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Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice is evidenced by failing to provide an appropriate screening medical exam for 2 (#3, #18) of 20 (#1- #20) reviewed medical records of patients who presented to the emergency department for evaluation (see findings tag A-2406).

Based on record review and interview, the hospital's emergency department failed to provide an appropriate medical screening exam for 2 ( #3, #18) of 20 (#1- #20) patients who presented to the emergency department for evaluation.

Findings:
Review of Policy #400, Emergency Medical Treatment & Labor Act (EMTALA), revised 01/1014, revealed in part:

IV. Definitions: . . .
g. Emergency Medical Condition: means:
1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonabley be expected to result in:
a. Placing the health of the patient (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
b. Serious impairment to bodily functions, or
c. Serious dysfunction of any bodily organ or part; or
d. With respect to a pregnant woman who is having contractions:
-that there is adequate time to effect a safe Transfer to another hospital before delivery; or
-That Transfer may pose a threat to the health or safety of the woman or the unborn child.

Review of Policy #ED.316, Assessment of Patients in ED, revised 06/2021, revealed in part, 3. If a bed is not available in the main ED after triage and it is not possible to move the patient directly to the treatment area, the patient may be placed in the waiting area...Patients in the waiting room will be re-evaluated for change or detoerioration of condition at a mimimum of every one hour with documentation in the Electronic Health Record (EHR): vital signs should be repeated every 2 hours and at discharge... Patients in the waiting room should be reassessed hourly; this may be done using the across the room method, with vital signs being obtained every two hours.

Patient #3

Review of the emergency department record for Patient #3 revealed she presented to the emergency department on 03/14/2024 at 6:06 a.m. with a chief complaint of migraine headache. Her vital signs were temperature of 98.3° F, pulse 89, Resp 16, BP 168/93, 98%.

Review of the provider's note dated 03/14/2024 at 6:47 a.m. revealed in part:
History
Chief Complaint
- Migraine
Patient #3 is a 64-year-old female with a history of obesity, HTN, diabetes, hyperlipidemia and migraines who presents complaining of a migraine that has been intermittent for the past two months. She states that she has seen her neurologist and has been prescribed some new medications but she did not attempt to take anything at home this morning prior to coming to the ER. She endorses nausea, denies any vomiting, She states that she feels like she is going to pass out. This is consistent with prior migraines. . . .

Review of Systems

Physical Exam
Blood pressure (1) 168/93, pulse 89, temperature 98.3°F (36.8°C)x, temperature source Oral, resp .rate 16, SpO2 98%.
BP Method: Automatic
BP Location: Left arm

Physical Exam
Vitals and nursing note reviewed.
Constitutional:
General: She is not in acute distress.
Comments: Appears comfortable
HENT:
Head: Normocephalic and atraumatic.
Eyes:
General: No scleral icterus.
Right Eye: No discharge.
Left Eye: No discharge.
Neck:
Trachea: No tracheal deviation
Pulmonary:
Effort: Pulmonary effort is normal. No respiratory distress.
Breath sounds: No stridor
Abdominal:
General: There is no distention.
Musculoskeletal:
General: No deformity. Normal range of motion.
Cervical back: neck supple
Skin:
General: Skin is warm and dry
Neurological:
Mental Status: She is alert and oriented to person, place and time.
Psychiatric:
Behavior: Behavior normal

Procedures

Medical Decision Making
Differential diagnosis includes migraine, tension headache

Further review of the medical record revealed at 6:41 a.m. the patient was given 1,000 milliliters of 0.9% sodium chloride I.V., droperidol 2.5 milligram I.V., and diphenhydramine 50 milligrams I.V. At 6:42 a.m. the patient received ketorolac 15 milligrams I.V. Reassessment of her pain at 7:17 a.m. revealed the patient was no longer experiencing pain and repeat vitals at 7:28 a.m. were normal. The patient was discharged at 9:29 a.m.

In interview on 04/09/2024 at 12:55 p.m. S1DQ verified there were not laboratory studies and no imaging studies performed on Patient #3.

In interview on 04/10/2024 between 9:29 a.m. and 9:33 p.m., S4MD was allowed to review the medical record. S4MD verified that patients presenting with migraine headaches should receive a through neurologic examination and more detail was needed in the documentation for this patient.

Patient #18
Review of the emergency department record for Patient #18 revealed the patient was a 3 month old infant with a history of atrial flutter who was brought to the emergency department on 04/05/2024 at 9:27 p.m. for evaluation after a motor vehicle collision. The patient was assessed as ESI Acuity Level 5. The patient's medications at home included Vitamin D3, propranolol, and digoxin.

Review of the provider's note from 04/05/2024 at 10:05 p.m. revealed in part:
History
Chief Complaint
- Motor Vehicle Crash

3 mo M PMHx atrial flutter presents to the ED for MVC x yesterday. Patient was the restrained back seat passenger of his mother's vehicle. Patient in his car seat starting accident. Rear-ended at low speed, No airbag deployment. Patient's mother just wants patient to be evaluated to make sure he is okay. Patient is still acting normally. . . .

Blood pressure . pulse , temperature source , resp. rate , Sp02 .

Physical Exam
Vitals and nursing notes reviewed.
Constitutional:
General: He is irritable. He is not in acute distress.
Appearance: Normal appearance. He is well-developed. He is no toxic- appearing.
HENT:
Head: Normocephalic and atraumatic. Anterior fontanelle is flat.
Nose: Nose normal.
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: Oropharynx is clear.
Eyes:
General: Red reflexes is present bilaterally.
Extraocular Movements: Extraocular movements intact.
Conjunctiva/sclera: Conjunctivae normal.
Pupils: Pupils are equal, round, and reactive to light.
Cardiovascular:
Rate and Rhythm: Normal rate and rhythm.
Pulses: Normal pulses.
Heart sounds: Normal heart sounds.
Abdominal:
General: Abdomen is flat.
Palpations: Abdomen is soft.
Musculoskeletal:
General: Normal range of motion.
Cervical back: Normal range of motion and neck supple.
Skin:
General: Skin is warm and dry.
Capillary Refill: Capillary refill takes less than 2 seconds.
Turgor: Normal
Neurological:
General: No focal deficit present.
Mental Status: He is alert.

Procedures

Medical Decision Making
Ddx: MVC
3-month-old male seen here today for MCV. Vital signs are stable nontoxic appearing. Physical examination unremarkable. Advised patient to follow-up with pediatrician and instructions to go to Children's ER with new or worsening symptoms.

The patient was discharged to home on 04/05/2024 at 10:05 p.m.

In interview on 04/09/2025 at 2:48 p.m., S1DQ verified vital signs were not taken on the patient.

In interview on 04/10/2024 at 8:18 a.m., S6RN verified the infant was sleeping when he went to take the vital signs and he did not want to awaken the infant and forgot to take the vitals when the infant woke up.