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), C2406.

Based on document review and interview, the facility failed to document an assessment of the patient's condition on arrival to the ED (emergency department) to ensure the individual was appropriately prioritized until a MSE (medical screening exam) by a physician or other QMP (qualified medical provider) was completed for 1 of 20 medical records (MR) reviewed (Patient #1).

Findings include:

1. Review of the policy/procedure Emergency Department Scope of Care (approved 2-17) indicated the following: "Triage assessments are done on arrival to the department and care is initiated based on the patient's triage designation and level of acuity ..."

2. Review of the policy/procedure Emergency Department General And Specific Policies (approved 2-17) indicated the following: "Every ED patient will be seen by a physician and receive a Medical Screening Exam."

3. Review of the MR for Patient #1 indicated that the patient presented to the ED on 10-12-17 at 0012 hours for complaint of nonconsensual sex and lacked documentation indicating a triage assessment was performed on arrival to the ED by a Registered Nurse or a MSE was performed by a Physician. The MR indicated the patient requested a sexual assault examination at the time of registration and no MR documentation indicated the patient was informed of a need to go to another hospital for a sexual assault forensic exam and/or requested to wait for a Registered Nurse to come and perform a triage assessment and for a Physician to perform a MSE before the patient left the facility.

4. On interview on 10-19-17 at 1655 hours, the Chief Nursing Officer, staff A2 and the ED Nurse Manager, staff A4, confirmed the MR lacked documentation indicating a triage assessment or MSE was performed, or the patient was informed of a need to go to another hospital for a sexual assault forensic exam, or requested to wait for a Registered Nurse to perform a triage assessment and interview with the patient.