezes/stridor/retractions; CV: RRR, No murmurs, + dist pulses; Abd: soft, NT/ND, No hepatosplenomegaly, MSK: TENDERNESS LEFT SHOULDER, No edema/erythema/cyanosis; skin, no rash; Neuro: AAOx3, No sensory, motor deficits....... ROS: NO BACK PAIN, LEFT SHOULDER PAIN, no rash, No lower extremity edema, No changes in neurological status/function."

Even with the addendum added it did not show evidence that the provider provided a thorough examination and a appropriate medical screen of the patient injury.

C. Interviewed interviewee #4, patient at 1:30 pm on April 4, 2018 via telephone who explained that he was on a ladder at his house trimming the tree when a branch of the tree he was cutting knocked him off the ladder tipped and he fell injuring his left arm and shoulder. As a result he was in a lot of pain and his arm was stuck in a high five position with his left arm above his head, he could not bring it down. A friend brought him to Christus Spohn Hospital Corpus Christi - South emergency room.

He said when he arrived there was a young lady who was behind a window with a glass and asked what could they do for him. He explained what happen and she gave him some paperwork to fill out. He said there was another person behind the glass, a female (he could not recall the name of the person or their title) who called him in and only checked his blood pressure and asked him a few questions. He said no one at that time looked at his arm or shoulder or touched and examined the injured area at all or hands on examined any part of his body. He said the person who checked his blood pressure and asked questions, then sent him to the waiting room where he was called shortly after to go to the x-ray department. He went into the X-ray department than back to the waiting room. He was called in to a treatment room where he was told that his x-ray on his shoulder showed nothing, it was normal. They said it was probably just the muscle strained. He said a male than came in and gave a muscle relaxant and something for the pain and sent him on his way. He thought it was strange how things happened. He said he never saw a physician or at least someone who identified themselves as a provider and no one physically examined his injured area but yet they were saying his shoulder was normal. He said he had a shirt on that covered the injured area. He was never asked him to remove the shirt so someone can physically examine him. No one attempted to check his range of motion. He was told to come back if he had further problems. He said the next day he was in much pain and his injured shoulder looked deformed and different.

The patient was going to go back to Christus Spohn but thought about the care he received there the day before and decided to go to another emergency center close by where he lived. He said at this facility they gave him excellent care where he was seen immediately and both a nurse and physician gave him a hands on examination, testing range of motion. He was given medication for pain. He was given an x-ray where they found he had a dislocation in his left shoulder, the injured area. The physician did a shoulder reduction and was able to put his shoulder back in place and conducted a follow up x-ray to make sure his shoulder was properly placed. He said his injured arm felt so much better after the physician performed this procedure. They placed his arm in a shoulder sling for support and gave him Tylenol 3 as needed. Which he said he did not even need to take the Tylenol 3's.

D. Interviewed Staff # 2, attending Nurse,at 2:30 pm on March 29, 2018 in the administration conference room, who did not remember the patient. He reviewed patient #1 emergency record and could not provide evidence that an appropriate medical screening was conducted on the patient, there was no documentation at that time of one being completed by provider. Interviewed staff #3, Nurse Director, at 3:00 pm on March 29, 2018 who reviewed patient #1 emergency record and could not provide evidence that an appropriate medical screening was conducted. Interviewed staff #1, Regional Quality Director, at 12:30 pm on March 29, 2018 in the administration conference room. Staff #1 reviewed patient #1 emergency record and thought it was strange the provider medical screening did not show evidence that an appropriate medical screening was done. She said the medical record looks incomplete and the provider has 30 days to complete record.

The addendum was provided to investigator April 6, 2018. Dictated by provider March 31, 2018.

E. Interviewed Staff #5, provider at 3:00pm on April 6, 2018 via telephone, who said she remembered the patient and did a full medical screening on the patient that she thought was appropriate. She said she followed the patient all the way through. She said during the on-site visit her documentation was not in the record during that time. She had 30 days to complete the record and said she completed her entry a week after the on-site investigation.

The addendum was reviewed and did not show evidence that an appropriate hands on screening was conducted on patient.

F. Review emergency treatment record of patient (MR#14) 45 y/o male who visited the facility (Christus Spohn Hospital Corpus Christi-South) on March 10, 2018. Chief Complaint: Patient fell off a scaffold. A different provider saw the patient. During the medical screening the provider provided a full on hands medical screening. The provider documented findings and assessed range of motion of affected extremities on the patient. There was no doubt that an appropriate medical screening was provided for this patient which result in acknowledging that an emergency medical condition exisited. The patient received stabilizing treatment to prevent deterioration of the medical condition.