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Based on interviews, medical record review, review of the facility's Emergency Department (ED) log book, facility policies, and Medical Staff Bylaws and review of Emergency Medical Services (EMS) records, it was determined the facility failed to provide, within its capacities, an appropriate and effective medical screening evaluation (MSE) to ensure stabilizing medical treatment was provided for one (1) of twenty (20) sampled patients that presented to the ED for treatment of an Emergency Medical Condition.

Findings include:

See A2406 and A2407 for findings.

Based on interview, record review, review of the facility policies, Medical Staff bylaws and Emergency Services Medical Services (EMS) records, it was determined the facility failed to ensure, within its capabilities, a medical screening examination to ensure stabilizing medical treatment for one (1) of twenty (20 ) sampled residents (Patient #9).

The findings include:

Review of the facility policy, EMTALA-Medical Screening, dated August 2005, revealed the facility must provide for an appropriate Medical Screening Evaluation (MSE) within the capacity of the facility and must be performed by individuals qualified to perform such an examination to determine whether an emergency medical condition exists. The policy further revealed the facility was required to reach, within reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition does or does not exist. Per the policy, the MSE was an on-going process and the record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred.

Review of the facility Medical Staff Bylaws, Appendix 1, dated August 2014, Article XVI, Emergency Services, Treatment and Transfer of Individuals (EMTALA), revealed the facility should provide a medical screening examination. Per the Medical Staff Bylaws, if it is determined the individual has an emergency medical condition (EMC) should provide the individual with further medical examination and treatment as required to stabilize the EMC, within the capability of the facility or to arrange for transfer to another facility.

Review of the ED log, dated 03/15/2020 through 04/15/2020, revealed an ED visit on 03/30/2020 for complaints of back pain. Continued review revealed Patient #9 present to the ED, via family vehicle, on 04/03/2020 at 2:16 PM with the chief complaint of back pain and abdominal pain. The patient was discharged from the facility to home at 5:19 PM. Further review of the log revealed the patient presented to the ED, via EMS, on 04/04/2020 at 2:18 PM, with complaint of back pain and was discharged from the facility to home, via EMS, at 11:52 PM.

Review of the ED medical record for Patient #9, dated 03/30/2020, revealed the patient presented to the ED at 2:29 PM with a chief complaint of back pain. The family member reported they suspected a urinary tract infection (UTI), but due to the patient's advanced Alzheimer's disease could not be sure of symptoms.

Review of the ED medical record for Patient #9, dated 04/03/2020, revealed the patient presented to the Facility #1's ED at 2:16 PM via family vehicle. The record revealed the patient was accompanied by a family member who reported the patient had back and abdominal pain for one (1) week.

Continued review of the ED medical record for Patient #9 revealed the patient presented to Facility #1's ED, via EMS, on 04/04/2020 at 2:18 PM (24 hours since last in ED, and 3rd ED visit in 6 days) with the chief complaint of back pain.

Review of the EMS record, dated 04/04/2020, revealed Patient #9 was picked up for transport to Facility #1's ED related to back pain and the patient was not able to get up. The record further revealed the patient had been to the facility ED three (3) times this week for back pain and the patient continues to scream in pain and is unable to get up. The EMS record also revealed vital signs at 1:31 PM were blood pressure, 176/90, heart rate-81, at 2:00 PM blood pressure-156/127 and heart rate-65. The distance from Patient #9's home to Facility #1 was approximately sixteen (16) miles.

Review of the ED Interventions/Assessments/Treatments, dated 04/04/2020 revealed the patient was triaged at 2:20 PM by RN #3. The triage note revealed the patient was brought in by EMS due to back pain and the patient had been seen at the ED twice, prior to this visit, for the same issue. A family member reported patient was grabbing left leg and screamed when transferred from EMS gurney to stretcher. The documented vital signs at the time of triage were temperature 97.3 degrees, blood pressure 176/86, heart rate 84, and respiratory rate 16. RN #3 used the FLACC (Face, Legs, Activity, Crying, and Consolability) pain assessment tool and documented a score of four (4), which indicated moderate pain. The record also revealed frequent blood pressure checks (hourly) due to elevated readings ranging from 177/85 to 162/87. Further review revealed the patient was seen by the provider, the Physician Assistant-Certified (PA-C), at 2:28 PM. The ED Interventions/Assessments/Treatments documentation, by RN #6, revealed the patient was discharged, via EMS, at 11:52 PM, disposition "home." Documentation by RN #6 revealed the patient had a blood pressure of 172/88 and pain level at seven (7), on 0-10 pain scale at the time of discharge. The form also included ED notes by RN #5, at 7:30 PM, which revealed the hospitalist called to instruct the patient to go home and call the orthopedist on Monday, as he is aware of the patient. Further ED note by RN #7, at 8:17 PM, revealed the patient's daughter was upset regarding the hospitalist not wanting to admit the patient.

