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Based on review of medical records (MR), facility policy, Medical Staff Rules and Regulations, and staff interviews, it was determined the facility failed to provide necessary stabilizing treatment for an emergency medical condition in one of eleven MRs reviewed with falls, including Patient Identifier (PI) # 1.

This deficient finding had the potential to negatively affect all patients served by the facility's
Emergency Department.

Findings include:

Patient #1 is an 83 year old individual who presented for evaluation after an unwitnessed mechanical ground level fall. He had a workup and discovery of several traumatic injuries. Of these, a facial laceration and humeral fracture were the only injuries addressed by the provider. Several other injuries including traumatic subdural and subarachnoid hemorrhages, and a femoral neck fracture were discovered on the workup but were not addressed; the patient had inadequate stabilizing treatment for these emergency medical conditions.

Cross Refer to A2407 for findings.

Based on review of medical records (MR), facility policy, Medical Staff Rules and Regulations, and staff interviews, it was determined the hospital failed to provide necessary stabilizing treatment for an emergency medical condition.

This deficient practice affected Patient Identifier (PI) # 1, one of eleven patients reviewed who presented to the Emergency Department (ED) after a fall, and had the potential to negatively affect all patients seeking treatment at this ED.

Findings include:

Medical Staff Rules and Regulations

Revised: July 2022

...Section VI Emergency Medical Screening, Treatment, Transfer, and On-Call Roster Policy

...6.1 Screening, Treatment, and Transfer

...6.1(b) Stabilization:

(1) Any individual experiencing an Emergency Medical Condition (EMC) must be stabilized prior to transfer or discharge...

(2) A patient is stable for discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions or when the patient requires no further treatment and the treating physician has provided written documentation of his/her findings...

Policy Title: Medical Staff Rules and Regulations Attachment B: Emergency Medical Treatment and Labor Act (EMTALA) Index...

EMTALA Medical Screening Stabilization Policy

Revised: January 2025

Policy: Each hospital must have written guidelines outlining the requirements for appropriate medical screening and stabilization procedures which comply with applicable federal and state law.

...5. A hospital, regardless of size or patient mix, must provide screening and stabilizing treatment within the scope of its capabilities...

7. Medical Screening Examination (MSE) is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or an appropriate transfer occurs. There should be evidence of this evaluation prior to discharge or transfer...

PI # 1 presented to the ED on 5/12/25 at 12:49 PM via ambulance after an unwitnessed fall outside. He/she had a laceration on the right upper eyebrow with swelling per the paramedic's documentation on the Prehospital Care Report Summary.

Review of the Nurse's Notes revealed the following documentation at 12:54 PM: "Complains of pain in head(ache) and right hip pain currently 5/10 on the pain scale. Patient appears uncomfortable."

Review of the Physician's Orders at 1:56 PM revealed orders for Xrays of the chest, right elbow, right hip and pelvis, and computed tomography (CT) of the head, neck, and face without contrast.

The Xray of the right hip and pelvis was interpreted at 2:57 PM by the radiologist. It showed a "Nondisplaced fracture of the anatomic neck of the proximal right femur." There is no documentation that the result was reviewed by Employee Identifier (EI) # 1, Nurse Practitioner, or by EI # 2, the physician covering the ED on 5/12/25.

The CT of the head, neck, and face was interpreted by EI # 3, Radiologist, at 3:46 PM. It showed, "Posttraumatic bifrontal subdural hematomas with small volume subarachnoid hemorrhage and right periorbital edema and/or hematoma." There is no documentation the results were reviewed by EI # 1 or EI # 2 prior to discharging the patient home.

A discharge order was entered for PI # 1 at 10:11 PM by EI # 1. PI # 1's discharge diagnoses included:

1. Other fracture of shaft of the right humerus, initial encounter for closed fracture.
2. Laceration without foreign body of scalp and facial laceration above the right eyebrow.

Discharge instructions for PI # 1 were to follow-up with the orthopedist on 5/13/25 at 8:30 AM and to follow-up with his/her primary care provider in two to three days. PI # 1 was also instructed to return to the ED for suture removal in ten days.

An interview was conducted on 7/10/25 at 3:33 PM with EI # 2. EI # 2 was asked whose responsibility it was to review the results of all ordered tests prior to discharge, and he/she replied, "the primary provider of the patient." EI # 2 was also asked how a patient with the same CT findings would be treated. EI # 2 replied, "It would be reasonable to transfer because we do not have neurosurgery on site. We would call a higher level of care facility and speak with neurosurgery for a transfer discussion." EI # 2 was also asked if it was his/her professional opinion that PI # 1 received a complete MSE and stabilizing treatment. EI # 2 responded, "No. All of the issues were not addressed prior to discharge."

An interview was conducted on 7/10/25 at 3:27 PM with EI # 1. EI # 1 was asked when he/she was first made aware of the results of the CT of the head, neck, and face. EI # 1 stated, "it was days later." When asked whose responsibility it was to review diagnostic imaging results in the ED, EI # 1 responded, "myself and the physician. For PI # 1, it would be me and EI # 2 and the radiologist obviously."

Patient #1 had inadequate stabilizing treatment for all identified emergency medical conditions prior to discharge.