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Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#2) of 23 Emergency Department (ED) records reviewed. The hospital's average monthly census was 3,663.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)," dated 07/14/22, showed:
- An EMC was a medical condition that manifested itself by acute (sudden onset) symptoms of sufficient severity (including severe pain, psychiatric [relating to mental illness] disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
- A MSE was the process required to reach, with reasonable clinical confidence, the point at which it could be determined whether or not an EMC existed. The MSE was an ongoing process, and the medical record must reflect continued monitoring based on the patient's needs and continue until the patient was either stabilized, discharged, admitted to inpatient care, or appropriately transferred.
- A patient was stable for discharge when, within reasonable clinical confidence, it was determined that the patient had reached the point where his or her continued care, to include diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient was given a plan for appropriate follow up care with the discharge instructions, or the patient required no further treatment and the treating physician had provided written documentation of his or her findings.

Review of the hospital's undated policy titled, "ED Minimum Shift Required Documentation for Nurses," showed the administration of intravenous (IV, in the vein) pain medication required a reassessment within 30 minutes of administration. Vital signs (VS, measurements of the body's most basic functions) should be documented in real time for every ED encounter, and more frequently if indicated per order such as the use of telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen), an unstable status, or cardiac complaint.

Review of the hospital's policy titled, "Triage (process of determining the priority of a patient's treatment based on the severity of their condition) Assessment of Patients by Emergency Severity Index (ESI)," dated 10/17/24, showed:
- Triage involved a rapid, directed patient assessment which provided an assignment of an acuity (the severity of a patient's illness and the level of service needed) level for each patient who arrived in the unit based on the ESI algorithm.
- Based on the algorithm, an acuity level of two answered yes to the questions, "high risk situation, or confused/lethargic (weak, sluggish)/disoriented, severe pain or distress, and Danger zone VS. Parameters for VS were not included.
- Severe pain or distress was determined by clinical observation and/or patient rating of greater than or equal to a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) score of greater than or equal to seven out of 10.

Please refer to A-2406 for further details.

Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#2) of 23 Emergency Department (ED) records reviewed.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)," dated 07/14/22, showed:
- An EMC was a medical condition that manifested itself by acute (sudden onset) symptoms of sufficient severity (including severe pain, psychiatric [relating to mental illness] disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
- A MSE was the process required to reach, with reasonable clinical confidence, the point at which it could be determined whether or not an EMC existed. The MSE was an ongoing process, and the medical record must reflect continued monitoring based on the patient's needs and continue until the patient was either stabilized, discharged, admitted to inpatient care, or appropriately transferred.
- A patient was stable for discharge when, within reasonable clinical confidence, it was determined that the patient had reached the point where his or her continued care, to include diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient was given a plan for appropriate follow up care with the discharge instructions, or the patient required no further treatment and the treating physician had provided written documentation of his or her findings.

Review of the hospital's undated policy titled, "ED Minimum Shift Required Documentation for Nurses," showed the administration of intravenous (IV, in the vein) pain medication required a reassessment within 30 minutes of administration. Vital signs (VS, measurements of the body's most basic functions) should be documented in real time for every ED encounter, and more frequently if indicated per order such as the use of telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen), an unstable status, or cardiac complaint.

Review of the hospital's policy titled, "Triage (process of determining the priority of a patient's treatment based on the severity of their condition) Assessment of Patients by Emergency Severity Index (ESI)," dated 10/17/24, showed:
- Triage involved a rapid, directed patient assessment which provided an assignment of an acuity (the severity of a patient's illness and the level of service needed) level for each patient who arrived in the unit based on the ESI algorithm.
- Based on the algorithm, an acuity level of two answered yes to the questions, "high risk situation, or confused/lethargic (weak, sluggish)/disoriented, severe pain or distress, and Danger zone VS. Parameters for VS were not included.
- Severe pain or distress was determined by clinical observation and/or patient rating of greater than or equal to a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) score of greater than or equal to seven out of 10.

