HospitalInspections.org

Based on review of medical records (MR), staff interviews and facility documentation, it was determined the facility failed to comply with §489.24 by failing to provide an appropriate medical screening examination (MSE) to rule out an emergency medical condition (EMC) (Refer to A2406).

Cross Reference:
489.24(a) & 489.24(c) Medical Screening Exam

Based on review of policies and medical record review it was determined that the facility failed to provide an appropriate medical screening examination to one (1) of twenty (20) patients, Patient #1. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A policy was reviewed titled "Emergency Medical Treatment and Labor Act (EMTALA)" date reviewed 2/1/23. This policy has a section titled "Policy" which states, in part, "West Virginia University Hospitals (WVUH) will comply with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) by ensuring that when an individual comes by him or herself or with another person to WVUH or its premises and a request is made by the individual or on the individual's behalf for medical examination or treatment, WVUH or a department thereof will provide for an appropriate Medical Screening Examination within the capability of the WVUH Emergency Department, including ancillary services routinely available to the Emergency Department, to determine whether or not an emergency medical condition exists ..." This policy contains a section titled "Medical Screening Examination Procedure 1. When a Medical Screening Examination (MSE) is Required" which states, in part, "B. An individual in a non-WVUH-owned ambulance, which is on WVUH property or premises, is considered to have come to the WVUH Emergency Department."

A document titled "WVU Medicine Thomas Hospitals Medical Staff Bylaws 2024", revised 2024. This document has a section titled 'Emergency Room Coverage' which states, in part, "B. Every patient who presents to Thomas Memorial Hospital Emergency Department will have a screening exam beyond the initial triage, performed by an Emergency Department Physician or Physician Assistant to determine whether or not an emergency medical condition exists. Emergency medical condition means that any medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that the absence of immediate medical attention could reasonably be expected to result in 1. Serious jeopardy to the health of the individual, pregnant woman or her unborn child. 2. Serious impairment of any bodily function or serious dysfunction of any organ part.."

A medical record review was conducted for Patient #1. The patient arrived in the Emergency Department (ED) via Emergency Medical Services (EMS) at 2:29a.m. on 6/17/24.

The medical record contains an entry titled "ED Triage Note entered by Emp #19 on 6/17/24 at 2:37a.m. which states, in part, "Patient called 911 for blood sugar (BS) check for feeling like [he/she] was going to pass out. According to EMS they check on [him/her] frequently and [he/she] is currently altered compared to normal. Glucose on scene two hundred eighty-four (284). Patient does have a history (hx) of schizophrenia. Current BS two hundred seventy-five (275). Denies any pain. Patient (Pt) very hard to talk to, talking all over the place."

The medical record contains a section titled "ED Primary Provider Note" entered by Emp #6 at 2:29a.m. on 6/17/24, which states, in part, "Chief Complaint Patient presents with altered mental status. Arrival: The patient arrived by ambulance [he/she] presenting to the ED via EMS for complaints of elevated blood sugar. EMS was contacted because [his/her] blood sugar check. Patient apparently told them that [they] felt like [they] was [sic] going to pass out ...Patient has EMS to check on [him/her] rather frequently, they report that [he/she] seemed to be acting a little different than typical ...They do report a strong aroma of marijuana. Patient's glucose was two hundred eighty-four (284) when they arrived. [It should be noted that the facility's Latest Reference and Units for Glucose is seventy (70) - one hundred (100) milligrams per deciliter (mg/dl)]. Patient does have a history of schizophrenia. They declined that patient had any suicidal or homicidal thoughts or comments to them ...The patient is extremely tangential on thoughts [he/she] has no reported suicidal or homicidal thoughts ...[He/She] is uncertain of why [he/she] is here but [he/she] reports that [he/she] may want checked out, but [he/she] is uncertain." This entry has a section titled "Physical Exam" which states, in part, "Constitutional: Alert and oriented and patient responds with questions in tangential thought and speech, strong aroma of marijuana ...Psych: The patient's mood and manner are tangential thoughts unable to remain still continuously moving."

The medical record contains an entry titled "ED Nurse Notes" entered by Emp #7 on 6/17/24 at 3:53a.m. which states, "Patient walked out of EC [sic]. [He/She] stated that a family member was coming to get [them]." May it be noted that no additional mental health testing or laboratory work was ordered or completed, and the elopement documentation is not contained within the medical record.

The entry has a section titled "Patient Data" which states, in part, "Labs Ordered / Reviewed - No data to display. No orders to display." This entry has a section titled "Disposition' which states, "Eloped."