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Based on hospital Medical Staff Bylaws, Rules and Regulations review, policy reviews, medical record reviews, physicians 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).

The findings include:

1. The hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 24 DED patients (#22) sampled who presented to the hospital for evaluation and treatment; and the hospital's leadership failed to ensure individual(s) determined qualified and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction to provide appropriate medical screening examinations (MSE) were defined by the hospital's Medical Staff bylaws or rules and regulations for 1 of 1 hospital's Medical Staff bylaws, rules and regulations reviewed (Hospital A).

~ Cross refer to §489.24(r) and §489.24(c) Medical Screening Examination - Tag C2406.

2. The hospital's Dedicated Emergency Department Physician failed to provide within the capabilities of the staff and facilities available at the hospital for further medical examination and treatment as required to stabilize the medical condition for 1 of 24 sampled patients (#22).

~ Cross refer to §489.24(d)(1-3) Stabilizing Treatment - Tag C2407.

Based on current Medical Staff Bylaws, Rules and Regulations review, policy reviews, medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 24 DED patients (#22) sampled who presented to the hospital for evaluation and treatment; and the hospital's leadership failed to ensure individual(s) determined qualified and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction to provide appropriate medical screening examinations (MSE) were defined by the hospital's Medical Staff bylaws or rules and regulations for 1 of 1 hospital's Medical Staff bylaws, rules and regulations reviewed (Hospital A).

Findings included:

Review on 10/25/2016 of current health system policy "Emergency Medical Treatment and Labor Act - EMTALA", Policy Number: 1RI.ADM.0003, revised 01/15/2015, revealed, "...DEFINITIONS: ...D. 'Emergency Medical Condition:' 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain....) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual....in serious jeopardy, or b. Serious impairment to bodily functions, or c. Serious dysfunction of any bodily organ or part. ...E. 'Medical Screening Examination (MSE):' The screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist. ...F. 'Qualified Medical Person (QMP):' An individual who is credentialed and has medical staff privileges to perform a medical screening exam in accordance with the medical staff bylaws, rules and regulations. ...EMTALA PROVISIONS OVERVIEW EMTALA is a federal law that addresses how hospitals deliver emergency services to the public. This federal law has specific legal duties for hospitals, including the following: A. Provide an appropriate Medical Screening Exam (MSE) to any individual who comes to the emergency department (ED) to determine whether or not an Emergency Medical Condition (EMC) exists... PROCEDURE: MEDICAL SCREENING EXAMINATION: A. Any individual who presents to the Emergency Department (ED)....and requests examination or treatment (request is made by or on behalf of the individual) will undergo a MSE to determine whether such individual is experiencing an EMC. ...E. When appropriate, the MSE will include those ancillary services routinely available to the ED. The MSE is not an isolated event, but an ongoing process. The medical record must reflect monitoring appropriate to the patient's clinical condition until the patient is determined not to have an EMC or, if an EMC exits, until the patient is stabilized and transferred. F. An ED physician on duty will be responsible for the general care of all patients presenting to the ED. This responsibility remains with the ED physician until the patient's accepting physician or an on-call specialist assumes responsibility or the patient is discharged. ...."

1. Hospital A, closed DED record review on 10/25/2016 for Patient #22, revealed a 37 year old male presented via private vehicle to the DED on 02/11/2015 at 0306 (visit #1) with a chief complaint of "ABDOMINAL PAIN." Review of Triage documentation at 0310 by RN #1 revealed "Stated Reason for Visit: lower abdomen pain radiating to bilat (bilateral) legs, started in am (morning)." Review of triage vital signs revealed Blood Pressure (BP) 197/120 (elevated), Heart Rate (HR) 84, Respiratory Rate (RR) 26 (elevated), Temperature (T) 98.7° F orally, Oxygen Saturation (O2Sat) 98% room air (RA), Height 76 inches, Weight 193.1 pounds, and Pain assessed as 10/10 (0 pain free, 10 worst pain). Review revealed a Glasgow/Trauma Score of 15 (normal). Review revealed a PMH (past medical history) of Hypertension (high BP), seizures, pseudoseizures, and depression. Review of home medications revealed, Valsartan (Diovan) [for high BP]. The patient was assigned an acuity level: ESI (emergency severity index) 3 - Urgent.

Review of ED Assessment documentation by RN #2 at 0336 revealed Neurological - alert, awake, and oriented X4 (person, place, time, and situation). Extremity Reflex/Sensation - Lower Extremity, Left - Normal Power. Lower Extremity, Right - Normal Power. Left Lower Extremity Sensation - Sensation Intact. Right Lower Extremity Sensation - Sensation Intact. Pulse Check - Dorsalis Pedis Pulse, Left - Normal. Dorsalis Pedis Pulse, Right - Normal. Gastrointestinal - Abdomen Description - Soft, Tender. Bowel Sounds - Present. Nausea - Yes. Genitourinary - Urinary WDL (within defined limits) Yes. Review of pain reassessment at 0413 revealed 10/10 (no change). Review of vital signs reassessment at 0441 revealed BP 156/88, HR 77, RR 20, and O2Sat 99% RA. Review of pain reassessment at 0635 revealed a 7/10. Review of ED Assessment documentation by RN #2 at 0707 revealed Neurological - alert, awake, and oriented X4. Extremity Reflex/Sensation - Upper Extremity, Left - Normal Power. Upper Extremity, Right - Normal Power. Lower Extremity, Left - Moves with Gravity Eliminated. Lower Extremity, Right - Moves with Gravity Eliminated. Left Lower Extremity Sensation - Numbness, Tingling, Pain (a change in assessment). Right Lower Extremity Sensation - Numbness, Tingling, Pain (a change in assessment). Pulse Check - Dorsalis Pedis Pulse, Left - Normal. Dorsalis Pedis Pulse, Right - Normal. Gastrointestinal - Abdomen Description - Soft, Tender. Bowel Sounds - Present. Nausea - No. Musculoskeletal - Current Functional Status - At Baseline (On Admission). Tone - Normal.

Record review revealed a MSE was performed at 0308 by Physician A. Review of MSE documentation (not timed) by Physician A on a "LOWER EXTREMITY INJURY/PAIN" T - Sheet (template based documentation system), revealed a chief complaint of pain to right and left thigh, knee, leg, and calf. Review of History of Present Illness revealed onset 1 hour, duration - continues, severity of pain - moderate, pain quality - sharp. Review revealed, "just starting [sic] hurting from hips to feet both sides." Associated symptoms - none. Review revealed, "PMH/SH/FH (past medical history/social history/family history) [check mark in box] Reviewed on nurse's notes and agree." Review of Systems - ROS All Systems reviewed and negative except as indicated. Review of Physical Exam revealed, "[check mark in box] vital signs reviewed." Appearance - distressed, mild. HIP/PELVIS - tenderness. Normal neurovascular exam. THIGH - tenderness, no deformity, no swelling/ecchymosis, skin intact. KNEE - tenderness, no deformity, no swelling/effusion, skin intact, Full ROM (range of motion) with pain. Leg - pain on palpation, no deformity, no calf tenderness. FOOT and ANKLE - pain on palpation, no deformity. LOWER EXTREMITY NEUROVASCULAR EXAM - normal pulse, normal motor. Decreased sensation from hips to feet. HEENT (head, ears, eyes, nose, throat) - normal. NECK - Normal. CARDIOPULMONARY - (section left blank). GI/GU (Gastrointestinal/Genitourinary) - [section left blank]. BACK - normal. SKIN - normal. NEUROLOGICAL - no focal deficits. PSYCHIATRIC - oriented X3. Mood/affect normal. Further review revealed the following check box options, " I HAVE PERFORMED A MEDICAL SCREENING EVALUATION NO EMERGENCY MEDICAL CONDITION EXITS FURTHER EVALUATION NEEDED TO RULE OUT AN EMC" (all left blank). Review revealed, "Mr. (Patient #22's name) is well known to us for pseudoseizures. His pain symptoms tonight do not correlate to any medical problem I know of. I suspect somatization/conversion DO (disorder)." Review revealed a CLINICAL IMPRESSION of Right and Left lower extremity pain c/w (consistent with) conversion disorder. DISPOSITION - home. Condition - stable.

