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Based on policy review, central log review, record review, and staff interview, the acute care hospital failed to enforce policies to ensure compliance with 42 CFR 489.24 and the related requirements at 42 CFR 489.20 for 1 of 1 patient records reviewed (Patient #1) who presented to the emergency department for a nurse visit (as entered in the emergency department central log).

Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements of §489.24. Failure of the hospital to enforce their Emergency Medical Treatment and Labor Act policy limited the hospital's ability to determine if the patient had an emergency medical condition requiring stabilizing treatment.

Findings include:

The acute care hospital failed to ensure a qualified medical provider performed a medical screening examination to determine if an emergency medical condition existed. (Refer to A2406)

Based on policy review, central log review, record review, and staff interview, the acute care hospital failed to ensure a qualified medical provider performed a medical screening examination to determine if an emergency medical condition existed for 1 of 1 patient records reviewed (Patient #1) who presented to the emergency department for a nurse visit (as entered in the emergency department central log). Failure to have a qualified medical provider perform a medical screening examination limited the hospital's ability to determine if the patient had an emergency medical condition requiring stabilizing treatment.

Findings include:

Review of the policy "EMTALA [Emergency Medical Treatment and Labor Act]" occurred on 10/03/23. This policy, dated 10/2022, stated, ". . . POLICY The Hospital shall comply with the emergency care obligations imposed by EMTALA. These obligations include the following: Medical Screening Examination. If a person comes to the Hospital and a request is made for their emergency care . . . the qualified medical personnel will, within the Hospital's capability and capacity, conduct and document an appropriate medical screening examination reasonably calculated to identify an emergency medical condition. . . . Qualified medical personnel. Hospital's governing body hereby designates the following as medical personnel qualified to perform a medical screening examination on emergency department patients as required by EMTALA: (1) physicians, (2) midlevel providers (e.g. [for example], PAs [physician assistants], NPs [nurse practitioners], and other advance practice nurses) acting within the scope of their licensure . . ."

Review of the emergency department's May 1 through October 2, 2023 central log showed an entry on 07/31/23 for Patient #1. The entry stated, "nurse visit" and "finger lac [laceration]"

Review of Patient #1's 07/31/23 emergency department record occurred on 10/03/23. The registration form indicated the patient registered on 07/31/23 at 21:25 and the hospital discharged the patient on 07/31/23 at 22:14. The "ED [emergency department] First Look Triage Form," indicated a registered nurse assessed the patient on 07/31/23 at 21:57. The record stated, "General Chief Complaint: breaking down boxes and cut left index finger . . . Primary Pain Intensity: 6 [0-10 scale] . . . Recommended ESI [emergency severity index] Level: 3 [1-5 scale]"
The record lacked evidence a qualified medical provider conducted an examination to determine if an emergency medical condition existed. The record lacked evidence of treatment provided and the disposition of the patient.

Upon request, the hospital failed to provide further record of Patient #1's 07/31/23 emergency department visit.

During interview at 9:00 a.m. on 10/04/23, an administrative nursing staff member (#1) confirmed Patient #1's 07/31/23 emergency department record lacked evidence of a medical screening examination by a qualified medical provider.