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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 Labor Act (EMTALA) requirements.

FINDINGS

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

Tag 2406: - Applicability of Provisions of this Section (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction. Based on interviews and document review, the facility failed to ensure patients received a medical screening exam (MSE) according to facility policy. Specifically, the facility failed to ensure patients presenting to the facility with a potential emergency medical condition (EMC) were medically screened according to facility policy. This failure impacted two of 22 patients' medical records reviewed.

Based on interviews and document review, the facility failed to ensure patients received a medical screening exam (MSE) according to facility policy. Specifically, the facility failed to ensure patients presenting to the facility with a potential emergency medical condition (EMC) were medically screened according to facility policy. This failure impacted two of 22 patients' medical records reviewed. (Patients #2 and #9)

Findings include:

Facility policies:

According to the Emergency Medical Treatment & Active Labor Act (EMTALA) policy, the facility will provide an appropriate MSE to determine whether an EMC exists for an individual who presents to the emergency department (ED), requesting or needing examination or treatment for a medical condition. If it is determined that the individual has an EMC, the facility will provide further medical examination and treatment as required to stabilize the emergency medical condition or arrange for the transfer of the individual to another medical facility. The MSE 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 before discharge or transfer. Medical records should contain documentation such as medically indicated screenings, tests, mental status, impressions, and diagnoses. For individuals with psychiatric symptoms, the medical records should indicate an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others.

According to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy, the purpose is to outline the standards of care for assessment, reassessment, and vital signs. Reassessment of the patient is a continuous, ongoing process based upon specific assessment parameters as well as in response to changes in diagnosis, treatments, procedures, and the plan of care. Patient condition and ongoing changes in status warrant more frequent reassessment and documentation of specific system changes. For patients with an Emergency Severity Index (ESI) of ESI 3, the initial vital signs are completed upon arrival. For patients with abnormal vital signs, the vital signs are assessed at a minimum of every two hours four times, then every four hours if stable. Patients will receive vital signs one hour before discharge.

Reference:

According to the provider order set titled "ED Alcohol Withdrawal," an initial loading dose of Phenobarbital (causes relaxation or sleepiness) 10 milligram (mg) /kilogram (kg) can be administered intravenously (IV). Reassess Clinical Institute Withdrawal (a physiological response to stopping drugs or alcohol) Assessment for Alcohol (CIWA) one hour after medication administration. If the patient has a persistently elevated CIWA, recurrent IV dosing of Phenobarbital 5mg/kg can be administered 30 minutes after completion of the previous infusion. Assess vital signs every hour. Reassess CIWA one hour after medication administration.

For initial dosing of benzodiazepines (central nervous system depressants which cause sleepiness and relaxation), physicians can choose IV Diazepam with an initial loading dose of five to 10 mg or Lorazepam with an initial loading dose of one to 3mg. Reassess CIWA one hour after medication administration. For recurrent dosing of benzodiazepines, when the CIWA score is under 11, administer Lorazepam 2mg tablets or Chlordiazepoxide 50mg capsules. Reassess CIWA one hour after medication administration. Assess vital signs every hour. When the CIWA is eight to 14, administer Diazepam 5mg intravenously every 30 minutes as needed for alcohol withdrawal or Lorazepam 1mg intravenously every hour. Reassess CIWA one hour after medication administration. Assess vital signs every hour.

1. The facility failed to ensure patients presenting to the facility for an EMC received appropriate and consistent MSEs per facility policy.

A. Medical record review

i. A review was conducted of Patient #2's medical record which revealed Patient #2 had presented to the ED for acute alcohol intoxication (a temporary condition that affects the central nervous system causing impairment in judgment and behavior) on 3/5/24 at 7:51 p.m.

During the encounter starting at 7:51 p.m., the triage registered nurse (RN) documented Patient #2's history of alcoholism and current state of intoxication. This RN documented that Patient #2 was drowsy and confused. The RN performed a Columbia Suicide Severity Rating Scale (C-SSRS) which revealed the patient was at high risk of suicide and documented interventions that were to be implemented.

The physical exam section of the initial provider note by Provider #1 revealed the patient was intoxicated, disheveled, and had slurred speech. Provider #1 documented clear lungs, regular heart rate and rhythm, and lack of edema (excess fluid) in the extremities (arms and legs). Provider #1 did not include any other assessments related to the physical examination of Patient #2 to rule out an EMC. Provider #1 did not request laboratory testing, imaging, or a psychiatry consult to rule out an EMC pertaining to the symptoms Patient #2 presented with, including potential severe malnutrition, acute liver disease, infection, overdose, or head injury.

