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Based on review of hospital policy and procedure and closed medical record reviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

1. The hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 30 sampled patients who presented onto the hospital's property (Patient #3).

~ Cross refer to 489.24(r) and 489.24(c) Medical Screening Examination - Tag A2406.

Based on reviews of hospital policy and procedure, closed medical record review the hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 30 sampled patients who presented onto the hospital's property (Patient #3).

The findings include:

Review of the hospital's policy, "EMTALA - Medical Screening Examination/Qualified Medical Personnel", revised April 2013 revealed, "PURPOSE: To define a medical screening exam and identify who is qualified to perform the medical screening exam. PROCEDURE: I. Policy Statement Any individual who presents to a dedicated emergency department (whether on-campus or off-campus) requesting examination for a medical condition shall be provided an appropriate medical screening examination, performed by individuals qualified to perform such medical screening examinations. ...A. The medical screening examination will be conducted by qualified medical personnel. 1. The purpose of the medical screening examination is to determine whether an emergency medical condition exists...4. The medical screening examination includes a generalized assessment and a focused assessment based on the patient's chief complaint and includes monitoring of the patient until he or she is stabilized, appropriately transferred or discharged...".


Closed DED medical record review on 10/13/2015 for Patient #3 revealed a 37 year-old female who presented via ambulance on 09/13/2015 at 1828 from a group home after "falling while ambulating with her walker". Record review revealed a medical screening examination (MSE) was started by Physician's Assistant (PA) #2 at 1840 with PA #2 ordering a "lumbar spine complete - 4/5 view" and oxycodone/acetaminophen (pain medication) which was given by mouth at 1846. Review of PA #2's documented History of Present Illness (HPI) revealed, "patient presents with back pain following fall. Patient resident at group home. Per group home staff patient has been requesting Percocet or Morphine. On arrival patient screaming at top of her lungs uncooperative. No ecchymosis (bruising) noted to back. Severe spondylosis (stiffening of the spine as a result of disease) noted. No other injury reported by patient or staff. Denies LOC (loss of consciousness) or hitting head ...Occurred: just prior to arrival Severity: mild Injuries/Pain Location: back Reason for Fall: unknown Loss of Consciousness: no loss of consciousness Associated Symptoms: denies symptoms ...Past Medical History (PMI) Medical History (General): high cholesterol, seizure, other. Medical record review revealed PA #2 performed a physical assessment, with a review of systems documented as, " REVIEW OF SYSTEMS " with all systems documented as "no symptoms reported" except for "Musculoskeletal: see HPI, back pain ...Neurological/Psych: no symptoms reported, oriented, understands concepts ...PHYSICAL EXAM obese EENT (eyes, ears, nose, throat) within normal limits Head head inspection normal, no evidence of injury Eye bilateral: normal inspection, EOMI (Extraocular movements intact (muscles that control eye movement)), PERRL (pupils equal, round and reactive to light), other (no nystagmus (uncontrolled movements of the eye) no photophobia (sensitivity to light))...Neck within normal limits, full range of motion, normal inspection, normal alignment, non-tender, supple Respiratory no respiratory distress, no symptoms noted, no accessory muscle use Lungs Bilateral lungs clear Cardiac Cardiovascular/Chest: normal peripheral pulses, no symptoms noted ...Back no CVA tenderness, no vertebral tenderness, muscle spasm Extremity no calf tenderness, normal capillary refill, no evidence of injury, normal inspection, normal motor function, no edema, normal range of motion, normal sensation, non-tender Psychological belligerent, uncooperative, other (yelling screaming for Percocet and to be placed on a bed) Neurological within normal limits ...LAB/EKG/XRAY/CT Progress Note: X-ray Impression per my view of lumbar moderated degenerative disc disease chronic changes spondylosis. Nothing acute per my view...Diagnosis: fall back pain constipation Condition: IMPROVED...". Record review revealed a that Patient #3's ability to ambulate was not assessed. Medical record review revealed PA #2's assessment signed by DED MD #3 on 09/13/2015 at 2039. On 09/13/2015 at 1931 the medical record revealed that RN # 5 documented " Pt's ride from group home arrived at ED and pt is d/c (discharged) home. Pt. wheeled out in wheelchair by this RN". According to the initial history taken when Patient #3 arrived to the emergency department revealed the patient fell while ambulating with her walker. There was no documentation in the medical record to indicate Patient #"s ability to ambulate prior to discharge from the emergency department. The facility failed to ensure that an appropriate medical screening examination was completed as evidenced by failing to document Pt #3's mobility status on 9/13/2015 prior to discharge status post second fall.


Closed DED medical record review on 10/13/2015 revealed (Patient #3) returned to Hospital A's DED via ambulance on 09/15/2015 ( 2 days later) at 1300. Record revealed Patient#3 was triaged by RN #6 at 1303 with a chief complaint of " PT FROM ADULT CENTER. GENERALIZED PAIN, ASKING FOR PAIN MEDS ALL DAY. PAIN BUT CANT FEEL LEGS " . Medical record revealed that on 09/15/2015 at 1326 a MSE was started by PA #3. Disposition: Sep 15, 2015" with the decision to transfer to Hospital B with a diagnosis of "Acute Spinal Cord Injury and secondary diagnosis of pulmonary embolism" .
Closed medical record review on 10/13/2015 from Hospital B for Patient #3 revealed "Hospital Course" (Patient #3)) is a 37 yo woman ...who presented to the ED with acute paraplegia and urinary retention s/p (status/post (after)) two recent falls at her group home, most recently 3 days prior to admission. She presented as a transfer from (Hospital A) in (named location of Hospital A) ...En route, she was given ...NS (Normal Saline (salt solution)) ...and morphine. The patient was evaluated by orthopedics (the study of bones, joints, and nerves) in the ED who felt that she would require stabilization of her spinal fractures. However, given the several day duration of her symptoms, it was thought to be unlikely that she would recover any of her neurologic functions, and she would not require emergent intervention.**Acute T9-T10 fractures s/p T7-T12 open posterior stabilization: The patient underwent the above procedure on 9/16/2015 for her injuries. She recovered well after surgery and was quickly transitioned to oral pain medication. Unfortunately, the patient did not regain any of her neurologic s/p operation. She has flaccid paralysis of the bilateral lower extremities with decreased sensation below the level of the umbilicus...".