Review of Patient #2's medical record, dated 06/25/25, showed:
- At 9:11 AM, she arrived at the ED with a chief complaint of midline chest and abdominal pain with nausea, vomiting, and diarrhea since the previous night.
- At 9:15 AM, VS were obtained, and her blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) was 169/88. No other VS were taken throughout the ED visit. Her pain scale assessment score was 10 out of 10. Her acuity level was two.
- Provider documentation indicated she had presented with similar pain in the past and recently visited the ED for a motor vehicle accident (MVA). The pain felt like a burning sensation up into her chest and was mild. She was hypertensive but her other VS were stable.
- Her home medications list included medication used to treat high BP.
- At 12:06 PM, four milligrams (mg) of IV morphine (an opioid pain medication) was administered. No pain scale assessment or reassessment was recorded.
- At 1:09 PM, four mg of IV morphine was administered. Her pain scale assessment score was four out of 10. No pain scale reassessment was recorded.
- She was referred to a gastroenterologist (physician who specializes in the digestive system) for follow up and was diagnosed with acute gastritis (inflammation of the stomach) and cyclical vomiting (repeated, severe episodes of nausea and vomiting, followed by periods of complete wellness).
- There were no VS orders in the medical record.
- At 1:47 PM, she was discharged.

During a telephone interview on 09/16/25 at 10:45 AM, Staff I, Nurse Practitioner (NP, a nurse with advanced clinical education and training), stated that he remembered caring for Patient #2 on 06/25/25. She had been vomiting which likely caused her increased BP. He was unsure how often VS were to be recorded in the medical record and he was surprised the only BP reading in the chart was 169/88. Typically, when he entered a room to see a patient he would cycle a BP reading on the monitor. If her BP remained elevated during the visit, he would have provided medications. He believed other VS sets were taken but possibly not recorded. If no other VS were taken, that would be concerning. He referred Patient #2 to a gastroenterologist only, not her primary care provider.

During a telephone interview on 09/16/25 at 10:31 AM, Staff G, NP, stated that he would not treat a systolic pressure (the pressure against the artery during the heartbeat, when the heart is pushing blood out) in the 140-150's in the ED, but would refer the patient to their primary care provider. If a systolic pressure were higher, such as 180-190's, he would re-evaluate it and potentially provide treatment in the ED.

During an interview on 09/16/25 at 12:07 PM, Staff E, ED Director, stated that VS were typically automatically taken every 15 minutes when a patient was connected to a monitor. The frequency of recorded VS would depend on the patient's acuity. The frequency of VS for a patient with an acuity level of two would depend on their presentation. She was unsure how often VS were required and would refer to the policy. If a BP had been 169/88, she would expect a second set of VS to have been taken. She would not necessarily be concerned with a BP that high; it would be dependent on the patient's presentation.

During a telephone interview on 09/16/25 at 10:00 AM, Staff J, Registered Nurse (RN), stated that she cared for Patient #2 on 06/25/25. If a BP were 169/88, she would notify a physician. She was surprised no other VS were taken before Patient #2 was discharged.

During a telephone interview on 09/16/25 at 12:26 PM, Staff H, RN, stated that VS should be rechecked after the administration of medications like morphine. If a patient had a BP of 169/88, she would have rechecked it but would not focus on it unless it were "sky high," such as a systolic pressure of 180 or greater. Sometimes the ED was busy, and VS may not have been a priority. The monitors in the ED rooms would automatically cycle, taking a BP, every 15 minutes, but the nurse would have to validate the readings.

During an interview on 09/16/25 at 9:36 AM, Staff L, RN, stated that if a BP was elevated, she would first consider the patient's history and presentation. Secondly, she would discuss the BP with the provider. She would document in the free text section of the medical record any discussion that was made with the provider regarding abnormal VS. VS were typically repeated within one hour of discharge, but she was unsure if that was required by policy.