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Based on policy review,Medical Staff Rules and Regulations, medical record review and staff and physician interviews, the hospital failed to comply with 42 CFR §489.24.

The findings included:

1. The hospital failed to provide a thorough medical screening examination, including ancillary services routinely available, to determine whether an emergency medical condition existed for three (3) of 28 patients reviewed (Patient #4, Patient #6, and Patient #21)..

~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406.

2. The hospital staff failed to provide stabilizing treatment within the capability of the hospital's Dedicated Emergency Department (DED) for one (1) of 28 sampled Dedicated Emergency Department patients (Patient #6).

~ Cross refer to §489.24(d)(1-3) Stabilizing Treatment - Tag A2407.

Based on policy review, review of the dedicated emergency department (DED) log, review of the canceled list and staff interviews, the hospital failed to accurately document on its DED central log all patients that presented to the hospital's DED for treatment.

The findings included:

Review on 04/30/2025 of the hospital's "EMTALA Policy" last revised 01/2024 revealed "... The hospital will maintain a central log of individuals presenting to the emergency department seeking assistance. The log will contain at minimum patient name, mode of arrival, date, and discharge disposition. ..."

Review on 04/29/2025 of the DED Logs for dates October 2024 through April 26, 2025, were printed and received. During review of the logs the disposition was noted to be discharge, left without treatment (LWOT), eloped, against medical advice (AMA), admitted, transferred, and arrived in error. In further inquiry in the "arrived in error" disposition, it was learned that some patients that present to the ED either request to leave before being seen or they are in the wrong location looking for radiology or the laboratory. In these cases, the patients are canceled out of the ED visit.

Review on 04/30/2025 of the list of the "canceled" patients for the time period October 2024 through April 26, 2025, revealed 80 patients had been canceled out of their visits. Of those 80 patients, 52 were patients that had a reason for requesting to be seen in the ED, 12 patients arrived in error; meaning they had radiology or laboratory appointments, 2 patients were medical records that needed to be merged together, 9 patients were labeled as "test" patient, and 5 patients were duplicated on the list. The two logs were compared and the 80 patients on the canceled list were not on the DED EMTALA Log presented.

Interview on 04/29/2025 at 1458 with Patient Access (PAS) #10 and PAS #11 revealed the patient comes to the emergency department and gets registered. The patient is added to the tracking board and asked to sit in the lobby. When the patient decides to leave prior to triage and they tell the patient access staff at the registration desk, the patient access staff cancels the appointment which removes the patient off the tracker board. PAS #10 and PAS #11 were unsure if the patient once canceled appears on the DED EMTALA log.

Interview on 04/30/2025 at 1313 with Director #12 revealed patients that are on the cancellation list are not on the DED EMTALA Log. Staff are working on it currently and those patients are being put on the log now and going forward all patients that present to the ED will be on the log. Education has gone out to the staff. Monitoring of the change has been going on since the education has gone out.

Review of the education sent out via email on 04/29/2025 at 1917 revealed a new process for removing patients from the ED Tracker Board. The new process was effective immediately.

Based on policy review, medical record review and staff and physician interviews, the hospital failed to provide a thorough medical screening examination, including ancillary services routinely available, to determine whether an emergency medical condition existed for 3 of 28 patients reviewed (Patient #4, Patient #6, and Patient #21).

The findings included:

Review of the hospital's EMTALA Policy last revised 01/2024 revealed " ... provide to any individual who is not a patient of the hospital and who 'comes to the emergency department' an appropriate medical screening evaluation within the capability of the hospital's emergency department to determine whether an Emergency Medical Condition is determined to exist ... ."

1. Medical record review on 04/30/2025 revealed Patient #4, a 34-year-old, arrived to the hospital on 11/29/2024 at 0042. The arrival complaint was "vomiting." Review of triage revealed "...PT REPORTS THAT SHE HAS BEEN VOMITING FOR X 3 DAYS AND HAS NOT BEEN ABLE TO EAT." Review of the ED Provider Note, at 0143, revealed "... comes in with nausea and vomiting of 3 days duration, unable to keep any fluids down....Medical Decision Making....patient will be given IV fluids and medicines for the nausea and be reevaluated ....Patient also states ....has had a therapeutic abortion by taking medications about 4 days ago. ..." Record review revealed Patient #4 received fluids and medications for pain and nausea and departed the ED at 0702 with a diagnosis of nausea and vomiting unspecified. Although there was mention in the provider note of an abortion 4 days ago, no evidence was found that an ultrasound was done or whether the patient was evaluated for bleeding.

