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Based on document review and staff interviews, Hospital A's administrative staff failed to ensure the Emergency Department (ED) staff followed Hospital A's policies to ensure that 1 of 20 patients reviewed (Patient # 1) who presented to the ED with an emergency medical condition (EMC) received an appropriate medical screening examination (MSE). Failure to provide an appropriate MSE at Hospital A's ED resulted in Patient # 1 not receiving appropriate care and subsequently being evaluated and admitted to Hospital B 2 hours and 40 minutes later for treatment of acute on chronic congestive heart failure, unspecified heart failure type, acute on chronic respiratory failure with hypoxia and hypercapnia, and an abnormal chest x-ray. Hospital A's administrative staff identified an average of 392 patients per month who presented to the dedicated emergency department.

Findings include:

1. Review of the policy "EMTALA - Transfer and Emergency Examination," Reviewed on 3/11/2022, revealed in part, " ... to establish a procedure for the examination, stabilization, and transfer of individuals coming to Clarke County Hospital emergency department when a request has been made for examination or treatment for a medical condition, including active labor, regardless of the individual's ability to pay. This policy is also intended to assure appropriate treatment and transfer protocol in compliance with EMTALA (the Emergency Medical Treatment and Labor Act)." According to the policy stabilize means to "provide such medical treatment of the condition as may be necessary to ensure, 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 a facility; or with respect to a woman in labor, to deliver (including the placenta). Stable for discharge: a patient is stable for discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonable performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions. Discharge: Prior to discharging an individual seeking emergency medical services (except an individual with an unstabilized emergency medical condition being transferred to another medical facility), the examining health care practitioner shall document in the individual's medical record that; the individual is not in an emergency medical condition, or the individual's emergency medical condition is stabilized."

2. Review of the policy "Discharge or Transfer of Patients Treated in the Emergency Department," Reviewed on 2/8/2022, revealed in part, " ... establish criteria for the staff in regards to discharging the patient in accordance with the physician's directed discharge. The physician will indicate the discharge disposition of the patient in the Emergency room record and upon discharge, and the patient will be escorted out of the department whenever possible."

3. During an interview on 1/5/23 at 3:23 PM with Hospital A's physician B reported, they look at the whole situation of a patient in the emergency department, and the number one thing, is this something that could be managed at home, or would it be unsafe for them to go home? Hospital A's Physician B reports they collaborates with the patient and assesses if the patient is medically necessary for admission. One of the main things is safety at home, taking into consideration the patient's condition and resources available for them at home. Hospital A's Physician B assesses whether treatment could be managed at home given the patients current symptoms and overall status. Then determine if the patient would require treatment through intravenous (IV) or just increasing oral treatment. Then making the decision whether to admit for observation or inpatient care, or discharge them home. Hospital A's Physician B reported during a follow up question, they look at the big picture and question will the patient be safe at home. If the answer is no, then is it something we can care for at Hospital A? If the patient is unsafe to go home, and they do not need a higher level of care, then I make the determination to admit. Following another question pertaining to the frequency of a patient coming to the ED for care, Hospital A's physician B reported, it would generally be the same, but there is a heightened approach, recognizing they may need a higher level of care. Again, looking at the situation and reviewing if the patient is safe to be at home. If a patient returns, they may not have had the resources they/we thought they did.

4. Review of Patient #1's medical record from Hospital A revealed, Patient #1 verbalized safety concerns to Physician B. Documentation in Patient # 1's ED progress note from Hospital A revealed, the patient raised concern about the smell in the home being a problem for Patient #1's breathing due to the smell of cat urine. Physician B encouraged Patient # 1 to get a hotel for the night or stay with a relative if they can't get the cat problem cleaned up tonight, but Physician B could not admit Patient #1 to Hospital A because of a bad smell in the home.

5. Review of Patient # 1' s medical record from Hospital A revealed, Hospital A's EMS (Emergency Medical Services) Prehospital Care Report showed Patient # 1 was picked up from Patient # 1's home on 11/15/22 at 4:00 PM by Hospital A's owned/operated ambulance for anxiety, emotional shock or stress, and shortness of breath. The report noted there was at least 6 cats and 2 dogs inside the trailer with dog and cat feces throughout the trailer, and a strong smell of cat urine and ammonia inside. Vital signs (VS) were assessed showing pulse oximetry (SPO2) was 98%, pulse (P) was 86, Respirations (R) were around 16. Patient # 1 was unsure if they wanted to be seen at Hospital A or not, but Hospital A's emergency medical technician (EMT) explained to Patient # 1 the poor air quality inside the home is likely contributing to Patient #1's breathing problems. Patient # 1 agreed to be transported to Hospital A.

