HospitalInspections.org

Based on record review and interview, the facility staff failed to ensure compliance with 42 CFR 489.24.

Findings include:

The facility failed to provide a thorough and complete medical screening exam for 1 of 20 patients (Patient #1) who presented to the ED (Emergency Department) in a total of 20 medical records reviewed. See tag C2406.

Based on record review and interview the facility failed to provide a thorough and complete Medical Screening Exam for 1 of 20 patients (Patient #1) who presented to the ED (Emergency Department) in a total of 20 medical records reviewed.

Findings include:

Review of facility's policy, "Emergency Services Policy-[Facility]" dated 11/25/2024 revealed: " ...All patients who come to the Emergency Department requesting care will receive a medical screening examination and the necessary treatment to stabilize an emergency medical condition without unnecessary delay and without regard to the patient's ability to pay ..."

Review of facility's policy, "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy-[Facility] dated 01/30/2023 revealed: " ...If the medical screening examination reveals that the patient has an emergency medical condition, an offer of treatment necessary to stabilize the emergency medical condition is made to the patient, or the patient's representative. On-call providers are available within a reasonable time frame, as determined by site specific by-laws, to provide any necessary stabilizing care to a patient with an emergency medical condition ..."


A review of Patient #1's medical record revealed that Patient #1 was a 21-year-old who came to the ED accompanied by a friend on 03/08/2025 at 3:08 AM after being "sucker punched" in the face and complaining of dental trauma.

Review of the "ED Provider Notes" dated 03/08/2025 at 3:15 AM revealed: " ...He has a permanent retainer positioned behind his bottom central and lateral incisors. The left side of his retainer is no longer connected/cemented to the tooth. His right lower canine is pushed back into the mouth as well lateral incisor. He has a small laceration to gum just beneath right lateral incisors, this is not large, not gaping. No other head trauma noted. TMJs (temporomandibular joint-a hinge that connects the jaw to the skull) feel intact without crepitance (crackling or crunching sound) or asymmetry ...Neurological: Alert and oriented to person, place, and time ...I did reach out to on call DDS (doctor of dental surgery) ...who recommended following up with his orthodontist team and starting him on Abx (antibiotics). He did not feel he needed to see the pt more urgently. Patient will head home this weekend and I advised him to try to follow up by Monday ...No other imaging or testing is indicated at this time. I do not have any concern for jaw fracture or head injury ..."

Further review of the medical record revealed that Patient #1 received Oxycodone (pain medication) 5 mg orally on 03/08/2025 at 3:45 AM and Ketorolac injection (pain and anti-inflammatory medication) 15 mg intramscular at 3:46 AM. Patient #1 received a Tdap (tetanus-diptheria-acellular pertussis) vaccine 0.5 ml at 3:46 AM. Pain was reassessed at 4:14 AM with a pain rating of 5. Vital signs remained within normal limits. Patient #1 given clindamycin (antibiotic) 300 mg orally on 03/08/2025 at 4:28 AM. Patient #1 given after care instructions which included care instructions for mouth laceration, instructions to pick up prescriptions for clindamycin 300 mg to take 1 capsule every 8 hours for 5 days and ketorolac 10 mg to take every 6 hours as needed for pain, at preferred pharmacy, instructions to follow up elsewhere with primary care provider in 1 day, and instructions to follow up at hospital #1 again if symptoms worsen. Patient #1 discharged on 03/08/2025 at 4:36 AM accompanied by a friend.

There was no evidence in the electronic medical record that any imaging studies or lab work was completed on Patient #1.

A review of Patient #1's medical record from Hospital #2 on 03/08/2025 at 3:49 PM revealed Patient #1 presented to Hospital #2 after being seen by a dentist who suspected a possible mandible fracture. CT(computed tomography-radiology image test) scan revealed bilateral mandibular fractures. Maxillofacial surgery was consulted and Patient #1 had surgery on 03/08/2025 to repair the fractures.

During an interview with ED Physician Assistant (PA) D on 05/21/2025 at 10:10 AM when asked what types of testing they would order for a patient who came in that had been physically assaulted in the face, ED PA D stated that they typically would get a CT Scan of the head and cervical spine to ensure that there were no fractures or internal injuries.

During an interview on 05/21/2025 at 2:00 PM with ED Physician M who cared for Patient #1 in the ED, when asked if any radiology tests were ordered, ED Physician M stated "I try not to scan young people if they don't have to be. I did not feel that the jaw was displaced so I chose not to do radiology studies." ED Physician M stated that she did consult with the oral Maxo facial physician on call. After explaining her findings, the oral Maxo facial physician felt the patient could wait and be seen by a dentist on Monday. ED Physician M stated that Patient #1 was pleasant, alert and oriented. He seemed agreeable to the plan and was discharged home after he met with the police as he wanted to file a report.

During an interview on 05/21/2025 at 3:15 PM, ED Medical Director N stated that he had reviewed the case involving Patient #1. He stated that the case was also reviewed by the entire morbidity and mortality physician group and discussed with the group. When asked when radiology tests are ordered, ED Medical Director N stated that it is per physician discretion based on their findings. ED Medical Director N stated that there is not a set rule that all patients who come in after being physically assaulted require radiology tests. ED Medical Director N stated it is difficult to say in this case if radiology tests should have been completed because he knows that Patient #1 sustained fractures that required surgery.