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Based on document review, medical record review and interview, the hospital did not comply with the requirements at 489.24 and 489.20, Specifically, 1) In 2 of 21 (Patient #2 and Patient #4) medical records reviewed the hospital failed to provide an appropriate medical screening exam to patients who presented to the emergency department for evaluation to determine if an emergency medical condition existed. 2) In 1of 4 (Patient #3) medical records reviewed of patients who required a transfer to a higher level of care, it lacked documentation of an appropriate transfer. This could lead to untoward patient outcomes. Please reference findings at Tag 2406 and Tag 2409.

Based on document review, medical record review and interview, in 2 of 21 (Patient #2 and Patient #4) medical records reviewed, the hospital failed to perform an appropriate medical screening exam to determine if an emergency medical condition existed. This could lead to untoward patient outcomes.

Findings include:

-- Review of the hospital's policy and procedure titled, "Emergency Patient Medical Screening Guidelines," revised 4/2023, indicated according to emergency medical treatment and labor act (EMTALA), if any individual comes to the hospital emergency department and requests examination or treatment for a medical condition the hospital must provide, without discrimination, an appropriate medical screening exam to determine whether an emergency medical condition exists.

-- Review of Patient #2's (15-day-old female) medical record revealed, she presented to the emergency department on 12/25/2023 at 1:56 am with a chief complaint of a cough. The patient was triaged at 2:59 am (no triage level was assigned).

Nursing documentation revealed, Patient #2 arrived with parents. Per patient's father, she has had an intermittent cough at home since Friday (12/22/2023). Patient #2 may have been exposed to a febrile illness. "Patient was asleep on initial observation. Responds to tactile stimuli and is alert once awake. She does have a decreased response to painful stimuli as in she stops crying quickly without soothing. Patient is moving all extremities. Blood glucose 74 (normal 40 - 99) via heel."

3:04 am - Initial vital signs at were as follows: temperature 100.2 Fahrenheit (rectally), heart rate 168, respirations 42 and oxygen saturation 98%. "Patient #2 is readily responsive to painful/noxious stimuli on assessment, but quiets quickly without being soothed. Last full feeding was around 6:00 pm last night, per her parents. Patient then fell asleep and on waking, patient's father stated that she didn't eat much and fell back to sleep. Wetting diapers per normal. Full term, uncomplicated vaginal delivery 12/10/23. She is receiving breast milk every 1.5 - 2 hours per father. Patient offered Pedialyte and latched to bottle nipple without difficulty but did gag frequently while eating. Patient does have an occasional, wet cough. Lung sounds clear on auscultation. The parents spoke with the provider and will be transporting the patient to another hospital emergency department with pediatrics at this time. Patient discharged at 3:18 am. Disposition set to discharge."

Provider documentation (on 12/31/2023 at 10:16 pm - 6 days after discharge) revealed, "Patient was seen, found to
be mildly hypoglycemic. Given sugar water by nurse. Considering that patient was born at gestational age, but is within 15 days, there is concern that patient needs inpatient care at least for couple of days for observation. Shared decision making was made with family members, will likely need to be transferred to Hospital B as we do not have inpatient pediatric floors. Family members found it easier to go to Hospital B's emergency department, and get evaluated there, and to be transferred to floors by there."

History and Physical
Review of Systems (blank)

Physical Exam
Vitals and nursing note reviewed.
Constitutional:
General: She is active.
Appearance: Normal appearance. She is not diaphoretic.
Comments: Crying but consoled by mother
HENT:
Head: Normocephalic.
Eyes:
General:
Right eye: No edema or discharge.
Left eye: No edema or discharge.
No periorbital edema or erythema on the right side. No periorbital edema or erythema on the left side.
Extraocular Movements: Extraocular movements intact.
Cardiovascular:
Pulses: Normal pulses.
Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds.
Skin:
General: Skin is cool.
Findings: There is no diaper rash.
Comments: No rashes noted
Neurological:
Mental Status: She is alert.

The facility failed to do a complete and comprehensive medical screening exam to determine if the patient had an emergency medical condition requiring a higher level of care.

-- Per interview of Staff A, Emergency Department Medical Director on 4/10/2024 at 12:30 pm, Staff A indicated Patient #2 had a fever and needed a sepsis workup, viral panel, lumbar puncture, etc. Staff A received notification that there was only a progress note written for Patient # 2 in the chart, and that their needed to be a full note with system review and full assessment completed. The physician involved in the care of Patient #2 had gone to the waiting room and explained to Patient # 2's parents what would need to be done. The patient's mother did not want to stay. The physician explained to the parents the risks of leaving, however, the mother still wanted to leave. Staff A discussed that a Leave Against Medical Advice form should have been completed prior to Patient #2 and her parents leaving the emergency department. Staff A indicated all emergency department physicians have been educated on EMTALA and that training occurred two times in the last year.

