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Based on record review, interview, document review and policy review the hospital failed to follow policy and ensure emergency medical treatment and labor act (EMTALA) requirements were met by failing to provide an appropriate medical screening examination (MSE) within the hospital's capabilities to determine whether an emergency medical condition (EMC) existed. This deficient practice has the potential for all patients to be discharged/leave with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the person's condition, including death.

Findings Include:

Review of Policy 6230-28-P titled, "EMTALA SCREENING, STABILIZATION, MANAGEMENT OF TRANSFER," dated January 2020, showed,

"4. If an individual (or injured employee or visitor) needing examination or treatment for a medical condition presents to the emergency department: a. It is SRHC's policy to provide an appropriate medical screening examination to all individuals presenting at the emergency department requesting examination or treatment of a medical condition; and either to seek to stabilize an emergency medical condition if one exists, or to transfer the individual appropriately and in conformity with legal and regulatory requirements."

"7. An "EMERGENCY MEDICAL CONDITION" is defined as: a. A medical, psychiatric, severe pain, or obstetric condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in: i. Placing the individual's health in serious jeopardy (or, if the individual is pregnant, placing the woman's or the unborn child's health in serious jeopardy); or ii. Serious impairment to bodily functions; or iii. Serious dysfunction of any bodily organ or part."

"9. "To STABILIZE" an individual's "emergency medical condition" means "to provide such medical "treatment of the condition as may be necessary to assure within reasonable medical probability, that no material deterioration of the individual's condition is likely to result from or occur during the transfer." If a pregnant woman having contractions is found to be in an emergency medical condition, to stabilize means to deliver the baby and the placenta. Stabilization is a clinical determination made by the physician and is in no way based upon financial consideration."

"14. Those health practitioners designated to perform medical screening examinations (MD's/DO's/NP's/PA's) are identified in the SRHC Medical Staff Rules and Regulations and approved by the governing body."

"PROCEDURE MEDICAL SCREENING EXAMINATIONS"

1. Whenever any individual comes to the emergency department and requests, or someone on behalf of the individual requests, an examination or treatment for a medical condition, a medical record will be initiated by the ED triage nurse. The triage nurse will determine a level of need for care as per health center policy and prior to any inquiry regarding the individual's method of payment or insurance status. A triage exam is NOT a medical screening examination.
2. The emergency department physician, personal physician, Nurse Practitioner (NP), and Physician Assistant (PA) shall conduct a medical screening examination to determine whether or not an "emergency medical condition" exists. All ancillary health center services routinely available to the emergency department shall be utilized, if indicated, in conducting the medical screening examination.
3. If there is any doubt as to the existence of an "emergency medical condition" as defined above, it shall be presumed that the patient has an emergency medical condition.
4. Based on the screening results, the health center will pursue the following:
a. If an EMERGENT condition exists: The patient will be stabilized to the best of the health center's ability. If an emergency condition does not exist this too will be documented in the medical record. If the patient's condition has been stabilized as defined above, the physician, NP, or PA shall fully and clearly document the basis for this determination in the medical record. At this time, the patient may be referred for further nonemergency medical treatment through the health center's facilities, a private physician, through other appropriate health care facilities or any other facility, and/or the patient may be discharged.
b. If the patient's condition is unstable, stabilizing treatment shall continue to be provided within the capabilities of emergency department services. The patient may not be discharged. If a decision is made to transfer an unstabilized patient, the transfer must be in accordance with the procedures on "Transfers of the Emergent/Unstable Patient."


The hospital failed to ensure each individual who came to the emergency department (ED) had an appropriate medical screening examination (MSE) within the hospital's capabilities to determine whether an emergency medical condition (EMC) existed for one patient (Patient 1) of 20 ED records reviewed. (Refer to tag A-2406)

Based on policy review, record review, and interviews, the hospital failed to ensure each individual who came to the emergency department (ED) received an appropriate medical screening examination (MSE) within the hospital's capabilities, to determine whether an emergency medical condition (EMC) existed for one patient (Patient 1) of 20 ED records reviewed. This deficient practice has the potential for all patients to be discharged/leave with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the person's condition, including death.

