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Based on document review and interview, it was determined the Hospital failed to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24.

Findings include:

1. The Hospital failed to provide a medical screening examination. Refer to A-2406.

Based on document review and interview, it was determined that for 1 of 20 (Pt. #1) clinical records reviewed of patients who presented in the Emergency Department (ED), the Hospital failed to provide a medical screening examination (MSE).

Findings include:

1. On 5/3/17 the policy entitled "Emergency Medical Treatment at (Hospital) (reviewed 8/23/16) was reviewed and required, "III. Policy: ...it is the policy of (the Hospital) that all persons 'who come to the hospital' seeking Emergency Medical Care shall receive an appropriate Medical Screening Examination (MSE) and evaluation to determine whether an emergency medical condition (EMC) exists..."

2. On 5/3/17 at approximately 10:20 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 35 year old female that presented to the Emergency Department on 5/1/17 at 8:32 PM with a chief complaint of leg pain, possible DVT (deep vein thrombosis-blood clot). Pt. #1 checked out on 5/1/17 at 8:49 PM. Pt. #1's clinical record lacked documentation of a medical screening examination.

3. On 5/3/17 at approximately 11:41 AM, the Medical Director of the Emergency Department (MD #1) was interviewed. MD #1 stated that if a patient presents to the Emergency Department with a complaint of a blood clot in the legs, it is expected that the patient is triaged, receives a medical screening, has a Venous Doppler (ultrasound of the arteries and veins), and depending on the results of the diagnostic test, be treated. MD #1 stated that "it depends on the severity of the findings. The patient may be admitted for treatment or can be discharged home."

4. On 5/3/17 at approximately 2:40 PM, the Financial Coordinator (Registration) (E #5) was interviewed. E #5 was on duty the evening of 5/1/17. E #5 stated that "the patient presented to the window with leg pain. She (Pt. #1) stated she had a test done today (not clear where) and was told to come to the ER. I registered her and told her to have a seat in the waiting room, and that the triage nurse would call her." E #5 stated that "she (Pt. #1) was seen by the triage nurse."

5. On 5/3/17 at approximately 3:47 PM, the Director of Critical Care and Specialty Services (E #6) was interviewed. E #6 stated that E#7 told him that she (E #7) had a conversation with Pt. #1 about the treatment and the possible time of her being in the hospital if the diagnosis of DVT was confirmed, and that Pt. #1 may need to be admitted or stay overnight for observation. E #6 stated that E #7 tried to talk Pt. #1 into staying, but the patient refused. E #6 stated that the expectation would have been that E #7 documents her interaction and conversation with Pt. #1 in the progress notes.

6. On 5/4/17 at approximately 7:15 AM, the Registered Nurse (E#7) was interviewed. E#7 was the assigned Triage Nurse on duty the evening of 5/1/17, when Pt. #1 presented to the Emergency Department. E #7 stated that Pt. #1 arrived with her husband to the Emergency Department complaining of pain to the right leg. E #7 stated she told Pt. #1 that "normally we (the Hospital) don't have an ultrasound technician at night to conduct Venous Doppler. This would be a test that is done in the morning. E #7 stated "(Pt. #1) told me 'I don't want to be billed or charged.' Please forget I was here." E#7 stated, "I did not document my conversation in (Pt. #1's) clinical record."