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Based on observation, a review of records and interviews, the facility failed to maintain an on-call list of specialized physicians for nephrology services who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition within the capabilities and capacity of the facility for 1 of 10 patients reviewed (Patient #1) presenting to the emergency department in need of emergent dialysis and not stabilized.

Specifically, the facility provides inpatient dialysis services including emergent dialysis 24 hours a day, 7 days a week to the general public as a specialty without providing on-call nephrology.

These findings have the potential to cause harm to all patients receiving care at the facility by the facilities failure to provide the necessary treatment and services within the hospitals capabilities and capacity to care for patients presenting to the emergency room with nephrology needs.

Findings included:

Observations were conducted on 11/29/22 at 5:00 PM of the facility's Dialysis unit located within the hospital. There were 6 dialysis stations observed in the center. There were two Registered Nurses (RN) available in the unit (RN#1 and RN#2).

Review of the Hospital Database Worksheet dated 8/1/22 completed by the hospital's Chief Executive Officer (CEO), documented Renal Dialysis (Acute Inpatient) is provided by facility staff only (coded as a 1).

Review of the facility's Physician credentialling files for Nephrologists revealed the facility had 8 Nephrologist Physician's credentialed (Nephrologist #1, #3, #4, #5, #6, #7, #8 and #9) and a Nephrologist, #2 that was credentialed as the facility's Medical Director of Nephrology/Dialysis for the hospital.

Review of Patient #1 records for September, October and November 2022 revealed he presented to the facility's dedicated Emergency Department (ED) on the following dates and was transferred to another facility for emergent need of dialysis:11/28/22 arrived and transferred 11/29/22, 11/21/22, 11/14/22, 11/7/22, 10/31/22, 10/24/22, 10/17/22, 10/10/22, 10/3/22, 9/26/22, 9/27/22, 9/18/22 arrived and transferred 9/19/22, 9/9/22, 9/4/22 arrived and transferred 9/5/22.

Review of Patient #1's records for the 4 past ED presentations on 11/29/22, 11/21/22, 11/14/22, and 11/7/22 to this facility and transferred to another facility 130 miles away revealed the following:

1.) 11/28/22 arrived, 11/29/22 transferred to another facility 130 miles away for dialysis.
Review of Patient #1's (ED) Documentation dated 11/28/22 indicated: Acuity level 2, Shortness of breath (SOB) and Dizziness, Medical Doctor (MD) #2 documented Certified Medical Emergency as YES. Review of the Memorandum of Transfer (MOT) dated 11/29/22 indicated: Stable Yes, Emergency YES. MOT document has printed name of MD #2 but is not signed.

Further review of the ED Documentation revealed Pt #1 lab value for Calcium was 12.0 mg/dl, [Normal Calcium level ranges from 8.5 to 10.5 mg/dl]. Elevated Calcium level is Hypercalcemia.

In review of the hospital policy "Emergent Dialysis including After Hours" dated 4/26/2022 and 07/2022 Hypercalcemia is a Criteria for emergent dialysis for established End Stage Renal Dialysis (ESRD) patients.

2.) 11/21/22 arrived and transferred to another facility 130 miles away for dialysis.
Review of Patient #1's ED Documentation dated 11/21/22 indicated: Acuity level 2, SOB and Weakness. MD #3 documented Certified Medical Emergency as YES. Review of the MOT dated 11/21/22 indicated: Stable Yes, Emergency No.
Further review of the ED Documentation revealed Pt #1 lab value for Calcium was 10.7 mg/dl.

3.) 11/14/22 arrived, 11/15/22 transferred to another facility 130 miles away for dialysis.
Review of Patient #1's ED Documentation dated 11/14/22 indicated: Acuity level 3, SOB. MD #4 documented Certified Medical Emergency as YES. Review of the MOT dated 11/15/22 indicated: Stable Yes, Emergency Yes. MOT document has no printed name of Physician and is not signed.

Further review of the ED Documentation revealed Pt #1 lab value for Calcium was 11.2 mg/dl. MD # 4 notes "Pt understands that no nephrologist in Laredo will treat him and will require transfer to San Antonio, TX." MD #4 also documents that an order for "IV Calcium as well as sodium bicarbonate and patient declined treatment also."

4.) 11/7/22 arrived, 11/8/22 transferred to another facility 130 miles away for dialysis.
Review of Patient #1's ED Documentation dated 11/07/22 indicated: Acuity level 3, Vomiting, MD #2 documented Certified Medical Emergency as YES. Review of the MOT dated 11/08/22 indicated: Stable Yes, Emergency Yes.

Further review of the ED Documentation revealed Pt #1 lab value for Calcium was 11.7 mg/dl. RN #3 documented "Patient refused to receive potassium cocktail orders by" MD #2 "stated he did not need to get medication and all he needed was dialysis. Orders to transfer patient and initiated at 12:10 with house supervisor and transfer center. Pending Acceptance."


Review of the facility's "Emergency Room On-Call Roster" for November 2022 revealed the following on-call specialists listed:
Medicine
OB/GYN
Pediatrics
Ortho
Surgery 1st & 2nd
Neuro Surgery
Urology
ENT
Cardiology
Pulmonology
Bariatric
Gastro

Further review revealed each specialty including a provider's name for each day of the month. There was no Nephrology listed for on-call.

Interview on 11/29/22 at 4:30 PM with the hospital's CEO, stated the hospital did not have a credentialed nephrologist that would assume care for Patient #1 due to his history of behaviors. The CEO stated the hospital did not provide Nephrology "on-call." The CEO stated the facility's Medical Director/Nephrologist who was over the hospital's dialysis unit was contracted through agreement and did not provide patient care.

In an interview on 11/29/22 at 5:00 PM with the Dialysis center's Registered Nurse (RN) #1 in charge, stated the following: The facility's dialysis unit dialyzed 12 patients today that were inpatient in the hospital. RN #1 said they dialyze an average of 14 to 15 patients daily and staff 5-6 RN's per shift with a Nephrologist (#2) Medical Director that is contracted to oversee the dialysis department. RN #1 said the Nephrologist #2 is not on staff and works in another city; "he's remote" and comes once a month to the clinic to conduct quality monitoring and Performance Improvement reviews. RN #1 stated the patients need to be admitted to the facility to receive dialysis. The facility provides in center dialysis and bedside at the hospital. RN #1 said the Dialysis center is open 6AM-6PM, 6 days a week Monday through Saturday and there is on call dialysis nursing staff 24/7 for after-hours dialysis needs. RN #1 stated they can provide Dialysis bedside in the ED department if a Nephrologist gives orders.

Interview on 12/1/22 at 2:50 PM with Nephrologist #1, indicated the following:
Nephrologist #1 stated that she does not participate in on-call, or consult for this facility. She will only give orders for her own established patients. Nephrologist #1 said there was a group of 3 Nephrologist's in town that the hospital will "consult" with if needed for dialysis orders when they present to the hospital ED. Nephrologist #1 said if she was ever on-call in the future for this facility or consulted on emergent basis, that she would not take Patient #1 as a patient even on emergent basis; she has already discharged him from service. She said Patient #1 has "entitlement behaviors."

Interview on 12/5/22 at 1:30 PM with Patient #1, who was in the Emergency Department pending transfer stated the following:
He has been transferred from this hospital the past 5 weeks to another hospital that is 130 miles and over 2 hours away to be dialyzed because none of the Nephrologists in this town will give the hospital orders to dialyze him at this specific hospital's dialysis clinic. Patient #1 said he came in today to the ED presenting with shortness of breath, dizziness and vomiting this morning. Patient #1 said he comes to the facility's ED once a week and then gets transferred to another hospital where he usually gets dialysis two days in a row before being discharged back to his hometown. When surveyor asked why Nephrologist #1 discontinued him as a patient, he stated "she's tired. Tired of this. Tired of the complaints on me." Patient #1 said he has called all of the Nephrologists and clinics in this town to try to get an outpatient clinic and everyone denies him; further stating, "Who have I killed? How do they know me? HIPPA violation?" Patient #1 stated he has called people "assholes and stupid." Patient #1 said he did not have a primary care physician and he was trying to establish care with one.

Interview on 12/5/22 at 2:30 PM with ED Physician #1 stated he was currently in the process of transferring Patient #1 to another hospital that is 130 miles away who accepted him for dialysis. ED Physician #2 said that none of the Nephrologist in this town would accept or consult for Patient #1; even on an emergent basis. He has a history of behaviors and noncompliance by refusing or going Against Medical Advice (AMA) when he doesn't get what he wants. ED Physician #1 said he did call the local Nephrologist group today the hospital consults with and they rejected him.

Interview with the facility's Risk Manager on 12/5/22 at 2:45PM stated the Nephrologists in this town will not consult with Patient #1 or give orders on an emergent basis because they believe they would have to assume Patient #1's care for "30 days."

In a confidential interview it was stated the hospital does not have Nephrology on-call because the hospital does not want to pay Nephrologists to be "on-call" and therefore Nephrology is consulted for non-established ESRD patients instead.

Interview on 12/6/22 at 4:15 PM with Nephrologist #3, stated the following:
He knew Patient #1 when he was the Hospitalist for Patient #1 the day Nephrologist #1 fired him and he cared for Patient #1 while he was inpatient (5/20/22-7/29/22). Nephrologist #3 also covered for Nephrologist #1 a few years ago when he took care of Patient #1 during that time. Nephrologist #3 said he would not take Patient #1 as a patient, even on an emergent basis unless he was actually "on-call" for the hospital. He said he had no current obligation to see Patient #1 or consult for him on an emergent basis since he was "not on-call." Nephrologist #3 said Patient #1 has created so much "chaos" and complained to the Texas Medical Board against physician's and that he would have to hire a lawyer to defend himself, because Patient #1 will report for something. Nephrologist #3 stated Patient #1 is always threatening lawsuits and has reported to so many agencies, entities, etc. regarding his care. Nephrologist #3 said that a physician is not going to accept care when there is fear of litigation, and that no clinic will take him. Nephrologist #3 said Patient #1 will be nice and polite to your face and then later the nurses will cry to you because of his behaviors. Nephrologist #3 said he is not called by the hospital for consults; that another group of Nephrologists get the consults.

