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Based on record review of 36 sampled patient records, the facility failed to provide adequate Medical Screening Examination (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for Patient #12 on 8 occasions and failed to provide stabilizing treatment to Patient # 12 when the patient presented to the Emergency Department (ED) with an EMC on 2 occasions. The staff failed to follow policies and procedures related to provision of an adequate MSE and stabilizing treatment within their capabilities for a patient with an EMC. Findings are:

A. Review of the hospital's Emergency Medical Screening Policy B, last revised 8/08, includes the following under section F): Medical Screening Examination (MSE). An examination within the capabilities of the hospital's Emergency Department, including ancillary services routinely available to the Emergency Department to determine with reasonable clinical confidence whether an Emergency Medical Conditions exists. The Medical Screening Examination must be provided by qualified medical personnel." See deficiency at A2406 under example G pertaining to the ED visits by Patient #12 to the ED on 6/23/10, 6/24/10, 6/25/10, 6/27/10; 2 visits on 6/28/10, 7/7/10 and 7/16/10. All 8 visits were found to lack an adequate MSE sufficient to determine if the patient had an EMC.

B. Record review of facility policy titled "Emergency Medical Screening " last revised 8/08 states "if the Medical Screening Examination reveals that the patient has an emergency medical condition, Regional West Medical Center shall provide either: 1) Within the capabilities of the staff and facilities available at Regional West Medical Center for further examination and treatment as required to stabilize the medical condition: or 2) Appropriate transfer to another medical facility." See deficiency at A2407 under example E and F pertaining to the ED visits by Patient #12 on 7/26/10, and 7/28/10 in which the patient presented with symptoms and testing to confirm an EMC and needed emergency dialysis. The ED did not offer Patient # 12 emergent dialysis to stabilize his condition.

Based on a total review of 36 closed Emergency Department (ED) patient records, staff interviews, physician interview, review of the hospital capabilities for dialysis services, review of the hospital's Emergency Medical Screening policy and other hospital records, the hospital failed to provide within their capabilities an appropriate and sufficient Medical Screening Examination (MSE) for a total of 8 ED visits for Patient #12 who had been diagnosed several years ago with End Stage Renal Failure. The hospital is a Trauma II level ED, with 9 beds, 2 trauma rooms and is licensed for 164 beds.
Findings are:

A. Review of the hospital's Medicare Database Worksheet verified by the hospital administrator on 7/9/10 revealed the hospital's capabilities include a dedicated ED, cardiac and medical/surgical intensive care unit, emergency psychiatric services and acute renal dialysis (provided under agreement).

B. During a phone interview with the Chief Nursing Officer (CNO) on 7/23/10, the CNO confirmed that the hospital has the capability to provide dialysis to patients at the bedside in the Intensive Care Unit (ICU). Patients located outside the ICU receive dialysis treatments in an appropriately equipped room on the Restorative Care Unit.

C. During an interview on 7/9/10 at 10:00 AM, Dr-A confirmed that he provides dialysis services to patients with end stage renal disease and is the only physician on staff at the hospital privileged to provide dialysis. Dr-A confirmed that he is on call 24 hours a day, 7 days a week. Dr-A stated "They (the Internists on staff at the hospital) know they can always call me. The internal medicine clinic submits a schedule to the hospital and the ED knows when I am available." Dr-A stated that he oversaw dialysis treatment for Patient # 12 ( 3 times a week) at the same outpatient clinic that contracts with the hospital to provide inpatient dialysis. Dr-A stated that the outpatient clinic discontinued dialysis services to Patient # 12 on June 21, 2010 and since that time the patient has been coming to the hospital's ED for dialysis treatments.


D. Review of the hospital's Emergency Medical Screening Policy B, last revised 8/08, incudes the following under section F): Medical Screening Examination (MSE). An examination within the capabilities of the hospital's ED, including ancillary services routinely available to the ED to determine with reasonable clinical confidence whether an Emergency Medical Conditions exists. The Medical Screening Examination must be provided by qualified medical personnel.
Medical Screening Procedures: A, Entitlement to Medical Screening Examination: Any individual who is not otherwise a patient of the hospital, shall be provided an appropriate Medical Screening Examination within the capabilities of the ED (including ancillary services routinely available to the ED) as follows. 1. Presentation in a Dedicated Emergency Department (DED). Upon presentation at the ED and upon a request for examination or treatment for a medical condition. (The ED, Obstetrics Department and the Behavioral Health Unit are considered dedicated Emergency Departments).

E. Review of the June and July 2010 ED log revealed that Patient # 12 presented to the ED requesting dialysis multiple times after the outpatient dialysis clinic terminated his care on June 21, 2010.

