HospitalInspections.org

Based on ED log review, medical record review, policy review, Mayo Clinic Reference review, observation, and staff and patient interview, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. This had the potential for negative outcomes and life-threatening complications. Findings include:

Refer to A2406 as it relates to the failure of the hospital to ensure a medical screening examinations were performed for all patients presenting to the ED and within the capability of the hospital.

Refer to A2407 as it relates to the failure of the hospital to provide stabilizing treatment.

The effects of these practices put all patients presenting to the ED for emergency medical treatment at risk of significant negative outcome.

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Based on ED log review, medical record review, policy review, observation, and staff and patient interview, it was determined the hospital failed to ensure an appropriate MSE was conducted for 2 of 3 patients (Patients #6 and #12) who presented to the ED with pregnancy related chief complaints and whose records were reviewed. Failure to conduct a complete MSE had the potential for significant harm to the patient and unborn child. Findings include:

A facility policy titled, "EMTALA Guidelines," revised 12/26/24 stated, "All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis ... Medical Screening Exams (MSEs) shall include at a minimum the following: ... physical exam of affected systems and potentially affected systems ... necessary testing to rule out emergency medical conditions."

A facility policy titled, "Medical Screening Examination (MSE)," revised 3/11/25, stated, "All patients presenting to ... and seeking care ... must be accepted and evaluated ... All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis."

A facility policy titled, "Medical Screening Exam - Pregnant Patient," revised 8/01/25, draft copy, was provided to surveyors and was reviewed. This policy stated, "Medical Screening Exams (MSEs) for pregnant patients should include ... B. obtain clean catch urine sample, C. Fetal assessment: Fetal heart rate monitoring (Bedside ultrasound or Doppler, depending on gestational age and equipment). D. Perform sterile vaginal exam (SVE), if indicated."

The above policies were not followed. Examples include:

1. Patient #6 was a 34 year old female who presented to the ED on 4/16/25 at 12:34 AM with a chief complaint of 5 weeks pregnant via IVF with lower abdominal pain and bleeding. Patient #6 was registered and disposition was listed as LWBS.

A phone interview was conducted on 8/19/25 beginning at 4:05 PM with the ED RN, RN A, who was on shift when Patient #6 presented. She was asked if she recalled Patient #6 and she stated she believed she did. She stated she brought her [Patient #6] to a room to triage. She stated, "I called [Physician A] in the room to say we had a patient here with abdominal bleeding and she wanted to see if she had an ectopic or if pregnancy was viable and [Physician A] said he would see her but to just let her know we don't have ultrasound available in the middle of the night. I told the patient and husband and they were angry and left before [Physician A] could see them."

A phone interview was conducted with Patient #6 on 8/20/25 beginning at 9:30 AM. Patient #6 recounted her ED visit on 4/16/25 as follows, "I was brought back to a room ... The RN was on the phone with the doctor, I was in fear of an ectopic. The RN said to me and my husband there was nobody here who can do a scan but we can transfer you. My husband and I were upset and so we left, but if they had done an exam he would have found that I was miscarrying and there were retained parts and tissue in the cervix because that's what they found at [other ED] within 45 minutes of being there. At [other ED] they used forceps and removed the tissue in the cervix and my pain stopped. Then I was transferred to [acute care hospital]."

It was unclear why Patient #6 was not provided an MSE.

2. Patient #12 was a 28 year old female who presented to the ED on 6/29/25 with a chief complaint of "vaginal bleeding 26 weeks pregnant." The visit was cancelled and the only information in the medical record was a face sheet with patient information such as name, birthday, and insurer. Her disposition was LWBS.

The registration clerk, Staff A, who was working when Patient #12 presented to the ED was interviewed on 8/19/25 beginning at 3:14 PM. She confirmed she remembered Patient #12. When asked what happened and why Patient #12 left, she stated the RN had a conversation with Patient #12 and told her they could see her, but had no ultrasound available, and that would be the quickest way to determine if she was having a miscarriage. She said Patient #12 then decided to seek care elsewhere.

