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Based on review of facility policy, medical record review, and interviews, the facility failed to ensure an appropriate medical screening examination for 1 patient (#1) who presented to the Emergency Department with abdominal pain of 33 records reviewed.

The findings included:

Patient #1 was admitted on 5/17/2023 at 3:17 PM to the Emergency Department (ED) with complaints of abdominal pain. The patient was triaged with an Emergency Severity Index (ESI) score of a 3 indicating urgent needs. She described her pain as an achy, burning pain and reported her pain score of 10/10. A medical screening examination was initiated by the ED Physician at 3:30 PM where an examination was performed, and diagnostic testing was completed. The patient's husband became upset related to the patient had not received pain medications. The ED staff and ED Physician had spoken with the patient and the husband regarding no acute findings and the diagnoses of Gastroenteritis and constipation. The patient left the ED at 6:08 PM (2 hours and 43 minutes after arrival) where the patient refused to sign the discharge paperwork. On 5/18/2023 (1 day after discharge at Facility A) patient presented to Facility B with complaints of abdominal pain. The Gastrointestinal (GI) workup was completed and during the patient's admission a HIDA (Hepatobiliary Iminodiacetic Acid) scan (scan to diagnose gallbladder, bile ducts or liver concerns) was performed which showed gallbladder function less than 25%.

Refer to A-2406

Based on review of facility policy, medical record review, and interviews, the facility failed to provide an appropriate and ongoing Medical Screening Examination (MSE) for 1 patient (#1) who presented to the Emergency Department (ED) of 33 records reviewed.

The findings included:

Review of facility policy, Emergency Medical Treatment and Patient Transfers, last revised 3/18/2017, showed "...medical screening examination; when an individual comes to the Emergency Department of the hospital...for a medical screening examination or treatment, an appropriate medical screening examination, within the capabilities of the emergency department...shall be provided to determine whether an emergency medical condition exist...it must be remembered that a medical screening examination goes beyond initial triage...a medical screening examination is not an isolated event, it is an ongoing process. The record must reflect continued monitoring according to the patient's needs and must continue until the completion of stabilizing treatment and the patient is discharged, admitted, or appropriately transferred..."

Medical record review of an ED Nursing Triage record dated 5/17/2023 at 3:32 PM showed Patient #1 presented to the ED with complaints of abdominal pain located in the center of the abdomen. The pain started the morning of 5/17/2023. The patient had previous history of ulcers and a umbilical hernia. The patient described her pain as a 10/10 indicating severe pain. She was triaged with an Emergency Severity Index (ESI) score of a 3 indicating urgent needs.

Medical record review of an ED Physicians record dated 5/17/2023 at 3:30 PM showed the patient presented with abdominal pain, nausea, and constipation. Her pain was located to the entire abdominal area described as a dull, crampy type pain. Her physical examination showed abdominal tenderness, normal bowel sounds to all four quadrants with no peritoneal signs. Diagnostic testing included the following: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Lactic Acid, Amylase, Lipase, Magnesium, and a Computed Tomography (CT) of the abdomen and pelvis.

There was no further diagnostic testing to determine the cause of the patient's acute abdominal pain and the patient's pain was not addressed.

Medical record review of the ED Nursing documentation dated 5/17/2023 at 6:08 PM showed the patient was discharged home. The patient left the ED and refused to sign the discharge instructions which was witnessed by two ED Nurses.

Medical record review of an ED Physicians record dated 5/17/2023 at 8:50 PM showed the patient's diagnoses included acute Gastroenteritis (a common disease syndrome, causing a combination of nausea, vomiting, diarrhea, and abdominal pain) with constipation (occurs when your bowel movements become less frequent and stools become difficult to pass).

There was no documentation of the patient's pain being addressed or further diagnostic testing to determine the cause of the pain or cardiac evaluation.