Interview on 12/6/22 at 4:38 PM with Nephrologist #2, stated the following:
He is the Medical Director of Nephrology/Dialysis for the hospital. He is credentialed with the hospital but does not provide patient care. Nephrologist #2 said he used to work with a group in this town and will occasionally cover for their patients. Nephrologist #2 said the hospital did not have an "on-call schedule" for Nephrology and he did not know why the hospital didn't have Nephrology "on-call" since they have most every other specialty on-call. He stated he has never known the hospital to have on-call Nephrology; at least not for the 6 years he was there in this town. Nephrologist #2 said he knew about Patient #1's behaviors from the Nurses that work in the dialysis center of the hospital. Nephrologist #2 said his agreement with the hospital as the Medical Director for Nephology/Dialysis was to supervise the functioning of dialysis and quality. He said he did not have any agreement to provide clinical care and had no duty to provide care to any patient that presents to the hospital. Nephrologist #2 said he has talked to all of the Nephrologists in Laredo for this patient trying to get him care and they all have denied taking him as a patient due to his "litigious behaviors." Nephrologist #2 said he did not feel comfortable providing emergent care for Patient #1 because he would not be seeing him face to face as he is not in the area and the fact that nobody else wants to take him; he doesn't cooperate. These kinds of behaviors are a potential liability due to his history.

Additional Patient's reviewed that presented to the ED and received Nephrology consults resulting in admission and dialysis treatments for stabilization without transfer to another facility:

Patient (Pt) #3, Date of Service (DOS) 11/02/2022, Presented with ESRD needing Hemodialysis (HD), Consult was obtained with Nephrologist #5, orders for HD was given by Nephrologist #6.

Pt #4, DOS 11/03/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #5, orders for HD was given by Nephrologist #8.

Pt #6, DOS 10/16/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #5.

Pt #9, DOS 10/29/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #7.

Pt #10, DOS 10/28/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #3.

Pt #11, DOS 12/03/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #5, orders for HD was given by Nephrologist #2.

Pt #20, DOS 11/05/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #7.

Pt #14, DOS 11/06/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #4, orders for HD was given by Nephrologist #3.

Pt #16, DOS 10/09/2022, Presented ESRD needing HD, orders obtained from Pt Nephrologist #8.

Review of the facility policy titled, Emergency Dialysis After Hours, last reviewed 07/2022 by RN #1 presented to surveyors on 12/5/22 revealed the following:
Purpose: to ensure those patients in need of emergent hemodialysis are provided with appropriate and timely care once a patient has been accepted by a nephrologist.
POLICY
USUAL CRITERIA FOR EMERGENT DIALYSIS AFTER HOURS (1800 -0700), SUNDAYS AND HOLIDAYS
Established ESRD Patients:
1. Serum potassium levels > 6.5 mEq/L and/or EKG changes or hyperkalemia.
2. Acute pulmonary edema.
3. Severe Acidosis.
4. Post-operative cases in need of regular hemodialysis (delaying hemodialysis in these patients may result in complications the next day).
5. Hypercalcemia.
6. Any condition deemed emergent by Nephrologist. [On-call was removed from previous policy dated 4/26/22]

PROCEDURE
1. The physician should contact the Nephrologist and have a physician to physician
conversation and discussion of assessment. [On-call was removed from Nephrologist]

Review of the Emergency Dialysis including After Hours policy provided on 11/29/22, last revised 4/26/22 indicated the following:
Purpose: to ensure those patients in need of emergent hemodialysis are provided with appropriate and timely care.
POLICY
USUAL CRITERIA FOR EMERGENT DIALYSIS AFTER HOURS (1800-0700), SUNDAYS AND HOLIDAYS
Established ESRD Patients:
1. Serum potassium levels > 6.5 mEq/L and/or EKG changes or hyperkalemia.
2. Acute pulmonary edema.
3. Severe Acidosis.
4. Post-operative cases in need of regular hemodialysis (delaying hemodialysis in these patients may result in complications the next day).
5. Hypercalcemia.
6. Any condition deemed emergent by "Nephrologist on call".

PROCEDURE
1. The physician should contact the Nephrologist on call and have a physician to physician
conversation and discussion of assessment

Additional policy reviewed: Hemodialysis in Emergency Services last revised 4/26/22.
Purpose: to provide a framework for providing care to the patient population arriving in the ED needing hemodialysis at one of the affiliated facilities on an emergent basis.
II. PRACTICE GUIDELINE:
A. This patient population must meet at least one of the follow criteria.

B. In the Emergency Department setting there are distinctive medical emergencies that require unique workflow. One of those indications is emergent hemodialysis for renal failure patients to provide definitive care. Particular instances that can be considered for hemodialysis in the Emergency Department would include:
1. Fluid Overload evidenced on radiology images
2. Refractory Hypertension
3. Symptomatic Hyperkalemia1
o Local laboratory results are critical high
o or levels to 6.2mmol/L
4. Pericarditis
5. Critical Metabolic Acidosis2 (pH & PaCO2)
o Local laboratory results are critical high pH & PaCO2
o or levels s to pH 7.2
o or levels to PaCO2 65mmHg
6. Critical Blood Urea Nitrogen3
o Local laboratory results are critical high BUN
o or levels to BUN 100mg/dL
7. Uremic Encephalopathy or Neuropathy Symptoms
8. Bleeding Diathesis related to Uremia
9. Certain Poisonings and Injections amenable to dialysis such as toxic alcohols, salicylates, acetaminophen, lithium, valproic acid, metformin, or associated medications/irritants1
o Local laboratory results are critical high
o or Salicylates to 400mg/L
o or Acetaminophen to 50mg/L
o or Lithium to 2.0mmol/L
o or Valproic Acid 150mg/L

This list should not be considered an all-inclusive list but a list to begin to consider clinical care. Decision to utilize hemodialysis is always up to the clinician overseeing clinical care with appropriate consultation to nephrology partners.

C. When considering inpatient admission the patient should meet inpatient admission criteria.

EMTALA Stabilization and Medical Screening Exams, Policy #9500.359, Effective 09/2006, Last reviewed 02/2012, Pages 1-8 in part,
POLICY:
To ensure that all patients presenting on [facility names] property and requesting emergency medical services, and patients presenting to a Dedicated Emergency Department requesting medical services and non-emergency services, receive an appropriate Medical Screening Examination and Stabilization services as required by the Emergency Medical Treatment and Active Labor Act ("EMTALA"), 42 U.S.C. Section 1395 and all Federal regulations and interpretative guidelines promulgated thereunder.
I. DEFINITIONS

A. Appropriate Transfer: occurs when I) the transferring Hospital provides medical treatment within its capacity and capability that minimizes the risks to the individual's health and in the case of a woman in labor, the health of the unborn child; 2) the receiving facility has the appropriate space and qualified personnel for the treatment of the individual and has agreed to accept Transfer of the individual and to provide appropriate medical treatment; 3) the transferring Hospital sends to the receiving Hospital all medical records (or copies thereof) related to the Emergency Medical Condition, including available history, that are available at the time of Transfer pertaining to the individual's Emergency Medical Condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies and telephone reports of the studies, treatment provided and the informed written consent of certification required, name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment; any other records that are not readily available at the time of the Transfer are sent as soon as practicable after the Transfer; and 4) the Transfer is effected through Qualified Medical Personnel and appropriate transportation and equipment, as required, including the use of necessary and medically appropriate life support measures during the Transfer.

B. Capacity: refers to the Hospital's physical space, equipment, supplies and services (e.g. trauma care, surgery, intensive care, pediatrics, obstetrics, burn unit, neonatal unit or psychiatry), including ancillary services that the Hospital provides. Capacity encompasses number and availability of qualified staff, beds, equipment and the Hospital's past practices of accommodating additional patients in excess of its occupancy limits.

C. Capabilities: refers to the ability of the Hospital to accommodate the individual requesting examination or treatment of the Transferred individual. The capabilities of the Hospital's staff mean the level of care that the Hospital's personnel can provide within the training and scope of their professional licenses.

G. Emergency Medical Treatment and Active Labor Act ("EMTALA"): refers to Section 1866 and 1867 of the Social Security Act, 42 U.S.C. Section 1395dd, which obligates the Hospital to provide medical screening, treatment and Transfer of individuals with Emergency Medical Conditions or women in labor. It is also referred to as the "anti-dumping" statute and COBRA.

H. Emergency Medical Condition:
1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
b. Serious impairment to bodily functions; or
c. Serious dysfunction of any bodily organ or part; or

M. Medical Screening Examination: is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor. Such screening must be done within the Hospital's capabilities and available personnel, including on-call physicians. The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either Stabilized or appropriately transferred.

N. Non-Emergent: based on an appropriate Medical Screening Examination, the Qualified Medical Personnel has determined that the patient does not have an Emergency Medical Condition.

0. On-Call List: refers to the list that the Hospital is required to maintain that defines those physicians who are "on-call" for duty after the initial Medical Screening Examination to provide further evaluation and/or treatment necessary to stabilize an individual with an Emergency Medical Condition. The purpose of the On-Call List is to ensure that the Dedicated Emergency Department is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide treatment necessary to stabilize individuals with Emergency Medical Conditions. If a Hospital offers a service to the public, the service should be available through on¿ call coverage of the Dedicated Emergency Department.

