HospitalInspections.org

Based on document review, it was determined that 1 of 20 (P1) medical records reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide a complete medical screening exam.

Findings Include:

1. See findings cited at 42 CFR 489.24, A2406.

Based on document review, the facility failed to provide a complete medial screening exam (MSE) and failed to follow policy related to withdrawal of care for 1 of 20 patients. (P1)

Findings include:

1. Facility policy titled Emergency Medical Treatment and Labor Act (EMTALA) with publication date of 1/15/25 indicates on page 1 under policy statements "All patients who present to Indiana University Health for emergency care will receive a medial screening examination regardless of ability to pay." Page 3 states "If a patient withdraws their request for examination or treatment, an appropriately trained individual from the emergency department team will attempt to discuss the medical issues related to a voluntary withdrawal. In the discussion, the emergency department team member will: a. offer the patient further medical examination and treatment as may be requested to identify and stabilize an emergency medical condition; b. inform the patient of the benefits or (sic) the examination and treatment, and of the risks of withdrawal prior to receiving the examination and treatment; and c. ask the patient to sign an informed consent noting the refusal to consent to examination and treatment. If the patient refuses to sign the form, a description of risks discussed and of the examination and/or treatment that was refused shall be documented on the form and in the medical record."

2. Review of P1's MR was reviewed and indicated the patient was 38 y/o (year/old) assessed at H1's ED on 2/08/25 at approximately 12:30 pm, with diagnoses including but not limited to abdominal pain.
a. Triage documentation dated 2/8/25 at 12:30 pm indicated P1 was seen by a nurse and reported a chief complaint of right lower abdominal pain and vomiting since 2/7/25, P1 reported he/she had a history of ovarian cyst rupture(s) with two prior cesarean sections. P1 reported taking a 5 mg-325 mg Norco prior to presenting at H1's ED (Emergency Department)

b. Physician order documentation dated 2/8/25 at 12:32 pm indicated STAT orders for urinary laboratory tests. Urinalysis results indicated a large presence of hemoglobin in P1's urine and trace bacteria.

c. Vital signs documentation dated 2/8/25 at 12:34 pm indicated P1's vitals were as follows. Numerical pain reported score of 10/10. Temporal temperature of 36.1 degrees Celsius (equivalent to 96.98 degrees Fahrenheit). Respiratory rate of 19 br/min (breaths per minute). Systolic blood pressure 159 mmHg (millimeters of mercury) over 90 mmHg diastolic. Heart rate of 72 bpm (beats per minute).

d. Triage nursing documentation dated 2/8/25 at 12:34 pm indicated P1 was ambulatory upon arrival to H1's ED, had right lower quadrant pain since 2/7/25, and had an acuity score of 3.

e. Physician order documentation dated 2/8/25 at 12:59 pm indicated STAT (Immediately) provider orders for CT (Computed Tomography) of the abdominal and pelvis with contrast, CMP (Comprehensive Metabolic Panel), Magnesium, and CBC (Complete Blood Count) laboratory blood tests. At 1:09 pm a medication order for 4 mg (milligrams) of Zofran was to be given IV Push once. At 2:00 pm medication orders for 1000 mg Tylenol once by mouth, 800 mg Ibuprofen once orally, 4 mg orally disintegration Zofran once under the tongue, and 5 mg oxycodone once orally were ordered NOW. These orders were not completed prior to the patient leaving d/t (due/to) lack of bed availability in the ED. The patients pain of 10/10 was not addressed prior to leaving facility.

f. Provider note documentation dated 2/8/25 at 1:01 pm indicated P1 was given an MSE (Medical Screening Exam) by PA1 (Physician Assistant Certified). P1's screening was performed in the triage area of the ED because all ED rooms were currently housing ED patients. P1's MSE indicated P1 reported to PA1 right flank pain times one day, pain was associated with nausea and vomiting, P1 reported to Pa1 he/she trialed NORCO (Hydrocodone and Acetaminophen) without success prior to presenting to H1. P1 was alert and oriented times 3, his/her abdomen was soft, non-tender, non-distended, was without rebound tenderness, had no guarding with bowel sounds present. P1 had a normal mental status and was ambulatory with a steady gait. P1 did have right flank tenderness with a 10/10 reported pain score. Medical decision-making included orders for imaging to rule out cyst/torsion, and laboratory blood and urine tests. The most likely cause of pain was anticipated to be kidney stone based on hematuria and flank pain. P1 was placed in the ED waiting room after MSE to await an open bed. Orders were placed for imaging, bloodwork, and IV (Intravenous) anti-emetic medication.

g. Provider note documentation dated 2/8/25 at 2:03 pm indicated H1's ED did not currently have available rooms in the ED. Unfortunately, facility staff are unable to administer medications to patients in the waiting room, which PA1 discussed with P1 on initial evaluation. PA1 evaluated P1 in the triage room to expedite his/her evaluation and care. P1 and family requesting Tramadol currently; pt and family discussed with nursing staff that pain medications cannot be administered in the waiting room d/t safety concerns. Family asked if they would be seen quicker if they called 911, and discussed with nursing staff that they would still be triaged according to severity of illness. PA1 offered Tylenol, Ibuprofen, and PO (by mouth) Zofran at that time. P1 and family have left the waiting room. P1 was believed to have eloped. Upon P1's assessment,

h. ED Nursing Progress Note dated 2/8/25 at 2:27 pm indicated P1 was laying on the lobby floor screaming. Upon N1's (Registered Nurse) arrival, family of P1 asking for Tramadol to be given in the lobby. N1 explained to P1 and family that Tramadol would not be given in the lobby and would need to be given in a room when available for safety purposes. P1's family stated that the patient needed the medicine now and that the family member would call 911 to get a room in the back. P1's family member was informed there were not currently available beds in the ED at that time, P1 had already been triaged, placed in the waiting room, and would come back to the waiting room via EMS (Emergency Medical Services) if 911 was called. PA1 had previously evaluated P1 in triage, urine tests were collected and sent per provider order, and imaging was ordered. P1 greeted by PD1 (Security Officer). P1 ambulated out of the ED to car displaying a steady gait with family members to another hospital. Family member stated he/she "will be filling out the survey",

i. The medical record lacked documentation that the patient was taken to an ED room for complete MSE and further care.

j. The medical record lacked documentation that facility followed policy related to withdrawal of treatment for patient P1.