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Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare-participating hospitals in emergency cases as evidenced by:


A-2406: Medical Screening Examination

For 2 of 24 patients, the hospital failed to ensure there was documentation of continued monitoring based on the patient's needs. Patient #13 presented with a possible extremity infection. The provider ordered imaging; labwork and intravenous antibiotics during the initial Medical Screening Examination (MSE). The patient was sent back to the lobby to wait for an ED room. The patient left "AMA" (Against Medical Advice) from the lobby approximately four hours later with no documentation that the physician's orders were implemented or documentation of why the orders were not implemented. Patient #18 also received an initial MSE with lab work and imaging services ordered and the patient sent back to the waiting room. There were abnormal lab results including one "critical" result which was called to a Registered Nurse. The patient left "AMA" seven hours later from the waiting room without being notified of the abnormal results or documentation of continued monitoring.

Based on reviews of clinical records, policies and procedures, hospital documents, logs and records, and staff interviews, it was determined for 2 of 24 patients, the hospital failed to ensure there was documentation of an appropriate Medical Screening Exam (MSE) with continued monitoring based on the patient's needs. Patient #13 presented with a possible extremity infection. The provider ordered imaging; labwork and intravenous antibiotics during the initial Medical Screening Examination (MSE). The patient was sent back to the lobby to wait for a room in the Emergency Department (ED). The patient left "AMA" (Against Medical Advice) from the lobby approximately four hours later with no documentation that the physician's orders were implemented or documentation of why the orders were not implemented. Patient #18 also received an initial MSE with lab work and imaging services ordered during triage. The patient was sent back to the waiting room to wait for an ED room There were abnormal lab results including one "critical" result which was called to a Registered Nurse. The patient left "AMA" seven hours later from the waiting room without being notified of the abnormal results or documentation of continued monitoring.

The hospital's "Emergency Medical Treatment and Active Labor Act Policy" included: "Medical Screening Examination (MSE) is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists, or a woman is in labor...The MSE is an ongoing process, and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized, admitted to inpatient care, or appropriately transferred...."

The hospital's "Critical Result Reporting Policy" included: "...Definitions: Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate a life threatening situation."

Additional ED records were randomly selected for review related to the provision of medical screen examinations. Patient #13 presented to the ED on 02/02/2022 at 5:17 p.m. The patient was triaged by a Registered Nurse at 5:41 p.m. The patient was evaluated by a Physician's Assistant at 5:45 p.m. whose documentation included: "...(Patient #1) developed L-foot throbbing pain last night and woke up this morning with drainage...General malaise that started this morning. the L-foot has an open wound with purulent drainage between the interdigital space of the hallux and adjacent digit; the L-foot is erythematous with streaking up the anterior shin; the patient is TTP (tender to palpation) at the wound site...Patient declines pain medication at this time. Imaging, labs, and Abx (antibiotic) ordered...." The provider entered orders at 5:57 p.m. for an x-ray of the patient's left foot, lab-work; and intravenous antibiotics. The patient was documented by nursing staff to have left "AMA" (Against Medical Advice) at 10:15 p.m.. The patient refused to sign an AMA form, and there was no documentation of why the patient left. There was no reassessment of the patient nor was there documentation that the labwork or x-rays ordered by the PA as part of the MSE were obtained and no documentation that the IV antibiotics ordered by the PA were administered during the four hour period of time the patient was in the ED.

Patient #13's ED was reviewed with Staff #5 who acknowledged the physician's orders were not initiated.

Patient #18 presented to the ED on 11/9/2021 at 3:27 p.m. and triaged at 3:58 p.m. A Medical Screening Exam was started at 4:19 p.m. by a Physician's Assistant whose documentation included: "...Pt c/o (complained of) emesis x 1 week and rectal bleed also x 1 week; only blood when he wipes though pt then states he has been having diarrhea x 1 week with red tint. Rt groin hernia 5 years, reducible per pt; has not been evaluated in past. Also c/o abd pain Right sided, extending into Rt testicle...Performed an initial assessment of this patient. The patient cannot be roomed at the time of MSE due to lack of bed availability in the ED; the patient is awaiting room placement by the RN clinical manager of the ED. A comprehensive ED assessment and evaluation of this patient; including physical examination, analysis of all test results and completion of medical decision making, will be conducted by additional ED providers. The patient was instructed to inform ED staff of any changes in condition or symptoms while they are waiting to be roomed. If the patient decides to leave the ED before results are made available to them and/or before room is available (sic) for comprehensive assessment and evaluation of the patient, then the patient takes full responsibility for the consequences of this action. The patient has verbalized understanding of this discussion...." The above documentation starting with "Performed an initial assessment of this patient...." was found in multiple ED records and felt by hospital staff to fulfill the requirement for an MSE. The PA ordered lab work at 4:25 p.m. which included a Comprehensive Metabolic Profile (CMP). The blood was collected at 4:50 p.m. and resulted by the lab at 5:32 p.m. with the following results outside of the lab's established reference range:

