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Based on interview and document review, the hospital failed to maintain compliance with 42 CFR 489.24 with respect to the Emergency Medical Treatment and Labor Act (EMTALA).

Findings include:

See C-2406; "... the hospital failed to ensure a comprehensive medical screening examination (MSE) was completed for 1 of 20 patients (P1) reviewed when an identified hemothorax (an accumulation of blood within the pleural cavity) was not assessed or acted upon to ensure a potentially life-threatening emergency medical condition (EMC) did not exist and/or worsen."

Based on interview and document review, the hospital failed to ensure a comprehensive medical screening examination (MSE) was completed for 1 of 20 patients (P1) reviewed when an identified hemothorax (an accumulation of blood within the pleural cavity) was not assessed or acted upon to ensure a potentially life-threatening emergency medical condition (EMC) did not exist.

Findings include:

P1's current caretaker (CT)-A at her assisted living facility (ALF) was interviewed on 2/12/21, at 1:37 p.m. CT-A explained P1 resided at the ALF, and had sustained an unwitnessed fall in her room on 2/6/21, which resulted in complaints of right knee and right-sided chest pain. P1 was subsequently sent to the Ely Bloomenson Community Hospital (Hospital # 1) emergency department (ED) with her family member (FM)-A present and returned the same day. The hospital had provided some discharge paperwork which outlined P1 had sustained "three rib fractures." FM-A had reported the physician who treated P1 merely explained they should heal on their own, and P1 should "take it easy" for the next few days. However, within a couple of days, P1 then developed extreme right-sided chest pain and the staff had identified a "little bit of wheezing" with her respirations. They proceeded to send her to a different hospital (Hospital # 2) ED which then completed a more extensive work-up, and found P1 had actually sustained six fractured ribs and not three as had been reported by Hospital #1. Further, CT-A stated Hospital #2 completed computed tomography (CT) scanning which revealed "new and old blood" around her lung which was described as a "hemothorax." P1 was subsequently sent via emergency medical service (EMS) to a higher level of care, and had to have a chest tube placed to remove the pooled blood from around her lung. CT-A expressed concern with a potential lack of adequate screening and work-up at Hospital #1, as they were told by Hospital #2 P1 likely had the hemothorax since she fell and sustained the rib fractures which should have been addressed when she first presented for emergency medical care at Hospital #1 on 2/6/21.

On 2/12/21, at 3:34 p.m. P1's FM-A was interviewed and verified they accompanied P1 to the Hospital #1 ED on 2/6/21, after P1 sustained a fall at her ALF. FM-A explained the ED physician (MD)-C completed an x-ray which identified P1 had "three broken ribs" which were "in place" and should heal on their own with time and rest. P1 was then discharged back to her care center. However, a few days later, the care center contacted him and voiced P1 was "in terrible pain" and her "oxygen level" was poor, so the assisted living wanted to send her to the ED for evaluation. P1 was then sent to the Hospital #2 ED where they did a CT scan and found she actually had six broken ribs, and not just three as had been voiced by Hospital #1 on 2/6/21, along with "blood in the right side of her lung cavity." FM-A expressed the physician at the Hospital #2 ED contacted him and voiced she "didn't understand" why the pooled blood around P1's lung had not been treated or acted upon at the Hospital #1 ED as it was visible on the x-ray Hospital #1 had completed on 2/6/21. FM-A stated P1 was subsequently sent to the "trauma center" and had to have a chest tube placed which drained "almost a liter of blood" from the hemothorax. FM-A expressed frustration over the lack of screening and timely treatment of P1's hemothorax at the Hospital #1 ED, and voiced he had never been told or informed she had such a complication when they were at the Hospital #1 ED on 2/6/21. FM-A added, "The bleeding in the lungs could have killed her."

The Hospital #1's untitled ED central log, dated 1/24/21, to 2/16/21, identified P1 was registered in the ED on 2/6/21, at 1:35 p.m. with a chief complaint which read, "Fall." The record identified P1 did not refuse treatment and was discharged at 3:30 p.m. the same day.

P1's (Hospital #1 ED) Patient Care Timeline, dated 2/6/21, outlined the actions and orders completed during P1's Hospital #1 ED visit. P1 presented at 1:35 p.m. and was seen by MD-C at 1:43 p.m. A set of vital signs was obtained which identified P1 had an elevated blood pressure, normal oxygen saturation and was in acute pain which was listed as being a sharp pain on her anterior chest. The timeline listed a chief complaint of, "Fall," with dictation present reading, "[FM-A] states that [P1] got up from chair this morning and fell and hit her right side on arm of chair." At 2:01 p.m. an order was then placed for x-ray(s) which were resulted at 2:48 p.m. The timeline then outlined registration had been completed and at 3:00 p.m. read, "ED Disposition set to Discharge." P1 was then discharged at 3:30 p.m.

