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Based on policy and procedure review, medical record review, staff and medical staff interviews the facility failed to follow their policy regarding stabilizing treatment and ongoing monitoring of an emergency medical condition (EMC) prior to transfer for 2 (P1 and P5) of 6 sampled patient medical records. This failed practice has the potential to affect all patients who require stabilizing treatment of an EMC prior to transfer from the facility. According to facility provided data the Emergency Department (ED) sees an average of 2,750 and transfers 99 patients per month.

See citation A2406, A2407 and A2409, that also resulted in A2400 to not be met.

Based on policy and procedure review, medical record review, staff and medical staff interviews the facility failed to ensure all data collected for the medical screening exam (MSE) to rule out an emergency medical condition (EMC) was documented in the patient medical record for 2 (P1 and P5) of 20 sampled emergency department (ED) patients. This failed practice has the potential to cause harm or death to all patients who present to the ED with an EMC. According to facility provided data the ED sees an average of 2,750 and transfers 99 patients per month.

See citation A2400, A2407 and A2409, that also resulted in A2406 to not be met.

Findings include:

A. Review of facility policy, "Medical Screening Exam," MS34 approved 4/2023 revealed, screenings may include vital signs, oral history, physical examination of affected or potentially affected systems, consideration of known chronic conditions, any testing needed to determine presence of an emergency medical condition.

Review of facility policy, "Emergency Medical Treatment and Transfer Policy (EMTALA)," RI07 approved 2/2022 revealed, the MSE shall determine whether a medical emergency does or does not exist. Depending on the patient's presenting symptoms the MSE may range from a simple process involving only a brief history and physical examination, to a complex process with ancillary and diagnostic tests. The facility shall provide medical treatment within its capability and capacity that minimizes the risks to the individual's health.

Review of facility policy, "Guidelines for vital signs in the ED," PCB12 approved 6/2022 revealed, vital signs may reveal sudden changes in a patient's condition as well as changes that occur progressively over a time. Any difference between a patient's normal baseline measurement and present vital signs can be an indication for the Registered Nurse (RN) to initiate appropriate nursing therapies and pursue necessary medical interventions. Abnormal vital signs should be brought to the attention of the ED attending provider. All patients will have temperature, pulse, respirations, pulse oximeter, pain assessment, and blood pressure done upon arrival to the ED.

B. Review of P1's medical record revealed, P1 presented to the acute care hospital on 1/1/2024 at 2:53AM via car, walk in, with a chief complaint of fall going up concrete steps, struck back of head, with brief loss of consciousness, repeat questioning and memory lapses.

The ED notes revealed P1 had an ethanol level of 314 (3.14 blood alcohol level=intoxication). Triage vitals at 3:02AM lacked evidence of a blood pressure. The first documented blood pressure was at 5:01AM (2 hours after ED arrival, and 4 minutes prior to P5 transfer). P1's medical record lacked evidence of ongoing evaluation of neurological exam/assessment before or after CT head (imaging of the brain) at 3:41AM which revealed a 2-3-millimeter subdural hematoma (SDH) (bleeding clots in the brain and requires neurological physician/surgeon services to remove).

Review of P5's medical record revealed, P5 presented to the acute care hospital on 6/6/2024 at 7:48PM via ground ambulance, with a chief complaint of severe 10/10 pain to the right flank (midback) and a known kidney stone measuring 8mm on the right side (stones can cause a block in the tube urine passes through), that they "worked on earlier in the week, [P5 had a lithotripsy(procedure to breakup stones/blockages in the kidneys) 3 days prior to ED arrival]."

The MSE provided by Physician-A at 8:14PM revealed the review of systems included respiratory: positive for shortness of breath and wheezing. P5 ED note by Physician-A revealed a past medical history of Asthma (long-term condition that makes it harder for air to flow out of the lungs when breathing out). The ED notes lacked evidence of a respiratory physical exam by Physician-A, or a respiratory assessment by RN-B or C.

At 9:07PM Physician-A ordered a nebulizer medication DuoNeb (treatment to open the airways in the lungs-to improve breathing, shortness of breath and wheezing). The medical administration record revealed a DuoNeb was given at 9:24PM (1 hour after P5 reported shortness of breath and wheezing).

The Respiratory Therapy (RT) treatment flowsheet revealed the first respiratory assessment was done at 9:25PM documented dyspnea at rest (difficulty breathing), lung sounds included all four lobes diminished, expiratory wheezes in the right and left upper lobes (a sound you can hear when someone is breathing out, commonly occurs with conditions like asthma that requires medical intervention/treatment). The RT post treatment respiratory assessment revealed "improved, bilateral lung sounds clear, diminished."

