Wellington Regional Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 29151 Based on clinical record review, surveillance video review, policy review and staff interview, it was determined, the hospital failed to adopt and enforce a policy to ensure compliance with the EMTALA requirements at 42 CFR 489.20 and 489.24, as evidenced by failure to provide an appropriate Medical Screening Exam (MSE) to determine the extent of an emergency medical condition, and to provide care and treatment to relieve or eliminate such condition. This failure affected 1 of 21 sampled patients (Patient #21). The findings included: Based on clinical record review, surveillance video review and interviews conducted on 04/14/25 and 04/15/25, the hospital failed to provide written evidence that a patient, who presented to the Emergency Department (ED) seeking medical care, was registered in the ED central log and received a medical screening exam and stabilization treatment. These failures affected Patient #21 as detailed in citation A 2406.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 29151 Based on record review, video surveillance review, policy review and interview, it was determined the facility failed to ensure the central log included all individuals who presented to the Emergency Department (ED) seeking treatment. This failure affected one (1) of 21 sample patients (Patient #21). The findings included: Review of the facility policy, titled, EMTALA (Emergency Medical Treatment and Labor Act), last revised 08/03/22, documents: “CENTRAL LOG POLICY Central Log Procedure. a. Hospital will maintain a Central Log either in an electronic format in Cerner (Cerner ED Activity Log) or on paper. The report is reconciled on a regular basis. b. All ancillary logs maintained by all Hospital Departments, including the DED (Dedicated Emergency Department) are incorporated by reference and become part of Hospital’s EMTALA Central Log. c. The Central Log must contain at a minimum, the name of the individual, the date, time and means of the individual’s arrival, the individual’s age, the individual’s sex, the individual’s record number, the nature of the individual’s complaint, the individual’s disposition, the individual’s time of departure, and whether the individual: refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was stabilized and discharged; or expired. d. A log entry for all individuals protected under EMTALA should be made by the appropriate individual. Further, in non-DED departments of the hospital where an individual may present with an EMC, the department will provide the necessary information from the point of contact to the DED for logging purposes. e. The Central Log of individuals protected by EMTALA will be available within a reasonable amount of time for surveyor review and must be retained for a minimum of five years or as delineated by State regulation from the date of disposition of the individual.” Review of the surveillance video conducted on 04/14/25 at approximately 12 noon while accompanied by the Director of the ED, (Emergency Department), the ED Medical Director and the Director of Women Services revealed on 03/11/25 at 1:01 AM, a female carrying a baby in a car seat, entering the ED. The female interacted with the ED staff (Identified as Staff C, a nurse extern). The Staff C and the female went out the door with a wheelchair. A few seconds later, a female in a wheelchair (identified as Patient #21), a male (identified as Patient #21’ significant other) and the female carrying the baby (identified as Patient #21’s sister) entered the ED and interacted with Staff C and the security guard. The patient’s significant other and sister presented identification and received a visitor pass. During the video Staff C is seen contacting someone over the phone. Staff B, the Triage Nurse, is also seen interacting with the patient and family members and contacting someone over the phone. The video shows multiple interactions between the staff and the patient. Patient #21 left the facility without being seen or examined on 03/11/25 at 1:27 AM. Review of the facility Emergency Department Central Logs dated 03/11/25 revealed the hospital staff failed to maintain a record of every patient presenting to the emergency department. There was no record of Patient #21 in the Central Log. There is no record of any patient refusing care. A phone interview with Staff B, the Triage Nurse, was conducted on 04/15/25 at 8:38 AM while accompanied by the ED Director, revealed his recollection of events. Patient #21 came in with two family members, and said she was here for obstetrics services (OB ED). Staff B recalled the patient had birthed the baby and was saying something about needing sutures and a procedure and that she was not here to check in for the emergency room. The family explained Patient #21’s midwife wanted the patient to be seen by the OB doctor. Staff B contacted the OB ED and was told that the patient had to go through