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Based on hospital policy review, medical record review, and physician interview the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

The hospital's Dedicated Emergency Department (DED) qualified medical professional failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 30 sampled DED patients (#10).

~ Cross refer to §489.24(r) and §489.24(c) Medical Screening Examination - Tag A2406

Based on hospital policy review, medical record reviews, and physician interviews the hospital's Dedicated Emergency Department (DED) qualified medical professional failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 30 sampled DED patients (#10).

The findings include:

Review on 01/17/2019 of the Transfer/EMTALA Policy approved on 01/2016 revealed "...II. MEDICAL SCREENING EXAMINATION (MSE) Individuals coming to the hospital requesting an examination or medical treatment must be provided a medical screening examination beyond initial triage. Triage is not equivalent to a medical screening examination ...A medical screening examination is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist ..."

Review of the closed DED medical record on 01/15/2019 for Patient #10, revealed a 53-year-old male that presented to the DED by private vehicle on 11/13/2018 at 1408 with a chief complaint of shortness of breath. Review revealed triage was initiated at 1417. Review of the triage nursing note revealed "Patient presents with shortness of breath x 5 days. Denies chest pain, fever, nausea, vomiting." Review revealed vital signs were obtained and were: Temperature (T) 97.8 oral, Pulse (P) 83, Respirations (R) 16, Blood Pressure (BP) 126/84 sitting, with a pulse oximetry of 95%. The patient was noted to have a pain score of 0 (on a scale of 0-10, with 10 being the worst pain). Patient #10 was assigned an acuity of 3. Review of the Provider Notes by Nurse Practitioner #1 (NP) revealed " ...Medical screening initiated and orders placed by (NP #1) 11/13/2018 2:17 PM HPI (History of Present illness): 53 y.o. male presents with shortness of breath onset 5 days ago. States he has been using his inhaler with no relief. Denies chest pain, fever, cough, nausea, or vomiting. Physical Exam: Constitutional: Alert and Oriented Patient seen and received a medical screening examination in triage. Appropriate orders have been initiated based on my brief physical examination and HPI. Patient sent to main ED (emergency department) for further evaluation and final disposition ..." Review revealed NP #1's note was cosigned by MD #2. Review revealed at 1418 NP#1 ordered: Troponin I, Comprehensive Metabolic Panel, Complete Blood Count and Differential, Chest X-ray, and EKG (Electrocardiogram-measures electrical activity of the heartbeat). Review of the EKG results at 1429 revealed "Sinus Rhythm Possible Left atrial enlargement Otherwise normal ..." Review of the Chest X-ray results at 1441 revealed "IMPRESSION: Borderline mild congestive heart failure ..." Review of the CBC results at 1504 revealed normal results except for: RDW 17.1% [Reference Range 11.5-15.5] and Eosinophil Absolute 1.3x10*3/uL [Reference Range 0.7-4.0]. Review revealed NP #1 ordered a B Type Natriuretic Peptide at 1522. Review of the CMP results at 1525 revealed normal lab values except for: BUN 28MG/DL [Ref Range 8-24], Glucose 104 MG/DL [Ref Range 70-99], and Creatinine 1.94 MG/DL [Ref Range 0.50-1.35]. Review revealed a normal troponin resulted at 1527 and a normal BNP resulted at 1648. Review of the triage nursing notes at 1704 revealed "Patient cussing at staff and asking to speak to administrator. Patient informed Charge RN will speak to patient." Review of the charge nurse note at 1727 revealed "Pt was noted in lobby to have called triage and cursing staff about wait time. Pt was given explanation of wait time and that test has been ordered and pending results. Pt still was not receptive to plan and continued to curse staff. Upon arrival to ed lobby was standing yelling "exploitative language" this and thid (sic) place sucks. Pt was informed to come back to speak one on one about his concerns. Pt then sts (starts) screaming with no shob (shortness of breath) noted "exploitative language" this I cant walk and you can wheel me back there. Pt threw his stickers in floor and then was taken back to pdc (consult room) for consult. Pt begins to scream and sts (states) I cant breath and informed he needed to lower his voice and he was not in distress if he couod (sic) yell and curse that loud. Pt informed to monitor language and volume. Pt did not adhere and was told that all roms (sic) were full at this time and his vs (vital signs) were stable. Pt sts I called 911 because (name of insurance) health care told me to come to ed and be seen. Pt again cursing and sts I am here don't act like you don't see me and I can't "exploitative language" breath (sic). Pt was speaking in clear tone with no shob noted. Pt was made aware to stop cursing and and (as written) he interrupts ans(sic) sts I am leaving. t(sic) was then pushed in w/c and made aware that he needed tom (sic) leave due to his threatening behavior and cursing staff and he stated he wanted to. Pt was taken to lobby by security and still cursing and again made aware to leave facility. Pt was amb (ambulating) and then goes outside and calls 911. (EMS) arrives and called me with pt still cursing in background and they were informed he was not allowed in facility due to actions and behavior. If he was in emergency deemed by them he could return but he needed to be transported elsewhere for care at this time. Pt per ems sts he wanted to go (initials of a hospital listed) and get out of this "exploitative language" place." Review NP #1's note revealed "Patient had apparently left after my brief medical screening evaluation in triage. I was not notified of patient's decision to leave, nor was I able to perform a complete or more thorough physical evaluation. Furthermore, I did not have the ability to notify my attending physician of their departure. Patient was last seen in stable condition. Patient left AGAINST MEDICAL ADVICE after triage." Review revealed Patient #10's disposition was eloped and he was taken out of the electronic medical record system at 1742. Review revealed Patient #10's vital signs were not rechecked prior to his departure and a medical screening examination was not performed on Patient #10.

