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ALOMERE HEALTH 111 17TH AVENUE EAST ALEXANDRIA, MN 56308 May 8, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on documentation review and interview, the hospital failed to ensure compliance with the requirements of 42 CFR 489.24 as evidenced by the deficient practice cited in 489.24(r) and (c).

The hospital failed to ensure all patients who presented to the ED received an appropriate medical screen examination.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on documentation review and interviews, the hospital failed to provide all patients who present to the emergency department (ED) with an appropriate medical screening examination for 1 of 21 (P3) patients who presented to the ED. Findings include:

Patient #3 (P3):
(P3) hospital ED record was reviewed and revealed he (MDS) dated [DATE] at 8:47 a.m. P3 arrived via ambulance. P3's chief complaint was left lower extremity swelling and redness and abdominal pain. The triage documentation also included a concern of left lower extremity (LLE) redness and swelling. The LLE was also warm to touch. P3 was found to have equal bilateral pedal pulses. The nursing assessment, dated 4/5/15 at 9:01 a.m., noted P3 had an ecchymotic area on the left lateral lower hip and swelling of his left leg. Physician L saw P3 and conducted a medical screening examination for the abdominal concerns. P3 was treated with intravenous fluids, intravenous potassium and was given a prescription for antibiotics. Physician L noted P3 had a concern regarding skin changes in his left lateral hip region and his extremities did not demonstrate anything acute. P3 had no edema and no skin breaks. No further tests or diagnostics were completed related to P3's leg swelling and redness. There is no documentation as to whether Physician L checked P3's pedal pulses. The final diagnoses noted abdominal pain and a lower urinary tract infection. The discharge instructions did not include any follow up instructions related to P3's leg.Hospital ED documentation from 4/10/15 was reviewed for P3. Physician Assistant N's notes of 4/10/15 at 9:34 a.m. revealed P3 presented for an evaluation of left leg swelling for about a week. Physician Assistant N completed a MSE which noted P3 had mild to moderate swelling located from his hip to knee. There was ecchymosis around P3's left knee and lateral femur. P3 had strong pulses bilaterally, and no pain. There was no swelling below the knee. A venous ultrasound was negative for deep venous thrombosis. An x-ray of the left knee, femur, pelvis showed a displaced femur fracture, a non displaced femur fracture, and a hip fracture at the neck. P3 required transfer to another hospital.

Physician L, the ED physician on duty 4/5/15, was interviewed on 5/8/15 at 3:00 p.m. and he stated the primary concern for P3's ED visit was abdominal pain. He conducted an MSE for the abdominal pain. Physician L looked at P3's leg and hip and did not notice swelling or discoloration. He did not remember anyone discuss P3's leg concerns with him. There was no indication for x-rays seen that day, such as trauma, asymmetry of swelling or ecchymosis of the femur and hip.

Physician E, ED medical director, was interviewed on 5/8/15 at 1:55 p.m. There was conflicting documentation between the nursing assessment and the physician medical screen examination for P3's ED visit on 4/5/15. The nursing assessment noted swelling of the left leg and ecchymosis but the physician documentation noted extremities, aside from [DIAGNOSES REDACTED], did not demonstrate anything acute, and P3 had no edema and no skin breaks. Physician L provided no further documentation regarding of the left lateral lower hip. Based on P3's nursing assessment, he expect the MSE to include further testing, such as an ultrasound to rule out a deep vein thrombosis or an x-ray to rule out a fracture.
Review of the Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance Policy and Procedure, last updated on 8/20/14, noted: Medical Screen Examination- The initial and on-going evaluation of the presenting patient conducted by a physician or physician assistant, including history, physical examination, appropriate testing, completion of appropriate documentation, and evaluation of the patient .....Necessary Definitive Care- Medical care and treatment appropriate and necessary to reduce/remove the risk of deterioration to the patient's medical condition prior to transfer or discharge. Procedure- ....all persons presenting at the emergency department or any other area of the hospital requesting treatment or examination shall be provided a Medical Screening Examination ....appropriate to their presenting condition.