Review of the HPI, dated 04/04/2020, by the PA-C and Physician #1, revealed the patient was in the ED for evaluation of back/hip pain, present for about six (6) days. Documentation revealed the patient was not able to walk and was screaming in pain during the previous night. The PA-C also noted the family member stated the pain was worse when he/she moves and nothing makes it better. Continued review of the HPI revealed the patient was evaluated for hip and back pain and an x-ray of the hip was unremarkable. Medical decision-making (MDM) narrative, authored by Physician #1, revealed the patient's condition was discussed with the family and the recommendation was for the patient to stay for further evaluation, including an orthopedic consult for Monday (04/06/2020). The MDM also revealed the patient was not able to ambulate by self and three (3) prior evaluations have not revealed the problem. It was noted the patient usually walked around independently. HPI then revealed consultation with the hospitalist by Physician #1 and documentation noted the hospitalist refused to admit the patient. The consultation documentation further revealed the recommendation from the hospitalist was to give stronger pain medication and discharge. It was noted the hospitalist stated he would not admit the patient because he would not do anything different and was concerned regarding the patient being exposed to infection in the hospital.

Review of the Medication Administration Summary, dated 04/04/2020, revealed Patient #9 was administered Normal Saline intravenously initiated at 6:47 PM, and Toradol (Nonsteroidal anti-inflammatory, for pain relief) 15 milligrams (mg) intramuscular at 3:47 PM.

Review of the EMS report, dated 04/04/2020, revealed a medical transport request, at 11:45 PM, from Facility #1 of Patient #9 to residence. The report revealed EMS arrived at the facility at 11:48 PM. Further review of the report revealed during the transport, the patient's condition worsened and the patient began to scream in pain of back and legs. Documentation revealed the EMS personnel were not able to make the patient comfortable and vital signs at 12:03 AM were blood pressure of 197/130, heart rate of 92 and respirations 18. Continued review revealed, at the request of a family member, EMS diverted to the closest ED, Facility #2, at that time. Distance between Facility #1 and Facility #2 was 14.8 miles.

Review of Facility #2's Emergency Physician Record, dated 04/04/2020 at 12 midnight, revealed Patient #9 presented to ED with back pain and pain rated at ten (10) on 0-10 pain scale. Review of the ED Nursing documentation, 04/05/2020 at 12:38 AM, revealed a blood pressure reading of 182/91. Further review of the ED Nursing notes revealed Patient #9 received the medication Morphine Sulfate (pain medication) 2 mg via intravenous push (IVP) and Zofran (anti-nausea medication) 4 mg IVP at 1:05 AM. The ED record further revealed a CT of abdomen and pelvis, without contrast, was performed on 04/05/2020 with a conclusion of compression deformity of the T12 vertebrae. A CT of the dorsal spine, without contrast, was also performed on 04/05/2020 with conclusion of compression fracture with deformity to T12. Documentation also revealed the patient was transferred to Facility #3 on 04/08/2020 for further treatment of the T12 fracture. The distance between Facility #2 and Facility #3 was 121 miles.

Review of Facility #3's medical records for Patient #9 revealed a history and physical (H&P) by the neurosurgeon revealed per magnetic resonance image (MRI) of thoracic and lumbar spine, performed at Facility #3, a T12 vertebral body fracture with over 50% loss of height and moderate canal stenosis. The H&P also revealed a plan for surgery to perform a kyphoplasty (procedure where the vertebrae is opened with a balloon and a cement like material injected to help relieve pressure and stabilize the vertebrae) on 04/10/2020. Further review of the medical record revealed the patient did have the procedure on 04/10/2020 and was discharged home with home health services on 04/16/2020.

