HospitalInspections.org

Based on interview and document review, the hospital failed to implement their policies and procedures for evaluation and treatment of a patient that presented for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients receive a comprehensive medical screening examination risks poor health outcomes, injury, and death.

Based on interview and document review, the hospital failed to implement its policies and procedures to perform a complete medical screening exam (MSE) in accodance with the Emergency Medical Treatment and Labor Act (EMTALA) for 1 of 29 patient records reviewed (Patient #1).

Failure to perform a complete medical screening exam places patients at risk for poor health outcomes when they are discharged before the medical screening process is completed.

Findings included:

1. Document review of the hospital policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)," last review 03/21, showed that the hospital needed to have an ongoing process in the medical records that reflected continued monitoring of the patient to ensure the patient was stable prior to discharge.

Document review of the hospital policy titled, "Emergency Department Charting," last review 03/18, showed that patients needed to have vital signs taken within 1 hour prior to discharge.

2. Document review of Patient #1's medical record showed that:

a) Patient #1 presented to the hospital on 01/19/22 at 5:07 PM, with a complaint of rectal bleeding. The hospital provided a medical screening exam by a physician. The patient was determined not to have an emergency medical condition at the time of the medical screening exam.

b) Patient #1's vital signs on arrival to the emergency department (ED) on 01/19/22 at 5:07 PM were: Blood pressure 110/73, heart rate 94, respirations 18, and oxygen saturation of 95% on room air.

c) Patient #1 was discharged on 01/19/22 at 7:01 PM from the ED. The patient did not have any discharge vitals signs documented at the time of discharge.

3. On 02/23/22 at 8:45 AM, the investigator interviewed a licensed nurse in the emergency department (ED) (Staff #1). Staff #1 stated that patients needed to have vital signs taken within 60 minutes of discharge to ensure the patient was stable for discharge.

4. On 02/23/22 at 9:45 AM, the investigator interviewed the Director of the Emergency Department (Staff #5). Staff #5 stated that vital signs needed to be taken 60 minutes prior to discharge.