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Based on review of facility policy, medical record review, Emergency Medical Services report and interviews the facility failed to provide an appropriate ongoing medical screening examination for one Emergency Department (ED) patient (#27) who was admitted with shoulder pain of 30 ED patients reviewed.

The findings included:

Patient #27 was admitted to the facility on 9/1/2022 with complaints of pain to her neck and shoulders which had been present for several days prior to admission. The patient had previously been diagnosed with COVID 19 on 8/23/2022 and treated as an outpatient with Paxlovid (antiviral medication) and Doxycycline (antibiotic). She was receiving supplemental oxygen at home related to shortness of breath and low oxygen saturations. On arrival at the ED her oxygen saturations were 95% on room air. She complained of pain to her left neck and pain between her shoulder blades. A medical screening examination was completed by the ED physician which showed the patient had normal bilateral breath sounds. She was diagnosed with COVID 19 and malaise (general feeling of illness). No diagnostic testing was completed for the patient during her admission to the ED on 9/1/2022. While the patient was in the ED, there was discussion with the patient's family related to why a chest x-ray or laboratory diagnostic testing was not completed for the patient related to the patient having been previously diagnosed with COVID 19 and the patient having a productive cough. The ED staff had spoken with the family and ED Physician and no diagnostic testing was completed for the patient. The patient was discharged on 9/1/2022 at 12:37 PM. On 9/2/2022 the patient was admitted to Facility B with exertional shortness of breath, oxygen saturations of 87% on room air, a stabbing pain into her chest with breathing, and a productive cough. Diagnostic testing was completed which showed the patient had an elevated white blood count (indicating infection) and her chest x-ray showed right lower lobe pneumonia. She was placed on oxygen at 3 liters by nasal cannula, admitted to the facility, and started on antibiotics. She was discharged home on 9/6/2022.

Refer to A-2406

Based on review of facility policy, medical record review, Emergency Medical Services report, and interviews the facility failed to provide an appropriate ongoing medical screening examination for one Emergency Department (ED) patient (#27) who was admitted with shoulder pain of 30 ED patients reviewed.

The findings included:

Review of facility policy, EMTALA Guidelines, last revised on 10/23/2018, showed "...all patients shall receive a medical screening examination that includes providing all necessary testing or on call services within the capability of the hospital to reach a diagnosis...medical screening exams shall include at a minimum the following:...vital signs, history, physical exam of affected systems and potentially affected systems, exam of chronic conditions, necessary testing...to rule out emergency medical conditions, necessary interventions to stabilize the patient...Emergency Medical Conditions: a medical condition manifesting itself by acute symptoms of sufficient severity [including severe pain] such that the absence of immediate medical attention could be reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment of bodily functions, serious dysfunction of any bodily organ or part..."

Medical record review of an Emergency Medical Services (EMS) Trip report dated 9/1/2022 at 10:17 AM showed the patient was transported to Facility A related to back pain and difficulty in walking. She had previously been diagnosed with COVID 19 two weeks ago.

Medical record review of an ED Nursing Triage record from Facility A dated 9/1/2022 at 10:37 AM showed the patient presented by EMS with complaints of 'horrible pain in my neck and shoulders since Saturday' (8/28/2022). The patient "...denies pain at this time, but states when it hurts, it is 10/10 and stabbing...I should not still have pain is what my family member that works at a doctor's office told me..." The patient's vital signs were as follows: Blood Pressure (BP) 178/87, Pulse 75, Respirations 20, Pulse Oximetry 95% on room air, and Temperature 96.1 degrees F (Fahrenheit).

Medical record review of an ED Physicians Record dated 9/1/2022 at 11:05 AM showed the patient complained of pain to the left neck and shoulders. She had COVID 19 two weeks ago and still had body aches between the shoulder blades. She denied any shortness of breath or chest pain. Her physical examination showed "...tenderness to palpation over the left neck and decreased range of motion (ROM) due to pain but otherwise no acute findings...lungs clear with equal breath sounds bilaterally...pt. [patient] is HD [hemodynamically] stable, afebrile, and saturating well on room air [RA], cardiopulmonary exam is normal..." Her diagnoses included COVID 19 and Malaise (general feeling of illness). No diagnostic tests were ordered or completed.

Medical record review of an ED Nurses Note dated 9/1/2022 at 11:30 AM (documented at 7:20 PM) showed the patient's family member provided information the patient had been hurting in between her shoulder blades which radiated under the patient's arm. The patient had previously been diagnosed with COVID 19.

Medical record review of an ED Nurses Discharge note dated 9/1/2022 at 12:37 PM (documented at 6:31 PM) showed "...patient left the department...another option for the patient is to go to Primary Care Physician (PCP) and obtain an outpatient chest x-ray..."

Medical record review of an ED Nurses Note dated 9/1/2022 at 12:39 AM (documented at 7:58 PM) showed "...discharged patient and brought to waiting room by wheelchair to [named family member]. [Named family member] asking explanation, 'Did they do a chest x-ray?, any blood work'? Nurse answered no to both questions and stated it is up to the doctor and he did not deem them necessary for today's visit. [Named family member] upset by response, 'I figured he would do a chest x-ray or check her cardiac enzymes. She had pain between her shoulder blades...is there anyway I can speak with him'? Informed [named family member] the nurse would speak with MD [medical doctor] about seeing her..." At 12:41 PM "...patient reassessed. Informed MD. MD states 'I will speak with her. Let her know it will be awhile. I have to see these patients first, then I will be out there'..."