Interview with the family member on 10/13/2020 at 4:25 PM, revealed Patient #9 had been to the ED at Facility #1 on three (3) occasions, 03/30/2020, 04/03/2020, and 04/04/2020 for back pain. The family member stated Patient #1 was not getting any better, and there was no improvement in pain. She stated the patient had not slept the night before the 04/04/2020 transport, due to pain. She further stated on 04/03/2020 she returned to the ED due to patient continuing to complain of back pain and now with abdominal pain. She stated they gave him/her a laxative and discharged home. The family member then revealed on 04/04/2020 the patient was screaming in pain and EMS was called to transport to Facility #1. She stated another family member accompanied the patient on 04/04/2020. The family member then stated she understood the facility was going to keep the patient but then the family with the patient called and stated they were going to discharge, even though he/she was still hurting. The Family Member stated she was informed the hospitalist stated give the patient a stronger narcotic medication and to send home. Further interview with the family member revealed she received a call from the hospitalist on 04/05/2020 explaining why he did not admit the patient. She stated he told her they had two (2) patients with breathing problems and did not feel comfortable with admitting Patient #9.

Interview with RN #2 at Facility #1 on 10/14/2020 at 2:30 PM, revealed she had no remembrance of the 04/03/2020 ED visit by Patient #9. The RN stated orders from patients with back pain complaints are provider/patient driven.

Interview with RN #3 at Facility #1 on 10/15/2020 at 10:25 AM, revealed she had no memory of anything related to the ED visit by Patient #9 on 04/03/2020.

Interview with the PA-C at Facility #1 on 10/14/2020 at 2:07 PM, revealed she did vaguely remember Patient #9 but could not recall any details.

Interview with Physician #1 at Facility #1 on 10/14/2020 at 2:15 PM, was not able to speak to the 04/03/2020 ED visit by Patient #9. He stated did not have memory related to this patient or the situation.

Interview with the ED Director at Facility #1 on 10/14/2020 at 4:15 PM, revealed the ED did not have a policy/procedure related to treatment of back pain. She stated back pain management/treatment was provider and patient driven.

Interview with the hospitalist at Facility #1 on 10/14/2020 at 3:30 PM, revealed he was aware of Patient #9 and stated on 04/04/2020 he did not admit the patient as the patient did not have criteria for admission, no information to validate admission, i.e. no abnormal x-ray or report of injury. He further stated no analgesics had been tried for the patient, only muscle relaxants and the patient had not had any further testing. He further revealed as a general rule he would avoid hospitalization if able, due to the increased possibility of infections, any infection. He further stated he had contacted the orthopedist and had personally made an appointment for Monday (04/06/2020) for the patient.

Interview with Emergency Medical Technician (EMT) on 10/14/2020 at 1:45 PM revealed he recalled the run on 04/04/2020 to transport Patient #9 from Facility #1 to the residence. He stated they were about five (5) miles from Facility when the patient started to "scream" due to pain. He added they actually stopped the ambulance and conferred with a family member who was following the ambulance as to the patient's current condition. The EMT stated the family member requested they transport the patient to the ED at Facility #2.

Interview with the ED Medical Director at Facility #1, on 10/14/2020 at 4:30 PM, revealed he was familiar with Patient #9's visits to the ED in early April. He further stated the CT of the abdomen/pelvis would have shown any obvious spinal abnormalities and none were reported on the 04/03/2020 scan. He further stated the constipation could be a cause for back pain.

Summary:

Patient #9 presented to the Emergency Department (ED) on 03/30/2020, 04/03/2020 and 04/04/2020 with complaints of back pain. Record review revealed Patient #9 presented to the ED on 04/04/2020, via EMS, at 2:18 PM with a complaint of continued back pain. Patient #9 received Toradol intramuscularly at 3:57 PM for the back pain. The patient also received x-rays of the left hip and the pelvis, which were without abnormality. Review of the ED history and physical revealed the ER Physician recommended Patient #1 stay in the facility for further evaluation; however, the hospitalist determined the patient did not meet criteria for admission and could be managed at home. The patient was discharged to home, via EMS, from the facility at 11:52 PM with a reported pain level at seven (7), on a 0-10 pain scale, which indicated pain was "unmanageable." Review of the EMS record revealed the patient had to be diverted to Facility #2 due to complaints of extreme back pain and a blood pressure reading of 197/130.

Review of the medical record from Facility #2 revealed a 04/05/2020 CT of Dorsal Spine, without contrast, revealed a compression fracture with deformity of Thoracic vertebrae twelve (T12) with 50% collapse of body of T12 and retropulsion of posterior border of T12 was causing spinal stenosis (Narrowing of the spinal canal resulting is compression of the nerve roots or spinal cord by bony spurs or soft tissues). The patient was then transferred to Facility #3 for further treatment of a T12 fracture on 04/08/2020.