Findings Include:

Review of Patient 1's ED medical record showed the patient presented to the ED on 10/24/22 at 6:41 PM. The reason for visit "COVID positive, Symptoms worse." The triage nurse documented the patient's family member reported the patient complained of a "cough, fever, shortness of breath", and that his oxygen saturation level was "83 - 88% (normal 90 - 100 %) and was "given a breathing treatment at home." Patient 1 tested positive for COVID-19 at an urgent care clinic on 10/22/22. Further documentation showed the patient was unvaccinated and seeking treatment for COVID-19 symptoms. Patient 1's diagnoses included obesity and diabetes. Review of Patient 1's history of present illness (HPI) showed, Patient 1 reports symptoms approximately 2-3 days ago. He reports he had headache, myalgia (muscle pain), cough, and dyspnea (difficulty breathing), and that his oxygen saturation at home was in the mid 80's while at rest. Review of the medical history showed Patient 1 also had COVID-19 in October 2021. Staff I, RN was assigned to provide care for the patient. Review of the 6:41 PM vital signs showed a temp of 98.3 degrees Fahrenheit (normal 97.5 - 98.6), a rapid pulse of 109 beats per minute (normal 60-90), respirations of 20 (normal 12-20), respiratory effort, "short of breath", an elevated blood pressure of 130/63 (normal range 90/60 -
120-80) and an oxygen saturation of 95% (normal 90-100%) while on room air.

Review of the Medical Decision Making (MDM) Notes showed, discussion was had with Patient 1 regarding recommendation for monoclonal antibodies given his advanced age, obesity, and comorbidities. The MDM showed Patient 1 was not hypoxic (inadequate levels of oxygen in the tissues and cells), not exhibiting any signs of respiratory distress, and did not wish to pursue further treatment here in the emergency department. He is an appropriate candidate for discharge to home. Further review showed the physician discussed with Patient 1 at length regarding his stability at this time for discharge, however, given COVID-19 and its potential to worsen and cause him to have worsening symptoms, he would need to remain vigilant at home.

Patient 1 was discharged home on 10/24/21 at 7:11 PM (within 30 minutes of arrival complaining of worsening symptoms), with instructions to follow up with his primary care physician in 2-3 days or return to the ED if
symptoms worsened.

The evidence in Patient 1's medical record showed the hospital failed to provide the patient with a medical screening examination sufficient to determine whether an emergency medical condition existed. The 73 year old patient with multiple co-morbid conditions, persistent tachycardia (heart rate greater than 90 beats per minute) and a positive
COVID test was at risk for sepsis, overwhelming infection and respiratory failure (risks of COVID for older adults). The documentation in the medical record showed the patient declined monoclonal antibody treatment in the ED. The ED physician documented the patient was clinically stable despite being persistently tachycardic. There is no documentation of the patient's risk/benefit for receiving treatment or further evaluation and no evidence of oxygen saturation testing during exertion, laboratory testing/results, chest x-ray, or arterial blood gas levels.

Review of Patient 1's Hospital B's record showed Patient 1 presented to the ED on 10/25/21 at 1:06 PM - less than 24 hours after discharge from Salina Regional Hospital. Vital Signs showed BP 142/79, Pulse 112, respirations 18, Temperature 99.5 and oxygen saturation 95% on room air. The MDM showed Patient 1 reported feeling very poorly for the past few days, that he was from Salina and tested positive there. He worsened and then came here for further testing and therapeutics. At 4:25 PM, ED staff walked Patient 1, the record showed he was very weak and became hypoxic with oxygen saturations in the mid to upper 80s along with tachycardia (fast heart rate). The hospitalist was consulted and Patient 1 was admitted to Hospital B on 10/25/21 at 7:39 PM, for COVID-19 with severe generalized weakness and hypoxia on exertion.

Review of Patient 1's, Hospital B discharge summary showed Patient 1 continued to decline with mild respiratory distress. Oxygen demands continued to increase. Patient was placed on high flow oxygen at 55 liter per min. (L/min) and an FiO2 [fraction of inspired oxygen] (an estimation of the oxygen content a person inhales) of 100% with oxygen. Saturation between 88 and 91% with intermittent prongng (sic). Patient 1 was placed on BIPAP [Bilevel positive airway pressure] (a device that helps with breathing) and sick appearing, with labored respirations and unable to come off BiPAP. Renal (kidney) failure and uremia (buildup of toxins in the blood when the kidneys stop filtering the toxins out through the urine) worsened. Patient 1 expired one 11/04/22.

During an interview on 05/10/22 at 10:00 AM. Staff F, ED Physician provided care for Patient 1 on 10/24/21. Staff F stated that Patient 1 had been positive for COVID-19 for two or three days and was not hypoxic (low oxygen in tissues). Staff F stated Patient 1 did not show severe signs or symptoms and did not meet criteria for admission. When asked why no laboratory work or chest x-ray were performed, Staff F stated there was no need.

During a telephone interview on 05/10/22 at 6:15 PM, Staff I, ED RN stated she was present with the ED physician (Staff F) when the physician asked Patient 1 why he/she did not get the COVID-19 vaccine and the patient replied there had not been enough study done on the vaccine. Staff I heard the physician tell Patient 1 that if the patient felt uncomfortable getting the vaccine, the patient might not feel comfortable getting the IV Monoclonal Antibodies because there were less studies done on the antibodies.