Medical record review showed the patient presented to Facility B on 5/18/2023 (1 day after discharge from [Facility A] at 1:40 PM. She was evaluated and admitted to the facility. She was diagnosed with epigastric pain and an abnormal EKG (electrocardiogram records electrical signal from the heart to check for different heart conditions) changes. Patient #1 was admitted with diagnoses including the following: Chest Pain, etiology unclear where cardiology was consulted; Epigastric Pain with history of hiatal hernia and esophagitis (inflammation of the esophagus) and GI (gastrointestinal) was consulted; Abnormal EKG; abdominal pain, hypertension; Fibromyalgia (widespread chronic pain, fatigue, cognitive symptoms) and COPD.

Medical record review of a GI consult dated 5/19/2023 at 12:55 PM showed the patient had a 6 month history of upper abdominal pain with reported weight loss. The consult showed "...doubt her persistent symptoms are due to peptic ulcer...concerned with possibility of chronic cholecystitis (inflammation of the gallbladder) and recommend HIDA (Hepatobiliary Iminodiacetic Acid) scan (scan to diagnose problems with the liver, spleen, and gallbladder)...."

Medical record review of a Surgery Consult dated 5/22/2023 at 2:10 PM showed the patient's HIDA scan showed a gallbladder ejection fraction of 25% and surgery was consulted for consideration of laparoscopic cholecystectomy (gallbladder removal). The plan of care was discussed with the patient and the patient could be discharged home after the procedure if no complications.

Medical record review of an Operative Report dated 5/22/2023 at 3:14 PM showed a laparoscopic cholecystectomy was performed with no complications.

During an interview on 6/6/2023 at 2:55 PM, ED Physician #1 stated he evaluated the patient on 5/17/2023 when the patient arrived with complaints of abdominal pain. The patient was awake, alert, and oriented and her pain appeared to wax and wane. Diagnostic testing was ordered and completed which included a CBC, CMP, Lipase, Amylase, Magnesium, Lactic Acid, and a CT of the abdomen and pelvis. The diagnostic tests showed no acute findings and there were no gallbladder concerns identified. The patient's husband had concerns and was upset related the patient had not received pain medications. Physician #1 stated "...I tried to explain to him with abdominal pain, we do not normally give pain medications which may mask symptoms should there be anything acute going on. I told them I would check the results and discuss the results with him, but he and the patient started yelling and stated they were leaving and refused to wait. I did not see any acute findings on the CT results..." An ultrasound of the gallbladder was not performed and the patient was not given pain medications.

During an interview on 6/6/2023 at 3:00 PM, Registered Nurse (RN) #1 stated the patient came in with abdominal pain. She stated "...when she arrived in the ED, she stated she needed Percocet [pain medication] for her pain, and I had told her the ED Physician would see her and he would make the decision related to the treatment plan. About an hour later, the patient's husband came to the desk and was yelling at us and demanding to see the ED physician. I told him [Physician #1] was off the unit at that time and he would be right back, but he continued to yell and was demanding. He kept yelling and was upset the patient had not been given any pain meds. I tried to explain to him that we did not give pain meds with abdominal pain in case there was something acute going on. [Physician #1] spoke with him and told him he would look at the CT and discuss the results with he and his wife. The patient's husband stated they were leaving and told us to take the IV out. He stated they were gong to a 'real hospital' where they could get pain meds..."

During an interview on 6/6/2023 at 3:10 PM, Licensed Practical Nurse (LPN) #1 stated the patient and her husband were yelling and demanded the patient's IV be removed. The patient had requested Percocet for pain and stated that was the only thing that worked for her except IV pain medications. The patient refused to sign the discharge paperwork and stated they were going to "...real hospital where they could see a real doctor..."

During a telephone interview on 6/6/2023 at 7:30 PM, the complainant stated "...my wife was in terrible pain and they did not even offer her any pain meds. They did labs and a CT scan and we waited 3 hours and waited to see the doctor...he [Physician #1] said she had mild constipation. I told them I was taking her somewhere else where they would do something for my wife and we left..." The patient was taken to [Facility B] the next day [5/18/2023] and the patient was admitted. The patient was told "...something was wrong with her heart and kept her there for 6 days. She had to have her gallbladder removed..." The patient stated she had right sided pain and her pain was '10+' when she went to the ED and they [Facility A] did not offer her any pain medications.