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Based on interview and record review, the hospital failed to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. This failure had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. The hospital failed to ensure the MSE was provided in a timely manner to determine whether or not an EMC existed for two of 20 sampled patients (Patients 5 and 11). Cross reference to A2406.

2. The hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for one of 20 sampled patients (Patient 4) when the ED staff did not ensure the pain management for Patient 4 as per the hospital's P&P. Cross reference to A2407.

Based on interview and record review, the hospital failed to ensure the MSE was provided in a timely manner to determine whether or not an EMC existed for two of 20 sampled patients (Patients 5 and 11) when the ED staff failed to ensure the circumstances for Patients 5 and 11 leaving the ED prior to being seen by the physician for medical screening was documented as per the hospital's P&P.

These failures had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving the ED services in the hospital.

Findings:

Review of the hospital's P&P titled Patient Transfers to Equal or Higher Level of Care - EMTALA dated 4/11/23, showed if the patient leaves before having a medical screening exam and has left without notice to personnel of his/her intent to leave, the circumstances should be documented on the patient's record.

a. On 7/29/24, Patient 5's closed medical record review was conducted with the ED Director. Patient 5's medical record showed the patient visited the ED on 2/25/24 at 2219 hours, with a chief complaint of an arm injury.

Review of the Patient Care Timeline showed on 2/25/24 at 2233 hours, RN 2 documented Patient 5 left without being seen before triage.

On 7/29/24 at 1417 hours, the ED Director acknowledged Patient 5's medical record did not have documentation as to the circumstances of Patient 5 leaving the ED.


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b. On 7/29/24 at 1300 hours, an interview and concurrent record review was conducted with RN 1.

Review of the ED central log showed Patient 11 arrived at the ED on 4/26/24 at 2101 hours, presenting with complaints of a fall with head injury and had left before being triaged.

However, review of Patient 11's medical record did not show the staff had documented the circumstances surrounding the patient's departure prior to being triaged and having a medical screening exam.

RN 1 verified the findings during the concurrent interview and record review and stated the triage nurse would make at least three attempts to locate the patient in the lobby, restroom, or outside of the ED, and document these attempts.

On 7/30/24 at 0940 hours, an interview was conducted with the ED Director who verified the above process for locating patients.

Based on interview and record review, the hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for one of 20 sampled patients (Patient 4) when the ED staff did not ensure the pain management for Patient 4 as per the hospital's P&P. This failure had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

Review of the hospital's P&P titled Emergency Department: Patient Assessment, and Reassessment dated 10/11/23, showed ED patients in a treatment area will have a reassessment performed a minimum of every one hours and will include an update on patient condition. The reassessment of pain level is to be documented with routine vital signs, along with before and after pain interventions.

Review of the hospital's P&P titled Pain Management dated 3/19/24, showed the RN will assess the patient's pain and document the pain assessment. The assessment of pain includes the patient's self-reported pain level, physical or behavioral symptoms of pain, vital signs, conditions known to cause pain for this patient, and the patient's history of pain and interventions used to alleviate the pain. Based on the assessment, the RN begins to formulate a plan of care to alleviate the patient's pain. Non-medical forms of treatment may be utilized e.g., back rub, position change, etc. Pain management methods should be taken into the consideration and address the physical, emotional, psychological, behavioral, cultural, spiritual, social, and economic faces of pain. If non-medical measures do not alleviate the patient's pain adequately, the RN may utilize pain medication as ordered by the physician. The reassessment of pain occurs between 30 to 60 minutes of administration: within 30 minutes for medication given IV route and 60 minutes for medications administered via oral, subcutaneous, or intramuscular routes. One of the hospital's pain assessment tools is the numeric, 0-10 pain scale (zero indicates the patient has no pain and 10 indicates the patient has the most severe pain).

Review of the Vital and Pain Assessment Flowsheet showed the following prompts for the pain assessment:

- Pain rating
- Pain onset and duration
- Pain side and orientation
- Pain description
- Pain radiation to
- Nonverbal indicators of pain
- Pain management interventions
- Response to pain interventions

On 7/29/24, Patient 4's closed medical record review was conducted with the ED Director.

Patient 4's medical record showed Patient 4 came to ED on 2/18/24 at 0127 hours, with a chief complaint of shortness of breath and chest pain.

Review of the pain assessment showed on 2/18/24 at 0136 hours, Patient 4's numeric pain rating was "8" or severe pain. However, there was no documentation of another pain assessment until 0417 hours, when Patient 4's numeric pain rating was "6", or moderate pain. Additionally, further review of the medical record failed to show any non-medical interventions or reassessment of Patient 4's pain was documented for the patient on 2/18/24 from 0136 to 0417 hours.

On 7/30/24 at 1003 hours, the above findings were shared and acknowledged by the ED Director.