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Based upon interview and record review, the facility failed to:

A. ensure emergency room patients were assigned ESI (Emergency Severity Index) levels that followed the algorithm being used at the facility in 3 (Pt #'s 6,13, and 18) of 33 patients reviewed.

B. ensure the facility policy for Triage/Patient Assessment included the algorithm being used at the facility.

Refer to Tag A 1104

Based upon observation, interview and record review, the facility failed to:

A. ensure the emergency department assigned ESI (Emergency Severity Index) levels that followed the algorithm being used at the facility in 3 (Pt #'s 6,13, and 18) of 33 patients reviewed.

B. ensure the facility policy for Triage/Patient Assessment included the algorithm being used at the facility.


This deficient practice had the likelihood to cause harm to all patients who came to the emergency room for treatment at the facility.


Findings include:


PATIENT #6
Review of the medical record for Patient #6 revealed the following:


TRIAGE NOTE

Patient #6 was triaged on 8/2/2018 at 2:46 PM. The Primary Treatment complaint was backache. Patient #6 complained of lower back pain and difficulty walking for one month. Patient #6's note said he was sent to the (ER) emergency room by Dr. Brown for admission. Vitals were noted to be: Blood pressure 142/80, Temperature 98.4, pulse 92, respirations 16/min, and pulse oximeter was 98%. Patient #6 pain level was 10 on a 1-10 scale. ESI (Emergency Severity Index) was Level 4. According the facility algorithm, the ESI level should have been a level 2. Level 4 ESI reassessment per facility policy is 1-2 hours, and ESI level 2 is 5-15 minutes.

ED PROVIDER NOTE

Patient #6 was seen on 8/2/2018 at 3:43 PM. Patient #6's Primary Complaint was lower back pain. Patient #6 complained of lower back pain and difficulty walking for one month. Patient #6's note he was sent to the (ER) emergency room by Dr. Brown for admission. Patient #6 was a 55-year-old male with chronic back pain worse x 4 weeks. The pain was radiating to bilateral legs associated with numbness and tingling. The pain was worse on bending and standing, laying made the pain better.

PATIENT VITAL SIGNS/REASSESSMENT - Pt #6

8/2/2018 1440

Blood pressure 142/80, Pulse 92, Respirations 16, Temperature 98.4, Pulse Oximeter 98%

There were no additional vital signs taken while Patient #6 was in the emergency room. Patient #6 was discharged at 5:25 PM, 2/12 hours after triage.



PATIENT #13

Triage Note

Patient #13 was a 35-year-old patient was presented to the emergency room at 7:57 PM on 10/25/2018. Patient #13's primary complaint said the patient was in the triage room by herself and her companion was in the waiting room. The note said Patient #13 was being threatened by her companion. The note said the patient will be moved back for safety and law enforcement will be called. The triage note said Patient #13 had older injuries to face. Patient #13 complained that her neck was sore from being choked, and had been hit on the abdomen and back recently. Patient #13's pain level was 8 on a 1-10 scale. ESI (Emergency Severity Index) was Level 3. According to the facility algorithm, the ESI level should have been a level 2. Level 3 ESI reassessment per facility policy is 15-45 minutes, and ESI level 2 is 5-15 minutes.


Patient Disposition Note

The patient disposition note dated 10-26-2018 at 12:05 AM noted the patient left Against medical advice. The note said Patient #13 could not wait anymore.

There was no Medical Screening examination by the physician noted in the record. Patient #13 was at the emergency room for approximately 4 hours.


PATIENT VITAL SIGNS/REASSESSMENT - Pt. #13

10/25/2018 7:57 pm.

Blood pressure 141/88, Pulse 109, Respirations 18, Temperature 97.8, Pulse Oximeter 100%

There were no additional vital signs taken while Patient #13 was in the emergency room. Patient #13 left against medical advice at 12:05 AM, 4 hours after triage.



PATIENT #18

Patient #18 was 40-year-old male who presented to the emergency room on 8/7/2018 at 2:08 AM. Patient #18's primary complaint details noted the following; Patient #18 complained of left sided rib pain radiating to his abdomen. Patient #18 note said the pain had been going on for two days. Vital signs taken at triage were as follows: Temperature 98.2, Blood pressure 145/82, pulse, 89, respirations 18. Pain level was triaged at 10 on a 1-10 scale. ESI (Emergency Severity Index) was Level 3. According the facility algorithm, the ESI level should have been a level 2. Level 3 ESI reassessment per facility policy is 15-45 minutes, and ESI level 2 is 5-15 minutes.


ED (Emergency Department) Provider Note

Patient #18 was seen on 8/7/2018 at 6:29 AM, 4 hours after presenting to the emergency department.


