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Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically, the medical screening exam, resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include:

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A-2406 Failure to provide an appropriate medical screening exam

Based on record review and interview, the facility failed to perform a medical screening exam for 1 (P-1) of 30 patients reviewed who received services in the emergency department resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include:

On 6/20/2024 at 1255, review of the discharge log for the past 6 months (12/2023-present) revealed one finding for a female patient that was transferred to Facility C as alleged in the complaint to the State Agency (SA); however, it did not have the same events. Multiple female patients from 6/7/2024 were selected for sample that were transferred; however, none matched the description of events as was recounted in the complaint to the SA.

On 6/20/2024 at 1615, review of a list of facilities under the Facility A's provider number was reviewed and it was noted there were several "outpatient clinics." A request was made for the facility to determine if any of the outpatient clinics were urgent cares, and, if so, was there a transferred female patient that matched the events described in the complaint to the SA.

On 6/21/2024 at 0920, Chief Nursing Officer (CNO) Staff A stated there was a dermatology office renting space in Facility A who had a patient (P-1) sent to the emergency department (ED) for an EKG (electrocardiogram); however, the patient did not want to be admitted to the ED. Following the EKG, the patient returned to the dermatology office. The dermatology office later called an ambulance to transport the patient to Facility B. Staff A stated there was no medical record and the patient was not in their system (had not been registered). The only thing present was an EKG with P-1's name on it.

On 6/21/2024 at 0925, CNO Staff A was queried as to her expectation of staff when a patient is taken to the ED for services to which she stated, "Anytime a patient goes to the ER (emergency room), receiving anything, they should be registered and seen."

On 6/21/2024 at 0947, Nurse Practitioner (NP) Staff J stated she worked both the dermatology clinic and the ED. She stated she saw P-1 in the dermatology office for a severe skin infection. As part of the evaluation, vital signs were obtained and P-1's heart rate (HR) was 29 beats per minutes (bpm). "She had a history of A-fib (atrial fibrillation-irregular heart rate; heart's upper chambers beat out of coordination with the lower chambers.)... She stated she felt 'off' and 'lightheaded' with movement and was short of breath." Staff J stated she had decided to call an ambulance, but P-1 refused. She wanted to drive home and have her daughter take her to Facility B where her cardiologist was. Staff J did not feel it was safe for P-1 to drive home and stated she was concerned P-1 was in complete heart block (also known as 3rd degree heart block - abnormal heart rhythm resulting from a defect in the cardiac conduction system in which there is no conduction through the atrioventricular node leading to complete dissociation of the p waves and the qrs waves; can be fatal if not treated right away). Staff J encouraged P-1 to go down to the ED in Facility A for an EKG, and P-1 agreed. "I looked at it as though they were doing me a favor since I work down there too... The EKG showed Wenckebach (2nd degree heart block Type I - progressive prolongation of the PR interval until eventually an atrial impulse is completely blocked)... The trip to the ED seemed to scare her heart rate up a little and it was normal there. So I took her back to the dermatology office." Staff J stated upon return to the dermatology office, P-1's HR dropped again and the patient was symptomatic, so they called an ambulance to transport P-1 to Facility B. Staff J further stated, "Incidentally, (P-1) called the dermatology office yesterday and stated she ended up going to (Facility C) instead of (Facility B) because they were on diversion."

On 6/21/2024 at 1006, Patient Care Technician (PCT) Staff K stated she was in the ED performing EKG's on patients when she was stopped by NP Staff J who asked her to do an EKG for her (on P-1). Staff K "pulled" NP Staff J and P-1 into Triage 2 (an area where EKG's can be done for triaged patients awaiting evaluation) to do the EKG. Staff K stated she asked the patient her name and date of birth because she was not "in the system." Staff K stated, "During the EKG, (NP Staff J) and (P-1) were talking about checking in (to the ED)." Upon finishing the EKG, Staff K stated she handed it to NP Staff J and then left to continue performing EKG's on other patients.

On 6/21/2024 at 1023, ED Medical Director Staff L stated, "If bringing someone to the ED for a test, they (the patient) should be part of the ED system." Staff L further stated there should be an easy way for a patient to obtain an EKG on an outpatient basis.

On 6/21/2024 at 1035, CNO Staff A stated, "There are ways of doing an outpatient EKG, but not through the ED. If they are coming to the ED, they need to be registered as an ED patient."

Facility policy #501.021 titled "Emergency Medical Treatment and Active Labor Act" effective 12/20/2017 states, "Any individual who presents to Emergency Department of this hospital shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition... Potential emergencies presenting to outpatient locations other than the Emergency Department... On-campus outpatient departments and Provider Based Clinics. 1) Patient will be evaluated and stabilized within the capabilities of the department. 2) Physician or mid-level provider will discuss patient with Emergency Department. 3) Physician will order moving patient to Memorial Healthcare Emergency Department or transferring to another hospital within the requirements of this policy. 4) If no physician or mid-level provider is available, patient will be moved to Memorial Healthcare Emergency Department."