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Based on policy review, medical record review and interview, the facility failed to provide an appropriate medical screening exam for one (1) of 20 (Patient #3) sampled patients.

The findings included:

1. Medical record review revealed Patient #3 presented to Hospital #1's Emergency Department (ED) on 11/11/24 at 9:07 AM with a chief complaint of legs swelling and blood in the urine. Patient #3 was a 66 year old female who presented to the ED via private vehicle. Patient #3 reported both legs swelling, blood in the urine and an odor to the urine for 1 day.

A Medical Screening Exam (MSE) was initiated on 11/11/24 at 9:49 AM by Physician #1. Physician #1 documented that Patient #3 reported ankles swelling at times, ankles had chronic changes associated with Peripheral Vascular Disease (PVD- circulation disorder caused by narrowing or blockage of blood vessels), but there was no swelling noted during MSE. Patient reported she did not wear compression stockings and didn't know what blood pressure medication she was taking. Physician #1 documented the history of present illness as bilateral lower extremity chronic changes without wounding or swelling. Patient had elevated blood pressure. Patient reported no pain. Physician #1 documented on the physical examination, "...Alert, mild distress..."

Physician #1 ordered a N-terminal pro-B-type natriuretic peptide (NT-ProBNP- lab test used to diagnose and monitor heart failure) on 11/11/24 with a result of 904 picograms per milliliter (pg/ml). Normal level is less than 125 pg/ml for people under 75 years old. Physician #1 ordered a Troponin T High Sensitivity (Troponin T HS- lab test used to diagnose heart attack and risk of cardiovascular disease) on 11/11/24 with a result of 26 nanograms per Liter (ng/L). Greater than 22 ng/L for women could indicate high risk for cardiovascular disease and above 14 ng/L that increased in follow-up testing could indicate concern for heart attack. Physician #1 ordered a urinalysis with microscopic on 11/11/24. The urinalysis revealed a moderate amount of blood in the urine, white blood cell count (WBC) of 22 (10 or more may indicate inflammation or infection), red blood cell count (RBC) of 36 (less than 3 would be within normal range), and 4 plus bacteria (could be an indicator of bacterial infection).

Physician #1 documented Patient #3's impression and plan as follows, "...Diagnosis...Hypertensive [high blood pressure] urgency, Hematuria [blood in urine], Lichen of skin [inflammation of skin]...Disposition...Discharged...Prescriptions...losartan [used to treat high blood pressure] 25 mg [milligrams] oral tablet [tab]...1 tab, oral, daily, 30 tab...Follow up with...Dermatology [named hospital] Within 1 to 2 weeks...FOLLOW UP WITH A PRIMARY CARE DOCTOR...Podiatry [named hospital] Within 1 to 2 weeks...FOLLOW UP WITH UROLOGIST FOR YOUR BLOOD IN YOUR URINE..."

Review of the medical record for Patient #3 at Hospital #2 revealed the Patient arrived to the ED on 11/15/24 at 4:14 PM. Patient #3's chief complaint was altered mental status that started around noon. Patient #3 reported past medical history of stroke with right sided weakness. Review of Patient #3's ED course at Hospital #2 revealed, "...patient does have a mild AKI [acute kidney injury] as well as elevated troponin. Given these findings with her altered mental status, we would like to have her admitted...Diagnoses...Hypertensive Encephalopathy...Acute cystitis with hematuria..."

Patient #3 was discharged home on 11/11/24 at 2:53 PM. Hospital #1 did not address or order follow-up testing of the abnormal NT-ProBNP or Troponin T HS during Patient #3's stay in the ED on 11/11/24 to further assess Patient #3's cardiac condition. Hospital #1 did not address or treat Patient #3's abnormal urinalysis while in the ED on 11/11/24 or provide prescription treatment upon discharge. Hospital #1 failed to provide a complete MSE to determine if Patient #3 had an Emergency Medical Condition.

Refer to A-2406

Based on policy review, medical record review and interview, the facility failed to provide a complete or appropriate medical screening exam (MSE) to determine if an Emergency Medical Condition (EMC) existed for 1 of 20 (Patient #3) sampled patients who presented to the facility's Emergency Department (ED) seeking medical care.

The findings included:

1. Review of the facility's "EMTALA" policy (revised 5/10/21) revealed, "...An MSE consists of an assessment and any ancillary tests (based on the patient's chief complaint) necessary to determine if an emergency medical condition (EMC) exists...Emergency medical condition (EMC) is a medical condition manifesting itself by acute, severe symptoms...that, without immediate medical attention, could result in...Serious impairment to bodily functions, or Serious dysfunction of any bodily organ or part...If an EMC exists...[named hospital] will provide appropriate treatment to stabilize the EMC..."

2. Medical record review revealed Patient #3 presented to Hospital #1's ED on 11/11/24 at 9:07 AM with a chief complaint of legs swelling and blood in urine. Patient #3 was a 66 year old female who presented to the ED via private vehicle. Patient #3 reported both legs swelling, blood in urine and an odor to the urine for 1 day. Patient #3 reported recent blood pressure changes with a past medical history of Hypertension.

A MSE was initiated on 11/11/24 at 9:49 AM by Physician #1. Physician #1 documented Patient #3 reported ankles swelling at times, ankles had chronic changes associated with Peripheral Vascular Disease (PVD- circulation disorder caused by narrowing or blockage of blood vessels), but there was no swelling noted during the MSE. Patient reported she did not wear compression stockings and didn't know what blood pressure medication she was taking.