PATIENT VITAL SIGNS/REASSESSMENT - Pt. #18

8/7/2018 2:08 AM

Blood pressure 145/82, Pulse 89, Respirations 18, Temperature 98.8, Pulse Oximeter 98%


8/7/2018 6:40 AM

Blood pressure 130/80, Pulse 81, Respirations 16, Temperature was not reassessed, Pulse Oximeter 99%

There were no additional vital signs documented in the medical record between 2:08 AM and 6:40 AM, over 4 hours. Patient #18 was discharged at 6:40 AM.


During an observation of the triage process for Patient #19 on 10-30-2018 at 3:47 PM, a triage algorithm was noted to be hanging on the wall in the triage room.

Staff #15 was the RN (Registered Nurse) in the triage area. Staff #15 was asked if the facility followed the algorithm when triaging patients and assigning an ESI level for patients in the emergency room. Staff #15 confirmed they did.

Review of the facility policy titled, "TRIAGE - PATIENT ASSESSMENT" with an effective date of 11/1/2017 revealed no algorithm in the policy. Review of the reassessment guidelines for ESI/triage levels in the policy showed the following:

" ...Level 1 - Immediate care, life threatening conditions ...
.....Level 2 - Major injury or illness but stable, treatment and reassessment should occur in 5 to 15 minutes ...
.....Level 3 - Urgent - treatment and reassessment should occur in 15-45 minutes ...
.....Level 4 - Semi-Urgent - treatment and reassessment should occur in 1-2 hours ...
.....Level 5 - Routine - Treatment and reassessment should occur within 4 hours ..."


Review of the Algorithm used to determined ESI/ triage levels that the facility followed revealed the following:

"Level 1 - Requires immediate life-saving intervention?

Level 2 - High Risk Situation? Confused/lethargic/disoriented? Severe pain/distress?

Danger Zone Vitals:
Less than 3 months - Heart rate greater than 180, Respirations greater than 50, O2 (Oxygen) saturations less than 92%
3 months to 3 years - Heart rate greater than 140, Respirations greater than 40, O2 saturations less than 92%
Greater than 8 years old - Heart rate greater than 100, Respirations greater than 20, O2 saturations less than 92%

Level 3 - If None of the above are present

Level 4 - How many resources are needed? One - Level 4

Level 5 - How many resources are needed? Two - Level 5"



Staff #3 confirmed the facility was using the algorithm to triage and assign ESI levels for patients at the facility. Also, Staff #3 confirmed the algorithm was not in the facility policy.

Compliance with 489.24

Based on observation, interview, and record review the facility failed to comply with regulation 489.24.


The facility failed to:


A. ensure Medical Screening Examinations (MSE) were provided by qualified professionals and were completed in a timely manner in 2 (#'s 13 and 18) of 33 patients.

B. ensure that a physician certified that the medical benefits reasonably expected from the medical treatment at another facility outweighed the increased risks from the transfer in 12 (Patient #'s 22-33) of 12 patients reviewed.

C. ensure that a physician determined the medical condition of the patient being transferred was stabilized prior to transfer in 12 (Patient's #22-33) of 12 patients.

D. provide stabilizing treatment which was within their capabilities in 1 (Patient #6) of 1 patient. The facility failed to initiate an order for a MRI (Magnetic Resonance Imaging) for Patient #6 who was instructed to go to the emergency room by his treating physician for the service. Patient #6 was transported by EMS (Emergency Medical Services) from his home to Facility #2 (#17) less than 24 hours after discharge and required emergent surgery.


This deficient practice had the potential to harm all patients who presented to the Emergency Room.






MEDICAL SCREENING EXAM

Review of the emergency medical records for Patient #13 revealed the following:


Triage Note

Patient #13 was a 35-year-old patient was presented to the emergency room at 7:57 PM on 10/25/2018. Patient #13's primary complaint said the patient was in the triage room by herself and her companion was in the waiting room. The note said Patient #13 was being threatened by him. The note said the patient will be moved back for safety and the law enforcement will be called. The triage note said Patient #13 had older injuries to face. Patient #13 complains that her neck is sore from being choked, and had been hit on the abdomen and back recently.

Nursing Notes

A note dated 10-25-2018 at 8:40 PM said Patient #13 came in complaining of chest pain but then became distraught and stated her visit was really because her companion had been abusing her. Authorities were notified.

The police department were noted to be at the bedside at 8:18 PM.


Lab/Test results

Lab glucose level was done at 8:40 PM on 10-25-2018. A urine HCG (Pregnancy) test was done at 8:14 PM on 10-25-2018.

A CT (Computed tomography) of the face was done at 10:42 PM on 10-25-2018.


Patient Disposition Note

The patient disposition note dated 10-26-2018 at 12:05 AM noted the patient left Against medical advice. The note said Patient #13 could not wait anymore.

