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Based on document review and interviews, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

FINDINGS

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

Tag 2406: MEDICAL SCREENING EXAM §489.24(a)(c) - (a) Applicability of Provisions of this Section c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital's dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. Based on document review and interviews, the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA). Specifically, the facility failed to provide a medical screening exam for a patient who experienced sepsis (a life-threatening condition when the body's immune system has an overwhelming response to infection). (Patient #1)

Based on document review and interviews, the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA). Specifically, the facility failed to provide a medical screening exam for a patient who experienced sepsis (a life-threatening condition when the body's immune system has an overwhelming response to infection). (Patient #1)

Findings include:

Facility policies:

The Emergency Medical Treatment and Labor Act (EMTALA) policy read, its purpose was to ensure the facility complies with the requirements of the federal EMTALA regulations. Stabilized with respect to an Emergency Medical Condition (EMC) means to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to occur. It is the policy of the facility that if it is determined that the individual has an EMC, the facility will provide the individual with such further medical examination and treatment as required to stabilize the EMC within the capability and capacity of the facility. If an EMC is determined to exist, the facility shall provide any necessary stabilizing treatment or an appropriate transfer.

The Emergency Department Triage and Throughput policy read, all patients presenting for care will receive a medical screening exam (MSE) by the Emergency Department (ED) provider in addition to their triage exam. Triage is the initial assessment and sorting of patients, not a location. The registered nurse (RN) will assign an ESI (emergency severity index) level based on ENA (Emergency Nursing Association) ESI criteria and judgment of the triage nurse. The RN will perform an initial evaluation. The RN will document assessments and reassessments periodically during the patient's stay. Reassessments will occur according to ESI level: ESI-1 at least every 30 minutes; ESI-2 at least every one hour; ESI-3 - ESI-5 at least every two hours. ED triage and practices will be a topic of department performance improvement plans. Indicators include but are not limited to, triage scoring practices and reassessment practices.

Reference:

According to the National Institutes of Health (NIH), Systemic Inflammatory Response Syndrome (SIRS), 5/29/23, retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK547669/#:~:text=Objectively%2C%20SIRS%20is%20defined%20by,CO2%20less%20than%2032%20mmHg SIRS is defined as any two of the following criteria: body temperature above 100.4 Fahrenheit (F) or below 96.8 F, heart rate greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute, and white blood cell (WBC) count greater than 12000 or less than 4000 /microliters or over 10% immature WBC.

1. The facility failed to provide a medical screening exam for a patient who experienced sepsis.

A. Document Review

i. Medical record review revealed Patient #1 was brought to the ED by ambulance on 1/7/25 at 4:23 a.m. with a chief complaint of severe low back pain. Patient #1 was discharged at 11:00 a.m. with a diagnosis of back spasms (sudden involuntary muscle contractions). Additional medical record review revealed Patient #1 returned to the ED less than 24 hours later on 1/8/25 at 6:41 a.m. with chief complaints of back and neck pain, dizziness, and shortness of breath (SOB). Patient #1 was diagnosed with sepsis and an epidural abscess (a collection of pus that forms in the space between the spinal cord and the bones of the spine, causing permanent neurological damage, spinal cord injury, and death). Further, the record revealed Patient #1 was transferred to another facility at 10:45 a.m. for spine surgery and hospitalization. Further review of the medical record revealed the following:

a. Review of Patient #1's medical record revealed upon initial arrival to the ED on 1/7/25, Patient #1's initial vital signs included a blood pressure (BP) 150/96 (normal range is less than 120/80), heart rate 111 (normal range 60 - 100 beats per minute), respiratory rate 22 (normal range 12 - 20 breaths per minute), and temperature 97.8 F (normal range 97 F - 99 F). Patient #1's pain level was documented as 10/10 and described as a sudden onset of shooting pain. The record revealed no sepsis screen in the documentation. Patient #1 was triaged as an ESI-3 (a triage system tool score indicating an urgent condition requiring prompt but not immediate attention). Additionally, documentation revealed Patient #1's past medical history was significant for atrial fibrillation (irregular heartbeat), diabetes, and osteomyelitis of the right hand.

b. The medical record also revealed Patient #1 had lab work drawn, received intravenous (IV) fluids, pain medications, and a CT scan (detailed x-ray which creates cross-sectional images) of the lumbar spine, abdomen, and pelvis. At 5:16 a.m., Provider #2 documented Patient #1 had been tachycardic (rapid resting heart rate >100 beats per minute), had an elevated WBC count of 20.16 (normal range 3.5 - 11.5), neutrophils (immature WBC) 18.46 (normal range 2.0 - 8.0), and lactic acid level (acid produced by the body when oxygen is limited) of 1.9 (normal range 0.5 - 2). Provider #2 also ordered a procalcitonin laboratory test (a protein produced by the body in response to infection) and a urinalysis. Provider #2 documented a hand-off of Patient #1's care to the daytime ED provider with the additional lab work pending, as well as the need for reassessment of Patient #1's condition after pain medications and a trial of walking to determine Patient #1's final disposition.

