HospitalInspections.org

Based on hospital policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and ongoing medical screening examination (MSE) for one (1) of 20 (Patient #18) sampled patients.

The findings included:

Medical record review revealed Patient #18 presented to Hospital #1's ED on 6/23/2025 at 4:00 PM via "walk-in" with a chief complaint of a fall, with pain in the lower back, right hip, right knee and right elbow. Triage assessment revealed Patient #18 was alert and oriented with limited mobility. Patient #18 rated the pain as 5- 6 out of 10 on pain scale of 0-10 (0 is no pain and 10 is the worse pain ever). Patient #18's chief pain complaint was in the"hip/pelvis" and described the pain as being constant. A MSE was initiated on 6/23/2025 at 5:02 PM by Provider #1. Provider #1 performed an examination and ordered tests to determine any untoward effects from the patient's fall. An x-ray of the hip and pelvis, signed by the radiologist on 6/25/2025 at 6:03 PM, documented "...strongly suspected impaction fracture of the right femoral neck... Please correlate with clinical findings, recommend follow-up CT [Computed Tomography; helps healthcare providers detect diseases and injuries] or MRI [magnetic resonance imaging - uses magnetic fields and radio waves to create detailed images of the inside of the body] if the clinical picture is unclear..."

At the end of the shift on 6/23/2025, Physician #1 assumed care of Patient #18 from Provider #1. Physician #1 documented she had interpreted the patient's x-rays and Patient #18 was without evidence of fracture. Physician #1 further documented CT imaging had been obtained and reviewed by the radiologist; the Patient is without evidence of significant acute injury.
Review of and addition text note revealed Physician #1 "... called today [6/27/2025] to notify family of radiologist x-ray read as the R [right] femoral head fracture was missed on wet read. The patient is now at [named Hospital #2] awaiting surgical fixation..."

Cross Refer to A-2406.

Based on hospital policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and ongoing medical screening examination (MSE) for one (1) of 20 (Patient #18) sampled patients reviewed.

The findings included:

1. Review of the hospital's "Medical Staff Rules and Regulations" policy (revised 4/2025) revealed, "...Medical Screening Exam...A. Federal and state laws and regulations provide that any individual who comes to the Hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by individuals qualified to perform such examination to determine whether or not an emergency medical condition exists...C. The MSE is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred..."

Review of the hospital's "[Named State] EMTALA [Emergency Medical Treatment and Labor Act], Medical Screening Examination and Stabilization" policy (revised 9/2024) revealed, "...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and...the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition...A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists...An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual's presenting signs and symptoms...The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC...The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer..."

2. Medical record review revealed Patient #18 presented to Hospital #1's ED on 6/23/2025 at 4:00 PM via "walk-in" with a chief complaint of a fall, with lower back and right hip pain as well as right knee and right elbow pain. Patient #18 arrived in the ED with family who reported the Patient slipped and fell and had a skin tear to the right arm. The family member denied the Patient hit her head. Family reported the Patient had a history of Dementia (condition characterized by impairment of memory loss and/or judgment). The Triage assessment, initiated at 4:02 PM, revealed Patient #18 was alert and oriented x 3 (to person, place and time), mobility was limited, and pain was rated as 5- 6 out of 10 on pain scale of 0-10 (with 0 indicating no pain and 10 indicating the worse pain one can experience). The chief complaint of Patient #18 was the "hip/pelvis" with pain characterized as constant. The Patient was triaged as a level "3" on the Emergency Severity Index (ESI - used in emergency rooms to quickly assess patient acuity and prioritize care) was urgent.

A MSE was initiated on 6/23/2025 at 5:02 PM by Provider #1. Provider #1 documented Patient #18 presented to the ED with family after an accidental slip and fall. Patient #18 had complaints of a skin tear to the right upper extremity, discomfort to the lower back, right hip and knee. The Patient had been ambulatory since the fall. The Family denied Patient #18 hit her head or had any loss of consciousness (LOC). Provider #1 documented on the physical examination that Patient #18 had "...Lower Ext [extremities]/Pelvis Atraumatic, Inspection w/o [without] erythema [redness of the skin], eccymosis [ecchymosis; medical term for a bruise], break in skin, or gross deformity, Full range of motion, Neurologic intact, Vascular intact ..."

The following x-rays were ordered on 6/23/2025 at 5:15 PM by Provider #1: x-ray of right elbow, x-ray of hip with pelvis (bilateral), x-ray of right knee.

X-ray of hip with pelvis (signed by radiologist on 6/24/2025 at 6:03 PM) revealed "strongly suspected impaction fracture of the right femoral neck ...Please correlate with clinical findings, recommend follow-up CT or MRI [magnetic resonance imaging - uses magnetic fields and radio waves to create detailed images of the inside of the body] if the clinical picture is unclear"

Provider #1 documented Progress Note #2 as "Patient laboratory investigations as well as imaging pending at end of my shift. Case discussed with [named Physician #1], care transferred, disp [disposition] pending imaging results and reassessment. Re-Eval [re-evaluation] Status Improved..."

Provider Handoff note by Physician #1 revealed, "This patient's care was assumed from initial mid-level provider who saw and evaluated the patient on arrival. Patient care was assumed awaiting completion of ED evaluation. Patient plain film radiographs have been interpreted by me without evidence of fracture. CT imaging has been obtained and reviewed by radiologist. Patient is without evidence of significant acute injury..."

Patient #18 was discharged from the ED to home on 6/23/2025 at 10:15 PM.

An "Additional Text" note by Physician #1 revealed, "...[named Physician #1] called today (6/27/2025) to notify family of radiologist x-ray read as the R [right] femoral head fracture was missed on wet read [preliminary interpretation of a medical image]. The patient is now at [named Hospital #2] awaiting surgical fixation..."

Medical record review of Patient #18's history and physical from Hospital #2 revealed Patient #18 presented to the ED at Hospital #2 on 6/26/2025 for evaluation of right hip pain. The pain had been ongoing for three days. A CT scan of the right hip/thigh noted a severely displaced subcapital femoral neck fracture (fracture at the base of the femoral head). Patient #18 was admitted to the hospital and scheduled for surgical repair of the hip on 6/27/2025.

In an email correspondence on 7/15/2025 at 11:03 PM, Physician #1 stated she was very familiar with the patient (Patient #18). Physician #1 stated she made an attempt to reach out to the family and apologize for her error, the night she found out she had missed the fracture. The Patient was already at another facility to have her hip repaired at that time.

Patient #18 presented to Hospital #1 on 6/23/2025 at 4:00 PM after an accidental fall. Patient #18 complained of pain to the right hip/thigh area. The Initial physical examination by Provider #1 revealed no deformity to the lower extremities. An x-ray of bilateral hips/pelvis was ordered and initially read in the ED by Physician #1. Physician #1 did not interpret any evidence of an acute fracture. Patient #18 was discharged home on 6/23/2025 at 10:15 PM. A radiologist report of the hip/pelvis x-ray was signed the following day on 6/24/2025 with the impression of strongly suspected impaction fracture of the right femoral neck with a recommendation to follow-up with a CT or Magnetic Resonance Imaging (MRI) if the clinical picture was unclear.

There was no documentation Provider #1 assessed Patient #18's ability to ambulate or bear weight to the right lower extremity during the initial physical examination on 6/23/2025. There was no documentation Physician #1 reassessed Patient #18's lower extremity musculoskeletal status, the ability to ambulate or the ability to bear weight, prior to discharging Patient #18 home on 6/23/2025. Hospital #1 failed to provide a complete Medical Screening Examination to determine if Patient #1 had an Emergency Medical Condition.