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Based on document review, record review, policy review and interview the Hospital failed to ensure the emergency medical treatment and labor act (EMTALA) requirements were met by failing to provide an appropriate and ongoing medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed. Failure to provided an appropriate and ongoing MSE places patients at risk for harm and injury up to and including death.

Findings Include:

Review of a document titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance," revised 09/2021, showed that, " ...To ensure that all persons coming to the Hospital... ...requesting emergency services receive an appropriate medical screening examination within the Hospital's capability to determine whether an emergency medical condition exists. If an emergency medical condition is found to exist, the Hospital will stabilize or transfer the individual in accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA)...MSE ..."medical screening examination" and refers to the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists ... Such screening must be done within the facility's Capability and available personnel, including on-call physicians and other QMP's [Qualified Medical Professional]. The medical screening examination is an ongoing process and the medical records must reflect continued monitoring based on the individual's needs and must continue until the individual is either stabilized or appropriately Transferred ...C. How to provide the medical screening exam ...5. An MSE is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the individual's needs and must continue until he/she is Stabilized or an appropriate Transfer has occurred. There should be evidence of this evaluation documented in the medical record prior to discharge or Transfer ...Admission of an Individual 2. The Hospital's obligation under EMTALA ends once an individual has been seen, screened, and admitted for inpatient services ..."

Review of a policy titled, " Patient Status Order/Level of Care," revised 09/2018, stated that " ...Observation Status is used when an outpatient needs to be placed in a hospital bed and monitored in order to determine if the patient should be admitted to Inpatient, discharged, or if additional outpatient treatment is required ...Definitions ...Level of Care/Patient Status-means the level of Inpatient or Outpatient Services a patient receives ...Observation is a Level of Outpatient Care ...Outpatient in a bed means a patient that is having a service in the location of a room on one of the nursing units. Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatient or if they are able to be discharged from the hospital ...III. Procedure: Observation Status B. Those hospital stays in which the physician cannot reliably predict the beneficiary to require a hospital stay greater than 2 midnights would be appropriate for observation ...likewise once the patient is stable and able to be discharged, an appropriate discharge order, if not already present, would be obtained."

Review of a policy titled, "Neurological Assessment", revised 08/2022, " ...Procedure: A basic neurological assessment is defined as: level of consciousness (LOC), orientation, behavior, facial symmetry, ability to move all extremities, strength of extremities, pupillary response, speech clarity and meaningfulness..."

Review of a policy titled, "Head Injuries", revised 03/2022, stated that "Policy Statement ...the nursing interventions will include a comprehensive bedside assessment of neurological status, planning for diagnostic testing, continued monitoring of patient status, and education for care required at discharge ...Definitions ...Head injury: Any trauma that leads to injury of the scalp, skull, or brain. These injuries can range from a minor bump on the scalp to a serious brain injury ...Procedure:1. Practice ...D. The Neuro Assessment policy shall be followed ..."

Review of a policy titled, "Guidelines for Nursing Practice", revised 05/2023, showed that " ...Neurological ...B. Additional neurological monitoring will be completed as ordered ..."


1. The Hospital failed to provide an appropriate and ongoing medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed for 1 of 20 patients (Patient 1) who presented to the emergency department (ED) seeking emergency medical care and was admitted for observation. (Refer to Tag A-2406)

Based on record review, policy review, document review and interview the Hospital failed to provide an appropriate and ongoing medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed for 1 of 20 patients (Patient 1) who presented to the emergency department (ED) seeking emergency medical care and was admitted for observation. The hospital's failure to ensure an appropriate MSE was completed has the potential for all patients to be discharged with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the person's condition, including harm and death.

Findings Include:

Patient 1

Review of Patient 1, medical record showed a 47-year-old female who presented to the Emergency Department (ED) on 05/04/23 at 7:32 PM via ambulance. Patient 1 was triaged at an Emergency Severity Index (ESI) 3 (stable and should be seen urgently). Patient 1's chief complaint was worsening lower abdominal pain with nausea. Patient 1's past medical history included a history of Traumatic Brain Injury (TBI), abdominal pain, asthma (a respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing, hypertension (high blood pressure), hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), Supraventricular Tachycardia (a rapid heartbeat that develops when the normal electrical impulses of the heart are disrupted), congestive heart failure (the hearts capacity to pump blood cannot keep up with the bodies need), Myocardial Infarction MI (decreased or complete cessation of blood flow to a portion of the heart called the myocardium) , Urinary Tract Infection (UTI) , Post-traumatic Stress Disorder PTSD (an anxiety disorder caused by very stressful, frightening or distressing events), anxiety, manic depression (episodes of mood swings ranging from depressive lows to manic highs), and Diabetes Mellitus type 2 (a chronic condition that affects the way the body processes blood sugar). Patient 1 has multiple allergies to antibiotics used to treat infection.