Q. Physician Certification: refers to written certification by the treating physician ordering the Transfer and prior to the patient's Transfer, that based on the information available at the time of Transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from effecting the Transfer. The Physician Certification must include a summary of the risks and benefits upon which the Physician Certification is based and the reason(s) for the Transfer.

R. Qualified Medical Personnel: refers to those individuals defined by the Hospital's Medical Staff Bylaws, Rules and Regulations and approved by the Hospital's governing board to perform the initial Medical Screening Examinations for those individuals who come to the Dedicated Emergency Department and request examination or treatment.

II. MEDICAL SCREENING/STABILIZATION
C. Medical Screening Examination Requirements
4. The Medical Screening Examination includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an Emergency Medical Condition.
5. A Hospital, regardless of size or patient mix, must provide screening and stabilizing treatment within the scope of its abilities, as needed, to the individuals with Emergency Medical Conditions who come to the Hospital for examination and treatment.
6. The Medical Screening Examination must be the same Medical Screening Examination that the Hospital would perform on any individual coming to the Hospital's Dedicated Emergency Department with those signs and symptoms, regardless of the individual's ability to pay for medical care. If the Medical Screening Examination is appropriate, and does not reveal an Emergency Medical Condition, the Hospital has no further obligations under EMTALA or this policy.
7. A Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. The Hospital must apply, in a non-discriminatory manner and regardless of ability to pay, a screening process that is reasonably calculated to determine whether an Emergency Medical Condition exists.
8. Depending on the patient's presenting symptoms, the Medical Screening Examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as, but not limited to, lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures.
9. Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is Stabilized or an Appropriate Transfer occurs. There should be evidence of this evaluation prior to discharge or Transfer.
Facilities must establish processes to ensure that I) a Dedicated Emergency Department physician on duty is responsible for the general care of all patients presenting themselves to the Dedicated Emergency Department; and 2) the responsibility remains with the Dedicated Emergency Department physician until the patient's private physician or an on-call specialist assumes that responsibility, or the patient is discharged or an Appropriate Transfer occurs.

EMTALA Medical Screening Stabilization Policy, No Policy #, Effective 11/1/2003, Last reviewed 3/26/2019.
Policy Title: EMTALA Medical Screening Stabilization Policy

References and Citations: Emergency Medical Treatment and Active Labor Act {"EMTALA"), 42 U.S.C. Section 1395
INTRODUCTION: All individuals presenting on Hospital property requesting emergency medical services, individuals presenting to a Dedicated Emergency Department requesting medical services, and patients arriving/presenting via ambulance requesting medical services shall receive an appropriate Medical Screening Examination and Stabilization services as required by the Emergency Medical Treatment and Active Labor Act ("EMTALA"), 42 U.S.C. Section 1395 and all Federal regulations and interpretative guidelines promulgated thereunder.

POLICY: Each Hospital must have written guidelines outlining the requirements for appropriate medical screening and stabilization procedures which comply with applicable federal and state law.
DEFINITIONS:
MEDICAL SCREENING/STABILIZATION

Medical Screening Examination Requirements
1. Hospitals are obligated to perform the Medical Screening Examination to determine if an Emergency Medical Condition exists.
2. Medicare participating Hospitals that provide emergency services must provide a Medical Screening Examination to any individual regardless of diagnosis, financial status, race, color, national origin, handicap, ability to pay, or other protected category.
3. Individuals coming to the Dedicated Emergency Department must be provided a Medical Screening Examination. Triage is not equivalent to a Medical Screening Examination. Triage merely determines the "order" in which patients will be seen, not the presence of absence of an Emergency Medical Condition.
4. The Medical Screening Examination includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an Emergency Medical Condition.
5. A Hospital, regardless of size or patient mix, must provide screening and stabilizing treatment within the scope of its capabilities, as needed, to the individuals who come to the Hospital for examination and treatment.
6. The Medical Screening Examination must be the same Medical Screening Examination that the Hospital would perform on any individual coming to the Hospital's Dedicated Emergency Department with those signs and symptoms, regardless of the individual's ability to pay for medical care. If the Medical Screening Examination is appropriate, and does not reveal an Emergency Medical Condition, the Hospital has no further obligations under EMTALA or this policy.
7. Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or an Appropriate Transfer occurs. There should be evidence of this evaluation prior to discharge or Transfer.
8. All medical screenings do not have to be equally extensive.
9. No Hospital may establish, maintain, or enforce a policy that prohibits personnel from leaving the Hospital to examine and/or treat an individual in need of emergency services in the immediate vicinity of the Hospital.
10. A Hospital that is not in diversionary status may not refuse or fail to accept a telephone or radio request for Transfer or admission. Such failure or refusal could represent a violation of the Hospital's obligations under EMTALA. Even when on diversionary status, if a patient arrives on campus, Hospital must provide a Medical Screening Examination within its Capacity and Capability, as well as Stabilizing Treatment.

Facilities must establish processes to ensure that 1) a Dedicated Emergency Department physician on duty is responsible for the general care of all patients presenting themselves to the Dedicated Emergency Department; and 2) the responsibility remains with the Dedicated Emergency Department physician until the patient's private physician or an on-call specialist assumes that responsibility, or the patient is discharged or an Appropriate Transfer results in the patient reaching a receiving facility.

Review of the facility's linkedin page at, https://www.linkedin.com/company/laredo-medical-center/about
documented to the general public "inpatient dialysis" as a specialty service provided.

Based on observations, record review and interview the facility failed to provide stabilizing treatment within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the emergent medical condition for 1 of 10 patients reviewed (Patient #1) presenting to the emergency department in need of emergent dialysis.

Findings included:

Observations were conducted on 11/29/22 at 5:00 PM of the facility's Dialysis unit located within the hospital. There were 6 dialysis stations observed in the center. There were two Registered Nurses (RN) available in the unit (RN#1 and RN#2).

Review of the Hospital Database Worksheet dated 8/1/22 completed by the hospital's Chief Executive Officer (CEO), documented Renal Dialysis (Acute Inpatient) is provided by facility staff only (coded as a 1).

Review of the facility's Physician credentialling files for Nephrologists revealed the facility had 8 Nephrologist Physician's credentialed (Nephrologist #1, #3, #4, #5, #6, #7, #8 and #9) and a Nephrologist, #2 that was credentialed as the facility's Medical Director of Nephrology/Dialysis for the hospital.

Review of Patient #1 records for September, October and November 2022 revealed he presented to the facility's dedicated Emergency Department (ED) on the following dates and was transferred to another facility for emergent need of dialysis:11/28/22 arrived and transferred 11/29/22, 11/21/22, 11/14/22, 11/7/22, 10/31/22, 10/24/22, 10/17/22, 10/10/22, 10/3/22, 9/26/22, 9/27/22, 9/18/22 arrived and transferred 9/19/22, 9/9/22, 9/4/22 arrived and transferred 9/5/22.

Review of Patient #1's records for the 4 past ED presentations on 11/29/22, 11/21/22, 11/14/22, and 11/7/22 to this facility and transferred to another facility 130 miles away revealed the following:

1.) 11/28/22 arrived, 11/29/22 transferred to another facility 130 miles away for dialysis.
Review of Patient #1's (ED) Documentation dated 11/28/22 indicated: Acuity level 2, Shortness of breath (SOB) and Dizziness, Medical Doctor (MD) #2 documented Certified Medical Emergency as YES. Review of the Memorandum of Transfer (MOT) dated 11/29/22 indicated: Stable Yes, Emergency YES. MOT document has printed name of MD #2 but is not signed.

Further review of the ED Documentation revealed Pt #1 lab value for Calcium was 12.0 mg/dl, [Normal Calcium level ranges from 8.5 to 10.5 mg/dl]. Elevated Calcium level is Hypercalcemia.

In review of the hospital policy "Emergent Dialysis including After Hours" dated 4/26/2022 and 07/2022 Hypercalcemia is a Criteria for emergent dialysis for established End Stage Renal Dialysis (ESRD) patients.

2.) 11/21/22 arrived and transferred to another facility 130 miles away for dialysis.
Review of Patient #1's ED Documentation dated 11/21/22 indicated: Acuity level 2, SOB and Weakness. MD #3 documented Certified Medical Emergency as YES. Review of the MOT dated 11/21/22 indicated: Stable Yes, Emergency No.
Further review of the ED Documentation revealed Pt #1 lab value for Calcium was 10.7 mg/dl.

3.) 11/14/22 arrived, 11/15/22 transferred to another facility 130 miles away for dialysis.
Review of Patient #1's ED Documentation dated 11/14/22 indicated: Acuity level 3, SOB. MD #4 documented Certified Medical Emergency as YES. Review of the MOT dated 11/15/22 indicated: Stable Yes, Emergency Yes. MOT document has no printed name of Physician and is not signed.

Further review of the ED Documentation revealed Pt #1 lab value for Calcium was 11.2 mg/dl. MD # 4 notes "Pt understands that no nephrologist in Laredo will treat him and will require transfer to San Antonio, TX." MD #4 also documents that an order for "IV Calcium as well as sodium bicarbonate and patient declined treatment also."

4.) 11/7/22 arrived, 11/8/22 transferred to another facility 130 miles away for dialysis.
Review of Patient #1's ED Documentation dated 11/07/22 indicated: Acuity level 3, Vomiting, MD #2 documented Certified Medical Emergency as YES. Review of the MOT dated 11/08/22 indicated: Stable Yes, Emergency Yes.

Further review of the ED Documentation revealed Pt #1 lab value for Calcium was 11.7 mg/dl. RN #3 documented "Patient refused to receive potassium cocktail orders by" MD #2 "stated he did not need to get medication and all he needed was dialysis. Orders to transfer patient and initiated at 12:10 with house supervisor and transfer center. Pending Acceptance."


