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Based on review of documentation and interviews, the facility failed to ensure that all patient medical record entries were complete, as evidenced by the failure to document Animal Control had been notified of a stray dog bite for one of one patient reviewed (Patient #14) for animal bites.

Findings were:

Facility policy entitled "Reportable Conditions and/or Crimes - Identifying and Managing" last revised 11/21/2023 reflected in part, "Animal Bites/Exposure: 1. Animal bites (possible rabies exposures) are reportable to the appropriate Animal Control officer in the county where the incident occurred. Reporting is mandatory..."

Review of the medical record for Patient #14 revealed in part, "Admission 2/22/2024 11:45 Chief Complaint: complains of dog bite to L (left) shin...Was seen in urgent care yesterday was bit by a stray. Unable to find dog...Medication Administration: rabies immune globulin, human 1500 Units, IM (02/22/24 12:38 CST), rabies vaccine, purified chick embryo cell, 1 ml, IM (02/24/2024 12:48 CST)..."

During an interview on the morning of 3/20/24, Staff #2 stated, "When a patient comes to the Emergency Department due to an animal bite, we have a packet that is completed. The packet is sent to Animal Control in the county where the incident occurred. The packet we complete is not a part of the patient's record. And, a copy of the packet is not kept. The nurse should document that the packet was sent to Animal Control and it was reported, but in the case of Patient #14,, it was not documented that this was done."

During an interview on the morning of 3/20/2024, Staff #1 stated "When a patient comes in with an animal bite, the expectation is that the incident is reported to Animal Control. If it is not documented, we cannot prove it was done. Documentation is part of the process. Our policy and procedure states that reporting is mandatory."

The above findings were verified with Staff members #1 and #2 on the morning of 3/20/2024.

Based on review of documentation and interviews, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department when 1 of 20 patients reviewed (Patient #1) presented to the Emergency Department (ED) and did not receive a medical screening examination when presenting to the ED on 2/1/24.

Findings were:

Review of the facility provided policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA) and Transfer", last revised 6/8/2023 reflected in part, "...Standards for Medical Screening Examinations:
1. Patients who come to a dedicated Emergency Department requesting examination and treatment will be Triaged and receive a Medical Screening Examination by a QMP (Qualified Medical Professional).
2. The Medical Screening Examination (MSE) extends until the point that the QMP determines that an Emergency Medical Condition does or does not exist. A patient should continue to be monitored based on the patient's needs, and monitoring should continue until the individual is stabilized or admitted or appropriately transferred.
3. When an individual presents with psychiatric symptoms, the Medical Screening Exam should include an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. When the Hospital determines that an individual poses a danger to self or others, this is considered an Emergency Medical Condition (EMC).
4. If the Medical Screening Examination does not reveal the existence of an Emergency Medical Condition, the patient may, if appropriate, be referred for further non-emergency treatment through the Hospital's facilities or a private physician and/or may be discharged with appropriate follow-up instructions documented according to department procedures..."

A review of the emergency department record for Patient #1 revealed in part, "...2/1/24 8:54 "M08 (EMS) arrived on scene to find a 50 y/o (year old) female c/o (complaining of abdominal pain. She said she has gastroparesis, and this happens to her frequently. She has been to the ER multiple times for this problem and to a GI (gastro-intestinal) doctor. She has Vicodin for the pain, and she tried to take it this morning but vomited it up. She said today she cannot stop dry heaving. She said her GI doctor told her to just continue the cycle of going to the hospital and taking pain meds when this happens. She said today it started around 5:30 am. She has not missed any dialysis or been sick recently. She said the pain feels the same as it was in the past. She denied shortness of breath, chest pain, numbness, tingling, headache, recent trauma. Patient was found sitting down on her couch in her living room. She was awake and tracking and answered when spoken to. Patient airway was patent, and she was able to maintain it on her won. Patient breathing was unlabored and of equal rate and depth. Patient skin was pink and dry...
Triaged 2/1/24 8:58 am. Vitals: Blood pressure: 198/77. Respiratory rate: 26 br/min (breaths per minute). Pulse 90
Complaints of abdominal pain.
Chief complaint: gastroparesis flare up at 0500; took Vicodin without relief, hasn't missed dialysis, EMS reports refused pain medications.
History of present illness: 50 year old female with pmhx (past medical history) of bipolar, ESRD (End-Stage Renal Disease), dialysis Monday Wednesday Friday presents to ED with chronic abdominal pain via EMS. Denies any missed dialysis. States she took her medications this morning without relief.
Discharge diagnosis: Abdominal pain, anxiety.
Discharge education provided 2/1/24 at 17:40 hours."

During an interview on the afternoon of 3/19/24, Staff #3, ED Physician stated, "I do know this patient. I have seen her many times. On that particular day (2/2/2024), I met her at the door and evaluated her when she came in via ambulance. I told her she has a High Alert Plan and that he couldn't give her certain medications. So, she decided to leave. There were other things we could have done, other than just medications. She is a dialysis patient. She does have multiple medical issues. We could have treated her vomiting and abdominal pain. She was at the ED the day before (2/1/2024) and she got a full work-up."

Patient #1 presented to the ED on 2/1/24 with abdominal pain, cramping, and vomiting, had an elevated blood pressure on arrival, and had a history of ESRD with dialysis use, DKA [diabetic ketoacidosis], and hypertensive urgency; however, Patient #1 did not receive an appropriate MSE, as there was no thorough review of systems related to Patient #1's chief complaint and elevated blood pressure, lab work was not included in the evaluation, including an initial blood glucose level. Without these components completed, an EMC could not be determined.