HospitalInspections.org

Based on observation, document review, and interview it was determined the Hospital failed to ensure compliance with 42 CFR 489.24

Findings include:

1. The Hospital failed to complete a comprehensive Medical Screening Exam (MSE)to include an assessment of pts complaint of right hip pain following a fall in the lobby of the Emergency Department (ED). (See A-2406)

Based on document review, video review and interview it was determined that in 1 of 20 (Pt #1) Emergency Department (ED) records reviewed, the Hospital failed to complete a comprehensive Medical Screening Exam (MSE) to include an assessment of patient's complaint of right hip pain, following a fall in the lobby of the ED.

Findings include:

1. The "Emergency Medical Treatment and Patient Transfer Policy (EMTALA)" revised 06/25 was reviewed. It stated, " ... Comes to the emergency department with respect to an individual requesting examination and treatment means the individual is on the hospital property (including parking lot, campus, ambulance Bay, and other departments of the hospital) ... Emergency Medical Condition means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, ... ) such as the absence of immediate medical attention could reasonably be expected to result in: ... b. Serious impairment to bodily function, or c. Serious dysfunction of any bodily organ or part ... The medical screening examination is an ongoing process and the medical records must reflect continuing monitoring based on the patients need and continue until the patient is either stabilized ... Stabilized/Stabilization: ... 1. Stable for discharge: A patient is stable for discharge, when within reasonable clinical confidence, It is determined that the patient has reached the point where his/her continued care, including diagnostic workup and/or treatment could reasonably be performed as an outpatient provided the patient is given a plan for appropriate follow up with the discharge instructions; or, the patient requires no further treatment and the treating physician has provided a written documentation of his/her findings..."

2. On 09/2/25 at 11:30 AM, the ED waiting room security video was reviewed with Supervisor of Security (E#7). The video captured (Pt#1) walking independently into the ED waiting room on 8/1/25 at 7:11 PM. As (Pt#1) walked across the waiting room towards the reception desk, (Pt#1's) legs buckled and (Pt#1) fell to the floor, landing on his right side/hip at 7:11:53 PM. (Pt#1) was not observed breaking the fall before landing on the floor. While (Pt#1) lay on the floor, an emergency medical services (EMS) paramedic (E#21) already present in the waiting room was observed responding to (Pt#1). Another EMS paramedic (E#22) was observed coming out of the ED treatment room door and kneeling down beside (Pt#1), followed by the ED Charge Nurse (E#12). (E#12) was observed standing for a few seconds in front of (Pt#1) on the floor, then walking around the ED waiting room and retrieving a wheelchair which she rolled back over to (Pt#1). At that time, (E#21), (E#22), and one armed security guard (E#9) lifted (Pt#1) off the floor and into the wheelchair. At approximately 7:15 PM, (E#12) wheeled (Pt#1) back into the ED treatment area through the same door she came out of. (Pt#1) lay on the floor for a total of approximately 4 minutes and 7 seconds. On 08/02/25 at 2:21 AM, an unarmed security guard (E#10) was observed holding (Pt#1) under the left arm and assisting with walking from the ED waiting room out the door to the parking lot. (Pt#1) was observed holding his right hip area and walking with a limp. There was no further accessible video beyond the ED waiting room doors.

3. (Pt#1's) medical records were reviewed throughout the survey. The Patient Care Timeline dated 08/01/25 at 7:18 PM to 08/02/25 at 2:25 AM) had no documentation regarding (Pt#1's) fall in the ED lobby approximately 6 minutes and 7 seconds prior to 7:11:53 PM. The ED Provider Notes dated 8/1/25 at 8:29 PM, by ED physician (E#13), stated "Subjective: (Pt#1) presents to the ER (emergency room) via private vehicle with complaints of dizziness, lower abdominal pain and unable to urinate since 12:30 pm ... (Pt#1) was in our waiting room when he felt lightheaded and felt like he was going to pass out. He caught himself as he was falling. He did not lose total consciousness. He denies any injury to his head ... Review of Systems: ... Musculoskeletal: Negative for arthralgias (joint pain) and back pain ... Objective: ... Physical Exam: Vitals (Afebrile (without fever), vital signs stable) ... Constitutional: ...Comments: Small frail appearing ... Musculoskeletal: General: No swelling. Normal range of motion. Cervical back: Normal range of motion and neck supple ... . Final diagnoses: Dizziness (Primary). Hematuria (bleeding), unspecified type. Hydronephrosis (swollen kidney), unspecified hydronephrosis type ... ED Disposition: Discharge."
-Pt #1's exam on 8/1/25 did not include assessment/evaluation of leg pain/injury after falling in the waiting room.