Review on 01/17/2019 of the EMS "Patient Care Record" revealed Patient #10 called 911 at 1701 and EMS arrived outside of (Hospital A's) ER where Patient #10 was at 1705. Review of Paramedic #1's assessment at 1706 revealed " ...53 y.o. male sitting in wheelchair outside the ER at (Hospital A). Pt. had been taken there earlier today by his sister for asthma related issues. Apparently prior to our arrival there had been a verbal altercation between the pt. and the triage nurse an (sic) subsequently the charge nurse. The pt. had been asked to leave the hospital property and so he called 911. Pt. was audibly wheezing and states he's been having trouble with is (sic) breathing since last Thursday. Pt. denies any chest pain, no nausea or vomiting noted. Pt. with wheezing in all lobes both inspiratory and expiratory as well as ronchi (sic) in the upper lobes. Pt. has a productive cough with thick white secretion. Pt. initially stated that he was just going to call his sister to come back and pick him up. I encouraged him to seek further medical care at a different facility. I explained to him that he would need to understand that no matter where he went there would be the potential that he would have to wait but that I strongly recommend he be seen. He agreed to be seen and agreed to be cooperative. Pt. secured to stretcher with all straps an (sic) shoulder harness. Vitals and interventions as documented Pt's initial room air SpO2 88% (SPO2-oxygen saturation- level of oxygen carried to the blood -under 90% considered low). Breathing treatments increased SpO2 to 98%. 12-lead unremarkable. Pt. stated he was feeling much better but his lung sounds remained unchanged. Transported non-emerg, to (Hospital B) and released to staff without incident." Review revealed Patient #10 received two breathing treatments one with albuterol and one with albuterol and atrovent, IV Solu-Medrol, EKG, and IV Placement from EMS. Review revealed EMS left Hospital A with Patient #10 at 1735 and arrived to Hospital B at 1800.

