HospitalInspections.org

A. Based on hospital policy, record review and staff interview, it was determined that in 1 of 10 Emergency Department (ED) records reviewed, the hospital failed to provide health care services in accordance with written policies.

Findings include:

1. The hospital policy titled "Medical Screening" under 5. E. b. The ED physician will do a hands-on medical screening examination of the patient and complete a physician medical screening examination record, c. All systems on the physician medical screening examination record must be addressed. Each system should be marked with a check mark, NA or WNL."

2. The ED record of Pt. #1 was reviewed on survey date 9/2/10. Pt. #1 presented to the ED on 5/19/10 with chief complaint of "back pain, lower, rated 10/10 after lifting chair." Documentation on the physician MSE (Medical Screening Examination) record failed to indicate that an assessment of the ears, eyes, nose, throat, skin, and extremities was completed. Documentation indicated these areas were blank on Pt. #1's MSE record.

3. During an interview with the Chief of Operations on 9/2/10 at 2:00 PM, the above finding was confirmed.