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Based on hospital policy review, medical record review, staff and physician interviews, the hospital failed to comply with §489.24 as evidenced by the hospital's Dedicated Emergency Department (DED) failing to ensure an appropriate medical screening examination with ongoing monitoring and follow up for a patient with an emergency medical condition was performed.

The findings include:

~ Cross refer to 489.24(r) and 489.24(c) Medical Screening Examination, Tag A2406.

Based on hospital policy review, medical record review, staff and physician interviews, the hospital failed to provide an appropriate medical screening examination (MSE) with ongoing monitoring for a patient with an emergency medical condition (EMC) in 1 of 20 sampled patients that presented to the hospital's Dedicated Emergency Department (DED) (Patient #7).

The findings include:

Review of the "EMTALA" policy effective 02/2011 revealed "Policy: All patients who come to the Dedicated Emergency Department (which includes both the basic Emergency Department and Labor and Delivery) of (named hospital), or who otherwise present on hospital property, requesting medical examination or treatment, or has such a request made on his or her behalf, will receive a medical screening examination to determine whether or not an Emergency Medical Condition exists, and any services, within the capability of the Hospital, necessary to stabilize any such Emergency Medical Condition. Such Medical Screening Examinations, stabilizing services, and transfers of medically unstable patients from the Hospital, must comply with the requirements of the Emergency Medical Treatment and Active Labor Act ("EMTALA"), as set forth herein. ..."

Closed medical record review of Patient #7 revealed an 81 year-old female that presented to the DED via ambulance on 11/18/2014 at 0232 with a chief complaint of a fall at the nursing facility. Review of triage notes at 0235 revealed the patient reportedly fell going to the bathroom and hit the back of her head resulting in a hematoma to the back of her head. Review of triage notes revealed a blood pressure (BP) of 119/71, pulse (P) 72, respirations (R) 16, temperature (T) 98.0 degrees Fahrenheit and oxygen saturation (SPO2) 94% on 2 liters of oxygen. Review revealed the patient reported a pain level of 0 at triage. Review of nursing notes revealed the patient was alert, awake, cooperative, clear speech, lung sounds with wheezing throughout lung fields and chronic use of nasal oxygen. Record review revealed the patient had a history of atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, hypertension, myocardial infarction, peripheral vascular disease, pneumonia and diabetes. Review of a physician's medical screening examination revealed MD #5 assessed the patient at 0237. Review of the notes recorded the patient fell on her way to the bathroom prior to arrival and had a contusion to the back of her head and upper back. Review revealed the patient had no nausea or vomiting, no loss of consciousness and no chest pain. Review of the notes revealed the patient had a headache. Review of physician's notes recorded the patient denied respiratory, cardiovascular and genitourinary symptoms. Physician's notes revealed the patient was in no apparent distress, had no active bleeding, with full range of motion to her neck and positive midline tenderness to left back. Notes recorded the patient was alert and oriented times three, no motor weakness, cranial nerves normal, hearing and speech normal and pupils equal and reactive to light. Review revealed radiology studies included lumbar spine x-ray, pelvis x-ray, chest x-ray and CT of the head and pelvis. A 12 lead EKG was ordered with results of atrial fibrillation. There were no laboratory studies ordered. Review of the pelvis CT revealed the patient had a "transverse lower sacral insufficiency fracture which is nondisplaced." Review revealed the head CT resulted in no evidence of acute intracranial injury. Review of the chest x-ray revealed no active cardiopulmonary disease. All other radiology studies were negative. Review of the DED physician's notes revealed an impression of "head trauma" and "multiple contusions, sacral insufficiency fracture."
Review revealed Acetaminophen 975 milligrams was administered orally for neck pain of 5 (scale 1 - 10 with 10 worst pain) at 0514. Review of nursing notes revealed vital signs were BP 118/51, P 75, R 16, T 98.1 Fahrenheit, SPO2 95% at 0659. Review revealed discharge instructions were provided and the patient was discharged back to the nursing facility at 0721.

