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Based on interviews, medical record review, review of the facility's Emergency Department (ED) logbook, and review of facility policies, it was determined the facility failed to ensure stabilizing medical treatment was provided for one (1) of twenty (20) sampled patients (Patient #1) that presented to the facility's ED for an Emergency Medical Condition. Patient #1 presented to the facility's ED on 07/16/18 at 2:00 PM with complaints of "back pain." Physician Assistant (PA) #1 assessed Patient #1 on 07/16/18 at 2:52 PM, ordered a Decadron injection (a steroid medication used to treat inflammation), and discharged the patient home at 4:37 PM on 07/16/18, with a diagnosis of low back pain. There was no documented evidence that any diagnostic testing was conducted. Patient #1 returned to the facility via Emergency Medical Services (EMS) on 07/16/18 at 11:15 PM, approximately six hours after discharge, with the same complaint, "lower back pain." The facility admitted Patient #1 and determined Patient #1 had Multilevel Degenerative Disc Disease (gradual deterioration and thinning of the discs) with Spinal Stenosis (narrowing of the spaces within the spine that can put pressure on the nerves that travel throughout the spine), and Neural Foraminal Narrowing (constriction of the nerve passageways in the spine).
Patient #1 Had a lot of testing completed.

The chest x-ray was NOT addressed and a possible mass on the chest x-ray was not pursued with further diagnostics or treatment. Physical exams were poorly detailed related to complaint of back pain.

The chest x-ray dated 07/17/2018 states:
"Large opacity is seen in the mid left lung periphery. Pneumonia is likely but clinical correlation is needed as underlying mass cannot be excluded at this time. Clinical correlation is needed. Short- term follow-up exam 3-4 weeks after completion of appropriate therapy will be needed to document complete resolution and to exclude underlying process."

Based on interviews, medical record review, review of the facility's Emergency Department (ED) logbook, and review of facility policies, it was determined the facility failed to ensure stabilizing medical treatment was provided for one (1) of twenty (20) sampled patients (Patient #1) that presented to the facility's ED for an Emergency Medical Condition. Interviews revealed Patient #1 presented to the facility's ED on 07/16/18 at 2:00 PM with complaints of "back pain." Patient #1 was provided with a Medical Screening Exam by Physician Assistant (PA) #1 at 2:52 PM, a Decadron injection (a steroid medication used to treat inflammation) was administered at 4:37 PM, and the patient was discharged home at 4:37 PM with a diagnosis of low back pain. There was no documented evidence any diagnostic testing was conducted. Patient #1 returned to the facility via Emergency Medical Services (EMS) on 07/16/18 at 11:15 PM, approximately six hours after discharge, with the same complaint, "lower back pain."

The facility admitted Patient #1 and after diagnostic imaging was conducted, it was determined Patient #1 had Multilevel Degenerative Disc Disease (gradual deterioration and thinning of the discs) with Spinal Stenosis (narrowing of the spaces within the spine that can put pressure on the nerves that travel throughout the spine), and Neural Foraminal Narrowing (constriction of the nerve passageways in the spine).

Additionally,

Patient #1 Had a lot of testing completed.

The chest x-ray was NOT addressed and a possible mass on the chest x-ray was not pursued with further diagnostics or treatment. Physical exams were poorly detailed related to complaint of back pain.

The chest x-ray dated 07/17/2018 states:
"Large opacity is seen in the mid left lung periphery. Pneumonia is likely but clinical correlation is needed as underlying mass cannot be excluded at this time. Clinical correlation is needed. Short- term follow-up exam 3-4 weeks after completion of appropriate therapy will be needed to document complete resolution and to exclude underlying process."

The findings include:

Review of the facility's policy titled "Treatment and Transfer of Individuals who Request Emergency Medical Services," approval date August 2018, revealed the facility should not delay the provision of a medical screening exam, further treatment, or appropriate transfer in order to inquire about the individual's method of payment or insurance status. The facility should not request prior authorization for services before the patient received a medical screening exam and any further treatment that would be required to stabilize the emergency medical condition. The policy further stated an emergency physician or non-physician practitioner would contact the patient's physician, at any time, to seek advice regarding the patient's medical history and additional information relevant to the medical treatment and screening of the patient. However, such consultation should not inappropriately delay services.

Review of the facility's Medical Staff ByLaws approved on 03/28/18 revealed the ED attending physician would be responsible for the completion of medical records for each patient to which they were assigned to care for. The documentation should support the medical decision-making for diagnostic testing, impressions, and treatment. The ByLaws further stated the ED record initiated by mid-levels was to be signed off by the supervising physician within twenty-one (21) days of the patient's visit.

Review of the credentialing file for PA #1 on 09/17/18 at 1:00 PM revealed PA #1 was appointed privileges on 10/25/17; however, there was no documented evidence the facility oriented/educated PA #1 on their EMTALA policies.

Review of the ED logbook revealed Patient #1 presented on 07/16/18 at 1:59 PM. The documented reason for the visit was "back pain." Continued review of the logbook revealed Patient #1 was discharged on 07/16/18 at 6:18 PM with a disposition of "[discharge] home." Further review of the ED logbook revealed Patient #1 returned on 07/16/18 at 11:27 PM, with "Apnea and Bradycardia." According to the logbook, the facility admitted Patient #1 on 07/17/18 at 2:02 PM.

