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Based on medical record review, policy review, incident report review, ED log review, ED standards of care review, and staff 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 delayed ED care, ED patients not being documented on the hospital's ED log, negative outcomes, and life-threatening complications . Findings include:

Refer to A2401, as it relates to the failure of the hospital to report potential EMTALA violations.

Refer to A2405, as it relates to the failure of the hospital to ensure patients presenting to the hospital for emergency services were documented in their ED log.

Refer to A2406, as it relates to the failure of the hospital to ensure a medical screening examinations were performed within their capability.

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









A

Based on medical record review and staff interview, it was determined the hospital failed to report potential EMTALA violations for 2 of 3 patients (#12 and #16) who were transfers from a local acute hospital ED. This had the potential to delay emergency care for these patients. Findings included:

1. Patient #12 was an 80 year old female who presented at [local acute care hospital] ED on 2/26/23 for chest discomfort and shortness of breath. Patient #12 had an EKG performed and was then transferred to IFCH at 3:38 PM for further cardiac work up. A "Patient Transfer" record from sending hospital stated, "needs higher level of care ...Transported by: ALS". IFCH received Patient #12 via wheelchair with no cardiac monitor or oxygen. Patient #12 was discharged to home on 2/26/23 at 5:24 PM.

In an interview with the ED Manager on 10/31/23 beginning at 3:40 PM, the record of Patient #12 was reviewed. When the ED Manager was asked why Patient #12 transferred to IFCH, he stated, "there was no MD at [local acute care hospital ED], so MD here would review and anticipate a cardiology consult."

In an interview with Risk Management on 11/1/23 beginning at 3:52 PM, the record of Patient #12 was reviewed. The Risk Manager was asked if Patient #12 had been reported to the SA or CMS as an individual who had been transferred in an unstable EMC from another hospital, she replied, "no."

2. Patient #14 was a 41 year old female who presented at [local acute care hospital] ED on 3/2/23 at 4:26 AM with complaint of post-surgical abdominal pain. An abdominal CT scan was ordered by the ED provider. A note by sending ED provider stated, "I did speak with the CT scan at the neighboring facility who states that there will be a slight delay. Unfortunately patient quires[sic] high level of care and will be transferred to IFCH." It was unclear if the transfer was due to Patient #14's need for a higher level of care or need for a CT scan.

Patient #14 was transferred to IFCH on 3/2/23 and seen by the ED physician at 5:17 AM. A CT scan was performed, and Patient #14 was discharged to home later that day with antibiotics and a follow-up referral with a surgeon.

In an interview with Risk Management on 11/1/23 beginning at 3:52 PM, the record of Patient #14 was reviewed. The Risk Manager was asked if Patient #14 had been reported to the SA or CMS as an individual who had been transferred in an unstable EMC from another hospital, she replied, "no."

Based on policy review, incident reports, ED log review, and staff interview, it was determined the hospital failed to ensure patients presenting to the hospital for emergency services were documented in the ED log for 1 of 1 post-partum patient (Patient #8) who gave birth at home and whose record was reviewed. This caused a post-partum patient who presented to the hospital for emergency services not to be captured as presenting to the ED. Findings included:

A hospital policy titled, "Emergency Department Patient Log," approved 3/22 stated, "A patient log shall be maintained on each individual who comes to the Emergency Department." This policy was not followed.

Hospital incident reports from 5/1/23 to 10/30/23 were reviewed. One incident report dated 5/23/23, stated, "Pt was brought in by ems[sic] to IFCH ed[sic] after having her baby at home. Pt complaint was just giving birth bleeding and low platelets. Pt was in the ed[sic] and taken to (acute care hospital) labor and delivery was not seen by an ed[sic] physician for Medical screen."

The hospital's ED log from 4/28/23 to current was reviewed. It did not include Patient #8.

On 10/31/23 beginning at 3:25 PM the ED Nurse Manager was interviewed. He confirmed Patient #8 was not documented in the ED log.

Patient #8 presented to the hospital for emergency services but was not logged.

Based on policy review, incident reports, ED log review, staff interviews, and medical records review, it was determined the hospital failed to provide a medical screening examination within their capability for 2 of 24 patients (#8 and #9) who presented to the ED and whose records were reviewed. This had the potential for all patients presenting to the ED for emergency medical care at risk for negative outcomes. Findings included:

A hospital policy titled, "Emergency: EMTALA Guidelines For Emergency Department Services," approved 2/23 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. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic."