-- Per interview of Staff B, Registered Nurse on 4/10/2024 at 12:55 pm, Patient #2 was 15 days old and was seen on 12/25/2023. Patient #2 was very sick and had a cough, fever and was excessively crying. Staff B was not working triage on that day but does recall an emergency department provider seeing her in triage. The parents wanted to leave and go to another facility and that the provider spoke with the parents about the risks of leaving.

-- Review of Patient #4's medical record revealed, he presented to the emergency department on 12/5/2023 at 4:05 pm via emergency medical services with a chief complaint of constipation x 1 week. Prehospital vital signs as documented by emergency medical services were as follows: blood pressure 147/91, pulse 103, respirations 16, oxygen saturation 95%.

4:48 pm - Nursing documented, "Patient #4 had been locked in the bathroom for some time. Once the door was opened, Patient #4 was found to be smoking crack in the bathroom."

4:52 pm - Nursing documented, "Patient #4 found with drugs in the bathroom, escorted out by security."

There is no documentation that a medical screening exam was performed or if the patient requested to be seen or to leave the facility.

-- Per interview of Staff C, Registered Nurse on 4/10/2024 at 12:05 pm, Patient #4 arrived by ambulance and he was a lower acuity patient. When an emergency medical services patient has a lower acuity, they go through the regular triage process (to waiting room. then triaged as soon as possible).

-- Per interview of Staff A on 4/10/2024 at 12:30 pm, Staff A was aware of Patient #4 being in the bathroom. A lot of patients use emergency medical services as a taxi. Providers are all educated on EMTALA and were made aware patients need a medical screening exam. The facility instituted the MDE code (call a provider to see a patient before leaving) for that reason to ensure patients receive an exam before leaving the facility. Staff A acknowledged the above findings.

-- Per interview of Staff D, Registered Nurse on 4/11/2024 at 2:50 pm, Staff D recalled Patient #4 and when first calling him for triage there was no response. Staff D went back to the waiting room again to get the patient and he/she/they could still not find him. There was someone in the bathroom. The patient said he couldn't come out. After a significant amount of time and the fact other patients needed to use the bathroom, he/she/they contacted security. When security opened the door there was aluminum foil with a white substance on it. Security then escorted the patient out of the facility.

-- During interview of Staff E, Accreditation Specialist on 4/10/2024 at 3:00 pm, he/she/they acknowledged the above findings.

Based on medical record review, document review and interview, in 1 of 4 (Patient #3) medical records reviewed of patients who were transferred to a higher level of care, it lacked documentation of the physician certification for transfer or risks and benefits certification of transfer specific to the patient's medical condition. This could lead to patients not being informed of potential risks and benefits related the transfer.

Findings include:

-- Per review of Patient #3's (7-year-old female) medcial record, she presented to emergency department on 1/2/2024 at 9:44 am with a chief complaint of generalized weakness. Per mother she was seen in the emergency department 3 days prior and was becoming weaker and won't eat or drink much. The patient was triaged was at 9:56 am and the patient was assigned an Emergency Severity Index level of 2 (on a scale of 1 -5, [1 being resuscitation and 5 non-urgent]). Vital signs were as follows: temperature 99.4 degrees Fahrenheit, blood pressure 105/69, heart rate 94, respirations 20 and oxygen saturation 100%.

Multiple laboratory studies were performed for example, complete blood count, blood glucose, magnesium, hepatic (liver) function panel, sedimentation rate, metabolic profile, venous blood gas, etcetera. Intravenous fluids were initiated, blood cultures obtained. Glucose was 110 (normal 65-99). Blood urea nitrogen/creatinine level 36 (normal 10.0-20.0 [elevated level can indicate dehydration]), white blood cell 22.7 (normal 4.5-14.5).

12:49 pm - Transfer center request ordered. Reason for transfer, higher level of care for pediatrics.

1:47 pm - Provider documented, "Patient meeting systemic inflammatory response syndrome (SIRS) criteria with fever of unknown origin. She has been given intravenous fluids and have started on intravenous antibiotics. The patient will need to be admitted and unfortunately, we do not have pediatric support here at the hospital. Hospital B's transfer center was contacted, they will check bed availability and call back."

3:05 pm - Provider documented, "given that patient has continued to look ill, has had worsening symptoms over the last 2 weeks with ongoing fevers, and workup concerning for leukocytosis, I reached out to Hospital B who connected me to their pediatrics department. I spoke with a provider who accepted the patient in transfer/admission to their pediatrics unit. Awaiting bed assignment from the facility. Clinical Impressions: systemic inflammatory response syndrome and fever of unknown origin."

3:59 pm - Patient transferred to another facility by ambulance. Nurse to nurse report given.

There was no documentation of certification for transfer or the risk and benefits of such transfer.

-- During interview of Staff E, Accreditation Specialist on 4/10/2024 at 3:30 pm, he/she/they acknowledged the above findings.