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Based on interview and record review, the facility failed to perform a medical screening exam on a patient who presented to the hospital requesting care and treatment for chest pain and shortness of breath. Failure to perform a medical screening exam can result in death or serious injury to a patient.

Findings:

An individual submitted a complaint to the Department of Health (DOH) reporting that on 10/31/2021 in the afternoon, a patient (patient # 21) was driven to the emergency room by her son with complaints of shortness of breath and chest pain. The patient was unable to walk into the emergency room due to weakness. The patient's son went into the emergency room to get a wheelchair to assist his mother. The triage nurse (Staff H) came out to the car and spoke with the patient. The patient informed the nurse of symptoms (chest pain and shortness of breath). The triage nurse informed the patient there was a 2 hour wait to be seen. The patient felt she could not wait 2 hours to be seen, went home, called an ambulance and went to a different facility for treatment. A deficiency is cited in the care of this patient as follows:

While performing an EMTALA survey on 8/23/2022-8/24/2022, DOH survey staff reviewed the emergency department log for October 2021 to August 2022. DOH staff found no record for the presence of patient #21 at the hospital. Hospital staff failed to record the name and disposition of patient #21 in the emergency department log for date of service 10/31/2021.

DOH staff requested a medical record for patient #21 on 8/23/2022-8/24/2022 and hospital staff indicated there was no medical record created for date of service 10/31/2021 for patient # 21. Triage nursing staff did not record triage notes or a nursing assessment regarding patient # 21.

DOH survey staff interviewed the triage nurse (Staff H) by telephone on 9/7/2022 at approximately 8:15 am. She had no recollection of going out to the car to speak with patient # 21.

DOH survey staff contacted and interviewed patient #21 on 8/26/2022 at 3:15 pm and again on 9/16/2022 at 1 pm. She stated that upon her arrival to the hospital emergency department, the triage nurse came out to the car. Patient # 21 told the nurse (Staff H) her symptoms. The nurse (Staff H) told the patient she would not be seen for 2 hours.