There was no Medical Screening examination by the physician noted in the record. Patient #13 was at the emergency room for approximately 4 hours.



Review of the emergency medical records for Patient #18 revealed the following:


Triage Note

Patient #18 was 40-year-old male who presented to the emergency room on 8/7/2018 at 2:08 AM. Patient #18's primary complaint details noted patient #18 complaining of left sided rib pain radiating to his abdomen. Patient #18's note said the pain had been going on for two days. Vital signs taken at triage were as follows: Temperature 98.2, Blood pressure 145/82, pulse, 89, respirations 18. Pain level was triaged at 10 on a 1-10 scale.


Labs/Test results

Chemistry panel, complete blood count, and PT/INR were obtained at 4:10 AM on 8-7-2018.

Chest X-Ray was taken on 8-7-2018 at 3:56 AM.

Urinalysis was done on 8-7-2018 at 4:05 AM.

EKG (Electrocardiogram) was done on 8-7-2018 at 6:04 AM.



ED (Emergency Department) Provider Note

Patient #18 was seen on 8/7/2018 at 6:29 AM, 4 hours after presenting to the emergency department.


Patient Disposition Note

Patient #18 was discharged on 8/7/2018 at 6:35 AM, 6 minutes after the provider completed the medical screening.


During an interview on 10/31/2018 after 10:00 AM Staff #3 confirmed the above findings.

Review of facility policy titled, "EMTALA GUIDELINES FOR EMERGENCY DEPARTMENT SERVICES" with a revision date of 12/14/2017 revealed the following:

...All patients shall receive a medical screening exam that includes all necessary testing and on call services within the capability of the hospital to reach a diagnosis."




TRANSFERS

Patient #22

Review of Memorandum of Transfer (MOT) for Patient #22 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual's condition has not been stabilized, however the individual will benefit from a higher level of care." The physician signature line showed a V.O. (Verbal Order) Physician #23/Staff#24 The physician did not sign the certification and there was no documentation of the physician certification in the transfer note.


Patient #23

Review of the MOT for Patient #23 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a signature for Physician #25 signed by Staff #26. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.




Patient #24

Review of the MOT for Patient #24 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a signature for Physician #27 signed by Staff #28. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.


Patient #25

Review of the MOT for Patient #25 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a TO (Telephone Order) Physician #29/Staff #24. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.

Patient #26

Review of the MOT for Patient #26 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a TO (telephone order) Physician #27/Staff #30. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.

Patient #27

Review of the MOT for Patient #27 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a TO (Telephone Order) Physician #29/Staff#24. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.





Patient #28

Review of the MOT for Patient #28 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a TO (Telephone order) Physician #31/ signed by Staff #24. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.

Patient #29

Review of the MOT for Patient #29 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a TO (Telephone order) Physician #35/ signed by Staff #24. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.

Patient #30

Review of the MOT for Patient #30 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a signature for Physician #32 signed by Staff #28. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.

Patient #31

Review of the MOT for Patient #31 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a signature for Physician #33 signed by Staff #34. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.

Patient #32
Review of the MOT for Patient #32 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a TO (Telephone order) Physician #27/ signed by Staff #24. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.

Patient #33

Review of the MOT for Patient #33 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a signature for Physician #27 signed by Staff #26. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.



On October 11, 2018 after 11:00 AM during an interview, Staff #1 confirmed the above findings. Staff #1 was asked if the facility reviewed the completed MOT for completion and accuracy. Staff #1 said the ER (Emergency room) MOTs are audited by the ER Director, but there are no audits for any other department.


Review of the facility policy titled, "EMTALA Guidelines for Emergency Department Services" dated 12-14-2017 revealed the following:

...A physician certification that the risks of transferring the patient are outweighed by the potential benefits. The individual risks and benefits must be documented and the patient's medical record must support these ..."







STABILIZING TREATMENT

Review of the medical record for Patient #6 revealed the following:


TRIAGE NOTE

Patient #6 was triaged on 8/2/2018 at 2:46 PM. The Primary Treatment complaint was backache. Patient #6 complained of lower back pain and difficulty walking for one month. Patient #6 stated he was sent to the (ER) emergency room by Dr. Brown for admission. Vitals were noted to be: Blood pressure 142/80, Temperature 98.4, pulse 92, respirations 16/min, and pulse oximeter was 98%. Patient #6 pain level was 10/10. ESI (Emergency Severity Index) was Level 4.

ED PROVIDER NOTE

Patient #6 was seen on 8/2/2018 at 3:43 PM. Patient #6 Primary Complaint was lower back pain. Patient #6 complained of lower back pain and difficulty walking for one month. Patient #6 stated he was sent to the (ER) emergency room by Dr. Brown for admission. Patient #6 was a 55-year-old male with chronic back pain worse x 4 weeks. The pain was radiating to bilateral legs associated with numbness and tingling. The pain was worse on bending and standing, laying made the pain better.


