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Based on document review and interview, the facility failed to provide a medical screening exam for 1 of 26 patients (patient #2).


Findings Include:

1. See findings cited at 42 CFR 489.24, A2406.

Based on document review and interview, the facility failed to provide a medical screening exam for 1 of 26 patients (patient #2).

Findings include;

1. Facility policy titled, Triage of Emergency Department Patients, last revised 09/24, indicates on page 3 of 5: VI. A medical screening examination (MSE) will be completed by a physician, physician assistant, nurse practitioner or nurse (only on SANE cases), on all patients that present to the Emergency Department.

2. Review of medical records indicated patient #2 arrived in the emergency department (ED) at 5:42 p.m. on 03/04/2025. The patient's arrival complaint was shaking, chemo patient and shortness of breath with info under comment indicating patient to ED via wheelchair, patient was seen then this am, spouse stated they got home this afternoon and he/she started shaking and crying, patient is having tremors in left leg and left hand. The patient was taken to triage at 6:01 p.m. and assessed by S1 (Registered Nurse). Patient was assigned an emergency severity index (ESI) of 3 after assessment and was taken to the ED waiting room. The MR indicated the patient left without being seen at 7:43 p.m. The medical record lacked a medical screening exam.

3. Interview with S1 on 03/17/2025 at approximately 3:50 p.m. confirmed they were staffing the ED triage on 03/04/2025 and indicated they recalled several patients. S1 indicated they had cared for patient 2 early in the day and in the triage later in the day. S1 confirmed patient 2 was experiencing some tremors in their extremity and indicated patients had to wait in the ED waiting room after being triaged.