the regular ED. The interview continued and then ED Director kept asking Staff B if he tried to register the patient and Staff B, stated yes, but the patient did not want to be registered, the family members kept saying the patient was here for OB care. Staff B stated the family called the patient’s midwife and they were told to leave and go to another hospital. Staff B stated the interaction was not escalated, because the midwife told the patient to leave and go to another hospital. Staff B confirmed Patient #21, who presented at the emergency department seeking care after giving birth and requesting obstetric services, was not registered on the hospital ED central logs. A phone interview was conducted with Staff C, the Nurse Extern (NE), who greeted Patient # 21, on 04/15/25 10:05 AM. Staff C explained Patient #21 presented with a friend, saying she just delivered a baby a few hours ago and she needed to have her vaginal tear repaired. Staff C called the OB ED and the charge nurse told her the patient needed to be seen in the ED first and when she told the patient’s sister, she got upset and said the midwife from the birth center told her to leave and go to another hospital. The patient did not speak very much, the sister and significant other were doing the talking, and the patient did not want to be registered and left. Staff C confirmed Patient #21, who presented at the emergency department seeking care after giving birth and requesting obstetric services, was not registered on the hospital central ED logs.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 29151 Based on policy review, record review, surveillance video review and interview, it was determined the hospital failed to substantiate the provision of emergency services for one (1) of 21 sampled patients (Patient #21) as evidenced by lack of a medical screening exam (MSE) to determine if a medical condition existed and if so to provide care and treatment to relieve or eliminate the condition. The findings included: Facility policy, titled, EMTALA (Emergency Medical Treatment and Labor Act), last revised 08/03/22 documents: Review of the “Emergency Medical Condition (“EMC”) means: l . A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part; or 3. With respect to a pregnant woman who is having contractions: a. that there is inadequate time to effect a safe transfer to another hospital before delivery; or b. that transfer may pose a threat to the health or safety of the woman or the unborn child; or N. Medical Screening Examination (“MSE”) is the process (which begins with the initial collection of an individual’s vital signs and other medical data collection) required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists, or a woman is in labor. Screening is to be conducted to the extent necessary, by physicians and/or other QMP to determine whether an EMC exists. With respect to an individual with psychiatric symptoms, an MSE consists of both a medical and psychiatric screening. Procedure: A. When a Medical Screening Examination is Required An individual MUST receive an MSE, within the capabilities of Hospital’s DED, including ancillary services routinely available, to determine whether or not an EMC exists, or with respect to a pregnant woman having contractions, whether the woman is in labor, and whether or not the treatment requested is explicitly for an emergency condition if: l . The individual comes to Hospital’s DED, including by transfer from another hospital, and a request is made on his or her behalf for examination or treatment for a medical condition. 2. The individual arrives on the Hospital Property other than a DED and a request is made on the individual’s behalf for examination or treatment for an EMC. 3. The individual arrives on the Hospital Property, either in the DED or Hospital Property other than the DED, and no request is made for evaluation or treatment, but the appearance or behavior of the individual would cause a Prudent Layperson Observer to believe that the individual needed such examination or treatment and that the individual would request that examination or treatment if he or she were able to do so.” Review of the surveillance video conducted on 04/14/25 at approximately 12 noon while accompanied by the Director of the ED (Emergency Director), the ED Medical Director and the Director of Women Services revealed on 03/11/25 at 1:01 AM, a female carrying a baby in a car seat, entering the ED, the female interacted with the ED staff (Identified as Staff C, a nurse extern). Staff C and the female went out the door with a wheelchair. A few seconds later, a female in a wheelchair (identified as Patient #21), a male (identified as Patient #21’ significant other) and the female carrying the baby (identified as Patient #21’s sister) entered the ED and interacted with the Staff C and the security guard. The patient’s significant other and sister presented identification and received a visitor pass. During the