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Based on record review and interview, the hospital failed to ensure compliance with the requirements of CFR 489.24 as evidenced by failing to provide a medical screening exam on all patients that presented to the emergency department with an emergency complaint for 2 (#1, #2) of 20 patients sampled. This deficient practice is evidenced by Patient #1, and Patient #2 not receiving a medical screening exam after presenting to the ED (See findings under tag C-2406).

Based on record review and interviews, the hospital failed to maintain an accurate and complete Emergency Department Patient Log on each individual who came to the Emergency Department as evidenced by failing to document in the central log a patient who presented seeking medical attention for pain for 1 (#2) of 20 (#1-20) ED patients sampled.

Findings:

A review of the ED Log from December 2022 to present February 2023 revealed no patient information for patient #2 on 01/27/23.

Interview on 02/20/23 at 9:15 a.m. with patient #2 confirmed that he had come to the ED at hospital (a) on 01/27/23 around 5:00-6:00 p.m. He further stated that he was met in the lobby area by a nurse but could not recall her name. He stated that he explained that he was hurting in his side and thought he had a kidney stone or infection. He was told by the nurse that the hospital CT scan was not working and they could do nothing for him, he would have to go somewhere else. He further stated that he was in pain and they could have done what hospital (b) did which was start an IV for fluids and gave him pain medicine before sending him home.

Interview on 02/20/23 at 12:00 p.m. with S4RN stated that she triaged on the date in question on 01/27/23 and vaguely remembers a man and wife entering the lobby complaining of pain in his side and stated he thought he had a kidney stone. She further stated that she directed them to the clerk for information and that she would come back after and triage the patient. She stated the patient's wife requested that he get a CT scan and at that time she informed the man and his wife that the hospital's CT scan was down at that time. S4RN further stated that she would be back in a few minutes. She further stated when she returned, they were gone. She asked the clerk at the desk and was told that they left and did not give any information.

Review of the medical record from hospital (b) dated 01/27/23 at 4:28 p.m. revealed patient #2 presented to the ED and stated I'm having right flank pain. Review of CT of the abdomen and pelvis dated 01/27/23 at 5:20 p.m. revealed findings of a 25 mm cyst within the left lobe of the liver. There is otherwise normal appearance to the non-contrasted liver, adrenals, pancreas, abdominal aorta, and peri-aortic areas. There is a 6 mm stone within the mid portion of the right ureter with mild hydronephrosis of the right renal collecting system and minimal perinephric standing about the right kidney. There is a 7 mm stone and the inferior calyx of portion of the right kidney. There's a tiny 10 mm cortical cyst on the superior aspect of the left kidney. Left kidney appears otherwise normal. Diagnosis hydronephrosis with renal and ureteral calculus obstruction, calculus of ureter. Patient was treated for kidney stone and was discharged home to follow up with urologist.

Based on record review an interview, the hospital failed to ensure each individual who comes to the ED is provided an appropriate MSE within the capability of the hospital's ED to determine whether or not an EMC exists. This deficient practice was evidenced by failure to provide a MSE for a patients who present to the ED for 2 (#1, #2) of 20 (#1-#20) sampled patient's.

Findings:

Review of the hospital policy titled, EMTALA Guidelines, revised date 02/17/20, revealed in part A. All patients presenting to book in general hospitals, emergency department, seeking care, or presenting elsewhere on the hospitals, main campus and requesting emergency care, must be accepted and evaluating, regardless of the patient's ability to pay. In the absence of an actual request for services, if a prudent, layperson observer would believe, based on the individuals, appearance or behavior that the individual needs an examination or treatment for a medical condition, EMTALA still applies in the person must be excepted in evaluating for treatment.
B. All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician's office or clinic.
C. The triage of a patient for manage care contracts without a medical screening. Exam is not acceptable under EMTALA. Prior authorization may be obtained after medical screening and stabilization services are completed. This does not preclude qualified medical personnel from consulting with the patient's private physician as long as the consultation does not inappropriately delay, required medical services.

Patient #1
Review of the hospital ED Log from December 2022 to February 2023 revealed documentation on 01/30/23 at 3:15 p.m. patient #1 presented to the ED for chief complaint of fall. Patient #1 was triaged at 3:18 p.m. Documentation confirms patient #1 was assigned to the ED at 3:35 p.m. Documentation at 3:45 p.m. revealed patient left prior to medical screening. Documentation revealed patient was in triage MD explained we did not have the resources/CT at this time. Patient was referred to hospital (b) for full capability for evaluation. Patient and spouse states understanding.

Interview on 02/20/23 at 10:50 a.m. with S5Physician currently in the ED, reviewed note from patient #1's ED record and confirmed that the physician should have performed a medical screening on the patient.

Review of the medical record for patient #1 from hospital (b) revealed the patient was seen at 5:38 p.m. on 01/30/23 with a chief complaint of Altered Mental Status. CT scan on 01/30/23 showed no acute findings. Patient was admitted to the hospital overnight for urinary tract infection and was discharged on 01/31/23.

Patient #2
Interview on 02/20/23 at 9:15 a.m. with patient #2 confirmed that he had come to the ED at hospital (a) on 01/27/23 around 5:00-6:00 p.m. He further stated that he was met in the lobby area by a nurse but could not recall her name. He stated that he explained that he was hurting in his side and thought he had a kidney stone or infection. He was told by the nurse that the hospital CT scan was not working and they could do nothing for him, he would have to go somewhere else. He further stated that he was in pain and they could have done what hospital (b) did which was start an IV for fluids and gave him pain medicine before sending him home.

Review of the medical record for patient #2 from hospital (b) revealed presented to the ED on 01/27/23 at 4:28 p.m. for flank pain. Review of CT of the abdomen and pelvis dated 01/27/23 at 5:20 p.m. revealed findings of a 25 mm cyst within the left lobe of the liver. There is otherwise normal appearance to the non-contrasted liver, adrenals, pancreas, abdominal aorta, and peri-aortic areas. There is a 6 mm stone within the mid portion of the right ureter with mild hydronephrosis of the right renal collecting system and minimal perinephric standing about the right kidney. There is a 7 mm stone and the inferior calyx of portion of the right kidney. There's a tiny 10 mm cortical cyst on the superior aspect of the left kidney. Left kidney appears otherwise normal.

Diagnosis hydronephrosis with renal and ureteral calculus obstruction, calculus of ureter. At 7:20 p.m. response to treatment, the patient symptoms have remarkably improved after treatment, the patient's symptoms have resolved after treatment. Further review of discharge instructions dated 01/27/23 revealed refusal of service to patient/guardian displays, adequate decision-making capability, and despite a detailed discussion of alternatives, benefits, risk, and consequences of refusal, patient stated he would rather wait to see if he can pass his stone and then see an urologist on Monday.