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Based on document review and interview, the facility failed to complete a medical screening exam for 1 of 20 medical records reviewed. (patient #1)

Findings Include:

See findings cited at A2406.

Based on document review and interview, the facility failed to conduct a medical screening exam (MSE) within their capabilities for 1 of 20 medical records reviewed (patient #1).

Findings include;

1. Facility policy titled EMTALA last reviewed 10/22 indicates on page 5 under policy that a MSE will be conducted to determine whether the patient has an EMC (emergency medical condition). The hospital will conduct a consistent MSE, in a non-discriminatory manner, for all patients with similar medical conditions.

2. Review of medical record (MR) for patient #1 indicated the following:
He/she presented to the facility at 0957 on 11/29/23 with cognitive changes and concern of urinary retention after a recent surgery. A review of a late entry provider note dated 12/1/23 at 1951 hours by MD1 (Doctor of Osteopathic Medicine/Emergency Medicine) indicated the following: "I was notified by (MD3/Doctor of Medicine/Family Practice Physician) that (he/she) saw the patient in the office for a follow-up visit. (He/She) noticed that the patient had some mental status changes that might be related to (his/her) recent urological surgery. (MD3) informed me that (he/she) recommended the patient follow-up with (MD4/Doctor of Medicine/Urologist), however the patient and (his/her family member) insisted on coming to (Facility #1's) ER (Emergency Room). Upon arrival the patient and (his/her family member) were brought to the triage room to discuss the concern. (Patient #1's family member) informed me that the patient had recent surgery by (MD4), and there was concern of (him/her) retaining urine. I informed (Patient #1's family Member) that we were happy to evaluate the patient however (he/she) has required urological intervention by (MD4) in the past and would eventually need to be transferred after initial evaluation here in the department. (Patient #1's family member) informed me that (he/she) preferred to take the patient directly to (Facility #2's) ER, which is close to (MD4's) office, such that all the records for the patient would be in 1 place and (he/she) would not have to wait for transfer. ...No physical exam was performed at this time due to the patient's decision to go to (Facility #2)."

2. The MR lacked a medical screening exam to determine if an EMC existed or that the patient/family were provided the risk and benefits of leaving without being evaluated.

4. Review of patient #1's medical record from Facility #2 indicated the following:
A review of Patient #1's Emergency Room Physician Note dated on 11/29/23 at 10:48 p.m. indicated that Patient #1 was seen by a provider at Facility #2 on 11/29/23 at 6:47 p.m. and was brought in by Patient #1's family member for altered mental status times three days. Patient #1's family member brought the patient to (his/her) primary provider in (City #3) who advised him/her to go to the ED. Patient #1 was unable to provide history (himself/herself), therefore Patient #1's family member provides the history. Patient #1's family member states that patient developed upper respiratory infection symptoms around Thanksgiving of body aches, chills, and a cough. Patient's family member states that everytime the patient gets sick with these type of symptoms (he/she) has altered mental status. Patient #1 has dry mucous membranes and unable to speak in coherent sentences. " Medical Decision Making ...Hospitalist has agreed to accept patient overnight for observation of altered mental status and UTI (urinary tract infection). Condition: Stable. Disposition: Admit."

5. During an interview with MD1 on 1/12/24 at 10:05 a.m, MD1 verified that there was no medical screening examination and/or diagnostic testing completed on Patient #1 because Patient #1's family member made the decision to take Patient #1 to Facility #2 to see MD4.