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Based on ambulance run report review, medical record review and interviews the hospital failed to ensure that an adequate medical screening examination and stabilizing treatment was provided for a patient (Patient #2) who presented to the hospital's Dedicated Emergency Department (DED) for evaluation on 04/24/2020.

The findings include:

1. The hospital failed to ensure that an adequate medical screening examination was provided for a patient (Patient #2) who presented to the hospital's DED for evaluation of nausea and vomiting on 04/24/2020.

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

Based on ambulance run report review, medical record review, policy and procedure review, Guest Relation Specialist Telephone Log review, and interviews the hospital failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department to determine whether or not an emergency medical condition existed for 1 (Patient #2) of 25 sampled patients who presented to the emergency department for evaluation/treatment.

The findings include:

Review of an Ambulance Run Sheet written by Paramedic #1 on 04/24/2020 at 1757 (4 hours and 16 minutes after Patient #2 was received by Hospital A) revealed, "...Arrived to find a 74 y/o (year old) male supine in floor outside bathroom in residence. Family member present on scene ... The patient states he was nauseated and vomited. He got weak and sat down in (sic) the floor. He denies any chest or other pain, no shortness of breath. He states he feels weak and is having chills. He states he has not eaten this morning but did take his insulin. He states he has had an-ongoing (sic) infection in his foot ... Temp: 102.7 (degrees Fahrenheit [F])..." Review revealed Patient #2's blood glucose was documented as 301, for which Paramedic #1 initiated intravenous (IV) access and initiated a Normal Saline fluid bolus, with the amount unspecified. Patient #2 was transported to Hospital A.

Closed medical record review (Visit #1) conducted on 07/14/2020 revealed Patient #2 was a 74-year-old male who presented to Hospital A by ambulance on 04/24/2020 at 1341 via ambulance complaining of Nausea and Vomiting. Patient #2's vital signs at 1402 were: blood pressure (BP) 129/68, pulse (P) 82, respirations (R) 18, pulse oximetry (SPO2) 95 % on room air, and temperature (T) 99.4 F. Review of a triage note written by Registered Nurse (RN) #1 on 04/24/2020 at 1402 revealed, "...Stated Complaint: Pt (patient) complains of nausea and vomiting this morning. Pt states he threw up 3 times today. Denies any pain at this time ... ED Risk Assessment - Sepsis: No..."Review of a Provider Note written by Medical Doctor (MD) #1 on 04/24/2020 at 1551 revealed, "...Pt complains of nausea and vomiting this morning. Pt states he threw up 3 times today. Denies any pain at this time ... States he is felling better at this point. No fevers no trauma no cough (sic). No sick contacts. No diarrhea symptoms are moderate worse with eating or drinking (sic) ... Physical Exam ... General: Well-appearing alert in no acute distress ... Abdomen: Soft, nontender, normoactive bowel sounds. No masses palpated Extremities: Warm and well-perfused, no obvious deformities, pulses intact. According to the medical record, the section titled "Problem List/Past Medical History/Ongoing were listed in part, Diabetic foot, Diabetic Neuropathy, and Diabetic Ulcer of the foot with necrosis of bone," Patient #2 had a diabetic foot ulcer that was not evaluated or addressed during the first visit on 4/24/2020. Skin: Without rash or edema Neuro; GCS is 15, alert, moving all extremities equally Medical Decision Making Patient with vomiting. Benign exam no signs of an acute intra-abdominal event. Suspect viral syndrome will treat with fluids antiemetics and reevaluate. Check labs. Reexamination/Reevaluation Labs reveal mild leukocytosis otherwise negative chemistry shows some chronic kidney disease but is otherwise negative. Patient feels better with fluids and meds. Given leukocytosis CT scan of the abdomen is done and is negative for acute finding. Patient is doing well tolerating p.o. (by mouth intake) will be discharged (sic) Diagnosis: Vomiting, leukocytosis ... Discharge Follow Up Appointments [Named Provider] Follow up within: As needed..." Potentially clinically significant laboratory values identified after performing a CBC with differential, and General Chemistry include: a WBC of 17.1 abnormal (normal range identified as 3.6 to 10.4, noting a prior result on 01/02/2020 of 7.1), Glucose of 334 (normal range identified as 70 to 125, noting a prior result on 02/03/2020 of 315), Creatinine of 1.84 (normal range identified as 0.67 to 1.10, noting a prior result on 02/03/2020 of 1.87), GFR Non-African Estimated of 36 (normal range identified as >59, noting a prior result on 02/03/2020 of 35). A 1 view chest X-ray was performed, with an impression of "No acute disease identified." A CT of the abdomen was also performed with an impression of "No acute abnormality demonstrated. No evidence for the cause of the patient's symptoms." Fluids and medications administered during the DED visit included 1 liter of Lactated Ringers and 8 mg Zofran, both administered intravenously. Patient #2 was discharged home on 04/24/2020 at 1545, noting vital signs obtained at 1541 as follows: blood pressure (BP) 129/68, P 75 and SPO2 95% on room air. Review revealed no evidence of any other documented respirations, blood pressure, or temperature checks during the DED visit. The facility failed to ensure that their Policy and procedure was followed as evidenced by failing to evaluate the patient's feet without shoes , in regards to the foot ulcer, would have been an appropriate MSE, and in keeping with professional standard of care (feet assessments of Diabetics) as stated in the facility's policy.