Provider #1's note read Patient #2 stated their family "could probably" pick them up after discharge. The RN note at 9:45 p.m. read Provider #1 had ordered a "road test" to assess Patient #2's ability to ambulate (walk), and as the patient was able to walk alone, they were to be discharged home in a ride-hailing service. In the discharge vitals note recorded on 3/5/24 at 10:07 p.m., although an RN documented Patient #2 was "oriented," their level of orientation was not assessed. Provider #1 also failed to conduct a follow-up neurological assessment prior to discharge to ensure the patient was clinically sober and safe for discharge. The RN note documented nurses assisted the patient to the vehicle at the time of discharge. The record did not reveal any attempts to contact Patient #2's family or friends to provide Patient #2 with transportation home.

The ED provider note by physician (Provider) #1 written on 3/5/24 at 7:51 p.m. and filed at 9:05 p.m., revealed Provider #1 had not assessed Patient #2's statement of wanting to "disappear" as indicative of suicidal ideas or plans and had therefore documented that Patient #2 would not be placed on a hold (an involuntary commitment for plans to harm oneself or others or due to a state of disability). An edited ED provider note written by Provider #1 on 3/5/24 and filed at 11:08 p.m., four minutes after the patient returned to the ED in an unresponsive state, read that Provider #1 had specifically asked Patient #2 about suicidal thoughts and Patient #2 had stated they were not suicidal.

The lack of physical assessment, including a neurological and psychiatric exam, laboratory testing, imaging, and referral to psychiatry as well as the lack of consideration of other potential etiologies given Patient #2's confusion and drowsiness revealed an inappropriate MSE. Provider #1's failure to determine clinical sobriety by conducting a thorough clinical evaluation and/or blood alcohol screening prior to discharge contributed to the overall failure to provide an appropriate MSE which was in contrast to the EMTALA policy which read, the facility provided an appropriate MSE for individuals who presented to the ED, needing examination or treatment. The MSE condition continued until the patient was stabilized.

ii. A review was conducted of Patient #9's medical record which revealed Patient #9 had presented to the ED for alcohol intoxication on 4/1/24 at 5:18 p.m. The medical record revealed Patient #9 had a history of alcohol withdrawal seizures (abnormal electrical activity in the brain). The triage RN note at 5:33 p.m. revealed Patient #9's blood pressure (BP) was 164/97 (normal was 120/80) and pulse rate (PR) was 105 (normal was 60-100). At 5:39 p.m., six minutes later, the record revealed the patient was given hydroxyzine (a medication used to help with relaxation) for anxiety. Laboratory testing revealed Patient #9's blood alcohol level (BAL) was 352, indicating severe alcohol intoxication. At 5:40 p.m., the RN conducted a CIWA and the patient scored 11, which indicated moderate alcohol withdrawal. The record did not reveal any provider orders or additional interventions by the nursing staff after the CIWA was performed. In addition, there was no evidence of additional CIWA assessments conducted during the patient's stay to determine if alcohol withdrawal symptoms were increasing, which could have indicated a higher risk for seizure. This was in contrast to an interview with physician assistant (Provider) #6 on 5/23/24 at 9:02 a.m., who stated a CIWA score of 11 required the CIWA to be performed again at regular intervals not more than an hour apart., Provider #6 also stated patients who scored a CIWA score of 11 were required to be on telemetry (heart and oxygen monitoring) and vital signs to be assessed every 30 minutes to one hour.

The Provider note documented Patient #9 had anion gap metabolic acidosis (a buildup of acid in the body that could lead to shock or death) which they attributed to alcoholic ketoacidosis (increased acid due to breakdown of fats in the body). The laboratory testing failed to reveal additional workup to rule out other causes of the acidosis which if present, increased Patient #9's seizure risk. Also, the lack of this additional workup indicated gaps in the MSE as the provider was not able to assess, treat, and stabilize other potential causes of the acidosis.

At 6:51 p.m. (an hour and 18 minutes after the triage vitals), the RN assessed Patient #9's PR at 98 but did not reassess BP, which had been elevated on admission, or perform another CIWA, which was also elevated on admission At 6:54 p.m., Patient #9 was discharged home. This discharge home without reassessment of an abnormal BP was in contrast to an interview with RN #7 on 5/23/24 at 7:35 a.m. who stated a blood pressure of around 160/90 was concerning as the risks to discharging a patient with these vitals included cardiovascular risk (negative impacts to the heart and blood vessels). Patient #9 was also discharged home without reassessing their CIWA score which was initially scored at 11. This lack of reassessment of an elevated blood pressure reading and elevated CIWA score was in contrast to an interview with Provider #6 on 5/23/24 at 9:02 a.m., which revealed they administered medications and conducted frequent patient assessments of patients with CIWA scores of 11, as hypertension (high blood pressure) and tachycardia (high heart rate) indicated more severe alcohol withdrawal with risks such as seizures, electrolyte (which help conduct electrical impulses necessary for sustaining life) imbalances, and dehydration.