The RN who spoke with Patient #12, RN B, was no longer employed at the hospital at the time of survey.

The DON was interviewed on 8/19/25 during medical record review. She stated OB ultrasound was available during the week from 8:00 AM to 5:00 PM. She stated there was a bedside ultrasound machine some physicians used after hours for OB, depending on their comfort level with it. She stated, "ED docs [sic] are not comfortable with OB."

The ED Medical Director, Physician A, was interviewed on 8/19/25 at 3:23 PM. When asked why some physicians do bedside OB ultrasound and some do not, he stated it depends on what they are comfortable with. He stated it can be comforting to the mother to see fetal movement. He stated on weekends if ultrasound is needed they schedule for the next available appointment or arrange for a transfer. He stated an OB ultrasound does not usually change management of the patient. He stated, "It's completely informal and can show them the baby is alive."

During the same interview with the Physician A, Patient #12's case was reviewed. Physician A confirmed he reviewed Patient #12's case. He stated they tell patients with presenting with OB complaints after hours it is likely they would need an ultrasound and a formal transfer, and most people would rather not delay their care. When reviewing the scenario where Patient #12 decided to go to another facility based on lack of ultrasound capability at night, he stated, "I don't think at nighttime it's uncommon."

Physician B, an ED physician, was interviewed on 8/21/25 beginning at 9:46 AM. When asked if he did bedside OB ultrasounds at night, he stated he would if the patient had already had an initial ultrasound. When asked what the bedside OB ultrasound could show he said it could confirm the intrauterine pregnancy, detect fetal heart tones, detect placental hemorrhage, and do a mini anatomy scan.

It was unclear why some physicians could do bedside OB ultrasound and some could not. It was unclear why Patient #12 was not provided an MSE within the capability of the hospital.

The facility failed to ensure all patients presenting to the ED were provided an MSE within the capability of the hospital. This failure created potential for serious harm, serious impairment, serious injury, or death. Obstetric emergencies are time sensitive and delays could result in significant injury, up to and including, death of the obstetric patient or the fetus. Failure to provide an MSE also caused the potential for other disease processes to go undiagnosed and caused patients traveling significant distances with medical emergencies to go without appropriate monitoring.

The facility was notified of the Immediate Jeopardy finding on 8/20/25 at 1:14 PM. A plan of correction was submitted and accepted on 8/20/25 at 3:54 PM which included updated policies and in services outlining that availability of services would not be discussed with the patient until an MSE was complete. Observations and interviews were conducted in the ED on 8/21/25 beginning at 9:46 AM. The facility was notified the Immediate Jeopardy was removed at 10:16 AM on 8/21/25.

Based on medical record review, staff interview, Mayo Clinic Reference, and policy review, it was determined the hospital failed to provide stabilizing treatment within the capability of the hospital for 1 of 22 patients (Patient # 20) whose medical records were reviewed. Failing to provide stabilizing medical treatment had the potential to allow a medical condition to progress up to and including death. Findings include:

A hospital policy titled, "Emergency Department (ED) Scope of Service" revised date of 5/13/25, stated, "All necessary definitive treatment will be given to the patient within the hospital's capabilities. ED patients are then evaluated for response to treatment. They are are then admitted, transferred for further treatment not provided by the hospital, or discharged with follow-up instructions as appropriate." This policy was not followed. An example includes:

Patient #20 was a 40 year old female who present to the ED on 7/23/25 with a chief complaint of "HIGH BLOOD GLUCOSE."

An ED triage note by the RN at 10:43 AM noted under the label "Chief Complaint" included the following: "fatigue, urinary frequency, increased thurst [sic]. has [sic] been out of metformin [sic] for over a month having issues with refills."

A note under a section titled "Medical Decision Making" stated, "1044 hrs.-patient seen evaluated ... No clinical evidence of DKA [diabetic ketoacidosis]. Patient's mucous membranes are moist and pink. Will obtain labs to screen for other conditions. No overt evidence of sepsis toxicity or acute infectious process. Patient agreeable to workup treatment plan of care."