Telephone interview with MD #13, on 05/01/2025 at 0923, revealed if the patient's complaints were about a lot of pain or vaginal bleeding it would have changed the approach. Interview revealed the patient's labs were okay, vital signs were reviewed and Patient #4 was not tachycardic, so based on what the physician saw, Patient #4 was stable for discharge. Bleeding with some pain was to be expected as long as it was not excessive and passing clots.

Record review revealed Patient #4 returned to the ED on 11/30/2024 at 1432. Review of the ED Care Timeline at 1433 revealed an updated complaint of "Vaginal Bleeding." The Triage Note at 1442 indicated "Pt states that she had an abortion 4 days ago and is still having vaginal bleeding and N/V (nausea, vomiting), Pt was seen here two days ago for the same thing and sent home with nausea meds. She states that she wants someone to tell her why she is still bleeding. She called her phys (physician) .... and they told her to come to the ER." Review of the ED Provider Note, at 1617, revealed "......PMH (past medical history)...HERE FOR INTERMITTENT VAGINAL BLEEDING X 2 DAYS S/P (status post) ELECTIVE ABORTION. PT. STATES SHE WAS TOLD SHE WILL HAVE BLEEDING BUT SHE WAS NOT SURE IF SHE IS BLEEDING TOO MUCH OR NOT.... PT. HAS CHANGED 7 PADS SINCE 8 AM TODAY. ..." A Review of Systems indicated "....Genitourinary: Positive for pelvic pain and vaginal bleeding. ..." The Physical Exam indicated "...Abdominal: General: Abdomen is flat. Palpations: Abdomen is soft. ..." At 1624 the disposition was selected, "ED Disposition set to Home." The ED Care Timeline noted an ED Note at 1700 which indicated "PA (Name) informed that the patient was refusing to leave, Spoken by PA (Name) and patient decided to go to other facility." Record review did not reveal any documentation of a genitourinary exam, of the amount of bleeding observed in the hospital or of a vaginal ultrasound being performed.

Interview on 05/01/2025 at 1305 with PA #14 revealed the PA reviewed the notes and recalled Patient #4. Patient #4 came in with vaginal bleeding. The PA got blood work and the Quant HCG was at an expected level. PA #14 stated Patient #4 said she had changed 7 pads since the morning, which was not a lot over that timeframe. Interview revealed if the patient said "soaked" through the pads, that would have been documented that "soaked" was a key word. PA #14 stated he examined the patient's abdomen and it was not tender. PA #14 indicated he did not do a pelvic exam because she told him her bleeding was not excessive and blood work and vital signs were good. Further, the HCG quant (blood test) was expected to be high, and Patient #4 said she had an appointment for follow-up with OB in 48 hours. "There was no need for a pelvic ultrasound," the PA stated, "she was very stable." Related to the patient not wanting to leave the ED, PA #14 indicated she wanted to know why she was still bleeding and was told "that was expected." The patient started to get loud and said she would go somewhere else, interview revealed.

Interview with MD #17, on 05/01/2025 at 1340, revealed MD #17 was the attending ED physician on the day of Patient #4's second visit. The interview revealed he heard about the case after the fact by the PA. The PA stated he went back to try and talk with Patient #4 but she stated she was leaving. MD #17 indicated the patient's vital signs were stable, she had capacity to decide and was told to go see OB/GYN. Interview revealed outpatient follow-up felt reasonable.

DED record review revealed Patient #4 returned to the Emergency Department again on 12/03/2024 at 0103 and was admitted, received antibiotics, a D&C (surgical procedure) and blood transfusion.



