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Based on record review and interview the facility failed to ensure a medical screening exam for a patient that present to the Emergency Department and to arrange an appropriate transfer for a patient to another medical facility. This deficient practice can lead to serious injury or death of all patients seeking medical care in this facility's Emergency Department.

The findings are:

A. The facility failed to perform a medical screening exam. Refer to Tag A-2406

B. The facility failed to have a process in place to ensure appropriate transfer of patients who chose to travel by personal vehicle. Refer to Tag A-2409

Based on record review and interview the facility failed to ensure that an appropriate medical screening exam was done for 2 (P[patient]1, P12) out of 20 (P1-P20) patients reviewed for seeking emergency care This deficient practice can lead to patient's not receiving emergency care.

The findings are:

A. Record review of facility policy titled, "EM004 EMTALA-Medical Screening Examination and Stabilization" dated 05/19/2013 under, "Policy" it is stated, "1) Any individual who Comes to the Emergency Department will be provided an appropriate Medical Screening Examination performed by a Physician or Qualified Medical Person to determine if the individual has an Emergency Medical Condition. If an individual is determined to have an Emergency Medical Condition, [Facility Name] will provide further examination and treatment necessary To Stabilize the Emergency Medical Condition, within [Facility Name] Capability and Capacity."

B. Record review of P1's electronic health records for visit date 08/16/2023 at 10:37 AM revealed the following:

1. Emergency medicine note dated 08/16/2023 at 11:21 AM revealed the patient presented to the emergency department with complaints of dizziness and tingling. Patient was brought in by ambulance for left sided tingling that were worsening. Patient noted to have a history of atrial fibrillation (abnormal heart rhythm) and myocardial infarction (heart attack).

2. Review of vital signs taken at 10:37 AM revealed an elevated blood pressure of 176/74. Final set of vitals taken at 2:50 PM revealed an elevated blood pressure of 197/88.

3. Review of electrocardiogram (EKG, test done to reveal the electrical currents of the heart) on 08/16/2023 at 11:37 AM revealed sinus bradycardia (slow but regular heartbeat) reviewed by the provider at 11:38 AM.

4. Review of the medications administered on 08/16/2024 revealed that patient was given a normal saline bolus (fluids given through the veins) at 2:50 PM.

5. There was no evidence that patient was evaluated for a possible stroke with tests such as an NIH stroke scale (National Institute of Health, standardized tool to assess for stroke) or CT (Computed Tomography, scan that can be done of the head to evaluate for stroke).

C. Record review of P12's electronic health records for visit date 11/18/2023 at 11:55 AM revealed:

1. Review of emergency medicine note on 11/18/2023 at 12:07 PM revealed that patient was brought in for alcohol intoxication.

2. Review of patient's vital signs on 11/18/2023 at 12:02 PM were: elevated blood pressure 146/88, pulse 108, oxygen saturation 93%, temperature 97.5. Patient's vital signs at 12:05 PM were blood pressure 132/86, pulse 107, oxygen saturation 90%, temperature 97.9.

3. Review of discharge instructions on 11/18/2023 at 12:13 PM revealed a blank note. Patient was provided a follow-up appointment for 11/20/2023. Patient was prescribed ibuprofen (over the counter medication given for pain) and patient was provided education on alcohol intoxication.

4. Provider's note did not address patient's abnormal vital signs nor were further tests ordered to evaluate patient's condition.

D. Record review of P12's electronic health records for admission on 11/18/2023 at 11:47 PM revealed:

1. Chest X-ray ordered by S(Staff)18, clinical on 11/19/23 at 5:21 AM showed no acute findings.

2. X-ray right leg ordered by S18, clinical on 11/19/23 3:30 AM showed suspicious appearing fracture related to either acute on chronic fracture or infection.

3. Review of vital signs revealed that on 11/18/2023 at 11:45 PM patient's vital signs were: elevated blood pressure 138/80, normal temperature 97.3, elevated heart rate 118, normal oxygen saturation 94%. Further review of flowsheets revealed that patient did require supplemental oxygen for low oxygen readings.

4. The D-dimer collected on 11/18/2023 at 3:58 AM was 1,963 (normal range <500).

5. Patient was discharged on 11/19/2023 at 6:47 AM. There is no evidence that there was a provider examination for the care provided in the emergency department.

E. During an interview on 01/03/2024 at 5:05 PM with S(Staff)17, Chief Medical Officer it was confirmed that there should be a providers note for a patient that received care in the emergency department.

Based on record review and interview the facility failed to have a process in place for patients that choose to transfer via private vehicle and ensure they understand the risks involved for 1(P[patient]6) out of 5 (P3, P6, P10, P14, and P15) patients reviewed for transferring to another facility. This deficient practice could lead to unsafe conditions during transport for a patient that is requiring medical attention.

The findings are:

A. Record review of facility policy titled, "EMTALA-Transfers" dated 02/06/2023 on page 5 it is stated, "7) Requirements for an Appropriate Transfer. The following procedures will be followed to ensure an Appropriate Transfer of an individual with an Emergency Medical Condition that has not been Stabilized:. . . d) Transportation. The Transfer will be carried out through the use of qualified personnel and transportation equipment, as determined by the transferring Physician, including the use of necessary and medically appropriate life-support measures during the Transfer." Continued on page 7 it is also stated, "9) Transfer of an Individual whose Emergency Medical Condition is Stabilized. An individual with an Emergency Medical Condition that has been Stabilized may be transferred in accordance with the following procedures:. . . f) Lovelace Women's Hospital will carry out the Transfer with appropriate transportation equipment and staff in accordance with #7d of the Procedure above."

B. Record review of document titled, "Inter-Hospital Patient Transfer" dated 11/26/23 found in P6's medical record in section 2 it is stated, "Preconditions to transfer (All Must Be Met). . .
D. The patient will be transferred by qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures." There is a handwritten checkmark next to "D". Under "Mode of Transport" there is a box checked next to "Other" and it is handwritten "POV [privately owned vehicle]".

C. Record review of a provider note dated 11/26/2023 at 1:49 PM revealed that P6's presented with a chief complaint of urinary retention, nausea, and vomiting for 2 days.

1. Under "Additional Findings" at 3:00 PM it is noted, "attempted IV (intravenous access to administer medications or fluids) access x2 unsuccessfully. . . pt (patient) reportedly not breastfeeding well and only chewing on bottle nipple. . . Pt remains drowsy."

2. Under "Disposition" at 5:55 PM it is stated "pt transferred to [outside hospital name] PEDS-ED (pediatric emergency department). Patient's vital signs at discharge were: blood pressure 83/61, heart rate 140, respiratory rate 26, temperature 97.4.

3. Review of nursing notes stated P6 was lethargic and decreased level of consciousness decreased skin turgor.

4. Lab work reveals leukocytosis (high white count), Carbon Dioxide 6.2 (normal 4.7-6).

5. Under "Clinical Impression" it stated, "Called [name of provider at receiving hospital] - Go to ED [emergency department] for assessment. Accepted by [name of provider at receiving hospital] Pt [patient] finished 4 oz [ounces] prior to leaving. Safe for POV. . ." No evidence of discussion of risk of transfer documented other than motor vehicle collision.

D. During an interview on 01/04/2023 at 2:15 PM with S(staff)15 it was asked what the policy was for patients to transfer by private vehicle. S15 explained that there was no specific policy but their process is to discharge the patient with instructions to go to another hospital.