P1's (Hospital #1) ED Provider Notes, dated 2/6/21, identified P1 as a 90-year-old female with dementia who presented after an unwitnessed fall who then proceeded to have complaints of right lateral chest wall pain. FM-A was present and voiced no change in P1's mentation had been noted in the past six hours since the fall. The report continued and outlined, "Patient is on Eliquis [a blood thinning medication] for atrial fibrillation." P1's current medications and past medical history were listed; and a physical examination was recorded for P1 with, "[breath sounds] equal and clear, No wheezes, rales or rhonchi, Right lateral chest wall tenderness in midaxillary line along costal margin." The report continued and outlined no laboratory testing had been completed for P1 and a section labeled, "Imaging Results," outlined the preliminary results of P1's completed x-ray on 2/6/21. This read, "[x-ray] RIBS RIGHT 2 OR MORE VIEWS PA [posterior and anterior] CHEST ... There are fractures of the 7th through 9th anterior lateral right ribs and possibly the 6th rib. Dependent pleural fluid likely hemothorax. No pneumothorax. Cardiac silhouette is mildly enlarged. OA [osteoarthritis] changes right shoulder. IMPRESSION: Caudal right rib fractures with associated hemothorax." The imaging results were timed 2/6/21, at 2:48 p.m. The report continued and outlined, "[P1] evaluated for unwitnessed fall ... is on anticoagulants secondary to atrial fibrillation ... do not suspect intracranial or spinal injury resulting from the fall ... only complaint is right lateral rib tenderness without evidence for flank or right upper quadrant tenderness and I [MD-C] do not suspect kidney or liver injury. Chest x-ray shows no pneumothorax however there are 3 rib fractures at the seventh eighth and ninth ribs lateral underlying the area of maximal tenderness. Discussion was held with the patient and her son regarding expected course of healing and pain management. Return to the [ED] for shortness of breath, worsening symptoms." The note and report were then signed by MD-C on 2/6/21, at 3:56 p.m.

P1's medical record was reviewed with the Hospital #1 ED manager (EDM) on 2/16/21, at 2:31 p.m. The medical record lacked evidence P1's identified hemothorax had been acted upon or assessed to determine the severity of the injury or if it presented a potential EMC to P1, despite P1 being an elderly patient on anticoagulation with known cognitive impairment who sustained an unwitnessed fall. The record lacked evidence the identified hemothorax had been reviewed with the patient or FM-A to determine what, if any, course of action needed to be completed or pursued (i.e., CT scan or transfer to higher level of care) to rule out whether the hemothorax posed a potential EMC to P1 at the time. EDM verified the record lacked such evidence and voiced the documentation "was vague." EDM then explained when an imaging diagnostic was completed (i.e., an x-ray), the results were reviewed by both the ordering physician and an offsite radiologist. However, the results were, at times and depending on the acuity of the patient, not reviewed by both parties prior to the patient being discharged from the ED. Further, EDM reviewed P1's completed x-rays and voiced both the preliminary and final interpretations completed by the off-site radiologist outlined a hemothorax was likely present on 2/6/21.

On 2/17/21, at 7:30 a.m. registered nurse (RN)-A and RN-B were interviewed. They recalled P1, and explained FM-A had brought her into the ED after she sustained a fall at her care center. RN-A recalled P1 was ambulating "a little guarded" and had poor cognition with some complaints of pain on her right chest side, however, never complained about trouble breathing or being short of breath to her knowledge. MD-C ordered a chest x-ray which he then reviewed and "said she's ready for discharge." RN-B then explained she reviewed P1's after-care instructions with P1 and FM-A before she left and was discharged. RN-A and RN-B both voiced they were not aware a potential hemothorax had been identified on the completed x-ray(s) and verified they did not review any information with FM-A pertaining to one. RN-A added, "I don't remember being aware of a hemothorax." RN-A and RN-B both expressed they did not feel P1 was in distress when she left the ED. Further, RN-A and RN-B verified the hospital had the capability to complete a CT scan onsite if one had been ordered.

