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Based on medical record review the facility failed to ensure an appropriate medical screening exam based on the individual's presenting symptoms was incomplete for 1 of 22 sample patients (#7) who presented to the emergency room (ED). The findings were:

Refer to A-2406 for details concerning the facility's failure to perform an appropriate medical screening examination for one patient (#7) who presented to the ED with left eye swelling, pain and ear infection.

Based on medical record review the facility failed to ensure an appropriate medical screening exam based on the individual's presenting symptoms was completed for 1 of 22 sample patients (#7) who presented to the emergency room (ED). The findings were:

1. Review of the ED record showed patient #7 arrived on 10/16/23 at 7:31 PM and the medical screening exam (MSE) was performed at 8:36 PM. There was no delay in the performance of the MSE, however there was only a limited physical exam performed. The following concerns were identified:

a. The emergency medical condition identified was conjunctivitis, blepharitis and possible early cellulitis.
b. The patient was provided ketorolac eye drops, pain medication (ibuprofen), continue antibiotic eye drops and oral antibiotic prescription by other providers, and outpatient follow-up if symptoms did not improve in 24-48 hours.
c. The patient did not receive a visual acuity nor a full physical exam.

2. Review of the patient's inpatient medical record showed the patient sought emergency services at another hospital 50 miles away on 10/18/23 and was sent back to Wyoming Medical Center and admitted as an inpatient from 10/18-10/23/23 for IV antibiotic therapy related to orbital cellulitis.