P5's entire medical record lacked evidence of a blood pressure until 10:01PM (2 hours after arrival to ED), confirmed by RN-A.

C. During an interview on 7/29/2024 at 2:31PM, Physician-A revealed, ED note for P5 review of systems is what the patient is telling the physician. Physician-A confirmed there was no documentation of a respiratory physical exam on initial or throughout P5's ED stay. Did not recall notification of respiratory status of P5 when order for DuoNeb was placed at 9:07PM. "I don't always put a note in when I reassess." There is often hallway beds when the ER is full [overflow area when the 21 ED rooms are full], guessing that is why P5 had to wait in the lobby when arriving by EMS.

During an interview on 7/29/2024 at 3:32PM, Staff-A revealed, recall of P5 Someone came to the window and said P5 felt like was having an asthma attack. "I called the triage nurse, no answer, called the lead nurse and told them P5 feels like they're having an asthma attack, and can someone come check on him." Did not recall who came to check on P5 but they, "took P5 to triage in a wheelchair and P5 never returned to the lobby." Staff-A did not recall seeing P5 laying on the lobby floor.

During an interview on 7/29/2024 at 11:46AM, RN-A confirmed that P1's medical record lacked evidence of triage blood pressure, ongoing vital signs, and neurological assessments prior to transfer. RN-A confirmed that P5's medical record lacked evidence of a respiratory exam. RN-A confirmed a respiratory assessment was not done until 9:25PM (1 hour and 10 minutes after P5 complained of shortness of breath and wheezing).

During an interview on 7/29/2024 at 1:33PM, RN-B revealed, RN-B was in the triage room with another patient when P5 arrived via EMS. EMS brought P5 to the lobby, put P5 in a wheelchair. "I stopped what I was doing in triage to get a quick report from EMS." P5 was being registered at the desk when RN-B came out of the triage room. RN-B revealed that occasionally when the ED is full [capacity 21], when EMS arrives if the patient is stable enough, they will send them to the "triage cue," and get report from EMS as if the patient was a walk in, "coming through the door." RN-B recalled finishing with the patient in triage, and then returning to the lobby to get P5 to triage. When RN-B got to the lobby P5 was laying on the floor due to pain, got back into the wheelchair, and wheeled to triage room. P5 was complaining of not being able to breath in the triage room but was talking to "me" [RN-B]. RN-B got P5's pulse oximetry and took a quick listen to the lungs in the back, "P5 was moving air." RN-B thought the pain was making P5 short of breath, and recalled the vital signs, "being okay, but was hurting." RN-B recalled the spouse reporting history of asthma. RN-B recalled telling P5 "you're moving air, your pulse ox is good, calm down and we will get you to a room." RN-B reported P5 condition to the team lead and requested a room vs. returning P5 back to the lobby. RN-B was able to get P5 into a room, and "wasn't with me long [in triage]." RN-B did not recall if anyone notified of P5 laying on the floor in the lobby. RN-B recalled trying to get a blood pressure on P5 in the triage room but was unable due to P5 was rocking back and forth in the wheelchair.

During an interview on 7/29/2024 at 2:07PM, RN-C revealed, P5 was in pain with a history of kidney stones, hard time breathing due to the pain, and couldn't take deep breaths. RN-C recalled P5, and spouse being upset with arriving by squad and being put in the waiting room. RN-C recalls trying to address pain. RN-C did not recall P5 or RN-B reporting asthma history, or why DuoNeb was ordered. RN-C said the standard vital signs in the ED once the patient is roomed is every 2 hours but is situational to the patient and their condition on frequency. RN-C recalls obtaining vital signs but does not recall if hit the validation button for them to flow over to the medical record.

During an interview on 7/30/2024 at 12:23PM, Physician-B revealed, P1 peer review appears standard from door to diagnosis timeline, a serial neurological exam/assessments would be unlikely unless indicated before transfer. Physician-B confirmed first documented blood pressure for P1 was 0501AM, 4 minutes before P1 transferred to a higher level of care for neurological services.

Based on policy and procedure review, medical record review, staff and medical staff interviews the facility failed to provide treatment of an emergency medical condition (EMC) within hours of the medical screening exam (MSE), and ongoing monitoring of an EMC for 2 hours prior to transfer for 2 (P1 and P5) of 20 sampled emergency department (ED) patients. This failed practice has the potential to cause harm or death from a delay in stabilizing treatment to all patients who present to the ED with an EMC. According to facility provided data the ED sees an average of 2,750 and transfers 99 patients per month.

