HospitalInspections.org

Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24 (2) (iii).

The findings included:

Based on policy review, closed medical record review, staff and physician interviews, the hospital dedicated emergency department (DED) failed to perform an appropriate medical screening exam for one (1) of 20 sampled records by failing to provide Ultrasound [US] services available to Emergency Department patients when criteria was met. (Patient #8).

~ Cross refer to Appropriate Transfer - Tag A2406.

Based on policy review, closed medical record review, staff and physician interviews, the hospital dedicated emergency department (DED) failed to perform an appropriate medical screening exam for one (1) of 20 sampled records by failing to provide Ultrasound [US] services available to Emergency Department patients when criteria was met. (Patient #8).

The findings included:

Review of the policy, Imaging Services Call Policy, last revised 07/2024 revealed "PURPOSE: To define expectations of staff in various modalities and to establish criteria for appropriateness of callback in each modality. ... DEFINITIONS: ...The purpose of this policy is to define call coverage for [Hospital C] and [Hospital A] Imaging Department. ...Ultrasound is open/available M-F, 0730 - 1900, Saturday 7a - 1630 and on call afterward. ... Venous Doppler Study - Patient not currently on blood thinners and pain, erythema, and swelling in extremity of interest. ... PROCEDURE: ... **Note*** If a patient presents to the Emergency Department and needs a study performed that is considered NON-EMERGENT, the patient will be done the following morning or at the patient's convenience, unless the ordering physician contacts the Radiologist for approval and has precertification to have procedure. The ER will instruct the patient to call central scheduling to make an appointment. They will be added to our schedule as an outpatient and will be done at their scheduled time. The patient is to contact or follow up with the Emergency Department for their results."

Closed medical record review on 02/05/2025 for Patient #8 revealed a 56-year-old female was admitted to Hospital A DED on 10/14/2024 at 2025 for lower extremity pain. Triage at 2107 revealed Patient #8 arrived by private vehicle. Patient #8 had a Pain score of 5 (scale 0 no pain, - 10 most pain) and was assigned an acuity of 3 [emergency severity index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acutely ill]. Review revealed "Patient reports left lower leg pain behind her left knee over the past 4 days with redness and tenderness increasing." The MSE began at 2110 by the DED Physician's Assistant #10. Patient #8 did not have lab work or imaging ordered to be completed on 10/14/2024.

Review of the Emergency Department Note filed 10/14/2024 at 2110 by the DED PA #10 revealed "Chief Complaint: Left lower extremity pain redness swelling ...History of present illness HPI details: 56-year-old female here today with left lower extremity pain redness and swelling has been driving 18 hours. She states she has been mildly tachycardic but no respiratory distress nontoxic ill-appearing no recent trauma. Physical Exam: ... Extremities: pulses intact with good cap refills, no LE [lower extremity] pitting edema or calf tenderness, mild-to-moderate tender to palpate posterior left thigh negative Homan cord sign [pain associated with forced dorsiflexion of the ankle] mild erythema [redness of skin] two-point discrimination intact normal gait. ...Emergency Department Course/Plan/MDM Progress: patient was given Lovenox weight dose will have outpatient ultrasound done in the morning if positive she will sign back into the emergency department placed on Eliquis and appropriate workup. If negative patient will go home to follow up with primary care doctor she agrees with plan. ... Clinical Impression: left lower extremity pain/rule out DVT. ... Disposition Patient condition: stable; ED Disposition: home; ..."

Discharge instructions given at 2130 "call in the morning to this hospital to make sure ultrasound is here and available, if not go to Hospital C to have ultrasound performed. If symptoms persist or worsens, please go to the nearest hospital for re-evaluation." Discharge included a paper script with order "Dx [diagnosis] L [left] Ext [extremity] pain/redness. US L Lower Ext for DVT [deep vein thrombosis] 10/15/2024." Patient #8 was discharged on 10/14/2024 at 2130. Patient #8 did not return the next day for the US of left lower extremity.

Telephone interview on 02/06/2024 at 1130 with DED PA #10 revealed he had no recall of Patient #8's visit. "She was stable for discharge, that is our standard of care. I always call to see if I can get anyone to come in. I refer to the Wells/Criteria [standard of care] for DVT/PE [pulmonary embolus] check list. I review that list. The standard of care of 1 dose of lovenox, which was given. He had no active chest pain, no shortness of breath [SOB]. This was the standard of care. I explained to the patient in depth what to look for. That's what I did. I talked with radiology department. I ask them if I can get an US. If the patient had chest pain/SOB then you would transfer them. If not, I added blood thinners to cover. This is standard of care. I make sure to tell the patient, to stay after the ultrasound and get the report if positive, then to sign back into the ED. A patient that agrees to return, 99% of patients come back. We don't discharge patients that are unstable. You discharge stable patients; you cover them and get them back for US. I would transfer a patient to [Hospital C], to the ED/Hospitalist if patient needed care right then. I can reach out to Dr. [ED Medical Director] anytime I need to. The interview revealed DED PA #10 felt standard of care was followed for Patient #8.

Telephone interview on 02/07/2025 at 0948 with the DED Medical Director of Hospital A revealed " ...So I have not reviewed these cases. This whole pattern unsatisfactory, we would all prefer to have US techs .... If a patient was not on blood thinning medications that would meet criteria. If you suspect DVT, and don't have US, it was appropriate to initiate therapy and get the US the next availability. ...It sounds like the 2nd patient [patient #8] did meet criteria for ultrasound to be called back. It is our pattern to call the radiologist and ask regardless. Clearly [PA #10] felt she could have a DVT. There may have been a lapse in the 2nd case [Patient #8]. ...I'd always had a concern for this policy. This illustrates well this could be an issue. ... If a patient came in with an EMC [emergency medical condition] and needed an US, and US service at Hospital A was not available, then sending the patient to Hospital C by EMS to get that done was there. ... The Providers at Hospital A were not satisfied with US services at Hospital A, due to the US Techs being called back to Hospital C. We have to wait for a US tech or transfer the Patient over to Hospital C by EMS. We are told it is difficult to get adequate staff for US technicians ...." The interview revealed Patient #8 met criteria for US technician to be called in to rule out a DVT. The interview revealed the hospital policy was not followed.