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Based on policy reviews, and staff interviews, the hospital failed to ensure 1 (Patient 21-no record) of 21 sampled patients was provided a Medical Screening Examination (MSE) to determine within the hospital's capabilities whether an Emergency Medical Condition (EMC) existed, in accordance with the facility Emergency Medical Treatment and Transfer Policy. Patient 21 presented to the Emergency Department for medical care for a 2 week history of diarrhea and recent blood noted in the stool; and failed to follow their policy for stabilizing treatment for 1 patient ( Patient 5) that presented to the Emergency Department on 2 consecutive visits, the initial visit the patient came in with the complaint of leg and back pain and was found to have a very high elevated blood pressure (281/168); the patient returned 3 hours later with vomiting and had a very high elevated blood pressure (279/212). Patient 5 did not receive any interventions to stabilize the blood pressure prior to leaving the ED on either visit. This failure has the potential for all patients presenting to the ED to have an untreated EMC which could result in harm or death due to the delay in stabilizing treatment.

Findings are:

See also A 2406.

A. Review of the 4/2016 policy titled, EMTALA (Emergency Medical Treatment and Transfer) Medical Screening revealed:
-A medical screening examination (MSE) is an examination within the capability of the Hospital's Emergency Department, including ancillary services routinely available to the Emergency Department, to determine with reasonable clinical confidence whether an (EMC) Emergency Medical Condition exists. A medical examination is not an isolated event, but a process that continues until the patient is stabilized or transferred. The MSE must be provided by a Qualified Medical Personnel (QMP).
-An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in: a)placing the health of the individual in serious jeopardy; or b) serious impairment to bodily functions or c) serious dysfunction of any bodily organ or part.
-Stabilize is to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from, or occur during, the transfer of the individual from the facility. Stabilized, with respect to an EMC other than a woman in labor, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility.
-Discharge-Prior to discharging an individual seeking emergency medical services (except an individual with an unstabilized EMC being transferred to another medical facility), a QMP shall document in the individual's medical record that the individual is not in an EMC or the individual's EMC is stabilized.

B. The hospital failed to follow their policy dated 4/2016 titled, EMTALA (Emergency Medical Treatment and Transfer) Medical Screening" Emergency Medical Treatment and Labor Act (EMTALA) and did not provide Patient 21 with a medical screening exam when the patient presented to the Emergency Department on 2/21/2023 and request to be seen for a 2 week history of diarrhea and blood in stool.

C. The hosptial failed to follow their policy dated 4/2016 titled, EMTALA (Emergency Medical Treatment and Transfer) Medical Screening" Emergency Medical Treatment and Labor Act (EMTALA) and did not provide Patient 5 with stabilizing treatment of very high blood pressure on 2 consecutive visits, the initial visit the patient came in with the complaint of leg and back pain and was found to have a very high elevated blood pressure (281/168); the patient returned 3 hours later with vomiting and had a very high elevated blood pressure (279/212). Patient 5 did not receive any interventions to stabilize the blood pressure prior to leaving the ED on either visit.

Based on outside medical records, staff interviews and review of the facility EMTALA policy and procedures the facility failed to ensure 1 (Patient 21) of 21 sampled patients was provided with a Medical Screening Examination (MSE) to determine within the hospital's capabilities the presence of an Emergency Medical Condition (EMC). Patient 21 presented to the Emergency Department (ED) seeking medical care for a 2 week history of diarrhea and recent blood noted in stool, the staff failed to provide a MSE. The total sample of 21 patients were reviewed. This failure has the potential for all patients presenting to the ED to have an untreated MSE which could result in harm or death due to delay in treatment.

Findings are:

A. An interview with the Chief Nursing Officer (CNO) on 2/28/23 at 1:00 PM revealed, "I am aware of why you would be here. We had received a call on 2/21/23 at 11:00 AM that a patient (Patient 21) had come to the emergency room, then directed to the Medical Clinic and was not seen prior to leaving and driving to another health facility. I looked into the situation and verified that the patient did come to the Emergency Department (ED) with concern of 2 weeks of diarrhea and that morning noted blood in the stool. I checked with the Medical Clinic and they did have the patient scheduled to see our on-call provider at 10:45 AM. The Clinic staff told me that the patient had been checking with their insurance and found that it would pay if seen in the ED or and urgent care. The patient was told that they could go back to the ED, and the patient refused and said would go to another health facility (2 hours away)."

