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Based on review of facility policy, facility documentation, medical record review and interviews, the facility failed to provide an appropriate and ongoing Medical Screening Examination (MSE) for one (1) patient (Patient #1) who presented to the Emergency Department (ED) with a Foreign Body in the left eye of 19 ED records reviewed.

The findings include:

Patient #1 entered Facility A's ED on 1/13/2024 (no time) with a complaint of a Foreign Body in his eye. Patient #1 was registered. The ED Physician spoke with Patient #1 and said he would be glad to see the patient and try to remove the foreign body. The ED Physician told the patient Facility B had an ophthalmologist on call and if he preferred, he could go to Facility B. Patient #1 left Facility A's ED and went to Facility B's ED by private vehicle. The patient had not been evaluated at Facility A. There was no Medical Screening Examination (MSE). The patient's electronic registration at Facility A was canceled. The patient was not listed on Facility A's Central ED Log.

Patient #1 arrived at Facility B's ED on 1/13/2024 at 2:22 PM, and presented with a metal shaving in his left eye. A black metallic foreign body was removed by a Physician Assistant. The patient was discharged at 5:04 PM.

Cross Refer to A-2406.

Based on review of facility policy, facility documentation, and interviews, the facility failed to maintain a Central Emergency Department (ED) Log for one (1) patient (Patient #1) who presented to the ED with a Foreign Body in the left eye of 19 ED records reviewed.

The findings include:

Review of the facility policy, "Emergency Medical Treatment And Labor Act (EMTALA)," reviewed 9/22/2023, revealed "...The hospital shall keep a central log of all patients who come to the hospital's DEDs seeking examination or treatment for a medical condition...The central log may consist of several logs...The central log includes the patient's name and indicates if the patient was discharged, transferred, admitted and treated, stabilized and transferred, the patient refused treatment or was refused treatment..."

Review of facility documentation revealed Facility A self-reported the incident on 1/22/2024 at 11:33 AM. As a result of the incident, Facility A developed an action plan for Quality Assurance and Performance Improvement. Facility A failed to recognize a Central Log had not been maintained when Patient #1's encounter was deleted. Facility A's action plan did not include any quality assurance performance improvement measures to maintain a Central ED log.

During an interview on 9/29/2025 at 12:31 PM, with Facility A's Patient Access Manager, they stated the patient encounter at Facility A was canceled since Patient #1 was not evaluated. The Patient Access Manager stated canceling the patient's encounter would ensure Patient #1 would not be billed and shared the ED Central Log is electronically built from patient registration encounters.

During an interview on 9/29/2025 at 3:00 PM, with Facility A's Quality and Risk Manager, they stated the patient was registered but the encounter was deleted since the patient left and went to Facility B and confirmed Patient #1's name is not listed on the ED Central Log.

During an interview on 9/30/2025 at 3:45 PM, the ED Medical Director stated the ED physician on duty on 1/13/2024, "...tried to do the patient a favor." He stated by sending Patient #1 to Facility B the patient would only have one medical bill to pay and could see an Ophthalmologist. He stated Patient #1 did not have an evaluation at Facility A. There is no medical record for Patient #1 on 1/22/2024.

Based on review of facility policy, facility documentation, and interviews, the facility failed to provide an appropriate and ongoing Medical Screening Examination (MSE) for one (1) patient (Patient #1) who presented to the Emergency Department (ED) with a Foreign Body in the left eye of 19 ED records reviewed.

The findings include:

Review of the facility policy, "Emergency Medical Treatment And Labor Act (EMTALA)," reviewed 9/22/2023, revealed "...It is the policy of each [Facility A] hospital to provide an appropriate MSE...All individuals who present to a DED for examination or treatment of ANY medical condition, whether or not emergent...A [Facility A] hospital must not Transfer a patient to another facility, unless the hospital does not have the Capacity or Capability needed to Stabilize the patient or the patient/Authorized Legal Representative requests a Transfer..."

Facility documentation revealed Facility A self-reported the incident on 1/22/2024 at 11:33 AM. As a result of this incident, Facility A developed a quality assurance performance improvement action plan with monitoring of the MSE, which included re-education of ED Physicians and ED staff. The education plan focused on EMTALA requirements for a MSE. This process began on 1/29/2024.

During an interview on 9/29/2025 at 12:31 PM, with Facility A's Patient Access Manager, they stated the patient encounter at Facility A was canceled since Patient #1 was not triaged and a MSE was not performed.

During an interview on 9/29/2025 at 3:00 PM, with Facility A's Quality and Risk Manager, she stated she had investigated and self-reported this incident. She stated Patient #1 left Facility A and went to Facility B by private vehicle. Facility A's ED Physician did not perform a Medical Screening Exam (MSE).

During an interview on 9/30/2025 at 3:45, the ED Medical Director stated Patient #1 was not seen or evaluated at Facility A's ED on 1/13/2024.