Review revealed the following medications administered by a RN as ordered by Physician A: 1. Promethazine (Phenergan) 25 mg (milligrams) IM (intramuscular), ordered 02/11/2015 at 0326 - administered at 0334; and
2. Diphenhydramine (Benadryl) 50 mg IM, ordered 02/11/2015 at 0433 - administered at 0441.

Review revealed no diagnostic laboratory or radiological studies ordered by Physician A.

Review of ED Depart Summary revealed "Diagnosis: Leg pain Specific ED Discharge Instructions: Follow up with your doctor. It is stress that is causing your leg pain. ...Your ED Physician recommends that you follow up with: Your Primary Care Physician: (Physician's name). ...PATIENT EDUCATION INFORMATION: Instructions Given: ANXIETY REACTION." Review revealed the patient was discharged from the DED at 0804 (4 hours and 58 minutes after presentation).

Review on 10/25/2016 of an (XYZ name) County Emergency Medical Services (EMS), Patient Care Report (PCR) for Patient #22 revealed, Medic 1 was dispatched to a residence on 02/11/2015 at 1337. Review revealed Medic 1 arrived on scene at 1344, departed scene at 1351, and arrived at Hospital A at 1359. Review of the narrative revealed, "CALLED RE (reference) PARALISYS [sic]. ON ARRIVAL, FOUND THE ABOVE PT SUPINE ON COUCH. PT STATES THAT HE WENT TO (Hospital A name) LAST NIGHT FOR LEG PAIN. HE STATES THAT HE WAS GIVEN INJECTIONS AND SENT HOME. HE STATES THAT HE NOW HAS ABDOMINAL PAIN, BACK PAIN AND ....CAN NOT MOVE OR FEEL HIS LEGS. ON EVAL (evaluation), PT LEGS COLD TO TOUCH AND APPEAR PALE. PT IS PLACED ON STRETCHER, MOVED TO UNIT AND EMERGENCY T-PORT (transport) TO (Hospital A name) BEGAN. WHILE ENROUTE, IV AND MONITOR PLACED ....PT STILL HAS NO PMS (pulse, motor, and sensation). ON ARRIVAL, PT PLACED IN ER ROOM 6...." Review of initial assessment documentation by an EMT-Paramedic at 1345 revealed, Abdomen - DISTENTION, General, Left Upper (+) Distention, Right Upper (+) Distention, Left Lower (+) Distention, Right Lower (+) Distention. Back - PT STATES LOW BACK PAIN, Lumbar/Sacral (+) Pain on ROM. Extremities - Left leg, (+) Abnormal Pulse Abnormal Sensation Paralysis; Right leg, (+) Abnormal Pulse Abnormal Sensation Paralysis; Pulse Pedal Absent; Capillary Refill, (+) Left lower 3 seconds, Right Lower 3 seconds. Neurological - BOTH LEGS PARALYSIS.

Hospital A, closed DED record review for Patient #22 revealed the patient returned via EMS ambulance to the hospital's DED on 02/11/2015 at 1403 (visit #2) [5 hours and 59 minutes after discharge] with a chief complaint of "PARALYSIS" and "LEG PAIN - SWELLING." Review of Triage documentation at 1406 by RN #3 revealed "Stated Reason for Visit: pt (patient) reports rcvg (receiving) 2 inj (injections) and now legs unable to move, cool to touch; back and abd (abdominal) pain; slow cap refill in both feet; more pain in rt. (right) leg. ..." Review of triage vital signs revealed BP 192/88, HR 88, RR 18, T 98.2° F orally, O2Sat 97% RA, Height 70 inches, Weight 200.8 pounds, and Pain assessed as 10/10. Review revealed a Glasgow/Trauma Score of 15. Review revealed a PMH of Hypertension, seizures, pseudoseizures, and depression. Review of home medications revealed, Valsartan (Diovan). The patient was assigned an acuity level: ESI 2 - Emergent.

Review of ED Assessment documentation by RN #4 at 1425 revealed Neurological - alert and oriented X4. HEENT WDL (within defined limits) - Yes. Pulmonary Data WDL - Yes. Gastrointestinal WDL - Yes. Genitourinary WDL - Yes. Musculoskeletal WDL Yes, Except For - Moves All Extremities Well - No. Other: Paralysis of both legs and no rectal tone. Bilateral. Range of Motion, Limited Function. Integumentary WDL - Yes.

Review of vital signs and pain reassessment documentation revealed at:
1415: BP 225/81, HR 80, and O2Sat 98% RA;
1430: BP 212/81 and O2Sat 95% RA;
1432: Pain reassessment 10/10 (no change);
1445: BP 193/79 and O2Sat 95% RA;
1500: BP 202/88 and O2Sat 96% RA;
1515: BP 206/87 and O2Sat 95% RA;
1530: BP 200/86, RR 15, and O2Sat 96% RA;
1532: Pain reassessment 6/10;
1545: BP 197/88 and O2Sat 96% RA;
1600: BP 205/88 and O2Sat 95% RA;
1615: BP 205/88 and O2Sat 96% RA;
1630: BP 221/89 and O2Sat 96% RA;
1645: BP 221/89 and O2Sat 95% RA;
1700: BP 213/91 and O2Sat 95% RA;
1715: BP 212/95 and O2Sat 96% RA;
1730: BP 211/101 and O2Sat 96% RA;
1740: BP 223/97, HR 83, RR 16, and T 98.2° F;
1745: BP 224/93 and O2Sat 96% RA;
1800: BP 207/88 and O2Sat 96% RA;
1815: BP 220/104 and O2Sat 96% RA;
1830: BP 236/105 and O2Sat 95% RA;
1845: BP 244/102 and O2Sat 96% RA; and
1858: BP 234/106 and O2Sat 96% RA.

Record review revealed a MSE was performed at 1408 by Physician B. Review of MSE documentation (not timed) by Physician B on a "GENERAL ADULT ILLNESS" T - Sheet, revealed a chief complaint of "- Back Pain LE (Lower Extremity) weakness." Review of History of Present Illness revealed, "Low Back Pain for ~ (approximately) 24° (hours), & Weakness + Numbness in both LE. - States he has no control of his stool. - Pt seen this am in ER for same but sent home - D/W (diagnosed with) possible conversion D/O (disorder)." Review of associated symptoms revealed, arthralgia low back. Alleviating factors none. Review revealed, "PMH/SH/FH [check mark in box] Reviewed on nurse's notes and agree." Review of Systems - ROS All Systems reviewed and negative except as indicated. Review revealed, Neuro/Psych was circled. Review of Physical Exam revealed "[check mark in box] vital signs reviewed." Appearance - normal. HEENT - normal. NECK - Normal. RESPIRATORY - normal breath sounds. CARDIAC - RRR (regular rate rhythm), no murmur. GI/GU - non tender, normal bowel sounds, no organomegaly (enlarged organs). RECTAL - "No Rectal Tone. Loss of Sensory & motor Fnx (function) below inguinal line." BACK - midline & muscular tenderness. SKIN - normal. EXTREMITIES - "No sensory fnx in BLE (bilateral lower extremities) - complete pendesis [sic] of (B)LE." No pedal edema. NEUROLOGICAL - CN II XII (cranial nerves 2 thru 12) intact. No sensory loss. No focal weakness. PSYCHIATRIC - oriented X3. Mood/affect normal. Further review revealed, "[check mark in box] I HAVE PERFORMED A MEDICAL SCREENING EVALUATION NO EMERGENCY MEDICAL CONDITION EXITS FURTHER EVALUATION NEEDED TO RULE OUT AN EMC." Review revealed, RADIOGRAPHS - visualized. MRI (magnetic resonance imaging) Lumbar (-) [negative]. Review of ED COURSE revealed, "Discussed with Dr. [Physician D name] (Neuro) Time 1730 pm." Review revealed, CLINICAL IMPRESSION - Bilateral lower extremity paralysis - R/O (rule out) Guillain-Barre Syndrome - Leukocytosis. DISPOSITION - transfer. Condition - fair.