Patient #2 returned (Visit #2) to the DED on 04/26/2020 at 1305 by personal vehicle, noting triage vital signs of: BP 148/84, P 67, R 18, SPO2 99 % on room air, and T 97.9 F. Review of a ED Document written by the DEDMD (Dedicated Emergency Department Medical Director) on 04/26/2020 at 1738 revealed, "...Chief Complaint foot wound ... History of Present Illness This is a 74-year-old diabetic male who presents to the emergency department with drainage bleeding and a foul odor from a wound on his left lateral foot. The patient states that he has had ulcers on the bottom of his feet associated with his diabetes for years. He has had increased pain in the right foot and drainage redness and swelling in the left over the past couple of days. Patient states that he used to go to the wound center but has not been there in some time ... Review of systems ... Skin ... chronic ulcers with worsening both feet ... Medical Decision Making Differential diagnosis includes cellulitis/diabetic foot wound infected. Osteomyelitis ... Reexamination/Reevaluation Patient's white blood cell count is 10.7. The x-ray of the left foot does show some changes in the metatarsal head which could only be early osteomyelitis ... Further review of the medical record revealed in part, "Electronic Orders dated 4/26/2020 at 1352, d/t (due to) documentation. Patient have ulcers or non-healing wound...yes". Do not think this is in relation to the episode of vomiting and syncope he had 2 days ago. Will recommend admission and discussed (sic) with the hospitalist..." Patient #2 was admitted to the hospital with a primary diagnosis of Osteomyelitis of foot, left, acute. He was ultimately discharged on 05/01/2020 at 1534.

During the survey MD #1 who cared for Patient #2 on 4/24/2020 was out of the country and unavailable for interview.

The facility's Policy and Procedure titled, EMTALA Compliance Including Patient Transfer (Emergency Medical Treatment and Labor Act), Policy number PR-120.05, Review of the policy revealed in part, "I. Medical Screening Examination..A request for Medical Screening Examination: An appropriate medical screening examination will be appropriate performed on any individual who "comes to the emergency department....B. Appropriate medical screening examination: The purpose of the medical screening examination is to determine whether the individual has an emergency medical condition. The medical screening examination should be appropriate to based on the signs and symptoms of the individual, and in keeping with the professional standard of care."


Interview was conducted with the DED Manager on 07/15/2020 at 1033. Interview revealed her expectation for nursing assessments are focused on the patient's complaint, and the DED nurses do not necessarily perform head-to-toe assessments on every DED patient. Interview revealed upon review of Patient #2's medical record, no focused nursing assessment other than the triage note could be found. Interview revealed it appeared according to the medical record that the triage nurse assessment and the initial MSE were occurring simultaneously.

