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Based on record review and interview the facility failed to meet the Emergency Medical Treatment and Labor Act (EMTALA) to ensure a medical screening exam was done on 1 patient (P[patient]1) out of 20 patients (P1-P20) being reviewed. This deficient practice can possibly lead to patients leaving the hospital in an unstable condition.

The findings are:

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

Based on record review and interview the facility failed to provide a medical screening examination that determined if an Emergency Medical condition exists to 1 P (Patient) out of 20 (P1-P20) patients being reviewed. This deficient practice could have possibly lead to a patient's death.

The findings are:

A. Record review of the facility's policy titled Emergency Medical Treatment and Labor Act Compliance Policy dated 01/2024 stated "Any person who comes to the hospital facility requesting assistance for a potential emergency medical condition or services will receive a medical screening performed by a qualified provider to determine whether an emergency condition exists."

B. Record review of P1s Medical Record, revealed the following:

1. Under Face sheet P1 presented to the emergency department on 03/03/24 at 9:21 AM and was discharged from the emergency department on 03/03/24 at 9:55 AM.

2. The Triage Note revealed that P1 presented to the Emergency Department with a chief complaint of Bilateral Testicle Swelling. During Triage the facility completed a set of vital signs. This note also indicated that "Patient left a LTAC [long term acute care] s/p [status post] stent placement in bilateral thigh 2 days ago [sic]. . ." indicating the patient had a procedure in which he had bilateral thigh stents placed.

3. The section "ED Note Physician" revealed:
a. A Medical Screening Exam (MSE) was conducted on 03/03/2024 at 9:26 AM by Staff (S)8, Clinical Staff member.
b. Under "History of Present Illness" stated ". . . [patient] is now having swelling in his legs in his testicles [sic]." Indicating patient has swelling in his legs and testicles.
c. P1 had "Pitting Edema from the lower waist down including the testicles." The MSE revealed that labs or diagnostic tests, such as an ultrasound (a test that shows images through sound waves), were not done to rule out an Emergency Medical Condition such as stent occlusion, local hematoma, or testicular torsion. The MSE revealed no consultations were conducted with any specialists regarding stent placements.
d. The section Review of Systems (ROS) revealed there was no GI (Gastrointestinal) examination. Under "Heart" states "Normal rate, regular rhythm, no murmur", and does not mention that the patient is tachycardic (elevated heart rate). There is no Genitourinary (GU) examination of the patients testicles or palpation of the patients testicles or penis to evaluate swelling. The ROS also states the patient has "Generalized weakness" without any futher evaluation of the weakness.

e. There is no documented review of the vascular access site from the recent vascular surgery noted in the patients medical record.

4. Review of P1s Discharge Instructions dated 03/03/24 at 9:50 AM reveled P1's Discharge Vitals as the following; Heart Rate 103 (normal 60-100), Respiratory rate 25 (Normal range 10-20) and a blood pressure of 159/70 (Normal systolic blood pressure 90-120). These are the same vital signs taken during triage in the Emergency Department, this is the only time the emergency department took vital signs on P1. The elevated Blood pressure, elevated heart rate, and elevated respiratory rate were not addressed during the Emergency Department Visit and there were no additiontal vital signs taken for reevaluation. The discharge instructions state under "Diagnosis from Todays Visit" is "Congestive heart failure [heart disease where the heart is unable to pump blood efficiently]". There is no imaging or labs to determine if congestive heart failure is present.

5. Medications in the discharge instructions revealed P1 was discharged with a new prescription for Apixaban 5 mg (milligram) oral tablet and P1 was instructed to continue taking Xarelto 20 mg tablet which could result in an increased risk for bleeding as two of the medications are blood thinners (Xarelto and Apixaban).

C. Record review of P1's Death Certificate revealed that P1 passed away the following day on 03/04/24. There was no autopsy completed.

D. During an interview on 07/31/24 at 3:30 PM with S7, Clinical Staff Member, when asked what treatment for a patient that recently had bilateral thigh stent placements would look like if the patient presented with bilateral lower extremity pitting edema and scrotal edema, S7 explained that this was two different pathologies but he would first consult the vascular specialist that placed the stents and then proceed with imaging such as an ultrasound to test for testicular torsion and also order a CT scan as the swelling in the legs can indicate a stent occlusion. When asked in what situation he would order Xarelto and Apixaban together S7 stated "I wouldn't do that they're the same class of medications."