Review revealed the following medications administered by a RN as ordered by Physician B: 1. Hydromorphone (Dilaudid) 1 mg IVP (intravenous push), every 1 hour PRN (as needed) for pain, ordered 02/11/2015 at 1430 - administered at 1432 and 1532;
2. Ondansetron (Zofran) 4 mg IVP, ordered 02/11/2015 at 1430 - administered 1432; and
3. Metoprolol (Lopressor) 5 mg IVP, ordered 02/11/2015 at 1850 - administered at 1858.

Review revealed the following diagnostic laboratory and radiological studies ordered by Physician B and completed:
1. CBC (complete blood count) with Differential - ordered 02/11/2015 at 1432, collected at 1442, revealed WBC (white blood cell) 18.8 [reference range 3.2-11.8];
2. Magnesium - ordered 02/11/2015 at 1433, collected at 1442, revealed 2.7 [reference range 1.6-2.6];
3. Comprehensive Metabolic Panel - ordered 02/11/2015 at 1433, collected at 1442, revealed Creatinine 1.48 [reference range 0.72-1.25]; AST (liver enzyme) 187 [reference range 5-34];
4. Auto Differential - ordered 02/11/2015 at 1447, collected at 1442, revealed Auto Neutrophils Absolute # 16.5 [reference range 1.3-8.1]; Auto Segmented Neutrophils % 87.7 [reference range 35.0-75.0]; Auto Lymphocytes 4.4 [reference range 19.0-48.0];
5. MRI Lumbar Spine W/O (without) Contrast - ordered 02/11/2015 at 1508, completed at 1650, revealed "IMPRESSION: Normal."

Review of a Certification of Transfer dated 02/11/2015 and signed by Physician B at 1944 revealed, "I. MEDICAL CONDITION. Diagnosis, Acute nontraumatic Paraplegia. R/O Guillain-Barre Syndrome. Medical Screening Exam Completed. Emergency Medical Condition Identified - Patient Stable." Review revealed vital signs prior to transfer at 1929 were BP 223/97, HR 83, RR 16, and T 98.2° F.

Review of Discharge documentation at 1956 by a RN revealed "Discharge Comments Transferred to (Hospital B name) A412 (room number) with report. Pt is alert, VSS (vital signs stable) and no other change. Small decrease BP after Lopressor and (Hospital B name) Nurse Made aware."

Hospital B, closed medical record review on 10/26/2016 for Patient #22 revealed the patient was admitted directly to inpatient room #A412 on 02/11/2015 at 2047. Review of a NEURO Admission H&P (history and physical) Note, dated 02/11/2015 at 2224 by Physician D (Neurologist) revealed, "...Patient accepted in transfer from (Hospital A name) ER because of acute onset of pain and lower extremity paralysis since 03:00 on 2/11/2015. ...He endorses that he has felt fine for the past few days ....He woke up with leg pain first, R>L (right greater than left) and the inability to move his legs. He took an ambulance to the ED where he was though [sic] to have an anxiety reaction per review of the notes. Report from the transferring physician suggests that he got a short [sic] of something for pain and some steroids. He was sent home around 08:00. The patient came back in an ambulance around 14:00 because he was unable to walk, his feet were cold and his pain had worsened, now with new onset abdominal pain. The ER doctor noted that he was areflexic in his lower extremities, had no sphincter tone and ordered an MRI L-spine which came back as normal. He called requesting further neurologic evaluation..." Review of a Computed Tomography (CT) report for a CT angiogram of the thorax and abdomen, dated 02/12/2015 at 0324 revealed, "Findings CLINICAL: suspected aortic dissection resulting in acute cord injury? Symptoms suggestive of T8 to T10 level. ...THORAX IMPRESSION: 1. Type A aortic dissection involving the ascending aorta just above the aortic valve flaps with the greatest transverse dimension of the ascending aorta measured at 4.4 cm. ABDOMEN IMPRESSION: 1. Type A dissection extending into the right renal artery with 2 areas of infarcted right kidney. 2. The abdominal aorta is occluded just above the bifurcation. ..." Review of a physician's consultation note, dated 02/12/2015 at 0430 by Physician E (Cardiothoracic/Vascular Surgeon), revealed "I was asked to see Mr. (Patient #22 name) in consult, who is a 37-year-old gentleman that presented to (Hospital A name) Emergency Room yesterday at 3:00 a.m. on 02/11/2015, complaining of acute onset of lower extremity pain and weakness. He is a very poor historian, this was an acute onset event, who was awakened in the middle of the night with the right leg worse than his left leg pain and inability to move his legs. He was taken to the Emergency Room. Per Dr. (Physician D name) notes, he was thought to be having an anxiety reaction as the patient does have some history of conversion disorder. He was treated with pain medication and steroids and sent home at approximately 8:00 a.m. He returned by ambulance to [sic] 1400 because of his inability to walk. His pain was worsened and he had new onset of abdominal pain. It was noted at that time by the ER physician, per Dr. (Physician D name) note that the patient was areflexic with no sphincter tone and an MRI scan of the L-spine was normal. Dr. (Physician D name) was consulted for further neurologic evaluation. The patient was transferred to (Hospital B name), and the patient was noted to have elevated creatinine and underwent MRI scans of his cervical, lumbar and thoracic spine without any abnormalities identified, and also underwent a CT angiogram of the chest and abdomen which revealed a Type A aortic dissection, with a flap that begins just above the aortic valve, significantly compresses the true lumen, with extension of the dissection into both carotid arteries, and terminates in the abdomen below the renal arteries where the aorta is occluded with no flow seen below that level in the true or false lumen. The ascending aorta measuring 4.4 cm (centimeters) in diameter. There is evidence of right renal infarction. ...PHYSICAL EXAMINATION: GENERAL: The patient is a poor historian, he is conversant, complaining of abdominal pain and bilateral leg pain. ...ABDOMEN: His abdominal wall is firm, tense, his abdomen is mildly distended. He also is very tender to palpation with positive peritoneal signs. NEUROLOGIC: His neurologic exam as articulated by Dr. (Physician D name), shows that his cranial nerves are intact. He has normal strength and tone in his upper extremities. His lower extremities demonstrate no movement. He has diffuse fasciculations in the upper areas of his thigh extending into the calf. He has no sensation of his lower extremities, he has absent reflexes bilaterally in his lower extremities. VASCULAR: ...His lower extremity exam shows that he has no palpable or dopplerable pulses in the femoral, popliteal, posterior tibial or dorsalis pedal arteries. There is no evidence of any venous flow. EXTREMITIES: Shows his extremities to be pale, cool in the upper thigh too cold at the level of the lower calf and feet. The feet have rigor present, the calf muscles are firm, with fasciculations present. ...SUMMARY This is a young gentleman with malignant hypertension, medical noncompliance, with acute Type A aortic dissection that is over 24 hours old, who has by CT angio, evidence of severe compromise of his true lumen, with complete aortic occlusion in the mid abdomen, and physical examination consistent with an acute abdomen, likely secondary to bowel ischemia, right renal infarction by CT, and evidence of cadaveric lower extremities bilaterally. This is an unrecoverable condition, and surgical intervention would not change the ultimate outcome. I discussed the fact that this is a fatal condition, and that the delay in diagnosis has brought his level of progression of ischemia to a point that it is irreparable. His mortality is 100%. He will need Palliative Care consult and I would focus predominantly on comfort measures. ..." Record review revealed the patient expired on 02/12/2015 at 1910 (40 hours and 4 minutes after initial presentation to Hospital A's DED on 02/11/2015 at 0306).