Review of a document titled, "History and Physical Reports", dated 05/05/23 at 0035 (12:35 AM) showed that. "[Patient 1] is a 47-year-old female seen and examined 05/05/23 0035. Patient presents to ER [emergency room] complaining of left flank pain with radiation to left side of abdomen, urinary urgency/frequency/hesitancy, dysuria (pain with emptying of the bladder) with cloudy urine since yesterday, and nausea and diarrhea. Patient describes left flank pain with radiation to left-sided abdomen as "constant", "pressure", "sharp", alleviated with passing small amount of urine, no exacerbating factors, treated with hot baths, massage, and positional changes. Patient denies fever, chills, shortness of breath, chest pain, vomiting. ER labs report White Blood Count (WBC) 14.7 (normal value ranges 4.5-11.0 m/mol), sodium 133 (normal value ranges 135-145 mmol/liter) , glucose 494 (normal value ranges 70-110 mg/dL), magnesium 1.6 (normal value ranges 1.7-2.2 mg/dL), lactic acid 1.44 (less than 2 mmol/L), Urinalysis (UA) 1+ leukocytes (an indicator of infection in urine), WBC greater than 50, 2+ bacteria, yeast present (additional indicators of infection in urine). Computerized Tomography (CT) abdomen/pelvis negative for acute process. Discussed patient with the ER physician and agreed to observation admission for further work-up and treatment."

Review of Patient 1's medical record dated 05/05/23 at 4:27 AM showed Staff M, RN, documented, "UP BR with pct Stood up and states hit top of head on sink counter "I think I just got up too fast" Asked by nurse if having problems with mobility at home she states working on obtaining walker and assistive devices for home. Refused ice pack Gait appears steady here. ...Teaching done related to report redness, tenderness, pain or swelling and or change in legs/calves. Verbalizes understanding."

Review of Patient 1's medical record dated 05/05/23 at 3:45 AM failed to show documented evidence the provider was notified of Patient 1 hitting head on the sink in the bathroom when standing up from the toilet and failed to perform a neurological assessment per hospital policy while admitted as an observation patient on the 2 South floor.

During an interview on 08/10/23 at 8:37 AM, Staff K, Patient Care Technician (PCT) stated "mostly she called out using her call light after going to the bathroom and stated she hit her head. I went in looked at her and I did not see any obvious bump on her forehead, and she wanted Tylenol and I went and got the nurse. She said she felt like she had a bump on her forehead. I did not notice any urine on the floor. She was in the process of sitting down."

During an interview on 08/10/23 at 9:15 AM, Staff M, Registered Nurse (RN), stated "I did not see any redness or bump on her head. I offered to call her physician and get a CT (computerized tomography a test used to create detailed images of bones and soft tissue). The patient refused to let me. I did not call the doctor. She refused lab draws. I did not fill out an event report. I did not report to the physician she hit head. In hindsight I should have called the physician."

During an interview on 08/10/23 at 8:57 AM, Staff N, RN stated "She [Patient 1] was only there for a little bit. As soon as I completed my assessment she demanded to leave. She did say she had a headache and that she had hit her head. I don't remember if she had a bump on her forehead, I touched it but I didn't feel one. The patient refused to let me turn on the light. No other signs of a concussion while I had taken care of her. She left around 9 or 10 in the AM. I only cared for her briefly. I do remember that I offered the CT scan and she refused."

Review of a document titled, "Complaint/Grievance Event", unknown date and time, showed that Patient 1 reported she now has symptoms that are different that her usual i.e., sleeping more, skull/head pain, balance is worse, vision disturbance, has a lump that is smaller now. She was instructed to follow up with her primary care physician which she reported she had done and then was encouraged to go to ED or urgent care for evaluation. Further review of the document showed that interviews were conducted with Staff K, Staff M, and Staff N. In these interviews documentation showed that Staff N, RN stated that she offered to call the doctor multiple times.

Review of Patient 1's medical record dated 05/10/23 at 6:31 PM showed that Patient 1 presented to the Emergency Department (ED) with a chief complaint of head pain because of her hitting her head on 05/04/23 or 05/05/23 during observation at above named hospital. Further review showed it is unknown if Patient 1 lost consciousness. The medical history showed that Patient 1 had a history of multiple TBI's and concussions. Patient 1 was evaluated and discharged with a diagnosis of a closed head injury with a concussion and strict instructions to follow up with her neurologist in two to three days.

The hospital failed to ensure an appropriate and ongoing Medical Screening Exam (MSE) was completed while Patient 1 was in observation status on 05/05/23. Documentation failed to show evidence a provider was notified of an incident of Patient 1's report of hitting her head on the bathroom sink on 05/05/23 at 3:45 AM that resulted in Patient 1 returning to the ED on 05/10/23 at 6: 31 PM in which Patient 1 was diagnosed with a closed head injury and concussion.