P1's corresponding (Hospital #1) After Visit Summary, dated 2/6/21, identified P1 was seen in the ED by MD-C after sustaining a fall. The report listed, "Diagnosis [bolded] Rib Fractures," and an additional section labeled, "Imaging Tests," outlined only a chest x-ray had been completed. The provided instructions directed P1 should follow up with her primary physician " ... As needed," and should take Tylenol as needed for pain. The report outlined the patient would be notified of any test(s) or imaging studies which were not completed at the time of discharge and which resulted as "abnormal." Further, an attached Essentia Health Rib Fracture, printed 2/17/21, was provided to P1 upon discharge which outlined home care considerations for rib fracture(s). The After Visit Summary, nor the attached information on rib fractures, outlined any dictation or evidence P1's potential hemothorax had been reviewed or discussed with P1 or FM-A to determine what, if any, treatment or diagnostic testing would be completed; nor was there evidence additional diagnostic testing or treatment had been offered and declined.

On 2/17/21, at 8:00 a.m. EDM and the chief nursing officer (CNO) were interviewed. They reviewed P1's medical record and verified MD-C did have the x-ray results with the dictation present which identified a 'likely hemothorax.' EDM voiced he was unable to speculate on how or why the identified hemothorax had not been acted upon or further diagnostic imaging obtained but acknowledged the lack of documentation in the medical record was "leaving a lot of questions and speculation." Further, the CNO and EDM both verified they were unaware of the events involving P1 or this concern until the abbreviated survey started.

On 2/17/21, at 10:49 a.m. certified nurse practitioner (NP)-A was interviewed and verified she treated P1 when she presented to the Hospital #2 ED on 2/9/21. NP-A recalled P1 presented to the ED on 2/9/21, and demonstrated chest wall pain along with being "short of breath." NP-A stated she treated P1 for her pain and reviewed her previous ED visit (from Hospital #1) which outlined she had sustained rib fractures while on anticoagulation medication. As a result, Hospital #2 considered P1 as "a trauma alert" and completed a "pan scan" which included several CT scans. From those completed CT scans, they determined P1 actually had sustained six broken ribs (not three as had been identified on the Hospital #1 x-ray) and had a "moderate hemothorax." NP-A then consulted with the trauma center, and the decision was made to send her to a higher level of care where P1 ended up having to have a chest tube placed for the hemothorax. NP-A voiced, in her opinion, a CT scan should have been obtained on 2/6/21, when P1 presented to the Hospital #1 ED as it was a more sensitive test and would have helped better demonstrate the injuries she had sustained (i.e., six fractures versus three on x-ray). NP-A verified a CT scan would have shown how large the hemothorax was and helped to determine what treatment would have been needed. NP-A voiced she had reviewed the medical record from P1's Hospital #1 ED visit and verified it lacked any dictation or evidence why the needed CT scan(s) had not been completed. NP-A explained the CT scan P1 had completed at Hospital #2, on 2/9/21, had evident 'new and old' blood next to her lung which was likely the hemothorax still evolving and worsening. NP-A stated P1 should have been considered a trauma patient on 2/6/21, when she presented to the Hospital #1 ED, and added it was not her opinion but rather "this is protocol." NP-A stated the lack of advanced imaging and treatment for P1's hemothorax on 2/6/21, was "concerning" given P1's age and risk factors, and added she felt a hemothorax would be considered an EMC in P1 as she "was a fairly risky patient."

P1's corresponding (Hospital #2) ED Provider Note dated 2/9/21 and completed by NP-A, identified P1 presented to the ED with right-sided anterior rib pain. The note outlined P1 had sustained a fall on 2/6/21, and had been seen in the Hospital #1 ED by MD-C where P1 "... was found to have caudal right rib fractures of ribs 7 through 9 and possibly the 6th rib, with dependent pleural fluid, likely hemothorax." P1 was recorded as "screaming out in pain" and being "unable to get out of bed" on 2/9/21, which prompted the ED visit. A physical examination was completed which outlined P1 as "ill-appearing" and having decreased breath sounds. P1's oxygen saturation was recorded at 88%. The note continued, "The patient's right lung was with decreased breath sounds; she had very poor inspiratory effort secondary to pain ... Given the patient fell with findings of hemothorax and multiple rib fractures, with now, worsening pain and slightly increased work of breathing the patient needs a CT scan. Independent review with [another physician] reveals at least 6 rib fractures, a older hemothorax and also new blood within the chest." P1 was subsequently transferred to a higher level of care. The report outlined a section labeled, "Assessment," which included, "... Traumatic hemothorax, subsequent encounter." Further, the report outlined the results of the completed chest and abdomen CT scan(s) which read, "... Lungs: Right-sided pleural effusion, associated hemothorax, underlying atelectasis ..." An 'Impression' was recorded which read, "1. Right 6th through 10th rib fractures with displacement of some of the rib fractures. 2. Right-sided hemothorax, underlying atelectasis."

