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Based on staff interview, record review, and facility policy review, the facility Emergency Department failed to provide an appropriate and complete Medical Screening Exam (MSE) by a qualified medical person for eight (8) of 20 patients reviewed: Patient #1, Patient #2, Patient #3, Patient #11, Patient #12, Patient #13, Patient #14, and Patient #15.

Findings Include:

Review of facility's Policy and Procedure for Triage in the Emergency Room (ER), with revision date of 04/23/2023, reveal ." ...Purpose: ...all patients that come to the emergency room for treatment are triaged by a registered nurse and have a medical screening exam (MSE) by the ER Physician or ER Provider ...Those patients classified by the Registered Nurse as non-Urgent after triage and confirmed by the ER physician by MSE may be directed to the rural health clinics ...or a medical clinic of the patient's choice ...".

No other Emergency Medical Treatment and Labor Act policies were presented for review.

During the exit conference on 09/28/2023 at 12:30 p.m. with the Chief Executive Officer and Director of Nursing, survey findings were discussed, and no further documentation was submitted for surveyor review.

Cross Refer to C2406/489.24(a)(1) for the facility's failure to provide an appropriate medical screening exam (MSE) for Patient #1, Patient #2, Patient #3, Patient #11, Patient #12, Patient #13, Patient #14, and Patient #15 within the capability of the hospital Emergency Department.

Based on staff interview, record review, and facility policy review, the facility's Emergency Department (ED) failed to provide a Medical Screening Exam (MSE) for eight (8) of 20 patients reviewed: Patient #1, Patient #2, Patient #3, Patient #11, Patient #12, Patient #13, Patient #14, and Patient #15.

Findings Include:

Interview with the Director of Nursing (DON) 09/27/2023 at 1:45 p.m. revealed, " ... it is the facility policy that a patient can be referred to the Clinic if found not to have an emergency medical condition by the nurse ..."

Interview with the Chief Executive Officer (CEO) on 09/27/2023 at 1:51 p.m. confirmed, a Medical Screening Exam is separate from a Triage assessment.

Review of Patient #1's Emergency Department (ED) medical record for service date 06/29/2023 revealed patient arrived at 10:37 a.m. via walk-in with a complaint of neck spasms since this morning and reports sleeping wrong last night. Triage assessment was completed at 11:00 a.m. Tympanic Temperature 98.4 Fahrenheit (F), Pulse 97 beats per minute, Respiratory Rate 18 breaths per minute, peripheral capillary oxygen saturation (SpO2) 98%, weight 91 kilograms (kg). There is no documented blood pressure. Triage acuity level five (5) (nonurgent). The Nursing Narrative Note dated 06/29/2023 at 11:06 a.m. reveals, " ...patient triaged to the Primary Clinic for "now" appointment ...". There is no Medical Screening Exam or discharge order documented by Nurse Practitioner (NP) #1 prior to discharge.

Review of Patient #2's ED medical record for service date 05/18/2023, revealed patient arrived at 3:18 p.m. with a complaint of back pain due to prior wreck. Triage documentation reveals the chief complaint as " ... patient arrived for a follow up for back pain after motor vehicle accident (MVA) last week ...". Blood pressure 140/91, pulse 109 beats per minute, respirations 18 breaths per minute, tympanic temperature 98.8 F, SpO2 98% on room air, weight 181 kilograms (kg). Triage acuity level five (5) (nonurgent). The Nursing Narrative Note 05/18/2023 at 3:58 p.m. reveals, " ...Patient triaged to clinic for "now appointment...". There is no Medical Screening Exam documented prior to discharge. There is no Against Medical Advice (AMA) form or Refusal of Treatment form available for review.