video, Staff C is seeing contacting someone over the phone. Staff B, the Triage Nurse, is also seen interacting with the patient and family members and contacting someone over the phone. The video shows multiple interactions between the staff and the patient. Patient #21 left the facility without being seen for a MSE on 03/11/25 at 1:27 AM. A phone interview with Staff A, OBED (obstetrics emergency department) Charge Nurse was conducted on 04/14/25 at 12:23 PM, while accompanied by the Director of Women Services. Staff A explained she was on duty on 03/11/25 and recalled the ED calling the unit regarding Patient #21, and the physician intercepted the call. Staff A overheard the conversation, and the physician told the ED that she was not seeing the patient, that is was illegal for the midwife to send a patient with a 3rd degree laceration and asked where was the midwife’s back-up doctor for the birth center. At the same time, the midwife from the birth center called the unit, then the physician spoke to the midwife and stated that she was going to report her for sending the patient in this condition. The charge nurse stated the patient was not seen. The ED told them that the patient was signing out AMA and was going to another hospital. The patient never came to the OB ED and when asked, the charge nurse stated she did not report the event to her leadership, she thought the ED staff was going to do it and she is aware that all patients seeking care, have to be seen, but again the physician said she would not see the patient and there was nothing else she could do. A phone interview with Staff B, the Triage Nurse, was conducted on 04/15/25 at 8:38 AM while accompanied by the ED Director, that revealed his recollection of events: Patient #21 came in with two family members, and said she was here for obstetrics care (OB ED). Staff B recalled the patient had birthed the baby and was saying something about needing sutures and a procedure and that she was not here to check in for the emergency room. The family explained that Patient #21’s midwife wanted the patient to be seen by the OB doctor. Staff B contacted the OB ED and was told that the patient had to go through the regular ED. The family members kept saying the patient was here for OB care and then the family called the patient’s midwife and were told to leave and go to another hospital. A phone interview was conducted with OBGYN (obstetrics and gynecology physician) on 04/15/25 at 9:14 AM, while accompanied by the ED Medical Director revealed, the OBGYN was on duty on 03/11/25. It was night shift, very busy night, she can’t recall all the details but somehow there was a call, an issue with a patient from a birth center and the midwife did not know what to do after she sustained a laceration after the baby’s birth. At some point, the midwife called the unit, she spoke to her and told her that she was abandoning her patient, she was floored how they can run such an unqualified institution, that she needed to call her supervising provider to handle the situation. The OBGYN asked for the midwife’s name and license and the midwife gave her name but would not give her license, “she did not want to be used for something that is obviously wrong”. The OBGYN added that the midwife called the patient and asked the patient to sign herself out AMA (against medical advice) from the hospital and to go to Hospital A. The OBGYN was asked if she had spoken to the ED nurse and confirmed she did. She told Staff B, “she did not want to see this patient, she did not want to deal with it”. The OBGYN was asked if she knew where the patient was at the time of the conversation with Staff B and stated she did not know. The ED Medical Director, then intervened and asked the OBGYN if she refused the patient and replied with a no, adding she told the ED nurse the patient needed to go through the ED. Interview with the Nurse Midwife was conducted on 04/16/25 at 1:02 PM that revealed Patient #21 was her patient at the birth center. After delivery, the patient sustained a laceration, based on her training and scope of practice, she was not able to repair it, and the patient was discharged with instructions to go to the hospital to repair the tear. The patient chose Wellington Regional Medical Center (WRMC). The Midwife called the hospital (WRMC) and spoke to the nurse, she gave her the name of the patient, what had happened and what she needed, and the nurse stated it was okay to send her just to make sure she had paperwork. Then she received a call from the patient and family members stating the hospital would not see her and they are denying her care. The midwife then called the OBGYN physician, and was told she was not touching her patient, that she was unethical, and the midwife tried to explain to the OBGYN her scope of practice, but the physician was not interested in seeing her patient. After the conversation, she then called Hospital A and asked them to see her patient. Hospital A agreed, and