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Based on a review of the Bylaws, Rules and Regulations, medical record (MR) review, facility policy and procedure, and interviews with staff, it was determined the hospital failed to: provide an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department (ED) to determine whether an emergency medical condition existed for all patients who presented to the ED seeking care.

These deficient practices affected one of twenty sampled patients that presented to the ED for a MSE.

Findings included:

Cross Refer to findings at A 2406.

Based on review of medical records (MR), facility Bylaws, Rules, and Regulations, facility policy, and interviews with staff it was determined the hospital failed to:

1. Document who is qualified to perform a MSE.

2. Provide an appropriate medical screening examination (MSE) within the capability of the facility's emergency department (ED) to determine whether an emergency medical condition existed for all patients who presented to the ED.

This did affect one of twenty sampled ED patients reviewed, to include Patient Identifier (PI) # 9, and had the potential to affect all ED patients served by the facility.

Findings include:

A review of the facility Bylaws, Rules and Regulations revealed no documentation of who is qualified to perform the MSE.

A review of the facility's policy, EMTALA Guidelines, revealed no documentation of who is qualified to perform the MSE and the facility had no policy pertaining to the MSE.

PI # 9 presented to the facility ED on 3/31/25 at 12:06 PM with a chief complaint of threat to kill himself.

A review of the MR revealed no MSE was performed.

An interview was conducted on 7/24/25 at 11:26 AM with EI # 1, Chief Nursing Officer, and EI # 2, Associate Chief Nursing Officer, who confirmed there was no documentation the MSE was performed.