6. Review of Patient # 1' s medical record showed a lack of an appropriate Medical Screening Examination. According to Hospital A's policy "EMTALA - Transfer and Emergency Examination," the examining health care practitioner shall document in the individual's medical record that; the individual is not in an emergency medical condition, or the individual's emergency medical condition is stabilized." Patient # 1's medical records lacked supporting documentation that their emergency medical condition was stabilized following treatment, and prior to discharge. Record review supported unfavorable living conditions, which could have effected Patient # 1's health and safety, and was discussed by Patient # 1 with Hospital A's ED physician.

Please refer to C-2406 for additional information

Based on document review and staff interviews, Hospital A's administrative staff failed to ensure Hospital A's ED staff provided 1 of 20 emergency patients reviewed (Patient # 1) with an appropriate medical screening examination (MSE) after presenting to the Emergency Department (ED) by ambulance seeking medical care. Failure to provide an appropriate MSE at Hospital A's ED resulted in Patient # 1 not receiving appropriate care and subsequently being evaluated and admitted to Hospital B 2 hours and 40 minutes later for treatment of acute on chronic congestive heart failure, unspecified heart failure type, acute on chronic respiratory failure with hypoxia and hypercapnia, and an abnormal chest x-ray. Hospital A's administrative staff identified an average of 392 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient # 1' s medical record from Hospital A revealed, EMS (Emergency Medical Services) Prehospital Care Report showed Patient # 1 was picked up from the home on 11/15/22 at 4:00 PM by Hospital A's owned/operated ambulance for anxiety, emotional shock or stress, and shortness of breath. When Hospital A's EMS arrived, Patient # 1 was found sitting on the couch surrounded by trash, food, multiple oxygen tanks, numerous books, and a magazine. There was at least six cats and two dogs inside the trailer. There was dog and cat feces throughout the trailer, and a strong smell of cat urine and ammonia inside. The floor was covered with a slimy black film. There were bugs crawling on the walls, carpet, and furniture. Patient # 1 stated Patient # 1 requires assistance from Patient # 1's husband to move from the couch to the bathroom and bed. Patient # 1 has oxygen tubing running throughout the trailer. Patient # 1 stated that Patient # 1 was watching television when Patient # 1 had a sudden onset of shortness of breath. Vital signs (VS) were assessed showing pulse oximetry (SPO2) was 98% (normal range is usually 95% or higher), pulse (P) was 86 (normal range 60-100), Respirations (R) were around 16 (normal range 12-16). Patient # 1 was unsure if they wanted to be seen at the hospital or not, but emergency medical technician (EMT) explained that the poor air quality inside the home is likely contributing to Patient # 1's breathing problems. Patient # 1 agreed that was true and stated they were going to be moving out of the trailer in the next few days and leaving everything behind. EMT spoke with Patient # 1's daughter by phone while in the home, and the daughter requested Patient # 1 be transported to Des Moines for care. It was explained by Hospital A's EMT to Patient # 1's daughter, they needed to transport patient to Hospital A for initial care. Patient # 1 agreed to be transported. Patient # 1 was alert and oriented. Airway was patent. Breathing was normal with equal rise and fall of the chest, and was on 6 liters (L) of oxygen (O2).

2. During an interview on 1/5/23 at 3:23 PM with Hospital A's Physician B reported, they look at the whole situation of a patient in the emergency department, and the number one thing, is this something that could be managed at home, or would it be unsafe for them to go home? Hospital A's Physician B reports they collaborates with the patient and assesses if the patient is medically necessary for admission. One of the main things is safety at home, taking into consideration the patient's condition and resources available for them at home. Hospital A's Physician B assesses whether treatment could be managed at home given the patients current symptoms and overall status. Then determine if the patient would require treatment through intravenous (IV) or just increasing oral treatment. Then making the decision whether to admit for observation or inpatient care, or discharge them home. Hospital A's physician B reported during a follow up question, they look at the big picture and question will the patient be safe at home. If the answer is no, then is it something we can care for at Hospital A? If the patient is unsafe to go home, and they do not need a higher level of care, then I make the determination to admit. Following another question pertaining to the frequency of a patient coming to the ED for care, Hospital A's Physician B reported, it would generally be the same, but there is a heightened approach, recognizing they may need a higher level of care. Again, looking at the situation and reviewing if the patient is safe to be at home. If a patient returns, they may not have had the resources they/we thought they did.