The lack of assessment including comprehensive laboratory testing to fully evaluate Patient #9's acidosis, repeated CIWA scoring for an initially high score, and repeated vitals for an elevated blood pressure contributed to the provider's failure to provide an appropriate MSE which was in contrast to the EMTALA policy which read, the facility provided an appropriate MSE needing examination or treatment. This assessment and monitoring continued until the patient was stabilized.

This review of medical records for Patients #2 and #9 was in contrast to the EMTALA and Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policies which read, the facility provided an appropriate MSE to determine whether an EMC existed for individuals who presented to the ED, requesting or needing examination or treatment for a medical condition. The MSE was an ongoing process and this ongoing assessment and monitoring continued until the individual was stabilized. Assessment and reassessment of the patient occurred in response to changes in diagnosis, treatments, and the plan of care. Patient condition and ongoing changes in status warranted more frequent reassessment. Vital signs were assessed before discharge.

B. Interviews

i. On 5/21/24 at 10:16 a.m., an interview was conducted with ED case manager (CM) #3. CM #3 stated they assisted patients with discharge planning to facilitate safe discharges. They stated asking a family or friend to transport the patient home was always the first option once the patient was safe for discharge. CM #3 stated a safe discharge complemented the medical care to reduce the need for aftercare, future hospitalizations, and to ensure proper care after discharge.

ii. On 5/22/24 at 2:47 p.m., an interview was conducted with RN #4. RN #4 stated patients who presented with alcohol intoxication were screened with a breathalyzer or serum alcohol test and a CIWA to assess their level of intoxication in order to help guide treatment and estimated time to sobriety. This was in contrast to the review of Patient #2's medical record which showed no evidence that the patient received alcohol testing or a CIWA assessment. RN #4 stated staff treated the patients' symptoms if the patients were assessed as being in alcohol withdrawal in order to keep the patients safe.

RN #4 stated once patients were clinically sober, which they defined as walking steadily, talking in complete sentences, and able to safely arrive at their destination, and could pass the "road test," which RN #4 described as observations of the patients walking down the hallway, steadily and without needing assistance, the patients were safe for discharge. RN #4 stated the "road test" was ordered by the provider to assess the patients' abilities to safely arrive at their destinations. They stated patients with a higher tolerance for and more habitual use of alcohol, had better control of their movements when performing the road test, even if intoxicated. RN #4 stated patients were asked if someone was able to provide them with a ride home, but if not, patients were provided with a ride-hailing service or an ambulance ride. RN #4 stated the appropriate discharge process was important to ensure patients' safety, for example, to ensure patients did not fall and hit their heads or accidentally cause harm to themselves as they were not able to safely care for themselves while on the way home.

iii. On 5/22/24 at 1:46 p.m., an interview was conducted with RN #5. RN #5 stated they preferred family or friends to assist patients with discharging home and if a trusted family or friend could not provide transport, providers might hold patients until they were sober. RN #5 stated for a patient to be able to use public transport at discharge, they would need to be at "perfect zeros," which RN #5 defined as functioning at baseline, which was in contrast to the review of Patient #2's medical record. They stated the provider was ultimately responsible for determining a patient's safety for discharge and the method of transport home.

iv. On 5/23/24 at 7:35 a.m., an interview was conducted with RN #7. RN #7 stated their initial patient assessment included airway, breathing, and circulation (ABCs), a head-to-toe assessment, and then a focused assessment based on the patient's chief complaint. RN #7 stated they performed a CIWA on patients who smelled like alcohol and may have been altered mentally to rule out alcohol withdrawal and then implemented various monitoring including cardiac (heart) and oxygen. They stated CIWAs were done on arrival and repeated every 30 minutes to an hour depending on the patient's presentation which was in contrast to a review of Patient #9's medical record. RN #7 stated the provider would order repeat CIWA assessments based on the severity of the CIWA score. They stated the provider would also order medications such as phenobarbital or lorazepam to manage the patient's withdrawal symptoms, which included anxiety, nausea, dehydration, or seizures.