Review of Patient #3's ED medical record for service date 04/07/2023 reveals patient arrived at ED at 2:19 p.m. with a complaint of seizure. There is no Triage document, Triage acuity level, or history and physical for review. There is no Medical Screening Exam available for review. The discharge order was documented on 04/07/2023 at 3:06 p.m. by Physician #2. Discharge instructions for seizures, instructions for a follow up appointment with Primary Care within one month. Discharge instructions are electronically signed by Registered Nurse (RN) #4 on 04/07/2023 at 3:06 p.m. The Coding Summary report with Secondary code of Z53.21 diagnosis as procedure and treatment not carried out due to patient leaving prior to being seen by health care provider. There is no Against Medical Advice (AMA) form for review. There is no refusal of treatment form for review and no documentation the facility attempted to obtain.

Review of Patient #11's ED medical record for service date 05/11/2023 reveals patient arrived at the ED at 9:27 p.m. complaining of abscess of left buttock. Vital signs were documented at 10:50 p.m. with temperature of 98 degrees Fahrenheit, blood pressure 129/76, pulse 96 beats per minute, respirations 20 breaths per minute, oxygen level 98% on room air. No documentation of a MSE review. No documentation available for what time the patient left the ED. No Against Medical Advice (AMA) form for review, no refusal of treatment form submitted for review and no documentation the facility attempted to obtain.

Review of Patient #12's ED medical record for service date 06/05/2023 reveals patient arrived at the ED at 9:09 a.m. with complaint of chronic left shoulder and arm pain. Triage time recorded at 9:22 a.m. with weight 36.5 kg, respirations 20, Blood pressure 140/92, pulse 66 beats per minute, oxygen level 98% on room air recorded at 10:00 a.m. Patient #12 was triaged to the Primary Clinic. No documented MSE. No Refusal of Treatment Form or Against Medical Advice (AMA) form submitted for review or documentation of the facility's attempt to obtain.

Review of Patient #13's ED medical record for service date 07/13/2023 reveals patient arrived at the ED at 4:24 p.m. with a complaint of body aches. Patient #13 was triaged to the Primary Clinic and discharged from the ED without a triage assessment or MSE on 07/13/2023 at 4:24 p.m. No Against Medical Advice (AMA) or Refusal of Treatment form documented for review and no documentation of the facility's attempt to obtain.

Review of Patient #14's ED medical record for service date 08/18/2023 reveals patient (eight [8] year old) arrived at the ED at 4:36 p.m. with possible insect bites to chin. Triage time was recorded at 4:59 p.m. Pulse 88 beats per minute, respirations 20, oral temperature 98.8 F, oxygen level 99% on room air, weight 18 kg. Triage acuity level five (5) (nonemergent). Nurses' narrative note on 08/18/2023 at 5:00 p.m. revealed patient mother does not wish to wait in ED and requests clinic appointment. Medical Clinic was called, and an appointment scheduled for a "now" appointment. Patient #14's Mother agreed. No Medical Screening Exam performed. No refusal of treatment form for review or documentation of the facility's attempt to obtain.

Review of Patient #15's ED medical record for service date 08/07/2023 reveals patient arrived at the ED at 1:55 p.m. with complaint of fever times three (3) days, no cough. Triage notes reveal temperature 98.1 degrees Fahrenheit, pulse 81, respirations 18, blood pressure 113/75, O2 Sat 96%. Patient #15 was triaged to a medical clinic. Patient #15 was discharged from Emergency Department 08/07/2023 at 1:58 p.m. without a MSE provided.

Review of facility's Policy and Procedure for Triage in the Emergency Room, with revision date of 04/23/2023, reveal ." ...Purpose: ...all patients that come to the emergency room for treatment are triaged by a registered nurse and have a medical screening exam (MSE) by the ER Physician or ER Provider ...Those patients classified by the Registered Nurse as non-Urgent after triage and confirmed by the ER physician by MSE may be directed to the rural health clinics ...or a medical clinic of the patient's choice ...".

No further policy review completed and no other Emergency Medical Treatment and Labor Act policies presented for surveyor review.

During the exit conference on 09/28/2023 at 12:30 p.m. with the Chief Executive Officer and Director of Nursing, survey findings were discussed, and no further documentation was submitted for review.