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Based on record review and interview, the hospital's emergency department physician failed to complete a complete medical screening prior to discharge or transfer in 3 (#1, #2, and #11) of 3 patient charts reviewed. Also, the hospital failed to follow its "Model Policies and Procedures For The Examination, Treatment and Transfer Of Individuals in Need of Emergency Services" policy..

Cross Refer to 2406

Based on record review, policy review, and interview, the hospital's emergency department physician failed to complete a complete medical screening prior to discharge or transfer in 3 (#1, #2, and #11) of 3 patient charts reviewed. Also, the hospital failed to follow its "Model Policies and Procedures For The Examination, Treatment and Transfer Of Individuals in Need of Emergency Services" policy.

This deficient practice had the likelihood to cause harm to all patients presenting to the emergency department (ED)with emergent medical conditions.

Findings include:

Patient #1

A review of the electronic health record (EHR) for Patient #1 revealed the following:

Patient #1 was a 68-year-old who arrived at the ED via Emergency Medical Services (EMS) on 02/09/2025 at 6:53 PM. EMS documented that Patient #1 was observed to have facial injuries, bleeding from the mouth, and hypoxia with an oxygen saturation (O2 sat) of 89%. Patient #1 was triaged at 8:52 PM by the ED nurse who charted the patient as "autistic and non-verbal" and had a chief complaint of a ground-level fall (GLF) on concrete, with a laceration above the left eye and a nosebleed. Patient #1's vital signs (VS) were as follows:

Blood Pressure (BP) -118/92
Heart Rate (HR) -86
Respirations (Resps) -18
Temperature (Temp) -98.1
Oxygen Saturation (O2 sat) 98%
Glasgow Coma Scale (GCS) (a neuro assessment tool used to evaluate the level of consciousness in a person after a brain injury)-14

The patient's record revealed that an ED trauma flow sheet was initiated. The ED nurse documented a bedside report of "GLF hitting face, bleeding from nose and mouth, attempted to place a C-collar, patient became agitated." Also, the ED nurse documented that the patient arrived at the ED with "lacerations to the face, raccoon eyes, abrasions, and bleeding from the nose and mouth."

The ED nurse gave the patient an Emergency Severity Index (ESI) (The Emergency Severity Index has five levels, with Level 1 representing the most urgent cases requiring immediate life-saving intervention, and Level 5 being the least urgent, needing only a basic history and physical exam; essentially ranking patients based on their acuity and the resources needed for their care) of 3- Urgent.

Further review of the ED trauma flow sheet revealed the following;

At 7:01 PM, the ED nurse documented that the patient became agitated with the pulse oximeter (a non-invasive device that measures blood oxygen saturation and heart rate) and did not want to keep pulse oximeter on.

At 7:10 PM, Patient #1 received an initial Medical Screening Exam (MSE) by the ED Physician. The ED Physician noted that the patient had a facial laceration of 2 centimeters. There was no documentation found that the ED Physician documented characteristics of the wound or if the wound was actively bleeding. In addition, the ED Physician did not note any other abnormalities in the MSE assessment and documented a normal exam. A review of the nurse's documentation on the trauma flow sheet revealed that the patient had "raccoon eyes, deformity to the nose with nasal bleeding, and the patient had blood in the mouth." There was no documentation found that the ED Physician performed an assessment of Patient #1's oral or nasal airway. There was no documentation found to support that the ED Physician assessed Patient #1's eyes due to the "raccoon" bruising or performed an extraocular movement exam (EOM) (assessment for how well the eyes move in all directions).

There was no documentation found that the patient received wound care or repair of the laceration. There was no documentation found that a tetanus (a vaccine that protects against tetanus, a serious and potentially fatal bacterium) was offered or administered.

The ED Physician ordered a Computed Tomography scan (CT) of the cervical spine, head, and maxillofacial. There was no documentation found to support that the ED Physician ordered labs after performing the MSE assessment. In addition, Patient #1 was administered 4 milligrams of morphine intramuscularly.

