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Based on record review and interview, the hospital failed to document an appropriate medical screening examination (MSE) that was within the capability of the hospital's emergency department (ED), for 1 of 20 sampled patient (#7). Refer to findings in A-2406.

Based on record review and interview, the hospital failed to document an appropriate medical screening examination (MSE) that was within the capability of the hospital's emergency department (ED), for 1 of 20 sampled patient (#7).


Findings:

Patient #7's record reflected the patient arrived at the hospital on 01/14/10 at 5:10 p.m. with the complaint of "Back pain and Spasms", was triaged at 5:13 p.m. with vital signs of B/P 169/106, P 117 R 14, and provided a past medical history of heart disease with past stent insertion. No laboratory or diagnostic tests were performed. The Physician's Assistant (PA) executed a document at 5:56 p.m. that indicated "Medical Screening Complete: Immediate medical attention not necessary, no acute symptoms of sufficient severity . . . no immediate serious impairment or dysfunction of body functions or organs is reasonably expected. Direct patient to registration." There was no documentation reflecting that a physical exam by the PA had been completed to come to the conclusion, and no other documentation by the PA or Emergency Physician. The record reflected the patient was sent to registration at 6:20 p.m. where s/he elected to not continue medical care at the hospital at this time and that s/he refused the medical resource booklet.

Interview with the Director of Quality Resource Management and the chief nursing officer (CNO) on 02/04/10 at 11 a.m. confirmed the hospital had a policy that allowed patients of "low acuity" to be screened by the PA with no additional documentation and if cleared, sent to registration to make arrangements to pay for additional services or co-pays. The hospital failed to document that an appropriate MSE was completed for patient #7 on January 14, 2010.

Review of patient #21's record (the same patient as #7) reflected the patient arrived at another hospital at 7:05 p.m. on 01/14/10 complaining of chest pain, was triaged, medically screened, and it was determined after EKG, Lab work, and medical exam the patient should be admitted for chest pain rule out acute myocardial infarction (AMI). The patient's discharge summary reflected AMI, coronary artery disease, dyslipidemia, and that the patient received an angioplasty requiring stents prior to discharge from the hospital.