See citation A2400, A2406, and A2409 that also resulted in A2407 to not be met.

Findings include:

A. Review of facility policy, "Emergency Medical Treatment and Transfer Policy (EMTALA)," RI07 approved 2/2022 revealed, the dedicated ED shall provide the necessary MSE, stabilizing treatment for EMCs, or shall transfer the patient if the hospital does not have the capability or capacity. The MSE shall determine whether a medical emergency does or does not exist. Depending on the patient's presenting symptoms the MSE may range from a simple process involving only a brief history and physical examination, to a complex process with ancillary and diagnostic tests. The facility shall provide medical treatment within its capability and capacity that minimizes the risks to the individual's health.

Review of facility policy, "Guidelines for vital signs in the ED," PCB12 approved 6/2022 revealed, vital signs may reveal sudden changes in a patient's condition as well as changes that occur progressively over a time. Any difference between a patient's normal baseline measurement and present vital signs can be an indication for the Registered Nurse (RN) to initiate appropriate nursing therapies and pursue necessary medical interventions. Abnormal vital signs should be brought to the attention of the ED attending provider. All patients will have temperature, pulse, respirations, pulse oximeter, pain assessment, and blood pressure done upon arrival to the ED.

B. Review of P1's medical record revealed, P1 presented to the acute care hospital on 1/1/2024 at 2:53AM via car, walk in, with a chief complaint of fall going up concrete steps, struck back of head, with brief loss of consciousness, repeat questioning and memory lapses.

The ED notes revealed P1 had an ethanol level of 314 (3.14 blood alcohol level=intoxication). Triage vitals at 3:02AM lacked evidence of a blood pressure. The first documented blood pressure was at 5:01AM (2 hours after ED arrival, and 4 minutes prior to P5 transfer). P1's medical record lacked evidence of ongoing evaluation of neurological exam/assessment before or after CT head (imaging of the brain) at 3:41AM which revealed a 2-3-millimeter subdural hematoma (SDH) (bleeding clots in the brain and requires neurological physician/surgeon services to remove).

Review of P5's medical record revealed, P5 presented to the acute care hospital on 6/6/2024 at 7:48PM via ground ambulance, with a chief complaint of severe 10/10 pain to the right flank (midback) and a known kidney stone measuring 8mm on the right side (stones can cause a block in the tube urine passes through), that they "worked on earlier in the week, [P5 had a lithotripsy(procedure to breakup stones/blockages in the kidneys) 3 days prior to ED arrival]."

The MSE provided by Physician-A at 8:14PM revealed the review of systems included respiratory: positive for shortness of breath and wheezing. P5 ED note by Physician-A revealed a past medical history of Asthma (long-term condition that makes it harder for air to flow out of the lungs when breathing out). The ED notes lacked evidence of a respiratory physical exam by Physician-A, or a respiratory assessment by RN-B or C.

At 9:07PM Physician-A ordered a nebulizer medication DuoNeb (treatment to open the airways in the lungs-to improve breathing, shortness of breath and wheezing). The medical administration record revealed a DuoNeb was given at 9:24PM (1 hour after P5 reported shortness of breath and wheezing).

The Respiratory Therapy (RT) treatment flowsheet revealed the first respiratory assessment was done at 9:25PM documented dyspnea at rest (difficulty breathing), lung sounds included all four lobes diminished, expiratory wheezes in the right and left upper lobes (a sound you can hear when someone is breathing out, commonly occurs with conditions like asthma that requires medical intervention/treatment). The RT post treatment respiratory assessment revealed "improved, bilateral lung sounds clear, diminished."

P5's entire medical record lacked evidence of a blood pressure until 10:01PM (2 hours after arrival to ED), confirmed by RN-A.

C. During an interview on 7/29/2024 at 2:31PM, Physician-A revealed, ED note for P5 review of systems is what the patient is telling the physician. Physician-A confirmed there was no documentation of a respiratory physical exam on initial or throughout P5's ED stay. Did not recall notification of respiratory status of P5 when order for DuoNeb was placed at 9:07PM. "I don't always put a note in when I reassess." There is often hallway beds when the ER is full [overflow area when the 21 ED rooms are full], guessing that is why P5 had to wait in the lobby when arriving by EMS.