Review on 10/26/2016 of a Follow-up Summary for Diagnosis/Treatment Event (11369) with time-line attached revealed, "Follow-Up Actions" with Date(s) 02/13/2015, 02/16/2015, 02/17/2015, 03/05/2015, 03/09/2015, 03/16/2015, 03/25/2016, and 04/01/2015. Further review revealed, "From Dr. (Physician H name) via email: Case Summary: This 37-year-old male reportedly had a history of pseudoseizures. He presented to (Hospital A name) the morning of February 11, 2015 complaining of bilateral lower extremity pain as well as lower abdominal pain. He was noted to be hypertensive with a blood pressure of 197/120 in triage, but came down to 150/88 at discharge. No laboratory studies drawn. Patient discharged with a diagnosis of conversion disorder. Subsequent nursing communications indicate that the patient was having a hard time walking at discharge from the (Hospital A name) emergency room. The patient came back to the (Hospital A name) emergency room that afternoon. He had activated EMS. He reported that his legs felt cold. He could not walk. He had suffered loss of bowel control. Laboratory evaluation revealed acute kidney injury and an AST of 187. White count elevated to 18. The EMS and ED documentation reflect blood pressures in the 190-200 range. Physical examination documents no rectal tone and loss of sensory/motor function in the lower extremities. The ED documentation indicates that they were considering a diagnosis of Guillain-Barre Lumbar MRI was performed to (Hospital A name) which was normal. He was transferred that evening to (Hospital B name). He is evaluated promptly by neurology. The neurology progress note indicates that there [sic] were at least considering vascular disorders as they note 'he does not have a history of aortic aneurysm or other vascular problems' in their initial progress note. The patient's lower extremities are noted to be cool. The neurology physical examination also documents a distended 'very tender' abdomen with absent bowel sounds. They begin their evaluation with an MRI of the thoracic and cervical spine. They do indicate that they have reviewed his MRI of the lumbar spine with radiology specifically to evaluate for evidence of aortic pathology which is not seen. The MRI of the cervical and thoracic spine was unremarkable. Follow-up CT angiography of the abdomen is performed at 2:40 AM. This shows evidence of Type A aortic dissection. On reevaluation at 4 in the morning the patient is noted to have absent pulses in the lower extremities. He is described as having an acute abdomen. The vascular surgery service is consulted and they note that he has had severe compromise of blood flow to the lower half of his body resulting in bowl ischemia and renal infarction. They note that his mortality is 100%. They discuss with the family that this is an unrecoverable condition and surgical intervention will not change the ultimate outcome. The patient is transitioned to comfort care and expired rapidly. The primary concern here is the delay in diagnosis. While he did not exhibit the typical presentation for an aortic aneurysm, there was evidence of end organ damage on his initial labs drawn on his second visit to (Hospital A name) - AST of 187, creatinine of 1.4. In a patient with abdominal pain radiating to the back one would think about aortic dissection, although in fairness he was quite young. I wonder if the patient's history of high ER utilization and reported history of pseudoseizures worked against him and anchored providers to a psychiatric diagnosis despite objective evidence of organic pathology during his first ER visit. At (Hospital B name) the neurology team's differential diagnosis does include vascular pathology and they proceed with abdominal imaging expeditiously after his MRI is unrevealing as to the source of his symptoms. Surgery is consulted promptly, but his ischemia has progressed to far for surgical interventions to be helpful." Review of "Details" revealed "Forwarded to (Hospital A name) Peer Review Committee, to formally request that (Hospital B name) Peer Review Committee act on behalf of (Hospital A name) Peer Review Committee to conduct peer-professional review of records and other information concerning specific clinical concerns regarding clinical care delivered to patients at (Hospital A name) Peer Review Committee. ..."

Interview on 10/27/2016 at 0900 with Physician B revealed, he had been on Hospital A's medical staff since 2002 and worked for the hospital's contracted ED physician group. He was familiar with Patient #22 and had seen the patient on prior ED visits. He was the attending ED physician who conducted the MSE on the patient during the return visit on 02/11/2015 (visit #2). He read what the RN documented at triage and his questions to the patient were based from the triage notes and what the patient told him during exam. At some point he reviewed or was shown Dr. (Physician A name)'s notes from the prior visit on 02/11/2015 (visit #1) and that the patient was diagnosed with conversion disorder. The patient's main complaint on exam was back pain and lower extremity weakness. The patient had "no other major complaints." He was aware the patient complained of abdominal pain to the triage RN and "I did not get that information from the patient." The patient had no abdominal pain upon examination. The abdomen was negative and non-tender. The patient "certainly had back pain and lower extremity findings that were suspicious for spinal cord injury." The patient had no rectal tone, no sensory to lower legs, and motor impairment. A spinal cord injury or disease process was suspected. Labs and a MRI were ordered. The MRI was negative. The patient had an elevated BP and pain of 10/10 most likely due to back pain, an "on-going condition" and no pain to his lower extremities. The patient was given Lopressor, Dilaudid, and Zofran. Dr. (Physician D name) with Neuro was consulted at Hospital B and the patient was transferred to Hospital B. The patient's diagnosis was bilateral lower extremity paralysis rule out Guillain-Barre Syndrome and leukocytosis. The patient "absolutely" presented with an EMC. The EMC was "ongoing at transfer." "I feel there was no EMTALA issue with the transfer." He was aware of the patient's diagnosis (Type A Aortic Dissection) and outcome (death) after being transferred to Hospital B. He received EMTALA education and training provided annually through the hospital.

Interview on 10/27/2016 at 0945 with RN #2 revealed he was a RN in Hospital A's ED. He was the primary ED nurse assigned to take care of Patient #22 on 02/11/2015 at 0306 (visit #1). He was "familiar" with the patient and had talked to a lawyer recently for the hospital about the patient's care, approximately 4 weeks ago. He was not present when the ED Physician (Physician A) evaluated the patient. He did not triage the patient. He did not recall exactly what the patient complained about. "He (the patient) hurt." Primarily in his abdomen or legs? "I saw the patient walk into the department without difficulty and walk out and come back in." When the patient came back in it looked like he was having some difficulty. The patient was alert, oriented X4, and "very anxious." Review of the ED record during the interview for 02/11/2015 (visit #1), revealed at 0336 he documented the patient's bilateral lower extremities as "Normal Power" and "Sensation Intact." The patient had normal pedal pulses and his abdomen was tender, soft, with positive bowel sounds. At 0707 he documented the patient's bilateral lower extremities as "Moves with Gravity Eliminated" and "Numbness, Tingling, Pain." Musculoskeletal was at baseline with no change. He did not recall if the change in lower extremity assessment was reported to the ED physician. At discharge the patient was discharged in a wheelchair. The patient reported his legs were hurting. "Seems like I had to assist him to ambulate at discharge." The patient called a manager from his work to come and pick him up from the ED, a lady. Discharge instructions were reviewed with the patient. "I was worried about the lady getting the patient into his home. I had to help the patient into the wheelchair and into the car." He did not remember if he notified the ED physician the patient was having difficulty ambulating at discharge. EMTALA education and training was provided annually by the hospital. He has had a "recent review."

Interview on 10/27/2016 at 1020 with RN #3 revealed she was a RN in Hospital A's ED and the patient's record had been discussed with her 1-2 months ago by the hospital's attorney. She recalled the patient, he had been there multiple times and was seen on a regular basis. She triaged the patient on 02/11/2015 at 1403 (visit #2). The patient arrived by EMS ambulance. The patient was unable to move from the EMS stretcher to the ED bed. The patient was confused and not quite himself. He was awake with eyes open. She documented the reason for the visit from what was being told to her. The patient was not able to give much information, report primarily came from EMS personnel. She did not perform a hands on physical exam. Pain was a 10/10 and GCS 15. She did not recall her general impression of the patient upon arrival to the ED. She did not recall any other interactions with the patient after triage. EMTALA education and training was provided in yearly competencies by the hospital.