B. Review of the 4/2016 policy titled, EMTALA (Emergency Medical Treatment and Transfer) Medical Screening revealed:
-A medical screening examination (MSE) is an examination within the capability of the Hospital's Emergency Department, including ancillary services routinely available to the Emergency Department, to determine with reasonable clinical confidence whether an (EMC) Emergency Medical Condition exists. A medical examination is not an isolated event, but a process that continues until the patient is stabilized or transferred. The MSE must be provided by a Qualified Medical Personnel (QMP).
-A QMP may be a Physician, Physician Assistant and a Nurse Practitioner.
-RN MSE Allowed- A registered nurse (RN) may perform the MSE in the absence of the signs and symptoms listed above (Significant Trauma; Chest Pain; Acute Dyspnea; Coma; Seizure; overdose/poisoning; Cardiac/Respiratory Arrest; Acute Diabetic complications; Emergency childbirth; Persistent V/D; Foreign body in eye; Shock; CVA or TIA; Severe Pain; Circulatory deficit in limb; sever or sudden headache). Upon completion of the MSE, the RN shall call the on-call physician, PA or NP to report the results of his/her nursing assessment. If the RN determines that the individual is in an EMC, a physician, PA or NP shall provide further examination and treatment. If the MD determines that the individual is not in an EMC, the RN, pursuant to physician, PA or NP telephone orders, may provide nursing services, refer the individual to a private clinic for further treatment, and/or discharge the individual with instructions.
-An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in: a)placing the health of the individual in serious jeopardy; or b) serious impairment to bodily functions or c) serious dysfunction of any bodily organ or part.

C. Review of the Urgent Care Health Facility (2 hours away) medical record dated 2/21/23 arriving at 12:41 PM revealed:
-The patients chief complaint was diarrhea x 2 weeks after taking Augmentin (antibiotic) for a sinus infection, and today there was some blood on the toilet paper, loose stools and bad flatulence. (passing gas rectally). Vital Signs 97.8°, 126/72, 69 and 93% on room air.
-Provider orders included, Clostridium Difficile Toxin (test to check for the bacterium that causes infection), stool cultures and fecal lactoferrin (test to check for intestine inflammation). Due to impending weather will start the patient on Flagyl (antibiotic) 500 mg (milligram) 3 times a day for the next 14 days while awaiting results.
- Test results revealed, Clostridium Difficile Toxin -Positive; and fecal lactoferrin -Positive.
-The patient was discharged to home with diet instructions, to increase fluids, take medication as instructed, follow up as needed and in 2 weeks with primary care physician. Urgent Care will contact when results returned.

D. An interview with Registered Nurse B (RN B) on 3/1/23 at 10:30 AM regarding Patient 21 arriving at the ED on 2/21/23. RN B indicated that she was sitting at the nursing station and saw (Patient 21) wandering around by the ED. I asked if I could help, and (Patient 21) said yes I think I need to be seen. We walked into ED Room 2, I asked what was going on. Said had diarrhea for 2 weeks and saw some blood today. I told the patient that I have the ED or could go to the clinic and would see the same provider. I told the patient if they couldn't see them soon then could come back to ED. Asked RN B if any vital signs were done, if the patient was placed in the central log or if the clinic physician was called. RN B stated, "No, just walked the patient part of the way and directed where the clinic was."

Per the verification in RN B's interview the facility did not follow their policy regarding and RN MSE. There was no ED medical record for Patient 21 created.

Based on record review, staff interviews and review of policy and procedures the facility failed to provide stabilizing treatment to 1 (Patient 5) of 21 sampled patients. Patient 5 presented to the Emergency Department (ED) on 2 consecutive visits, the initial visit the patient came in with the complaint of leg and back pain and was found to have a very high elevated blood pressure (281/168); the patient returned 3 hours later with vomiting and had a very high elevated blood pressure (279/212). Patient 5 did not receive any interventions to stabilize the blood pressure prior to leaving the ED on either visit. This failure has the potential for all patients presenting to the ED to have an untreated EMC which could result in harm or death due to the delay in stabilizing treatment.

