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Based on hospital EMTALA policy review, medical record reviews, physician and staff interviews, the hospital failed to comply with 42 CFR §489.24 Special Responsibilities of Medicare Hospitals in Emergency Cases and the related requirements at §489.20 (l), (m), (q), and (r), which pertain to the Federal Emergency Medical Treatment and Labor Act (EMTALA).

Findings included:

1. Based on hospital EMTALA policy reviews, medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physicians failed to provide an appropriate Medical Screening Examination (MSE) to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 21 sampled DED patients (#11) who presented to the hospital for evaluation and treatment for complaint status/post fall.
~ Cross refer to §489.24(r) and §489.24(c) Medical Screening Examination - Tag A-2406.

1. Based on hospital EMTALA policy reviews, medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physicians failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 21 sampled DED patients (#11) who presented to the hospital for evaluation and treatment for complaint of a fall.

The findings include:

Review of the Policy titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance" effective date 10/26/2018 revealed
"PROCEDURE:Medical Screening Examination (MSE): 1. Any individual that presents on hospital property and requests--or has such a request made on his or her behalf--...will be provided a MSE to determine if an emergent medical condition exists....The MSE will be uniform for patients presenting with similar symptoms regardless of the location."

Review of the closed DED medial record on 01/08/2019 for Patient #11 (Visit #1) revealed a 78-year-old male that presented to the DED on 12/05/2018 at 1534 with a chief complaint of fall. Review of triage nursing notes documented at 1536 revealed "Pt (patient) presents to ED (emergency department) via named EMS (emergency medical services) s/p (after) fall. EMS reports that patient was coming out of storage unit when he slipped off the lip and stumbled. Pt presents with large hematoma (bruise) to R (right) eyebrow. Per EMS no LOC (loss of consciousness). Pt presents to ED alert and oriented. " Review of the Focused Assessment and Pain documented on 12/05/2018 at 1538 revealed "Triage Pain Assessment- Pain Score: 3, Pain Location: Shoulder, Pain Orientation: Right, Pain Descriptors/Indicators: Aching. " Review of the medical record revealed on 12/05/2018 at 1543 a CT (computed tomography) Head wo (without) contrast was ordered by MD (medical doctor) #1. Review of the CT Head results on 12/05/2018 at 1606 revealed " Impression: 1. Large right forehead hematoma. No underlying fracture or postseptal swelling. 2. No evidence of intracranial injury. 3. Small vessel infarct in the right caudate head. " Review of the Provider note dated 12/05/2018 at 1626 revealed " HPI (history of present illness): Named patient is a 78 y.o. male history of minus gravis fall. He says that he was opening a ... when he stumbled and fell hitting his forehead over his right eye and then falling backward onto the back of his head. He denies losing consciousness. Denies nausea or vomiting. Says the event happened about an hour ago and he has since significantly swollen around the upper part of his right eye. He says that his vision is at his baseline. Denies any numbness or weakness or neck pain ...Physical Exam: Head: Right superior periorbital swelling which is moderate to severe with overlying abrasion without any active bleeding or significant laceration. Tenderness to palpation which is mild without any depression or bogginess. Musculoskeletal: ...No tenderness to the thoracic nor lumbar spines ...Radiology: CT without any acute intracranial injury. However, there is a small vessel infarct in the right caudate head of undetermined age. Plan: Patient at this time continues to be neurovascularly intact at this baseline. However, he is reporting increased soreness now to his right ' shoulder blade. ' There is no overlying ecchymosis or tenderness to palpation. Patient has full range of motion of his right shoulder. Likely mild contusion from the fall. I discussed the CT findings including the caudate infarct. Patient is not complaining of any new neurologic symptoms. Unlikely that this would be an acute issue especially given that this fall happened more or less just before he came into the hospital. It would be unlikely that this timing would result in an infarct being visualized on a CT during this emergency visit. Patient will follow-up with his primary care doctor. Advised the patient as well as daughter that he would likely have a black and blue marks that will extend over the right side of his face over the next several days from the blood from his injury ...he is understanding of the plan willing to comply. Final Clinical Impression/ED Diagnoses: Fall. Cephalohematoma (pooling of blood from damaged blood vessels between the skull and inner layers of the skin). Abrasion. " Review of the Pain Assessment at 1639 revealed " Pain Score: 5, Pain Location: Shoulder, Pain Orientation: Right, Pain Descriptors/Indicators: Aching. " Record review revealed Patient #11 was discharged at 1652. There was no documentation in the medical record to indicate that Patient #11's chest wall was palpated for rib injury s/p fall on 12/5/2018. The facility failed to ensure that an appropriate medical screening examination was provided for Patient #11 prior to discharge on 12/5/2018.

