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Based on a review of documents, policies, medical records, and staff interviews, the hospital failed to enforce its EMTALA policies to ensure staff provided a proper medical screening exam for 1 of 25 sampled patients who presented in the Emergency Department (ED) of the hospital on June 20 2015 with an emergency medical condition (Patient #15).

Failure to ensure the ED staff provided an appropriate medical screening exam for each patient requesting emergency medical care in the ED in accordance with the hospital ' s EMTALA policy could potentially result in delay in patient treatment, harm and/or poor outcomes for patients.

Findings include:

1. Review of the hospital policy titled, "EMTALA" review date 5/15, revealed the following in part, " ...if an individual comes to the Emergency Department the hospital will provide an appropriate medical screening examination within the capability of the Hospital's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department...the examination will be conducted by an individual(s) determined qualified by Hospital Bylaws or rules and regulations...the hospital will provide an individual with an emergency medical condition such further medical examination and treatment as required to stabilize the emergency medical condition...an emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain)...serious impairment to bodily functions or serious dysfunction of any bodily organ or part...If after an initial medical screening examination, a physician or Qualified Medical Person determines that the individual requires the services of an on-call physician, the on-call physician will be contacted...the on-call physician shall not refuse to respond to a call on the basis of...preexisting medical condition...the hospital shall maintain an on-call list of physicians including specialists who are available to examine and treat an individual with an emergency medical condition. The obligations of on-call physicians are set forth in...Exhibit G ... "

Review of "Exhibit G" titled, "Physician On-call Coverage" revealed in part, " ...A physician on the facility's roster of physicians on-call to the Emergency Department has a legal obligation under EMTALA to come to the facility to provide assistance with the medical screening exam, emergency and/or stabilizing treatment for a patient when requested by the emergency room physician...the on-call physician must provide medical services to the ED patient within the full scope of their current hospital privileges ... "

Refer to A 2407 for additional information concerning the medical screening examination of Patient #15.

Based on review of hospital documents, medical records, patient and staff interviews, the hospital failed to ensure Patient #15 received further examination and stabilizing treatment for his emergency medical condition prior to transfer. The investigation involved review of the Emergency Department medical records for 25 sampled patients who presented to the ED for an emergency medical condition from March of 2015 through June 29, 2015.

Failure to ensure Patient #15 received further examination and stabilizing treatment within the scope of services available at Mercy Medical Center placed the patient at extreme risk of suffering lasting bowel, bladder, and sexual dysfunction, and paralysis of the lower extremities.

Findings Include:

1. Review of the document titled, "Services and Treatment Offered at Mercy Neurosurgery" included in part, " ...Mercy treats and consults on the following disorders and medical issues...herniated discs...Neurosurgery services...discectomy...laminectomy ... "

Review of the document titled, "Amended and Restated By-Laws" dated 4/23/14, included in part, " ...Each Practitioner shall have appropriate authority and responsibility for the care of his or her patients, subject to the scope of his or her licensure and clinical privileges, as delineated by the Board of Directors...the Medical Staff Executive Committee shall make recommendations to the Board of Directors concerning...appointing...Medical Staff membership...granting...clinical privileges ..."

Review of the document titled, "Medical Staff By-Laws" dated 2/26/15, included in part, " ...Mercy Medical Center - Des Moines and Mercy West Lakes...are governed by a single Board of Directors...clinical privileges...the permission granted to a Medical Staff Member or practitioner to render specific services to patients...each member of the Medical Staff will...provide his/her patients with care at the generally recognized professional level of quality and efficiency established by the Medical Staff...prepare and complete...the Medical record...for all patients the physician...in any way provides care to...assist the Hospitals in fulfilling Federal regulations for EMTALA for emergency medical screening and stabilization of patients...providing emergent/urgent care...for which he/she is responsible by virtue of his/her clinical specialty ..."

"...request for consultation...the attending physician requests consultation from another credentialed Member of the medical staff to...render an opinion, seek advice regarding a specific condition, consult and manage care of specific aspect of care until resolved...the ED physician will only contact consultants...at the discretion of the admitting/attending physician with the exception of emergent conditions...the consultant provides the level of assistance as requested by the attending physician...a written progress note and consultation form is included in the medical record..."

2. Review of the closed medical record showed Patient #15 presented to the ED by ambulance on 6/20/15 at 5:01 PM complaining of back pain that had worsened over the past 5 - 6 days. At 6:06 PM, ED physician D examined Patient #15 and documented the patient had decreased sensation in his left lower extremity up to the med-thigh and decreased sensation in the right lower extremity up to approximately the knee. At 7:50 PM patient #15 underwent an MRI (special imaging study that creates detailed images of the body structures and organs) which showed a large rupture of the disc (cushion between the vertebrae) in the lower spine. ED physician D diagnosed patient #15 with acute cauda equina syndrome (an emergency medical condition requiring surgery to relieve pressure to the nerves at the lower end of the spine in order to prevent permanent incontinence, sexual dysfunction, and leg paralysis). Further documentation showed the on call neurosurgeon declined to perform surgery because the hospital did not have the tools needed for the surgery given the patient's weight. At 10:28 PM patient #15 was transferred to Hospital B by ambulance to receive surgical stabilizing treatment for his emergency medical condition.

The medical record did not contain evidence that the on call neurosurgeon came to the ED to provide further examination or treatment to stabilize patient #15's emergency medical condition or that the hospital laced the necessary capabilities to stabilize the patient's surgical emergency.

