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Based on policy and procedure review, medical record review and interview, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements. See A2406 for details.

Based on clinical record review, policy review, observation, and interview, it was determined the facility failed to ensure one (#1) of 25 (#1-#25) patients received an appropriate and timely medical screening exam (MSE). Failure to provide an appropriate and timely MSE did not ensure the facility was aware of whether or not Patient #1 had an emergency medical condition, which caused a delay in medical treatment. The failed practice affected Patient #1 and had the likelihood to affect all patients presenting to the Emergency Department (ED). Findings follow:

A. Review of policy and procedure titled, "EMTALA Guidelines for Emergency Department Services," revised 07/2011, showed. "Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment of the transferred individual. Capacity includes the space and equipment capacity of hospital as well as the medical and hospital staff available to treat the individual."

B. Review of policy and procedure titled, "EMTALA Guidelines for Emergency Department Services," revised 07/2011, showed. "On-Call Physicians, an on-call physician specialty list including all specialties privileged at this facility and listing physicians by name will be openly posted in the Emergency Department and a record of all on-call lists shall be maintained for five years."

C. In an interview on 09/25/23 at 1:40 PM, the Chief Nursing Officer (CNO) confirmed the findings in A-B.

D. Review of Patient #1's clinical record from Baxter Health on 09/26/23 showed the following:

1) Review of Admission Summary showed the patient was admitted to the ED on 12/25/22 at 10:49 PM, with a Chief Complaint of 25 weeks pregnant and flank pain.

2) Review of Vital sign flowsheet dated 12/25/22 to 12/26/22 showed the following:
a) On 12/25/22 at 11:02 PM - Temperature (T) 97.9 degrees Fahrenheit, Pulse (P) 84 Beats per Minute (BPM), Respirations (R) 20.
b) On 12/25/22 at 11:06 PM - P 95, Blood Pressure (B/P) 167/97 millimeters of mercury (mmHg).
c) On 12/25/22 at 11:30 PM - P 75, B/P 155/105 mmHg.
d) On 12/25/22 at 11:50 PM - P 83, B/P 166/97 mmHg.
e) On 12/26/22 at 12:00 AM - P 89, B/P 155/86 mmHg, Fetal Heart Tones (FHT) 148 BPM.
f) On 12/26/22 at 12:20 AM - P 77, B/P 127/78 mmHg.
g) On 12/26/22 at 1:30 AM - P 87, B/P 176/91 mmHg.
h) On 12/26/22 at 1:50 AM - P 81, B/P 127/73 mmHg.
i) There was no evidence that a Temperature was taken after admission at 11:02 PM and was discharged on 12/26/22 at 2:11 AM.

3) Review of the ED nurse assessment, showed the following:
a) On 12/25/22 at 11:32 PM, the patient complained of right lower back pain with 8/10 on the pain scale with no evidence of pain medication given.
b) IV (Intravenous) placement was inserted on arrival.
c) On 12/26/22 at 2:04 AM, the patient complained of pain 10/10 on the pain scale. Ketorolac (Toradol) 60 mg (Milligrams) was given IM (Intramuscular) and Norco 7.5mg-325 mg was given orally. (Per the Food and Drug Administration, Toradol is listed as a Category C medication during pregnancy, which showed animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.)
c) There was no evidence IV hydration was given for flank pain with a potential differential to include pyelonephritis and kidney stone.

4) Review of Emergency documentation dated 12/25/22 at 11:23 PM, blood and urine test showed the following results:
a) CBC (Complete Blood Count):
Hemoglobin 12.8 g/dL (grams per deciliter)
Hematocrit 37.5 g/dL
Red Blood Cell Count 4.33 g/dL
White Blood Cell Count 15.7 g/dL (High) (Normal range 4.5-11.0)

b) Urinalysis (UA)
Color Yellow
Clarity Clear
Specific gravity 1.013
pH 7.5
Glucose Negative
Bilirubin Negative
Ketone Negative
Blood Negative
Protein Negative
Urobiligen 0.2 (mg/dL)
Nitrites Negative
Leukocytes Negative
c) There was no evidence of additional micro and culture sensitivity completed on the urinalysis.

5) Review of Radiology report showed the following:
a) The OB (Obstetrics) ultrasound (US) findings were single live intrauterine gestation with heart rate of 141 BPM.
b) The Renal US findings were as follows:
1) The Right kidney showed no stones with minimal caliectasis with hydronephrosis with no suspicious masses.
2) The Left kidney showed no stones no hydronephrosis, and no suspicious masses.

6) Review of Emergency Physician note dated 12/25/22 at 11:07 PM showed, "Patient present with complaint of right flank pain. Patient states she is approximately 25 weeks pregnant. Patient states pain is constant. History of present illness: 27-year-old reporting 25-week pregnancy and pain over the right flank and right hip area. Her pain started earlier tonight. No fever. No hematuria. No vaginal bleeding or discharge. No anterior abdominal pain. Impression: single live intrauterine gestation measuring 25 weeks 3 days, within normal range for clinical dates. Fetal heart rate is 141 BPM (Beats per Minute). No gross abnormality is identified. Biometric measurements as above. Patient instructions: Rest, limit walking/standing, heat to painful area, follow up with your physician."

7) Review of Emergency Physician Progress note dated 12/25/22 at 11:07 PM showed no evidence the ED physician assessed the high blood pressure or reassessed pain complaints during the ED admission.

8) Review of Emergency Physician Progress note dated 12/25/22 at 11:07 PM, showed no evidence the ED physician obtained a past medical history, conducted a repeat assessment to determine if further treatment was required, addressed the high White Blood Cell Count, assessed for UTI (Urinary Tract Infection) or consulted with an OB/GYN (Obstetrics/Gynecology) to determine disposition of the patient.

9) Review of discharge instructions dated 12/26/22 at 2:11 AM showed to follow up with Primary Care Physician.

10) There was no evidence discharge instruction were provided to include:
a) The instructions regarding flank pain, pregnancy, and hypertension.
b) A discharge diagnosis.
c) Medications to take for pain.
d) The time frame to follow-up with Primary Care Physician (PCP) and OBGYN.

E. In an interview on 09/26/23 at 8:40 AM, the Emergency Department Director confirmed the findings in D.

F. Review of Patient #1's Physician notes in the clinical record from University of Arkansas for Medical Sciences (UAMS) on 09/26/23 showed the following:
1) On 12/26/22 at 6:27 PM, the patient was admitted to ED with a Chief Complaint of nausea and vomiting, severe back and right flank pain, and fever of 102.7 degrees.
2) On 12/26/22 the patient was admitted to Labor and Delivery (L & D) unit with a diagnosis of Pyelonephritis secondary to bilateral nephrolithiasis. The patient was given IV hydration and antibiotics (Cefepime and Vancomycin).
3) On 12/27/22 at 6:16 AM the patient was transferred to Medical Intensive Care Unit (MICU) for urosepsis and metabolic acidosis.
4) On 12/27/22 at 8:33 PM, after transferring to MICU, the patient continued to decline and required intubation, sedation (Precedex and Fentanyl) and blood pressure support (Levophed and Vasopressin).
5) On 12/28/22 at 7:55 AM, the patient was extubated and at 9:21 AM, Fetal demise greater than (>) 22 weeks was delivered without complications
6) On 12/29/22, the patient was transferred to the post-partum unit.
7) On 12/31/22 at 10:45 AM, the patient Discharge Summary showed the following final diagnosis:
a) Pyelonephritis affecting pregnancy in second trimester
b) Septic Shock
c) Fetal demise greater than (>) 22 weeks, delivered
d) Urine culture with E Coli (Escherichia coli) growth