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Based on interview and record review, the hospital was not in compliance with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases, in that, 1 of 1 patient (Patient #1) was not provided a complete medical screening exam and appropriate transfer.

Cross Refer to Tags 2406 and 2409

Based on interview and record review, the physician (Physician #4) did not provide a complete medical screening exam for 1 of 1 patient (Patient #1) who presented in the emergency department for difficulty breathing on 11/13/22. The hospital did not provide within its capabilities, including ancillary services routinely available and consultations by on-call specialist physicians an appropriate medical screening examination that was, within reasonable clinical certainty, sufficient to determine whether or not an Emergency Medical Condition existed.

Findings included:

Patient #1 was a 9-month-old male patient who presented in the emergency department (ED) on 11/13/23. At 04:50 the patient was triaged by Personnel #5 and noted the reason for visit was mother stated "I'm worried about his breathing." "Objective assessment: Patient #1 SOB (shortness of breath) with AB (abdominal) retractions. Congestion noted." "Chief Complaint: Respiratory. Priority: 2:2." At 05:05 Presenting signs/symptoms: "SOB. Congestion. Nasal flaring. Respirations even and unlabored: No. Respiratory effort and pattern: Mod. intercostal retractions."

11/13/22 at 05:03 Physician #4 noted "9m male no pmhx (past medical history), vaccination up to date, brought by mother with congestion and difficulty breathing. No fever reported, no direct sick contacts. He was admitted to the ICU in Hospital B last month with respiratory distress from rhinovirus, never intubated but required supplemental oxygen. Patient #1 was discharged about three weeks ago and was doing well at home until tonight."

"Review of Systems...Respiratory: Reports: Cough, Problem breathing, Shortness of breath. Denies: Apnea, Grunting." "Focused Physical Examination...Respiratory distress moderate, Stridor mild...Wheezing/Retractions. Retractions moderate, Supracostal retractions...Cardiovascular. Heart Rate/Rhythm. Tachycardia."

Re-Evaluation & MDM. "Re-Evaluation/Progress. Child has noticeable retractions and is tachypneic, but without severe distress. No retractions and does not show signs of fatigue. Discussed with mother, offered to attempt nebulizer treatments, and suctioning here and call for transfer - but Hospital B is likely not accepting patients..." "Disposition Decision. Discharged to Home Yes. Time 0505. Date 11/13/22."

Patient #1 was not provided further workup. Patient #1 required observation, chest x-ray, and nebulizer treatments to assure respiratory status improved. History notes indicated Patient #1 had retractions and tachypnea, which at 9 months required further intervention/evaluation. Without immediate medical attention, serious impairment could result to bodily functions or serious dysfunction of any bodily organ or any part of an organ. Patient #1 left the ED prior to completion of MSE and appropriate treatment.

During an interview on 05/16/23 at 11:50 AM via phone call with Personnel #1 present in the interview, Physician #4 stated he wanted to get a chest x-ray and provide a nebulizer treatment. The mother refused. The mother told him Patient #1 was previously hospitalized at Hospital B about a month ago. The mother wanted to go back to Hospital B. Physician #4 was asked to clarify his notes about "Hospital B is likely not accepting patients." Physician #4 replied he earlier wanted to transfer a patient to Hospital B but was told they were at capacity. The physician was asked if he would provide oxygen therapy to a patient with SPO2 of 95% room air. The physician responded the baby was crying and fussy already, oxygen treatment was not provided..."

Policy and Procedure #PCS 208 "EMTALA-Texas Medical Screening Examination and Stabilization Policy" date reviewed 04/2022 page 2 required "V. Procedure: A. When a MSE is Required. A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED (dedicated emergency department), to determine whether or not an EMC exists...1. The individual comes to a DED of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition, including where: a. The individual requests medication to resolve or provide stabilizing treatment for a medical condition..."

Based on interview and record review, the physician (Physician #4) did not provide an appropriate transfer for 1 of 1 patient (Patient #1) who had difficulty breathing on 11/13/22. On 11/13/22 at 05:06 a nursing staff (Personnel #5) notified Physician #4 that the mother would "take the child (Patient #1) to Hospital B on her own." No attempt was made to transfer Patient #1 through the usual and customary process.

