HospitalInspections.org

Based on a document review and interview, it was determined for 1 of 20 patients (Pt #1) presenting to the Emergency Department (ED), the Hospital failed to ensure the patient was documented in the Emergency Department Log.

Findings include:

1. The Emergency Department log from 9/1/24 through 4/14/25 was reviewed on 4/14/25 with Regulatory Compliance & Accreditation Manager (E#3). Pt#1 was not included on the log. A request was made for Pt#1's record at Hospital A. No record was provided as Pt#1 was not included on the ED log and was not registered at Hospital A. There was no medical screening exam (MSE) done, no lab work completed, or any other testing done for Pt#1.

2. On 4/17/25 at 9:30 AM, an interview was conducted with Regulatory Compliance & Accreditation Manager (E#3). When asked if E#3 could provide a policy on documenting patients on the ED Log, E#3 stated, "We do not have a particular policy on documenting patients on the ED log. The patient should have been entered into the ED log upon arrival!" E#3 verbally agreed that Hospital A did not document Pt#1 on the ED log.

Based on document review and interview, it was determined that in 1 of 20 (Pt #1) Emergency Department (ED) records reviewed, the Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination (MSE).

Findings include:

1. The policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) (Published 10/1/24) was reviewed. The policy noted, " ... A. Initial Medical Screening. 1. When an individual comes to the Emergency Department and requests emergency care or treatment, the hospital must provide an appropriate Medical Screening Examination (beyond medical triage) by qualified medical personnel (physicians, non-physician advanced providers and registered nurses) as determined by the medical staff and hospital board of directors. 2. The Medical Screening Examination must be within the hospital's capacity and capability and include ancillary services routinely available to determine if an emergency medical condition exists. The hospital must follow these guidelines: ... d. No patient will be discharge or transferred without a medical screening examination. 3. The Medical Screening Examination shall be documented in the electronic medical record (EMR)."

2. The policy titled, "Basic Emergency Department Protocol (Reviewed 2/24)" was reviewed. The policy noted, " ...C. Implementation: ...iv. Obstetrical patients: a. All patients of childbearing years will be asked if they are currently pregnant or if they have delivered in the past six weeks. The patient's pregnancy status will be documented in the electronic medical record. b. Pregnant patients presenting with complaints of labor will be sent directly to the OB Department if they are greater than twenty weeks gestation ... d. Fetal heart tones will be taken and documented on pregnant patients. f. Obstetrical consults will be done in a timely fashion."

3. ED Log dated 9/1/24 through 4/14/25 was reviewed with Regulatory Compliance & Accreditation Manager (E#3) on 4/14/25. Pt#1 was not included on the on the log. A request was made for Pt#1's record at Hospital A. No record provided as Pt#1 was not included on the ED log and was not registered at Hospital A. E #2 verbally agreed there was no medical screening exam (MSE), no lab work completed, or any other testing/stabilization completed for Pt#1.

4. On 4/14/25 at 2:30 PM, an interview was conducted with OB Manager (E#9). E#9 was asked if E#9 recalled Pt#1. E#9 stated was made aware of Pt#1 on 2/7/25 at 5:00 AM. E#9 referred to an email on 2/7/25 sent by E#9 to OB staff regarding Pt#1 not getting an MSE. The email stated, "In this instance, we must accept and evaluate the patient... Once the patient is at our doorstep, we are responsible and must medically screen them. We also cannot decline an ambulance that is inbound, the OB staff or OB physicians do not have the authority to do that. When you are in doubt in a situation like this, call the Nursing Supervisor." E#9 verbally agreed that Hospital A did not complete a MSE on Pt#1.