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Based on medical record review and review of grievance documentation, the facility failed to ensure an appropriate medical screening exam based on the individual's presenting symptoms was completed for 1 of 32 sample patients (#1) who presented to the emergency department (ED). The findings were:

Refer to C-2406 for details concerning the facility's failure to perform an appropriate medical screening examination for one patient (#1) who presented to the ED with signs and symptoms including dizziness, fatigue, and stumbling.

Based on medical record review and review of grievance documentation, the facility failed to ensure an appropriate medical screening exam based on the individual's presenting symptoms was completed for 1 of 32 sample patients (#1) who presented to the emergency department (ED). The findings were:

1. Review of the ED record showed patient #1 was triaged on 8/31/23 at 2:37 PM. The chief complaint was listed as dizziness, tired, fatigue, stumbling and numbness of the feet. The patient had esophageal cancer. Review of the physician's emergency department report dated 8/31/23 also showed "stumbling" was listed under the chief complaint. Further review of the physician documentation showed no evidence the patient's gait was evaluated to determine if there was a neurological deficit. Laboratory testing was done but not a CT scan. The physician's assessment was cancer-related fatigue and the patient was discharged home.

2. Review of grievance documentation provided to the surveyor on 11/8/23 showed a family member wrote a grievance letter on 10/18/23 regarding the 8/31/23 ED visit. The family member stated the patient had been feeling "not quite right" for a week and a half. The patient was tired, dizzy and sometimes would stumble. The family member stated when they went to the ED " ...we told them [s/he] had been tired, dizzy, stumbling, and a slight headache." The diagnosis was cancer fatigue. The following day the patient was still not feeling well so they went to another hospital's ED. The family member wrote " ...They did a CT scan showing a mass on the cerebellum, first thinking [s/he] had a stroke, then did a MRI which showed it was a baseball sized tumor. He was taken by ambulance to [hospital name] for surgery."