At 8:00 PM, the ED nurse documented that Patient #1 had an O2 saturation "in the 70s." The patient was placed on a nasal cannula (NC) with oxygen at 4 liters per minute, and documented that there was no improvement. The ED nurse placed a non-rebreather mask (NRB) with oxygen at 15 liters per minute and documented that the patient had "improvement with O2 and that respiratory was at the bedside." There was no documentation found to support that the patient had a chest x-ray ordered or had an Arterial Blood Gas (ABG) (a blood test that measures the levels of oxygen and carbon dioxide in the blood) for hypoxia.

There was no documentation found to support that the ED nurse notified the ED Physician of the patient's abnormal O2 saturation. There was no documentation found to support that the patient received a reassessment from the ED Physician. At 8:25 PM, the patient returned from CT to the ED. Patient #1's CT scan results revealed that the patient had significant facial fractures for a ground-level fall. There was no documentation found that the ED Physician completed a reassessment or ordered additional imaging of the patient after the CT scan findings. There was no documentation found that the patient received prophylactic antibiotics.

A review of Patient #1's vital signs revealed that between 8:00 PM and 10:15 PM (135 minutes), the patient did not have a full set of vital signs documented.

A further review of the trauma flow sheet revealed that at 9:00 PM, the ED nurse documented suctioning blood from the patient's mouth. There was no documentation found of reassessment or intervention for the patient's bleeding. There was no documentation to support how much blood was suctioned from the patient by the ED nurse. There was no documentation found that the ED nurse notified the ED Physician that Patient #1 continued to bleed from the mouth. ED Physician failed to reassess blood coming from the mouth.

At 10:09 PM, the ED Physician ordered labs, an ABG, and an EKG. There was no documentation found that the ED Physician completed a reassessment or why the additional tests were ordered.

A review of Patient #1's ABG results revealed a pH of 7.26, pCO2 of 56, and a pO2 of 40, indicating hypercapnic respiratory acidosis and hypoxia. There was no documentation found of reassessment or intervention by the ED Physician.

At 10:35 PM, the ED nurse documented, "Patient becoming increasingly more agitated and oxygen saturations decreasing into the 70s. Patient blood pressure dropping." The vital signs documented for the patient at this time were "BP 99/56, HR 121, Resps 32, O2 sats 75%."

There was no documentation found to support that the ED nurse reported the abnormal vital signs to the ED Physician. There was no documentation found to support that the patient received a reassessment from the ED Physician.

A further review of Patient #1's chart revealed that at 10:56 PM, Patient #1 was intubated (a medical procedure where a tube is inserted into the trachea to maintain an open airway) by the ED Physician due to "Acute Hypoxic Respiratory Failure." The ED nurse documented that Patient #1 was started on a Levophed (a vasoconstrictor used to treat life-threatening low blood pressure) drip. At 11:15 PM, the Levophed drip was discontinued, and a Propofol (intravenous anesthetic formulation used for induction and maintenance of anesthesia) drip was initiated at 11:20 PM.

At 11:06 PM, Patient #1 was taken to radiology for a chest x-ray to check the endotracheal tube placement. A review of the chest x-ray revealed that "diffuse bilateral airspace opacities may represent pulmonary edema or pneumonia." There was no documentation found that this was noted or that treatment was initiated by the ED Physician.

In addition, Patient #1 received an X-ray of the left hand. A review of the X-ray results revealed a "comminuted minimally displaced fifth metacarpal neck fracture." There was no documentation found in the ED Physician's MSE to indicate why this x-ray was ordered. The ED Physician failed to assess or treat the fracture.

At 11:39 PM, the ED nurse documented that EMS was at the bedside to transfer the patient, and Patient #1 was "rolled and cleaned." Patient #1 was transferred via EMS to Hospital #2 with a diagnosis of closed head injury, acute hypoxic respiratory failure, nasal bone fractures, zygomatic arch fractures, pterygoid plate fractures, and orbital wall fractures.