Interview on 10/27/2016 at 1425 with Physician C revealed he was Hospital A's ED Medical Director. He had been on the hospital's medical staff for 1 year and had been ED Medical Director for 10 months and worked for the hospital's contracted ED physician group. He had been an ED physician for 36+/- years. Re

Based on policy reviews, medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department Physician failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 1 of 24 sampled patients (#22).

Findings included:

Review on 10/25/2016 of current health system policy "Emergency Medical Treatment and Labor Act - EMTALA", Policy Number: 1RI.ADM.0003, revised 01/15/2015, revealed, "...DEFINITIONS: ...D. 'Emergency Medical Condition:' 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain....) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual....in serious jeopardy, or b. Serious impairment to bodily functions, or c. Serious dysfunction of any bodily organ or part. ...E. 'Medical Screening Examination (MSE):' The screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist. ...G. 'To stabilize or stabilized:' 1. With respect to an emergency medical condition, the patient is provided such medical treatment of the condition as is necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the patient; or ...3. The emergency medical condition has resolved. ...EMTALA PROVISIONS OVERVIEW EMTALA is a federal law that addresses how hospitals deliver emergency services to the public. This federal law has specific legal duties for hospitals, including the following: ...B. Provide necessary stabilizing treatment to an individual with an EMC....within the hospital's capability and capacity... PROCEDURE: STABILIZATION: A. When the hospital determines that an individual has an EMC, and the EMC is appropriate and within the capacity and capability of the hospital facilities and qualified personnel, the individual experiencing an EMC must be stabilized prior to transfer or discharge, except as set forth below in Item E. ...C. 'Stabilization' for discharge is achieved when the patient's EMC has resolved to the point within reasonable clinical confidence, where the patient's continued care, where appropriate, including further diagnostic work-up and/or treatment, could be performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with discharge instructions. ...E. An individual experiencing an EMC who has not been stabilized may be transferred appropriately...."

Hospital A, closed DED record review on 10/25/2016 for Patient #22, revealed a 37 year old male presented via private vehicle to the DED on 02/11/2015 at 0306 (visit #1) with a chief complaint of "ABDOMINAL PAIN." Review of Triage documentation at 0310 by RN #1 revealed "Stated Reason for Visit: lower abdomen pain radiating to bilat (bilateral) legs, started in am (morning)." Review of triage vital signs revealed Blood Pressure (BP) 197/120 (elevated), Heart Rate (HR) 84, Respiratory Rate (RR) 26 (elevated), Temperature (T) 98.7° F orally, Oxygen Saturation (O2Sat) 98% room air (RA), Height 76 inches, Weight 193.1 pounds, and Pain assessed as 10/10 (0 pain free, 10 worst pain). Review revealed a Glasgow/Trauma Score of 15 (normal). Review revealed a PMH (past medical history) of Hypertension (high BP), seizures, pseudoseizures, and depression. Review of home medications revealed, Valsartan (Diovan) [for high BP]. The patient was assigned an acuity level: ESI (emergency severity index) 3 - Urgent.

Review of ED Assessment documentation by RN #2 at 0336 revealed Neurological - alert, awake, and oriented X4 (person, place, time, and situation). Extremity Reflex/Sensation - Lower Extremity, Left - Normal Power. Lower Extremity, Right - Normal Power. Left Lower Extremity Sensation - Sensation Intact. Right Lower Extremity Sensation - Sensation Intact. Pulse Check - Dorsalis Pedis Pulse, Left - Normal. Dorsalis Pedis Pulse, Right - Normal. Gastrointestinal - Abdomen Description - Soft, Tender. Bowel Sounds - Present. Nausea - Yes. Genitourinary - Urinary WDL (within defined limits) Yes. Review of pain reassessment at 0413 revealed 10/10 (no change). Review of vital signs reassessment at 0441 revealed BP 156/88, HR 77, RR 20, and O2Sat 99% RA. Review of pain reassessment at 0635 revealed a 7/10. Review of ED Assessment documentation by RN #2 at 0707 revealed Neurological - alert, awake, and oriented X4. Extremity Reflex/Sensation - Upper Extremity, Left - Normal Power. Upper Extremity, Right - Normal Power. Lower Extremity, Left - Moves with Gravity Eliminated. Lower Extremity, Right - Moves with Gravity Eliminated. Left Lower Extremity Sensation - Numbness, Tingling, Pain (a change in assessment). Right Lower Extremity Sensation - Numbness, Tingling, Pain (a change in assessment). Pulse Check - Dorsalis Pedis Pulse, Left - Normal. Dorsalis Pedis Pulse, Right - Normal. Gastrointestinal - Abdomen Description - Soft, Tender. Bowel Sounds - Present. Nausea - No. Musculoskeletal - Current Functional Status - At Baseline (On Admission). Tone - Normal.

Record review revealed a MSE was performed at 0308 by Physician A. Review of MSE documentation (not timed) by Physician A on a "LOWER EXTREMITY INJURY/PAIN" T - Sheet (template based documentation system), revealed a chief complaint of pain to right and left thigh, knee, leg, and calf. Review of History of Present Illness revealed onset 1 hour, duration - continues, severity of pain - moderate, pain quality - sharp. Review revealed, "just starting [sic] hurting from hips to feet both sides." Associated symptoms - none. Review revealed, "PMH/SH/FH (past medical history/social history/family history) [check mark in box] Reviewed on nurse's notes and agree." Review of Systems - ROS All Systems reviewed and negative except as indicated. Review of Physical Exam revealed, "[check mark in box] vital signs reviewed." Appearance - distressed, mild. HIP/PELVIS - tenderness. Normal neurovascular exam. THIGH - tenderness, no deformity, no swelling/ecchymosis, skin intact. KNEE - tenderness, no deformity, no swelling/effusion, skin intact, Full ROM (range of motion) with pain. Leg - pain on palpation, no deformity, no calf tenderness. FOOT and ANKLE - pain on palpation, no deformity. LOWER EXTREMITY NEUROVASCULAR EXAM - normal pulse, normal motor. Decreased sensation from hips to feet. HEENT (head, ears, eyes, nose, throat) - normal. NECK - Normal. CARDIOPULMONARY - (section left blank). GI/GU (Gastrointestinal/Genitourinary) - [section left blank]. BACK - normal. SKIN - normal. NEUROLOGICAL - no focal deficits. PSYCHIATRIC - oriented X3. Mood/affect normal. Further review revealed the following check box options, " I HAVE PERFORMED A MEDICAL SCREENING EVALUATION NO EMERGENCY MEDICAL CONDITION EXITS FURTHER EVALUATION NEEDED TO RULE OUT AN EMC" (all left blank). Review revealed, "Mr. (Patient #22's name) is well known to us for pseudoseizures. His pain symptoms tonight do not correlate to any medical problem I know of. I suspect somatization/conversion DO (disorder)." Review revealed a CLINICAL IMPRESSION of Right and Left lower extremity pain c/w (consistent with) conversion disorder. DISPOSITION - home. Condition - stable.

Review revealed the following medications administered by a RN as ordered by Physician A: 1. Promethazine (Phenergan) 25 mg (milligrams) IM (intramuscular), ordered 02/11/2015 at 0326 - administered at 0334; and
2. Diphenhydramine (Benadryl) 50 mg IM, ordered 02/11/2015 at 0433 - administered at 0441.

Review revealed no diagnostic laboratory or radiological studies ordered by Physician A.

