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Based on interview and record review, the facility failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) as evidenced by:

1. The facility failed to provide an adequate medical screening exam (MSE) in a timely manner for Patient 1. (Refer to C 2406)

2. The facility failed to ensure the signage regarding EMTALA and participation in the Medicaid/Medicare program were posted in all areas of the ED. (Refer to C 2402)

Deficiencies were issued at C 2402 and C 2506.

Based on observation, interview, and document review, the hospital failed to prominently post signage in all areas of its Emergency Department (ED) informing the public of their rights to seek and receive emergency services with respect to examination and treatment of emergency medical conditions including women in labor and the hospital's participation in Medicaid/Medicare program.

This failure to provide signage had the potential for the public and patients to be unaware of their rights when obtaining healthcare for medical conditions.

Findings:

A tour of the ED on 2/1/23 at 9 am included an ED lobby and waiting area, a trauma room with two beds, three other rooms, and a short hall from inside the ED that led out through double doors to the ambulance parking area. The EMTALA (Emergency Medical Treatment and Active Labor Act) signs relating to the right to receive emergency services were seen in the ED lobby area, but not other areas including in the hall for ambulance patients or any of the rooms.

During an interview on 2/1/23 at 9:05 am, the ED Manager (EDM) stated patients who come in by ambulance, enter through the ambulance entrance to the ED and directly to a room and do not wait in the ED lobby area.

During an interview on 2/1/23 at 9:15 am, EDM confirmed EMTALA signs were in the ED lobby but not in other areas so if pt brought in by ambulance directly to trauma room or other room there were no signs for them to see and no signs advising of the hospital's participation in the Medicaid Medicare program. EDM said she would post the necessary signs.

The facility's "EMTALA - Emergency Medical Treatment and Active Labor Act - transfer of Patients with Emergency Non-Emergency Medical Condition," policy, approval date 4/25/17, was reviewed. It indicated, "Posting Signs: 1. Conspicuous signs will be posted in the Emergency Department, Admitting Department, and hospital entrance which states the rights of individuals to emergency treatment and whether the hospital participates in the Med-Cal program."

Based on interview and record review, the facility (Hospital A) failed to ensure an adequate medical screening exam (MSE) was performed in a timely manner, to determine if an emergency medical condition was present for one of 14 patients (Patient 1), who presented to the Emergency Department (ED) with a complaint of chest pain. The hospital delayed in obtaining lab results, establishing intravenous (IV) access, and administering medications for Patient 1. This caused a delay in the treatment and diagnosis of a NSTEMI (non-ST-elevation myocardial infarction, heart attack) and transfer to Hospital B for a higher level of care.

Findings:

A review of Patient 1's record indicated she presented to ED on 1/19/23 at 3:51 pm via ambulance after choking episode. She was seen by the ED physician (MD 1) at 3:55 pm. An Electrocardiogram (EKG, records electrical signals from the heart) was ordered by MD 1 and completed at 3:59 pm and a chest x-ray was completed and read at 4:28 pm. Labs including a complete blood count (CBC, used to find a wide range of conditions including anemia and infection), comprehensive metabolic panel (CMP, gives information about the body's fluid balance, levels of electrolytes, and how well the kidneys and liver are functioning), Lactic acid (help diagnose sepsis, a life-threatening reaction to bacterial infection) were ordered at 4 pm, blood was collected by the lab at 4:10 pm, and results available by 4:41 pm. Results were within normal range except for the Lactic Acid. This result was higher than normal, and the ED staff were notified of this abnormal result by 4:42 pm. 1000 milliliters IV fluids were given as ordered by MD 1. Other lab orders included a Troponin level (measures the levels of troponin proteins in the blood. These proteins are released when the heart muscle has been damaged such as occurs with a heart attack. The more damage there is to the heart the greater the amount of troponin in the blood) at 6:27 pm but this lab was not done during this ED visit. A note from the nurse and MD 1 one hour prior to discharge indicated Patient 1 had no complaints of pain. Patient 1's blood pressure and oxygen saturation remained stable throughout this ED visit, and she was discharged at 7:40 pm and instructed to return for any worsening.

