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Based on interview and record review Baylor Scott and White Orthopedic and Spine hospital failed to provide continued appropriate medical screening examination for a patient presenting with a complaint of right eye, face, neck, and arm pain. The facility instructed to go to another hospital. This failure to appropriately provide a continued medical screening examination places patients at risk of continued pain, worsening conditions, and a possible permanent decrease in functions.

Findings include:

Review of the Patient #1's medical records reflected on 2/8/21, at 10:58 a.m., a 47-year-old female presented to the hospital with a chief complaint of right eye, face, neck, and arm pain. Her symptoms began on 1/28/21, three days after she was diagnosed with COVID.

Review of Baylor Scott and White Orthopedic Hospital's (Facility #1) medical record for Patient #1, dated 2/2/2021, reflected, "Disposition: Discharged home 02/08/21 12:03:00, to home, via Pvt car w son, to be taken directly to Facility #2, EMERGENCY DEPT FOR FURTHER EVAL, son states he will take her directly there.
Limitations: Go directly to Facility #2.
Follow up with: Go directly to Facility #2 EMERGENCY DEPARTMENT directions given.
Counseled; Patient, Family, regarding diagnosis, regarding treatment plan, Patient indicated understanding of instructions, the importance of being taken directly to Facility #2 EMERGENCY DEPT FOR FURTHER EVAL, son states he will take her directly there.
Electronically Signed By: Staff #9, DO
Date and name: 02/08/21 12:20 CST

The facility failed to meet 42 CFR 489.24(a)(1)(i): The facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed

Based on interview, and record review, the facility failed to initiate an appropriate transfer for a patient (Patient #1) that presented at the facility requesting medical treatment. Baylor Scott and White Orthopedic hospital failed to provide transportation, instead the facility instructed the patient's son to drive Patient #1 directly to hospital #2; this is an inappropriate transfer. Facility #1 did not contact Facility #2 (an acute care facility) for the acceptance of the transfer and did not ensure there was available space and qualified personnel for the treatment of the individual at Facility #2.

Findings include:

Review of Baylor Scott and White Orthopedic Hospital's (Facility #1) medical record for Patient #1, dated 2/2/2021, reflected,
"Impression and Plan
Viral infection
Plan
Disposition: Discharged home 02/08/21 12:03:00, to home, via Pvt car w son, to be taken directly to Facility #2, EMERGENCY DEPT FOR FURTHER EVAL, son states he will take her directly there.
Limitations: Go directly to Facility #2.
Follow up with: Go directly to Facility #2 EMERGENCY DEPARTMENT directions given.
Counseled; Patient, Family, regarding diagnosis, regarding treatment plan, Patient indicated understanding of instructions, the importance of being taken directly to Facility #2 EMERGENCY DEPT FOR FURTHER EVAL, son states he will take her directly there.
Electronically Signed By: Staff #9, DO
Date and name: 02/08/21 12:20 CST

Addendum on February 09,2021 20:22 CST
Shortly after Patient #1 was discharged from our emergency room, I received a phone call from ER Dr at Facility #2's emergency department, stating that he had Patient #1 in the emergency room and did not have any records from us. I then told him that we did not send records because we really did not transfer her, that we only discharged her from our facility and recommended that she go to Facility #2."

During an interview, on the morning of 06/06/22, in an administrative office, Staff #1, RN stated, "Staff #9, DO told me to call Facility #2's Emergency room, the patient wanted to go to Facility #2, she said she accidentally came to this ER. Staff #9, DO discharged her, the patient said she was going to Facility #2 to establish care; they are the county hospital."