Review of the facility's "Emergency Room On-Call Roster" for November 2022 revealed the following on-call specialists listed:
Medicine
OB/GYN
Pediatrics
Ortho
Surgery 1st & 2nd
Neuro Surgery
Urology
ENT
Cardiology
Pulmonology
Bariatric
Gastro

Further review revealed each specialty including a provider's name for each day of the month. There was no Nephrology listed for on-call.

Interview on 11/29/22 at 4:30 PM with the hospital's CEO, stated the hospital did not have a credentialed nephrologist that would assume care for Patient #1 due to his history of behaviors. The CEO stated the hospital did not provide Nephrology "on-call." The CEO stated the facility's Medical Director/Nephrologist who was over the hospital's dialysis unit was contracted through agreement and did not provide patient care.

Interview on 11/29/22 at 3:20 PM with the facility's ED Physician Director stated Patient #1 would arrive weekly to the ED by Emergency Medical Services (EMS) and the attending physician will order screening labs; usually an EKG and Chest X-ray. Patient #1 would sometimes refuse all screening tests except for labs and states he; "just need dialysis and transfer me."
ED Physician Director further stated that Patient #1 usually meets the parameters and criteria for emergent dialysis due to his Hypokalemic state and it has usually been 7-10 days since his last dialysis treatment.

In an interview on 11/29/22 at 5:00 PM with the Dialysis center's Registered Nurse (RN) #1 in charge, stated the following: The facility's dialysis unit dialyzed 12 patients today that were inpatient in the hospital. RN #1 said they dialyze an average of 14 to 15 patients daily and staff 5-6 RN's per shift with a Nephrologist (#2) Medical Director that is contracted to oversee the dialysis department. RN #1 said the Nephrologist #2 is not on staff and works in another city; "he's remote" and comes once a month to the clinic to conduct quality monitoring and Performance Improvement reviews. RN #1 stated the patients need to be admitted to the facility to receive dialysis. The facility provides in center dialysis and bedside at the hospital. RN #1 said the Dialysis center is open 6AM-6PM, 6 days a week Monday through Saturday and there is on call dialysis nursing staff 24/7 for after-hours dialysis needs. RN #1 stated they can provide Dialysis bedside in the ED department if a Nephrologist gives orders. RN #1 said they used to dialyze Patient #1 routinely for years when his Nephrologist #1 would give direct admit orders to the hospital to dialyze. RN #1 stated that Patient #1 historically was verbally abusive and disrespectful to the nurses and staff; that Patient #1 would "want to call the shots and dictate his care." Examples given were; "to be dialyzed for 4.5 hours and not 3 hours as ordered, or he would specify the filter to use, refuse certain monitoring," etc. RN #1 said that Nephrologist #1 was very patient with Patient #1 and gave him many chances before she fired him as a patient.

Interview on 12/1/22 at 2:50 PM with Nephrologist #1, indicated the following:
She was Patient #1's Nephrologist for 5 years and initially saw him in an outpatient clinic setting. Patient #1 had a history of being disrespectful and verbally abusive to the clinic staff. Patient #1 had been discharged from multiple clinics due to his behaviors and the ESRD network had been working with him for a few years now trying to get him outpatient clinic services since the last clinic he was at closed. Once he was discharged from outpatient, Patient #1 then began coming to this facility for dialysis treatments when she would give him orders for admission and dialysis. Patient #1 continued to be rude and disrespectful to the nurses and staff, calling them names, etc. He would dictate his care and was continuously non-compliant. Nephrologist #1 said the last time that he was verbally abusive to the nurses; that she asked him to apologize and if he didn't apologize, she was no longer going to be his physician anymore. Nephrologist #1 said he never apologized and took responsibility, so she gave him a 30-day notice to discharge care. Nephrologist #1 stated that she does not participate in on-call, or consult for this facility. She will only give orders for her own established patients. Nephrologist #1 said there was a group of 3 Nephrologist's in town that the hospital will "consult" with if needed for dialysis orders when they present to the hospital ED. Nephrologist #1 said if she was ever on-call in the future for this facility or consulted on emergent basis, that she would not take Patient #1 as a patient even on emergent basis; she has already discharged him from service. She said Patient #1 has "entitlement behaviors." Nephrologist #1 said that Patient #1 called her asking if she was telling other Doctor's about him because he could not find a Nephrologist to take over his care when he was trying to go to another Nephrologist. She did say that another Nephrologist called her to ask her about Patient #1 and she told this other specific Nephrologist what happened in the past.

Interview on 12/5/22 at 1:30 PM with Patient #1, who was in the Emergency Department pending transfer stated the following:
He has been transferred from this hospital the past 5 weeks to another hospital that is 130 miles and over 2 hours away to be dialyzed because none of the Nephrologists in this town will give the hospital orders to dialyze him at this specific hospital's dialysis clinic. Patient #1 said he came in today to the ED presenting with shortness of breath, dizziness and vomiting this morning. Patient #1 said he comes to the facility's ED once a week and then gets transferred to another hospital where he usually gets dialysis two days in a row before being discharged back to his hometown. When surveyor asked why Nephrologist #1 discontinued him as a patient, he stated "she's tired. Tired of this. Tired of the complaints on me." Patient #1 said he has called all of the Nephrologists and clinics in this town to try to get an outpatient clinic and everyone denies him; further stating, "Who have I killed? How do they know me? HIPPA violation?" Patient #1 stated he has called people "assholes and stupid." Patient #1 said he did not have a primary care physician and he was trying to establish care with one.

Interview on 12/5/22 at 2:30 PM with ED Physician #1 stated he was currently in the process of transferring Patient #1 to another hospital that is 130 miles away who accepted him for dialysis. ED Physician #2 said that none of the Nephrologist in this town would accept or consult for Patient #1; even on an emergent basis. He has a history of behaviors and noncompliance by refusing or going Against Medical Advice (AMA) when he doesn't get what he wants. ED Physician #1 said he did call the local Nephrologist group today the hospital consults with and they rejected him.

Interview with the facility's Risk Manager on 12/5/22 at 2:45PM stated the Nephrologists in this town will not consult with Patient #1 or give orders on an emergent basis because they believe they would have to assume Patient #1's care for "30 days."

In a confidential interview it was stated the hospital does not have Nephrology on-call because the hospital does not want to pay Nephrologists to be "on-call" and therefore Nephrology is consulted for non-established ESRD patients instead.

Interview on 12/6/22 at 4:15 PM with Nephrologist #3, stated the following:
He knew Patient #1 when he was the Hospitalist for Patient #1 the day Nephrologist #1 fired him and he cared for Patient #1 while he was inpatient (5/20/22-7/29/22). Nephrologist #3 also covered for Nephrologist #1 a few years ago when he took care of Patient #1 during that time. Nephrologist #3 said he would not take Patient #1 as a patient, even on an emergent basis unless he was actually "on-call" for the hospital. He said he had no current obligation to see Patient #1 or consult for him on an emergent basis since he was "not on-call." Nephrologist #3 said Patient #1 has created so much "chaos" and complained to the Texas Medical Board against physician's and that he would have to hire a lawyer to defend himself, because Patient #1 will report for something. Nephrologist #3 stated Patient #1 is always threatening lawsuits and has reported to so many agencies, entities, etc. regarding his care. Nephrologist #3 said that a physician is not going to accept care when there is fear of litigation, and that no clinic will take him. Nephrologist #3 said Patient #1 will be nice and polite to your face and then later the nurses will cry to you because of his behaviors. Nephrologist #3 said he is not called by the hospital for consults; that another group of Nephrologists get the consults.

Interview on 12/6/22 at 4:38 PM with Nephrologist #2, stated the following:
He is the Medical Director of Nephrology/Dialysis for the hospital. He is credentialed with the hospital but does not provide patient care. Nephrologist #2 said he used to work with a group in this town and will occasionally cover for their patients. Nephrologist #2 said the hospital did not have an "on-call schedule" for Nephrology and he did not know why the hospital didn't have Nephrology "on-call" since they have most every other specialty on-call. He stated he has never known the hospital to have on-call Nephrology; at least not for the 6 years he was there in this town. Nephrologist #2 said he knew about Patient #1's behaviors from the Nurses that work in the dialysis center of the hospital. Nephrologist #2 said his agreement with the hospital as the Medical Director for Nephology/Dialysis was to supervise the functioning of dialysis and quality. He said he did not have any agreement to provide clinical care and had no duty to provide care to any patient that presents to the hospital. Nephrologist #2 said he has talked to all of the Nephrologists in Laredo for this patient trying to get him care and they all have denied taking him as a patient due to his "litigious behaviors." Nephrologist #2 said he did not feel comfortable providing emergent care for Patient #1 because he would not be seeing him face to face as he is not in the area and the fact that nobody else wants to take him; he doesn't cooperate. These kinds of behaviors are a potential liability due to his history. Nephrologist #2 said he previous Nephrologist (#1) tried to get him into an outpatient clinic and gave him the option of home dialysis and he refused because he does not have a caregiver.

Additional Patient's reviewed that presented to the ED and received Nephrology consults resulting in admission and dialysis treatments for stabilization without transfer to another facility:

Patient (Pt) #3, Date of Service (DOS) 11/02/2022, Presented with ESRD needing Hemodialysis (HD), Consult was obtained with Nephrologist #5, orders for HD was given by Nephrologist #6.

Pt #4, DOS 11/03/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #5, orders for HD was given by Nephrologist #8.

Pt #6, DOS 10/16/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #5.

Pt #9, DOS 10/29/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #7.

Pt #10, DOS 10/28/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #3.

Pt #11, DOS 12/03/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #5, orders for HD was given by Nephrologist #2.

Pt #20, DOS 11/05/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #7.

Pt #14, DOS 11/06/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #4, orders for HD was given by Nephrologist #3.

Pt #16, DOS 10/09/2022, Presented ESRD needing HD, orders obtained from Pt Nephrologist #8.