Review of ED Depart Summary revealed "Diagnosis: Leg pain Specific ED Discharge Instructions: Follow up with your doctor. It is stress that is causing your leg pain. ...Your ED Physician recommends that you follow up with: Your Primary Care Physician: (Physician's name). ...PATIENT EDUCATION INFORMATION: Instructions Given: ANXIETY REACTION." Review revealed the patient was discharged from the DED at 0804 (4 hours and 58 minutes after presentation).

Review on 10/25/2016 of an (XYZ name) County Emergency Medical Services (EMS), Patient Care Report (PCR) for Patient #22 revealed, Medic 1 was dispatched to a residence on 02/11/2015 at 1337. Review revealed Medic 1 arrived on scene at 1344, departed scene at 1351, and arrived at Hospital A at 1359. Review of the narrative revealed, "CALLED RE (reference) PARALISYS [sic]. ON ARRIVAL, FOUND THE ABOVE PT SUPINE ON COUCH. PT STATES THAT HE WENT TO (Hospital A name) LAST NIGHT FOR LEG PAIN. HE STATES THAT HE WAS GIVEN INJECTIONS AND SENT HOME. HE STATES THAT HE NOW HAS ABDOMINAL PAIN, BACK PAIN AND ....CAN NOT MOVE OR FEEL HIS LEGS. ON EVAL (evaluation), PT LEGS COLD TO TOUCH AND APPEAR PALE. PT IS PLACED ON STRETCHER, MOVED TO UNIT AND EMERGENCY T-PORT (transport) TO (Hospital A name) BEGAN. WHILE ENROUTE, IV AND MONITOR PLACED ....PT STILL HAS NO PMS (pulse, motor, and sensation). ON ARRIVAL, PT PLACED IN ER ROOM 6...." Review of initial assessment documentation by an EMT-Paramedic at 1345 revealed, Abdomen - DISTENTION, General, Left Upper (+) Distention, Right Upper (+) Distention, Left Lower (+) Distention, Right Lower (+) Distention. Back - PT STATES LOW BACK PAIN, Lumbar/Sacral (+) Pain on ROM. Extremities - Left leg, (+) Abnormal Pulse Abnormal Sensation Paralysis; Right leg, (+) Abnormal Pulse Abnormal Sensation Paralysis; Pulse Pedal Absent; Capillary Refill, (+) Left lower 3 seconds, Right Lower 3 seconds. Neurological - BOTH LEGS PARALYSIS.

Hospital A, closed DED record review for Patient #22 revealed the patient returned via EMS ambulance to the hospital's DED on 02/11/2015 at 1403 (visit #2) [5 hours and 59 minutes after discharge] with a chief complaint of "PARALYSIS" and "LEG PAIN - SWELLING." Review of Triage documentation at 1406 by RN #3 revealed "Stated Reason for Visit: pt (patient) reports rcvg (receiving) 2 inj (injections) and now legs unable to move, cool to touch; back and abd (abdominal) pain; slow cap refill in both feet; more pain in rt. (right) leg. ..." Review of triage vital signs revealed BP 192/88, HR 88, RR 18, T 98.2° F orally, O2Sat 97% RA, Height 70 inches, Weight 200.8 pounds, and Pain assessed as 10/10. Review revealed a Glasgow/Trauma Score of 15. Review revealed a PMH of Hypertension, seizures, pseudoseizures, and depression. Review of home medications revealed, Valsartan (Diovan). The patient was assigned an acuity level: ESI 2 - Emergent.

Review of ED Assessment documentation by RN #4 at 1425 revealed Neurological - alert and oriented X4. HEENT WDL (within defined limits) - Yes. Pulmonary Data WDL - Yes. Gastrointestinal WDL - Yes. Genitourinary WDL - Yes. Musculoskeletal WDL Yes, Except For - Moves All Extremities Well - No. Other: Paralysis of both legs and no rectal tone. Bilateral. Range of Motion, Limited Function. Integumentary WDL - Yes.

Review of vital signs and pain reassessment documentation revealed at:
1415: BP 225/81, HR 80, and O2Sat 98% RA;
1430: BP 212/81 and O2Sat 95% RA;
1432: Pain reassessment 10/10 (no change);
1445: BP 193/79 and O2Sat 95% RA;
1500: BP 202/88 and O2Sat 96% RA;
1515: BP 206/87 and O2Sat 95% RA;
1530: BP 200/86, RR 15, and O2Sat 96% RA;
1532: Pain reassessment 6/10;
1545: BP 197/88 and O2Sat 96% RA;
1600: BP 205/88 and O2Sat 95% RA;
1615: BP 205/88 and O2Sat 96% RA;
1630: BP 221/89 and O2Sat 96% RA;
1645: BP 221/89 and O2Sat 95% RA;
1700: BP 213/91 and O2Sat 95% RA;
1715: BP 212/95 and O2Sat 96% RA;
1730: BP 211/101 and O2Sat 96% RA;
1740: BP 223/97, HR 83, RR 16, and T 98.2° F;
1745: BP 224/93 and O2Sat 96% RA;
1800: BP 207/88 and O2Sat 96% RA;
1815: BP 220/104 and O2Sat 96% RA;
1830: BP 236/105 and O2Sat 95% RA;
1845: BP 244/102 and O2Sat 96% RA; and
1858: BP 234/106 and O2Sat 96% RA.

Record review revealed a MSE was performed at 1408 by Physician B. Review of MSE documentation (not timed) by Physician B on a "GENERAL ADULT ILLNESS" T - Sheet, revealed a chief complaint of "- Back Pain LE (Lower Extremity) weakness." Review of History of Present Illness revealed, "Low Back Pain for ~ (approximately) 24° (hours), & Weakness + Numbness in both LE. - States he has no control of his stool. - Pt seen this am in ER for same but sent home - D/W (diagnosed with) possible conversion D/O (disorder)." Review of associated symptoms revealed, arthralgia low back. Alleviating factors none. Review revealed, "PMH/SH/FH [check mark in box] Reviewed on nurse's notes and agree." Review of Systems - ROS All Systems reviewed and negative except as indicated. Review revealed, Neuro/Psych was circled. Review of Physical Exam revealed "[check mark in box] vital signs reviewed." Appearance - normal. HEENT - normal. NECK - Normal. RESPIRATORY - normal breath sounds. CARDIAC - RRR (regular rate rhythm), no murmur. GI/GU - non tender, normal bowel sounds, no organomegaly (enlarged organs). RECTAL - "No Rectal Tone. Loss of Sensory & motor Fnx (function) below inguinal line." BACK - midline & muscular tenderness. SKIN - normal. EXTREMITIES - "No sensory fnx in BLE (bilateral lower extremities) - complete pendesis [sic] of (B)LE." No pedal edema. NEUROLOGICAL - CN II XII (cranial nerves 2 thru 12) intact. No sensory loss. No focal weakness. PSYCHIATRIC - oriented X3. Mood/affect normal. Further review revealed, "[check mark in box] I HAVE PERFORMED A MEDICAL SCREENING EVALUATION NO EMERGENCY MEDICAL CONDITION EXITS FURTHER EVALUATION NEEDED TO RULE OUT AN EMC." Review revealed, RADIOGRAPHS - visualized. MRI (magnetic resonance imaging) Lumbar (-) [negative]. Review of ED COURSE revealed, "Discussed with Dr. [Physician D name] (Neuro) Time 1730 pm." Review revealed, CLINICAL IMPRESSION - Bilateral lower extremity paralysis - R/O (rule out) Guillain-Barre Syndrome - Leukocytosis. DISPOSITION - transfer. Condition - fair.

Review revealed the following medications administered by a RN as ordered by Physician B: 1. Hydromorphone (Dilaudid) 1 mg IVP (intravenous push), every 1 hour PRN (as needed) for pain, ordered 02/11/2015 at 1430 - administered at 1432 and 1532;
2. Ondansetron (Zofran) 4 mg IVP, ordered 02/11/2015 at 1430 - administered 1432; and
3. Metoprolol (Lopressor) 5 mg IVP, ordered 02/11/2015 at 1850 - administered at 1858.