Additionally, the section of this policy titled "MEDICAL SCREENING EXAMS" stated, "Medical Screening Exams (MSEs) should include at a minimum the following:
Emergency Department Log entry, including disposition of patient
Patient's triage record
Vital signs
History
Physical exam of affected systems and potentially affected systems
Exam of known chronic conditions
Necessary testing to rule out emergency medical conditions
Notification and use of on-call staff to complete previously mentioned guidelines
Notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary
Vital signs upon discharge or transfer
Complete documentation of the medical screening exam."

This policy was not followed. Examples included:

1. Patient #8 was a 28 year old female who was brought into the ED by EMS after delivering a baby at home on 5/23/23.

A hospital incident report involving Patient #8 dated 5/23/23 was reviewed and stated, "pt was brought in by ems[sic] to IFCH ed after having her baby at home. Pt complaint was just giving birth bleeding and low platelets. Pt was in the ed[sic] and taken to [local acute care hospital] labor and delivery was not seen by an ed[sic] physician for Medical screen."

On 10/31/23 beginning at 3:25 PM, the ED Nurse Manager was interviewed, and he confirmed Patient #8 was not documented in the ED log, was not given an MSE, and the only documentation the hospital had of Patient #8 was the incident report.

2. Patient #9 was a 12 month old female who presented to the ED on 8/20/23 with a chief complaint of diarrhea for 4 days.

a. Patient #9 did not have a blood pressure documented as part of her MSE on the 8/20/23 ED visit.

Patient #9 presented to the ED again on 8/21/23. Patient #9's medical record included a note on 8/21/23 documented by an ED triage RN at 8:12 PM which stated, "[ED physician] told them to come back today for rehydrations (sic)." Patient #9 did not have a blood pressure documented on the 8/21/23 ED visit.

On 10/31/23 beginning at 2:50 PM the medical record for Patient #9 was reviewed with the ED Nurse Manager. The ED Nurse Manager confirmed that Patient #9 did not have a blood pressure documented as part of her MSE on 8/20/23 ED visit or on the 8/21/23 ED visit.

b. On 8/20/23, Patient #9 received IV fluids and was discharged home with the IV catheter still in place with instructions to return the next day for further evaluation. The on-call pediatrician was not notified or consulted.

Patient #9 presented to the ED again on 8/21/23 as instructed. The on-call pediatrician was not notified or consulted during this visit.

On 10/31/23 beginning at 2:50 PM the medical record for Patient #9 was reviewed with the ED Nurse Manager. The ED Nurse Manager confirmed the on-call Pediatrician was not consulted for Patient #9 on 8/20/23 ED visit nor on the 8/21/23 ED visit.

The hospital failed to provide complete medical screening examinations for Patients #8 and #9 within the capability of the hospital.

Based on policy review, ED standards of care, hospital incident reports, staff interviews, and medical records review, it was determined the hospital failed to provide stabilizing treatment for 1 of 1 pediatric patient (Patient #9) who was discharged from the hospital ED twice in 24-hours and whose record was reviewed. This failure put Patient #9 at risk for life-threating complications. Findings included:

A hospital policy dated 2/2023 titled, "Emergency: EMTALA Guidelines For Emergency Department Services" was reviewed. The policy 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. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic." Additionally, the policy stated, " ...Hospital may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of his/her medical condition, he/she is legally unstable as per EMTALA." This policy was not followed.

Patient #9 was a 12 month old female who presented to the ED with parents for a chief complaint of diarrhea for 4 days. Patient #9's medical record was reviewed for an ED visit on 8/20/23 at 9:54 PM. Patient #9's medical record included a note on 8/20/23 documented by an ED physician which stated, "Pt experiencing diarrhea x 4 days. Pt went to [local acute care hospital] yesterday and was diagnosed with EHEC. Went back today to [local acute care hospital], got labs and NS. Pt's parents stated that she threw up after and described 'blood' in vomit, as well as stool." Additionally, the ED Physician note stated, "She does appear mildly volume depleted. We have started an IV. IV fluids been given. The child does have an overall excellent clinical appearance. We will have the patient return with parents tomorrow for recheck. The IV has been left in and we can rehydrate at that time if necessary."

Patient #9's medical record documented she was discharged to home 2 hours later at 11:56 PM.

Patient #9 returned to the ED for second visit 20 hours later on 8/21/23.

Patient #9's medical record was reviewed for the second ED visit on 8/21/23 at 8:12 PM. Patient #9's medical record included a note on 8/21/23 documented by an ED triage RN at 8:12 PM which stated, "[ED physician] told them to come back today for rehydrations (sic)."

The ED note for the 8/21/23 visit was documented by a PA and stated, "This is her third trip to the emergency department for recheck as they have been instructed to keep close watch on this due to the risk of hemolytic uremic syndrome. Her mom reports that she will drink water, but nothing with any sugar or nutrients." Additionally, the ED note stated, "The patient present (sic) to the emergency department with her parents for mandatory recheck of dehydration and E. coli ...On exam she appears very tired. She is ill-appearing, but not toxic...she will be rechecked tomorrow morning ...IV was left in place for recheck."