Interview with Patient #1 on 09/17/18 at 11:30 AM revealed he/she was taken via personal vehicle to the ED on 07/16/18 at approximately 2:00 PM by his/her family member. Patient #1 stated that he/she informed the triage nurse that his/her pain level was "15" on a scale of 0-10, and that he/she could not stand to sit in the wheelchair provided. Patient #1 stated that a nurse informed the patient that he/she "was not going to get any narcotics." Patient #1 stated he/she did not request pain medication, only requested that someone assist with pain management. Patient #1 stated PA #1 came and looked at the patient for a "few minutes," stated it was "sciatica" pain, and stated they would administer a steroid injection. Patient #1 stated PA #1 never assessed the patient's ambulation or range of motion, and no diagnostic testing was offered or discussed. According to Patient #1, his/her pain was never relieved and the facility did not wait to see if the Decadron injection was effective prior to sending the patient home. Continued interview with Patient #1 revealed that he/she went home and the pain continued to worsen. At approximately 10:30 PM, the patient stated he/she contacted EMS to transport him/her back to the ED because he/she could not tolerate going by car again. Patient #1 stated that he/she did not recall a lot about the second visit to the ED because of the "seizure" he/she had after the Toradol. Patient #1 stated that he/she was diagnosed with Degenerative Disc Disease and Arthritis and was referred to a spine specialist for follow-up treatment. Patient #1 stated the facility also discharged him/her with a prescription for Norco and Lidoderm for pain control. Further interview with Patient #1 revealed he/she believed if the facility had conducted diagnostic testing during the first visit, he/she would not have had all the complications associated with the second visit. Patient #1 stated the facility could have conducted a drug screen, reviewed his/her medication prescribing history, and looked at his/her medical record history to see that he/she did not utilize the ED and was not a drug addict, and treated him/her appropriately on the first visit.

Interview with RN #1 on 09/17/18 at 10:30 AM revealed she was the assigned nurse for Patient #1 during the first visit to the ED. RN #1 stated she never indicated to Patient #1 that the patient was at the facility to obtain narcotic medication and denied telling Patient #1 that the facility would not give him/her any narcotic pain medication. Continued interview revealed that she recalled Patient #1 had complaints of back pain and was assessed by PA #1. RN #1 stated that PA #1 ordered a Urine Analysis and a Decadron injection. RN #1 stated she administered the Decadron injection and then discharged the patient from the facility as per the order from PA #1.

Interview with PA #1 on 09/13/18 at 3:20 PM and on 09/17/18 at 12:00 PM revealed she was the assigned provider for Patient #1 for both visits to the ED on 07/16/18. PA #1 stated that during the first visit Patient #1 informed her that the back pain was "non-injury," had been present for two (2) days, and that the patient had taken Soma (a muscle relaxant) medication prior to coming to the ED. PA #1 stated that Patient #1 denied any loss of bladder or bowel function or other symptomology; therefore, other diagnostic testing was not indicated and would have not been paid for by insurance. Further interview with PA #1 revealed she prescribed a Decadron injection and instructions to follow up with a primary care provider or return if his/her condition worsened. PA #1 stated when Patient #1 returned to the ED on 07/16/18 at 11:15 PM she "picked [the patient] up" because she had seen him/her on the prior visit. PA #1 stated that because Patient #1's pain was worse, she ordered Toradol and a portable hip x-ray. Then, Patient #1 had "seizure" like activity and she ordered the Morphine, Zofran, and Phenergan. PA #1 stated Patient #1 was admitted to the hospital due to the vagal reaction from the Toradol, not because of the lower back pain.

Interview with the ED Manager on 09/17/18 at 11:15 AM and on 09/18/18 at 10:45 AM revealed she reviewed the records for Patient #1. The ED Manager stated the facility treated Patient #1 during the first visit exactly how they usually treat patients that present with back pain. The ED Manager stated that because Patient #1's back pain was "non-injury," diagnostic testing would be a "hard sell" to insurance companies and they would not reimburse for those tests. Further interview with the ED Manager revealed that all ED nursing staff were trained annually on EMTALA requirements, but she was not knowledgeable of how/when ED physicians and mid-level providers were trained.

Review of the medical record for Patient #1 revealed the facility documented Patient #1's arrival time on 07/16/18 at 2:00 PM and triaged Patient #1 at 2:00 PM for a chief complaint of "back pain." Nursing staff documented Patient #1's pain score as "10 unbearable" with "facial grimacing," and the patient's vital signs were as follows: pulse rate of 69, blood pressure of 158/84, and respiratory rate of 22.

Review of the ED General Exam dated 07/16/18 at 2:52 PM, revealed PA #1 assessed Patient #1 and documented that the patient had a two (2) day history of low back pain with some tingling in his/her left leg and foot, but had no mobility issues and could ambulate easily. Continued review of the documentation revealed on "Physical Exam," PA #1 documented that Patient #1 had "mild tenderness [with] palpation of the right lower back." "Symptoms consistent with sciatica and patient is to use a [muscle relaxer] previously prescribed along with ice and ibuprofen and Tylenol for pain." PA #1 documented that the impression was "low back pain."

