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Based on policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#2 and #3) of 34 Emergency Department (ED) and Labor and Delivery records reviewed.

Findings included:

Review of the hospital's policy titled, "Patient Transfers and Emergency Treatment and Labor (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition), reviewed 09/13/24, showed:
- MSE refers to the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists.
- The MSE is an ongoing process, and the medical record must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred.
- When an individual comes to the ED, the hospital must provide an appropriate MSE within the capability of the hospital's ED, including ancillary services routinely available to the ED, to determine whether or not an EMC exists.
- Depending on the individual's presenting symptoms, the MSE may involve performing ancillary studies such as diagnostic tests and procedures.

Review of the hospital's document titled, "Medical Staff Rules and Regulations," revised 10/2022, showed:
- An appropriate history and physical exam pertinent to the admitting diagnosis on all patients must be performed and entered into the medical record.
- An appropriate history and physical requires a review of systems and a complete physical examination.
- Documentation shall reflect the management and evaluation by the medical staff member managing the care of the patient.

Review of the hospital's policy titled, "Nursing Patient Assessment/Physical Assessment Within Defined Limits (WDL) for Adult Patients," revised 07/14/23 showed:
- The initial nursing patient assessment and focused reassessment will be performed by a registered nurse (RN) and documented in the medical record.

Review of the hospital's undated document titled, "Initial Competency, ED Charting Compliance," showed the nurse must demonstrate the importance of thorough and accurate documentation of the primary and secondary nursing assessment for the ED patient.

Based on observation, interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#2 and #3) of 30 Emergency Department (ED) and Labor and Delivery records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Findings included:

Review of the hospital's policy titled, "EMTALA," reviewed 09/13/24, showed:
- MSE refers to the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists.
- The MSE is an ongoing process, and the medical record must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred.
- When an individual comes to the ED, the hospital must provide an appropriate MSE within the capability of the hospital's ED, including ancillary services routinely available to the ED, to determine whether or not an EMC exists.
- Depending on the individual's presenting symptoms, the MSE may involve performing ancillary studies such as diagnostic tests and procedures.

Review of the hospital's document titled, "Medical Staff Rules and Regulations," revised 10/2022, showed:
- An appropriate history and physical exam pertinent to the admitting diagnosis on all patients must be performed and entered into the medical record.
- An appropriate history and physical requires a review of systems and a complete physical examination.
- Documentation shall reflect the management and evaluation by the medical staff member managing the care of the patient.

Review of the hospital's undated document titled, "Initial Competency, ED Charting Compliance," showed the nurse must demonstrate the importance of thorough and accurate documentation of the primary and secondary nursing assessment for the ED patient.

Review of Patient #2's medical record dated 12/04/24, showed:
- At 5:31 PM, she was a three-year-old who presented to the ED by ambulance following a motor vehicle crash (MVC).
- At 5:34 PM, she was assigned to a room with her father and brother.
- At 5:52 PM, her weight was measured and recorded as "actual" but did not indicate how the weight was obtained.
- At 6:51 PM, a Wong-Baker Faces Pain Scale (a self-assessment tool that helps communication about physical pain) showed "hurts little bit." Documentation did not show the pain location.
- At 7:04 PM, a primary assessment of airway, breathing, circulation and disability was WDL.
- At 7:19 PM, the history and physical showed the patient did not want to stand up after the crash. There was no musculoskeletal system (bones, muscles, joints, tendons and ligaments which all work together to provide the body with support, protection, and movement) assessment.
- At 8:10 PM, pelvic x-rays (test that creates pictures of the structures inside the body-particularly bones) showed no acute (sudden onset) findings.
- At 8:13 PM, a pain assessment showed "hurts little bit" and Patient #2 refused vital signs (VS, measurements of the body's most basic functions).
- At 8:50 PM, she was discharged and carried out by her father.
- The provider failed to obtain an appropriate history and physical which required a review of systems and a complete physical examination in accordance with hospital's Medical Staff Rules and Regulations.
- The physician's physical examination failed to document a musculoskeletal/extremities examination and whether or not the patient was able to ambulate in the ED.
- Observations revealed the patient did not want to stand following the accident.
- A partial lower extremity physical exam was verbally recalled by the provider, this was not documented in the medical record, and the provider confirmed he did not have the patient ambulate.
- The provider confirmed that swelling and bruising could not always be seen at first and bearing weight would have told him more about the injuries. The Medical Director confirmed that a musculoskeletal assessment was missing in the documentation for Patient #2.
- There was no nursing secondary assessment, to assist the medical provider in the management and evaluation of Patient #2's care, in accordance with the hospital's Medical Staff Rules and Regulations.
- An appropriate MSE, in order to determine if an EMC existed was not conducted in accordance with hospital's EMTALA policy.