Review of the facility policy titled, Emergency Dialysis After Hours, last reviewed 07/2022 by RN #1 presented to surveyors on 12/5/22 revealed the following:
Purpose: to ensure those patients in need of emergent hemodialysis are provided with appropriate and timely care once a patient has been accepted by a nephrologist.
POLICY
USUAL CRITERIA FOR EMERGENT DIALYSIS AFTER HOURS (1800 -0700), SUNDAYS AND HOLIDAYS
Established ESRD Patients:
1. Serum potassium levels > 6.5 mEq/L and/or EKG changes or hyperkalemia.
2. Acute pulmonary edema.
3. Severe Acidosis.
4. Post-operative cases in need of regular hemodialysis (delaying hemodialysis in these patients may result in complications the next day).
5. Hypercalcemia.
6. Any condition deemed emergent by Nephrologist. [On-call was removed from previous policy dated 4/26/22]

PROCEDURE
1. The physician should contact the Nephrologist and have a physician to physician
conversation and discussion of assessment. [On-call was removed from Nephrologist]

Review of the Emergency Dialysis including After Hours policy provided on 11/29/22, last revised 4/26/22 indicated the following:
Purpose: to ensure those patients in need of emergent hemodialysis are provided with appropriate and timely care.
POLICY
USUAL CRITERIA FOR EMERGENT DIALYSIS AFTER HOURS (1800-0700), SUNDAYS AND HOLIDAYS
Established ESRD Patients:
1. Serum potassium levels > 6.5 mEq/L and/or EKG changes or hyperkalemia.
2. Acute pulmonary edema.
3. Severe Acidosis.
4. Post-operative cases in need of regular hemodialysis (delaying hemodialysis in these patients may result in complications the next day).
5. Hypercalcemia.
6. Any condition deemed emergent by "Nephrologist on call".

PROCEDURE
1. The physician should contact the Nephrologist on call and have a physician to physician
conversation and discussion of assessment

Additional policy reviewed: Hemodialysis in Emergency Services last revised 4/26/22.
Purpose: to provide a framework for providing care to the patient population arriving in the ED needing hemodialysis at one of the affiliated facilities on an emergent basis.
II. PRACTICE GUIDELINE:
A. This patient population must meet at least one of the follow criteria.
B. In the Emergency Department setting there are distinctive medical emergencies that require unique workflow. One of those indications is emergent hemodialysis for renal failure patients to provide definitive care. Particular instances that can be considered for hemodialysis in the Emergency Department would include:
1. Fluid Overload evidenced on radiology images
2. Refractory Hypertension
3. Symptomatic Hyperkalemia1
o Local laboratory results are critical high
o or levels to 6.2mmol/L
4. Pericarditis
5. Critical Metabolic Acidosis2 (pH & PaCO2)
o Local laboratory results are critical high pH & PaCO2
o or levels s to pH 7.2
o or levels to PaCO2 65mmHg
6. Critical Blood Urea Nitrogen3
o Local laboratory results are critical high BUN
o or levels to BUN 100mg/dL
7. Uremic Encephalopathy or Neuropathy Symptoms
8. Bleeding Diathesis related to Uremia
9. Certain Poisonings and Injections amenable to dialysis such as toxic alcohols, salicylates, acetaminophen, lithium, valproic acid, metformin, or associated medications/irritants1
o Local laboratory results are critical high
o or Salicylates to 400mg/L
o or Acetaminophen to 50mg/L
o or Lithium to 2.0mmol/L
o or Valproic Acid 150mg/L

This list should not be considered an all-inclusive list but a list to begin to consider clinical care. Decision to utilize hemodialysis is always up to the clinician overseeing clinical care with appropriate consultation to nephrology partners.

C. When considering inpatient admission the patient should meet inpatient admission criteria.

EMTALA Stabilization and Medical Screening Exams, Policy #9500.359, Effective 09/2006, Last reviewed 02/2012, Pages 1-8 in part,

POLICY:
To ensure that all patients presenting on [facility names] property and requesting emergency medical services, and patients presenting to a Dedicated Emergency Department requesting medical services and non-emergency services, receive an appropriate Medical Screening Examination and Stabilization services as required by the Emergency Medical Treatment and Active Labor Act ("EMTALA"), 42 U.S.C. Section 1395 and all Federal regulations and interpretative guidelines promulgated thereunder.

I. DEFINITIONS

A. Appropriate Transfer: occurs when I) the transferring Hospital provides medical treatment within its capacity and capability that minimizes the risks to the individual's health and in the case of a woman in labor, the health of the unborn child; 2) the receiving facility has the appropriate space and qualified personnel for the treatment of the individual and has agreed to accept Transfer of the individual and to provide appropriate medical treatment; 3) the transferring Hospital sends to the receiving Hospital all medical records (or copies thereof) related to the Emergency Medical Condition, including available history, that are available at the time of Transfer pertaining to the individual's Emergency Medical Condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies and telephone reports of the studies, treatment provided and the informed written consent of certification required, name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment; any other records that are not readily available at the time of the Transfer are sent as soon as practicable after the Transfer; and 4) the Transfer is effected through Qualified Medical Personnel and appropriate transportation and equipment, as required, including the use of necessary and medically appropriate life support measures during the Transfer.

B. Capacity: refers to the Hospital's physical space, equipment, supplies and services (e.g. trauma care, surgery, intensive care, pediatrics, obstetrics, burn unit, neonatal unit or psychiatry), including ancillary services that the Hospital provides. Capacity encompasses number and availability of qualified staff, beds, equipment and the Hospital's past practices of accommodating additional patients in excess of its occupancy limits.

C. Capabilities: refers to the ability of the Hospital to accommodate the individual requesting examination or treatment of the Transferred individual. The capabilities of the Hospital's staff mean the level of care that the Hospital's personnel can provide within the training and scope of their professional licenses.

G. Emergency Medical Treatment and Active Labor Act ("EMTALA"): refers to Section 1866 and 1867 of the Social Security Act, 42 U.S.C. Section 1395dd, which obligates the Hospital to provide medical screening, treatment and Transfer of individuals with Emergency Medical Conditions or women in labor. It is also referred to as the "anti-dumping" statute and COBRA.

H. Emergency Medical Condition:
1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
b. Serious impairment to bodily functions; or
c. Serious dysfunction of any bodily organ or part; or

M. Medical Screening Examination: is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor. Such screening must be done within the Hospital's capabilities and available personnel, including on-call physicians. The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either Stabilized or appropriately transferred.

N. Non-Emergent: based on an appropriate Medical Screening Examination, the Qualified Medical Personnel has determined that the patient does not have an Emergency Medical Condition.

0. On-Call List: refers to the list that the Hospital is required to maintain that defines those physicians who are "on-call" for duty after the initial Medical Screening Examination to provide further evaluation and/or treatment necessary to stabilize an individual with an Emergency Medical Condition. The purpose of the On-Call List is to ensure that the Dedicated Emergency Department is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide treatment necessary to stabilize individuals with Emergency Medical Conditions. If a Hospital offers a service to the public, the service should be available through on¿ call coverage of the Dedicated Emergency Department.

Q. Physician Certification: refers to written certification by the treating physician ordering the Transfer and prior to the patient's Transfer, that based on the information available at the time of Transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from effecting the Transfer. The Physician Certification must include a summary of the risks and benefits upon which the Physician Certification is based and the reason(s) for the Transfer.

R. Qualified Medical Personnel: refers to those individuals defined by the Hospital's Medical Staff Bylaws, Rules and Regulations and approved by the Hospital's governing board to perform the initial Medical Screening Examinations for those individuals who come to the Dedicated Emergency Department and request examination or treatment.

T. Stabilized/Stabilization:
2. Stable for Transfer: A patient is Stable for Transfer if the treating has determined, within reasonable clinical confidence, that the patient is expected to leave the Hospital and be received at a second facility, with no material deterioration in his/her medical condition; and the treating physician reasonably believes the receiving facility has the capability to manage the patient's medical condition and any reasonably foreseeable complication of that condition. The patient is considered to be Stable for Transfer when he/she is protected and prevented from injuring himself/herself or others.
3. Neither Stable for Discharge nor Stable for Transfer requires the final resolution of the Emergency Medical Condition.
4. If a Hospital has screened a patient and found the patient to have an Emergency Medical Condition, and admits that patient in good faith in order to stabilize the Emergency Medical Condition, the Hospital has satisfied its special responsibilities under EMTALA with respect to that patient. At this point, the Hospital's obligations under EMTALA cease and the Hospital is required to provide care to its inpatients in accordance with the Medicare Conditions of Participation.

U. Transfer: the movement of an individual outside a Hospital's facilities at the direction of any person employed by, affiliated or associated, directly or indirectly, with the Hospital, but does not include such a movement of an individual who has been declared dead or who leaves the Hospital against medical advice or without being seen, or movement of an individual to or from a Hospital owned facility that is operating under the Hospital's provider number, as long as all persons with the same medical condition are moved to this location and there is bona fide medical reason for moving the patient. (See Compliance

Policy/Procedures: EMTALA¿ Emergency Transfers.)
II. MEDICAL SCREENING/STABILIZATION
A. General Requirements
In general, when an individual comes, by himself or herself or with another person, to the Dedicated Emergency Department of the Hospital and a request is made on the individual's behalf for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital (including ancillary services routinely available in the Dedicated Emergency Department and emergency services offered at outpatient departments or facilities) to determine whether an Emergency Medical Condition exists, or with respect to a pregnant woman having contractions, whether the woman is in active labor; and, if necessary, the Hospital must execute an Appropriate Transfer according to the guidelines of EMTALA and these policies. These same requirements apply if a person comes to areas in the Hospital other than the Dedicated Emergency Department and a prudent layperson believes the individual is in need of an emergency examination or treatment.