Medical record review of an ED Nurses Note dated 9/1/2022 at 12:44 PM showed "...patient's family member was informed that [Patient #27] was being discharged and when she discovered that [Patient #27] had not received a chest x-ray, as she had requested, she was angry. [Named family member] stated '[Patient #27] does not have clear lungs, she had MRSA [Methicillin-resistant Staphylococcus aureus] and just had COVID and still coughs up copious amounts of brown stuff. She did not tell him she had pain in her neck, and said she had pain across her shoulder blades...I am taking her to [Facility B] and if they find anything that contradicts what was found here, there will be trouble'..."

Medical record review of an ED Nursing Triage record from Facility B dated 9/2/2022 at 9:13 AM showed the patient presented with back pain, a productive cough with thick brown mucus, and wheezing. She had been diagnosed with COVID 19 on 8/23/2022. She was triaged with an ESI score of a 2 indicating emergent needs.

Medical record review of Laboratory and Radiology Diagnostic testing dated 9/2/2022 showed the following:
10:20 AM: Complete Blood Count: White Blood Count (WBC) 13.3 (elevated indicating infection), Neutrophils 9.8 (elevated)
12:29 PM: Chest x-ray: Findings suggestive of right lower lobe pneumonia

Medical record review of a Discharge Summary dated 9/6/2022 at 5:42 PM showed the patient was discharged home in stable condition. Her workup during her admission showed pneumonia, hypocalcemia (low Calcium blood levels), acute kidney injury, and hyponatremia (low Sodium blood levels). She was treated with Intravenous (IV) fluids and IV antibiotics.

During a telephone interview on 9/13/2022 at 10:10 AM, the patient's family member stated the patient had called her and told her she was having shortness of breath and pain in between her shoulder blades. She had called EMS and had the patient transported to Facility A's ED. She stated "...I had spoken with another physician who I work with and he told me the patient needed to go to the ED and have a chest x-ray. She had COVID 19 two weeks ago and was given medications to treat that. She has history of MRSA in the lungs. All I wanted was a chest x-ray and they did not do anything for her. I took her to [Facility B] and she was diagnosed with right lower lobe pneumonia..."

During an interview on 9/13/2022 at 11:40 AM the Chief Clinical Officer stated he was made aware of the complaints by the ED Nurse on 9/1/2022 by telephone. He had spoken with the [named family member] on the phone the next day, the family member wanted a chest x-ray and blood work done and nothing was done. The patient had been taken to another acute care facility on 9/2/2022. He stated "...I spoke with the ED physician about the patient's care and he stated the patient had clear bilateral breath sounds, her vital signs were stable, and her presentation did not warrant a chest x-ray..." He confirmed there was no diagnostic testing ordered or completed for the patient.

During an interview on 9/13/2022 at 1:35 PM, ED Physician #1 stated he evaluated the patient on 9/1/2022. The patient presented with 'very vague symptoms to her neck which did not hurt all the time but when it hurt it was 10/10'. He stated "...when she presented she denied any pain, no shortness of breath, and her pulse oximetry was stable. Her lungs were clear bilaterally. Her vital signs were stable. She had no fever, no tachypnea [increased respirations], she was not tachycardiac [elevated heart rate]...I did not think a chest x-ray was indicated at that time and did not feel lab diagnostic testing was warranted at that time. I discussed this with the patient and her discharge plan. The nurse did tell me the family wanted to speak with me and I told them I would talk with the family as soon as I saw other patients in the ED. They left before I could get out there to talk to them. She had previously been diagnosed with COVID 19 but she had no cough and did not report any productive cough..."

During a telephone interview on 9/13/2022 at 1:50 PM, Registered Nurse (RN) #1, stated the patient's [family member] expressed concerns the patient had not received a chest x-ray while she was in the ED. She stated "...she had previously had COVID 19 with a nonproductive cough...the nurse had spoken with the [family member]...she wanted to know why a chest x-ray was not completed as that is why she had sent the patient to the ED....we had spoken with the ED Physician, and he said he had seen the patient and she did not need a chest x-ray, and he was discharging the patient home...we told her the physician had seen the patient and had deemed a chest x-ray was not needed related to her lungs were clear bilaterally and her oxygen saturations were normal. The [family member] was insistent that a chest x-ray be completed..."

During a telephone interview on 9/13/2022 at 2:10 PM, RN #2 stated the patient did complain of pain to her shoulder with movement. She stated "...the [named family member] asked questions related to 'did the patient get a chest x-ray or labs' and I told her the patient did not. The ED physician had evaluated the patient and did not order any diagnostic testing,..she was very upset...we did talk to the ED Physician and he stated he had evaluated the patient and did not feel a chest x-ray was warranted...the patient had a nonproductive cough..."

During a telephone interview on 9/14/2022 at 2:05 PM, ED Physician #2 stated the patient presented with shoulder pain. The patient did not complain or shortness of breath or chest pain. She had tested positive for COVID 19 on 8/23/2022 and been treated by a PCP on an outpatient basis. ED Physician #2 stated "...her lungs were clear and her vital signs were stable with oxygen saturations normal on room air...the ED Physician did not obtain laboratory or radiology diagnostic testing..."