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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag 2406: Appropriate Medical Screening Examination. Based on record reviews and interviews, the facility failed to ensure patients were continually monitored according to facility policy and facility expectations to confirm if an emergent medical condition was present in eight of eighteen medical records reviewed of patients receiving care in the emergency department. (Patients #1, #4, #5, #6, #8, #9, #14 and #16)

Based on record reviews and interviews, the facility failed to ensure patients were continually monitored according to facility policy and facility expectations to confirm if an emergent medical condition was present in eight of eighteen medical records reviewed of patients receiving care in the emergency department. (Patients #1, #4, #5, #6, #8, #9, #14 and #16)

Findings include:

Facility policies:

According to the Treatment and Transfer of Individuals with Emergency Medical Conditions (EMTALA) policy, the medical screening examination is an ongoing process. The medical record must reflect an ongoing assessment of the patient's condition. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred. There should be evidence of this prior to discharge or transfer. The medical screening examination must be documented in the medical record.

According to the Vital Signs-Taking and Recording in the Emergency Department, all patients admitted to the Emergency Department (ED) will have a baseline set of vital signs completed at the time of triage and at discharge. Additional vital signs will be completed as warranted. Patients who remain in the ED for extended periods of time will have vital signs reassessed and documented at least every two hours. Patient condition may warrant more frequent assessments under the following guidelines: a. Emergent/Urgent/Unstable require full set of V/S every 5 - 15 minutes until 3 consecutive sets of stable vital signs then at least every hour: b. Abnormal V/S on admission, or the patient received medications or treatments known to affect vital signs (such as narcotics, epinephrine, Ng tube placements, etc.): Full V/S every 30 minutes until 3 consecutive sets of stable vital signs then at least every 2 hours. Pulse-oximetry readings will be taken on all patients with actual or potential respiratory or dyspneic complaints and all acute or critical patients.

The provider should be notified of any abnormal vital signs on the final set prior to discharge to include tachycardia (>100), SBP <90 or >180, tachypnea (>20), or febrile (temp. > or equal to 100.4).

According to the Pain Assessment, Reassessment and Management policy, it is the responsibility of all clinical staff to assess and periodically reassess the patient for pain and relief from pain including the intensity and quality (i.e., character, frequency, location and duration of pain), and responses to treatment.

Questions related to pain include, but are not limited to: Nature of pain, Duration, Type, Intensity, Any pain relief methods that have proven effective, Patient's desires for pain management, i.e., pain control, complete pain relief.

1. The facility failed to ensure patients' vital signs and pain levels were assessed and reassessed periodically and addressed when abnormal throughout their stay in the ED.

A. On 5/19/22 at 9:57 a.m., medical records were reviewed with the director of the ED (Director #4) and revealed a lack of pain and vital sign assessments, reassessments and interventions initiated after abnormal vital signs were found.

i. Patient #8 presented to the ED on 4/21/22 at 9:16 a.m. with a chief complaint of chest pain at a level of ten out of ten and complications from a bariatric procedure.

a. Record review revealed Patient #8's blood pressure was not assessed until 10:46 a.m., approximately one and a half hours after the patient arrived.

During the medical record review, Director #4 verified that an initial blood pressure was missing. Director #4 stated there should have either been a blood pressure taken when the patient first presented in triage or a reason why a blood pressure was not taken documented in the medical record.

At 12:30 p.m., Patient #8's vital signs were assessed. The next set of vital signs were taken at 1:47 p.m., which was one hour and 17 minutes later. This was in contrast to the Vital Signs-Taking and Recording in the Emergency Department (Vital Signs policy) policy which read Emergent/Urgent/Unstable patients required a full set of vital signs every 5-15 minutes until 3 consecutive sets of stable vital signs and then reassessed at least every hour.

At 3:30 p.m., Patient #8's vital signs were assessed which revealed a heart rate of 120 beats per minute (a heart rate of greater than 100 beats per minute was considered to be high according to the Vital Signs policy). The next set of vital signs was assessed at 5:45 p.m., which was two hours and 15 minutes later. This set of vital signs was missing a heart rate level. The next heart rate level was not assessed until 6:09 p.m., which revealed the heart rate was 130 beats per minute.

b. Review of Patient #8's oxygen saturation levels between 10:31 a.m. to 2:45 p.m. revealed the levels documented were between 79%-87%. Review of the provider orders revealed an order placed on 4/21/22 at 9:21 a.m., which instructed staff to titrate oxygen to maintain oxygen saturation levels above 90%. There was no evidence of interventions being enacted such as the administration of supplemental oxygen until 5:45 p.m.