There was no documentation found that wound care was provided or that there was an attempt to control Patient #1's bleeding during the ED visit.

An interview was conducted on 03/13/2025 at 9:00 AM with Staff #16. Staff #16 reported the patient did not present in bad shape upon arrival, and a trauma call wasn't called because the patient was at baseline. Staff #16 reported that the patient continued to deteriorate and had to be intubated. Staff #16 reported that the patient was bleeding from facial fractures, and they were draining blood down the back of the patient's throat. Staff #16 was questioned about providing wound care to the patient. Staff #16 stated, "I sat for 45 minutes, cleaned the patient's wounds, and suctioned the blood. I took several breaks to keep the patient calm. After the patient was intubated, I continued to clean the patient. Staff #16 was asked if the treatment was documented in the patient's chart. Staff #16 stated, "I did not document my treatment or wound care on the trauma flow sheet."


Patient #2

A review of the EHR for Patient #2 revealed the following;

Patient #2 was a 64-year-old who arrived at the ED via EMS on 02/18/2025 at 8:44 PM. Patient #2 had a chief complaint of headache, facial pain, and neck pain secondary to an assault with a broomstick. Patient #2 was triaged at 8:52 PM by the ED triage nurse, and the vital signs (VS) were as follows:

Blood Pressure 155/77
Heart Rate 67
Respirations 16
Temperature 98.3
Oxygen Saturation (O2 sat) 97%
Glasgow Coma Scale (GCS) (a neuro assessment tool used to evaluate the level of consciousness in a person after a brain injury)-15

The ED triage nurse gave the patient an ESI 3- urgent.

Further review of the ED triage nurse's documentation revealed that Patient #2 arrived at the ED with bilateral swollen black eyes, a swollen busted lip, and kerlex wrapped around the patient's head with blood. Also, the
ed nurse documented that Patient #2's" nose was bleeding with a postnasal drip that caused the patient to vomit blood clots".

At 8:59 PM, Patient #2 received an initial MSE by the ED Physician. The ED Physician documented that the patient had periorbital edema with ecchymosis and mild distress. The ED Physician documented that the patient had a cervical collar in place. There was no documentation found to support the ED Physician evaluated the patient's cervical spine for pain with movement or tenderness with palpation. The ED Physician documented that the patient had left-hand pain. There was no supporting documentation found to indicate if the patient had swelling, deformity, or wounds causing the patient's hand pain. The ED Physician documented a normal exam, but there was no documentation found to support that Patient #2 was undressed and received a full trauma exam to include an assessment of the patient's back, thoracic, and lumbar spine.

The ED Physician ordered an EKG, labs, and a CT of the cervical spine, head, and maxillofacial. In addition, Patient #2 received a hand x-ray, Cefepime 2 grams intravenously (IV), Morphine 4 milligrams IV, 2 doses of Zofran 4 milligrams, and a Tetanus booster intramuscularly.

A review of the ED nurse's documentation revealed that the patient had "bilateral black eyes, nasal bleeding, and bloody post-nasal drip." There was no documentation found that the ED Physician performed an assessment of Patient #2's oral or nasal airway. There was no documentation found to support that the ED Physician assessed Patient #2's eyes due to the bruising or performed an extraocular movement exam.

At 9:40 PM, the ED nurse documented that Patient #2 continued to "vomit blood clots" in the CT room. The patient had received Zofran 4mg for vomiting. There was no documentation found that the ED Physician completed a reassessment of the patient after the ED nurse reported the patient continued vomiting blood clots.

A review of Patient #2's CT scan revealed the patient had a "left retrobulbar hemorrhage" and significant facial fractures. There was no documentation found that the ED Physician reassessed Patient #2 after receiving the CT findings.

In addition, a review of the patient's hand x-ray revealed a "minimally displaced fifth metacarpal shaft fracture". There was no documentation found to support the ED Physician reassessed or splinted the patient's hand after the x-ray findings were received.

