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Based on policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#1) of 21 Emergency Department (ED) records reviewed from 11/01/24 through 08/25/25. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 3,139.

Findings included:

Review of the hospital's undated policy titled, "EMTALA," showed:
- An EMC was any condition that was a danger to the health and safety of the patient if not treated in the foreseeable future, or any condition that might result in a risk of impairment or dysfunction to a bodily organ or part of the patient if not treated in the foreseeable future.
- A MSE was a process required to determine within reasonable clinical confidence whether an EMC existed. The screening must be completed within the capabilities of the hospital, must determine if any further medical examinations and/or treatments might be required to stabilize the patient, or to determine that the patient needed to be transferred to a different facility.
- When the MSE indicated that a patient had an EMC, the hospital must provide stabilizing treatment within its capability and capacity or, if the hospital did not have the capacity or capability to provide stabilizing treatment, the hospital must provide a transfer to another hospital that had such capabilities.
- To be stabilized means being provided medical treatment necessary to ensure no medical deterioration of the condition was likely to occur.

Please refer to 2406 for further details.

Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) for one patient (#1) of 21 Emergency Department (ED) records reviewed from 11/01/24 through 08/25/25. These failures had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC).

Findings included:

Review of the hospital's undated policy titled, "EMTALA," showed:
- An EMC was any condition that was a danger to the health and safety of the patient if not treated in the foreseeable future, or any condition that might result in a risk of impairment or dysfunction to a bodily organ or part of the patient if not treated in the foreseeable future.
- A MSE was a process required to determine within reasonable clinical confidence whether an EMC existed. The screening must be completed within the capabilities of the hospital, must determine if any further medical examinations and/or treatments might be required to stabilize the patient, or to determine that the patient needed to be transferred to a different facility.
- When the MSE indicated that a patient had an EMC, the hospital must provide stabilizing treatment within its capability and capacity or, if the hospital did not have the capacity or capability to provide stabilizing treatment, the hospital must provide a transfer to another hospital that had such capabilities.
- To be stabilized means being provided medical treatment necessary to ensure no medical deterioration of the condition was likely to occur.

Review of Patient #1's medical record, dated 11/20/24, showed:
- At 1:21 PM, she was a 36-year-old who arrived at the ED with a chief complaint of heavy vaginal bleeding, abdominal pain and bloating, since having a colposcopy (a procedure used to examine the cervix [the lower, narrow end of the that forms a canal between the uterus and vagina] for any abnormalities) performed on 10/31/24.
- She had a past medical history which included, depression (extreme sadness that won't go away), attention deficit/hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors) and a recent abnormal pap smear (a screening procedure that examines cells from the cervix for abnormalities that may indicate cervical cancer). Her pap smear showed she had atypical squamous cells of undetermined significance (ASCUS, indicates there are abnormal cells on the cervix, but it is not clear if they are precancerous or cancerous) and was positive for human papillomavirus (HPV, a sexually transmitted infection of the virus that can cause genital warts and cervical cancer). A colposcopy was performed on 10/31/24, due to the abnormal pap smear.
- She was triaged and her VS were taken. Her pulse was 96, BP 141/96, and temperature of 97.8 degrees. A pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) showed she rated her pain as a five out of ten. A sepsis (life threatening condition when the body's response to infection injures its own tissues and organs) screening performed showed she was not at risk for developing sepsis.
- At 1:28 PM, Staff L, Physician, ordered a complete blood count with differential (CBC, a blood test performed to determine overall health including inflammation or infection), comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions), alkaline phosphatase (an enzyme responsible for bone growth and repair, normal is 45 to 117), a C-reactive protein test (CRP, a test that measures the amount of CRP in the blood to detect inflammation either for acute conditions or to monitor chronic conditions) and urinalysis (a laboratory examination of a person's urine).
- At 2:41 PM, her pregnancy test was negative. Her CBC showed, her white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) was 10.8, other laboratory results were normal.
- At 2:52 PM, her pulse was 80 and BP 133/65.
- At 3:00 PM, her pulse was 79 and BP 125/63.
- At 2:59 PM, Staff L, Physician, documented Patient #1 was calm, cooperative and comfortable. She was alert, awake, and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time).
- At 3:15 PM, her pulse was 74 and BP was 119/67.
- At 3:57 PM, a transvaginal ultrasound showed, the uterus was normal size, contour and echotexture. The endometrium (mucous membrane lining the uterus) was not thickened, at eight millimeters (mm). There was no free fluid and the left ovary had a normal appearance. A transabdominal ultrasound was performed to assess the right ovary, which showed it had a normal appearance.
- At 4:00 PM, her pulse was 74 and BP 116/66.
- At 4:13 PM, Staff L documented that he re-evaluated the patient. He reviewed her laboratory and ultrasound (a test that uses sound waves to create images of structures within the body) results. He ordered a urine culture to be performed on the urine sample she provided, to rule out a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra). The MSE provided to Patient #1, determined there was no evidence of cervicitis (inflammation of the cervix) as her inflammatory markers were not elevated. He determined she could be discharged home with instructions to follow-up with her OB/GYN within the next week. She was instructed to take over-the counter pain relievers and to return to the ED if she developed a fever or if her symptoms worsened. She was provided a follow-up referral to see a primary care provider, within two to three days. Discharge education provided included, education on vaginal bleeding and cervical biopsy (take a sample of tissue or cells for testing).
- A pelvic exam was not performed as part of her MSE.
- At 4:14 PM, she received a dose of Ketorolac (a nonsteroidal anti-inflammatory drug used to treat pain) intravenous (IV, in the vein) for pain.
- At 4:45 PM, she was discharged home.