Further review of Patient 1's record indicated she returned to the ED via private vehicle at 8:35 pm. She was seen by MD 1 at 8:40 pm who noted when Patient 1 returned home, the fire department was called to help assist Patient 1 into her house when she complained of chest pain and was driven back to the ED. Licensed Nurse (LN 3) attempted twice to start an IV at 8:40 pm but was unsuccessful. MD 1 ordered an EKG at 8:52 which was completed at 9:46 and showed a possible old infarction (heart attack). Labs were also ordered at 8:52 and included a CBC, CMP, Lactic Acid and Troponin. The blood for these labs was collected at 10:31 pm. The CBC, CMP and Lactic acid were within normal range. The Troponin was completed at 10:59 and the result, which was elevated at 794 (troponin interpretive guidelines greater than 120 suggestive of myocardial ischemia or injury) was called to the ER Registered Nurse (RN 1) at 11 pm. Aspirin and Nitroglycerin (a medication used to relieve chest pain) were given at 11:15 pm. MD 1 called Hospital B to transfer Patient 1 to a higher level of care with a diagnosis of NSTEMI. IV access was established at 12:50 am and Morphine IV was given to Patient 1 at 1:09 am and she was transferred via ambulance to Hospital B at 1:10 pm.

A review of Patient 1's record at Hospital B indicated she arrived to the ED at 2:12 am on 1/20/23, and had arrived by ambulance after being seen and treated at Hospital A. She was admitted with a diagnosis of NSTEMI and discharged home on 1/24/23.

During a concurrent record review and interview on 2/2/23 at 9:45 am, the Lab Director (LD) confirmed there had been initial lab tests ordered at 4 pm on Patient 1's first ED visit and a Troponin ordered at a later time at 6:27 pm. She said Patient 1 was then discharged prior to the Troponin being done and she did not know why. She said it was a team effort to get blood collected for labs. If the nurse was going to start an IV on the patient, then the nurse would get the blood for the labs at the same time. If the patient already had an IV, then staff from the lab would draw the blood from the patient. In this case Patient 1 already had an IV and had blood collected for lab tests, when the physician later ordered another lab test. LD said in this case if she had been working she would have assumed this later order was an add on and there would have already been blood in the lab to complete this test. She said she was not sure why patient was discharged without this result. The record would show that the lab was still pending.

LD reviewed Patient 1's second ED visit and said more lab tests were ordered during this visit including a Troponin. The orders were entered at 8:52 and blood collected at 10:31 pm. She confirmed one of the lab technicians drew the blood but did not know what transpired between the time of the order and the time of the blood draw. LD said the nurse would try to start an IV but if unable to do so will call the lab department. She said she did not know what time lab was called from the ED to draw the blood.


During a concurrent record review and interview on 2/2/23 at 10:10 am, RN 2 confirmed she cared for Patient 1 during her first visit until she went off duty at 7:15 pm. She did not discharge Patient 1. RN 2 said she spoke to both Patient 1 and her husband and Patient 1 complained of pain in the throat area. The fire department had suctioned the patient so she thought the patient's complaints of throat pain could be related to that. RN 2 said she did not recall Patient 1 or her husband complaining of chest pain. The Troponin ordered by MD 1 at 6:27 pm was reviewed. She said MD 1 does not always tell the nurses when he puts orders in the computer, but lab orders go directly to the lab department. She said she did not recall, at the time she went off duty if the Troponin had been done or not. RN 2 said the patient's electronic health record can be reviewed under order activity. This would show any order that had not yet been done. She said she tries to check the order activity prior to discharge for any patient.

