HospitalInspections.org

A. Based on a review of Hospital policy and procedure, a review of internal documentation, medical record review and staff interview, it was determined in 1 of 21 (Pt #1) medical records reviewed, the Critical Access Hospital (CAH) failed to ensure compliance with CFR 489.24.

Findings include:

1. The Hospital failed to ensure that Medical Screening Examinations were performed by physicians as required by the Hospital policy and procedure in 1 of 21 (Pt. #1) medical records reviewed..

See deficiency cited at CFR 489.24 (a) (l) (i), A 2406

A. Based on a review of Hospital policy and procedure, a review of the Emergency Department Log, medical record review and staff interview, it was determined that in 1 of 21 (Pt #1) medical records reviewed, the Hospital failed to ensure that every individual presenting to the Emergency Department was provided an appropriate medical screening examination.

Findings include:

1. The Hospital policy and procedure titled, "Triage and Medical Screening of Emergency Department Patients" was reviewed on 11/15/10. It indicated under, "Responsibilities: Emergency Department Nursing Staff, Emergency Department Physician..." Also, under, "Procedure: #1. Each patient presenting to the Hospital seeking medical care will be sent to the Emergency Department for triage and a medical screening."

2. The Emergency Department Log was reviewed on 11/15/10. It indicated on 10/11/10 at 2000, a "white infant female" (Pt #1) accompanied with the mother presented to the Emergency Department with a complaint of "Cough and Vomiting." The log indicated that Pt #1 was a LWBS (Left Without Being Seen), stating that the mother "wanted to go to Mt. Vernon." There was no documentation, i.e. a completed medical record, to indicate that Pt #1 had been sent to triage or had a medical screening examination. The medical record of Pt. #1 from Good Samaritan Hospital in Mt. Vernon was reviewed on 11/15/10. Documentation indicated that Pt. #1 arrived by ambulance on 10/11/10, carried by mother with chief complaint as "shortness of breath". Documentation indicated that Pt. #1 received several tests and was discharged in "Improved condition at 2215 with a discharge diagnosis of "Airway Obstruction-Resolved".

3. During an interview conducted on 11/15/10 at 10:40 AM with the Chief Executive Officer, it was determined that the mother of the infant had called him directly after the incident on 10/18/10. He stated that the mother brought the infant directly into the Emergency Department and spoke with 2 nurses and a physician, and voiced Pt #1's symptoms. The CEO stated that the mother was told by the physician that there was nothing that the Hospital could do for her. He stated that the mother went outside and across the street and called 911 for an ambulance to take the infant to another facility. The CEO indicated that the infant was treated by another Hospital.

4. During an interview conducted on 11/15/10 at 11:00 AM, the above findings were confirmed.