Findings are:

1st visit Sunday 10/9/22 at 9:06 PM -10:27 PM, and discharged home
A. Medical record review of the first ED visit on Sunday 10/9/22 at 9:06 PM - 10:27 PM for Patient 5 revealed the patient came to the ED via a friend with a complaint of left leg, back and hamstring pain. Initial vital signs were temperature 97.2°, BLOOD PRESSURE (BP) 281/168, pulse 93, respirations 20, and oximetry 90% with 2 liters of oxygen per nasal cannula. Per the physician note (ED Dr A) dated 10/9/22 stated, "(Patient 5) Did NOT go to scheduled dialysis on Friday, "went to the res [reservation] instead". "Does have very frequent ED visits and pain complaints. Apparently is non compliant with meds, also a very frequent problem." Repeat BLOOD PRESSURE at 10:25 PM was 285/165. Physician Assessment/Plan identified; 1) Chronic pain -gave 4 mg (milligram) Morphine for pain, 1 time dose only. Nurse reports patient had immediate pain relief. 2) non-compliance with renal dialysis -informed she needs to dialyze, if she wants to quit, I told her she needs to go on Hospice and plan on dying from renal failure. 3) Anxiety. 4) HYPERTENSION- VERY HIGH BP, apparently this is common, and she has not taken her meds again. 5) Morbid obesity. 6) Oxygen dependent.

Review of nurses notes dated 10/9/23 revealed:
-9:45 PM [A friend] is called at this time to make sure ride is provided before given pain med to patient. [A friend] agreed to come get patient.
-9:50 PM Morphine IM is ordered, Called Nebraska Medicine Pharmacist to see if can be given IM, Pharmacist informed that it can be given IM.
-9:58 PM Morphine 4 mg/ml (milligram/milliner) is given IM in right deltoid.
-10:02 PM Patient stated "it went away right after the shot.
-10:15 PM Patient is to bathroom. Comes back to room and emesis.
-10:22 PM Patient is out to ride vehicle. Instructions are given to patient.

The physician medication reconciliation form indicated that a new prescription for Bumetanide 1 mg (medication for blood pressure) to be taken twice a day. The discharge instructions sheet indicated medications given as morphine 4 mg IM (intramuscularly), printed information about back pain and a medication reconciliation sheet with the new medication. The record lacked administration of the new medication or specific instructions on the new medication and was advised to follow up with the primary care provider within 1 month, only if needed. The patient was provided a ride home via [a friend].

2nd visit Monday 10/10/22 at 1:28 AM and left Against Medical Advice (AMA) at 2:05 AM
Medical record review of the 2nd ED visit on Monday 10/10/22 at 1:28 AM for Patient 5 revealed the patient came to the ED via ambulance with a complaint of vomiting. Initial vital signs were temperature 97.2°, BLOOD PRESSURE (BP) 277/212, pulse 91, respirations 20, and oximetry 91% with 4 liters of oxygen per nasal cannula. The nurses note from LPN (Licensed Practical Nurse) G dated 10/10/22 revealed:
-1:47 AM, Provider (ED Dr A) is called, request to have Patient admitted. Orders given for hypertension. If Patient refuses care needs to sign out AMA.
-1:48 AM, Patient is informed of Doctors decision to admit patient, patient refuses to be admitted and states, "I'm just trying to get my breathing under control. (Patient 5) states "I will not call 911 again tonight."
-1:49 AM, Patient is informed if does not stay will need to sign out AMA, it is explained to patient the risks of refusing treatment, patient states understanding.
-2:05 AM, Chadron Police Department (CPD) here to take patient home, patient took off oxygen (02) and states can't breathe, oxygen tank given to CPD for patient to get home, patient is instructed to wear 02 when gets home, patient agrees.

Review of both ED medical records for Patient 5 on 10/9/22 and 10/10/22 lacked any laboratory check or of the administration of medication for the elevated blood pressure.

B. Interview with Chief Nursing Officer (CNO) on 2/28/23 at 10:30 AM, inquired if the CNO could arrange for an interview with LPN G, the CNO stated, "That person no longer works here and unable to reach LPN G." Asked the CNO to check the 10/10/22 ED medical record for the order for the hypertension medication that was referenced in the nurses notes. The CNO verified that the ED medical record for 10/10/22 lacked an order to the hypertension.