On 2/17/21, at 12:00 p.m. Hospital #1 ED chief medical officer (MD)-B was interviewed and verified he had reviewed P1's medical record. He voiced elderly patients with unwitnessed falls could be "kind of complex situations;" however, given P1's age and use of anticoagulation the "standard of care" would dictate "some form of advanced imaging" be completed. CMO-A verified P1's ED record lacked any evidence a CT scan had been completed, attempted or offered and refused on 2/6/21; and reiterated a hemothorax identified on x-ray likely would need some form of work-up as it was "something that's probably going to decline." CMO-A stated a possible "caveat" to not acquiring additional imaging would be if P1's FM-A had declined such testing; however, CMO-A voiced the medical record lacked evidence of such and MD-C "doesn't address it." CMO-A stated the radiologist' impression being printed in MD-C's note was "a catch" and should have been outlined in MD-C's rationale or in his progress note and added "the standard" would be to ensure dictation of such was captured in the medical record. CMO-A stated a CT scan would have helped to determine the extent of P1's injuries, including the hemothorax, and given her poor cognition you "can only go by the imaging" then. CMO-A voiced a hemothorax certainly "can be" an EMC and voiced MD-C's provided care seemed, at least through just a record review, to be "probably poor practice." However, CMO-A expressed he felt MD-C likely "met his criteria" for any EMTALA obligation but added "we don't know" since nothing was recorded in the medical record regarding the hemothorax and the decision-making process for its treatment.

On 2/17/21, at 3:02 p.m. MD-C was interviewed and verified he was the physician who provided care to P1 on 2/6/21, when she presented to the Hospital #1 ED after she sustained a fall at her ALF which led to her having complaints of right knee and "right rib pain." MD-C described P1 as having poor memory recall and being unable to verbalize how she ended up on the floor, so he wanted to complete a "really good exam" given she consumed Eliquis and there was risk for internal bleeding. MD-C stated he spoke with FM-A about doing more advanced testing, including metabolic testing and CT scan(s), however, FM-A declined to have such testing completed. MD-C stated he recalled reviewing P1's x-ray which showed "at least one fracture" along with the preliminary radiologists' impression which he remembered to read "small pleural effusion" and not a hemothorax. MD-C added, "I don't remember that being in the initial report." MD-C again stated he visited with FM-A and expressed P1's broken ribs were "a big injury" which would have qualified her to be admitted for further observation, however, MD-C again reiterated FM-A declined such treatment. MD-C explained he then had another conversation with FM-A about the healing process and P1's pain control needs before she was discharged. MD-C expressed he reviewed P1's x-ray and verified it had "blunting on that side [right]" which could have been blood given her multiple fractures. MD-C stated it also could have been fluid which had been present prior to her fall and a CT scan would have been needed to know. MD-C stated he was unable to recall if he conversed with FM-A about the possibility of a hemothorax being present, despite it being identified on the x-ray, and added, "I just don't remember." MD-C stated had he made a diagnosis of a hemothorax on P1, it would have been "an automatic admit [to the hospital]" given her age and risk factors. MD-C verified his completed note(s) and dictation in the medical record lacked evidence the hemothorax, including his offers of advanced imaging to diagnose such a complication, had been discussed or reviewed with P1 or FM-A despite his testimony voicing it had happened. MD-C stated, in hindsight, he "wished [he] would have pushed [FM-A] harder" on the treatment recommendations and "documented our conversation." Further, MD-C stated he P1's care on 2/6/21, and the situation overall was handled "in an appropriate way given her circumstances" with FM-A present and acting "as her surrogate."

On 2/17/21, at 3:29 p.m. FM-A was contacted and a subsequent interview held. FM-A again, denied ever being told by MD-C a hemothorax was present or additional imaging was recommended to rule out further complications on 2/6/21, when P1 presented to the Hospital #1 ED. FM-A stated MD-C merely voiced P1 had three rib fractures which should heal on their own with time and pain management, and then discharged her back to her care center. Further, FM-A stated he held physician' expertise in high regard, and if MD-C had made recommendations for P1 there was no reason he would not have supported proceeding with them.

A facility provided EMTALA (Transfer and Emergency Examination Policy) policy dated 11/6/19, identified the policy of Hospital #1 was to "... conduct medical screening examinations, provide stabilizing treatment, and transfer all individuals appropriately and without delay in compliance with federal guidelines." The policy outlined any person(s) presenting to the ED would have a MSE completed within the capabilities of the hospital to determine if an EMC exists.