RN #7 stated discharge vitals were important to assess changes in a patient's condition and to ensure the patient was safe for discharge. They stated they specifically looked for high or low blood pressure, low oxygen saturation, and a high heart rate. This was in contrast to a review of Patient #9's medical record which showed no evidence that the patient's blood pressure was reassessed prior to discharge. RN #7 stated a blood pressure around 160/90 was concerning. They stated the risks of discharging a patient with abnormal vitals such as an elevated BP included cardiovascular risk, stroke, and death. RN #7 stated patients were assessed and reassessed to ensure patient safety.

v. On 5/23/24 at 9:02 a.m. an interview was conducted with Provider #6. Provider #6 stated their MSE included vitals, a review of the presenting complaint, the past medical history, a head-to-toe assessment, and a physical exam. They stated this was modified depending on the patient's complaint and vital signs. Provider #6 stated the MSE was important to diagnose a patient, assess the severity of their condition, and determine the patient's disposition (placement) at discharge. Provider #6 stated the risk of not performing a thorough MSE was anything up to and including the death of the patient.

Provider #6 stated they performed alcohol testing for patients presenting with alcohol intoxication to assess alterations of mental status, the level of intoxication, and the possibility of withdrawal symptoms. They stated they may or may not order other laboratory testing for patients with alcohol intoxication but would base this decision on vital signs and other patient complaints. Provider #6 stated the only situation in which they had not ordered a full panel of labs was for a patient who presented with acute alcohol intoxication and had no recent history of trauma or complaints of nausea or vomiting. Provider #6 stated for this patient, they had still assessed the patient's alcohol level, ordered and administered intravenous (IV) fluids, obtained vital signs, and observed the patient over the course of several hours.

Provider #6 stated the CIWA was an assessment that was performed when they were concerned for the health of a patient withdrawing from alcohol. They stated the CIWA gave a numerical score which dictated the chance for more severe withdrawal symptoms, such as seizures, and the need for preventative medications. Provider #6 stated a CIWA score of 11 required medications to be given, the CIWA to be performed again at regular intervals, not more than an hour apart, the patient to be on telemetry (heart and oxygen monitoring), and monitoring of vital signs every 30 minutes to one hour, which was in contrast to a review of Patient #9's medical record. Provider #6 stated obtaining vitals was important to assess heart rate and blood pressure especially as these values informed the provider of the patient's level of withdrawal. They stated hypertension and tachycardia indicated a more severe withdrawal with risks such as seizures, electrolyte imbalances, and dehydration.

Provider #6 stated it was important for nurses to assess discharge vitals to rule out tachycardia (fast heart rate), febrile (high body temperature) illness, and hypertension which carried higher risks of poor outcomes such as infection and dehydration. Provider #6 stated if any of the discharge vitals were out of range, they needed to be informed. Provider #6 stated there was a risk of missing a change in patient condition and a chance to treat the patient while at the facility if discharge vitals were not performed.

vi. On 5/22/24 at 3:09 p.m., an interview was conducted with Provider #1. Provider #1 stated the MSE was used to determine if a patient had a medical emergency. They stated Patient #2 presented to the facility in an intoxicated state on 3/5/24 and they were this patient's treating physician. They said Patient #2 had ambulated safely and talked in complete, coherent sentences so they felt comfortable discharging them home several hours after arrival. Provider #1 stated Patient #2 initially wanted their family to pick them up but then told the provider their family was not an option so Provider #1 instructed the RN to obtain a ride-hailing service. Provider #1 stated Patient #2 was a young person who was used to obtaining rides from the ride-hailing service and was without a medical condition which would have prevented them from getting home safely via this type of transport. Provider #1 stated they were still on shift when Patient #2 was returned to the ED an hour and four minutes after discharge. They stated they then edited the medical record as they had not specifically documented Patient #2's denial of suicidal ideations or plans at the earlier visit.

Provider #1 stated they rarely ordered laboratory testing for alcohol levels in patients who presented with alcohol intoxication as a patient's alcohol tolerance was a more important factor than a lab value. Provider #1 also stated they had not performed any other workup for Patient #2 as the patient had been inpatient at another facility until earlier that day so they felt Patient #2's lab values would not be concerning. Provider #1 also stated patients needed to want help and Patient #2 was brought to the ED in an intoxicated state by ambulance and only wanted to return home.

Provider #1 stated Patient #2 did not have an emergency medical condition but rather suffered from chronic alcoholism which the patient had to be ready to address on their own timeline. Provider #1 stated they felt comfortable with their current process of screening and treating patients who presented with alcohol intoxication. They stated they would follow this same process for treating patients with alcohol intoxication in the future.

This interview was in contrast to the EMTALA policy which read, the facility provided an appropriate MSE to determine whether an EMC existed for individuals who presented to the ED, requesting or needing examination or treatment for a medical condition. The MSE was an ongoing process and this ongoing assessment and monitoring of the patient's condition continued until the individual was stabilized, appropriately admitted, or transferred.