B. The Location in Which the Medical Screening Examination Should Be Performed
The Medical Screening Examination and other emergency services need not be provided in a location specifically identified as an emergency room or Dedicated Emergency Department. If an individual arrives at a facility and is not technically in the Dedicated Emergency Department, but is on the premises of the Hospital and requests emergency care, he or she is entitled to a Medical Screening Examination. For example, all pregnant women may be directed to the labor and delivery area of the Hospital, if the Hospital has adopted and approved such a policy. The Hospital may use areas to deliver emergency services which are also used for other inpatient or outpatient services. Medical Screening Examinations or Stabilization may require ancillary services available only in areas or facilities outside of the Dedicated Emergency Department.

C. Medical Screening Examination Requirements
I. Hospitals are obligated to perform the Medical Screening Examination to determine if an Emergency Medical Condition exists.
2. Medicare participating Hospitals that provide emergency services must provide a Medical Screening Examination to any individual regardless of diagnosis, financial status, race, color, national origin, handicap, or ability to pay.
3. Individuals coming to the Dedicated Emergency Department must be provided a Medical Screening Examination. Triage is not equivalent to a Medical Screening Examination. Triage merely determines the "order" in which patients will be seen, not the presence or absence of an Emergency Medical Condition.
4. The Medical Screening Examination includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an Emergency Medical Condition.
5. A Hospital, regardless of size or patient mix, must provide screening and stabilizing treatment within the scope of its abilities, as needed, to the individuals with Emergency Medical Conditions who come to the Hospital for examination and treatment.
6. The Medical Screening Examination must be the same Medical Screening Examination that the Hospital would perform on any individual coming to the Hospital's Dedicated Emergency Department with those signs and symptoms, regardless of the individual's ability to pay for medical care. If the Medical Screening Examination is appropriate, and does not reveal an Emergency Medical Condition, the Hospital has no further obligations under EMTALA or this policy.
7. A Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. The Hospital must apply, in a non-discriminatory manner and regardless of ability to pay, a screening process that is reasonably calculated to determine whether an Emergency Medical Condition exists.
8. Depending on the patient's presenting symptoms, the Medical Screening Examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as, but not limited to, lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures.
9. Medical Screening Examination is not an isolated

Based on observation, record reviews and interviews the facility inappropriately transferred Patient #1 to another facility without providing stabilizing treatment; emergent dialysis, which is within the facility's capacity and capability.

Specifically, Patient #1's past four Emergency Department (ED) presentations to this facility on 11/28/22, 11/21/22, 11/14/22, and 11/7/22 revealed he was transferred to another facility 130 miles away with an unstabilized emergency medical condition (EMC) explicitly for the purpose of dialysis, when the facility had the capability and capacity to perform emergent dialysis.

As a result, on at least three of the last four transfers; 11/29/22, 11/14/22 and 11/7/22, the transfer was inappropriately delayed without sufficient medical justification despite the patient needing dialysis to stabilize his EMC.

Findings included:

Observations were conducted on 11/29/22 at 5:00 PM of the facility's Dialysis unit located within the hospital. There were 6 dialysis stations observed in the center. There were two Registered Nurses (RN) available in the unit (RN#1 and RN#2).

Review of the Hospital Database Worksheet dated 8/1/22 completed by the hospital's Chief Executive Officer (CEO), documented Renal Dialysis (Acute Inpatient) is provided by facility staff only (coded as a 1).

Review of the facility's Physician credentialling files for Nephrologists revealed the facility had 8 Nephrologist Physician's credentialed (Nephrologist #1, #3, #4, #5, #6, #7, #8 and #9) and a Nephrologist, #2 that was credentialed as the facility's Medical Director of Nephrology/Dialysis for the hospital.

Review of Patient #1 records for September, October and November 2022 revealed he presented to the facility's dedicated Emergency Department (ED) on the following dates and was transferred to another facility for emergent need of dialysis:11/28/22 arrived and transferred 11/29/22, 11/21/22, 11/14/22, 11/7/22, 10/31/22, 10/24/22, 10/17/22, 10/10/22, 10/3/22, 9/26/22, 9/27/22, 9/18/22 arrived and transferred 9/19/22, 9/9/22, 9/4/22 arrived and transferred 9/5/22.

Review of Patient #1's records for the 4 past ED presentations on 11/29/22, 11/21/22, 11/14/22, and 11/7/22 to this facility and transferred to another facility 130 miles away revealed the following:

1.) 11/28/22 arrived, 11/29/22 transferred to another facility 130 miles away for dialysis.
Review of Patient #1's (ED) Documentation dated 11/28/22 indicated: Acuity level 2, Shortness of breath (SOB) and Dizziness, Medical Doctor (MD) #2 documented Certified Medical Emergency as YES. Review of the Memorandum of Transfer (MOT) dated 11/29/22 indicated: Stable Yes, Emergency YES. MOT document has printed name of MD #2 but is not signed.

Further review of the ED Documentation revealed Pt #1 lab value for Calcium was 12.0 mg/dl, [Normal Calcium level ranges from 8.5 to 10.5 mg/dl]. Elevated Calcium level is Hypercalcemia.

Review of the Nursing Notes dated 11/28/22 @ 2030 by the RN House Supervisor documented that the patient was not accepted at a hospital in San Antonio (160 miles away) and as per transfer center they would need to reinitiate in AM. @0200 called over to the transfer center to obtain status on transfer. Multiple hospitals had declined and was pending approval for one hospital in Atascosa (130) miles. All other facilities will not take patient due to history. RN House Supervisor asked transfer center to reinitiate in the AM with another facility. Patient #1 has been calling to find out why he has not been transferred over and RN House Supervisor advised him there was not an accepting facility. Patient #1 mentioned to try other facilities in Beeville. At this time due to noncompliance from patient it has become more difficult to obtain placement. Will follow up with transfer center in AM.


In review of the hospital policy "Emergent Dialysis including After Hours" dated 4/26/2022 and 07/2022 Hypercalcemia is a Criteria for emergent dialysis for established End Stage Renal Dialysis (ESRD) patients.

2.) 11/21/22 arrived and transferred to another facility 130 miles away for dialysis.
Review of Patient #1's ED Documentation dated 11/21/22 indicated: Acuity level 2, SOB and Weakness. MD #3 documented Certified Medical Emergency as YES. Review of the MOT dated 11/21/22 indicated: Stable Yes, Emergency No.
Further review of the ED Documentation revealed Pt #1 lab value for Calcium was 10.7 mg/dl.

3.) 11/14/22 arrived, 11/15/22 transferred to another facility 130 miles away for dialysis.
Review of Patient #1's ED Documentation dated 11/14/22 indicated: Acuity level 3, SOB. MD #4 documented Certified Medical Emergency as YES. Review of the MOT dated 11/15/22 indicated: Stable Yes, Emergency Yes. MOT document has no printed name of Physician and is not signed.

Further review of the ED Documentation revealed Pt #1 lab value for Calcium was 11.2 mg/dl. MD # 4 notes "Pt understands that no nephrologist in Laredo will treat him and will require transfer to San Antonio, TX." MD #4 also documents that an order for "IV Calcium as well as sodium bicarbonate and patient declined treatment also."

Medical Decision Making documented, Patient #1 was accepted at a facility in Jourdanton and unfortunately this facility has been unable to secure transportation. The Nursing House supervisor has called 7 ambulance companies that the facility has under contract and none of these ambulance companies will transport patient to Jourdanton Texas due to lack of reimbursement from the patient's insurance company. This situation has been discussed with the Charge Nurse, House Supervisor, Chief Medical Officer, Chief Operations Officer, Chief Financial Officer, and the Chief Executive Officer.


4.) 11/7/22 arrived, 11/8/22 transferred to another facility 130 miles away for dialysis.
Review of Patient #1's ED Documentation dated 11/07/22 indicated: Acuity level 3, Vomiting, MD #2 documented Certified Medical Emergency as YES. Review of the MOT dated 11/08/22 indicated: Stable Yes, Emergency Yes.

Further review of the ED Documentation revealed Pt #1 lab value for Calcium was 11.7 mg/dl. RN #3 documented "Patient refused to receive potassium cocktail orders by" MD #2 "stated he did not need to get medication and all he needed was dialysis. Orders to transfer patient and initiated at 12:10 with house supervisor and transfer center. Pending Acceptance."

Nursing Notes dated 11/07/2022 at 12:11PM documented, Transfer initiated for diagnosis: ESRD, Hyperkalemia and Anemia. Multiple facilities requested in San Antonio Texas for acceptance and declined due to capacity.
Advised transfer center to continue searching and reinitiate tomorrow with San Antonio facilities.

11/08/2022 @ 0815 called over to transfer center to get updates on transfer. Multiple facilities declined in San Antonio due to capacity. Waiting to hear back from other facilities in San Antonio. Also advised transfer center to broaden search to Corpus Christi, TX and Mc Allen, TX to obtain acceptance. Information was relayed over to ER charge nurse on transfer status.

Review of the facility's "Emergency Room On-Call Roster" for November 2022 revealed the following on-call specialists listed:
Medicine
OB/GYN
Pediatrics
Ortho
Surgery 1st & 2nd
Neuro Surgery
Urology
ENT
Cardiology
Pulmonology
Bariatric
Gastro

Further review revealed each specialty including a provider's name for each day of the month. There was no Nephrology listed for on-call.

Interview on 11/29/22 at 4:30 PM with the hospital's CEO, stated the hospital did not have a credentialed nephrologist that would assume care for Patient #1 due to his history of behaviors. The CEO stated the hospital did not provide Nephrology "on-call." The CEO stated the facility's Medical Director/Nephrologist who was over the hospital's dialysis unit was contracted through agreement and did not provide patient care.