she proceeded to call her patient back and advised them that if WRMC wouldn’t treat her, she should go to Hospital A to seek the care that she required. The investigation determined Patient #21 presented to the ED seeking emergency care after complications of birth, vaginal laceration, and the hospital failed to provide a medical screening exam. Review of Hospital A records documented Patient #21 presented to the ED on 03/11/25 at 03:11 AM. The medical screening exam documents Patient #21, “a 31-year-old female, first pregnancy and delivery. Postpartum day #0 after spontaneous vaginal delivery at a birth center. Presents for evaluation of perineum and repair of vaginal laceration. Patient reports that she was in labor for less than twenty-four hours and delivered at 9:30 PM today. She was told by her midwife that the vaginal tear was beyond her expertise and sent to Wellington Regional Hospital for evaluation and repair. Patient presented to Wellington Regional Hospital ED and was told that the OB there refused to see her, that they could not treat her and told her to leave. They went back to the birth center, now with a significant delay of care. The patient was then sent to this hospital, ED by her midwife. The patient underwent a laceration repair at 4:44 AM.””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 29151 Based on clinical record review, policy review and staff interview, the hospital failed to adopt and enforce policies to ensure compliance with the Emergency Medical Treatment and Labor Act (EMTALA) requirements at 42 CFR 489.20 and 489.24, as evidenced by failure to provide an appropriate Medical Screening Exam (MSE) to determine the extent of an emergency medical condition (EMC), and to provide care and treatment to relieve or eliminate such condition. In addition, if such condition required services that were not available at Hospital A, the hospital failed to implement a transfer to a hospital with the necessary services available. This failure affected 1 of 20 sampled patients (Patient #1). The findings included: Based on clinical record review, policy review and interview conducted on 08/06/24 and 08/07/24, Hospital A failed to provide an appropriate medical screening exam to Patient #1, who presented to the Emergency Department (ED) seeking medical care for facial pain, swelling, and dental abscess. Patient #1 was discharged from Hospital A and then presented to the ED at Hospital B, 49 minutes after being discharged from Hospital A, with the same symptoms, The patient was subsequently diagnosed with Facial Cellulitis, Parapharyngeal swelling, Dental abscess and Leukocytosis, requiring specialty consultations, inpatient admission, surgical intervention and a long course of intravenous antibiotic therapy. Cross Refer to evidence of noncompliance at A2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 29151 Based on policy review, record review, and interview, the hospital failed to substantiate the provision of emergency services for 1 of 20 sampled patients (Patient #1) as evidenced by failure to perform an appropriate Medical Screening Exam (MSE) to determine if a medical condition existed, and if so to provide care and treatment to relieve or eliminate the condition. The findings included: Review of the hospital’s policy, titled, EMTALA, {Emergency Medical Treatment and Labor Act], last revised 08/03/22, documented, in part: “Hospital will provide an individual with an appropriate Medical Screening Examination within the Capability of Hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an Emergency Medical Condition exists, regardless of the individual’s ability to pay, when: (a) there has been a request for medical care by an individual within a Dedicated Emergency Department; (b) an individual requests emergency medical care on Hospital Property, other than in a Dedicated Emergency Department; or (c) a Prudent Layperson Observer would recognize that an individual in a Dedicated Emergency Department or on Hospital Property requires emergency treatment or examination, though no request for treatment is made.” Clinical record review conducted on 08/06/24 and 08/07/24 revealed Patient #1 presented to the Emergency Department (ED) on 03/14/24 at 1:50 PM seeking care for complaint of “right-side facial pain and swelling, the patient was diagnosed with dental abscess and was given antibiotic. Patient states getting worse”. The patient was triaged at 1:59 PM as a priority 4, non-urgent. The vital signs noted temperature 98.6, pulse 106, respiration 18, blood pressure 125/70, oxygen saturation 97% and pain level 5 of 10. The Medical Screening Exam (MSE) conducted on 03/14/24 at 2:06 PM documented a History of Present Illness (HPI) as, “the patient presents with facial pain and swelling for the past few days. Patient denies any fever, chills, nausea, vomiting, chest pain, shortness of breath or any other chief complaint or trauma. The onset was just prior to arrival. The course duration