Based on interview, record review, review of the facility policies, Medical Staff bylaws, Emergency Services Medical Services (EMS) records and facility KEPRO documents, it was determined the facility failed to provide stabilizing medical treatment for one (1) of twenty (20 ) sampled residents, (Patient #9).

The findings include:

Review of the facility policy, EMTALA-Medical Screening, dated August 2005, revealed the facility must provide for an appropriate Medical Screening Evaluation (MSE) within the capacity of the facility and must be performed by individuals qualified to perform such an examination to determine whether or not an emergency medical condition exists. The policy further revealed the facility was required to reach, within reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition does or does not exist. The MSE was to be an on-going process and the record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred.

Review of the facility Medical Staff Bylaws, Appendix 1, dated August 2014, Article XVI, Emergency Services, Treatment and Transfer of Individuals (EMTALA), revealed the facility should provide a medical screening examination and if it is determined the individual has an emergency medical condition (EMC) should provide the individual with further medical examination and treatment as required to stabilize the EMC, within the capability of the facility or to arrange for transfer to another facility.

Review of the ED medical record for Patient #9 revealed the patient presented to Facility #1's ED, via EMS, on 04/04/2020 at 2:18 PM with the chief complaint of back pain. Further review of the record revealed this was the third presentation to the ED, in the last week, for the chief complaint of back pain.

Review of the EMS record, dated 04/04/2020, revealed Patient #9 was picked up for transport to Facility #1's ED related to back pain and the patient was not able to get up. The record further revealed the family member explained to the EMS staff that the patient had been to the facility three (3) times this week for back pain and the patient continued to scream in pain and was unable to get up. The EMS record also revealed vital signs at 1:31 PM were blood pressure-176/90, heart rate-81, at 2:00 PM blood pressure-156/127 and heart rate-65. The distance from Patient #9's home to Facility #1 was approximately sixteen (16) miles.

Review of the ED Interventions/Assessments/Treatments, dated 04/04/2020 revealed the patient was triaged at 2:20 PM by RN #3. The triage note revealed the patient was brought in by EMS due to back pain and the patient had been seen at the ED twice, prior to this visit, for the same issue. A family member reported the patient was grabbing his/her left leg and screamed when transferred from the EMS gurney to stretcher. The documented vital signs at time of triage were temperature-97.3 degrees, blood pressure-176/86, heart rate-84 and respiratory rate-16. RN #3 used the FLACC (Face, Legs, Activity, Crying, and Consolability) pain evaluation tool and documented a score of four (4), which indicated moderate pain. The record also revealed frequent blood pressure checks (hourly) due to elevated readings ranging from 177/85 to 162/87. Further review revealed the patient was seen by the Physician Assistant-Certified (PA-C), at 2:28 PM. The ED Interventions/Assessments/Treatments documentation, by RN #6, revealed the patient was discharged, via EMS transport, at 11:52 PM, with the disposition "home." Documentation by, RN #6, revealed the patient had a blood pressure of 172/88 and pain level at seven (7), on 0-10 pain scale at time of discharge. The form also included ED notes by RN #5, at 7:30 PM, which revealed the hospitalist called to instruct the patient to go home and call the orthopedist on Monday, as he is aware of the patient. Further review of the ED note, by RN #7, at 8:17 PM, revealed the patient's daughter was upset regarding the hospitalist not wanting to admit the patient.

Interview with RN #3 at Facility #1 on 10/15/2020 at 10:25 AM, revealed she had no memory of anything related to the ED visit by Patient #9 on 04/03/2020 and 04/04/2020.

Review of the Emergency Department note, HPI (History of Present Illness), dated 04/04/2020, by the PA-C and Physician #1, revealed the patient was in the ED for evaluation of back/hip pain which has been present for about six (6) days. Documentation revealed the patient was not able to walk and had been screaming in pain during the previous night. The PA-C also noted the family member stated the pain was worse when he/she moved and nothing made it better. The provider also revealed the family stated the patient was unable and refusing to walk now. Continued review of the HPI revealed the patient was evaluated for hip and back pain and an x-ray of the hip was unremarkable. Medical decision-making (MDM) narrative, authored by Physician #1, revealed the patient's condition was discussed with the family and the recommendation was for the patient to stay for further evaluation, including an orthopedic consult on Monday (04/06/2020). The MDM also revealed the patient was not able to ambulate by self and had three (3) prior evaluations which had not revealed the problem. It was noted the patient usually walked around independently. HPI then revealed consultation with the hospitalist, by Physician #1, and the documentation noted that the hospitalist refused to admit the patient. The consultation documentation further revealed the recommendation from the hospitalist was to give stronger pain medication and discharge. It was noted the hospitalist stated he would not admit the patient because he would not do anything different and was concerned regarding the patient being exposed to infection in the hospital.