CONSULT NOTE

Physician #18 was consulted on 8/2/2018 at 4:55 PM. The note showed the following, "Discussed the condition and clinical exam of Patient #6. Patient #6 does not meet the criteria for admission. Ok to do pain control and discharge. Needs assistance for MRI."

The ED course showed the following:

The time stamp was 8/2/2018 at 4:55 PM. The note shows Staff # 9 had a long discussion with Patient #6. Patient #6 was told he needed to get an outpatient MRI and was told to follow up with his PCP (Primary Care Physician) who was consulted and willing to give Patient #6 a script for MRI. The note shows Patient #6 insists to be admitted to have an MRI but he does not have "quadi aguina sings". The note shows a CT from 6/2018 was reviewed. The note states, "The patient could not get assistance as he is not from this county so advised him to fu with PCP for an outpatient MRI order referred the pt to the Neurosurgeon advised him to fu after he has his MRI done. The pt is comfortable with discharge strict return precautions given."

Review of the CT (Computed Tomography) Scan dated June 4, 2018 revealed the following findings:

" ...Since the prior study, endplate irregularity with some bony destructive changes at the L5-S1 level which is concerning for spondylo-discitis...
...There is severe canal and bilateral foraminal narrowing at L3-L4 at L4-L5"

The following medications were documented as given in Patient #6 medical record:

Promethazine 12.5 MG Intramuscular at 4:44 PM on 8-2-2018 (Nausea)
Morphine 5 MG at 4:43 PM on 8-2-2018 (Pain)
Orphenadrine 60 MG Intramuscular at 4:43 PM on 8-2-2018 (Muscle Relaxer)

Patient #6's pain level at 4:43 PM was 9 on a 1-10 pain scale.

Patient #6 was discharged at 8/2/2018 There were no vital signs documented at discharge. There was no pain level documented at discharge. The only vital signs documented in the chart were at triage taken at 2:40 PM on 8-2-2018.

The mode of transportation at discharge was a wheelchair.

During an interview on 8-2-2018 at 10:20 AM, Staff #12 said the facility doesn't have any restrictions on ordering MRI; however, he does have to get approval from the physician. Also, the patient needs to be from the county.

Staff #3 confirmed the above findings.

Review of the facility policy titled, "EMTALA Guidelines for Emergency Department Services" dated 12/14/2017 revealed the following:

...All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal Law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic ..."



Review of the medical record for Patient #6 at facility #2 (#17) revealed the following:

Emergency Record:

Patient #6 was seen by Physician #20 on 8/3/2018 at 8:39 AM at facility #2 (#17)

"Time seen: Date & time 08/03/2018 08:39 AM
History source: Patient.
Arrival mode: Ambulance.
History limitation: None.

Additional information: Chief Complaint from Nursing Triage Note:
08/03/2018 8:15 AM Chief Complaint got dizzy this am and fell in garage. was seen at Memorial yesterday for numbness in legs.

History of Present Illness
The patient presents with syncope. The onset was A few hours. The course/duration of symptoms is constant. The location where the incident occurred was at home. The exacerbating factor is none. The relieving factor is none. Risk factors consist of none. Prior episodes: none. Therapy today: none.

Additional history: This is a 55-year-old male with history of chronic low back pain presenting for evaluation after syncopal episode that occurred a few hours ago. Patient states he was standing in the garage of his in-law's house when he felt dizzy and then passed out on the floor, hitting his head on the concrete. Patient does not recall falling. No seizure activity noted. No oral injury or bowel or bladder incontinence. Patient came to without any postictal symptoms. No blood thinners. Per EMS glucose was normal. Patient complaining of worsening low back pain and overall generalized weakness. Denies any chest pain, shortness breath, fever, recent illness, cough, congestion, hemoptysis, abdominal pain, nausea, vomiting, diarrhea, focal numbness or weakness, leg pain or swelling. No prior DVT, CHF or MI. Patient does take Soma and hydrocodone 10 mg chronically for pain.

Reexamination/ Reevaluation
Time: 08/03/2018 10:50 AM

Notes: Currently stable, vital signs are stable. Update patient family on labs so far, patient has never been here before, no previous labs for comparison. I discussed elevated WBC without suspicion for infection at this time, could possibly due to the steroids that patient had an injection on July 12, and was also prescribe additional 10-day course of steroids, he has not taken any steroids in the past 2 days. Back pain is currently tolerable. Also discussed with patient finding of low hemoglobin. Patient was told 4 months ago that his hemoglobin was low, was started on iron tablets. No history of ulcers or GI bleeding, last colonoscopy was about 5 years ago by Dr. Jones and was unremarkable. Patient does admit that he takes 800 mg of ibuprofen about 3-4 times daily for the past several months for his back pain. Patient agreeable with the stool guaiac because he has not had one done to evaluate for GI bleeding. Discussed with patient that this could be the reason why he had that the dizziness and syncopal episode this morning.

