HospitalInspections.org

Based on record review, hospital policy and staff interviews, it was determined the hospital failed to comply with all Emergency Medical Treatment and Labor Act requirements. Specifically, the hospital failed to provide Patient #1 with an appropriate Medical Screening Exam (MSE) for her presenting signs and symptoms, and failed to provide Patient #17 with the medical risks verses benefits of leaving the Emergency Department (ED) prior to completion of stabilizing treatment. This affected two of 20 medical records reviewed.

Findings Include:

Based on facility staff interviews, medical record reviews, policy and procedure review, the facility failed to provide an appropriate medical screening exam (MSE) to Patient #1 who presented to the Emergency Department seeking an evaluation for vaginal bleeding with abdominal pain and cramping. This affected one of 20 sampled patients.


Cross Refer to A2406.

Based on medical record review and interview, the hospital failed to document attempts to explain the risks verses benefits of leaving the facility before completion of medical treatment for an identified emergency medical condition. This affected one (Patient #17) of 20 medical records reviewed.

Cross Refer to A2407.

During exit conference with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and Chief Financial Officer (CFO) on 10/31/2024 at 1:45 p.m., survey findings were discussed, no further documents were submitted for review.

Based on facility staff interviews, medical record reviews, policy and procedure review, the facility failed to provide an appropriate medical screening exam (MSE) to Patient #1 who presented to the Emergency Department seeking an evaluation for vaginal bleeding with abdominal pain and cramping. This affected one of 20 sampled patients.

Findings Include:

Review of Patient #l's medical record revealed Patient #1 presented at the Emergency Department (ED) on 09/14/2024 at 10:43 p.m. with complaint of abdominal pain for one (1) week with cramping, positive home pregnancy test, last menstrual period August 4, 2024, home pregnancy test now negative. Medical record review revealed at 10:49 p.m. a triage assessment with blood pressure (B/P) 130/75; pulse 120; respirations 20; oral temperature 98.9 Fahrenheit; pain level of two (2) on a scale of zero (0) to ten (10) with Zero (0) being no pain and 10 the worse pain; triage acuity level four (4).

A Medical Screening Exam (MSE) was initiated at 10:47 p.m. However, the MSE failed to document an assessment of Patient #1's abdominal cramping, the presence or absence of tenderness, rebound or guarding.

Patient #1 was discharged on 09/1412024 at 11:09 p.m.

Review of the facility's policy, "EMTALA Compliance: Medical Screening Examination to Rule Out an Emergent Medical Condition", dated 05/2024, " ...to define the Medical Screening Examination process to rule out an emergency medical condition ...part of the Medicare Conditions of Participation, hospitals must abide by the EMTALA Law ...Triage ...Medical Screening Exam ...General Triage Process ...Triage Levels ...".

Review of the facility's policy, "Triage Assessment/Reassessment", dated 04/24/2024, " ...Triage ...Triage Acuity ...Level 1 (Resuscitation) ...Level 2 (Emergent) ...Level 3 (Urgent) ...Level 4 (Less/Semi Urgent) ...Level 5 (Non-urgent) ...". Medical Screening Examination (MSE): The process required to reach, with reasonable clinical confidence ...determined whether an emergency medical condition does or does not exist ...".

During exit conference with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and Chief Financial Officer (CFO) on 10/31/2024 at 1:45 p.m., survey findings were discussed, no further documents were submitted for review.

Based on medical record review and interview, the hospital failed to document attempts to explain the risks verses benefits of leaving the facility before completion of medical treatment for an identified emergency medical condition. This affected one (Patient #17) of 20 medical records reviewed.

Findings Include:

Review of the medical record for Patient #'17 revealed the patient presented to the Emergency Department (ED) on 05/19/2024 at 8:46 p.m. with a complaint of shortness of breath that started several days ago with a cough and sore throat. Patient was triaged at 8:53 p.m. Vital signs: Temperature 98 degrees Fahrenheit; Pulse 109; Respirations 18; blood pressure 128/73, saturation of peripheral oxygen (SPO2) 95 percent (%), pain assessment four (4) on a scale of zero (0) to ten (10) with Zero (0) being no pain and 10 the worse pain; Patient #17 was assigned a triage acuity level of three (3) (urgent). Nurse Practitioner started MSE at 8:53 p.m., chest X-rays ordered and ipratropium-albuterol (DUO-NEB) 0.5 - 2.5 milligrams (mg) per three (3) milliliters nebulizer solution. Bilateral breath sounds diminished, breathing treatment started at 9:01 p.m. by respiratory therapist.

Patient left during breathing treatment, stating "really just wanted a ride back to house." No documented evidence the facility staff attempting to explain the risks verses the benefits of leaving the facility before medical treatment was completed.

No policy and procedure provided to document process to obtain or attempt to obtain written and informed refusal of examination, treatment or an appropriate transfer in the case of an individual who leaves without completing treatment.

During exit conference with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and Chief Financial Officer (CFO) on 1013112024 at 1:45 p.m., survey findings were discussed, no further documents were submitted for review.