Findings included:

Patient #1 was a 9-month-old male patient who presented in the emergency department (ED) on 11/13/22. At 04:50 the patient was triaged by Personnel #5 and noted the reason for visit was mother stated "I'm worried about his breathing." "Objective assessment: Patient #1 SOB (shortness of breath) with AB (abdominal) retractions. Congestion noted." "Chief Complaint: Respiratory. Priority: 2:2." At 05:05 Presenting signs/symptoms: "SOB. Congestion. Nasal flaring. Respirations even and unlabored: No. Respiratory effort and pattern: Mod. intercostal retractions."

Physician #4 noted "Presentation. Chief complaint. Cough, wet, nasal congestion, nasal drainage, yellow...9m male...brought by mother with congestion and difficulty breathing. No fever reported, no direct sick contacts. He was admitted to the ICU (intensive care unit) at Hospital B last month with respiratory distress from rhinovirus, never intubated but required supplemental oxygen. Patient #1 was discharged about three weeks ago and was doing well at home until tonight." 11/13/22 04:50 Vital Signs. Pulse Ox: 95% O2 Delivery: Room air. Temperature 37.0 Centigrade. Pulse 161. Resp 32. Review of Vital Signs-Vital signs abnormal.

11/13/22 at 05:03 Review of Systems indicated "Constitutional: Reports: Crying more/fussy...Respiratory: Reports: Cough, Problem breathing, Shortness of breath." "Focused Physical Examination. Resp. distress moderate, Stridor mild...Wheezing/Retractions. Retractions moderate, Supracostal retractions...Cardiovascular. Heart Rate/Rhythm. Tachycardia..."

"Re-Evaluation/Progress. Patient #1 has noticeable retractions and is tachypneic, but without severe distress...Discussed with mother, offered to attempt nebulizer treatments, and suctioning here and call for transfer - but Hospital B likely not accepting patients. Her preference is to go to Hospital B by private vehicle, as he was admitted there recently....Clinical Impression. Primary Impression: Respiratory retractions."

11/13/22 05:06 Personnel #5 noted "Mother request to take child to Hospital B on her own. Physician #4 aware and will dc (discharge) patient..."

Disposition Decision. Discharged to Home Yes. Time 0505. Date 11/13/22.

No attempt was made to transfer Patient #1 through the usual and customary process. The patient was discharged, and the mother took Patient #1 directly to Hospital B via private vehicle. Physician #4 and staff were aware that the mother of Patient #1 intended to go to Hospital B after leaving Hospital A's ED. Hospital A did not attempt transfer process after medical provider and staff they had been told.

During an interview on 05/16/23 at 11:50 AM via phone call in the presence of Personnel #1. Physician #4 stated he wanted to get a chest x-ray and provide nebulizer treatment. The mother refused. The mother reported the infant was previously hospitalized at Hospital B about a month ago. The mother wanted to go back to Hospital B. The attending physician was asked to clarify his note about "Hospital B is likely not accepting patients." Physician #4 replied he earlier wanted to transfer a patient to Hospital B but was told they were at capacity.

Hospital B medical record of Patient #1 reflected the mother and patient arrived at Hospital B on 11/13/22 at 05:40. At 05:44 Vital Signs were Temp: 36.9 °C (98.4 °F). Temp Source: Temporal. Pulse: 176. Resp: 70. SpO2: 91%. At 04:45 Patient acuity was 2 and roomed in ED room exam 42 at 05:46. At 05:59 Vitals were reassessed. SpO2: 89% and oxygen therapy was initiated. Subsequently, at 07:56 "Disposition. Admit. Diagnosis: Acute respiratory distress..."

Policy and Procedure #PCS169 "EMTALA-Texas Transfer Policy of Patients Between
Hospital ..." Reviewed 04/2022 reflected "III. PURPOSE: To establish guidelines for either accepting an appropriate transfer from another facility or providing an appropriate transfer to another facility of an individual with an emergency medical condition ("EMC"), who requests or requires a transfer for further medical care and follow-up to a receiving facility as required by EMTALA, 42 U.S.C. § 1395dd, and all Federal regulations and interpretive guidelines promulgated thereunder."