During the medical record review, Director #4 confirmed there was no evidence that Patient #8 had been placed on oxygen until 5:45 p.m. Director #4 stated the expectation was if the oxygen saturation level was under 90%, oxygen should have been applied. Director #4 further stated that oxygen should have been applied at 10:31 a.m., when the patient's oxygen level was 87%.

c. Patient #8 presented with crushing chest pain rated ten out of ten per Emergency Medical Services (EMS) documentation. Initial nursing assessment indicated pain rated nine out of ten. Pain medications given included: Morphine at 10:14 a.m. and Dilaudid at 12:12 p.m., 2:15 p.m., 4:43 p.m., 6:27 p.m., and 8:35 p.m. There was no evidence of pain level reassessments noted in the medical record after pain medications were administered. This was in contrast to the Pain Assessment, Reassessment and Management policy, which read staff were to assess and periodically reassess the patient for pain and pain relief from pain, and response to treatment.

During the medical record review, Director #4 verified that no pain level reassessments were performed after the administration of pain medications. Director #4 stated the expectation was that after a pain medication was administered, a pain level reassessment should have been conducted to ensure the effectiveness of the medication and to see if further interventions were required. Furthermore, Director #4 stated it was crucial to address a patient's pain, that it was part of the evaluation for an emergency condition, and pain was a main reason why patients came to the ED.

ii. Patient #1 presented to the ED on 2/21/22 at 12:45 p.m. with a chief complaint of abdominal pain, nausea, and vomiting.

a. Record review revealed Patient #1's first set of vital signs were assessed at 1:27 p.m., and were not reassessed until the patient was discharged at 7:09 p.m. This was in contrast to the Vital Signs-Taking and Recording in the Emergency Department policy which read that patients who remained in the ED for extended periods of time will have vital signs reassessed and documented at least every two hours.

b. Patient #1 presented with complaints of abdominal pain. Record review revealed no evidence of pain level assessments during his stay in the ED. This was in contrast to the Pain Assessment, Reassessment and Management policy which read staff were to assess and periodically reassess the patient for pain and relief from pain.

iii. Patient #6 presented to the Emergency Department on 4/28/22 at 9:38 p.m. with a chief complaint of panic attack and psychiatric symptoms.

a. Record review revealed vital signs were assessed at 10:15 p.m., and not reassessed until 4/29/22 at 7:38 a.m. In addition, Patient #6 was given Ativan (a medication that has sedative effects that can decrease respirations) at 5:36 a.m. This was in contrast to the Vital Signs-Taking and Recording in the Emergency Department policy which read that patient conditions may warrant more frequent assessments if the patient received medications or treatments known to affect vital signs.

During medical record review, Director #4 verified that the policy for the assessment of vital signs for extended periods was not followed. Director #4 stated that Patient #6 should have been monitored when she was given Ativan, since the medication could have reduced her respiratory rate.

b. Record review revealed no evidence of pain level assessment during triage, or at any time throughout Patient #6's stay in the ED. This was in contrast to the Pain Assessment, Reassessment and Management policy which read staff were to assess and periodically reassess the patient for pain and relief from pain.

Similar findings of missing reassessments of pain levels and/or vital signs were found in the record reviews of Patients #4, #5, #9, #14, and #16.

B. Staff interviews revealed patients were expected to have vital signs assessed throughout their visit and that interventions should have been implemented when vital signs were abnormal.

i. On 5/17/22 at 2:00 p.m., an interview with Registered Nurse (RN) #9 was conducted, who worked in the ED. RN #9 stated that once an hour rounding was expected to be performed, where vital signs were assessed, and patients were asked about pain to see if interventions had worked. RN #9 further stated the standard was for vital signs to be documented every hour. She also stated that pain assessments were important to make sure interventions worked because patients came to the facility to feel better.

ii. On 5/18/22 at 10:56 a.m., an interview with the Chief Medical Officer (CMO) #11 was conducted. CMO #11 stated vitals were important and a big portion of what was looked at by the provider when determining an emergency medical condition. CMO #11 further stated if a patient presented with abnormal vital signs, it indicated they need to be monitored more heavily.

iii. On 5/18/22 at 12:16 p.m., an interview with the Manager of the Emergency Department (Manager #10) was conducted. Manager #10 stated that a full set of vital signs included a temperature, heart rate, blood pressure, and respirations. Manager #10 stated vital signs were expected to be checked before and after giving pain or anti-anxiety medications to see how the patient was responding. Manager #10 also stated that it was not typical for a patient to be in the ED overnight without having their vital signs assessed. Manager #10 explained a full set of vital signs was expected to be assessed prior to administering medications. Manager #10 stated that in order to consider a patient stabilized, staff would need to know what their vital signs were.

When Manager #10 was asked about pain assessments, she stated the assessments helped to determine what was going on with the patient, helped to guide the care, and also helped to properly provide an adequate plan of care for the patient. Manager #10 also stated if a patient reported pain, staff were expected to assess the pain further.