Calls-Consults
- 08/03/2018 11:00 AM, phone call, Paged Hospitalist, Staff #20, regarding the pt., left voicemail.
- 08/03/2018 12:16 PM, phone call, talked w/ Hospitalist, Staff #20, and he agrees to accept the pt., but would like a surgical consult.

Plan

Condition: Improved, Stable.
Disposition: Admit time 08/03/2018 12:16 PM, Place in Observation Telemetry Unit.
Counseled: Patient, Family, regarding diagnosis, regarding diagnostic results, regarding treatment plan, Patient indicated understanding of instructions, family understand and agree w/ plan."


Review of the MRI done on 8-3-2018 at facility #2 (#17) revealed the following:


MRI Spine Lumbar W/O Contrast

FINDINGS: Fluid is present in the L5-S1 disc space. There is edema in the L5 and S1 vertebral bodies. There is inflammation in the soft tissues adjacent to the L5-S1 level with small fluid pockets consistent with tiny abscesses. There is soft tissue material in the spinal canal at the L5-S1 level-partial related to disc material. Phlegmonous tissue may also be present. Disc bulges are present at L2-3, L3-4, and L4-5. Facet degenerative changes are present at these levels as well and there is severe central stenosis at each level. Bilateral foraminal stenosis is noted.

IMPRESSION:
1. Changes are consistent with discitis and osteomyelitis at L5-S1. Inflammation is present in the adjacent fat. There is abnormal soft tissue in the canal-possibly related to an epidural abscess.
2. Multilevel degenerative change with severe central stenosis at L2-3, L3-4, and L4-5.


Consultation

"Document Date/Time: 8/3/2018 9:42 PM

REASON FOR CONSULTATION: Lumbar abscess

HISTORY OF PRESENT ILLNESS: 55-year-old black male with known lumbar disc disease presented to the emergency room today after a syncopal episode fall. Is complaining of severe back pain so a MRI was ordered of the lumbar spine. He has a severe discitis at L5-S1 with some epidural abscess rating lumbar stenosis at multiple levels. He states that he has difficulty feeling his feet at this point and there is a lot of numbness and tingling in his feet. For the past medical history and general physical exam, please see H&P.

PHYSICAL EXAMINATION:

NEUROLOGICAL: Patient is awake alert answers questions appropriately follows commands all of his cranial nerves appear intact. He has 2+ out of 5 strength in the lower extremities bilaterally. He has decreased sensation to touch bilaterally in the lower extremities.

RADIOLOGICAL EVALUATION: Marked changes at the L5-S1 consistent with severe discitis with an epidural abscess measuring 6-8 mm creating severe spinal stenosis.

ASSESSMENT: Lumbar abscess with discitis L5-S1

PLAN: Plan the patient is to be taken to surgery tonight for the decompressive laminectomy and removal of abscess with placement of wound VAC."


Staff #21 and Staff #22 confirmed the findings from facility #2 (#17).

Based on interviews and record review the facility failed to ensure Medical Screening Examinations (MSE) were provided by qualified professionals and were completed in a timely manner in 2 (#'s 13 and 18) of 33 patients.


This deficient practice had the potential to harm all patients who presented to the Emergency Room.


Review of the emergency medical records for Patient #13 revealed the following:


Triage Note

Patient #13 was a 35-year-old patient was presented to the emergency room at 7:57 PM on 10/25/2018. Patient #13's primary complaint said the patient was in the triage room by herself and her companion was in the waiting room. The note said Patient #13 was being threatened by him. The note said the patient will be moved back for safety and the law enforcement will be called. The triage note said Patient #13 had older injuries to face. Patient #13'S note said the patient complained that her neck is sore from being choked, and had been hit on the abdomen and back recently.

Nursing Notes

A note dated 10-25-2018 at 8:40 PM said Patient #13 came in complaining of chest pain but then became distraught and stated her visit was really because her companion had been abusing her. Authorities were notified.

The police department were noted to be at the bedside at 8:18 PM.


Lab/Test results

Lab glucose level was done at 8:40 PM on 10-25-2018. A urine HCG (Pregnancy) test was done at 8:14 PM on 10-25-2018.

A CT (Computed tomography) of the face was done at 10:42 PM on 10-25-2018.


Patient Disposition Note

The patient disposition note dated 10-26-2018 at 12:05 AM noted the patient left Against medical advice. The note said Patient #13 could not wait anymore.

