HospitalInspections.org

Based on document review and interview, the facility failed to ensure that all patients who present to the Emergency Department receive a MSE (Medical Screening Exam) - (see Tag A2406).

Findings include:

1. See findings cited at 42 CFR 489.24(a), Medical Screening Exam A2406.

Based on document review and interview, the hospital failed to ensure an appropriate medical screening examination for an ER/ED (Emergency Room/Emergency Department) patient; for 1 of 20 closed medical records reviewed. (Patient # 11-A).

Findings include:

1. Review of established hospital policy titled: "EMERGENCY DEPARTMENT PLAN OF CARE FOR PROVIDING CARE/SERVICE (SCOPE OF CARE)", indicated on page 1, under 2.0, CRITERIA FOR ADMISSION, "All patients presenting to the Emergency Department...must be offered and provided with an appropriate medical screening examination". Last reviewed 2/2019.

2. Review of established hospital policy titled: "Emergency Medical Treatment and Active Labor Act ("EMTALA")", indicated on page 1, under PURPOSE, appropriate guidelines to ensure that all individuals who present to AH # 40, healthcare system dedicated emergency department or hospital property receive an appropriate medical screening examination". was not followed in relation to appropriate guidelines followed to ensure that all individuals who present to AH # 40's dedicated emergency department or hospital property received an appropriate medical screening examination, necessary treatment, stabilization and/or transfer. Last reviewed 7/2019.

3. Review of Medical Rules & Regulations, indicated on page 27, under Section 7. Emergency Services, 1. Screenings; "All patients presenting to the Emergency Department must be offered and provided with an appropriate medical screening examination"; "to identify whether the patient has an emergency medical condition", and on page 41, under (g), Responsibilities of the Members of the Department of Emergency Medicine, (1) "To provide emergency care compatible with the standards of the community for all patients who present to the Emergency Department".

4. Review of closed MR (medical record) for Patient # 11 (11-A), from AH # 40 (acute care hospital), indicated the following:
A. Patient (Pt) was a 28 year old who presented to AH # 40's ER/ED at 6:11 pm, on 7/31/2021, for complaint of alleged sexual assault. Patient was triaged at 6:40 pm; acuity = 2.
B. Nurse note at 6:40 pm, reflected patient stated she/he was sexually assaulted today; that she/he is sore at this time and is here to be checked out.
C. Nurse note at 7:02 pm, reflected patient stated events took place in Illinois. N # 21 (ER Triage Nurse) informed patient of benefits of having process take place in IL (Illinois).
D. Nurse note at 7:34 pm, reflected ED Destination - Room 9; and Pregnancy urine collected at 7:40 pm.
E. Nurse note at 8:21 pm, reflected Patient left.
F. The medical record lacked a Medical Screening Examination.

5. Review of closed MR for Patient # 11 (11-B), from AH # 50 (acute care hospital), indicated the following:
A. Pt presented to AH # 50's ER/ED, on 7/31/2021 at 9:33 pm, for chief complaint of Sexual assault.
B. Pt was triaged by nurse staff; acuity = 2. Nurse note reflected pt here for sexual assault examination that happened this afternoon in Chicago. Pt went to Hammond, IN (AH # 60 {Acute Care Hospital}) "24/7 ER", and was directed to AH # 40. AH # 40 "directed" pt "to come back to be examined in IL" (Illinois).
C. Pt seen/examined/evaluated by ER/ED Physician at 11:52 pm.
1. Physician noted pt found ride back to Indiana from Chicago, and went to AH # 60, where she/he was instructed to go to AH # 40.
2. AH # 40 "told" her/him "to go back to IL since that is the location of the sexual assault".
3. Pt "has not filed a police report yet, but" pt "would like a kit and to file a police report". Physical exam "deferred until evidence collection". All options discussed with pt; pt "agreeable to file police report, due a SA (Sexual assault) kit and "continue forward with STD" (Sexual transmitted diseases) prophylaxis, HIV (Human immunodeficiency syndrome) medications and "Plan B. pill".
D. Pt examined, assault kit completed, evidence collected at 3:00 am.
E. Pt discharged with materials for victims; instructions, prescriptions and follow-up information for outpatient services at 6:32 am (8/1/2021).

6. In interview with administrative staff member A # 2 (Director - Patient Care Services & ER Director), on 8/16/2021, at approximately 10:20 am, and at approximately 3:35 pm, confirmed the following:
A. Patient (Pt # 11-A) left without being seen by an ER Physician; she/he was never told "to go to Illinois"; benefits explained to patient, by triage nurse; if patient would go to have treatment/kit completed at a hospital in Illinois. Patient decided to leave.
B. Pts receive additional benefits in Illinois; additional counseling, vouchers; compensation for hospital bill and help with medications.
C. Not sure where patient left from; it was not documented; or if any attempts made to call/locate the patient.