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Based on review of policies, medical record review and interviews the hospital failed to ensure that a timely medical screening examination was provided to a patient who presented to the hospital's Dedicated Emergency Department [DED] for emergency care and treatment [Patient #4].

The findings include:

1. The hospital failed to ensure a timely and appropriate medical screening exam was performed to determine if an emergency medical condition existed for one (1) of 29 sampled patients reviewed [Patient #4] who arrived to the DED seeking emergency care and treatment

~Cross Refer to 489.24(a), Medical Screening Exam - Tag A2406.

Based on policy review, medical record review and interviews, the hospital failed to ensure a timely and appropriate medical screening exam was performed to determine if an emergency medical condition existed for one (1) of 29 patients reviewed [Patient #4] who arrived to the DED [Dedicated Emergency Department] seeking emergency care and treatment.

The findings included:

Review of the policy titled "Emergency Medical Treatment and Labor Act 'EMTALA'", effective date 01/29/2024, revealed medical screening examination was "...The process required determining, with reasonable confidence, whether or not an emergency medical condition exists. The MSE can range from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures... ."

Review on 03/18/2025 of the DED record for Patient #4, revealed the patient arrived by private vehicle 01/24/2025 at 1407. Review of the triage revealed "...Chief Complaint.... Male Urogenital Problems....Description of Symptoms.... Patient reports prostate swelling with two TURPS [Transurethral Resection of the Prostate]. States that he started urinating blood this am and now he is unable to urinate and has blockage. Patient appears to be in distress. ..." Review revealed vital signs at 1414 were temperature [T] 97.7, pulse [P] 115, respirations [R] 18, and blood pressure [BP] 204/93. Pulse oximetry was 99% on room air. A pain score of 10 [on a scale of 1-10, with 10 being most severe pain] in the urethra was noted and indicated "...Pain Behavior... Rubbing Site...Restlessness..." A note in triage was recorded that "Patient unable to sit in triage, demanded that he go to BR [bathroom] and try to void." Another nurse note at 1428 indicated "Spoke with [first name], PA whom was made aware of bladder scan of 273 and urinating blood. States not to insert catheter at this time." At 1435 a note documented "Informed wife that PA did not authorize catheter insertion in triage and she states that she is going to take patient to UC [Urgent Care] or PCP [Primary Care Provider] office."

DED medical record review, on 03/18/2025, revealed Patient #4 returned to the DED the same day 01/24/2025 at 1458 [18 minutes after dispositioned out of the ED for visit #1]. The stated complaint was "Trouble Voiding." The Triage Assessment noted "Patient previously to ED and left and went to UC and was told that they could not help him. Returned and states that he is still unable to void, noted with large amounts of blood when voiding. Patient will not sit in chair to be triaged." Review revealed a pain score of 10, acute pain noted as in the abdomen, with pain behavior noted as "Resting Quietly". The patient was again assigned an acuity of 3. At 1852, the ED disposition noted the patient "...Left Without MSE on 01/24/2025 with comments that Patient #4 was called at 1758, 1818, and 1841 with no answer. The Disposition note further indicated a physician was notified of the disposition. The disposition documentation recorded the patient denied pain at that time, although there was no indication anyone saw the patient leave. Review revealed Patient #4 was placed in the waiting room again upon arrival and was not called back until 1758 [3 hours after the second arrival]. The patient did not respond at that time.

Review of video views stated to be of Patient #4's two 01/24/2025 visits revealed the patient first arrived around 1407 and checked in with a female. Review revealed the patient walked slowly. The patient appeared to go into triage around 1412. The patient/family left the ED per the video around 1433. The video views showed they returned to the ED around 1455 Patient walked slowly. Female sat and patient started to sit, then stood and walked down the hall and back. Per the video the patient and female remained in the ED waiting. The patient appeared quite uncomfortable, and over the course of the video moved often, sat for short durations, leaned back in the seat, stood and leaned against the wall, walked slowly back and forth including towards the bathroom. At 1658, per the video views, the female walked back into the ED and spoke briefly with someone, then came back out to the waiting area around 1700. At 1713, per video review, they left the ED.

