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Based on record review and interview, the facility failed to ensure the medical record for 1 (Patient #21) of 25 (Patient #1-#25) records reviewed contained information to support the diagnoses to aid in decision making on the provision of care for the patient. Failure to provide information to support the diagnosis caused a delay in diagnoses and medical treatment for Patient #21 and had the likelihood to affect all patients presenting to the Emergency Department. Findings follow:

A. Review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act)," with a Revised date of 10/04/22 showed the following:
1) Medical Screening Exam (MSE) means the screening process required to determine with reasonable clinical confidence whether an EMC (Emergency Medical Condition) does or does not exist. Depending on the patients presenting symptoms, the MSE represents a spectrum ranging from a process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures within the capability of the hospital. A Physician or QMP (Qualified Medical Professional) must perform the MSE to determine if an EMC exists.
2)The MSE must be appropriate to the patient's presenting complaint and symptoms, and the medical history of the patient.
B. Review of Patient #21's clinical record showed the following:
1) An incident report dated 10/14/24 at 11:01 PM showed Pts (Patients) wife requested help moving pt (patient) from car into ED (Emergency Department). A wheelchair was offered.
2) Triage Notes on 10/14/24 at 11:10 PM showed the patient presented to the ED for evaluation of left knee pain and swelling, pt (patient) states he fell down 4 stairs. Reported a pain level of 8 on a 1-10 scale in the left knee. Was oriented, vital signs showed a blood pressure of 193/86. He was assigned an ESI (Emergency Severity level) level 4.
3) An ED summary dated 10/14/24 showed time seen by provider was 10/14/24 at 11:16 PM.
4) An ED Extremity Injury Assessment showed Left knee injury from fall with associated swelling and pain. Can raise extremity but not against resistance.
5) The ED MAR (medication administration record) showed Morphine Sulfate 2 mg/mL (milligrams per milliliter) inj (injection) 2 mg administered IV (intravenous) at 12:00 AM. Pain at 1:00 AM at 8, aching and constant. Hydrocodone/Acetaminophen 5-325 mg 2 tablets PO (by mouth) given at 1:51 AM, pain level at 8, aching and constant.
6) An ED Physician History and Physical showed, "History of present illness narrative 57-year-old African American male who came to the ER (Emergency Room) in the company of the wife because of pain in the left knee. Pain started after patient missing a step while using the stairway, and twisting the affected knee. He essentially fell from about 4 steps of the stairway. He reports an inability to put weight on the knee thereafter. He feels pain in the medial aspect of the knee. No obvious popping or crackling feeling in knee."
7) ED Physician Physical exam showed, "In apparent mild to moderate pain distress. Unable to put any weight on the affected left knee or ambulate. Left knee exam reveals apparently normal-looking knee."
8) ED Physician Radiology orders dated 10/14/24 at 11:28 PM, showed, XR (xray) knee RT (right) 3V (views) stat (immediately).
9) ED provider interpretation showed, "Review of the right knee personally viewed by me, and he reveals about a normal looking knee joint with no obvious bony deformities or fractures or dislocations."
10) The radiology report dated 10/14/24 showed "Order XR knee RT 3V reason for exam: knee injury and pain Impression: No acute fracture or dislocation. Mild to moderate osteoarthritis of the knee."
C. On 12/09/24 at 3:00 PM the findings in B were reviewed and confirmed via phone call with the Emergency Department Director and the Chief Nursing Officer. The Emergency Department Director confirmed there were no other radiology reports on file for Patient #21. They were asked if the Physician had ordered the test for the wrong knee? The ED Director said, "It looks like it."