Review of the Medication Administration Summary, dated 04/04/2020, revealed Patient #9 was administered Normal Saline (1500 milliliters) intravenously initiated at 6:47 PM, and Toradol (Nonsteroidal anti-inflammatory, for pain relief) 15 milligrams (mg) intramuscular.

Review of the EMS report, dated 04/04/2020, revealed medical transport request, at 11:45 PM, from Facility #1 of Patient #9 to residence. The report revealed EMS arrived at the facility at 11:48 PM. Further review of the report revealed during the transport the patient's condition worsened and the patient began to scream in pain, with pain in the back and legs. Documentation revealed the EMS personnel were not able to make the patient comfortable and vital signs at 12:03 AM were blood pressure of 197/130, heart rate of 92 and respirations 18. Continued review revealed, at the request of a family member, EMS diverted to the closest ED, Facility #2, at that time. The distance between Facility #1 and Facility #2 was 14.8 miles.

Interview with Emergency Medical Technician (EMT) on 10/14/2020 at 1:45 PM revealed he recalled the run on 04/04/2020 to transport Patient #9 from Facility #1 to the residence. He stated they were about five (5) miles from Facility #2 when the patient started to "scream" due to pain. He added they actually stopped the ambulance and conferred with a family member who was following the ambulance as to the patient's current condition. The EMT stated the family member requested they transport the patient to the ED at Facility #2.

Review of Facility #2's Emergency Physician Record, dated 04/04/2020 at 12 midnight, revealed Patient #9 presented to ED with back pain and with pain rated at a ten (10), on 0-10 pain scale. Review of the ED Nursing documentation, 04/05/2020 at 12:38 AM, revealed a blood pressure reading of 182/91. Further review of the ED Nursing notes revealed Patient #9 received the medication Morphine Sulfate (pain medication) 2 mg via intravenous push (IVP) and Zofran (anti-nausea medication) 4 mg IVP at 1:05 AM. The ED record further revealed a CT of abdomen and pelvis, without contrast, was performed on 04/05/2020 with a conclusion of a compression deformity of the T12 vertebrae. A CT of the dorsal spine, without contrast, was also performed on 04/05/2020 with a conclusion of compression fracture with deformity to the T12. Documentation also revealed the patient was transferred to Facility #3 on 04/08/2020 for further treatment of the T12 fracture. The distance between Facility #2 and Facility #3 was 121 miles.

Review of Facility #3's medical records for Patient #9 revealed a history and physical (H&P) by the neurosurgeon. The H & P revealed per magnetic resonance image (MRI) of thoracic and lumbar spine, performed at Facility #3, a T12 vertebral body fracture with over 50% loss of height and moderate canal stenosis. The H&P also revealed a plan for surgery to perform a kyphoplasty (procedure where the vertebrae is opened with a balloon and a cement like material injected to help relieve pressure and stabilize the vertebrae) on 04/10/2020. Further review of the medical record revealed the patient did have the procedure on 04/10/2020 and was discharged home with home health services on 04/16/2020.

Interview with the family member on 10/13/2020 at 4:25 PM, revealed Patient #9 had been to the ED at Facility #1 on three (3) occasions, 03/30/2020, 04/03/2020, and 04/04/2020 for back pain. She further stated on 04/03/2020 she returned to the ED due to patient continuing to complain of back pain and now with abdominal pain. She stated they gave him/her a laxative and discharged home. The family member then revealed on 04/04/2020 the patient was screaming in pain and EMS was called to transport the patient to Facility #1. She stated another family member accompanied the patient this time. The family member then stated she understood the facility was going to keep the patient but then the family with the patient called and stated they were going to discharge, even though he/she was still hurting. Per the family member, she was informed the hospitalist said to give the patient a stronger narcotic medication and to send home. Further interview revealed she received a call from the hospitalist on 04/05/2020 explaining why he did not admit the patient. She stated he told her they had two (2) patients with breathing problems and did not feel comfortable with admitting Patient #9.