Interview on 11/29/22 at 3:20 PM with the facility's ED Physician Director stated Patient #1 would arrive weekly to the ED by Emergency Medical Services (EMS) and the attending physician will order screening labs; usually an EKG and Chest X-ray. Patient #1 would sometimes refuse all screening tests except for labs and states he; "just need dialysis and transfer me."
ED Physician Director further stated that Patient #1 usually meets the parameters and criteria for emergent dialysis due to his Hypokalemic state and it has usually been 7-10 days since his last dialysis treatment.

In an interview on 11/29/22 at 5:00 PM with the Dialysis center's Registered Nurse (RN) #1 in charge, stated the following: The facility's dialysis unit dialyzed 12 patients today that were inpatient in the hospital. RN #1 said they dialyze an average of 14 to 15 patients daily and staff 5-6 RN's per shift with a Nephrologist (#2) Medical Director that is contracted to oversee the dialysis department. RN #1 said the Nephrologist #2 is not on staff and works in another city; "he's remote" and comes once a month to the clinic to conduct quality monitoring and Performance Improvement reviews. RN #1 stated the patients need to be admitted to the facility to receive dialysis. The facility provides in center dialysis and bedside at the hospital. RN #1 said the Dialysis center is open 6AM-6PM, 6 days a week Monday through Saturday and there is on call dialysis nursing staff 24/7 for after-hours dialysis needs. RN #1 stated they can provide Dialysis bedside in the ED department if a Nephrologist gives orders. RN #1 said they used to dialyze Patient #1 routinely for years when his Nephrologist #1 would give direct admit orders to the hospital to dialyze. RN #1 stated that Patient #1 historically was verbally abusive and disrespectful to the nurses and staff; that Patient #1 would "want to call the shots and dictate his care." Examples given were; "to be dialyzed for 4.5 hours and not 3 hours as ordered, or he would specify the filter to use, refuse certain monitoring," etc. RN #1 said that Nephrologist #1 was very patient with Patient #1 and gave him many chances before she fired him as a patient.

Interview on 12/1/22 at 2:50 PM with Nephrologist #1, indicated the following:
She was Patient #1's Nephrologist for 5 years and initially saw him in an outpatient clinic setting. Patient #1 had a history of being disrespectful and verbally abusive to the clinic staff. Patient #1 had been discharged from multiple clinics due to his behaviors and the ESRD network had been working with him for a few years now trying to get him outpatient clinic services since the last clinic he was at closed. Once he was discharged from outpatient, Patient #1 then began coming to this facility for dialysis treatments when she would give him orders for admission and dialysis. Patient #1 continued to be rude and disrespectful to the nurses and staff, calling them names, etc. He would dictate his care and was continuously non-compliant. Nephrologist #1 said the last time that he was verbally abusive to the nurses; that she asked him to apologize and if he didn't apologize, she was no longer going to be his physician anymore. Nephrologist #1 said he never apologized and took responsibility, so she gave him a 30-day notice to discharge care. Nephrologist #1 stated that she does not participate in on-call, or consult for this facility. She will only give orders for her own established patients. Nephrologist #1 said there was a group of 3 Nephrologist's in town that the hospital will "consult" with if needed for dialysis orders when they present to the hospital ED. Nephrologist #1 said if she was ever on-call in the future for this facility or consulted on emergent basis, that she would not take Patient #1 as a patient even on emergent basis; she has already discharged him from service. She said Patient #1 has "entitlement behaviors." Nephrologist #1 said that Patient #1 called her asking if she was telling other Doctor's about him because he could not find a Nephrologist to take over his care when he was trying to go to another Nephrologist. She did say that another Nephrologist called her to ask her about Patient #1 and she told this other specific Nephrologist what happened in the past.

Interview on 12/5/22 at 1:30 PM with Patient #1, who was in the Emergency Department pending transfer stated the following:
He has been transferred from this hospital the past 5 weeks to another hospital that is 130 miles and over 2 hours away to be dialyzed because none of the Nephrologists in this town will give the hospital orders to dialyze him at this specific hospital's dialysis clinic. Patient #1 said he came in today to the ED presenting with shortness of breath, dizziness and vomiting this morning. Patient #1 said he comes to the facility's ED once a week and then gets transferred to another hospital where he usually gets dialysis two days in a row before being discharged back to his hometown. When surveyor asked why Nephrologist #1 discontinued him as a patient, he stated "she's tired. Tired of this. Tired of the complaints on me." Patient #1 said he has called all of the Nephrologists and clinics in this town to try to get an outpatient clinic and everyone denies him; further stating, "Who have I killed? How do they know me? HIPPA violation?" Patient #1 stated he has called people "assholes and stupid." Patient #1 said he did not have a primary care physician and he was trying to establish care with one.

Interview on 12/5/22 at 2:30 PM with ED Physician #1 stated he was currently in the process of transferring Patient #1 to another hospital that is 130 miles away who accepted him for dialysis. ED Physician #2 said that none of the Nephrologist in this town would accept or consult for Patient #1; even on an emergent basis. He has a history of behaviors and noncompliance by refusing or going Against Medical Advice (AMA) when he doesn't get what he wants. ED Physician #1 said he did call the local Nephrologist group today the hospital consults with and they rejected him.

Interview with the facility's Risk Manager on 12/5/22 at 2:45PM stated the Nephrologists in this town will not consult with Patient #1 or give orders on an emergent basis because they believe they would have to assume Patient #1's care for "30 days."

In a confidential interview it was stated the hospital does not have Nephrology on-call because the hospital does not want to pay Nephrologists to be "on-call" and therefore Nephrology is consulted for non-established ESRD patients instead.

Interview on 12/6/22 at 4:15 PM with Nephrologist #3, stated the following:
He knew Patient #1 when he was the Hospitalist for Patient #1 the day Nephrologist #1 fired him and he cared for Patient #1 while he was inpatient (5/20/22-7/29/22). Nephrologist #3 also covered for Nephrologist #1 a few years ago when he took care of Patient #1 during that time. Nephrologist #3 said he would not take Patient #1 as a patient, even on an emergent basis unless he was actually "on-call" for the hospital. He said he had no current obligation to see Patient #1 or consult for him on an emergent basis since he was "not on-call." Nephrologist #3 said Patient #1 has created so much "chaos" and complained to the Texas Medical Board against physician's and that he would have to hire a lawyer to defend himself, because Patient #1 will report for something. Nephrologist #3 stated Patient #1 is always threatening lawsuits and has reported to so many agencies, entities, etc. regarding his care. Nephrologist #3 said that a physician is not going to accept care when there is fear of litigation, and that no clinic will take him. Nephrologist #3 said Patient #1 will be nice and polite to your face and then later the nurses will cry to you because of his behaviors. Nephrologist #3 said he is not called by the hospital for consults; that another group of Nephrologists get the consults.

Interview on 12/6/22 at 4:38 PM with Nephrologist #2, stated the following:
He is the Medical Director of Nephrology/Dialysis for the hospital. He is credentialed with the hospital but does not provide patient care. Nephrologist #2 said he used to work with a group in this town and will occasionally cover for their patients. Nephrologist #2 said the hospital did not have an "on-call schedule" for Nephrology and he did not know why the hospital didn't have Nephrology "on-call" since they have most every other specialty on-call. He stated he has never known the hospital to have on-call Nephrology; at least not for the 6 years he was there in this town. Nephrologist #2 said he knew about Patient #1's behaviors from the Nurses that work in the dialysis center of the hospital. Nephrologist #2 said his agreement with the hospital as the Medical Director for Nephology/Dialysis was to supervise the functioning of dialysis and quality. He said he did not have any agreement to provide clinical care and had no duty to provide care to any patient that presents to the hospital. Nephrologist #2 said he has talked to all of the Nephrologists in Laredo for this patient trying to get him care and they all have denied taking him as a patient due to his "litigious behaviors." Nephrologist #2 said he did not feel comfortable providing emergent care for Patient #1 because he would not be seeing him face to face as he is not in the area and the fact that nobody else wants to take him; he doesn't cooperate. These kinds of behaviors are a potential liability due to his history. Nephrologist #2 said he previous Nephrologist (#1) tried to get him into an outpatient clinic and gave him the option of home dialysis and he refused because he does not have a caregiver.

Additional Patient's reviewed that presented to the ED and received Nephrology consults resulting in admission and dialysis treatments for stabilization without transfer to another facility:

Patient (Pt) #3, Date of Service (DOS) 11/02/2022, Presented with ESRD needing Hemodialysis (HD), Consult was obtained with Nephrologist #5, orders for HD was given by Nephrologist #6.

Pt #4, DOS 11/03/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #5, orders for HD was given by Nephrologist #8.

Pt #6, DOS 10/16/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #5.

Pt #9, DOS 10/29/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #7.

Pt #10, DOS 10/28/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #3.

Pt #11, DOS 12/03/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #5, orders for HD was given by Nephrologist #2.

Pt #20, DOS 11/05/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #7.

Pt #14, DOS 11/06/2022, Presented with ESRD needing HD, Consult was obtained with Nephrologist #4, orders for HD was given by Nephrologist #3.

Pt #16, DOS 10/09/2022, Presented ESRD needing HD, orders obtained from Pt Nephrologist #8.