The Mayo Clinic website (https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-20371551https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-20371551) was accessed 8/25/25. It stated:

"Diabetic ketoacidosis is a serious health condition that can happen as a result of diabetes. It can be life threatening ... Diabetic ketoacidosis symptoms often come on quickly, sometimes within 24 hours ... Symptoms might include:
· Being very thirsty.
· Urinating often.
· Feeling a need to throw up and throwing up.
· Having belly pain.
· Being weak or tired.
· Being short of breath.
· Having fruity-scented breath.
· Being confused.

More-certain signs of diabetic ketoacidosis show up in home blood and urine test kits. They include:
· High blood sugar levels.
· High ketone levels in urine.

Seek emergency care if:
· Your blood sugar level is higher than 300 milligrams per deciliter (mg/dL), or 16.7 millimoles per liter (mmol/L) for more than one test.
· You have ketones in your urine and can't reach your healthcare professional for advice.
· You have many symptoms of diabetic ketoacidosis. These include being very thirsty, urinating often, feeling a need to throw up or throwing up, belly pain, weakness or tiredness, shortness of breath, fruity-scented breath, and confusion.

It's important to get care right away. If it's not treated, diabetic ketoacidosis can lead to death."

It was unclear how the provider determined the patient had "no clinical evidence of DKA" as patient presented with complaints of high blood glucose, increased urination, increased thirst, and fatigue.

Patient #20's medical record included an entry under a heading titled, "Point of Care Testing" labeled "Blood Glucose, MAR" dated 7/23/25 timed 10:35 AM with the following information "(H) 500 mg/dL"

Her medical record indicated that she received a "1,000 mL IV Bolus ONE TIME ... Infuse over 31 min" at 10:49 AM.

A further review of her medical record revealed she had a blood glucose reading from the lab at 11:06 AM of 483 mg/dL with the indication next to the reading of "(High)."

A note titled "Reexamination/Reevaluation" documented by Physician C stated "1137 hrs.- ... Workup results are reassuring. Patient does have elevated blood sugar but no evidence of DKA or an acute infectious process. Patient is notified of workup results. She is notified of her active prescription. Patient encouraged to take part of her health care and become an active participant in it. Patient encouraged to follow-up with a primary care provider of her choice. She agrees to call and schedule an appointment and follow-up with the appointment as scheduled. She is encouraged to return to emergency room for any problems as needed. She is discharged stable amatory [sic] improved."

It was unclear how Physician C determined Patient #20 was stable and improved as there was no documented follow up of the patient's presenting symptoms of increased thirst, increased urination, and her last blood glucose was noted to be high per the lab at 483 mg/dL. There was no reassessment documented of her blood glucose before she was discharged at 11:52 AM. Additionally, there was no documentation Patient #20 received any medications to lower her blood glucose levels.

Physician C was interviewed on 8/19/25 beginning at 2:37 PM. Patient #20's medical record was reviewed in his presence. He stated he knew who the patient was as he had just reviewed her record. He was asked about her blood glucose being 483 and being discharged without a recheck of her blood glucose or verification of her response to treatment. He stated, "we asked the social worker to come in. Our social worker is a lot better sometimes at exploring people's issues and she's also able to provide resource offerings that she's an expert on and I'm not. So, we brought the social worker in and the patient's whole persona just changed. She was like get me out of here. I remember that. We offered more fluids. She didn't want any further care and yes, a follow up blood sugar would have been done, should have been done but she wanted to leave right now. Now I know, because I just reviewed the chart, that that should have been documented a little bit better, but it was just like get me out of here I want to leave. She didn't want to discuss it."

Physician C confirmed none of the above information was recorded in Patient #20's record.

Patient #20's emergency room log entry included that she was discharged home and did not leave the emergency room AMA.

The hospital failed to ensure that all patients presenting received stabilizing treatment before being discharged.