Multiple attempts to contact RN #6, RN #5, and RN #7 at Facility #1 were attempted, but were unsuccessful.

Interview with the PA-C at Facility #1 on 10/14/2020 at 2:07 PM, revealed she did vaguely remember Patient #9 but could not recall any details. She further stated any discussion related to admission of a patient would more than likely occur between the physician and the hospitalist.

Interview with Physician #1 at Facility #1 on 10/14/2020 at 2:15 PM, revealed he was not able to speak to the 04/04/2020 ED visit by Patient #9. He stated did not have memory related to this patient or the situation. He stated he probably would have communicated a request to admit a patient to the hospitalist as that was the usual procedure.

Interview with the ED Medical Director at Facility #1 on 10/14/2020 at 4:30 PM, revealed he was familiar with Patient #9's visits to the ED in early April. He revealed back pain management and treatment were provider and patient driven. Further interview revealed he would have most likely admitted the patient for pain control and further testing, especially as this was the third ED visit for same issue.

Interview with the hospitalist at Facility #1 on 10/14/2020 at 3:30 PM, revealed he was aware of Patient #9 and stated on 04/04/2020 he did not admit the patient as there was no criteria for admission, no information to validate admission, i.e. no abnormal x-ray or report of injury. He further stated no analgesics had been tried for the patient, only muscle relaxants and the patient had not had any further testing. He further revealed as a general rule, he would avoid hospitalization if able, due to the increased possibility of infections, any infection. He further stated he had contacted the orthopedist and had personally made an appointment for Monday (04/06/2020) for the patient.

Review of a KEPRO (Medicare Quality Improvement Organization) investigation findings revealed KEPRO requested the medical records from Facility #1 on 06/25/2020. The final determination, dated 08/17/2020, revealed Patient #9's discharge from the ED was appropriate for ED visits dated 03/30/2020 and 04/03/2020. However, the determination for the 04/04/2020 visit concluded "there was an apparent lack of hospital bylaws and/or emergency department protocols when a hospitalist refuses admission and the patient's discharge was inappropriate."

Interview with the Community Chief Regulatory Affairs Officer (CCRAO) at Facility #1 on 10/15/2020 at 9:20 AM, revealed she was aware of Patient #9's ED visits due to notification by KEPRO, (a Medicare Quality Improvement Organization) for a chart review of all three (3) ED visits, 03/30/2020, 04/03/2020 and 04/04/2020 due to a complaint. She stated that she also reviewed the medical records and due to findings requested physician PEER review. She further revealed the records were reviewed by two (2) physicians and the findings were the patient did not meet criteria for admission by both reviewers and it was suggested the patient could have remained in observation status.

Interview with the Chief Nursing Officer (CNO) at Facility #1 on 10/15/2020 at 11:15 AM, revealed she was familiar with the KEPRO investigation related to a complaint. She stated she was aware that a PEER review was requested but was not directly involved in the conversation regarding the findings and any actions taken.

Interview with the Assistant Administrator at Facility #1 on 10/15/2020, revealed he was aware familiar with the KEPRO investigation related to Patient #9. He stated that he and the Chief Executive Officer (CEO) discussed the situation and was briefed on the medical records by the CCRAO. He stated at that time a decision was made to request a PEER review, one physician was a hospitalist from a facility within the corporation and the other was the ED Medical Director. He further stated the findings from the hospitalist and the ED Medical Director was the patient did not meet criteria for admission. The interview further revealed a meeting was held with the CEO, Assistant Administrator, Chief of Staff, and the hospitalist for Facility #1 regarding the investigation and the findings. He then stated actions taken to address the situation were an update to a current policy, Chain of Command for Patient Care Issues: Escalation Policy, dated 12/28/15. He revealed a process/procedure was developed to give specific contacts to be made for resolution of a patient care issue. This update was sent out in an email, dated 09/08/2020 to the ED Medical Director and two other physicians. The Assistant Administrator also provided the agenda for Medical Staff Executive Committee, dated 09/17/2020, which revealed under Old Business- Follow-up to OIG Patient Complaint and KEPRO Recommendations.

Interview with the CEO of Facility #1 on 10/15/2020 at 3:48 PM revealed when made aware of the KEPRO investigation he met with the facility's hospitalist regarding the issue. He stated following the investigation and the findings there was re-education provided to the medical staff on the escalation policy and the updates. He went on to state the policy had been enacted since the education resulted in a good outcome.