F. Interview with Chief Nursing Officer on 7/14/10 at 9:00 AM acknowledges Dr-A is the only physician to order dialysis and if Dr-A is not available then the policies and procedures are to transfer the patient to another facility. Review of Dr-A's on-call schedule for the ED could not be verified by documentation on a daily basis. Interview with Dr-A revealed that his schedule changes are either called in or e-mailed to the ED. There was no documentation provided for the changes in schedule.

G.. Review of the 36 patient ED medical records showed that for 1 patient (Patient # 12), who presented multiple times for treatment, the patient did not receive an adequate MSE in 8 instances on the following dates: 6/23/10, 6/24/10, 6/25/10, 6/27/10, 6/28/10, second visit on 6/28/10, 7/7/10 and 7/16/10.

Findings are:

Patient # 12 presented to the ED on 6/23/10 at 13:00 per private car. Medical record shows patient was triaged as 3-urgent, stating he was there for dialysis - his doctor at the outpatient dialysis clinic no longer sees him. Documentation in the medical record revealed patient # 12 was last dialyzed on 6/21/10, 2 days prior to this ED visit. Medical record documents at 3:00 PM Patient # 12 was noted to be loud and rude stating he needs dialysis now, the cab he needs to take home will not run after 8:00 PM and he cannot walk home because of his plantar fasciitis. Lab work obtained around 2:25 PM revealed patient # 12 had a critical Potassium level of 7.4 (an elevated Potassium is potentially life-threatening and can lead to sudden death from cardiac arrhythmias. Cardiac arrhythmias are diagnosed by performing an electrocardiogram, also known as an EKG). At 4:15 PM the ED discharged patient # 12 without performing an EKG. According to the statutorily required Quality Improvement Organization (QIO) medical review performed on 8/1/10, patient # 12 had an elevated Potassium. The hospital failed to provide Patient # 12 with an appropriate and sufficient medical screening which included an EKG to identify life-threatening cardiac arrhythmias before leaving the ED.

Patient # 12 presented per private vehicle to the ED on 6/24/10 at 8:47 AM. Patient # 12 last dialyzed on 6/21/10, 3 days prior to this ED visit. Medical record shows patient was triaged as 4 non-urgent and was requesting dialysis - stated that he was 8 lbs over his dry weight. At 10:05 AM the lab reported patient # 12's critically elevated Potassium to Dr-B. At 11:04 AM the ED discharged Patient # 12. According to the statutorily required QIO medical review performed on 8/1/10, the hospital failed to provide Patient # 12 with an appropriate and sufficient MSE. An EKG was warranted to ensure stability of Patient # 12 due to his elevated Potassium level. Record review showed no EKG was obtained during Patient # 12's ED visit to determine "stability" or the need for acute treatment.

Patient # 12 presented to the ED on 6/25/10 at 15:01, per private vehicle. Patient # 12 last dialyzed on 6/21/10, 4 days prior to this ED visit. Review of medical record shows patient was triaged as 3-urgent and "requesting dialysis". Documentation indicated patient # 12 has been referred to other centers to get established for routine dialysis; however, he had declined to pursue those avenues. Patient # 12 presented with complaints of feeling bloated and was 8-9 kilograms over his dry weight. Lab results revealed patient # 12 had a critically elevated Potassium level of 7.0. According to the statutorily required QIO medical review performed on 8/1/10, the hospital failed to provide Patient # 12 with an appropriate and sufficient MSE. An EKG was not completed. An EKG was indicated to assure patient # 12 was stable before leaving due to his elevated Potassium.

Record review revealed patient # 12 presented to the ED via ambulance requesting dialysis on 6/27/10 at 12:12 AM. Last dialysis was 6/21/10, 6 days ago. The ED physician, Dr-C examined patient # 12. Dr. C noted the patient had "Fine, scattered rales and rhonchi in both bases. Laboratory findings noted patient # 12 had an elevated Potassium level of 6.0. The ED did not obtain an EKG. According to the statutorily required QIO medical review performed on 8/1/10, the hospital failed to provide Patient # 12 with an appropriate and sufficient MSE. An EKG was not completed. An EKG was indicated to assure patient # 12 was stable before leaving due to his elevated Potassium level.

Patient # 12 presented to the ED on 6/28/10 at 6:42 AM per private vehicle requesting dialysis. Patient # 12 last dialyzed on 6/21/10, 7 days prior to this ED visit. Review of medial record revealed the ED triaged patient # 12 as 4-non-urgent and that he complained of a cough, and had a recent history of severely elevated potassium levels. The ED physician ordered lab work that did not include a Potassium level or any other blood tests to determine the status of patient # 12's kidney function. The ED physician order a chest x-ray which revealed Patient # 12 had probable community acquired pneumonia treated by a one time injection of an antibiotic. At approximately 8:00 AM the ED discharged Patient # 12. According to the statutorily required QIO medical review performed on 8/1/10, the hospital failed to provide Patient # 12 with an appropriate and sufficient MSE. Patient # 12 had a recent history of severely elevated Potassium levels and required a repeat Potassium level to determine stability prior to his discharge.