During a concurrent record review and interview on 2/1/23 at 6:45 pm, RN 1 confirmed she discharged Patient 1 from the first ED visit and was present in the ED during Patient 1's second visit. She said the other nurse she worked with on this shift was a Licensed Vocation Nurse (LN 3), so she was charge and triage (the preliminary assessment of patients) nurse. She was asked about the Troponin that had been ordered at 6:27 pm but not done prior to discharge. RN 1 said she did not know anything about an outstanding troponin that had not been done at the time of the discharge. She said she understood that all her labs had already been done on day shift. RN 1 was then asked why the labs were not collected until 10:31 pm when they had been ordered at 8:52 pm, during Patient 1's second ER visit. After reviewing the record, she said IV access was a problem and that was possible for the delay in getting the labs done and lab may have had a problem with getting blood, but that's not documented. She confirmed LN 3 had tried twice to get an IV for Patient 1 at 8:40 pm, but was unsuccessful, so Patient 1 had no IV access, until the Chief Nursing Officer (CNO) started an IV at 12:50 am (more than four hours later).

During a concurrent record review and interview on 2/2/23 at 11:28 am, the CNO confirmed he had worked night shift on 1/19/23 on the inpatient medical floor due to staffing issues. He said no one from the ED called and told him they were having IV issues. He said when he went to the ED to relieve LN 3 for a break, RN 1 told him they needed an IV in Patient 1. He started an IV although she was a difficult stick. The medication list for Patient 1's second visit was reviewed and he confirmed Toradol (pain reliever) was given IM (intramuscular) at 10:13 pm, Aspirin given by mouth at 11:25 pm, NTG (nitroglycerine for chest pain) sublingual (under the tongue) at 11:25 pm, and Morphine IV at 1:09 am, when the ambulance crew arrived to transport patient to Hospital B.

During a concurrent record review and interview on 2/2/23 at 1020 am, MD 1 recalled family had been feeding the patient and she had choked so they called 911 and the fire department showed up was and able to get the food out, but the patient had turned blue and had some bleeding around mouth. Labs, x-ray of chest, EKG, were done and were normal. The Lactic acid was elevated at 4.4 but the patient was given her one-liter IV fluids. The patient's husband was pushing to take her home. Since she had been monitored her for a while and she had voiced no complaints of chest pain to him, the patient was discharged home. When she got home, family called the fire department to help her get inside then the patient complained of chest pain, so she came back to the ED. This time she complained of chest pain so a chest pain work up was done and her troponin was almost 800 so she was transferred to Hospital B.

MD 1 stated for chest pain patients, we order CBC, CMP, troponin, Chest X-Ray, EKG, and IV saline lock for IV access and give Aspirin as soon as possible, NTG and morphine for pain. MD 1 reviewed the record and nurses notes about IV attempts at 8:40 pm and no IV access until 12:50 am. He said you need IV access with chest pain patients in case they code (cardiac or respiratory arrest). He said he did not know about the IV issues. The delay in getting blood drawn for labs was discussed and he said a two-hour delay was not acceptable and he also did not know about this delay. MD 1 stated Aspirin should be given right away within 10 minutes, and he was unaware of how long it took for Patient 1 to receive these medications after her arrival to the ED and said this was not acceptable. Patient 1's first visit was reviewed, and he said with this patient she had choking, was a large patient, had been cyanotic upon arrival of the fire department, and may have narrow coronary arteries so he added the Troponin lab order after the other labs had already been ordered and drawn. He said he did not know it had not been done before the patient was discharged and the time it took to get this done was too long. MD 1 said there was a delay in the care of Patient 1 regarding labs, meds and IV access. He said he orders labs, meds, IV, and other items and expects that the nurses will carry them out timely or tell him if unable to do so.

The facility's "Assessment - Emergency Patients," approval date 4/25/17 was reviewed. It indicated; the following should be documented by an Emergency Department Nurse: E. Follow-up on all diagnostic tests ordered. F. Notify physician, giving details. G. Carry out orders and treatments prescribed by the physician. H. Reassessment of patient following any treatment."