Patient #9 was discharged at 12:15 AM, approximately 4 hours after ED admission.

An article, "Misconceptions Regarding Hemolytic Uremic Syndrome", was accessed via the website www.acep.org on 11/2/23 (American College of Emergency Physicians). The article, dated July 25,2023 stated, "Misconception 6: HUS can be managed in the outpatient setting. Fact: Children diagnosed with HUS should be transferred to a pediatric facility to be evaluated by a pediatric nephrologist and hospitalized. Management is supportive and includes intravenous (IV) fluid hydration, blood pressure management, red blood cell transfusions, and dialysis...Hospitalization and close monitoring for dialysis needs is mandatory."

A hospital incident report dated 8/21/23 was reviewed and stated, "Pt had a total of 4 ED admissions within 3 days. On 4th admission pediatric charge [RN] was called and asked to assist in gaining access/blood work. Upon assessment of pt, [Pedicatric charge RN] noted peripheral mottling, delayed capillary refill (4 seconds), and listlessness in the pt. An initial 20ml/bolus was running and pt family mentioned pt had been diagnosed with Shiga Toxin E.Coli. During IV start and blood obtainment, pt noted to have little to no fight. Once completed, [Pediatric charge RN] spoke with ED bedside RN who stated pt was most likely going to be admitted to the pediatric unit. [Pediatric charge RN] responded they would prepare a room and be ready for pt. [Pediatric charge RN] began to follow pt in preparation for admission. Once labs were resulted [Pediatric charge RN] called ED bedside RN to follow up on direction of pt care and suggested an additional 20ml/kg bolus, due to concern of HUS, shock, and renal injury. An additional 20ml/kg bolus was given. At this time, [Pediatric charge RN] was still anticipating admission for continued monitoring, resuscitation, and care. However, pt was then, shortly after, discharged home."

On 11/01/23 beginning at 9:40 AM, the Pediatric charge RN was interviewed about Patient #9. She confirmed she started an IV and was concerned about the lack of response from Patient #9. Pediatric charge RN also stated Patient #9, "didn't have any blood pressures taken in the ED [at IFCH]." The Pediatric charge RN stated she was anticipating Patient #9 being admitted either to the Pediatric floor or transferred to a hospital with a PICU. The Pediatric charge RN confirmed she called the Pediatrican on-call to notify of the possible pediatric floor admission.

On 11/01/23 beginning at 10:00 AM the Pediatrician on-call the evenings of Patient #9's ED visits (8/20/23 and 8/21/23) was interviewed. The Pediatrician confirmed Patient #9 should have been admitted to the hospital. The Pediatrician was unsure why she was not consulted on Patient #9. The Pediatrician confirmed Patient #9 had concerning lab values. She also stated, "If the ED discharges a kid with an IV ...just don't. If you are telling them to come back, just admit them to peds."

On 11/01/23 beginning at 1:45 PM a request was made by surveyors to interview the PA who discharged Patient #9 on 8/22/23. The PA was not available for interview.

On 11/01/23 beginning at 1:45 PM the ED physician for Patient #9 on 8/21/23 was interviewed via telephone. He was asked why Patient #9 was discharged with an IV. The ED Physician confirmed the reason for the IV was for possible hydration the next day. The ED Physician also confirmed he did not consult with the on-call Pediatrician.

Patient #9's ED provider note from the out of state hospital from 8/22/23 at 4:43 AM was reviewed. The record indicated Patient #9 was seen approximately 4 hours after being discharged from IFCH (the drive time is about 3 hrs and 10 min; 217 miles).

The ED physician note from the out of state hospital stated, "Patient is a previously healthy 12 month old female who presents for evaluation of STEC and lethargy. On 8/18/2023, patient developed diarrhea. The next day, parents noticed blood in the diarrhea. They took her into the primary care doctor who ran labs and diagnosed her with STEC. Over the next few days, patient went into the ER 4 times and received 3 different fluid boluses. Her status continued to worsen and she became increasingly lethargic. She has been intermittently febrile Tmax 100.8 F[Fahrenheit]. She began vomiting and had 1 episode of bloody emesis. She is no longer taking anything by mouth except water. Pediatric hospitalist noticed that the patient has been discharged after receiving fluid boluses without additional work-up multiple times and encouraged them to come to [out of state hospital] for work-up." Additionally, the ED Physician note stated, "Given lethargy with likely early HUS will admit to PICU." Patient #9 was discharged to home 9 days later.

The hospital failed to provide stabilizing treatment for Patient #9.