Patient # 12 presented to the ED a second time on 6/28/10 at 23:40 PM. Patient # 12 last dialyzed on 6/21/10, 7 days prior to this ED visit. Review of medical record showed that at 00:09 AM the ED nurse documented Patient # 12 was alert, poorly responsive, non-cooperative, inappropriate, and fully verbal. Patient # 12 was very demanding and wanted dialysis. Dr-C noted patient # 12 here because the pharmacy will not fill his prescription for Kayexalate (prescription medication used to treat high levels of potassium in the body) and he wants it filled. Patient had a critically high potassium level of 7.0 on 6/26/10 but elected to not fill his prescription of Kayexalate until midnight tonight. At 1:18 AM blood drawn, Potassium level was critically elevated at 6.4. At 1:53 AM Dr-C noted that patient # 12 had a dialysis treatment scheduled for Wednesday 6/30/10 (which would have been 9 days since his last treatment). Patient # 12 was discharged with a prescription for Kayexalate 30 gm tablets qid (four times a day). According to the statutorily required QIO medical review performed on 8/1/10, the hospital failed to provide Patient # 12 with an appropriate and sufficient examination which included an EKG and consultation by the physician on call for dialysis since Patient # 12's BUN (blood urea nitrogen, one of several lab tests performed to evaluate kidney function ) had increased from 51 on 6/23/10 to 97 and had an altered mental status (poorly responsive and inappropriate).

On 7/7/10 at 1:06 PM Patient # 12 presented to the ED requesting dialysis and was triaged as 3-urgent. As documented in the medical record, patient states he was last dialyzed on 7/3/10, 4 days ago. Medical record documentation reads: Patient presents to the ER desk requesting dialysis, patient is slow to respond to questions and is unsteady on his feet. Patient denies having ingested ETOH (alcohol).
At 5:30 PM, Dr-B examined patient # 12 and ordered a Potassium level and later discharged him. According to the statutorily required QIO medical review performed on 8/1/10, the hospital failed to provide Patient # 12 with an appropriate and sufficient MSE to determine if the patient was under the influence of alcohol or drugs or otherwise determine the cause of his altered mental state.

Patient #12 presented to the ED on 7/16/10 at 3:57 PM requesting emergency dialysis and treatment for chronic pain. The patient stated he last had dialysis on 7/9/10, 7 days ago. The patients weight was elevated to 85.5 kg, 16.5 kg above his prescribed dry weight of 69 kg. Bilateral pitting edema was present. The ED physician ordered laboratory tests which revealed a critically elevated potassium level of 6.2, elevated phosphorus at 7.5 and elevated BUN at 104. He was provided a prescription for Kayexalate and discharged. According to the statutorily required QIO medical review performed on 8/20/10 the hospital failed to provide Patient #12 an appropriate and sufficient MSE. The patient did not have any cardiac monitoring or EKG performed to evaluate possible cardiac effects of the elevated potassium. A consult was not called to determine the need for emergency dialysis.


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Based on record review, review of facility dialysis contract, physician interview and review of facility policies, the facility failed to ensure adequate stabilizing treatment within the capabilities of the hospital were provided to Patient # 12 who presented to the ED on 2 occasions, 7/26/10 and 7/28/10. The patient was discharged with unstabilized Emergency Medical Condition (EMC) on both dates. The total sample was 36.

Findings are:

A. Record review of facility policy titled "Emergency Medical Screening " last revised 8/08 states "if the Medical Screening Examination reveals that the patient has an emergency medical condition, Regional West Medical Center shall provide either: 1)Within the capabilities of the staff and facilities available at Regional West Medical Center for further examination and treatment as required to stabilize the medical condition: or 2) Appropriate transfer to another medical facility."

B. Review of the hospital's Medicare Database Worksheet verified by the hospital administrator on 7/9/10 revealed the hospital's capabilities include a dedicated ED, cardiac and medical/surgical intensive care unit, emergency psychiatric services and acute renal dialysis (provided under agreement).

C. During an interview on 7/9/10 at 10:00 AM, Dr-A confirmed that he provides dialysis services to patients with end stage renal disease and is the only physician on staff at the hospital privileged to provide dialysis. Dr-A confirmed that he is on call 24 hours a day, 7 days a week. Dr-A stated "They (the Internists on staff at the hospital) know they can always call me. The internal medicine clinic submits a schedule to the hospital and the ED knows when I am available." Dr-A stated that he oversaw dialysis treatment for Patient # 12 ( 3 times a week) at the same outpatient clinic that contracts with the hospital to provide inpatient dialysis. Dr-A stated that the outpatient clinic discontinued dialysis services to Patient # 12 on June 21, 2010 and since that time the patient has been coming to the hospital's ED for dialysis treatments.




