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Based on record review and interview the facility failed to follow policy and EMTALA regulations by failing to provide a Medical Screening Exam in 1 of 20 patients (Pt. #1) in a sample of 20 records reviewed.

The facility failed to provide a Medical Screening Exam to a patient who presented to the Emergency Department. See Tag 2406.

Based on interview and medical record review the facility failed to provide a medical screening exam in 1 of 20 (Patient #1) in a total sample of 20 records reviewed.

Findings include:

The facility policy titled "Emergency Department Medical Screening" last reviewed 9/20/20 under Policy revealed, "...any person requesting emergency services, who presents to facility that provides emergency services must receive a medical screening exam (MSE). The purpose of the MSE is to identify whether an emergency medical condition exists (EMTALA)(Emergency Medical Treatment and Active Labor Act)...this has been delegated to the ER (Emergency Room) Registered Nurse by the medical staff. See bylaw... the RN completing the medical screen will assess document blood pressure, heart rate, respiratory rate, temperature, present illness of injury, severity of symptoms, possibility of labor, past medical history, present medications, allergies."

On 8/3/2021 at 11:30 AM in interview with Pt. (patient) #1, Pt. #1 stated that she presented to the ED (Emergency Department) at approximately 8:00 PM with complaints of neck pain from an ATV (all terrain vehicle) accident. Pt. #1 stated that she entered the ED and was told by an individual wearing a name badge that the CT (Computed Tomography--a type of digital X-ray scan) scanner was down and suggested that she seek treatment elsewhere. There is no entry in the ED log for Pt. #1. Pt. #1 was not offered or given a MSE.

Review of Pt. #1's medical record from the receiving hospital (Hospital #2) revealed "Date of Service: 7/25/2021 8:37 PM." The Health Care Provider note from Hospital #2 dictated at 9:25 PM revealed, "History of Present Illness: Patient arrives via private vehicle after she was told by the Shell Lake Emergency Room (Hospital #1) to go to Spooner since they did not have a CT scanner...Physical Exam...Patient is collared ( wearing a cervical neck collar which was applied by Hospital #2) and complains of posterior occipital head pain as well as stiffness in her entire neck..." Further review of the record from Hospital #2 revealed a CT scan was performed with "no significant findingss." Pt. #1 was given an injection of pain medications and discharged to home at 9:35 PM.

Hospital #2 is approximately 8 miles from Hospital #1.

On 8/3/2021 at 2:00 PM in interview with ED Manager C. ED Manager C stated that anyone who comes to the ED should be registered and given a MSE. "It appears that this didn't happen with this patient."