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Based on document review and interviews, the facility failed to comply with the requirements for 489.24 and the related requirements of 489.20.

Findings:

-- Please see specific findings under A2406.

Based on findings from medical record (MR) reviews and interviews, in 2 of 23 MRs reviewed, the medical screening exam (MSE) for two patients (Patient #1 and Patient #2) did not provide stabilizing treatment and resulted in discharge of patients in unstable condition.

Findings include:

-- Per review of Patient #1's MR, 47 year old male patient presented to the emergency department (ED) with a chief complaint of a fall which occurred approximately 12 hours prior to presentation. The patient indicated a previous diagnosis of chronic back pain and the injury made it worse. Patient also complained of right knee pain due to twisting it in the fall.

Patient #1's triage vital signs (VSs) were temperature (T) - 100.2 (tympanic), pulse (P)-111 respirations (R) - 20, and blood pressure (BP) - 171/100, the patient's weight was 170.1 kg (375 lbs) and 6 feet in height.

At 0216 Physician Assistant (PA) #1 evaluated the patient. The clinical impression was low back pain acute. The patient was discharged at 0234 with a prescription for oral Percocet 5/325 miligram (mg) and Flexeril 10 mg . Follow up instructions indicated he was to call and arrange an appointment with his private physician to recheck today's complaints and continuance of care.

At 0250, Flexeril 10 mg and Percocet 5/325 mg were administered orally. Documentation indicates at 0255 nursing assessment indicated the patient appeared distressed and complained of pain in the left and right low back and right knee with a pain of 10 out of 10 (10 being the most acute).

At 0259 the patient left the ED.

Patient #1 was discharged with an elevated BP and unresolved pain.

-- Per interview on 11/20/13 at 07:30 a.m. with PA #1, he/she evaluated Patient #1 and there were no significant findings.

- Per review of Patient #2's MR, 45 year old male presented to the ED with complaint of back pain. He was referred from the local military base infirmary. At 1121 his VSs were BP- 157/95, P- 50, R - 18, oral T of 97.2 and reported pain of 6 out of 10. Prior to his ED presentation he had visited the infirmary at the military base and received an injection of Morphine and Toradol, he had also taken Flexeril and Tylenol. No routine medications are documented.

At 1203, PA #2, documented the patient indicated the pain had started that morning after getting up off the couch. He felt a crunching and 2 pops and was unable to stand up straight. He complained of intermittent numbness. PA #2 documented the patient's past history included myocardial infarct (MI) x 2, vertigo, and migraines. The clinical impression was chronic low back pain with acute exacerbation. The patient was discharged with prescriptions for Flexeril 10 mg oral and Percocet 5/325 mg oral, with instruction to follow up with the military base infirmary tomorrow and to return to ED if condition worsens.

At 1251, he was medicated for pain with intravenous Dilaudid-Hydromorphone 0.5 mg and Valium 2 mg.

At 1330, the patient states symptoms have not improved, he ambulated 40 feet to nurse station with one stop and it was documented he did not ambulate well without assist.

At 1408, his BP was 167/107 and pain was 5/10.

At 1417, the patient left the ED.

Patient #2 was discharged with difficulty ambulating, elevated BP and with unresolved pain.

-- Per interview on 11/20/13 at 10:00 a.m. with attending ED physician #2, the elevated BP of 167/107 is attributable to pain and would not address in the ED.