Review revealed Patient #7 returned to the DED on 11/19/2014 at 0816 (24 hours and 55 minutes after prior discharge) via ambulance with a chief complaint of cough and shortness of breath. Review of triage notes at 0819 revealed the patient reportedly had low oxygen saturation in the 70's upon arrival to the nursing facility and was administered intravenous respiratory medication and nebulizer treatment prior to arrival to the DED. Review of triage notes revealed the patient was alert upon arrival with BP 109/49, P 72, R 20, T 100 Fahrenheit and SPO2 95% on 2 liters oxygen via nasal cannula. Review of nursing notes revealed the patient denied pain and had rhonchi bilateral upon auscultation of the lungs. Review revealed MD #4 documented a medical screening examination conducted at 0835 that recorded the patient was alert and complaining of cough. Review of the notes revealed the patient looked lethargic but was readily arousal and oriented. Notes recorded the patient was not complaining of difficulty breathing at the time of the exam and denied chest pain. Review of the physical exam recorded the patient ' s lungs were clear, normal breath sounds with no wheezing. Review of the DED record revealed diagnostic treatments included an EKG, chest x-ray, cardiac troponin assays, CBC, CMP (chemistry), D-Dimer, magnesium, prothrombin time, B-type natriuretic peptide, arterial blood gas and chest CT. Review of the record revealed critical lab results reported to MD #4 at 1001 that included a sodium level of 117 (normal range = 136 - 145), potassium 2.8 (normal = 3.5 - 5.1), CO2 level 46.0 (normal = 22.0 - 28.0). Review revealed critical lab results of a D-Dimer 1.07 (normal = 0 - 0.49) reported to MD #4 at 1010 and critical abnormal ABG (arterial blood gas) results bicarbonate 57.5 (normal 18 - 23), PCO2 63 (normal 35 - 48) and pH 7.75 reported at 1030. DED record review revealed a chest CT result that the patient had development a right middle lobe volume loss and airspace which may be atelectasis or pneumonia and new speculated densities in the right lower lobe that could represent a tumor or infection. Review of the physician's notes revealed an impression of "hyponatremia, COPD exacerbation, pneumonia." Review revealed the patient was administered IV fluids, potassium replacement and antibiotics. Review of vital signs at 1413 revealed BP 118/57, P 64, R 18, T 100 Fahrenheit and SPO2 94% on 2 liters oxygen. Review of nursing notes revealed the patient was admitted and transported to an inpatient bed at 1449.

Review of the inpatient physician's discharge summary dated 11/25/2014 revealed a discharge diagnosis of pneumonia, probably bacteremia, chronic congestive heart failure, diabetes, hypertension, patent foramen ovale, hypokalemia, hyponatremia and chronic obstructive pulmonary disease. Review revealed the patient was discharged back to a nursing facility on 11/25/2014.

Interview on 03/05/2015 at 0930 with MD #5 revealed he was the DED physician that evaluated and treated the patient in the DED on 11/18/2014 (first visit). Interview revealed the physician was unable to remember Patient #7 and he had reviewed the DED record. The physician stated the patient complained of pain to the back of her head after the fall, vital signs were good, x-ray was okay. MD #5 stated she received an appropriate medical screening examination. Interview revealed the patient had a sacral fracture and there was no treatment for that. MD #5 stated based on the physical exam notes the patient was in no distress, had a contusion to the back of her head with no active bleeding, she was alert and oriented, no motor weakness, alert and oriented, hearing and speech normal, heart was irregular. The physician stated the patient's heart was irregular and that he would have listened to the patient's heart and lungs prior to ordering an EKG, but it was not documented. The physician stated "I am sure it was done. I don't see it. I missed recording heart and lungs. I don't know why that was not recorded. For me to order an EKG, I had to listen to her heart and lungs." The physician stated the patient was her usual, baseline self or he would have done further testing. The physician stated labs are only done if indicated and there was no indication to do labs on this patient. The physician stated she was discharged and returned the next day with increased lethargy, decreased sodium and she was admitted.

Interview on 03/04/2015 at 1610 with MD #4 revealed he was the DED physician that evaluated and treated the patient in the DED on 11/19/2014 (return visit). Interview revealed the physician was unable to remember the patient and had reviewed the DED record. MD #4 stated he had no concerns regarding the lack of lab studies from the first DED visit. The physician stated it was "normal" to not do labs after a fall and that a focus review was done. The physician stated the patient was awake, alert and oriented and had no problem breathing. The physician stated elderly patients progress quickly when they get sick.