3. Review of Patient # 1' s medical record from Hospital A revealed, Patient # 1 was a 72-year-old female treated at Hospital A. Patient #1 was brought into the ED by ambulance on 11/15/22 for a chief complaint of shortness of breath. A medical screening exam (MSE) and a history and physical assessment was completed by Hospital A's ED physician. Documented description of Patient # 1 was, Patient # 1 was alert and oriented to person, place, and time throughout her ED stay, with a general appearance of being well-developed and ill-appearing. Patient # 1 did not seem toxic-appearing or diaphoretic, and had 2+ edema to the right and left lower leg present. Patient # 1's vital signs (VS) were as following, at the initial assessment, temperature (T) 97.7 degrees Fahrenheit (F)(normal range 97F-99F), pulse (P) 83 beats per minute (normal range 60-100), respirations (R) 18 breaths per minute (normal range 12-16), blood pressure (BP) 121/62 (normal range less than 120/80), and pulse oximetry (SPO2) 100% (normal range is usually 95% or higher) with oxygen (O2) on at 5 liters (L) by nasal cannula (NC). During the course of her ED visit at Hospital A, labs were completed, urinalysis (UA) was obtained, chest x-ray (CXR) with 2 views was done, and a 12-lead electrocardiogram (ECG) (a medical test that records the electrical signal from the heart to check for different heart conditions) was done. Abnormal lab values were as followed: Troponin was 0.05 (normal range 0-0.04 ng/mL); proBNP was 24,100 (normal range less than 300, test for heart function); carbon dioxide (CO2) was 39 (normal range 22-30, showing the body is not removing co2); glucose was 247 (normal range 74-100); anion gap was 1 (normal range 8-20, test for PH balance of your blood) and all other lab values were close to baseline or within normal limits (WNL). CXR impression showed favored volume overload/pulmonary edema (fluid in lungs), and possible infection could not be excluded. Pulmonary assessment by Hospital A's ED physician revealed Patient # 1's pulmonary effort (Breathing) was normal with no accessory muscle usage or respiratory distress. Breath sounds with no stridor (easy, non-labored). The medical decision making was, Patient # 1 was given 40 milligrams (mg) of intravenous (IV) Lasix, assessment supports congestive heart failure exacerbation given the increased dyspnea, bilateral lower extremity edema (fluid in legs), elevated labs test, and CXR (chest xray) findings. Hospital A's ED physician recommended to increase Patient # 1's Lasix 40 milligrams (mg) by mouth two times daily to 80 mg in the morning and 40 mg in the evening for the next 5 days while logging daily weights, and follow up with patient # 1 primary care provider (PCP) in 3 days. Patient # 1 wanted to stay in the hospital, but according to Hospital A's physician progress note, there was no medical indication. It notes that Patient # 1 raised a concern of a bad smell from cat urine in the home that exacerbates Patient # 1's breathing problems. Hospital A's physician encouraged Patient # 1 to stay at a hotel or with a relative, if they were unable to have the smell cleaned up tonight, but was unable to admit Patient # 1 due to a bad smell in the home. Diagnosis for Patient # 1's ED visit at Hospital A, was Acute on chronic congestive heart failure, unspecified heart failure type. Patient #1 was discharged home on 11/15/22 at 7:58 PM, by wheelchair with family. VS prior to discharge was T- 97.5 F, P - 101, R - 18, B/P - 127/94, SPO2 - 97% with O2 at 4L/NC. Hospital A's ED physician progress note revealed, patient # 1 had been "hospitalized for 3 days" in another hospital "three weeks ago for similar issues. Had elevated troponin (can indicated (CHF) congestive heart failure) and issues with CHF."

4. Review of Patient # 1' s medical record from Hospital A revealed, Patient # 1 was seen at Hospital A's ED on 10/9/22, arrived by ambulance at 2:37 PM, and was discharged home 10/9/22 at 4:43 PM, by wheelchair with family. Patient #1 was seen in Hospital A's ED for chief complaint of shortness of breath. Patient # 1 was brought back to Hospital A's ED on 10/20/22 at 4:12 AM, arrived by ambulance, and discharged home AMA on 10/20/22 at 5:52 AM, was ambulatory, and left with family. Patient # 1 was seen for chief complaint of shortness of breath.