During an interview on 7/29/2024 at 3:32PM, Staff-A revealed, recall of P5 Someone came to the window and said P5 felt like was having an asthma attack. "I called the triage nurse, no answer, called the lead nurse and told them P5 feels like they're having an asthma attack, and can someone come check on him." Did not recall who came to check on P5 but they, "took P5 to triage in a wheelchair and P5 never returned to the lobby." Staff-A did not recall seeing P5 laying on the lobby floor.

During an interview on 7/29/2024 at 11:46AM, RN-A confirmed that P1's medical record lacked evidence of triage blood pressure, ongoing vital signs, and neurological assessments prior to transfer. RN-A confirmed that P5's medical record lacked evidence of a respiratory exam. RN-A confirmed a respiratory assessment was not done until 9:25PM (1 hour and 10 minutes after P5 complained of shortness of breath and wheezing).

During an interview on 7/29/2024 at 1:33PM, RN-B revealed, RN-B was in the triage room with another patient when P5 arrived via EMS. EMS brought P5 to the lobby, put P5 in a wheelchair. "I stopped what I was doing in triage to get a quick report from EMS." P5 was being registered at the desk when RN-B came out of the triage room. RN-B revealed that occasionally when the ED is full [capacity 21], when EMS arrives if the patient is stable enough, they will send them to the "triage cue," and get report from EMS as if the patient was a walk in, "coming through the door." RN-B recalled finishing with the patient in triage, and then returning to the lobby to get P5 to triage. When RN-B got to the lobby P5 was laying on the floor due to pain, got back into the wheelchair, and wheeled to triage room. P5 was complaining of not being able to breath in the triage room but was talking to "me" [RN-B]. RN-B got P5's pulse oximetry and took a quick listen to the lungs in the back, "P5 was moving air." RN-B thought the pain was making P5 short of breath, and recalled the vital signs, "being okay, but was hurting." RN-B recalled the spouse reporting history of asthma. RN-B recalled telling P5 "you're moving air, your pulse ox is good, calm down and we will get you to a room." RN-B reported P5 condition to the team lead and requested a room vs. returning P5 back to the lobby. RN-B was able to get P5 into a room, and "wasn't with me long [in triage]." RN-B did not recall if anyone notified of P5 laying on the floor in the lobby. RN-B recalled trying to get a blood pressure on P5 in the triage room but was unable due to P5 was rocking back and forth in the wheelchair.

During an interview on 7/29/2024 at 2:07PM, RN-C revealed, P5 was in pain with a history of kidney stones, hard time breathing due to the pain, and couldn't take deep breaths. RN-C recalled P5, and spouse being upset with arriving by squad and being put in the waiting room. RN-C recalls trying to address pain. RN-C did not recall P5 or RN-B reporting asthma history, or why DuoNeb was ordered. RN-C said the standard vital signs in the ED once the patient is roomed is every 2 hours but is situational to the patient and their condition on frequency. RN-C recalls obtaining vital signs but does not recall if hit the validation button for them to flow over to the medical record.

During an interview on 7/30/2024 at 12:23PM, Physician-B revealed, P1 peer review appears standard from door to diagnosis timeline, a serial neurological exam/assessments would be unlikely unless indicated before transfer. Physician-B confirmed first documented blood pressure for P1 was 5:01AM, 4 minutes before P1 transferred to a higher level of care for neurological services.

Based on policy and procedure review, medical record review, staff and medical staff interviews the facility failed to provide a summary of benefits of transfer contained in the physician certification form for 1 (P1) of 20 sampled emergency department (ED) patients. This failed practice has the potential to cause a delay or lack of an informed decision making to all patients who require transfer from the ED. According to facility provided data the ED sees an average of 2,750 and transfers 99 patients per month.

See citation A2400, A2406, A2407 that also resulted in A2409 to not be met.

Findings include:

A. Review of facility policy, "Emergency Medical Treatment and Transfer Policy (EMTALA)," RI07 approved 2/2022 revealed, the transfer consent form must be completed when a patient in an emergency medical condition. The reasons for the patient's request shall be documented, as well as an indication that the patient is aware of the risk and the benefits of transfer.

B. Review of P1's medical record revealed, P1 presented to the acute care hospital on 1/1/2024 at 2:53AM via car, walk in, with a chief complaint of fall going up concrete steps, struck back of head, with brief loss of consciousness, repeat questioning and memory lapses. The facility conducting testing and determined that P1 would transfer to a higher level of care for neurosurgery interventions (brain bleed requiring a specialized physician to operate.)

P1's physician certification transfer form lacked evidence of benefits to transfer.

C. During an interview on 7/29/2024 at 2:07PM, RN-C confirmed the physician certification transfer form benefits to transfer was blank.