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2. Closed medical record review on 04/30/2025 for Patient #6 revealed a 62-year-old male that presented to the DED on 03/02/2025 at 0844 with a chief complaint of "Gout". The Nursing Triage note at 0850 revealed "Leg Pain (Pt [patient] c/o [complain of] left lower leg pain since Thursday night. Pt stated 'It is a gout flare up. I have them every now and again.')" Patient #6 was discharged home ambulatory at 1113 with an e-script (prescription sent electronically) for Prednisone (steroid medication) 20 mg tablets and Tramadol (pain medication) 50 mg tablets. Review of the ED Provider Note documented at 1122 revealed "... here for left ankle gout exacerbation with hx (history) of same. He denies trauma or calf pain. ... Medical Decision Making Here for gout flare up. Dx (diagnosis). Gout of left ankle Dc (discharge) home w. rx (with prescription) ED COURSE Clinical Impressions Acute idiopathic gout of left ankle ..."

Review of the medical screening exam failed to reveal documentation of which limb or joint was tender, no documentation of the presence or absence of joint effusion, edema, warmth, induration, crepitus or assessment of pulses.

Request to interview the Medical Provider involved in Patient #6's care during this visit revealed they were not available for interview.

Request to interview the Registered Nurse (RN) who triaged Patient #6 and the Discharging Nurse for Patient #6 revealed they were not available for interview.

Interview on 05/01/2025 at 1027 with Medical Doctor (MD) #2 revealed he was the Emergency Department Medical Director and he was not involved with the care for Patient #6. Interview revealed if a patient who is diabetic comes in with a foot injury/problem, the patient would be registered, then triaged. During the triage MD#2 would expect the nurse to test the patient's blood sugar, assess the foot pain/injury, and verify pulses in the extremity. Protocol orders can be used for example if the injury can use the pain order set. Once the patient gets into a room in the ED, expect the nurse to put the patient on a monitor depending on what the patient complained of. The provider would assess the patient, order any radiology, immunizations or medications as needed (i.e.: tetanus and antibiotics). If a patient returns to the ED after being seen recently, the patient would be seen. "A day later would be too early to see an improvement, however certainly we would see the patient."

3. DED Logs for dates October 2024 through April 26, 2025 were received and reviewed on April 29, 2025. Patient #21 was listed on the DED Log with an arrival date and time of 04/20/2025 at 2234 and a disposition date and time of 04/21/2025 at 1428. The disposition was "Arrived in Error".

Closed medical record review on 05/01/2025 for Patient #21 revealed an 11-year-old male that presented to the DED on 04/20/2025 at 2234 with a chief complaint of "behavioral, psych". Review of the ED Care Timeline at 2245 revealed documentation by the Registration staff that Patient #21 was "dismissed". Review of the medical record failed to have an AMA (against medical advice)form or a note to show a reason Patient #21 left the ED before being evaluated and having a medical screening exam performed. Review of the ED record revealed Patient #21 had no triage, vital signs, or history and physical examination completed.

Interview on 04/30/2025 at 1549 with Medic #13 revealed he looks at the log the next day to verify the disposition was entered and entered correctly. If the disposition is missing, Medic #13 enters the disposition. If the disposition is wrong, Medic #13 changes the disposition to the correct disposition. Medic #13 did not remember Patient #21, he changed or corrected the disposition when he did his review of the log. Interview revealed Medic #13 looks at the logs and makes changes or corrections to the disposition after the patients have left.

Interview on 05/01/2025 at 1335 with a Hospital Police Officer (HP) #5 revealed he "kind of" remembered Patient #21. HP #5 talked with the female, Patient #21's "aunt maybe", that brought the patient in. Per the female she was told by WCD (County Deputy) #9 to bring the patient here because the patient tried to set fire to the house. HP #5 asked the female why she did not get IVC (involuntary commitment) papers prior to coming to the hospital. HP #5 explained the IVC papers would give the facility "more authority to hold the kid here".

Interview on 05/01/2025 at 1630 with a Registered Nurse (RN) #8 revealed she did not remember Patient #21. Interview revealed she would have the patient sign an AMA form if they wanted to leave and if the patient refused to sign the form, she would have a second witness and put a note in the medical record.