- Pt#1 returned to the ED via EMS on 8/5/25 at 8:49 AM with a chief complaint of right hip pain. ED Provider Notes dated 8/5/25 at 8:55 AM by physician (E#14) stated, "Subjective: (Pt#1) with a history of prostate cancer comes into the emergency room because of right hip pain... Patient states that ever since then (8/1/25 - after fall) (Pt #1) has been having severe pain in the hip joint and has been unable to get up and walk..." An x-ray was completed and indicated, "Acute transverse avulsion fracture (when small piece of bone attached to ligament or tendon, breaks away from rest of bone) at the upper pole of the right greater trochanter with avulsion fracture along the superior rim of the left acetabulum laterally." A MRI (magnetic resonance imaging - medical imaging that uses strong magnetic field and radio waves to create detailed images) of the right hip was completed and indicated, "Final result ... (8/5/25 3:59 PM) ...Impression: 1. Nondisplaced intertrochanteric fracture of the right proximal femur (break in the upper part of thigh bone, specifically in the region between upper parts of femur where bone fragments remain in alignment with fracture occurring on right side) with redemonstrated of avulsion fracture of the superior (upper) aspect of the greater trochanter (bony prominence located at the upper end of the thigh bone). 2. Intramuscular edema (excess fluid accumulates within the muscles) of the right hip, likely reactive muscle strain secondary to the fracture ...

Pt #1 was admitted and had surgery (hip nailing) completed for the fracture.

Pt #1 was discharged on 8/7/25 at 12:04 PM. Pt #1's "Discharge Summary" dated 8/7/25 at 10:27 AM by hospitalist (E#18) stated, " ... Hospital Course: (Pt#1) presented to our facility after suffering a ground level fall where he had a nondisplaced IT (intertrochanteric) fracture of the proximal femur. Orthopedics consulted. (Pt#1) underwent IM nailing (intramedullary nailing - rod inserted into hollow center of broken long bone)..."

4. On 09/02/25 at 2:50 PM, an interview was conducted with Risk Management (E#5). (E#5) stated, "I just became aware and began investigating (Pt#1's) incident from a risk management standpoint this past Friday, 08/29/25. Our Chief Operational Officer (E#2) asked me to look into this after receiving a call from someone in the community who (Pt#1) had spoken to about the visit to the ED on 8/1/25. I also spoke with (Pt#1) on the phone who confirmed there had not been a fall at home, as documented in the ED notes on 08/05/25, but rather in the lobby of our ED on 08/01/25. (Pt#1) indicated to me the hip pain was self-reported to the ED staff several times during his visit and prior to discharge. I reviewed the video footage and saw the fall. I did not review the video footage of (Pt#1) leaving the ED upon discharge. I read in the ED notes (Pt#1's) exam was unremarkable and there was no mention of hip pain. I'm in the beginning stages of speaking with the staff involved in (Pt#1's) care. I can't speak to why an x-ray was not done."

5. On 09/03/25 at 11:55 AM, an interview with ED physician's assistant (E#15) was conducted. (E#15) stated, "I cared for (Pt#1) until about 11:00 PM on 08/01/25 at which time the physician (E#13) took over. (Pt#1) had a near syncopal episode in the lobby which got him back to the ED quicker than normal. Whenever I questioned (Pt#1) about that, (Pt#1) said that (Pt#1) got dizzy and just fell."

6. On 09/03/25 at 12:15 PM, an interview was conducted with ED physician (E#14). (E#14) stated, "I saw (Pt#1) on 08/05/25, (E#14) stated, "It is certainly a reasonable expectation to get an x-ray if a patient of that age took a fall and complains of pain."