Telephone interview was conducted with RN #1 on 07/15/2020 at 1042, who did not recall Patient #2. Interview revealed typically when receiving patients who present to the DED by ambulance, the accepting nurse receives a verbal report accompanied by a single sheet of paper with basic information, such as patient name, vital sings, blood glucose, and family point of contact information; which is normally taken by registration personnel to expedite registration into the facility's electronic medical record (EMR) system. Interview revealed RN #1 thought this sheet was eventually scanned into the patient's EMR. Interview revealed further nursing assessments were considered focused assessments based upon the patient's complaints. Interview revealed if something "glaringly obvious," for example unilateral weakness, the nursing assessment would expand to other systems as necessary.



Telephone interview was conducted with the DEDMD on 07/15/2020 at 1110. Interview revealed she was Patient #2's DED provider for his visit on 04/26/2020. Interview revealed due to a complaint from a member of Patient #2's family, his treatment on the 04/24/2020 visit was reviewed. Interview revealed the DEDMD interviewed MD #1 regarding the care provided. Interview revealed MD #1 stated he did not remove Patient #2's shoes and look at them because the patient was alert and not complaining about anything lower extremity related. Interview revealed the DEDMD did not feel the patient was a very good historian, despite his baseline alert and oriented mentation. Interview revealed obtaining patient histories from family has proven difficult due to visitation restrictions related to the Covid-19 virus. Interview revealed based on a complaint registered by Patient #2's family, opportunities for improvement, including attempting to reach out to patient's families via telephone to obtain more complete histories, have been identified. Interview revealed to the DEDMD's knowledge these practices were not in place in 04/2020 when Patient #2 presented to the DED. Interview revealed when the DEDMD evaluated Patient #2 on 04/26/2020 (visit #2), upon entering the room she could smell necrosis, so it was obvious the patient had an infection. Interview revealed she (DEDMD) asked the patient if his feet were bothering him, to which he replied his "feet were always bothering him." Interview revealed the DEDMD did not feel that MD #1's assessment on visit #1 was "lackadaisical," and that he was "going with what the patient told him and was complaining about, which were ongoing problems." Interview confirmed MD #1 was out of the country at the time of the survey and the DEDMD, having already interviewed him about this patient, did not feel that MD #1 would have any additional information to add regarding the care provided for Patient #2.

Telephone interview was conducted with RN #2 on 07/15/2020 at 1300, who discharged Patient #2 from the DED on 04/24/2020. Interview revealed she did not recall the patient. Interview revealed the normal discharge process includes a vital sign recheck, including pain level. Additional RN #2 always ensures the patient understands their discharge instructions and prescriptions. If a patient voices any further concerns, RN #2 would assess their concerns, and convey the new information to the patient's primary nurse and medical provider prior to discharge. Interview revealed RN #2 also always ensures safe transition to the departure vehicle or wheelchair to exit the department. If the patient chooses to walk out, RN #2 always attempts to assess for steady gait prior to the patient's ambulation.

Telephone interview was conducted with Paramedic #1 on 07/16/2020 at 0910, who did not recall Patient #2. Interview revealed temperatures are typically checked by EMS tympanically. Interview revealed Paramedic #1 did not recall his verbal report to RN #1, but he "would imagine that I would have reported the foot problem and temperature to the nurse, as the patient could have been borderline septic, and have a potential source of infection." Interview revealed Paramedic #1 did not recall whether any family members were present.

Review of a Guest Relation Specialist (GRS) Telephone Log presented to the surveyor on 07/16/2020 revealed Patient #2's wife was contacted by GRS #1 on 04/24/2020 at 1410. Review revealed, "...Can the patient communicate on their own? If no, has the nurse spoken to family/designee? Yes. Do you understand the care being provided to you? Yes. Do you have any questions that have not been answered by your care team? No. Have you been able to contact your family? If no, did you offer them resources to connect with their family? No cell phone. Rm. (room) phone broken (sic). (Patient #2's wife named with telephone number). Our mission is to deliver outstanding care. Are we showing that you matter to us? If no, were you able to resolve the patient's concerns ... Yes."

Telephone interview was conducted with GRS #1 on 07/16/2020 at 1128. Interview revealed the GRS team acts as a liaison between the facility staff and patients and their families. Interview revealed generally they talk to families in person or by telephone and ask if there are any additional question or concerns, and if they are satisfied with the care provided. Interview revealed GRS #1 did not specifically recall Patient #2 or his family, but if there were any additional questions or concerns, they would have been documented.