There was no Medical Screening examination by the physician noted in the record. Patient #13 was at the emergency room for approximately 4 hours.



Review of the emergency medical records for Patient #18 revealed the following:


Triage Note

Patient #18 was 40-year-old male who presented to the emergency room on 8/7/2018 at 2:08 AM. Patient #18's primary complaint details noted patient #18 complained of left sided rib pain radiating to his abdomen. Patient #18's note said the pain had been going on for two days. Vital signs taken at triage were as follows: Temperature 98.2, Blood pressure 145/82, pulse, 89, respirations 18. Pain level was triaged at 10 on a 1-10 scale.


Labs/Test results

Chemistry panel, complete blood count, and PT/INR were obtained at 4:10 AM on 8-7-2018.

Chest X-Ray was taken on 8-7-2018 at 3:56 AM.

Urinalysis was done on 8-7-2018 at 4:05 AM.

EKG (Electrocardiogram) was done on 8-7-2018 at 6:04 AM.



ED (Emergency Department) Provider Note

Patient #18 was seen on 8/7/2018 at 6:29 AM, 4 hours after presenting to the emergency department.


Patient Disposition Note

Patient #18 was discharged on 8/7/2018 at 6:35 AM, 6 minutes after the provider completed the medical screening.


During an interview on 10/31/2018 after 10:00 AM Staff #3 confirmed the above findings.

Review of facility policy titled, "EMTALA GUIDELINES FOR EMERGENCY DEPARTMENT SERVICES" with a revision date of 12/14/2017 revealed the following:

...All patients shall receive a medical screening exam that includes all necessary testing and on call services within the capability of the hospital to reach a diagnosis."

Based on interview and record review, the facility failed to provide stabilizing treatment which was within their capabilities in 1 (Patient #6) of 1 patient. The facility failed to initiate an order for a MRI (Magnetic Resonance Imaging) for Patient #6 who was instructed to go to the emergency room by his treating physician for the service. Patient #6 was transported by EMS (Emergency Medical Services) from his home to Facility #2 (#17) less than 24 hours after discharge and required emergent surgery.


This deficient practice caused harm to one patient and had the likelihood to cause harm to all patients needing an MRI at the facility.

Review of the medical record for Patient #6 revealed the following:


TRIAGE NOTE

Patient #6 was triaged on 8/2/2018 at 2:46 PM. The Primary Treatment complaint was backache. Patient #6 complained of lower back pain and difficulty walking for one month. Patient #6's note said he was sent to the (ER) emergency room by Dr. Brown for admission. Vitals were noted to be: Blood pressure 142/80, Temperature 98.4, pulse 92, respirations 16/min, and pulse oximeter was 98%. Patient #6 pain level was 10/10. ESI (Emergency Severity Index) was Level 4.

ED PROVIDER NOTE

Patient #6 was seen on 8/2/2018 at 3:43 PM. Patient #6's primary complaint was lower back pain. Patient #6 complained of lower back pain and difficulty walking for one month. Patient #6's note said he was sent to the (ER) emergency room by Dr. Brown for admission. Patient #6 was a 55-year-old male with chronic back pain worse x 4 weeks. The pain was radiating to bilateral legs associated with numbness and tingling. The pain was worse on bending and standing, laying made the pain better.


CONSULT NOTE

Physician #18 was consulted on 8/2/2018 at 4:55 PM. The note showed the following, "Discussed the condition and clinical exam of Patient #6. Patient #6 does not meet the criteria for admission. Ok to do pain control and discharge. Needs assistance for MRI."

The ED course note showed the following:

The time stamp was 8/2/2018 at 4:55 PM. The note shows Staff # 9 had a long discussion with Patient #6. Patient #6 was told he needed to get an outpatient MRI and was told to follow up with his PCP (Primary Care Physician) who was consulted and willing to give Patient #6 a script for MRI. The note shows Patient #6 insists to be admitted to have an MRI but he does not have "quadi aguina sings". The note shows a CT from 6/2018 was reviewed. The note states, "The patient could not get assistance as he is not from this county so advised him to fu with PCP for an outpatient MRI order. Referred the pt to the Neurosurgeon advised him to follow up after he has his MRI done. The pt is comfortable with discharge strict return precautions given."

Review of the CT (Computed Tomography) Scan dated June 4, 2018 revealed the following findings:

" ...Since the prior study, endplate irregularity with some bony destructive changes at the L5-S1 level which is concerning for spondylo-discitis...
...There is severe canal and bilateral foraminal narrowing at L3-L4 at L4-L5"

The following medications were documented as given in Patient #6 medical record:

Promethazine 12.5 MG Intramuscular at 4:44 PM on 8-2-2018 (Nausea)
Morphine 5 MG at 4:43 PM on 8-2-2018 (Pain)
Orphenadrine 60 MG Intramuscular at 4:43 PM on 8-2-2018 (Muscle Relaxer)

Patient #6's pain level at 4:43 PM was 9 on a 1-10 pain scale.