Based on hospital's policy, medical record reviews and staff interviews, hospital staff failed to provide stabilizing treatment within the capability of the hospital's Dedicated Emergency Department (DED) for one (1) of 28 sampled Dedicated Emergency Department patients (Patient #6).

The findings included:

Review on 04/30/2025 of the hospital's "EMTALA Policy" last revised 01/2024 revealed "... provide to any individual who is not a patient of the hospital and who 'comes to the emergency department' an appropriate medical screening evaluation within the capability of the hospital's emergency department to determine whether an Emergency Medical Condition exists. ...If an Emergency Medical Condition is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer. ..."

Closed medical record review on 04/30/2025 for Patient #6 revealed a 62-year-old male that presented to the DED on 03/05/2025 at 1816 with a chief complaint of "foot pain". The Nursing Triage note at 1823 revealed "PT (patient) REPORTS THAT HE STEPPED ON A NAIL ON HIS LEFT FOOT LAST NIGHT THROUGH HIS SHOE. PT IS NO (sic) UP TO DATE ON HIS TETANUS". Review of the ED Care Timeline at 1824 revealed the chief complaint was updated to "Foot injury (STEPPED ON NAIL LAST NIGHT)." Patient #6's left foot x-ray resulted at 1926 revealed "Impression: Normal left foot." Patient #6 was administered the tetanus vaccine at 1926. Review of the ED Care Timeline at 1949 revealed "ED Disposition set to Home." Patient #6 was administered ciprofloxacin 500 mg by mouth at 1959. Review of the ED Provider Note documented at 2018 revealed "62-year-old male patient with a history of hypertension (high blood pressure), diabetes (high blood sugar), COPD (chronic obstructed pulmonary disease - lung disease ), asthma (condition where your airways narrow and swell and my produce extra mucus), sleep apnea (breathing stops and starts during sleep) and gout (a form of arthritis that causes pain and swelling in your joints mostly your big toe) presents to the ED with a chief complaint of stepping on a nail through his shoe. Unsure of his last tetanus. Onset- 3/5/25 Location- left foot ... Characteristics- left foot injury ... Review of Systems ... Musculoskeletal: Negative for arthralgias (xxx), back pain, gait problem, joint swelling, myalgias, neck pain and neck stiffness. Left foot injury ... Physical Exam ... Skin ... Comments: Puncture wound to bottom of foot. ... ED COURSE Clinical Impressions Puncture wound of left foot, initial encounter Xray neg. (negative) Given tetanus, pain meds (medications) and ABT (antibiotics) Follow up with wound center. DIAGNOSIS: 1. Puncture wound of left foot, initial encounter ... MEDICATIONS: ... START taking these medications ciprofloxacin (CIPRO) 500 mg Oral Tablet Details Take 1 Tablet by mouth twice a day for 7 days., Disp (dispense)-14 Tablet ..." Patient #6 was discharged home at 2123.

Review failed to reveal evidence of irrigation or cleaning of the left foot puncture wound prior to Patient #6 leaving the ED.

Request to interview the Medical Provider involved in Patient #6's care during the second visit revealed they were not available for interview.

Interview on 04/30/2025 at 1738 with Nurse Practitioner (NP) #1 revealed she could not remember Patient #6. In reviewing the medical record NP #1 recalled Patient #6 came in complaining he had stepped on a nail the night before. He had x-rays of his foot and they were normal. Patient #6 was given a tetanus booster shot and the first dose of antibiotic prior to discharge. Patient #6 was instructed to follow up with the wound clinic to keep a close watch on the wound on his foot.

Interview on 05/01/2025 at 1027 with Medical Doctor (MD) #2 revealed he was the Emergency Department Medical Director and he was not involved with the care for Patient #6. Interview revealed if a patient who is diabetic comes in with a foot injury/problem, the patient would be registered, then triaged. During the triage MD#2 would expect the nurse to test the patient's blood sugar, assess the foot pain/injury, and verify pulses in the extremity. Protocol orders can be used for example if the injury can use the pain order set. Once the patient gets into a room in the ED, expect the nurse to put the patient on a monitor depending on what the patient complained of. The provider would assess the patient, order any radiology, immunizations or medications as needed (i.e.: tetanus and antibiotics).