Review of Patient #3's medical record dated 12/04/24, showed:
- At 5:32 PM, he was a two-year-old who presented to the ED by ambulance following a MVC.
- At 5:34 PM, he was given the same ED room as his father and sister.
- At 5:56 PM, his weight was measured and recorded as "actual" but did not indicate how the weight was obtained.
- At 6:46 PM, a Wong-Baker Faces Pain Scale showed "hurts little bit" Documentation did not show the pain location.
- At 6:47 PM, a primary assessment of airway, breathing, circulation and disability was WDL.
- At 7:22 PM, the history and physical showed Patient #3 did not want to stand on his own, which he typically did. There was no musculoskeletal system assessment.
- At 8:12 PM, x-rays of the right knee, chest and pelvis showed no acute findings.
- At 8:15 PM, a pain assessment showed "hurts little bit" and Patient #3 refused VS.
- At 8:51 PM, he was discharged and carried out by his father.
- The provider failed to obtain an appropriate history and physical which required a review of systems and a complete physical examination in accordance with hospital's Medical Staff Rules and Regulations.
- The physician's physical examination failed to document a musculoskeletal/extremities examination and whether or not the patient was able to ambulate in the ED.
- Observations revealed the patient had some bruising to the front of the scalp and did not want to stand following the accident.
- A partial lower extremity physical exam was verbally recalled by the provider, this was not documented in the medical record, and the provider confirmed he did not have the patient ambulate.
- The provider confirmed that swelling and bruising could not always be seen at first and bearing weight would have told him more about the injuries. The Medical Director confirmed that a musculoskeletal assessment was missing in the documentation for Patient #3.
- There was no nursing secondary assessment, to assist the medical provider in the management and evaluation of Patient #2's care, in accordance with the hospital's Medical Staff Rules and Regulations.
- An appropriate MSE, in order to determine if an EMC existed was not conducted in accordance with the hospital's EMTALA policy.

During an interview on 01/29/25 at 10:03 AM, Staff I, ED Medical Director, stated that he acknowledged a musculoskeletal assessment was missing in the documentation for Patients #2 and Patient #3. He stated that was an oversight and a learning opportunity. He expected nursing to complete and document a secondary assessment. He expected a skin assessment following a MVC.

During an interview on 01/29/25 at 1:29 PM, Staff M, Physician, stated that he documented his assessments. If a nurse did an assessment, he saw that in the medical record. He remembered the family and was concerned the children did not want to stand. He palpated both children which lead to the x-rays. Patient #3 had a tender knee, but he could not remember if he tried touching his lower leg. He did remember visualizing under his pants legs. Patient #2 spoke more, denied pain and seemed stoic. Swelling and bruising could not always be seen at first and palpating had to be hard sometimes, so bearing weight would have told him more about the injuries.

During an interview on 01/29/25 at 12:17, Staff C, Chief Nursing Officer (CNO), stated that visualizing a patient fully clothed is a limited assessment and he expected further assessment. Those assessments were done by engaging the parents to help or with a doctor. If there were abnormal findings, he expected that to be documented and discussed with the provider. If an assessment would have done harm, he expected the refusal to be documented and the oncoming nurse to try again. Refusals were to be documented. Assessments were fundamental to nursing practice. If the nurse was unable, he expected an assessment from the provider to include palpation and visualization under the clothing.

During an interview on 01/29/25 at 11:10 AM, Staff B, ED Manager, stated that the triage (process of determining the priority of a patient's treatment based on the severity of their condition) nurse completed screenings and documented the chief complaint which led to a more focused assessment. She expected a visual and palpable (using one's hands to assess the body) assessment was performed. Nurses could join a physician to do a visual and palpable assessment together if a patient was in distress. The nurse and provider documented their own assessment findings. She expected a musculoskeletal, skin and head-to-toe assessment (complete assessment of all patient body systems, including heart, lung, skin, VS, etc.). She expected the assessment was documented, even if it was within normal limits, to show the assessment was done. If a patient refused an assessment, she expected the nurse to elicit the family's help. She expected that a pediatric patient's weight was documented as either "actual" or with a written note to describe how the weight was obtained. If a patient refused to stand on the scale the refusal should be documented.

During an interview on 01/29/25 at 11:43 AM, Staff K, ED RN, stated that triage nurses documented chief complaints and assessments if anything was abnormal. Pediatric patients were weighed using a standing scale. Triage nurses made notes if patients refused to stand and reported that to the primary nurse. She assessed if a patient was moving their arms and legs after a MVC and expected a musculoskeletal assessment. She documented if the patient screamed during palpation. She remembered Patients #2 and Patient #3 did not want to interact with staff and got upset when they came near. She performed a general appearance assessment from across the room but did not palpate their bodies or visualize their skin under their clothing. She waited for the provider to do an assessment with him. She saw the doctor go into the room but did not recall why she didn't go with him. If she was unable to perform an assessment, she passed that on to the next nurse. She expected nurses to perform a focused assessment related to the patient's chief complaint or other known issues.

During an interview on 01/29/25 at 1:15 PM, Staff L, ED RN, stated that she performed a focused system assessment based on their chief complaint. The best way to assess was to palpate the skin where they were injured and document the findings as normal or abnormal. She noted patient refusals in the medical record. She remembered caring for the family as an oncoming nurse after shift change. She did a visual pain assessment but not a head-to-toe assessment on her own or with the doctor. She thought the MSE was done prior to her arrival.


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