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Based on record review, the hospital failed to ensure that a patient who presented to the emergency department (ED) received a complete medical screening exam to determine if an emergency medical condition existed.

Review of the patient medical record by State Agency (SA) survey staff revealed that patient #17 presented to the ED on 8/17/2022 at 0408 with the chief complaint recorded as "I have cyclic vomiting."

-Nursing triage began at 0426 where the patient reported vomiting for four days, several prior visits to the ED and abdominal pain at a level of "10."

-Physician "L" conducted an initial medical screening exam at 0515. The physician documented that the patient most likely had cyclic vomiting syndrome and ordered Haldol, Pepcid, Benadryl, Zofran, K-dur and one liter of intravenous fluids to be administered. The plan as specified in the ED physician assessment was to assess the patient's response to Haldol/Benadryl and fluids. However, there is no documentation in the medical record which indicates that physician "L" or any other Qualified Medical Provider (QMP) reassessed the patient for the efficacy of treatment. A reassessment is necessary to ensure that the treatment provided stabilized the patient.

Nursing documentation of assessment and care provided to patient #17 on 8/17/2022 was also lacking:

-The physical assessment conducted by RN "M" timed 0505 on 8/17/2022 was only partially documented; the nursing review of systems lacked documentation of a gastrointestinal/genitourinary evaluation.

-The medical record lacked documentation by the nursing staff that the medications and intravenous fluids ordered by the QMP were administered to the patient and what the patient's response to the medications and fluids was. Nursing staff documented that the patient had no pain prior to discharge but did not document if the patient's nausea and vomiting had resolved.

-The patient was discharged at 0830 without reassessment to determine if an emergency medical condition existed or if patient #17 was stable for discharge.