HospitalInspections.org

Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

The hospital failed to ensure a thorough medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) to determine whether or not an emergency medical condition existed for 2 of 24 sampled emergency department patients (Patients #21, 24).

~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag C2406

Based on policy review, medical record reviews and provider interviews the hospital failed to ensure a thorough medical screening examination (MSE) was provided to determine if an emergency medical condition (EMC) existed for 2 of 24 emergency department records reviewed (Patients #21 and # 24).

The findings included:

Review of the policy "EMTALA - Medical Screening Examination and Stabilization...", last revised 12/13/2021, revealed "...A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the (Dedicated Emergency Department) DED, to determine whether or not an EMC exists....Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital. ..."

1. DED record review on 03/15/2023 revealed Patient #21 presented to the Emergency Department on 12/10/2022 at 1520. Review of the ED Triage note, on 12/20/2022 at 1543, revealed " ...Stated Reason for Visit: vision changes at 1330 resolved spontaneously ....Acuity: 3 - urgent. Review revealed vital signs at 1543 were T 98.4, HR 76, RR 18, BP 149/72, Oxygen Saturation 97% on room air, and a pain score of 0. Review of the "ER Report" provider note, revealed " ...Chief Complaint VISUAL CHANGES History Of Present Illness 37-year-old male patient who is normally healthy presents here after an unusual episode which began somewhere between 13:30-14:00 today. Tells me he was sitting on the couch ....when he experienced fairly sudden onset of dizziness and loss of vision in the left eye. This occurred for about 3 to 4 minutes and then spontaneously resolved just as it had started. He had no preceding symptoms such as headache, chest pain, palpitations, shortness of breath, cough or straining. No seizure activity. He takes no medications. Denies any drugs or alcohol. Denies any traumas or injuries. He says he is completely back to his normal baseline now. He is with his wife here now. It is unclear exactly what caused his transient issue today but it seems to be completely resolved and is back to baseline. He definitely would not be a candidate for tPA (medication). Not strongly suspecting TIA, amaurosis fugax, pathological arrhythmia, atypical seizure. Ultimately, my attending physician and I discussed this case and believe that the patient is safe for discharge. Recommend that he follow-up with ophthalmology as well as PCP and he may need an MRI with referral to neurology. Given strict return precautions for new, worsening or concerning symptoms. Patient and his wife verbalized understanding and are in agreement with plan and discharge instructions. Diagnosis/Disposition 1. Transient visual disturbance, left. ..." Review of the labs did not reveal abnormal results. Review of the CT/Angiogram Neck and Head, on 12/10/2022 at 1647 revealed " ...IMPRESSION 1. No intracranial abnormality identified. No significant arterial abnormality within the head or neck seen.. ." Further review of "ER Report" revealed a physician note at 1813 that documented "I personally evaluated and examined the patient in conjunction with the APC and agree with the assessment, treatment plan and disposition of the patient ....Briefly, the patient is a 37-year-old male presenting with relatively sudden painless left-sided vision loss which has resolved after 2 minutes of symptoms. Currently is asymptomatic with a benign exam. Work-up today is reassuring. We discussed limitations of current work-up including possibility of occult and emergent intraocular or intracranial pathology. After detailed discussion of risk versus benefits, patient would prefer to go home and follow-up as an outpatient. He was given strict precautions, voiced understanding and agree to follow." Review revealed Patient #21 was discharged home at 1738.

Telephone interview, on 03/17/2023 at 1004, with Physician Assistant (PA) #5 revealed the PA did not recall Patient #21. Interview revealed it sounded like the work-up would have covered for anything emergent. Interview revealed PA #2 would not have wanted to have the patient leave against medical advice and be financially responsible especially since it was a subjective complaint, there were no symptoms on-site.

Telephone interview on 03/16/2023 at 1330 with Medical Doctor (MD) #6, who also saw Patient #21, revealed they discussed with the patient there was no MRI available at the hospital that day. Interview revealed there were limitations to a CT scan. Interview revealed Patient #21 was specifically offered transfer to another hospital or admission to this hospital, noting the MRI would be available the next day. Interview revealed Patient #21 was offered transfer to another hospital or admission but wanted to go home. The patient, MD #6 stated, was not interested in transfer or admission and planned to follow-up as an outpatient. Interview revealed Patient #21 was given contact numbers to ophthalmology and was to follow-up with his primary care provider. Patient #21 was also given strict return precautions. In regards to the question of AMA (against medical advice) or discharge, MD #6 stated that AMA was not positive and when you could not reliably determine the risks, to let the patient be involved and share in the decision making. Interview revealed shared decision making was important for patients. MD #6 also stated he tended not to use AMA when there were resolved symptoms. Interview revealed the patient wanted to go home and follow-up and the physician discussed all the risks and the patient understood the risks, that they were low but there were risks.

2. Review of the DED record of Patient #24 on 03/16/2023 revealed the patient arrived to the ED via EMS on 02/01/2023 at 1144. Review of the County Emergency Medical Services "Patient Care Record" revealed the call from Dialysis to EMS at 1107, EMS on the scene at 1114, departed the scene at 1131 and arrived to the destination (hospital) at 1136. Review of the "Narrative" revealed " ...Failure to thrive, Depression, suicidal ideations ....(Company name) staff reported to EMS that the pt lives with his mother, and she advised the staff that the pt has been getting angry for the past month when its time for dialysis, and throwing fits not to go. They stated that he has been very depressed and has made several suicidal comments including today. They also reported that the pt has not been taking his medications nor eating. Today when he arrived for dialysis he attempted to throw himself out of the chair and made it clear that he did not want the treatment, but they were able to succfeully (sic) dialyze him anyway ....Now they want him transported to the ER ....We found the pt sitting in a chair ....The pt had just finished dialysis ....The patient seemed aggravated that we were there ....Paramedic (Name) asked the patient if he was having suicidal thoughts and he stated 'I just want to go' .... The pts fistula is in his left arm, and his right arm is amputated at the shoulder. He is also a bilateral leg amputee. Therefor (sic) we were unable to obtain a BP ....We transported the pt routine traffic ....The pt remained stable. ..."