Review of the closed DED medical record on 02/01/2019 for Patient #10 at Hospital B, revealed a 53-year-old male who presented to Hospital B's Free-Standing DED via ambulance, from Hospital A's DED on 11/13/2018 at 1807 with a chief complaint of wheezing for 5 days. Review revealed triage was initiated at 1807. Review of the triage vital signs revealed T: 97.5, P: 85, BP: 112/82 R: 32 with a pulse oximetry of 99% on an aerosol mask at 8L/min. Review of the nursing triage notes revealed "Wheezing x5 days. Brought in by EMS from (Hospital A). Was given Albuterol 10 mg and Atrovent 5mg enroute. Also given Solumedrol 135mg IV enroute. Labs drawn at (Hospital A) and EKG done." Review revealed the MSE was initiated at 1831. Review of the physician note revealed "53-year-old male. History of asthma ...Started feeling short of breath earlier in the day. He presented to (Hospital A). Had labs obtained. Had an x-ray obtained. Had gotten no treatment. Was feeling more and more short of breath. He states he became anxious and panicked. Apparently he was escorted out of the emergency room because of 'being agitated'. He was markedly short of breath. He called 911. Per makes right (as written) to find him in a restaurant (as written) distress tachypneic with audible wheezing and saturations of the high 80s. He was given nebulized albuterol. He was given IV site Medrol (as written) transferred here ...Continued on continuously last epidural (as written) upon his arrival. This repeated x2 hours total of 20 mg. He has improved with each. He continues to have wheezing and prolongation. Chest x-ray shows no CHF or infiltrates. Normal troponin. EKG sinus rhythm no injury no ectopy. On a room air trial in between nebulizer treatments remains in the mid 80s. He is requiring 2INC (as written). I placed call to...hospitalist regarding admission ..." Patient #10 was admitted for an asthma exacerbation and transported to Hospital B's sister facility Hospital C on 11/13/2018 at 2157.

Review of the closed medical record at Hospital C, revealed Patient #10 was admitted to Hospital C on 11/13/2018 at 2228. Review of the History and Physical dated 11/14/2018 at 0703 revealed "(Patient #10) is a 53 y.o male with history of asthma, hypertension, chronic kidney disease stage III, gout, diabetes mellitus, diastolic dysfunction, blindness in the left eye presents to the ER at (Hospital B) with complaints of worsening shortness of breath ...ED Course: In the ER patient was found to be wheezing. Chest x-ray was unremarkable. Patient was given nebulizer treatment and steroids and since patient was having ongoing wheezing and shortness of breath patient is being further admitted for further management of asthma exacerbation. Has had recent 2D echo done last month which showed EF (ejection fraction-used a measure of the pumping efficiency of the heart) of 55-50% with grade 1 diastolic dysfunction..." Review revealed Patient #10 was discharged on 11/15/2018 at 1320 with a diagnosis of asthma exacerbation.

Interview on 01/16/2019 at 1115 revealed NP #1 did not recall Patient #10. Interview revealed NP #1 sometimes worked as a provider in triage. Interview revealed when NP #1 was a provider in triage she would see every patient that came through the door like a triage nurse. Interview revealed patient's that wanted a medication refill or had something like a rash or toothache she could see and then discharge from triage. Interview revealed patients that had urgent or emergent complaints she talked to them about what was going on and did a brief assessment. Interview revealed it was a priority to get patients triaged and a medical screening exam. Interview while reviewing NP #1's assessment for Patient #10 revealed she considered this a medical screening exam. Interview revealed NP #1 did not put a diagnosis in because she was waiting for his lab and x-ray results. Interview revealed NP #1 did not do a full physical exam on Patient #10.

Interview on 01/17/2019 at 1053 with MD #2 revealed he cosigned NP #1's note. Interview revealed when providers are in triage they start the medical screening exam. Interview revealed providers in triage see patients and start protocols that nurses cannot. Interview while reviewing NP #1's note revealed it was not a full and thorough medical screening exam it was the start of a medical screening exam. Interview revealed therefore it could not be determined if Patient #10 had an emergency medical condition. Interview revealed if a patient left against medical advice it meant that the risk and benefits of leaving were explained to the patient and there was an attempt for the patient to sign the against medical advice form. Interview revealed in Patient #10's case it was a left before treatment completed.

The facility failed to ensure that their policy was followed as evidenced by failing to ensure that Patient #10 was provided an appropriate medical screening examination on 11/13/2018. Additionally, the facility failed to ensure that staff understood the difference between triage and medical screenig examination as stated in the facility's policy.

NC00146371