HospitalInspections.org

Based on document review it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination. (A-2406)

An Emergency Medical Treatment and Active Labor Act (EMTALA) investigation was conducted on 8/13/24 through 8/14/2024 for complaint #IL00174764/241850. The EMTALA violation began on 6/22/24, due to Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination (MSE).

Based on document review and staff interview, it was determined that in 1 of 20 (Pt #10) Emergency Department (ED) records reviewed, the Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination (MSE).

Findings include:

1. Pt #10's medical record was reviewed throughout the survey (8/13/24 through 8/14/24). Pt #10 presented to the Emergency Department (ED) on 6/22/24 at 3:21 PM. Pt #10's chief complaint was shoulder pain. The Chronological View log dated 6/22/24 noted the following:

3:22PM: Triage (Request)
3:26PM: Reg Complete (Request)
4:16PM: Patient Checked Out
The record lacked evidence that the Triage Request for Pt #10 was completed and that a MSE was completed per policy.

2. On 8/14/24 at approximately 10:00 AM the policy, "Triage (revised 2/2015)" was reviewed. The policy stated " ...A date and time of triage will also be obtained and the information entered on the ER Triage Record. This record will be kept on a clipboard in the ER office and the patients will be called to the ER as rooms become available and according to condition. Should the patient leave the triage area, the triage record will be kept in the ER Left Without Being Seen Binder ...Procedure: The registered nurse will evaluate and categorize each patient upon arrival to the Emergency Department into either resuscitative, emergency, urgent, semi-urgent or routine categories ...Until the patient is triaged by the Triage RN and deemed to have a non-life-threatening condition, the Emergency Department Registration Clerk is not to obtain or request any financial information or demographic information."

3. On 8/14/24 at approximately 10:30 AM, the policy, "EMTALA GUIDELINES FOR EMERGENCY DEPARTMENT SERVICES (revised 2/2019)" was reviewed. The policy stated, "All patient shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services with the capability of the hospital to reach a diagnosis."

4. On 8/14/234 at approximately 11:00 AM, an interview was conducted with the Chief Nursing Officer (E#1). E #2 verbally agreed the clinical record lacked documentation that Pt #10 was triaged and did not receive a MSE.