3.. During an interview on 6/29/15 at 12:30 PM, Patient #15 reported he had severe back pain and was unable to get out of bed on 6/20/15. The patient stated he called an ambulance and was transferred to Mercy Medical Center ED. The patient stated his physician told him after the MRI test he would be transferred to a different hospital for back surgery because of his weight.

4. During an interview on 6/30/15 at 7:40 AM, ED Registered Nurse (RN) U said she was Patient #15's primary nurse on 6/20/15. She said ED Physician D ordered an MRI at 5:53 PM that day but there was a delay of approximately 3 hours in the MRI being completed. Nurse U said the results of the MRI did not return until 9:00 PM. Nurse U reported the patient had not urinated from the time he presented to the ED to the time he was transferred to Hospital B. Nurse U stated on 6/20/15 she did not get the patient up to walk, the patient pretty much stayed on his back and there were two of us that helped him shift side to side for comfort. Nurse U stated Patient #15 had decreased sensation and numbness to his lower extremities and that those symptoms continued throughout the time he was in the ED. Nurse U stated the pain medication she gave the patient didn't fully take away his pain but she felt it was tolerable for the patient.

5. During an interview on 6/30/15 at 2:55 PM, ED physician D stated the physician assistant (PA) for the on call neurosurgeon called and said Patient #15 had to be transferred because the hospital didn't have bariatric equipment to perform the surgery. ED physician D stated, "I know we have operated on bigger patients but maybe not for that (particular) surgery." ED physician D stated she was surprised by the on call PA's response and when she contacted Hospital B, the physician who agreed to accept the transfer was surprised as well.

6. During an interview on 6/30/15 at 3:45 PM, PA N (the on call Physician Assistant for the neurosurgeon group) stated he received report from Practitioner M, ARNP, on 6/20/15 at 7:00 PM, regarding a pending MRI test for a patient in the ER with decreased rectal tone, numbness and tingling of the lower extremities. PA N stated at approximately 9:00 PM before he went to bed he viewed Patient #15's MRI on the PAC system (picture archiving and communication system) on his home computer. PA N stated the MRI films revealed a large herniated disc compressed on the patient's nerve roots. PA N stated he agreed with the ED physician, the patient had cauda equina syndrome. When asked, PA N stated that cauda equina syndrome "Is an emergent situation because if you don't take it (herniated disc) out within 24 hours they can lose ability to walk ...bowel and bladder can lose function all together." PA stated the 24 hours begins with the onset of the symptoms. When asked if PA N knew when Patient #15 symptoms began, PA N stated, " No." PA N stated he did not go to the hospital and physically examine the patient.

7. During an interview on 7/1/15 at 7:30 AM, Neurosurgeon C confirmed he was the on-call neurosurgeon on 6/20/15. Neurosurgeon C stated he was contacted by PA N to look at MRI results for Patient #15. Neurosurgeon C stated he observed a large disc herniation at L3-L4 (near the end of the spinal column) compressing on the patient's nerve roots. Neurosurgeon C stated he discussed the MRI findings with PA N and did not contact ED physician D regarding the care and treatment of Patient #15. When asked if he evaluated Patient #15 in the ED, Neurosurgeon C stated he did not. Neurosurgeon C stated he did not view any medical information other than the MRI results, because they did not have the equipment at their hospital to perform a minimally invasive discectomy procedure and he did not fell comfortable performing an open discectomy so he chose to send the patient to someone that does it more often. Neurosurgeon C stated he performs the minimally invasive procedures for laminectomy/discectomy because patients go home the same day and have a less risk of complications. When asked if the neurosurgical group was aware that he would not perform an open procedure in an emergent situation, he stated, "I do open cases. We're talking about one surgical procedure and that's the way I do it." Neurosurgeon C confirmed he was credentialed to perform open and closed laminectomies, discectomy surgery on the vertebral/spinal column.

8. Review of Neurosurgeon C's credential file revealed on 6/22/14 the Medical Staff and Governing Board privileged him for the following procedures including but not limited to : laminectomies, fixation and reconstruction of the spine and its contents, surgery for intervertebral disc disease and surgery of the sympathetic nervous system.

9. During an interview on 7/1/15 at 9:45 AM, Chief of Physician's Officer A, acknowledged Neurosurgeon C had privileges for all core neurological procedures including but not limited open and minimally invasive discectomy and lumbar decompression. Practitioner A acknowledged their hospital had the capacity and capability to perform an open laminectomy and discectomy for Patient #15.

10. During an interview on 6/30/15 at 10:50 AM, RN/Administrative Director, Perioperative services reported the laminectomy/discectomy surgical procedures are common and performed regularly at Mercy Medical Center Hospital. She said the neurosurgeons completed 135 Laminectomy, Thoraco/lumbar discectomy with decompression surgeries in their Operating Room (OR) in the past 6 months.

11. During an interview on 6/30/15 at 11:10 AM, Surgical Lead RN K said the operating room (OR) at Mercy Medical Center was equipped to complete surgical procedures for patients up to 500 pounds. RN K reported on the afternoon and evening of 6/20/15 between the hours of 3:00 PM and 11:00 PM there were 2 surgical cases performed in the total of 17 available OR suites at Mercy Medical Center Hospital. In addition, the 4 OR suites normally dedicated for back/spine procedures were not used for the 2 surgical cases and were available.

12. Review of documents titled, "Operative Reports" revealed neurosurgeon C performed 32 Lumbar Laminectomy/Discectomy Surgical Procedures from 1/5/15 through 6/29/15 as follows:

a. One open procedure, 12 minimal invasive procedures, and 20 cases were not specified whether the procedure was open or minimally invasive.

b. 10 of 33 patients weighted 200 pounds or greater. Three of the 33 patients weighted 300 pounds or greater.