Lack of “Real” MSE Leads To EMTALA Citations

Patient #1 presented to the ED seeking an MRI, but the hospital did not have the mobile MRI on-site that day. The patient had seen an eye doctor earlier in the day who had been concerned following an eye exam and recommended the patient go to a hospital for an MRI. The RN then asked the doctor to see the patient. The doctor looked into the eye and took the patient’s pulse, and then suggested they go to a facility with an MRI to rule out possible stroke. The physician indicated that the patient was given the option to be evaluated or go elsewhere.

No refusal of care was noted. No medical screening was provided. No transfer arrangements were made with the destination hospital. No medical record was generated. The patient went to the destination hospital by private vehicle. Following a complaint by the receiving hospital, the physician reportedly generated a note on the visit.The hospital was cited for failure to provide a medical screening examination. (Tag C2406)

Patient #2 presented with complaints of urinating blood. Although the patient saw a physician, an MSE was not documented. The hospital was cited for failure to provide a medical screening examination. (Tag C2406)

Comment:

The incident involving patient #1 could have been cited on multiple additional grounds if the site surveyor had wished to load on violations, including a failure to stabilize, improper transfer, and lack of medical record.

Other technicalities might have also been added, brought on by comments by the doctor such as “Everything is written on my form. I have nothing else to say.” After saying he thought the patient was potentially having a stroke, he is reported to have commented, “No other focal symptoms were displayed. It could be Lyme disease for all I know.” Physicians must be very careful if asked to talk to surveyors, or they can often alienate the investigator and make matters much worse.

C2406-WI-2013-9-23