Physician #1 documented the history of present illness as bilateral lower extremity chronic changes without wounding or swelling. Patient had elevated blood pressure. Patient reported no pain.

Physician #1 documented on the physical examination, " ...Alert, mild distress ..."

Physician #1 ordered a N-terminal pro-B-type natriuretic peptide (NT-ProBNP- lab test used to diagnose and monitor heart failure) on 11/11/24 with a result of 904 picograms per milliliter (pg/ml). Normal level is less than 125 pg/ml for people under 75 years old. Physician #1 ordered a Troponin T High Sensitivity (Troponin T HS- lab test used to diagnose heart attack and risk of cardiovascular disease) on 11/11/24 with a result of 26 nanograms per Liter (ng/L). Greater than 22 ng/L for women could indicate high risk for cardiovascular disease and above 14 ng/L that increased in follow-up testing could indicate concern for heart attack.

Physician #1 ordered a urinalysis with microscopic on 11/11/24. The urinalysis revealed a moderate amount of blood in the urine, white blood cell count (WBC) of 22 (10 or more may indicate inflammation or infection), red blood cell count (RBC) of 36 (less than 3 would be within normal range), and 4 plus bacteria (could be an indicator of bacterial infection).

Physician #1 documented Patient #3's impression and plan as follows, "...Diagnosis...Hypertensive [high blood pressure] urgency, Hematuria [blood in urine], Lichen of skin [inflammation of skin]...Disposition...Discharged...Prescriptions...losartan [used to treat high blood pressure] 25 mg [milligrams] oral tablet [tab]...1 tab, oral, daily, 30 tab...Follow up with...Dermatology [named hospital] Within 1 to 2 weeks ...FOLLOW UP WITH A PRIMARY CARE DOCTOR...Podiatry [named hospital] Within 1 to 2 weeks ...FOLLOW UP WITH UROLOGIST FOR YOUR BLOOD IN YOUR URINE..."

Review of the medical record for Patient #3 at Hospital #2 revealed the Patient arrived to the ED at Hospital #2 on 11/15/24 at 4:14 PM. Patient #3's chief complaint was altered mental status that started around noon. Patient #3 reported past medical history of stroke with right sided weakness.

Patient #3's blood pressure was 148/77 on 11/15/24 at 4:19 PM, but it increased to 226/108 at 5:33 PM. Patient #3 received hydralazine (used to treat high blood pressure) 10 mg intravenous (IV) at 5:51 PM. Patient #3's blood pressure decreased to 128/60 at 6:05 PM. Patient #3's blood pressure started to increase again to 187/85 on 11/16/24 at 4:00 AM. Patient #3 received a second dose of hydralazine 10 mg IV on 11/16/24 at 4:54 AM, and Patient #3's blood pressure decreased to 153/68 at 5:00 AM and to 130/62 at 6:00 AM.

Patient #3 was admitted to Hospital #2 on 11/16/24. Review of Patient #3's ED course at Hospital #2 revealed, "...patient does have a mild AKI [acute kidney injury] as well as elevated troponin. Given these findings with her altered mental status, we would like to have her admitted...Diagnoses...Hypertensive Encephalopathy...Acute cystitis with hematuria..."

In an interview on 4/9/25 at 12:00 PM, the ED Nurse Manager stated it was a case by case basis, regarding Urinary Tract Infection (UTI) or blood in urine. The Manager stated if WBC's were elevated in the urine and the patient was having symptoms, the patient might receive fluids, antibiotics or pain medications while in the ED. The patient would most likely go home with antibiotics.

In an interview on 4/9/25 at 2:20 PM, ED Registered Nurse (RN) #1 stated patient history was going to count when it came to treating a UTI. Every case could be different. ED RN #1 stated the patient might get fluids while in the ED. If it was a complicated case, they would get intravenous (IV) antibiotics while in the ED and go home on by mouth antibiotics.

In an interview on 4/10/25 at 12:06 PM, ED Physician #1 stated Patient #3 was worked up in the ED and had some hematuria. If a patient was stable, like Patient #3, they should be referred to a urologist for scope of bladder that can be done on an outpatient basis. ED Physician #1 stated there was nothing emergent during Patient #3's ED visit.

In an email correspondence on 4/11/25, Physician #2 stated the course of treatment for hematuria would be highly dependent on the cause. The ED's role was to evaluate for emergent issues. Physician #2 stated an uncomplicated UTI would not alone merit admission to the hospital. There would need to be complicating factors such as sepsis. Physician #2 stated Patient #3 had no findings related to UTI that would require admission. Regarding elevated BnP and Troponin, Physician #2 stated, "An elevated BNP with clear lungs and no hypoxia would merit outpatient follow up. High sensitivity troponin testing is so sensitive that many times patients have low level elevations and a level that low would only need to be rechecked if there were concerns for acute coronary syndrome ...This patient had improved bp [blood pressure] after medication and had no symptoms suggestive of ACS [acute coronary syndrome]. There is no benefit to trend bnp levels as this is a lab test and clinical evaluation of the patient is the only additional testing necessary ..."

Patient #3 was discharged home on 11/11/24 at 2:53 PM. Hospital #1 did not address or order follow-up testing of the abnormal NT-ProBNP or Troponin T HS during Patient #3's stay in the ED on 11/11/24 to further assess Patient #3's cardiac condition. Hospital #1 did not address or treat Patient #3's abnormal urinalysis while in the ED on 11/11/24 or provide prescription treatment upon discharge. Hospital #1 failed to provide a complete MSE to determine if Patient #3 had an Emergency Medical Condition.