Review revealed the following diagnostic laboratory and radiological studies ordered by Physician B and completed:
1. CBC (complete blood count) with Differential - ordered 02/11/2015 at 1432, collected at 1442, revealed WBC (white blood cell) 18.8 [reference range 3.2-11.8];
2. Magnesium - ordered 02/11/2015 at 1433, collected at 1442, revealed 2.7 [reference range 1.6-2.6];
3. Comprehensive Metabolic Panel - ordered 02/11/2015 at 1433, collected at 1442, revealed Creatinine 1.48 [reference range 0.72-1.25]; AST (liver enzyme) 187 [reference range 5-34];
4. Auto Differential - ordered 02/11/2015 at 1447, collected at 1442, revealed Auto Neutrophils Absolute # 16.5 [reference range 1.3-8.1]; Auto Segmented Neutrophils % 87.7 [reference range 35.0-75.0]; Auto Lymphocytes 4.4 [reference range 19.0-48.0];
5. MRI Lumbar Spine W/O (without) Contrast - ordered 02/11/2015 at 1508, completed at 1650, revealed "IMPRESSION: Normal."

Review of a Certification of Transfer dated 02/11/2015 and signed by Physician B at 1944 revealed, "I. MEDICAL CONDITION. Diagnosis, Acute nontraumatic Paraplegia. R/O Guillain-Barre Syndrome. Medical Screening Exam Completed. Emergency Medical Condition Identified - Patient Stable." Review revealed vital signs prior to transfer at 1929 were BP 223/97, HR 83, RR 16, and T 98.2° F.

Review of Discharge documentation at 1956 by a RN revealed "Discharge Comments Transferred to (Hospital B name) A412 (room number) with report. Pt is alert, VSS (vital signs stable) and no other change. Small decrease BP after Lopressor and (Hospital B name) Nurse Made aware."

Hospital B, closed medical record review on 10/26/2016 for Patient #22 revealed the patient was admitted directly to inpatient room #A412 on 02/11/2015 at 2047. Review of a NEURO Admission H&P (history and physical) Note, dated 02/11/2015 at 2224 by Physician D (Neurologist) revealed, "...Patient accepted in transfer from (Hospital A name) ER because of acute onset of pain and lower extremity paralysis since 03:00 on 2/11/2015. ...He endorses that he has felt fine for the past few days ....He woke up with leg pain first, R>L (right greater than left) and the inability to move his legs. He took an ambulance to the ED where he was though [sic] to have an anxiety reaction per review of the notes. Report from the transferring physician suggests that he got a short [sic] of something for pain and some steroids. He was sent home around 08:00. The patient came back in an ambulance around 14:00 because he was unable to walk, his feet were cold and his pain had worsened, now with new onset abdominal pain. The ER doctor noted that he was areflexic in his lower extremities, had no sphincter tone and ordered an MRI L-spine which came back as normal. He called requesting further neurologic evaluation..." Review of a Computed Tomography (CT) report for a CT angiogram of the thorax and abdomen, dated 02/12/2015 at 0324 revealed, "Findings CLINICAL: suspected aortic dissection resulting in acute cord injury? Symptoms suggestive of T8 to T10 level. ...THORAX IMPRESSION: 1. Type A aortic dissection involving the ascending aorta just above the aortic valve flaps with the greatest transverse dimension of the ascending aorta measured at 4.4 cm. ABDOMEN IMPRESSION: 1. Type A dissection extending into the right renal artery with 2 areas of infarcted right kidney. 2. The abdominal aorta is occluded just above the bifurcation. ..." Review of a physician's consultation note, dated 02/12/2015 at 0430 by Physician E (Cardiothoracic/Vascular Surgeon), revealed "I was asked to see Mr. (Patient #22 name) in consult, who is a 37-year-old gentleman that presented to (Hospital A name) Emergency Room yesterday at 3:00 a.m. on 02/11/2015, complaining of acute onset of lower extremity pain and weakness. He is a very poor historian, this was an acute onset event, who was awakened in the middle of the night with the right leg worse than his left leg pain and inability to move his legs. He was taken to the Emergency Room. Per Dr. (Physician D name) notes, he was thought to be having an anxiety reaction as the patient does have some history of conversion disorder. He was treated with pain medication and steroids and sent home at approximately 8:00 a.m. He returned by ambulance to [sic] 1400 because of his inability to walk. His pain was worsened and he had new onset of abdominal pain. It was noted at that time by the ER physician, per Dr. (Physician D name) note that the patient was areflexic with no sphincter tone and an MRI scan of the L-spine was normal. Dr. (Physician D name) was consulted for further neurologic evaluation. The patient was transferred to (Hospital B name), and the patient was noted to have elevated creatinine and underwent MRI scans of his cervical, lumbar and thoracic spine without any abnormalities identified, and also underwent a CT angiogram of the chest and abdomen which revealed a Type A aortic dissection, with a flap that begins just above the aortic valve, significantly compresses the true lumen, with extension of the dissection into both carotid arteries, and terminates in the abdomen below the renal arteries where the aorta is occluded with no flow seen below that level in the true or false lumen. The ascending aorta measuring 4.4 cm (centimeters) in diameter. There is evidence of right renal infarction. ...PHYSICAL EXAMINATION: GENERAL: The patient is a poor historian, he is conversant, complaining of abdominal pain and bilateral leg pain. ...ABDOMEN: His abdominal wall is firm, tense, his abdomen is mildly distended. He also is very tender to palpation with positive peritoneal signs. NEUROLOGIC: His neurologic exam as articulated by Dr. (Physician D name), shows that his cranial nerves are intact. He has normal strength and tone in his upper extremities. His lower extremities demonstrate no movement. He has diffuse fasciculations in the upper areas of his thigh extending into the calf. He has no sensation of his lower extremities, he has absent reflexes bilaterally in his lower extremities. VASCULAR: ...His lower extremity exam shows that he has no palpable or dopplerable pulses in the femoral, popliteal, posterior tibial or dorsalis pedal arteries. There is no evidence of any venous flow. EXTREMITIES: Shows his extremities to be pale, cool in the upper thigh too cold at the level of the lower calf and feet. The feet have rigor present, the calf muscles are firm, with fasciculations present. ...SUMMARY This is a young gentleman with malignant hypertension, medical noncompliance, with acute Type A aortic dissection that is over 24 hours old, who has by CT angio, evidence of severe compromise of his true lumen, with complete aortic occlusion in the mid abdomen, and physical examination consistent with an acute abdomen, likely secondary to bowel ischemia, right renal infarction by CT, and evidence of cadaveric lower extremities bilaterally. This is an unrecoverable condition, and surgical intervention would not change the ultimate outcome. I discussed the fact that this is a fatal condition, and that the delay in diagnosis has brought his level of progression of ischemia to a point that it is irreparable. His mortality is 100%. He will need Palliative Care consult and I would focus predominantly on comfort measures. ..." Record review revealed the patient expired on 02/12/2015 at 1910 (40 hours and 4 minutes after initial presentation to Hospital A's DED on 02/11/2015 at 0306).

