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|UNIVERSITY HEALTH SYSTEM||4502 MEDICAL DR SAN ANTONIO, TX 78229||April 6, 2017|
|VIOLATION: MEDICAL SCREENING EXAM||Tag No: A2406|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on reviews of medical records, emergency department policies and procedures, and staff interviews, the hospital failed to ensure compliance with 42 CFR 489.24(a) Medical Screening Exam of the Emergency Medical Treatment and Labor Act (EMTALA).
The findings included:
(i) Failed to conduct an appropriate ongoing medical screening examination to determine if a medical emergency existed.
(ii) Failed to repeat, monitor, and reevaluate vital signs.
(iii) Failed to provide treatment options based on results of diagnostics and examination by a qualified practitioner.
A review of the medical record revealed the patient arrived at 9:30 p.m. on October 29, 2016 with a chief complaint of chest pain and palpitations for 2 days accompanied by shortness of breath with dizziness and a self reported elevated blood sugar of 492 two hours before arriving to the emergency room .
The patient was triaged at 9:32 p.m. and assigned a triage score of Emergency Severity Index of ESI 3. The patient's initial vital signs during triage was recorded: Temperature 98.3 F, Heart rate 89 bpm, Respirations 18 pm, Saturated oxygen 98% SaO2, and blood pressure 142/104 systolic and diastolic ^.
A medical screening examination began at 9:52 p.m. to include the history and physical examination of a [AGE] year old female that is well nourished, afebrile, cooperative and in no current respiratory distress. Heart rate and capillary refill were within normal ranges. Abdomen, extremities and neurological examinations are considered normal. The patient also received orders for laboratory studies of blood and urine, imaging for chest x-rays and medications as needed with the intent of placing the patient into a bed when one became available. The patient was instructed to not eat anything by mouth and to notify the nursing staff of any changes in condition. At 9:57 p.m. the patient submitted blood for labs: Complete blood count (CBC), Troponin I, Lipase Serum, B-type Natriuretic Peptide, Drug Abuse Screen Urine, Urinalysis Chemical, Electrocardiogram (EKG), Chest X-ray (2), Pharmacy chewable aspirin. The laboratory results revealed Glucose urine 1+, X-rays were negative for significant abnormalities.
a. Upon review a completed medical screening examination that addressed the chief complaint, elevated labs and determination of whether or not the patient did indeed have a medical emergency was incomplete.
b. No evidence was provided of continued monitoring since the initial triage and the next attempt to contact the patient was not until 10:00 a.m. on October 30, 2016, the following morning.
c. The patient remained in the emergency department for several hours (+10) and was not re-evaluated. The staff could not provide documentation of treatment for the elevated blood pressure 141/104 or 1+ glucose urine. The patient could not be located at 10:00 a.m. the following morning and was dispositioned as Left After Medical Screening Examination (LAMSE).
d. Reviews of the hospital's Policy No. 8.03 (8/12/15) Emergency Medical Treatment and Patient Transfer, page 1 of 21 revealed a failure to comply in that All individuals who come to the hospital seeking emergency medical treatment will receive a Medical Screening Examination, and appropriate protocols and procedures will be followed to ensure compliance with federal and state requirements regarding emergency medical treatment. Staff members #1 and #2 could not provide evidence of compliance with the requirements.