During an interview on 08/27/25 at 12:15 PM, Staff L, Physician, stated that Patient #1's lab work was within normal ranges. She didn't need a pelvic exam because she had just had a colposcopy and a transvaginal ultrasound was performed while she was in the ED. He didn't recall the patient pushing to have a pelvic exam performed. He thought she was set up to have an ultrasound repeated as an outpatient. When a patient presented to the ED with a complaint of vaginal bleeding, a MSE consisted of frequent vital sign checks, and checking their blood counts and urine to determine stability. The MSE was aimed at finding the cause of the bleeding and to determine how much blood they had lost or were actively losing. Patients were monitored in the ED for a few hours for evaluation and for active blood loss to be identified. Heavy blood loss was considered when a pad needed to be changed once or more per hour. When heavy bleeding occurred, blood counts would be rechecked a couple of hours after the first test was performed. The patient's vital signs were checked every 15 minutes during the time they are being evaluated. The decision to transfer a patient would be made if their vital signs became unstable or blood counts showed acute blood loss that the hospital was unable to manage The hospital had full OB services and a patient would not be transferred to another hospital for a higher level of OB care. He did not recall Patient #1 voicing any concerns about being discharged. Prior to discharging a patient, he would go into the room to speak with the patient, ask them if they understood the precautions they were to be discharged with and ask if there was anything they needed prior to being discharged. He felt Patient #1 was stable from a bleeding standpoint and was not concerned with her slightly elevated WBC count. He instructed her to return to the ED if she developed a fever or if her bleeding increased. She was also instructed to follow-up with her primary care and OB/GYN providers.

During an interview on 08/27/25 at 1:25 PM, Staff M, CMO, stated that a second peer review was completed for Patient #1's ED visit on 11/20/24. It was determined she received a complete and thorough MSE, for her chief complaint. Her VS and blood counts were stable throughout her ED visit. A pelvic exam was not indicated since a transvaginal ultrasound was performed. She was instructed to follow up with her OB/GYN. The MSE determined she did not have an EMC, at that time. She had several things happen in the weeks and months following her ED visit. The issues, which occurred later , were not caused by the care she received in the ED. She followed-up at Hospital B's OB/GYN clinic and her additional concerns were managed on an outpatient basis. In addition to the second peer review, Patient #1's case was presented to the Professional Practice Committee who determined she received appropriate care based upon her chief complaint. A pelvic exam was not needed in every case of vaginal bleeding and not doing one didn't mean she wasn't provided a complete MSE. Patient #1's WBC count was not elevated to the point they were concerned or considered an infection as a differential diagnosis. The patient never mentioned she had symptoms of bacterial vaginosis which was diagnosed at her follow-up OB/GYN visit. Her chief complaint did not include itching and vaginal discharge. Typically, bacterial vaginosis didn't cause an elevated WBC count or an invasive infection. When she went to her OB/GYN appointment a week or so after her ED visit, and reported that since her ED visit, she noticed vaginal discharge. She was diagnosed with bacterial vaginosis and was provided a medication for treatment.

Although requested, no interview was conducted with the physician who performed Patient #1's colposcopy, on 10/31/24.