Review of the facility policy titled, Emergency Dialysis After Hours, last reviewed 07/2022 by RN #1 presented to surveyors on 12/5/22 revealed the following:
Purpose: to ensure those patients in need of emergent hemodialysis are provided with appropriate and timely care once a patient has been accepted by a nephrologist.
POLICY
USUAL CRITERIA FOR EMERGENT DIALYSIS AFTER HOURS (1800 -0700), SUNDAYS AND HOLIDAYS
Established ESRD Patients:
1. Serum potassium levels > 6.5 mEq/L and/or EKG changes or hyperkalemia.
2. Acute pulmonary edema.
3. Severe Acidosis.
4. Post-operative cases in need of regular hemodialysis (delaying hemodialysis in these patients may result in complications the next day).
5. Hypercalcemia.
6. Any condition deemed emergent by Nephrologist. [On-call was removed from previous policy dated 4/26/22]

PROCEDURE
1. The physician should contact the Nephrologist and have a physician to physician
conversation and discussion of assessment. [On-call was removed from Nephrologist]

Review of the Emergency Dialysis including After Hours policy provided on 11/29/22, last revised 4/26/22 indicated the following:
Purpose: to ensure those patients in need of emergent hemodialysis are provided with appropriate and timely care.
POLICY
USUAL CRITERIA FOR EMERGENT DIALYSIS AFTER HOURS (1800-0700), SUNDAYS AND HOLIDAYS
Established ESRD Patients:
1. Serum potassium levels > 6.5 mEq/L and/or EKG changes or hyperkalemia.
2. Acute pulmonary edema.
3. Severe Acidosis.
4. Post-operative cases in need of regular hemodialysis (delaying hemodialysis in these patients may result in complications the next day).
5. Hypercalcemia.
6. Any condition deemed emergent by "Nephrologist on call".

PROCEDURE
1. The physician should contact the Nephrologist on call and have a physician to physician
conversation and discussion of assessment

Additional policy reviewed: Hemodialysis in Emergency Services last revised 4/26/22.
Purpose: to provide a framework for providing care to the patient population arriving in the ED needing hemodialysis at one of the affiliated facilities on an emergent basis.
II. PRACTICE GUIDELINE:
A. This patient population must meet at least one of the follow criteria.
B. In the Emergency Department setting there are distinctive medical emergencies that require unique workflow. One of those indications is emergent hemodialysis for renal failure patients to provide definitive care. Particular instances that can be considered for hemodialysis in the Emergency Department would include:
1. Fluid Overload evidenced on radiology images
2. Refractory Hypertension
3. Symptomatic Hyperkalemia1
o Local laboratory results are critical high
o or levels to 6.2mmol/L
4. Pericarditis
5. Critical Metabolic Acidosis2 (pH & PaCO2)
o Local laboratory results are critical high pH & PaCO2
o or levels s to pH 7.2
o or levels to PaCO2 65mmHg
6. Critical Blood Urea Nitrogen3
o Local laboratory results are critical high BUN
o or levels to BUN 100mg/dL
7. Uremic Encephalopathy or Neuropathy Symptoms
8. Bleeding Diathesis related to Uremia
9. Certain Poisonings and Injections amenable to dialysis such as toxic alcohols, salicylates, acetaminophen, lithium, valproic acid, metformin, or associated medications/irritants1
o Local laboratory results are critical high
o or Salicylates to 400mg/L
o or Acetaminophen to 50mg/L
o or Lithium to 2.0mmol/L
o or Valproic Acid 150mg/L

This list should not be considered an all-inclusive list but a list to begin to consider clinical care. Decision to utilize hemodialysis is always up to the clinician overseeing clinical care with appropriate consultation to nephrology partners.

C. When considering inpatient admission the patient should meet inpatient admission criteria.

EMTALA Stabilization and Medical Screening Exams, Policy #9500.359, Effective 09/2006, Last reviewed 02/2012, Pages 1-8 in part,

POLICY:
To ensure that all patients presenting on [facility names] property and requesting emergency medical services, and patients presenting to a Dedicated Emergency Department requesting medical services and non-emergency services, receive an appropriate Medical Screening Examination and Stabilization services as required by the Emergency Medical Treatment and Active Labor Act ("EMTALA"), 42 U.S.C. Section 1395 and all Federal regulations and interpretative guidelines promulgated thereunder.

I. DEFINITIONS

A. Appropriate Transfer: occurs when I) the transferring Hospital provides medical treatment within its capacity and capability that minimizes the risks to the individual's health and in the case of a woman in labor, the health of the unborn child; 2) the receiving facility has the appropriate space and qualified personnel for the treatment of the individual and has agreed to accept Transfer of the individual and to provide appropriate medical treatment; 3) the transferring Hospital sends to the receiving Hospital all medical records (or copies thereof) related to the Emergency Medical Condition, including available history, that are available at the time of Transfer pertaining to the individual's Emergency Medical Condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies and telephone reports of the studies, treatment provided and the informed written consent of certification required, name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment; any other records that are not readily available at the time of the Transfer are sent as soon as practicable after the Transfer; and 4) the Transfer is effected through Qualified Medical Personnel and appropriate transportation and equipment, as required, including the use of necessary and medically appropriate life support measures during the Transfer.

B. Capacity: refers to the Hospital's physical space, equipment, supplies and services (e.g. trauma care, surgery, intensive care, pediatrics, obstetrics, burn unit, neonatal unit or psychiatry), including ancillary services that the Hospital provides. Capacity encompasses number and availability of qualified staff, beds, equipment and the Hospital's past practices of accommodating additional patients in excess of its occupancy limits.

C. Capabilities: refers to the ability of the Hospital to accommodate the individual requesting examination or treatment of the Transferred individual. The capabilities of the Hospital's staff mean the level of care that the Hospital's personnel can provide within the training and scope of their professional licenses.

G. Emergency Medical Treatment and Active Labor Act ("EMTALA"): refers to Section 1866 and 1867 of the Social Security Act, 42 U.S.C. Section 1395dd, which obligates the Hospital to provide medical screening, treatment and Transfer of individuals with Emergency Medical Conditions or women in labor. It is also referred to as the "anti-dumping" statute and COBRA.

H. Emergency Medical Condition:
1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
b. Serious impairment to bodily functions; or
c. Serious dysfunction of any bodily organ or part; or

M. Medical Screening Examination: is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor. Such screening must be done within the Hospital's capabilities and available personnel, including on-call physicians. The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either Stabilized or appropriately transferred.

N. Non-Emergent: based on an appropriate Medical Screening Examination, the Qualified Medical Personnel has determined that the patient does not have an Emergency Medical Condition.

0. On-Call List: refers to the list that the Hospital is required to maintain that defines those physicians who are "on-call" for duty after the initial Medical Screening Examination to provide further evaluation and/or treatment necessary to stabilize an individual with an Emergency Medical Condition. The purpose of the On-Call List is to ensure that the Dedicated Emergency Department is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide treatment necessary to stabilize individuals with Emergency Medical Conditions. If a Hospital offers a service to the public, the service should be available through on call coverage of the Dedicated Emergency Department.

Q. Physician Certification: refers to written certification by the treating physician ordering the Transfer and prior to the patient's Transfer, that based on the information available at the time of Transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from effecting the Transfer. The Physician Certification must include a summary of the risks and benefits upon which the Physician Certification is based and the reason(s) for the Transfer.

R. Qualified Medical Personnel: refers to those individuals defined by the Hospital's Medical Staff Bylaws, Rules and Regulations and approved by the Hospital's governing board to perform the initial Medical Screening Examinations for those individuals who come to the Dedicated Emergency Department and request examination or treatment.

T. Stabilized/Stabilization:
2. Stable for Transfer: A patient is Stable for Transfer if the treating has determined, within reasonable clinical confidence, that the patient is expected to leave the Hospital and be received at a second facility, with no material deterioration in his/her medical condition; and the treating physician reasonably believes the receiving facility has the capability to manage the patient's medical condition and any reasonably foreseeable complication of that condition. The patient is considered to be Stable for Transfer when he/she is protected and prevented from injuring himself/herself or others.
3. Neither Stable for Discharge nor Stable for Transfer requires the final resolution of the Emergency Medical Condition.
4. If a Hospital has screened a patient and found the patient to have an Emergency Medical Condition, and admits that patient in good faith in order to stabilize the Emergency Medical Condition, the Hospital has satisfied its special responsibilities under EMTALA with respect to that patient. At this point, the Hospital's obligations under EMTALA cease and the Hospital is required to provide care to its inpatients in accordance with the Medicare Conditions of Participation.

U. Transfer: the movement of an individual outside a Hospital's facilities at the direction of any person employed by, affiliated or associated, directly or indirectly, with the Hospital, but does not include such a movement of an individual who has been declared dead or who leaves the Hospital against medical advice or without being seen, or movement of an individual to or from a Hospital owned facility that is operating under the Hospital's provider number, as long as all persons with the same medical condition are moved to this location and there is bona fide medical reason for moving the patient. (See Compliance

Policy/Procedures: EMTALA Emergency Transfers.)
II. MEDICAL SCREENING/STABILIZATION
A. General Requirements
In general, when an individual comes, by himself or herself or with another person, to the Dedicated Emergency Department of the Hospital and a request is made on the individual's behalf for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital (including ancillary services routinely available in the Dedicated Emergency Department and emergency services offered at outpatient departments or facilities) to determine whether an Emergency Medical Condition exists, or with respect to a pregnant woman having contractions, whether the woman is in active labor; and, if necessary, the Hospital must execute an Appropriate Transfer according to the guidelines of EMTALA and these policies. These same requirements apply if a person comes to areas in the Hospital other than the Dedicated Emergency Department and a prudent layperson believes the individual is in need of an emergency examination or treatment.

B. The Location in Which the Medical Screening Examination Should Be Performed
The Medical Screening Examination and other emergency services need not be provided in a location specifically identified as an emergency room or Dedicated Emergency Department. If an individual arrives at a facility and is not technically in the Dedicated Emergency Department, but is on the premises of the Hospital and requests emergency care, he or she is entitled to a Medical Screening Examination. For example, all pregnant women may be directed to the labor and delivery area of the Hospital, if the Hospital has adopted and approved such a policy. The Hospital may use areas to deliver emergency services which are also used for other inpatient or outpatient services. Medical Screening Examinations or Stabilization may r