C. Interview with the ED Physician on duty (ED Dr A) for 10/9/22 and 10/10/22 on 3/1/23 at 4:10 PM revealed that ED Dr A saw the Patient 5 on 10/9/22. ED Dr A reviewed the 10/9/22 medical record, ED Dr A indicated that this patient frequented the ED, that (Patient 5) had a history of medication non compliance and dialysis non compliance. When asked about the notation of the "very high BP 285/165, apparently this is common and has not taken meds again." I don't recall but I am sure I would have reviewed all these medications and asked her if she would to go home and take her medications. Verified that they gave Morphine to treat the complaint of leg and back pain that she came with, don't see any other medication administered.
Review of the 10/10/22 medical record with ED Dr A, revealed, that the patient was just seen by this doctor 3 hours earlier. The patient came into the ED with vomiting. The nurses notes say that the nurse called me and having just seen the patient, told the nurse to tell the patient that we needed to admit or would need to sign a leaving against medical advise. "The patient refused to stay, and signed the paper. The patient left before I could even get to see them." When asked if the ED Dr A had new what order she gave the nurse (LPN G), ED Dr A stated "have no recollection, as it was 4-5 months ago."

D. Phone interview on 3/1/23 at 3:00 PM with the Nephrologist managing Patient 5's dialysis revealed, this physician is the Dialysis Medical Director for the hospital. The Nephrologist stated that there is someone from their practice on call 24/hours per day and 7 days per week, if any physician wants to call and discuss any of their patients. When asked about the protocol for lab checks for the dialysis, the Nephrologist said that they need a full lab panel monthly and a hemoglobin check every other week. Inquired if the patient came to the ED with pain in back and legs, and while being assessed for that was found to have a high blood pressure of 285/165 and 281/168, if that would be related to the patient missing the last dialysis treatment and if in the doctors opinion that lab would be indicated. The Nephrologist stated, "the leg/back pain would not be an indicator for lab related to the missed dialysis but the elevated blood pressure maybe an indication for lab. The Nephrologist was also notified that the patient returned to the ED 2-3 hours later with nausea and vomiting and the blood pressure was 279/212, the Nephrologist stated, "the nausea/vomiting and high blood pressure may be an indication for lab and possibly emergent dialysis. My thought is a potassium of 6 or greater would indicate need for emergent dialysis, potassium in the 5's not considered an emergency."

E. A review of laboratory results showed that on 9/29/22 the potassium (normal 3.5-5.1) was 6.7 after missing the 9/28/22 dialysis; 10/5/22 the potassium was 5.2 had dialysis on 10/3/22, then dialysis on 10/5/22, then did not come for dialysis on 10/7/22, in ED on 10/9/22 & 10/10/22 before coming for the afternoon dialysis on 10/10/22.

F. Review of the Mayo Clinic website- High Blood Pressure article dated 9/15/2022 revealed the following categories to classify blood pressure:
-Normal blood pressure- when the blood pressure is normal if below 120/80 mmHg (millimeters of mercury)
-Elevated blood pressure. The top number ranges from 120 to 129 mm Hg and the bottom number is below, not above, 80 mm Hg.
-Stage 1 hypertension. The top number ranges from 130 to 139 mm Hg or the bottom number is between 80 and 89 mm Hg.
-Stage 2 hypertension. The top number is 140 mm Hg or higher or the bottom number is 90 mm Hg or higher.

Blood pressure higher than 180/120 mm Hg is considered a hypertensive emergency or crisis. Seek emergency medical help for anyone with these blood pressure numbers. Untreated, high blood pressure increases the risk of heart attack, stroke and other serious health problems. It's important to have your blood pressure checked at least every two years starting at age 18. Some people need more-frequent checks.

G. Review of the 4/2016 policy titled, EMTALA (Emergency Medical Treatment and Transfer) Medical Screening revealed:
-A medical screening examination (MSE) is an examination within the capability of the Hospital's Emergency Department, including ancillary services routinely available to the Emergency Department, to determine with reasonable clinical confidence whether an (EMC) Emergency Medical Condition exists. A medical examination is not an isolated event, but a process that continues until the patient is stabilized or transferred. The MSE must be provided by a Qualified Medical Personnel (QMP).
-An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in: a)placing the health of the individual in serious jeopardy; or b) serious impairment to bodily functions or c) serious dysfunction of any bodily organ or part.
-Stabilize is to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from, or occur during, the transfer of the individual from the facility. Stabilized, with respect to an EMC other than a woman in labor, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility.
-Discharge-Prior to discharging an individual seeking emergency medical services (except an individual with an unstabilized EMC being transferred to another medical facility), a QMP shall document in the individual's medical record that the individual is not in an EMC or the individual's EMC is stabilized.