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Based on review of records and interview with staff, the facility failed to ensure that an appropriate medical screening examination (MSE) to determine whether or not an emergency medical condition exists occurred for 1 of 20 patients whose records were reviewed. Patient #1 was discharged in an unstable condition following the MSE.

Findings were:

Facility policy #PCS084, entitled, ASSESSMENT/REASSESSMENT OF PATIENTS, states under Section 6(2) that "All triage assessments should be analyzed by a Registered Nurse to determine the triage acuity level according to the ENA (Emergency Nurses Association) Emergency Severity Index triage system, Levels I-V. Level I is the most severe, and is for patients who require immediate life-saving intervention. Level II is considered "Emergent," a high risk situation. Beginning with Level III, the policy indicates that any patient assigned this level would require 2 or more resources. In an interview conducted the afternoon of 9/12/11, the ED Director stated that a resource is defined as an intervention, such as IV, lab work, etc. There are no recommended number of resources assigned to the highest levels, I and II. Patient #1 was given a Level II, Emergent, status when she was admitted to the MCA ED on 8/20/2011, yet no resources were provided to the patient.

Review of the medical record for Patient #1 revealed that the patient presented to MCA ED on 8/20/11 at 5:20 pm complaining of "Chest and Headache." Complaints also included blurry vision and facial numbness. The patient's blood pressure reading was 210/115 (normal is below 140/90). The patient delivered a baby 4 days prior by C-Section at a different hospital, and had been diagnosed with high blood pressure during the pregnancy. The patient was discharged from the hospital where her delivery took place that same day, 8/20/2011.

According to nursing triage notes, Patient #1 reported not feeling well and reported headache pain as a 6 on a scale of 1-10. No other treatments or tests were ordered by the physician, Staff # 4. The physician clinical report stated that Patient #1 also complained of facial numbness and blurred vision. The patient reported to the physician that the results of an MRI at the hospital where she delivered her baby "did not make any sense" when explained to her. There was no documentation by the physician that the results of the MRI were obtained from the other hospital.

At 7:20 pm, the patient was cleared for discharge to home. According to nursing notes, at the time the patient was discharged, the family asked to speak with the physician. The physician did speak with the family at that time, however, there were no physician progress notes regarding the conversation documented in the medical record. Nursing notes indicate that the condition of the patient at discharge was "unchanged." Patient #1's blood pressure was 192/111 at the time of discharge. The patient's pain level remained 6/10. These findings in the medical record were confirmed by the facility CNO's review of the record on 9/12/2011.

A telephonic interview was conducted with the treating physician, Staff #4, at noon on 9/13/2011 in a conference room in the presence of hospital administrative staff. The physician recalled the conversation with the family, and confirmed that the conversation was not documented in the patient's medical record. The physician stated that the prescription for high blood pressure medications given to the patient at the time of discharge from the other hospital had not been filled yet and the physician thought the patient should give those a chance to work. The physician assumed the other hospital knew what they were doing when they discharged Patient #1 and they wouldn't have let her go if there was anything wrong on the MRI.

Review of other ED patient records revealed that four patients were recently seen in the ED for complaints of high blood pressure (readings lower than Patient #1). One patient was pregnant. These 4 patients all had resources provided to them such as lab work; 1 patient had a CT of the head due to headache and visual changes. Patient #1 was not provided any ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists, such as the other 4 patients were provided.

Review of Patient #1's medical record from another acute care hospital indicated that Patient #1 still felt ill after discharge to home from MCA ED on 8/20/11, left the facility and came to their hospital ED; the patient was then admitted for a 4 day stay for stabilization and treatment of high blood pressure, facial numbness, and visual changes.