Patient #6 was discharged at 8/2/2018 There were no vital signs documented at discharge. There was no pain level documented at discharge The only vital signs documented in the chart were at triage taken at 2:40 PM on 8-2-2018.

The mode of transportation at discharge was a wheelchair.

During an interview on 8-2-2018 at 10:20 AM, Staff #12 said the facility doesn't have any restrictions on ordering MRI; however, he does have to get approval from the physician. Also, the patient needs to be from the county.

Staff #3 confirmed the above findings.

Review of the facility policy titled, "EMTALA Guidelines for Emergency Department Services" dated 12/14/2017 revealed the following:

...All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal Law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic ..."



Review of the medical record for Patient #6 at facility #2 (#17) revealed the following:

Emergency Record:

Patient #6 was seen by Physician #20 on 8/3/2018 at 8:39 AM at facility #2 (#17)

"Time seen: Date & time 08/03/2018 08:39 AM
History source: Patient.
Arrival mode: Ambulance.
History limitation: None.

Additional information: Chief Complaint from Nursing Triage Note:

"08/03/2018 8:15 AM Chief Complaint got dizzy this am and fell in garage. was seen at Memorial yesterday for numbness in legs.

History of Present Illness
The patient presents with syncope. The onset was A few hours. The course/duration of symptoms is constant. The location where the incident occurred was at home. The exacerbating factor is none. The relieving factor is none. Risk factors consist of none. Prior episodes: none. Therapy today: none.

Additional history: This is a 55-year-old male with history of chronic low back pain presenting for evaluation after syncopal episode that occurred a few hours ago. Patient states he was standing in the garage of his in-law's house when he felt dizzy and then passed out on the floor, hitting his head on the concrete. Patient does not recall falling. No seizure activity noted. No oral injury or bowel or bladder incontinence. Patient came to without any postictal symptoms. No blood thinners. Per EMS glucose was normal. Patient complaining of worsening low back pain and overall generalized weakness. Denies any chest pain, shortness breath, fever, recent illness, cough, congestion, hemoptysis, abdominal pain, nausea, vomiting, diarrhea, focal numbness or weakness, leg pain or swelling. No prior DVT, CHF or MI. Patient does take Soma and hydrocodone 10 mg chronically for pain."

Reexamination/ Reevaluation

"Time: 08/03/2018 10:50 AM

Notes: Currently stable, vital signs are stable. Update patient family on labs so far, patient has never been here before, no previous labs for comparison. I discussed elevated WBC without suspicion for infection at this time, could possibly due to the steroids that patient had an injection on July 12, and was also prescribe additional 10-day course of steroids, he has not taken any steroids in the past 2 days. Back pain is currently tolerable. Also discussed with patient finding of low hemoglobin. Patient was told 4 months ago that his hemoglobin was low, was started on iron tablets. No history of ulcers or GI bleeding, last colonoscopy was about 5 years ago by Dr. Jones and was unremarkable. Patient does admit that he takes 800 mg of ibuprofen about 3-4 times daily for the past several months for his back pain. Patient agreeable with the stool guaiac because he has not had one done to evaluate for GI bleeding. Discussed with patient that that this could be the reason why he had that the dizziness and syncopal episode this morning.

Calls-Consults
- 08/03/2018 11:00 AM, phone call, Paged Hospitalist, Staff #20, regarding the pt., left voicemail.
- 08/03/2018 12:16 PM, phone call, talked w/ Hospitalist, Staff #20, and he agrees to accept the pt., but would like a surgical consult.

Plan

Condition: Improved, Stable.
Disposition: Admit time 08/03/2018 12:16 PM, Place in Observation Telemetry Unit.
Counseled: Patient, Family, regarding diagnosis, regarding diagnostic results, regarding treatment plan, Patient indicated understanding of instructions, family understand and agree w/ plan."


Review of the MRI done on 8-3-2018 at facility #2 (#17) revealed the following:


"MRI Spine Lumbar W/O Contrast

FINDINGS: Fluid is present in the L5-S1 disc space. There is edema in the L5 and S1 vertebral bodies. There is inflammation in the soft tissues adjacent to the L5-S1 level with small fluid pockets consistent with tiny abscesses. There is soft tissue material in the spinal canal at the L5-S1 level-partial related to disc material. Phlegmonous tissue may also be present. Disc bulges are present at L2-3, L3-4, and L4-5. Facet degenerative changes are present at these levels as well and there is severe central stenosis at each level. Bilateral foraminal
stenosis is noted.

