HospitalInspections.org

Based on document review and interview, it was determined that in 1 (patient #1) of 20 medical records (MR) reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide a medical screening exam.

Findings include:

1. See findings cited at 42 CFR 489.24(1), A2406.

Based on document review & interview, the facility failed to maintain a central log on each individual who comes to the emergency department, for 1 of 20 patients presenting to the facility. (Patient #1)

Findings include:

1. Review of policy/procedure EMTALA indicated the following;
All patients presenting to the ED must be logged on a central log with documentation of refusal of treatment, transfer, admission statement, stabilization or discharged as appropriate.
Medical screening must be provided by qualified medical personnel.
This policy/procedure was last reviewed/revised on 2/16.

2. Review of Nursing Note from patient #1's medical record (MR) dated 08-15-16 at 1413 hours indicated the following; Received call from facility #2 requesting transfer to this ED for patient C/O pain and concerns of right eye swelling and concussion. Per MD #1, patient to be transferred to facility #3, if possible, for neuro as we do not have eye specialist or neurologist here at this facility. EMS then arrived to this ED with patient and stated they were unaware of transfer to facility #3. Patient remained on EMS cot and was then taken to facility #3 per facility #2 order. Patient #1's MR lacked documentation that a Medical Screening exam was performed by a qualified medical personnel for patient #1's ED visit on 08-15-16 at 1413 hours.

3. On 08-22-16 at 1210 hours review of the ED Log lacked documentation that patient #1 presented to the facility on 08-15-16 at 1413 hours.

4. On 08-22-16 at 1635 hours staff #41, ED Director, confirmed that there was no documentation in the ED Log for patient #1's visit on 08-15-16 at 1413 hours.

Based on document review the facility failed to ensure that written policies and procedures governing an appropriate medical screening examination of all patients presenting to the facility was followed for 1 of 20 Emergency Department (ED) medical records (MR) reviewed. (Patient #1)

Findings include:

1. Review of policy/procedure EMTALA indicated the following; Medical screening must be provided by qualified medical personnel.
This policy/procedure was last reviewed/revised on 2/16.

2. Review of Nursing Note dated 08-15-16 at 1413 hours indicated the following; Received call from facility #2 requesting transfer to this ED for patient C/O pain and concerns of right eye swelling and concussion. Per MD #1, patient to be transferred to facility #3, if possible, for neuro as we do not have eye specialist or neurologist here at this facility. EMS then arrived to this ED with patient and stated they were unaware of transfer to facility #3. Patient remained on EMS cot and was then taken to facility #3 per facility #2 order. Patient #1's MR lacked documentation that a Medical Screening exam was performed by a qualified medical personnel for patient #1's ED visit on 08-15-16 at 1413 hours.