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Based on record review, patient interview, staff interview, physician interview, document review and policy review the facility failed to provide Patient #19, one (1) of 20 patients reviewed, an appropriate medical screening within the capability of the hospital's emergency department to determine if an emergency medical condition existed.


Findings include:


Cross Refer to A-2406 for the facility's failure to provide an appropriate medical screening within the capability of the hospital for Patient # 19.

Based on record review, patient interview, staff interview, physician interview, document review and policy review, the hospital failed to provide an appropriate medical screening within the capability of the hospital's emergency department to determine if an emergency medical condition existed for Patient #19, one (1) of 20 patients reviewed.


Findings include:


Review of the undated policy "(Hospital #1) The Relationship of the Emergency Department" revealed: "The Emergency Department physician is responsible for the degree of evaluation and treatment provided to any patient who presents himself or is brought to the emergency department. The emergency department is open 24 hours a day. ..." "Admit Protocol for Emergency Department Patients - Any patient who presents to the Emergency Department with a complaint is to be sent directly into the Triage room and triaged. According to symptoms patients are classified ... emergent, urgent, and non-urgent classifications. In the case of any patient, the hospital will provide within the facilities capabilities medical examination and such treatment that may be required to stabilize the medical emergency or to provide appropriate treatment to the patient...."


Review of the undated policy "(Hospital #1) Policy and Procedures for Evaluation, Treatment, and Transfer of Individuals with Emergency Conditions" revealed:
"I. Policy - A. It is the policy of this Hospital: (1) to provide a screening examination by a qualified medical person to any individual who comes to the emergency department seeking an examination or medical treatment (whether or not eligible for insurance benefits and regardless of ability to pay) to determine if the individual has an emergency medical condition; and (2) if it is determined that the individual has an emergency medical condition, to provide the individual with such further medical examination and treatment as required to stabilize the medical condition, within the capability of the Hospital, or to arrange for transfer of the individual to another medical facility in accordance with the procedure set forth below. The Hospital shall not delay the provision of a screening examination, further medical examination and treatment, or appropriate transfer in order to inquire about the individual's method of payment or insurance status.... III. Procedures - A. Medical Screening Examination - 1. The Hospital shall provide a screening examination for every person who comes to the emergency department and makes a request for examination or treatment of an Emergency Medical Condition. The medical screening examination shall be done by a physician or qualified medical person as defined in the policies, Section II, E. In no circumstances shall a Medical Screening Exam be conducted by a Registered Nurse or Licensed Practical Nurse without the involvement of a physician, since the Mississippi Nursing Board views this as beyond the scope of the license of both of those categories. A certified nurse practitioner may perform the medical screening exam... 3. The nature of the examination should be sufficient to determine with reasonable clinical confidence whether or not the patient has an Emergency Medical Condition."


Review of the hospital's policy "Subject: Triage" (revision date 04/11/05) revealed: "Policy: It is the policy of (Hospital #1 ) to provide emergency care to all patients who are in need. All patients who present to (Hospital #1) Emergency Department requesting a Medical Screening exam by a physician prior to providing demography and financial information. All patients will be considered patients once the ER staff is aware of their presence."
"Purpose: The purpose of immediate triage and Medical Screening is to determine the presence of an Emergency Medical Condition (EMC) in all patients who present to (Name of Hospital) for any condition."
"Goal: The goal of the triage process is to provide immediate triage for all individuals arriving at (Hospital #1) Emergency Department seeking treatment...."


Record review revealed Patient #19 arrived at (Hospital #1) ED (Emergency Department) on 02/04/13 at approximately 18:45 (6:45 p.m.) with complaint "Fell on her left arm today at 1730 (5:30 p.m., pt (patient) c/o (complained of) can't move L (left) arm." Further review of the medical record revealed there was documentation by the ED physician that "MSE (medical screening examination) complete." There was no documented evidence of a medical screening examination by the ED physician for Patient #19 on 02/14/2013. The facility failed to ensure that an appropriate medical screening examination was performed that was within the capability of the ED to determine if an EMC existed for Patient #19 on 02/04/2013.


Record review revealed that Patient #19 arrived at Hospital #2's ED on 02/04/13 at 2215 (10:15 p.m.) via ambulance with chief complaint of injury/pain to "left wrist, forearm, elbow, arm and shoulder". She was triaged as a "Level 4" (with 1 being the lowest and 5 the highest level). X-rays were performed of left upper arm, left forearm, left wrist, left shoulder and left elbow. All X-rays were negative for "acute osseous injury". At 2335 (11:35 p.m.) The ED physician ordered and Patient #19 was given "Lortab 5 mg (milligram) po (by mouth) for pain" with an "improved" response. At 2350 (11:50 p.m.) Patient #19 was discharged home from Hospital #2's ED with a left wrist splint with thumb abducted and a sling to her left arm. She was given prescriptions for" Lortab Tablet (Oral) 5-500mg 1 (one) tab every 4 (four) hours PRN (as needed) moderate to severe pain" and "Naprosyn Tablet (oral) 375mg 1 (one) tab 3 (three) times a day PRN". She was also given instructions regarding the need for a follow-up visit with an orthopedic doctor for follow-up xrays due to the possibility of stress fractures.


Interview with Patient #19 on 02/12/13 between 12:15 p.m. and 12:30 p.m. revealed that she told the RN (Registered Nurse) upon arrival to (Hospital #1's) ED that she fell on her arm and couldn't move it well. The patient stated that she was asked some questions in the lobby by the nurse and that she told the nurse that her arm hurt. The patient stated that she was not asked about the pain on a scale of zero (0) to ten (10) and that a physician did not examine her arm. She stated that at approximately 7:05 p.m., after the physician told her that she needed to be seen by the school nurse, she left the ED without receiving a medical examination by the physician. She returned to her college dorm room that same evening (02/04/13) at approximately 8:00 p.m. After her return from Hospital #1 she called for an ambulance. The (Fire and Rescue Department) also responded to the call. They placed a splint on her arm and transported her by ambulance to Hospital #2 in a nearby state. She was treated there and returned back to the dorm with her Dad.



On 02/12/13 between 1:45 p.m. and 2:00 p.m. Hospital #1's ED physician, who documented that a medical screening exam was performed, stated in an interview, "Not all patients have a medical screening exam. They come in and are triaged by the RN. The physician is always given the paperwork and the patient observed. In this case the patient was seen outside in the parking lot moving her arms freely." This interview verified that an appropriate medical screening examination was not conducted by the ED physician for Patient #19 on 02/04/2013.


In a telephone interview on 02/13/13 at 2:30 p.m., an employee of the local ambulance service stated that when the student called for the ambulance, the fire department responded. He stated that one (1) of the ambulance employees had placed a splint on the patient's arm before the fire department arrived. An ice pack was placed on her left wrist. The patient told them that she had "tolerable pain with movement." The ambulance service employee stated that upon examination by him, "her fingers were very tender, even to the light touch."