c. At 6:13 a.m., documentation revealed Patient #1's procalcitonin level was elevated at 0.48 (reference range <0.05). The record revealed this meant a low risk for progression to severe sepsis/septic shock; however, procalcitonin values measured early in systemic infection may still have been low. The record revealed in the workup of sepsis, values <0.5 ng/ml would not have excluded infection. Additionally, the medical record revealed at 7:00 a.m., Patient #1's vital signs were documented as follows: BP 113/76, heart rate 104, and no respiratory rate or temperature were recorded. At 7:05 a.m., Patient #1's heart rate was 109; no BP or respiratory rate were recorded at this time. Patient #1's pain level at 7:05 a.m. was documented as 5 of 10 and described as shooting. Further, documentation at 7:54 a.m. revealed Patient #1 had not tolerated the trial of ambulation well. Documentation revealed Patient #1 was able to take only a few steps without any assistive devices, which was not their baseline. The record read Patient #1 experienced severe back pain during the trial of walking.

d. A review of the daytime ED provider's documentation at 10:45 a.m. revealed Patient #1 had improved significantly after medications, with the most pronounced improvement after the administration of diazepam (a muscle relaxant). Also, the ED provider's documentation read Patient #1 had no clinical findings consistent with acute infection, imaging was negative, and Patient #1 had walked with some low back pain but it was much improved. At 10:52 a.m., Patient #1 was administered diazepam 2 milligrams (mg) orally and discharged from the ED at 11:00 a.m.

The ED provider's documentation was in contrast to the previous documentation of tachycardia, increased respiratory rate, elevated WBC, elevated neutrophils, elevated procalcitonin, and lactate near the high end of normal. Also, at 7:54 a.m., Patient #1 had not tolerated walking unassisted, which was not their baseline.

Furthermore, Patient #1's BP had not been reassessed since 7:00 a.m., heart rate had not been reassessed since 7:05 a.m., respiratory rate had not been reassessed since 5:17 a.m., and pain level had not been reassessed since 7:05 a.m. This was in contrast to the Emergency Department Triage and Throughput policy, which read ED patients with an ESI-3 should have been reassessed every two hours and with any change in condition.

e. Further review of Patient #1's medical record revealed Patient #1 returned to the ED on 1/8/25 at 6:41 a.m., less than 24 hours after discharge. Patient #1 returned with complaints of back pain, neck pain, dizziness, and SOB. At 6:50 a.m., Patient #1's VS were documented as follows: BP 173/106, heart rate 150, and temperature 101.2 F. Lab work was drawn, including blood cultures. An EKG at 7:28 a.m. revealed a rapid, irregular heartbeat. Patient #1 was administered a rapid IV fluid bolus of one liter. Lab work revealed WBC 14.77, Procalcitonin 1.21, and lactate 1.9. Results of an MRI of the lumbar spine at 8:35 a.m. revealed a multilevel lumbar epidural abscess. Further documentation revealed at 9:07 a.m., Patient #1 was started on Cardizem (medication to control rapid heart rate and irregular rhythm) IV. At 10:45 a.m., Patient #1 was transferred by ambulance to another facility for spine surgery and treatment of sepsis.

B. Interviews

i. On 3/20/25 at 8:26 a.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated ED patients received an initial triage assessment and a focused assessment based on the initial complaint. RN #1 stated reassessment in the ED should have occurred every two to four hours, depending on the acuity of the patient. Also, RN #1 stated the only documentation required before an ED patient was discharged was vital signs to ensure nothing had changed with the patient. RN #1 stated they would have documented a set of vital signs before the patient was discharged to ensure no change in the patient's condition had occurred.

This was in contrast to Patient #1's medical record, which revealed Patient #1 did not have vital signs and pain level reassessed before discharge from the ED.

ii. On 3/20/25 at 10:41 a.m., an interview was conducted with Physician #2. Physician #2 stated they provided care for Patient #1 from their arrival in the ED until hand-off of care to the day physician at 5:30 a.m. Physician #2 stated symptoms of sepsis included high WBC count, tachycardia, low BP, and fever. Physician #2 recalled Patient #1 had been in a lot of pain, and they were uncertain if the tachycardia was due to the pain or something else. Physician #2 stated Patient #1 had denied any trauma or injury that would have caused the back pain. Physician #2 stated Patient #1 had an oddly elevated WBC, so Physician #2 ordered more lab work before they handed off care to the day provider. Physician #2 stated Patient #1 had atraumatic back pain (back pain with no known injury), and they had been concerned they might have missed an infection like osteomyelitis (infection of the bone), so they had considered ordering an MRI but decided to wait until results of the additional lab tests were available. Provider #2 stated Patient #1 had no risk factors that would suggest an epidural abscess, such as IV drug abuse, recent surgery, diabetes, or being immunocompromised. Provider #2 stated it was important to reassess patients before discharge to ensure they felt better and had a safe discharge plan. Provider #2 stated they would not have discharged a patient who could not keep food down, had abnormal vital signs, or could not walk.

iii. On 3/20/25 at 2:39 p.m., an interview was conducted with Physician #3. Physician #3 had conducted a review of Patient #1's record. Physician #3 stated the red flags for sepsis in Patient #1's case would have been tachycardia, elevated procalcitonin, and high WBC count. Physician #3 stated an epidural abscess was a rare diagnosis, and an MRI would have been needed to diagnose it. Physician #3 stated Patient #1 did not have risk factors for an epidural abscess, such as IV drug use, recent surgery, diabetes, or an indwelling catheter (a tube that allows urine to drain from the bladder). Physician #3 stated medical decision making in this case had come down to an infection or musculoskeletal issues that caused the SIRS criteria to come up. Further, Physician #3 stated conditions that needed an MRI were not usually emergent; however, an epidural abscess was emergent because the abscess could have been rapidly progressive.