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Based on interview and record review, the hospital did not abide with the provider's agreement to comply with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The Emergency Department provider did not provide appropriate care to Patient #1 who presented in the ED in the early morning of 05/22/21 with a chief complaint of left leg pain and swelling. Provider #9's findings was UTI (urinary tract infection). Physician #13 agreed with the findings and plan of care. Physician did not see and/or assess Patient #1. Patient #1 was discharged on the morning of the same day. After discharged on 05/22/21, the patient sought medical care in Hospital B where she was admitted.

Cross refer to A2406 Failure to Provide Appropriate Medical Screening Examination

Based on interview and record review, the Hospital A's Emergency Department (ED) provider (Provider #9) failed to provide an appropriate medical screening exam that included Patient #1's chief complaint of left leg pain and swelling. Both the triage nurse (Personnel #11) and the ED primary care nurse (Personnel #10) notified Provider #9 about their findings of the patient's left leg. These findings were documented in the patient's medical record, citing 1 (Patient #1) of 4 pregnant patients that presented in the hospital's ED on 05/22/21.

Findings included:

Patient #1 presented in the ED on 05/22/21 at 00:45. At 01:04 Personnel #11 conducted a "Rapid Initial Assessment" that reflected "Subjective Assessment: Reason for Visit: Left leg pain and mild swelling, vomiting, weakness, hot flashes. Pain begins at left groin and radiates to lower leg, numbness throughout...What aspect of reason for visit is concerning to patient: left leg pain, swelling, and numbness...Objective Assessment: Alert and oriented x4...Limps when walking...Pain intensity 10...LMP (last menstrual period): 03/21/21. Chief Complaint: Extremity injury. Priority: ESI 3/urgent..."

At 07:24, Personnel #10 noted "Detailed Assessment...Upper/Lower Extremity...Extremity Injury. Mechanism of injury: No trauma. Presenting sign/symptoms: Edema at injury, unable to bear weight, Decreased range of motion, Difficulty walking, Extremity discomfort. Symptoms frequency: Unknown. Onset of current episode: Unknown...Gait, strength, balance: Non-ambulatory...Peripheral edema: Present/exists...Movement distal to wound/injury: None...Peripheral Edema location 1: Leg. Peripheral edema location (L/R) 1: Left. Peripheral edema location (A/P) 1: Anterior. Peripheral edema turgor description 1: tight. Peripheral edema type 1: Non-pitting."

At 07:25, Personnel #10 noted "Physical Findings." All body systems were within defined parameters (WDP) except for "Musculoskeletal WDP: No."

At 00:55, Provider #9 initiated the medical screening exam. Provider #9 noted "HPI (history of present illness) Preg (pregnancy) under 20 weeks. 24-year-old female, currently 10 weeks' pregnant presents to ED with complain left sided pelvic pain. Patient reports symptoms have been intermittent over the past few days. Reports aching pain, does not radiate, nothing makes it better, nothing makes it worse...Presentation: Chief Complaint: Pelvic pain, pregnant...Location: Suprapubic, Pelvis. Quality: Aching...Severity: Onset mild. Severity: Current moderate..." Review of Systems (ROS): ROS Statements. All systems reviewed were negative except "GU (genitourinary): positive pelvic pain, positive pregnant..." "Past Medical History-Adult: Stated Complaint 10 weeks OB, left leg pain, pitting edema x2 hours...Review of Nursing Notes: "review avail, and agree." "Basic Physical Exam...EXT: No gross abnormality...Focused PE: MS Back (musculoskeletal system): Back inspection NL (normal limits), non-tender..." "Re-Evaluation and Medical Decision Making" no time indicated "....UA c/w UTI. Labs showed leukocytosis. Otherwise unremarkable. Patient denied vaginal bleeding, no RH incompatibility. Updated on diagnostic testing results and plan for discharge with OBGYN f/u and antibiotics for UTI...Clinical Impression: Primary Impression: UTI in pregnancy. Secondary Impression: Pelvic pain affecting pregnancy. Ruled out Impressions: Ectopic pregnancy, Rh compatibility, Vaginal bleeding." There was no assessment in the musculoskeletal system about Patient #1's left lower extremity.

At 04:21, Provider #9 noted "Disposition Decision: Discharge to Home: Yes." Discharge/Care Plan: Counseled Regarding Diagnosis, lab results, Imaging studies, Prescriptions, Need for follow-up, when to return to ED. Prescription: Keflex. Prescription Reviewed Risks, Benefits, Alternative Treatment. Referrals: No primary or family physician." Electronically signed on 05/25/21 at 00:54.

During an interview with Personnel #8 on 05/27/21 at 1:18 PM in a conference room, Personnel #8 was asked if the ED providers could see the nurses' notes/assessments in real time. She replied yes they could, but "I will confirm it." At 2:10 PM the regional medical director confirmed that ED providers could access nurses' notes in real time. Personnel #8 was asked if a patient was classified as ESI 3, would a physician see the patient. She replied the physician could either see the patient or discuss the findings and plan of care with the LIPs (Licensed Independent Practitioners).

