Based on staff and other interviews and record reviews, the hospital failed to comply with the requirements of §489.24 by: Failure to provide a medical screening examination when Patient 1 arrived at the emergency room with a sustained leg fracture. (Refer to A 2406).

Based on record review and staff interview, the emergency room staff failed to provide Patient 1 a medical examination to deter ermine whether or not the leg fracture sustained from an injury was an emergency medical condition. The failure to provide medical examination potentially delayed the necessary medical treatment to the injured patient. Findings: A review of the ambulance run report, dated 11/5/15, documented by the paramedics, indicated that the paramedics team picked up Patient 1 at 1:33 AM, 11/5/15 on route to the hospital ' s Emergency Department (ED). The chief concern was an " open left lower leg fracture with deformity secondary to jumping over a railing and striking his lower leg on piping. Good distal PMS (Pulse, Motor, Sensation - that is - intact blood vessels, muscles and nerves). " The ambulance report continues to say that the " patient was initially transported to [hospital] ED with base approval. Upon entry to [hospital] our patient was denied service because of his injury, base was re-contacted and patient was transported to [another hospital]. " A review of the Emergency Medical Service (EMS) Incident Report: Refusal of Service, signed by the paramedics and dated 11/5/15, indicated, " We proceeded into the ER (emergency room ) to have him admitted . The triage nurse told us that they would not accept the patient and stated ' we will just have to transfer him anyway ' , and, ' we cannot do anything for that here ' . We explained to him that that a lower extremity fracture without neurological or vascular compromise was not trauma criteria and we were to take this patient to the Most Accessible Receiving Center. After a few minutes the triage nurse returned and waved off the admitting clerk and told us that the doctor would not accept the patient from us and that we needed to take him somewhere else. We loaded the patient into our ambulance and transported him to [another hospital emergency department]. " A review of Patient 1 ' s medical record, in a progress note dated 11/5/15, 01:44, RN1 documented, " Received call from dispatch stating they had a patient with a compound fracture. Nurse on phone notified dispatch that patient appears to be a trauma patient and may need a higher level of care. Dispatch informed nurse that they will contact ambulance unit to redirect. Several minutes later, ambulance arrived at [hospital] with patient, admitting representative registered patient, inquired by nurse whether paramedics received a call from dispatch to redirect patient. Paramedics did not have a response. Prior to triaging patient, ambulance left facility with patient. " During an interview on 4/20/16, at 10 AM, RN 1 stated that he "informed dispatch that the hospital does not have resources to provide care other than to stabilize and transfer to a a higher level of care, if possible to re-direct."He said that dispatch agreed to re-direct the patient to ED 2 which is a designated trauma center. RN 1 explained that this hospital does not have an orthopedic surgeon on call during the night shift and Patient 1 may need surgery for the fracture. RN 1 continued to explain that when the ambulance came a few minutes later, he asked them if they had received a call from dispatch to redirect because the patient appeared to be a trauma patient. RN 1 said he told the paramedics, "We will register the patient, take vital signs while we look for an available bed in the ED, which was completely full at the time. When I came back to the ambulance entry, they were ready to take the patient to a different hospital. They said, 'Is it ok? I said, 'Ok." A review of the hospital ' s Policy and Procedure titled, " Admission of Patients to the Emergency Department " , dated 4/2013, indicated it was the hospital ' s policy that all patients requesting emergency medical services would be given a medical screening examination and evaluation by a physician to determine if an emergency medical condition existed.