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Based on policy review, review of Medical Staff Rules and Regulations, medical record review, and interview, the facility failed to ensure an individual who presented to the emergency department was provided with an appropriate medical screening examination within the capability of the hospital's emergency department (ED) for 2 of 20 (Patient #1 and 7) sampled patients.


The findings included:

1. The facility failed to ensure all patients presenting to the ED received an appropriate medical screening exam to determine if an emergency medical condition existed.

Refer to 2406

Based on policy review, review of Medical Staff Rules and Regulations, medical record review, and interview, the facility failed to ensure an individual who presented to the emergency department was provided with an appropriate medical screening examination within the capability of the hospital's emergency department (ED) for 2 of 20 (Patient #1 and 7) sampled patients.

The findings included:

1. Review of the facility policy, "EMTALA [Emergency Medical Treatment and Labor Act]-Definitions and General Requirements," revealed, "...PURPOSE: To require, in conjunction with state-specific policies, that an acute care or specialty hospital with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to any individual...The hospital with an emergency department must provide to any individual...who 'comes to the emergency department' an appropriate Medical Screening Examination ('MSE') within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition ('EMC') exists, regardless of the individual's ability to pay. The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department ('DED')...Leaving DED Prior to Triage ('LPT'). If an individual presents to the DED and requests services for a medical condition, but the individual desires to leave prior to triage, the facility must request that the individual complete the Sign-In Sheet . Purpose of the Sign-In Sheet. For those individuals who presented to the DED who are not immediately placed in a bed, the Sign-In Sheet must be completed. The Sign-In Sheet is used to document the date and time of the request for medical screening, pre-registration information, and where applicable, a release of responsibility statement by the individual..."

Review of the facility policy, "Assessment/Reassessment/Plan of Care of Patients," revealed, "...PURPOSE...To promote safety by ensuring processes are in place to ensure each patient's physiological and psychosocial status is assessed in order to plan and provide for individualized care...Assessment...Patients receiving inpatient, outpatient, or emergency services had a timely, initial assessment of pertinent medical and psychosocial variables by qualified, privileged, interdisciplinary health care providers...The assessment process identifies the need for intervention, treatment and type of care to be provided...The patient assessment is collaborative to facilitate, identify and prioritize the patients' needs and determine care..."

Review of the facility policy, "Pain Assessment and Reassessment, Management and Documentation," revealed, "...PURPOSE: To establish an approach (assessment, plan of care, intervention, reassessment and documentation) to pain management consistent with patient needs, preferences and rights and with organizational...values...[Hospital #1] respects the patient's right to pain management...[Hospital #1] assesses, reassesses and manages its patients' pain consistent with scope of care, treatment, services and the patient's condition...Pain Assessment (includes the following)...Frequency...Pain descriptors and indicators...Patient Teaching...Documentation..."

2. Review of the facility's "MEDICAL STAFF RULES AND REGULATIONS," revealed, "...Medical Screening Exam...Federal and State laws and regulations provide that any individual who comes to the Hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by individuals qualified to perform such examination to determine whether or not an emergency medical condition exists...A Medical Screening Examination shall be provided to determine whether an emergency medical condition exists...This medical screening examination must be provided to all individuals regardless of diagnosis, race, age, creed, sex, handicap, sexual preference, national origin or financial status..."

3. Medical record review revealed Patient #1 was a 48-year-old female who presented to the Hospital #1 ED on 6/20/2022 at 7:44 PM with a chief complaint of a burn on the face and hand.

Tech #1 documented Patient #1 arrived by walk-in on 6/20/2022 at 7:44 PM as the first point of contact with Patient #1.

Nurse #1 documented Patient #1 left the ED on 6/20/2022 at 8:08 PM (24 minutes after arrival) with a disposition of leaving against medical advice (AMA).

Tech #1 documented Patient #1 arrived back in the ED on 6/20/2022 at 8:15 PM (7 minutes after leaving the ED).

Nurse #1 documented Patient #1 arrived by ambulance on 6/20/2022 at 8:15 PM and left the ED on 6/20/2022 at 8:39 PM (24 minutes after arrival to the ED by ambulance) with a disposition of leaving prior to triage.

Physician's Assistant #1 documented on 6/20/2022 at 8:20 PM that Patient #1 was called by triage nursing staff, but Patient #1 went out to the parking lot and called 911 (emergency medical services).

