HospitalInspections.org

Based on interviews and record review the facility failed to ensure Medical Screening Examinations (MSE) were provided by qualified professionals and were complete in 4 (#'s 2, 14, 24 and 30) of 31 patients.


This deficient practice had the potential to affect all patients presented to the Emergency Room.


Review of a facility "Cobra Guidelines" policy dated 04/2011 revealed:

" All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the Hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic."

Medical screening examinations (MSE) should include "Complete documentation of the medical screening exam."

Review of facility policies revealed there were no Medical Staff rules and regulations or policies addressing who was responsible for performing MSEs.

During an interview on 12/03/12 at 12:37 p.m., the RN CNO reported "the physicians are the only staff qualified to perform medical screenings. The nurses had no competencies for performing medical screenings."


Review of a facility "Transfer Policy" dated 03/2006 revealed the patient must be:

a.) evaluated by a physician who is present in the hospital at the time the patient present or is presented; or
b.) evaluated by a staff physician on call....."


Review of a facility interoffice memorandum dated 02/27/12 revealed "effective immediately the ED (Emergency Department) at this location will now start the MSE Process. There will be no alternatives to the policy. When a patient present themselves to the ED, they will fill out the form that they currently fill out stating why they are there. The Nurse will triage the patient as they have been doing, except the Nurse will leave the patient in the triage room and notify the physician that the patient is in waiting. The physician will examine the triage form that the nurse filled out, then the physician will do an examination of the the vitals, head, ears, eyes, nose, and throat and if the patient does not meet the Emergent specifications to be further treated in the Emergency Room, the Physician will receive the Medical Screening Examination sheet and will mark either Emergent or Non Emergent and present the patient to the Emergency Room Registration personnel, who will enter the patient into the system."



Review of an ED nursing record dated 08/08/12 revealed Patient #24 was a 21 year old female who presented with complaints of having "contractions q (every) 5 min X 20 min" at 10:10 p.m.. The patient was triaged by nursing at 10:10 p.m.

Review of admission consent forms dated 08/08/12 revealed Patient #24 signed payment information at 10:22 pm and information on her Medicaid eligibility was obtained at 10:23 p.m.

Review of the ED nursing record dated 08/08/12 revealed Patient #24 was taken to an ED room at 10:25 p.m.. There was documentation they were "awaiting for MD arrival."

Review of the ED nursing record dated 08/08/12 revealed at 11:05 p.m. a cervical exam was performed by the Emergency room Medical Doctor (MD) (Staff #10).

Review of the physician assessment dated 08/08/12 revealed he had reviewed the nursing assessment and vital signs that were taken. The physician documented the patient was 38 weeks pregnant and had cramping in the lower abdomen, increased frequency in past few hours, increased pain in 20 minutes, sharp pain, (+ ) leakage of fluid and (-) bleeding. The pelvic exam revealed Patient #24 had dilated 3.5-4.0 centimeters.

The physician's MSE was incomplete as it omitted cruial documentation including a history of fluid leakage. There is no documentation of any pooling of fluid or if testing was performed to identify spontaneous rupture of membranes. The patient was a 3.5 to 4 cm. dilated on cervical examination and was on early stage of labor despite lack of subjective contraction pain following examination. There was no external or internal fetal monitoring done to check for contractions and fetal reactivity or clinical attempt to check for contractions. There was no objective testing for spontaneous rupture of membrane done. The ptient was at risk for precipitous delivery or possible amnionitis from spotaneous rupture of membranes. Any of these could have been life-threatening to the mother or the fetus.



Review of an ED nursing record dated 08/29/12 revealed Patient #14 was a 29 year old male who presented with complaints of "cold symptoms" at 7:45 p.m.. There was a documented assessment performed by a Registered Nurse (RN), but there was no MSE by a physician on the chart. There was a consent on the record which had the following documentation:

"I understand that I have received a Medical Screen Examination by the Physician on duty in the Emergency Department. Based on the Physician's evaluation, I have been informed by Physician that my condition does not require emergency intervention. I also understand that I am not being refused treatment in the Emergency Department,......but that I must be responsible for the payment of services rendered for my Elective care in the Emergency Department"

The consent was signed by the physician and timed 8:34 p.m., but there was no patient signature of receiving this information.

Further review revealed the "Disposition" "Discharge Vitals", and "Condition" section was left blank.



Review of an ED nursing record dated 11/11/12 revealed Patient # 2 was a 2 year old male who presented with complaints of "congestion" at 5:00 p.m.. Patient #2 was triaged by nursing at 5:00 p.m. and was taken back to an ED room at 5:20 p.m. Patient #2 had no documentation of a completed MSE by a physician.



Review of an ED nursing record dated 12/01/12 revealed Patient #30 was a 21 year old female who presented with complaints of "sharp stomach pain radiating to the back." She had a pain level of 9.5 out of 10 ( 1 being minimal and 10 severe) at 8:00 p.m. Patient #30 was triaged by nursing at 8:00 p.m. and there was no documentation of being taken back to an ED room.

There was no documentation of a completed MSE by a physician on Patient #30.

Review of the ED nursing record dated 12/01/12 revealed Patient #30 left the hospital at 8:33p.m. There was no documentation of her disposition on discharge in the chart.

Review of the central log revealed Patient #30 left without being seen.


During an interview on 12/03/12 at 9:10 a.m., Staff #9 reported he was an ED physician. Staff #9 reported "the patients go to registration and then to triage. Triage was done in the ED room if the patient had, for example, chest pain. The RN did the assessment and filled out the detailed sheet in the triage room." Staff #9 reported they (meaning the physicians)
"did not do MSEs."

During an interview on 12/03/12 at 11:55 a.m., Staff #2 reported she was the ED director. Staff #2 reported" the physician's were doing the MSE. The nurses triage the patient and takes the assessment to the doctor and ask him if he wants to screen. After the nurses triage the patients and it is not an emergency, they are taken to the registration clerk. The clerk gets their insurance information and then they are taken back to the ED room. They just recently stopped asking for money before treatment. Recently there has been an increase in patients walking out because they do not have the insurance or the money to pay."