In summary, Patient #4 arrived to the DED on 01/24/2025 at 1407 with complaints of 10 of 10 pain, bleeding when attempting to urinate. The patient was placed in the waiting room and was witnessed getting into a vehicle to leave with the disposition noted at 1440. Notes indicated they were going to Urgent Care or a PCP office. The patient returned at 1458 stating they went to Urgent Care but they could not help them so returned. Pain was still documented as 10 of 10 and the patient was again triaged as an acuity of 3. There was no noted evidence the patient was reevaluated while in the waiting room even though he voiced a pain score of 10, would not sit in a chair even to be triaged and per video, the female with the patient walked into the back, sought out and spoke with someone then went back to the waiting area approximately 15 minutes prior to the patient leaving the ED for the second time.

Interview on 03/21/2025 at 0925 with PA #1 revealed the PA did not see Patient #4. Interview revealed PA #1 reviewed the chart and recalled the patient. The PA stated the patient had previous TURPs, a known enlarged prostate, was eliminating blood and very uncomfortable. Interview revealed the staff tried to get a urine sample but Patient #4 was unable to urinate. The PA was asked about a foley catheter in triage but wanted a bladder scan prior to a foley insertion. The bladder scan showed 273, which per the PA was not criteria for a foley catheter. The PA stated "my understanding was he had passed urine.... peeing blood. The PA further stated "...never saw a urine sample....knew he was in bathroom..." Interview revealed blood in the urine was not overly alarming to the PA. Interview revealed when the PA had a minute PA #1 got up to go see the patient and bring him back due to the concerns voiced but Patient #4 was not there. The standard of care for urinary retention, the PA stated, was a foley; there was no immediate indication to do screening labs.

Telephone interview with RN #2, on 03/19/2025 at 1358, revealed the RN recalled Patient #4. Interview revealed the patient could not urinate, had urinary retention, and was very upset because he wanted a catheter. Interview revealed a bladder scan was done but it was only around 200, which was not enough for the catheter. RN #2 stated she did not recall going into the bathroom to see how much bleeding there was and so could not confirm how much blood was in the urine. The patient stated when he went to the bathroom it was "trickling" and had blood in it. The RN stated the patient/family were insistent care was needed now, wanted to know where else they could go and kept quizzing and insisting on where they could go. Interview revealed they were insistent they needed immediate care and had to leave it they did not get it. RN #2 stated "I never insinuated we wanted him to leave....[the family] kept asking about where to go.... he needs help now." Interview revealed there was a lot of back and forth, apologizing, trying to do all she could but they were not waiting. Interview further revealed when Patient #4 returned to the ED for the second visit, the patient was much calmer. He stated his pain was 10 of 10, but he did not appear the way he had on the first visit, he went into the waiting room to wait. Interview revealed they sat in front of triage. Interview revealed the RN did not recall seeing the patient again after triage. Interview revealed that unless a patient needed orders completed, the next time they saw the patient was when they were called to the back.

Interview with DO #3, the ED Medical Director on 03/21/2025 at 1005 revealed the hospital was working on decreasing the left without being seen patients. They were trying to add a physician in triage to the provider staffing to initiate patient care quickly. Interview revealed physicians were told about patients that left without being seen afterwards so they could review and have patients called if there were concerns with any testing done while waiting.

Medical record review from Hospital B revealed Patient #4 presented to Hospital B's DED on 01/24/2025. A Triage Note, at 1756 (approximately 43 minutes after leaving Hospital A) revealed "Pt arrives due to 'needing a catheter'. Per pt, groin pain started early this morning. Pt went to (Hospital A), told to go to UC and then sent back to hospital. Pt has severe suprapubic pressure and bleeding from penis. Pt states he has prostate problems and has had 2 TURPs in the past. Currently has 580mL, per bladder scan." The ED Provider Note, time of service 1756 revealed "Patient placed in First Look pathway, seen and evaluated for chief complaint of lower abdominal pain onset today. Recent cystoscopy. Notes he is unable to pee. Patient and (sic) obvious discomfort. Pertinent exam findings include ill... Physical Exam.... Genitourinary: Comments: Gross hematuria in Foley....Medical Decision Making Patient is a very pleasant 83-year-old male....who presents for evaluation of difficulty urinating, lower abdominal pain. He began having hematuria earlier today at home and then became unable to urinate. On exam, patient appears uncomfortable. His bladder scan shows 580 mL in the bladder. A Foley catheter was placed which produced grossly bloody urine with clots. Review of the Discharge Summary, dated 01/27/2025, revealed Patient #4 was "...Admitted for clot hematuria requiring cystoscopy and clot evacuation on 1/25/2025. ..." Record review revealed Patient #4 was discharged home from Hospital B on 01/27/2025.