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Based on observation, interview and record review, the hospital was not in compliance with §42 CFR 489.20(1) of the provider's agreement that requires hospitals to comply with §42 CFR 489.24, Special Responsibilities of Medicare Hospitals in Emergency cases.

Specifically, the hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements of §489.24(a) and (c) by failing to provide an appropriate medical screening exam for Patient #1.

The hospital also failed to provide the required signage throughout the hospital's ED (emergency department) as required at §489.20(q).

Refer to A 2402 and A 2406 for evidence of specific findings.

Based upon observation and interview, the facility failed to ensure the emergency department (ED) posted the required signage specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment of emergency medical conditions and women in labor. Specifically, the facility failed to ensure signs (in a form specified by the Secretary) were posted in places likely to be noticed by all individuals entering the ED by using the ambulance entrance; as well as those individuals waiting for examination and treatment and in accordance with the facility's policy.

On 6/7/22 there were no signs observed in the treatment areas, or the ambulance entrance of the ED.

Findings included:

EMTALA complaint TX00415744

Review of the facilities EMTALA Policy, undated reveled on Page 9 the definition for signage referred to the hospital requirement to post signs conspicuously in a Dedicated Emergency Department (DED) or in a place or places likely to be noticed by all individuals entering the DED as well as those individuals waiting for examination and treatment in areas other than the DED located on hospital property, (e.g., outpatient departments, labor and delivery, waiting room, admitting area, entrance and treatment areas), informing individuals of their rights under Federal law with respect to examination and treatment for medical conditions, Emergency Medical Condition (EMC)'s and women in labor.

Further review on page 27 of the signage requirements indicated the hospital will post signage that, at a minimum, (1) is conspicuously posted in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment (e.g., entrance, admitting area, waiting room, treatment area); (2) is readable from anywhere in the area or a distance of at least twenty (20) feet; and (3) in language understandable by the population served by the Hospital.

Observations on 6/7/22 at 5:30 PM of the hospital's emergency department, with the Emergency department manager present revealed there were no signs (in a form specified by the Secretary) in the ED's treatment areas or the ambulance entrance area to the ED that specified the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor. This signage was only observed in the Emergency waiting room where individuals sign in requesting services, but not in the treatment rooms or the ambulance entrance areas to the ED.

During an interview on 6/7/22 at 5:35 PM with the ED Manager confirmed there were no signs posted conspicuously in the treatment areas or the ambulance entrance area to the ED; (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor.

Based on review of documentation and interview, the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition (EMC) existed for 1 of 1 patient (Patient #1) reviewed that presented to the emergency department (ED) on 4/7/22 with left breast pain.

Specifically, Patient #1 did not receive an appropriate and thorough MSE to include the physician ordered chest x-ray and/or other necessary assessment and diagnostics that may have detected a potential EMC.

Findings included:

Review of the Complaint Intake TX00415744 indicated the following:

Complainant, (Patient #1) a 22 year old female presented to the ED on 4/7/22 around 10:00 PM with left breast pain and difficult breathing. Upon arrival, the complainant signed in and waited for assistance. They were called for an intake where blood pressure, weight was taken, and a questionnaire was done. The complainant identified as uninsured. They were then taken into a room to wait for the physician.

A female nurse entered the room to ask questions regarding the chief complaint. When the physician arrived, a short conversation took place and he agreed to order exams. Shortly after the physician left the room, the same female nurse returned to inform the complainant that she was being released because the physician determined it was not an emergent situation and had instructed for the patient to be seen by their primary care physician.

The complainant was visibly upset by that decision and requested numerous times that testing be done before being released, but the nurse declined. The physician finally returned to the room after repeated requests and reiterated that there was nothing, they could do declining to do a blood test. The physician then walked out of the room stating he was busy while the complainant was still speaking.

The complainant declined to sign any paperwork prior to discharge because services had been denied. The front entrance staff disclosed that other patients had also complained about this particular physician.

The complainant did not seek treatment elsewhere after being dismissed and has continued with intermittent breast pain and difficulty breathing.

Review of Patient #1's ED Record dated 4/7/22 revealed the following, in part:

The ED triage Primary Pain Assessment completed by Registered Nurse (RN) #1 on 4/7/22 at 10:25 PM documented the following: Left Lateral Breast Pain. Numeric Rating: 7. Onset: Sudden. Time Pattern: Acute, Intermittent. Pain Duration: 3 Months. Quality: Aching, Pressure. Aggravating Factors: Movement, Palpation. Alleviating Factors: None. Interventions Implemented: Repositioning, Rest.