5. Review of Patient # 1' s medical record from Hospital B revealed, Patient # 1 was seen at Hospital B's emergency department (ED) on 11/15/2022 at 10:38 PM. Patient # 1 presented to the ED by personal vehicle with Patient # 1's spouse for chief complaint of shortness of breath. Hospital B's ED physician A completed an assessment of patient # 1, which revealed Patient # 1 was lethargic, awakened to voice, was alert to self, confused, but answered questions appropriately, and was not able to follow commands. Patient # 1' s general appearance was documented as normal appearance, and had right and left lower leg fluid present. Lung assessment revealed no respiratory distress with decreased breath sounds throughout, and wheezes heard throughout. VS were as followed: T - 99.6 F, P - 97, R - 22, BP - 125/79, and SPO2 75% with O2 on at 5L/NC. Lab work was completed which revealed abnormal lab values as following: proBNP was 48,088; Troponin was 79; white blood cell count (WBC) was 17.61 (normal range 4.00-11.00); lactic acid whole blood was 5.0 (normal range 0.5 - 1.9, possible signs of infection throughout the body); and all other lab values were WNL. CXR, revealed acute on chronic congestive heart failure, unspecified heart failure type, acute on chronic respiratory failure. Hospital B's ED physician discussed patient #1 condition with the cardiologist, who recommended continued Lasix and admission to Hospital B's hospitalist. Patient # 1 was admitted to the Hospital B on 11/15/22. Patient # 1 was discharged home with hospice on 11/23/22.

6. During an interview on 1/10/23 at 10:00 AM with Hospital B's Physician A reported, Patient # 1 had multi-organ dysfunction, anxiety, and respiratory distress. Patient #1 had end stage emphysema (damage to the air sacs in the lungs where O2 is exchanged), and an ejection fraction (EF) (a measurement, expressed as a percentage, of how much blood the left ventricle of the heart pumps out with each contraction) of 15% (normal 50% - 75%). Hospital B's Physician A reported they couldn't narrow down exactly what was going on with Patient # 1, due to the complexity of their health. Patient # 1 had multi-organ failure and family needed added assistance to care for them at home. Hospital B's Physician A revealed Patient # 1 and the family slowly started to opt for palliative care, opting out of treatment due to Patient # 1's lung and heart dysfunction. Patient # 1 had declined a head computed tomography (CT) scan. Patient # 1 was given an antibiotic for concern of pneumonia and was given Lasix. Patient # 1 was started on high flow O2, and by the next day was at baseline. Hospital B's Physician A reported BNP was 24,000 at Hospital A's ED, and was 48,000 when seen at Hospital B. Patient # 1 was sating (pulse oximetry) at 75% on 5L/NC when they arrived, and went right up with AIRVO (humidified high flow oxygen system). Hospital B's ED Physician A described Patient # 1 as someone who can decompensate at baseline, Patient # 1's okay baseline was bad, they had so many medical problems. Patient # 1 was one of those people that is just so sick at baseline, they could always be teetering on requiring a hospital admission. By the time Hospital B's Physician, A saw Patient # 1, they reported Patient # 1 could not have gone back home as Patient # 1 required more care, and could not have been safe at home. When asked Hospital B's Physician A about Patient # 1 being discharge from Hospital A's ED, Hospital B's Physician A reported they could see Hospital A sending Patient # 1 home if Patient # 1 was not having significant dyspnea, and VS were stable when seen in the ED, and because Patient # 1 is very sick at baseline, but confirmed by the time Hospital B's Physician A saw Patient # 1, Patient # 1 could not have been sent home. Hospital B's Physician A recalled looking at Patient # 1's chart, and they had been failure to thrive and ill appearing for months and getting them to agree to services was difficult. Hospital B's Physician A could see where Patient # 1 could have declined after being discharged from Hospital A, decompensating after going home, and becoming worse, but again confirmed when Hospital B's Physician A saw Patient # 1, Hospital B's physician A could not have sent that person home.

7. Patient # 1's medical record review showed Hospital A failed to provide Patient # 1 with an appropriate MSE, including evaluation of the patient's hazardous and possibly toxic living conditions and the impact on her oxygen dependency, her congestive heart failure and, chronic obstructive pulmonary disease.