HospitalInspections.org

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Based on interview and record review, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements when they did not provide an appropriate medical screening exam (MSE) for one out of 20 patients (Patient #1).
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On 02/25/2024, Patient #1 presented to the emergency department with complaints of left and right ankle pain after a fall. Medical records show that Patient #1 was provided with a partial MSE at 1156 AM, given an x-ray of the ankles that indicated a need for further evaluation at 1243 PM and noting a bimalleolar fracture of the right ankle, and was discharged from the ED at 1337 PM without further evaluation or an orthopedic consult.
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Cross reference to Tag A2406 CFR §489.24(c).
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Based on record review and interviews, the facility failed to perform and document an appropriate medical screening examination (MSE) in one of 20 patient records reviewed (Patient #1).
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Findings:
Facility A Chart Review:
On 02/25/2024 at 1156 AM during the medical screening process by Staff #8 (ED physician), a physical exam was completed noting, " ...no external signs of trauma..." and " ...Right Ankle - Swelling present, tenderness present, tender medial ligaments, ROM (range of motion) reduced. Joint effusion (fluid in the joint spaces) present. Negative: Achilles deficit, Anterior drawer test pos (positive), Deformity present, open fracture present, Pulse post tib (tibial) absent, Pulse post tib decreased, Neuro deficit present ....Left Ankle - Tender lat (lateral) ligaments, Tender medial ligaments, Tender lateral malleolus ... Patient at this time unable to bear weight due to pain ..."
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An x-ray of the right ankle resulted on 02/25/2024 at 1243 PM noted, " ...Fractures of the posterior and medial malleoli ... bimalleolar fracture of the right ankle ... Recommend further evaluation with a right lower leg series to evaluate for a Maisonneuve fracture of the more proximal fibula ..." A bimalleolar fracture is unstable, and a Maisonneuve fracture requires non weight bearing, thus leaving Patient #1 at non-weight bearing bilaterally (on both sides). There is no evidence that the Facility tried to obtain an orthopedic consult.
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A physician's note on 02/25/2024 at 1203 PM noted, " ...patient sustained a 2-part fracture of the medial malleolus. X-rays of the left ankle shows no bony abnormalities. Patient be diagnosed with sprain of left ankle. Ace wrap and walking boot were applied to (the) patients' lower extremities. Advised patient to follow RICE protocols patient is weight bearing as tolerated on the left ankle. She is non-weightbearing on the right ankle ..."
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The MSE did not complete further evaluations as recommended by the radiologist, which resulted in a failure to detect a second emergency medical condition (EMC) of a Maisonneuve fracture. Patient #1 was discharged home on 02/25/2024 at 1337 PM.
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Facility B Chart Review:
On 02/26/2024 at 1626 PM, Patient #1 went to Facility B and a triage assessment noted that the patient was complaining of "severe ankle pain." A Medical screening examination was initiated on 02/26/2024 at 1655 PM. At 1738 PM Patient #1 was accepted for admission for orthopedic surgery. The Maisonneuve fracture was not detected at Facility A. It was however detected intra-operatively at Hospital B.
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Interviews on the afternoon of 04/22/2024, Staff #10 (ED RN) and Staff #8 (ED Physician) confirmed the above findings and indicated that they were unaware that the MSE was incomplete for Patient #1.
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