Further review of Patient #1's medical record revealed PA #1 ordered a Urine Analysis with Culture and Sensitivity, if indicated for the patient on 07/16/18 at 3:27 PM and, according to the nursing notes, evaluated Patient #1 on 07/16/18 at 3:30 PM. Nursing staff continued to document at 3:32 PM that Patient #1 was still in pain in his/her right lower back.

Further review of Patient #1's medical record revealed Registered Nurse (RN) #1 administered an injection of Decadron (a corticosteroid medication used to treat inflammation) to Patient #1 on 07/16/18 at 4:37 PM and documented that Patient #1's pain level was "7." Nursing staff also documented at 4:37 PM on 07/16/18 that education was provided to the patient regarding "stretching exercise information and medication administered." The nurse also documented that the medication had "desired effect, with No Adverse/Side Effects." However, further review revealed the facility also discharged Patient #1 home with family on 07/16/18 at 4:37 PM with a pain level at "7" that was "moderate-distressing."

Physician #1 also documented that he discussed the case with PA #1 prior to the patient's disposition, reviewed the chart, and agreed with the history and physical exam and with the management, plan, and disposition of the patient. Physician #1 electronically signed the ED General Exam on 07/21/18 at 6:02 PM.

Review of the EMS patient care record revealed approximately six (6) hours after Patient #1 was discharged, EMS assessed the patient at his/her home on 07/16/18 at 10:41 PM, and documented that the patient had "severe lower back pain radiating down right leg and radiating up right flank." According to the report, Patient #1 was placed in the ambulance and "patient was unable to remain stationary any prolonged amount of time. Patient had to change positions several times in order to get some relief." The report stated Patient #1's care was transferred to facility staff on 07/16/18 at 11:11 PM.

Review of the medical record for Patient #1's second visit revealed Patient #1 arrived at the facility on 07/16/18 at 11:15 PM via EMS and was triaged at 11:15 PM for "lower back pain." Paramedic #1 (facility staff) documented Patient #1's pain score as "10 unbearable" with "facial grimacing" and with a description as "stabbing." Continued review of the record revealed Paramedic #1 documented Patient #1's vital signs as: pulse rate at 51, blood pressure of 151/79, and respiratory rate of 22.

Review of the ED General Exam dated 07/16/18 at 11:17 PM revealed PA #1 documented that Patient #1 presented earlier that day and was diagnosed with low back pain, which was most likely sciatica. The patient presented with worsening pain, and stated he/she was possibly having a reaction from Decadron that was administered during the first visit. Continued review of the documentation revealed on "ED Course" PA #1 documented that Patient #1 received Toradol (nonsteroidal anti-inflammatory drug (NSAID) that is used to treat moderately severe pain and inflammation), Zofran (medication to prevent nausea and vomiting), and morphine (narcotic pain medication). According to the PA's documentation, Patient #1 had what "appears to be a seizure and had an episode of apnea [not breathing]" minutes after morphine was administered. Further review of the ED General Exam revealed the care of Patient #1 was turned over to Physician #2 on 07/17/18 at 2:00 AM and Physician #2 documented the ED course as, "A short time after receiving Toradol the patient had a brief apneic spell. Since then [he/she] has been in bradycardia [low heart rate] and has had some blood pressure on the lower end. Patient needs to be admitted for observation and to further explore what is causing [his/her] pain and bradycardia. Physician #2 documented Patient #1's Impression as Apnea- transient, bradycardia, and low back pain.

Review of an MRI Lumbar Spine report dated 07/17/18 for "low back pain" revealed the patient had arthritis changes, bulging discs, mild central stenosis, and moderate right and moderate to severe left neural foraminal narrowing. The "Impression" was Multi-level degenerative disc and degenerative joint disease was seen throughout the lumbar spine.

Review of a Discharge Summary of Findings dated 07/18/18 revealed Patient #1 presented to the ED with acute low back pain. The patient was given Toradol and experienced a seizure-like episode with a short duration of apnea and bradycardia. The patient returned to baseline shortly after the episode and no repeat episodes were noted. According to the summary, a CT of the patient's Lumbar spine showed multi-level degenerative disc disease with spinal stenosis and neural foraminal narrowing. The summary stated Patient #1 received Norco (narcotic pain medication) and Lidoderm (topical anesthetic used to relieve pain) for back pain and was discharged with follow-up instructions to see a Spine Specialist for further care.

Additionally,

The chest x-ray was NOT addressed and a possible mass on the chest x-ray was not pursued with further diagnostics or treatment. Physical exams were poorly detailed related to complaint of back pain.

The chest x-ray dated 07/17/2018 states:
"Large opacity is seen in the mid left lung periphery. Pneumonia is likely but clinical correlation is needed as underlying mass cannot be excluded at this time. Clinical correlation is needed. Short- term follow-up exam 3-4 weeks after completion of appropriate therapy will be needed to document complete resolution and to exclude underlying process."