IMPRESSION:
1. Changes are consistent with discitis and osteomyelitis at L5-S1. Inflammation is present in the adjacent fat. There is abnormal soft tissue in the canal-possibly related to an epidural abscess.
2. Multilevel degenerative change with severe central stenosis at L2-3, L3-4, and L4-5."


Consultation

"Document Date/Time: 8/3/2018 9:42 PM

REASON FOR CONSULTATION: Lumbar abscess

HISTORY OF PRESENT ILLNESS: 55-year-old black male with known lumbar disc disease presented to the emergency room today after a syncopal episode fail. Is complaining of severe back pain so a MRI was ordered of the lumbar spine. He has a severe discitis at L5-S1 with some epidural abscess rating lumbar stenosis at multiple levels. He states that he has difficulty feeling his feet at this point and there is a lot of numbness and tingling in his feet. For the past medical history and general physical exam, please see H&P.

PHYSICAL EXAMINATION:

NEUROLOGICAL: Patient is awake alert answers questions appropriately follows commands all of his cranial nerves appear intact. He has 2+ out of 5 strength in the lower extremities bilaterally. He has decreased sensation to touch bilaterally in the lower extremities.

RADIOLOGICAL EVALUATION: Marked changes at the L5-S1 consistent with severe discitis with an epidural abscess measuring 6-8 mm creating severe spinal stenosis.

ASSESSMENT: Lumbar abscess with discitis L5-S1

PLAN: Plan the patient is to be taken to surgery tonight for the decompressive laminectomy and removal of abscess with placement of wound VAC."


Staff #21 and Staff #22 confirmed the findings from facility #2 (#17).

Based on interview and record review, the facility failed to ensure that physician certifications for transfers were completed for the time frame of August 1, 2018 to September 30, 2018.

The facility failed to:

A. ensure that a physician certified that the medical benefits reasonably expected from the medical treatment at another facility outweighed the increased risks from the transfer in 12 (Patient #'s 22-33) of 12 twelve patients.

B. ensure that a physician determined the medical condition of the patient being transferred was stabilized prior to transfer in 12 (Patient's #22-33) in 12 twelve patients.


This deficient practice had the likelihood to cause harm to all patients needing to be transferred.


Findings include:

Patient #22

Review of Memorandum of Transfer (MOT) for Patient #22 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual's condition has not been stabilized, however the individual will benefit from a higher level of care." The physician signature line showed a V.O. (Verbal Order) Physician #23/Staff#24 The physician did not sign the certification and there was no documentation of the physician certification in the transfer note.


Patient #23

Review of the MOT for Patient #23 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a signature for Physician #25 signed by Staff #26. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.




Patient #24

Review of the MOT for Patient #24 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a signature for Physician #27 signed by Staff #28. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.


Patient #25

Review of the MOT for Patient #25 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a TO (Telephone Order) Physician #29/Staff #24. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.

Patient #26

Review of the MOT for Patient #26 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a TO (telephone order) Physician #27/Staff #30. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.

Patient #27

Review of the MOT for Patient #27 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a TO (Telephone Order) Physician #29/Staff#24. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.





Patient #28

Review of the MOT for Patient #28 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a TO (Telephone order) Physician #31/ signed by Staff #24. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.

Patient #29

Review of the MOT for Patient #29 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a TO (Telephone order) Physician #35/ signed by Staff #24. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.

Patient #30

Review of the MOT for Patient #30 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a signature for Physician #32 signed by Staff #28. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.

Patient #31

Review of the MOT for Patient #31 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a signature for Physician #33 signed by Staff #34. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.

Patient #32
Review of the MOT for Patient #32 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a TO (Telephone order) Physician #27/ signed by Staff #24. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.

Patient #33

Review of the MOT for Patient #33 revealed that the patient transfer certification was not signed off by the physician to indicate if the patient was stable or unstable prior to transfer. The patient condition was noted as, "The individual has been stabilized such that within reasonable medical probability, no material deterioration of the individual's condition or the condition of the unborn child(ren) is likely to result from transfer." The physician signature line showed a signature for Physician #27 signed by Staff #26. The physician did not sign the certification and there was no other documentation of the physician certification provided by the facility.



On October 11, 2018 after 11:00 AM during an interview, Staff #1 confirmed the above findings. Staff #1 was asked if the facility reviewed the completed MOTs for completion and accuracy. Staff #1 said the ER (Emergency room) MOT's are audited by the ER Director, but there are no audits for any other department.


Review of the facility policy titled, "EMTALA Guidelines for Emergency Department Services" dated 12-14-2017 revealed the following:

...A physician certification that the risks of transferring the patient are outweighed by the potential benefits. The individual risks and benefits must be documented and the patient's medical record must support these ..."