ED Triage Vitals performed at 10:25 PM by RN #1 were: blood pressure at 143/81, pulse of 86, respiratory rate 16, Oxygen Saturation rate of 100, and Temperature 98.4 Degrees Fahrenheit.

Review of the Physician Orders (PO) revealed an ordered Chest X-Ray, 1 View Frontal on 4/7/22 at 10:48 PM ordered and entered by Physician A. The order details were Stat, Chest Pain.
Further review revealed the entered order at 10:48 PM for a Chest X-Ray was ended at 10:49 PM with the End-state Reason: "Exceeds Weight Limit."

Review of the Physician Orders revealed an ordered Drug Screen Urine 4 on 4/7/22 at 10:48 PM ordered by Physician A. Order details were Urine, Nurse collect, Stat collect, Once. Further review revealed the entered order at 10:48 PM for the Drug Screen Urine 4 was ended at 10:49 PM with the End-state Reason: blank without details.

There were not any other ordered diagnostic tests, screening tests, or blood laboratory orders (i.e., Complete Blood Count, Basic Metabolic Panel), etc.

Review of the Provider ED Physician record for Patient #1 on 4/7/22 at 10:53 PM documented the Chief Complaint from Nursing Triage Note as Left Breast Discomfort for 3 months. Medications: Prenatal Multivitamins. The Medical Decision Making, Differential Diagnosis was: Electrolyte imbalance, weakness. The Impression and Plan was General Weakness. Condition: Stable. The Disposition: Launch Disposition Order, Discharge Request (Order), Home Routine.

Review of the Orders indicated "Discharge Request" on 4/7/22 at 10:56 PM. Order details indicated Home Routine.

Review of the discharge information in patient #1's record revealed the diagnosis: "General weakness; Unspecified superficial injuries of breast, left breast, sequela." Patient to follow up with named physician, OB/GYN in 1-2 days.

During an interview on 8/5/22 at 10:05 AM with the facility's System Medical Director (SMD) Physician stated the following after review of Patient #1's ED medical record dated 4/7/22:
The SMD Physician stated that he did not have issues clinically. The SMD Physician stated the treatment was appropriate and further stated, "the documentation could have been better." The SMD Physician could not answer or indicate the reasoning Patient #1 did not receive the PO Chest X-ray without Patient #1's record documentation reflecting that information. The SMD Physician confirmed Patient #1 did not have a weight issue because she was 55 kilograms (121 pounds); stating that would not be accurate as indicated on the order end reason for the chest X-ray as "exceeds weight limit". The SMD Physician stated he spoke with the attending Physician- A and he did not remember Patient #1 and could not offer additional information. The SMD Physician stated there was not a delay in treatment; that Patient #1 presented at 10:24 PM, was seen at 10:33 PM, formulated a treatment plan, had ordered testing, and the rest was unclear based on the record documentation. The SMD said the record was incomplete or inadequate in the documentation to determine why the orders were ended or not completed. The SMD stated the facility attempted to contact Patient #1 for service recovery but was not successful.

Review of the facilities EMTALA Policy, undated, in part revealed the following:
Page10, 2. Procedure, A. When a Medical Screening Examination is Required

An individual MUST receive an MSE, within the capabilities of Hospital's Dedicated Emergency Department (DED), including ancillary services routinely available, to determine whether an EMC exists, or with respect to a pregnant woman having contractions, whether the woman is in labor, and whether or not the treatment requested is explicitly for an emergency condition if:
The individual comes to Hospital's DED, including by transfer from another hospital, and a request is made on his or her behalf for examination or treatment for a medical condition.

Page 12, C. Extent of Medical Screening Examination
1. An MSE is the process (which begins with the initial collection of an individual's vital signs and other medical data collection) required to reach with reasonable clinical confidence, the point at which it can be determined whether an EMC exists, or a woman is in labor.
2. The MSE may vary depending on the individual's signs and symptoms, from a simple process involving a brief history and physical examination to a complex process that also involves performing ancillary services and procedures.
3. The MSE is to be conducted to the extent necessary, by physicians and/or other QMP to determine whether an EMC exists.