-Potassium: Result 2.9 mEq/L - Reference Range: 3.7 - 5.9. This was documented to be a "critical" result with the following documented comments by the lab: "Results called (name), RN...at 11/09/2021 17:32:15 (5:32 p.m.) by (name) Tech and read back and verified by (name), RN...."
-Alkaline Phosphatase: Result 133 unit/L (High) - Reference Range 45-117
-AST: Result 59 unit/L (High) - Reference Range 15-37)
-Lipase - Result >1500 unit/L (High) - Reference Range 73-393. (Resulted at 7:36 p.m.)

There was no documentation that the RN who was notified by the lab of the critical Potassium level reported it to the ordering physician. Nursing documentation revealed the patient was discharged "AMA" on 11/10/2021 at 12:25 a.m. Documentation on the hospital's AMA form indicated the patient refused to sign it. A second of vital signs were obtained at 11:09 p.m., however, there was no documentation the patient was reassessed between the time critical result was reported to the RN, 5:32 p.m. on 11/9/2021, and when the nurse documented the patient left AMA, 12:25 a.m. on 11/10/2021, a period of approximately seven hours. There was documentation that the patient was notified of the critical and other abnormal lab results after he left.

Patient #18 returned to the ED on 11/11/2021 at 8:46 a.m. and was triaged at 8:59 a.m. with a chief complaint of: Abdominal pain for 2 days was here 2 days ago and left. Sharp righ (sic) flank. Goes into groin. Blood in urine since last night." The patient rated his pain level to be 9 out of 10. The initial MSE was documented at 9:21 a.m. and the ED physician's documentation included: "...Generalized abdominal pain, hematuria. Patient well appearing, mild generalized abdominal tenderness to palpation. He is hemodynamically stable at this time...Performed an initial assessment of this patient. A comprehensive ED assessment and evaluation of this patient, including analysis of all test results and completion of medical decision making, will be conducted by additional ED providers. The patient is awaiting room placement by the RN clinical manager of the ED. The patient cannot be roomed at time of MSE due to lack of bed availability in the ED. The patient was instructed to advise ED staff of any change in condition or symptoms. If the patient decides to leave the ED before results are made available to them that the patient takes full responsibility for the consequences of this action. The patient verbalized understanding of this discussion....." The patient was sent back to the lobby and then called back to a room in the ED at 11:05 a.m. The ED physician's documentation included: "...he is noted to have significantly elevated liver enzymes as well as a elevated lipase (of note the liver enzymes were only minimally elevated at his initial presentation 2 days ago whereas his lipase was significantly elevated at that time. Given the significantly elevated liver enzymes a liver injury work-up was started on him and his Tylenol level was noted to be elevated. I spoke with the patient and he reports taking a significant amount of Tylenol yesterday and the day before to try and treat his abdominal pain. For these reasons I am concerned that he has a toxic liver injury from the acetaminophen...I believe the patient would benefit from transfer to a facility that has hematology and potentially could do a liver transplant...." The patient was eventually accepted in transfer to another acute care hospital with those services.

Patient #18's ED record was reviewed with Staff #5, and she acknowledged there was no documentation that the critical potassium result documented on 11/9/2021 was reported to the physician nor documentation that the patient was notified after he left.

Medical Staff #1 reported during an interview on 03/02/2022 that it was the expectation for lab results to be monitored by the provider who ordered the lab work, imaging procedures, or other testing procedures. There was no policy or process provided that documented how results of lab work, imaging procedures, and/or other testing were acknowledged by the ordering provider(s) if a patient leaves prior to being roomed in the ED.

In summary, the hospital utilized a template to document that a Medical Screening Examination was performed during the initial triage of patients after presentation to the ED. Documentation in the template included a statement that there were no rooms available in the ED and that the patient would be sent back to the lobby to wait until there was an available bed. The documentation included: "... Performed an initial assessment of this patient. A comprehensive ED assessment and evaluation of this patient; including physical examination, analysis of all test results and completion of medical decision making, will be conducted by additional ED providers...." There was no documentation in the ED records for Patients #13 and #18 of continued monitoring based on the patient's needs following their policies and procedures.