Review of the closed DED medial record on 01/08/2019 for Patient #11 (Visit #2) revealed a 78-year-old male that presented to the DED on 12/08/2018 at 0048 with a chief complaint of fall. Review of triage nursing notes documented at 0052 revealed "Pt from home via named EMS d/t (due to) fall Wednesday. Pt was evaluated and negative scans of head and face but presents with pain to right shoulder and rib cage, arm. In NAD (no apparent distress). VSS (vital signs stable). Ambulatory (walk) with cane. " Review of the Focused Assessment and Pain documented at 0058 revealed " Triage Pain Assessment- Pain Score: 8, Pain Location: Shoulder, Pain Orientation: Right, Pain Descriptors/Indicators: Sore. " Review of the medical recorded revealed at 0104 MD #2 ordered labs and a 2-view chest x-ray. Review of the Chest x-ray results at 0204 revealed " Findings: There bibasilar atelectatic changes. No focal consolidation, pleural effusion, or pneumothorax. The cardiac silhouette is within normal limits. There is atherosclerotic calcification of the aortic arch. No acute osseous pathology. " Review of the medical recorded revealed at 0211 MD #2 ordered a CT of the abdomen, pelvis, and chest. Review of the medical record revealed fentanyl (pain medication) was administered at 0330. Review of the results of the CT scan of the chest at 0432 revealed " Impression: 1. Multiple mildly displaced right anterior rib fractures. No pneumothorax ... " Review of the Provider Note dated 12/08/2018 at 0449 revealed " HPI: Named Patient is a 78 y.o. male who comes into the hospital today with some right-sided chest pain. The patient states that he fell Wednesday and was seen here. The patient has CT scan of his head but now he has some right-sided pain underneath his shoulder blade and on his ribs. The patient states that he has had some mild difficulty breathing and he has had a cough which is making the pain worse. The patient states that he fell on his right side. He reports initially had some chest pain but it got better. He states that tonight at 9:00 it got worse. The patient states his pain is a 7 out of 10 in intensity. Currently the patient has some pain with breathing and moving. He also has some soreness in his upper abdomen ...Assessment and Plan-I did check some blood work. The patient ' s white blood cell count is 19.7 and his BNP (brain natriuretic peptide-test used in determining heart failure) is 238 but his remaining blood work is unremarkable. Patient initially received a chest x-ray which showed no focal consolidation but I sent him for a CT scan of his chest as well as his abdomen of pelvis. The patient ' s chest CT showed some mildly displaced right anterior rib fractures ribs 2 through 7 ...Given the multiple fractures as well as the tachypnea and hypoxia I felt it is appropriate to admit the patient to the hospitalist service for pain control for his multiple rib fractures. Final Diagnosis: Closed fracture of multiple ribs of right side. " Record review revealed Patient #11 was admitted on 12/08/2018 at 0600. Review of the discharge summary dated 12/13/2018 at 1020 revealed Patient #11 was treated for pneumonia, pain was managed, and discharged home in stable condition.

Interview on 01/09/2019 at 1041 with MD #1 and the Emergency Department Medical Director revealed MD #1 was the provider that treated Patient #11 on 12/05/2018 (1st visit). Interview revealed he recalled Patient #11 complained of pain and swelling to his right eye. He stated he also complained of pain in his right shoulder, his scapula area. Interview revealed Patient #11 was alert and oriented, responded appropriately, and no confusion noted. Interview revealed MD #1 had no concerns at the time of Patient #11s care that he possibly could have had fractured ribs, his main complaint was pain in his right eye and shoulder soreness. Interview revealed MD #1s standard process for treating elderly patients that sustained a mechanical fall was to rely on their complaint if they are alert and oriented and his full body assessment. He stated along with the patient ' s complaint and his physical assessment that would determine the need for further imaging or testing. He stated he felt Patient #11 was able to express his complaints. The medical director revealed that physicians perform a full body assessment on patients and that assists in determining the need for further testing or imaging. Interview revealed MD #1 felt that Patient #11 received an appropriate medical screening exam for the complaints Patient #11 had and what the full body assessment revealed.

Interview on 01/09/2019 at 1108 with MD #2 revealed she was the provider that treated Patient #11 on 12/08/2018 (2nd visit) when he returned to the DED. Interview revealed Patient #11s chief complaint was pain in his chest and shortness of breath secondary to a fall on 12/05/2018. Interview revealed she ordered a chest x-ray and labs and the chest x-ray did not identify any fractured ribs. She stated due to Patient #11s white blood cell count being elevated and the complaint of pain in his chest, she decided to order a CT scan of the chest to increase her level of care and determining an explanation for the symptoms. Interview revealed her standard process for treating alert and oriented elderly patients that suffer a mechanical fall is to perform a full body assessment to determine the need for additional testing or imaging and focus on their area of the complaint.

Interview on 01/09/2019 at 1135 with RN #1 revealed she was Patient #11s primary nurse on 12/05/2018 (1st visit). Interview revealed she recalled Patient #11 had a hematoma above his right eye. Interview revealed Patient #11 was alert and oriented. Interview revealed RN #1 did not recall of any additional complaints other than his eye pain. She stated he did not appear to be in much pain and at first, he was sitting on the side of the bed. She stated she assisted him in lying in the bed and no indication or reported pain in his chest when he moved.