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Based on document review, facility failed to provide a complete medical screening on 1 of 25 patient medical records reviewed. (Patient 25)

Findings Include:

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

Based on document review, facility failed to provide a complete medical screening on 1 of 25 patient medical records reviewed. (Patient 25)

Findings include:

1. Facility policy titled, Emergency Medical Treatment and Active Labor Act (EMTALA), PolicyStat ID 12682336, last approved 01/2024, indicated under Procedure, Standards for Medical Screening Examination, 2. The Medical Screening Examination extends until the point that the QMP determines that an Emergency Medical Condition does or does not exist. A patient should continue to be monitored based on the patient's needs, and monitoring should continue until the individual is Stabilized or admitted or appropriately transferred. 6. When the MSE reveals that the person has an EMC, the Hospital will provide Stabilizing Treatment as required to stabilize the medical condition or will transfer the patient in accordance with the Transfer provisions below. Stabilizing treatment is ongoing and must be continued until the patient is Stabilized or appropriately Transferred.

2. Review of Patient 6's medical record indicated the following:
(A) The patient presented on 9/10/24 with complaint of midsternal chest pain and nausea. The medical record (MR) indicated his/her systolic blood pressure was in the 70's at home which prompted him/her to call 911. At the facility, his/her blood pressure readings included, but were not limited to 110/53 at 1636 hours, 99/53 at 1715 hours, 100/55 at 1730 hours, 98/52 at 2000 hours, and 101/49 at 2020 hours. The MR lacked documentation that the patients low blood pressure was addressed. The MR indicated that his/her BUN (Blood Urea Nitrogen) was 23 (normal 7-17). The MR lacked documentation that the elevated BUN was addressed.
(B) The provider orders on 09/10/2024 at 1640 hours indicated Serial Cardiac Enzymes: Troponin now and then 3 hours after first collection. MR indicated the first Troponin was collected at 1711 hours and the second Troponin was collected at 1838 hours- per provider order, this lab should have been collected at 2011 hours. The second Troponin drawn was not at the appropriate time and per order. Provider notes on 09/10/2024 at 1807 hours indicated patient's EKG (Electrocardiogram) was nonischemic, troponin and repeat troponin was within normal limits; patient reports belching and passing gas, and their symptoms have improved, patient can be discharged to home. MR indicated at 1820 hours patient was discharged to home. The Per Emergency Department note, the patient was found unresponsive by tech outside of ED after discharge and was brought back into facility. Code was called and compressions were started. The patient did not survive and time of death was called at 2106 hours on 9/10/24.