Further review of the ED nurse's documentation revealed that at 10:05 PM, the ED nurse documented that the ED Physician was notified that Patient #2 had become more lethargic and confused. The patient had a change in GCS from a 15 to an 11.

There was no documentation to support that the ED Physician completed a reassessment of Patient #2 after being notified by the ED nurse that there was a change in the patient's mental status.

At 11:35 PM, the ED nurse documented that the ED Physician did not remove Patient #2's kerlex dressing and evaluate the patient's facial wounds during the patient's ED visit.

There was no documentation to support that the ED Physician removed the dressings, evaluated, or treated Patient #2's wounds.

At 11:55 PM on 02/18/2025, Patient #2 was transferred to another hospital for a higher level of care with a diagnosis of Pneumocephalus, complex facial fractures, retro-orbital hemorrhage, and a metacarpal fracture.



Patient #11

A review of the EHR for Patient #11 revealed the following;

Patient #11 was a 74-year-old who arrived at the ED via private vehicle on 12/17/2024 at 8:26 AM. Patient #11 had a chief complaint of a ground-level fall while walking, hitting the patient's head on the asphalt. Patient #11 reported head, neck, right knee, and right-hand pain. The ED nurse documented that the patient was on a prescription of Plavix (a blood thinner). The ED nurse activated the trauma code at 8:26 AM. The vital signs documented for Patient #11 were as follows;

BP 178/78
HR 60
Respirations 16
O2 sat 98 % on room air,
Temperature 97.9
GCS of 15

At 8:26 AM, Patient #11 received an initial MSE by the ED Physician. The ED Physician ordered a CT scan of the pelvis, a right wrist x-ray, and Norco 5/325 (pain medication) milligrams by mouth.

There was no documentation found to support that the patient received a cervical spine examination by CT scan or x-ray to rule out a cervical spine injury after a fall. There was no documentation found to support that the patient received a CT scan of the head or brain to rule out bleeding in the brain after a fall for a patient on blood-thinning medication. There was no documentation found to support that the ED Physician assessed the patient for a scaphoid fracture of the right wrist ( snuffbox tenderness,a key indicator for a break in one of the small bones of the wrist often not found on x-ray during the acute period).

At 10:11 AM, Patient #11 was discharged home with no documentation of discharge vitals signs.


A review of the hospital's "Model Policies and Procedures For The Examination, Treatment and Transfer Of Individuals in Need of Emergency Services" policy dated 06/2017 revealed the following:

"Medical Screening Examination (MSE)

1. The Hospital will provide an MSE for an individual who:

a. Comes to an on-campus DED, requesting examination or treatment for a medical condition or has such request made on his/her behalf, or if based on the individual's appearance or behavior, the individual appears to need an
examination or treatment for a medical condition; or

b. Comes to an off-campus department that is a DED, requesting examination or treatment for a medical condition or bas such request made on his/her behalf, or if based on the individual's appearance or behavior, the individual
appears to need an examination or treatment for a medical condition; or.....

3. The MSE will be performed by a physician or other QMP as designated by the Hospital's governing body, within the scope of the QMP's state license and privileges. The physician or QMP will determine with reasonable clinical confidence whether the individual has an EMC, as defined by EMTALA, utilizing the services within the capabilities of the DED and ancillary services and resources routinely available to the DED for individuals with similar symptoms.

4. The MSE is an ongoing process. The medical record will reflect an ongoing assessment of the individual's condition. Monitoring of the individual will continue until the individual (i) is stabilized, (ii) is admitted to the Hospital, (iii) is appropriately transferred, if an EMC exists and the individual requires care and
treatment that exceeds the Hospital's Capabilities, (iv) is discharged, or (v) expires. The MSE process must be documented in the medical record."

An interview was conducted on the afternoon of 03/12/2025 with Staff #4, Staff #5, and Staff #6 during the surveyor's medical records review. Staff #4, Staff #5, and Staff #6 acknowledged the surveyor's findings of incomplete medical screening exams.