of symptoms is constant. The character of symptoms is pain. The degree of pain at present is none. The exacerbating factor is none. The relieving factor is none. Risk factors consist of none. Prior episodes none and therapy today none.” It was noted the nursing triage notes contained minimal information, did not address previous procedures, length of time of the symptoms, when the antibiotic therapy was started and why the patient felt it was getting worse. The MSE included a physical examination, as follows: Ear/Nose/Mouth/Throat negative except as documented in HPI. Surgical history noted no active procedure history items have been selected or recorded. Physical examination documented Ear/Nose Mouth and Throat: tympanic membranes clear. The differential diagnosis noted Facial pain and Sinusitis. Patient #1 received Morphine and Clindamycin and blood workups included a complete blood count, chemistry and blood cultures. Laboratory results indicated elevated white blood count 16.76 (normal range is 4.5-10.5) and elevated liver function. Patient #1 was discharged home on 03/14/24 at 5:43 PM with prescription for pain medicine and follow up with oral surgeon. The physical exam documented many non-pertinent findings that were within normal limits. The area of focus based on the patient complaint noted EAR/NOSE/MOUTH/THROAT findings as tympanic membranes clear. There is no other documentation regarding the swelling of the face, degree of swelling, mouth or tongue examination, drainage or pain. Review of the Provider reexamination noted at 3:26 PM, documented, “patient verbalizes feeling much better at this time. Patient requesting to go home. Advised immediately return to ED if signs and symptoms return or worsen”. The record documented the provider ordered Antibiotic and blood cultures at the same time, 3:26 PM; Morphine was ordered at 4:00 PM; and additional blood work was ordered at 4:19 PM. The acuity level was updated to urgent. It was documented that Patient #1 left the ED on 03/14/24 at 5:43 PM with a prescription for pain management and follow up instruction with an oral surgeon. There were no vital signs or pain reassessment upon discharge. Patient #1 left Hospital A on 03/14/24 at 5:43 PM and presented to Hospital B on 03/14/24 at 6:32 PM, approximately 18.5 miles away. At Hospital B, Patient #1 received a Medical Screening Exam at 6:41 PM, an hour later. Patient #1 was diagnosed with facial cellulitis, complicated right mandibular infected dental implant with facial space involvement, and significant leukocytosis, pain level noted to be 10 of 10. Patient #1 was subsequently admitted for specialty consultations, intravenous antibiotic therapy and incision and drainage. The investigation ascertained the medical screening exam completed at Hospital A did not identify the degree of Patient #1’s medical condition requiring diagnostic imaging and specialty consultations to alleviate the condition. Interview with the Emergency Department Medical Director (ED MD) on 08/06/24 at 1:48 PM revealed in general, complaints of dental pain do not require imaging, unless there are significant findings. There are risks associated with imaging and radiation exposure. The provider will look for evidence of Ludwig, abscess formation, or fluid collection. In addition, the providers do a general assessment to include does the patient looks ill, do they have abnormal vital signs, it is a comprehensive decision. In most cases, tooth infections need to be treated with antibiotic, and a drill. The ED MD reviewed Patient #1’s clinical record and explained the care provided was in accordance to the patient’s presentation. The assessment did not indicate deep infection of the face, no significant findings are hinted on in the chart and explained the elevated white blood cell count is not a definite sign of infection, but it means stress to the body. The Medical Director agreed with the care provided. Interview with the Advanced Registered Nurse Practitioner (ARNP), who examined Patient #1, was conducted on 08/07/24 at 8:33 AM. The ARNP reviewed the record for Patient #1 and had limited recollection. The patient presented with dental pain, he performed a physical examination and stated that he charts by exception, he did not document swelling or edema or any other significant findings, if any abnormal signs are seen he would have documented it. The ARNP also explained he typically does not order blood work for dental pain complaints, he believes the patient wanted the blood work, and that is why it was done. He did not recall the patient asking for imaging studies or advising the patient to seek medical care at another hospital, the patient was discharged home with prescriptions and follow up care with an oral surgeon. The investigation determined Hospital A failed to provide an appropriate medical screening exam to Patient #1 resulting in a secondary visit to the ED at another hospital (Hospital B) within 49 minutes of discharge.”