There was no documentation ED nursing staff assessed Patient #1's vital signs, pain, or general presentation for either visit (6/20/2022 at 7:44 PM and 8:15 PM). There was no documentation ED nursing staff completed the Rapid Initial Assessment for either visit. There was no documentation ED nursing staff documented on or completed the Sign-In Sheet for Emergency Services for either visit. There was no documentation Patient #1 was seen or assessed by a medical provider or was provided a medical screening examination.

During a telephone interview on 8/2/2022 1:16 PM, Patient #1 stated she left the Hospital #1 ED and called 911 at sometime around 8:30 PM-8:45 PM (6/20/2022). Patient #1 stated she went to the Hospital #2 ED, and the ED nursing staff assessed her burns and pain and gave her ice packs and pain medication. Patient #1 stated the ED nursing staff told her to call the burn unit (at Hospital #2) if the burns started to blister. Patient #1 stated she did not call the burn unit but followed up with her primary care physician to treat her burns. Patient #1 stated she did not know the name of the EMS company that transported her to Hospital #2.

During a telephone interview on 8/3/2022 at 3:15 PM, Nurse #1 stated he remembered Patient #1. Nurse #1 stated Patient #1 was frustrated because the ED nursing staff could not immediately take her back to a room and told us, "F you, I'll call 911 and go to a real hospital." Nurse #1 stated he believed the ED nursing staff brought Patient #1 back to triage. Nurse #1 stated Patient #1 had very superficial burns, and the burns were slathered with mustard. Nurse #1 stated Patient #1 went outside the hospital and called 911. Nurse #1 stated EMS #1 picked Patient #1 up and brought her back to the Hospital #1 ED. Nurse #1 stated Patient #1 then called her friend to take her somewhere else because all the rooms were full. Nurse #1 stated Patient #1 had to wait for triage/MSE because the ED was extremely busy that night, and all the ED rooms were filled up. Nurse #1 stated Patient #1 demanded the ED nursing staff put something on her burns immediately and give her pain medication. Nurse #1 stated the ED nursing staff explained to Patient #1 that they were unable to treat her for pain until after she was assessed by a nurse because it was unsafe to treat her and put her back in the waiting room.

During an interview on 8/3/2022 at 3:28 PM, the ED Director verified Patient #1 presented to the ED on 6/20/2022 with complaints of burns at 7:44 PM, left the ED at around 8:08 PM and came back 7 minutes later at 8:15 PM via ambulance. The ED Director verified Patient #1 then left the ED on 6/20/2022 at 8:39 PM. The ED Director reviewed the ED record with the survey team and confirmed Patient #1 was not assessed by a triage nurse or medical provider on either of her visits to the ED.

Review of Patient #1's ED record from Hospital #2 revealed she presented on 6/20/2022 at 8:51 PM, by private car, with a chief complaint of burn. The Nursing triage was initiated 9:05 PM, with vitals documented as Temperature- 98.1, Pulse- 109, Respirations- 22 and Blood pressure 131/86. Patient #1 was assigned an acuity level 4- less urgent by the triage nurse. During triage, Patient #1 rated her pain as a 10 on a scale from 1-10 with 10 being the most painful. The triage nurse documented, "Pt [patient] is extremely tearful in triage due to the pain."

There was no available Emergency Medical Services trip report for the transport of Patient #1 to hospital #2.

4. Medical record review revealed Patient #7 was a 22-year-old female who presented to the Hospital #1 ED on 3/18/2022 at 9:58 PM with complaints of migraines and head pain.

Nurse #2 documented the Rapid Initial Assessment on 3/18/2022 at 10:51 PM (53 minutes after arrival to the ED) that Patient #7 was alert and oriented time 3 (person, place and time), but had a pain intensity of 0 (0-10 pain scale). Nurse #2 triaged Patient #7 at 10:51 PM with an Emergency Severity Index level of 3 (Urgent). Nurse #2 documented Patient #7 left the ED on 3/19/2022 at 2:05 AM with a disposition of leaving AMA.

There was no documentation ED nursing staff assessed Patient #7's vital signs, pain, or general presentation on 3/18/2022 until triage (53 minutes after arrival to the ED). There was no documentation Patient #7 was seen or assessed by a medical provider or was provided a medical screening examination.

5. During an interview on 8/3/2022 at 3:28 PM, the ED Director stated patients who present to the ED should be assessed using the rapid initial assessment. The ED Director stated the goal was for the triage nurse to conduct the rapid initial assessment within 10 minutes of arrival to the ED.