Review of the "ED Triage ..." performed 02/01/2023 at 1144 revealed " ...Stated Reason for Visit : 'don't know' ....Acuity : 2 - Emergent. ..." Review revealed vital signs obtained were T 98.5, HR 80, RR 18, Oxygen saturation 100% on room air and a pain score of 10. A systolic BP was noted at 90. Review of Triage "Mental Health Status - ED Triage V5" at 1224 did not reveal a suicide risk scale done in Triage, with the note stating " ...Assess CSSRS (Columbia Suicide Severity Rating Scale) ?: ER patient with no chief BH complaint." Review of the "Triage Mental Status Exam" at 1226 revealed "Mood ....Blunted Affect, Depressed ...Thought Process ....Impaired Focus/Concentration." Review of the "ER Report" provider documentation, service date/time 02/01/2023 at 1230, revealed "Chief Complaint Medical Screening exam ....History of Present Illness 51-year-old male patient fairly well-known to the emergency department presents here from (Company Name) dialysis at the request of the nurse practitioner there after the patient said 'I do not want a live like this'. Staff there ....believes that he has been less interactive than normal over the last couple of weeks. Patient did complete his dialysis today as he does on Monday Wednesday Friday. Patient has an extensive past medical history which is reviewed prior to my seeing him. I have seen the patient personally a few times here in the ER. When I first go to see the patient he says 'I feel like shit'. I always feel like shit'. He says that he does not feel any worse than normal. He lives at home with his mother. Denies any medication changes. Denies any acute inciting events or injuries. Physical Exam ....General: Alert and oriented to his normal baseline, no acute distress ....Skin: Warm, dry, no rash ....Musculoskeletal: Only his left upper extremity remains which is unremarkable and has good range of motion. Neurological: Alert and oriented to his normal baseline, no gross motor or sensory deficit observed. Psychiatric: Cooperative, flat affect. Medical Decision Making ... Differential Diagnosis ....: Electrolyte abnormality, anemia, head injury, dehydration Plan ....CT head, basic labs ....Treatment and Disposition: ED Course: [To me, the patient appears to be at his normal baseline. He is very depressed about his chronic medical condition which is understandable. He strictly denies any homicidal or suicidal ideation or any plan. Patient's chemistry panel here shows a sodium of 131, creatinine 4.09, estimated GFR of 19, calcium of 8, albumin 3.3, ALT of 7, osmolality of 263. Notably a normal ammonia. H/H of 9.3/30.9 showing some stable anemia. CT head without IV contrast showing no acute intracranial abnormality identified. We are able to give the patient some antihypertensives here and his blood pressure improved significantly. He continues to have his baseline affect. I do attempt to give him some additional antihypertensives but he refuses any further medications or treatments and demands to be discharged right away. I called his mother about his work-up results and our therapies and that I did recommend lowering his blood pressure further but he had declined and refused any further management. She said at this point she thinks that he is at his normal baseline and is requesting we discharge him now back home. They can easily return for new or worsening symptoms which I encouraged. Patient stable in no distress at time of discharge. Consultant discussions: [Mother and daughter] Shared decision making: [X] ...Diagnosis/ Disposition 1. Essential hypertension. ..." Review of vital signs revealed blood pressures taken as follows: 1443- 238/109, 1500 - 246/112, 1515 - 234/96, 1530 - 204/86 and 1615 - 181/79. Review of the Discharge revealed Pt #24 was discharged home with daughter at 1633. A comment was documented that "vss (vital signs stable), warm pink and dry, in no acute distress, daughter verbalizes (sic) understanding of d/c orders, to PV (private vehicle) per WC (wheelchair). Review did not reveal a Columbia suicide risk screen completed and did not reveal a psychiatric consult was requested or obtained while Patient #24 was in the ED.

Telephone interview on 03/17/2023 at 1004 revealed PA #5 recalled Patient #24. PA #5 stated the patient was well known to the ED and was typically sent by Dialysis Center. Interview revealed "I don't think he ever really wants to come to the ED ...the Dialysis Center sends him over." Interview revealed Patient #24 had "depressive language" but the PA did not feel he was suicidal. Interview revealed Patient #24 had been in the ED a number of times, saying he had personally seen him "4-5 times". Interview revealed you wouldn't want to put the patient in the ED for a 24-hour visit every time he came in. Interview revealed they could not change his medical condition and he did not want to make things hard for the patient every time he came in, stating he "wants him to feel comfortable" to come. PA #5 stated he was not in a position to review the medical record and so could not be clear, but he did not believe Patient #24 needed a psych eval. Interview revealed if you asked too many questions the patient would shut down so you had to read the situation with him and keep him talking. Interview revealed once the BP got to a safe level, he could be discharged. Interview revealed the patient had very good family support, including mother, sister and daughter. PA #5 stated he did a thorough medical screening examination and Patient #24 did not have an emergency medical condition.