Review on 10/26/2016 of a Followup Summary for Diagnosis/Treatment Event (11369) with time-line attached revealed, "Follow-Up Actions" with Date(s) 02/13/2015, 02/16/2015, 02/17/2015, 03/05/2015, 03/09/2015, 03/16/2015, 03/25/2016, and 04/01/2015. Further review revealed, "From Dr. (Physician H name) via email: Case Summary: This 37-year-old male reportedly had a history of pseudoseizures. He presented to (Hospital A name) the morning of February 11, 2015 complaining of bilateral lower extremity pain as well as lower abdominal pain. He was noted to be hypertensive with a blood pressure of 197/120 in triage, but came down to 150/88 at discharge. No laboratory studies drawn. Patient discharged with a diagnosis of conversion disorder. Subsequent nursing communications indicate that the patient was having a hard time walking at discharge from the (Hospital A name) emergency room. The patient came back to the (Hospital A name) emergency room that afternoon. He had activated EMS. He reported that his legs felt cold. He could not walk. He had suffered loss of bowel control. Laboratory evaluation revealed acute kidney injury and an AST of 187. White count elevated to 18. The EMS and ED documentation reflect blood pressures in the 190-200 range. Physical examination documents no rectal tone and loss of sensory/motor function in the lower extremities. The ED documentation indicates that they were considering a diagnosis of Guillain-Barre Lumbar MRI was performed to (Hospital A name) which was normal. He was transferred that evening to (Hospital B name). He is evaluated promptly by neurology. The neurology progress note indicates that there [sic] were at least considering vascular disorders as they note 'he does not have a history of aortic aneurysm or other vascular problems' in their initial progress note. The patient's lower extremities are noted to be cool. The neurology physical examination also documents a distended 'very tender' abdomen with absent bowel sounds. They begin their evaluation with an MRI of the thoracic and cervical spine. They do indicate that they have reviewed his MRI of the lumbar spine with radiology specifically to evaluate for evidence of aortic pathology which is not seen. The MRI of the cervical and thoracic spine was unremarkable. Follow-up CT angiography of the abdomen is performed at 2:40 AM. This shows evidence of Type A aortic dissection. On reevaluation at 4 in the morning the patient is noted to have absent pulses in the lower extremities. He is described as having an acute abdomen. The vascular surgery service is consulted and they note that he has had severe compromise of blood flow to the lower half of his body resulting in bowl ischemia and renal infarction. They note that his mortality is 100%. They discuss with the family that this is an unrecoverable condition and surgical intervention will not change the ultimate outcome. The patient is transitioned to comfort care and expired rapidly. The primary concern here is the delay in diagnosis. While he did not exhibit the typical presentation for an aortic aneurysm, there was evidence of end organ damage on his initial labs drawn on his second visit to (Hospital A name) - AST of 187, creatinine of 1.4. In a patient with abdominal pain radiating to the back one would think about aortic dissection, although in fairness he was quite young. I wonder if the patient's history of high ER utilization and reported history of pseudoseizures worked against him and anchored providers to a psychiatric diagnosis despite objective evidence of organic pathology during his first ER visit. At (Hospital B name) the neurology team's differential diagnosis does include vascular pathology and they proceed with abdominal imaging expeditiously after his MRI is unrevealing as to the source of his symptoms. Surgery is consulted promptly, but his ischemia has progressed to far for surgical interventions to be helpful." Review of "Details" revealed "Forwarded to (Hospital A name) Peer Review Committee, to formally request that (Hospital B name) Peer Review Committee act on behalf of (Hospital A name) Peer Review Committee to conduct peer-professional review of records and other information concerning specific clinical concerns regarding clinical care delivered to patients at (Hospital A name) Peer Review Committee. ..."

Interview on 10/27/2016 at 0900 with Physician B revealed, he had been on Hospital A's medical staff since 2002 and worked for the hospital's contracted ED physician group. He was familiar with Patient #22 and had seen the patient on prior ED visits. He was the attending ED physician who conducted the MSE on the patient during the return visit on 02/11/2015 (visit #2). He read what the RN documented at triage and his questions to the patient were based from the triage notes and what the patient told him during exam. At some point he reviewed or was shown Dr. (Physician A name)'s notes from the prior visit on 02/11/2015 (visit #1) and that the patient was diagnosed with conversion disorder. The patient's main complaint on exam was back pain and lower extremity weakness. The patient had "no other major complaints." He was aware the patient complained of abdominal pain to the triage RN and "I did not get that information from the patient." The patient had no abdominal pain upon examination. The abdomen was negative and non-tender. The patient "certainly had back pain and lower extremity findings that were suspicious for spinal cord injury." The patient had no rectal tone, no sensory to lower legs, and motor impairment. A spinal cord injury or disease process was suspected. Labs and a MRI were ordered. The MRI was negative. The patient had an elevated BP and pain of 10/10 most likely due to back pain, an "on-going condition" and no pain to his lower extremities. The patient was given Lopressor, Dilaudid, and Zofran. Dr. (Physician D name) with Neuro was consulted at Hospital B and the patient was transferred to Hospital B. The patient's diagnosis was bilateral lower extremity paralysis rule out Guillain-Barre Syndrome and leukocytosis. The patient "absolutely" presented with an EMC. The EMC was "ongoing at transfer." "I feel there was no EMTALA issue with the transfer." He was aware of the patient's diagnosis (Type A Aortic Dissection) and outcome (death) after being transferred to Hospital B. He received EMTALA education and training provided annually through the hospital.

Interview on 10/27/2016 at 0945 with RN #2 revealed he was a RN in Hospital A's ED. He was the primary ED nurse assigned to take care of Patient #22 on 02/11/2015 at 0306 (visit #1). He was "familiar" with the patient and had talked to a lawyer recently for the hospital about the patient's care, approximately 4 weeks ago. He was not present when the ED Physician (Physician A) evaluated the patient. He did not triage the patient. He did not recall exactly what the patient complained about. "He (the patient) hurt." Primarily in his abdomen or legs? "I saw the patient walk into the department without difficulty and walk out and come back in." When the patient came back in it looked like he was having some difficulty. The patient was alert, oriented X4, and "very anxious." Review of the ED record during the interview for 02/11/2015 (visit #1), revealed at 0336 he documented the patient's bilateral lower extremities as "Normal Power" and "Sensation Intact." The patient had normal pedal pulses and his abdomen was tender, soft, with positive bowel sounds. At 0707 he documented the patient's bilateral lower extremities as "Moves with Gravity Eliminated" and "Numbness, Tingling, Pain." Musculoskeletal was at baseline with no change. He did not recall if the change in lower extremity assessment was reported to the ED physician. At discharge the patient was discharged in a wheelchair. The patient reported his legs were hurting. "Seems like I had to assist him to ambulate at discharge." The patient called a manager from his work to come and pick him up from the ED, a lady. Discharge instructions were reviewed with the patient. "I was worried about the lady getting the patient into his home. I had to help the patient into the wheelchair and into the car." He did not remember if he notified the ED physician the patient was having difficulty ambulating at discharge. EMTALA education and training was provided annually by the hospital. He has had a "recent review."

Interview on 10/27/2016 at 1020 with RN #3 revealed she was a RN in Hospital A's ED and the patient's record had been discussed with her 1-2 months ago by the hospital's attorney. She recalled the patient, he had been there multiple times and was seen on a regular basis. She triaged the patient on 02/11/2015 at 1403 (visit #2). The patient arrived by EMS ambulance. The patient was unable to move from the EMS stretcher to the ED bed. The patient was confused and not quite himself. He was awake with eyes open. She documented the reason for the visit from what was being told to her. The patient was not able to give much information, report primarily came from EMS personnel. She did not perform a hands on physical exam. Pain was a 10/10 and GCS 15. She did not recall her general impression of the patient upon arrival to the ED. She did not recall any other interactions with the patient after triage. EMTALA education and training was provided in yearly competencies by the hospital.

Interview on 10/27/2016 at 1425 with Physician C revealed he was Hospital A's ED Medical Director. He had been on the hospital's medical staff for 1 year and had been ED Medical Director for 10 months and worked for the hospital's contracted ED physician group. He had been an ED physician for 36+/- years. Review of Patient #22's ED record during the interview for 02/11/2015 (visit #1), confirmed the patient's Chief Complaint and Stated Reason for Visit documented at triage by the RN was "Abdominal Pain" and "lower abdomen pain radiating to bilateral legs, started in am." And the patient's BP was 197/120 and pain was 10/10. Interview revealed often the Chief Complaint told to the RN and what the patient tells to the physician during examination can change. He normally, reads the triage notes and face sheet for what is documented. He wants to know what the vital signs are and what typ