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Based on interview and record review, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements. The facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department when 1 of 20 patients reviewed (Patient #1) presented to the Emergency Department (ED) and did not receive an appropriate medical screening examination when presenting on 3/15/24.


Refer to 2406.

Based on review of documentation, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department when 1 (Patient#1) of 20 patients presented to the Emergency Department (ED) on 3/15/24.

Findings were:

Patient #1 presented to the emergency department with 2 of 4 criteria meeting SIRS (systemic inflammatory response syndrome) criteria and infection. Sepsis screening was not completed as per facility protocol:

Facility protocol - Sepsis Algorithm titled "SEPSIS Early Detection and Treatment:
Alert to Patient with 2 SIRS (systematic inflammatory response syndrome)...
Temp >100.9 or <96.8
HR >90
RR >20
WBC >12K...
Diagnosis Order Set:
Lactate
Blood Cultures
CBC (complete blood count)
CMP (comprehensive metabolic panel)
PT/INR/PTT (coagulation studies)
Procalcitonin
UA C&S (urinalysis and urine culture & sensitivity)
CXR (chest x-ray)
Suspect Sepsis initial treatment:
COMPLETED WITHIN 3 HRS
1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30 ml/kg for hypotension or lactate 4.0

3/15/24 4:32 PM Patient #1, 5 weeks postpartum, presented to the emergency department - "Patient complaining of left flank pain, fever, headache onset yesterday. Patient denies any difficulty and painful urination. Patient states she had a history of kidney stones before. Patient denies n/v/d (nausea, vomiting, diarrhea)."
Vitals: Temp 35.7 degrees Celsius (96.3 degrees Fahrenheit), HR(heart rate) 114, Respirations 17, Blood pressure 124/67, SpO2: 98%.

On admission Patient #1 had 2 of 4 criteria meeting SIRS (systemic inflammatory response syndrome) criteria and infection - Temperature 96.3 degrees Fahrenheit and HR 114.
Later laboratory results returned with WBC (white blood cells) - 13K.
Urinalysis - 51-100 WBC, few bacteria, trace hematuria
plus patient #1's heart rate remained elevated throughout her stay as documented as HR 110 at 6:00 PM and HR 126 at 7:00 PM.

The following assessment is noted in the medical chart:
MSE: 5:37 PM Constitutional: ...Genitourinary: left flank tenderness. no frequency, no urgency, no hematuria ...Neurological: headache. no paresthesias, no sphincter control loss procedures, no focal weakness..All Other Systems were Reviewed and Found Negative ...Physical Exam: GU left flank tenderness ...Medical Decision Making: Antibiotics and pain medication given. Patient will be discharged home with antibiotics and fluids ...Clinical Impression: Final Diagnosis: Pyelonephritis ...ED Disposition: Discharge, condition stable ..."

ED Nurse note 5:45 PM "Patient alert and oriented x 4, complains of left flank pain since yesterday w/ha (with headache) and nausea today. PMHX Kidney stones. Patient reports being post-partum since 2/7/24. Patient denies cough, abdominal pain, dysuria. RR (respiratory rate) easy and non-labored. Abdomen soft and non-tender. Patient reports increase pain to left flank with palpation. Bilateral radial pulses palpable, skin cool, dry, and normal for race. Patient shivering and complains of feeling cold. Patient remains afebrile at this time."
Vital signs 3/15/24 6:00 PM: Temp 36.6 degrees C (97.8 degrees F), HR 110, respirations: 18, blood pressure 121/56, SpO2: 96%.

Medications ordered/administered:
CefTRIAXone (Rocephin) 1 g (gram) in lidocaine IM 3/15/24 at 6:38 PM,
HYDROcodone-acetaminophen (Norco) 5-325 mg po (Orally) dose: 1 tablet at 3/15/24 7:49 PM
ondansetron (Zofran) 4 mg po at 3/15/24 6:38 PM.

Labs ordered/completed: Urinalysis; Pregnancy, Serum, Qual; CBC with Differential; Comprehensive Metabolic Panel.

Medical Decision Making: 3/15/24 6:10 PM: "Patient #1 presented to the Emergency Department for evaluation, and she was triaged to room ED39. I reviewed the nursing notes, and she was evaluated by me.
Patient will be discharged home with antibiotics and fluids.
History and reduction (sic) given via interpreter who is not a family member the patient is not nauseated she can carry on a biotics (sic)
Disposition
Clinical Impression: Final diagnoses: Pyelonephritis
ED Disposition Discharge
Condition Stable"

No assessment for sepsis was performed by the physician. Lactate, blood cultures, PT/INR/PTT, Procalcitonin, urine culture or CXR were not ordered by the physician as required by hospital protocol. And no IV fluids were administered.

Patient had left flank tenderness on exam - no imaging ordered.

History of kidney stones - documentation reflected diagnostics were not completed to rule out hydronephrosis from obstructing urethral stone/s.

30 minutes prior to discharge, Patient #1 reported a 6/10 pain despite the administration of oral medications for pain.