D. Record review of Patient #12's inpatient admission on 7/18/10 for end stage renal disease and dialysis revealed Dr-A included "Parameters for acute inpatient dialysis" for this patient. Dr-A is the only physician at the hospital with privileges to order dialysis. In the record titled "Discharge Summary" Dr-A documented "Parameters for acute inpatient dialysis have been established, including a serum potassium greater than 6.5, pH of less than or equal to 7.1, refractory volume overload (symptoms include weight gain related to build up of fluids in tissues of the body and lungs) with a resting oxygen saturation of less than 85%, uremic encephalopathy [brain disorder], as well as other potential clinical indicators depending on presentation."

E. Patient #12 presented to the ED on 7/26/10 at 8:29 PM. The patient requested his abdomen be drained of fluid. The patient reported his last dialysis was on 7/19/10, 7 days ago. Dr. B, the ED physician performed the MSE examination. Patient #12's abdomen was found to be distended. The patient also had moderate lower extremity edema. Laboratory testing identified an elevated phosphorus of 7.1, elevated potassium of 5.3 and critically low calcium level at 6.9. The chest x-ray documented cardiomegly (enlarged heart), atelectasis, and peribrochial cuffing. The radiologist report suggested this could represent edema, viral pneumonitis or bronchiolitis. Dr-B discussed the findings with Dr- A, the hospital's only physician who has privileges to order dialysis. Dr-A determined emergency dialysis was not indicated. The patient was discharged. Statutorily required QIO medical review performed on 8/20/10 noted the patient had an EMC and did meet the requirements for emergent dialysis. The patient was not provided stabilizing treatment within the capabilities of the hospital and discharged with an untreated EMC.


F. Emergency Department (ED) medical record review of Patient #12's visit to the ED on 7/28/10 at 9:46 PM revealed the patient presented requesting dialysis and complaining of abdominal swelling. The patient reported he "missed dialysis" and states was last dialyzed 9 days ago (7/19/10). Weight was recorded as 93 kg (kilograms). The weight was 20 kg up from the patient's normal weight. The patient was triaged as urgent. The ED physician, Dr. G performed the MSE 10:59 PM. Physical exam noted the patient did not appear acutely ill and "is not toxic." He was not in any respiratory distress. Lung sounds demonstrated "diffuse auscultatory findings. Expiratory wheezing noted throughout." Heart murmur heard along the left sternal border. Abdomen distended, normal bowel sounds. Exam is noted as "consistent with ascites." Ascites is an abnormal finding of fluid buildup in the abdominal space. Abdomen was soft and non tender. Both lower extremities exhibited moderate pitting edema. An Albuterol respiratory treatment was given at 11:36 PM. After the treatment the patient still had complaints of mild trouble breathing, wheezes and rhonchi were noted bilaterally. Respiratory rate was 16 with pulse oximetry at 97 % on room air. Testing included laboratory blood testing. Potassium was elevated at 5.6 (normal 3.6-5), BUN elevated at 131 (normal 8-22), creatinine elevated at 18.0 (normal 0.7 - 1.3), calcium was low at 7.0 (normal 8.4-10.5) and alkaline phosphatase elevated at 196 (normal 43-122), phosphorus was elevated 8 (normal 7.32 -7.42). Arterial Blood Gases were normal for respiratory function. A physician consult to evaluate the need for emergency dialysis was not requested. The physician progress notes "I had a long discussion with the patient and his friend. I explained that he did not meet the criteria for emergent dialysis tonight. He will need to continue to follow up at his primary doctor [name of Community Action Partnership that provides reduced cost clinic staffed by physicians]." Discharge diagnosis "Chronic Renal Failure on Dialysis." He was discharged at 12:48 AM on 7/29/10.

Other than a respiratory treatment the patient did not receive any stabilizing treatment before discharge to address the renal failure or ascites. Dialysis was not offered to the patient. Review of on call services revealed Dr-A, the physician that orders dialysis was available for consult but was not contacted by Dr-G.

Statutorily required Quality Improvement Organization (QIO) medical review completed 8/20/10 determined the patient's findings from Dr-G's MSE revealed an Emergency Medical Condition (EMC). The patient required a consult with a physician for emergency dialysis who was not called. The elevated potassium, BUN, Phosphorus, weight gain and pitting edema would meet the requirements for emergency dialysis. The patient was not provided stabilizing treatment within the capabilities of the hospital and was discharged with an untreated EMC.