During an interview with Personnel #5 on 06/07/21 at 2:56 PM via email, Personnel #5 was asked for a policy and/or Medical Staff Rules and Regulations regarding physicians' supervision of LIPs in the ED. Personnel #5 replied there was no policy and procedure. Personnel #5 stated in the Medical Staff Rules and Regulations there was a section that talked about Physicians "co-signing and authenticating the charts."

During an interview on 05/27/21 at 2:10 PM in a conference room, Provider #9 stated there were two providers on 05/22/21. It was a busy night. Provider #9 was asked if she reviewed the nurses' notes prior to seeing Patient #1. She replied sometimes she reviews the nurses' notes. But stated, I want to ask the patient myself as to what brought them to the ED. Provider #9 stated she wanted to give the patient an opportunity to tell her what was going on with them. Patient #1 presented with left pelvic pain. Provider #9 stated she ordered an ultrasound (US) since the patient was pregnant. She stated her findings was UTI. Provider #9 discussed the findings and plan of care with the Ed Physician #13. The patient was treated for UTI and was discharged. Provider #9 stated the patient did not tell her about her leg pain and swelling. Had she told her about this, she would have ordered an ultrasound of the leg. She could also have ordered a D-Dimer lab work. Provider #9 could have accessed the nurses' notes to know that the patient's chief complaint was left leg pain and swelling. Provider #9 was notified by Personnel # 10 and Personnel #11 about Patient #1's left leg pain and swelling and their assessments. Personnel #10 and Personnel #11 documented their findings in the medical record which was accessible to Provider #9 at that time.

During an interview on 06/02/21 at 8:00 AM via phone call, Personnel #11 was asked if she remembered Patient #1.
She replied I clearly remember this patient. When I called her to the triage room, I noticed she was limping. She complained of left leg pain and swelling. The patient was wearing fleece pajamas and it was easy to "pull the pant legs up." I saw the entire left leg was "significantly larger than the right." The left leg was "firmer, flushed, and tight." Later, I saw Provider #9 go in the triage room where the patient was. When Provider #9 was at the triage desk, I asked her if she saw the patient's swollen left leg. Provider #9 asked me if the leg had pitting edema. I replied there was no pitting edema. Provider #9 told me there was nothing wrong with the patient's leg and stated she was not concerned about it. Personnel #11 stated Patient #1 might have DVT (deep vein thrombosis).

During an interview on 06/02/21 at 8:40 AM via phone call, Personnel #10 stated she took care of Patient #1 about 2:30 PM. Patient #1 complained of severe left leg pain. Personnel #10 stated she reviewed the triage notes which indicated the patient had left leg pain, swelling, taut, and limped when walking. She could see the left leg was bigger than the right, particularly the thigh. "I was worried about DVT." Personnel #10 was asked if she notified Provider #9 about her findings. Personnel #10 replied she did. Personnel #10 stated a urinalysis was ordered. I asked the patient if she could go to the restroom. The patient said she could. Personnel #10 stated the patient had a difficult time walking to the restroom. She could not bear weight on the left leg. "So I placed her in a wheelchair." When the patient was cleared for discharged, Personnel #10 stated the patient asked her "what about my leg.?" I told the patient that the provider would talk to her prior to discharge and she could ask that question.

Patient #1 left Hospital A's ED on 05/22/21 at 0529.

During an interview on 05/28/21 at 9:52 AM, 06/07/21 at 2:34 PM, and on 06/09/21 at 10:13 AM via phone, Personnel #7 informed the surveyor that Personnel #10 documented Patient #1's detailed assessment late, at 7:24 AM, almost 2 hours after the patient left. Personnel #7 also told the surveyor that the extremity recorded was inaccurate (Emergency Patient Record page 3 of 5). This should have been left lower extremity and not upper extremity right. On 06/09/21 at 10:13 AM via phone, Personnel #7 was asked if there was an ED policy for nurses to document the detailed assessment in real time. Personnel #7 replied there was none, but the expectation was nurses should be documenting in real time. Sometimes the nurses have other patients to attend to that would delay the documentation. Personnel #7 stated she talked to Personnel #10 about the delayed documentation and that Personnel #10 should have specified late entry in the documentation. Personnel #7 was asked how will the providers review the nurses' findings if the documentation was turned in late. Personnel #7 stated most providers do not review the nurses' notes except for the vital signs.

Hospital B's medical record reflected Patient #1 presented on 05/22/21 at 2:35 PM. Triage notes indicated "Pt (patient) wheeled to triage booth...Pt here for evaluation of lower abdominal pain that radiated to the left lower extremity (LLE)...LLE noted to be slightly bigger and redder when compared to RLE...Pt transferred to OGES for evaluation (obstetrics gynecology emergency services)."

At 3:25 PM, Patient #1 was in the OGES..."complaint of LLE pain 10/10 started at the left suprapubic pain and spread down to my leg...Reports is able to move a little bit but not bear any weight. On assessment extremity is considerably swollen, tense, skin is cold and colder from anterior to inferior portion of leg."

At 3:37 PM, a physician assessed the patient and noted "LLE pain/swelling, left side mons/groin pain. Reports 10/10 pressure-like/tense pain starting in her L mons/groin and radiating to LLE...Assessment: 24-year-old...at 9 weeks by LMP...who presents to the OGES with LLE pain/swelling, L-sided mons groin pain...Physical exam ...LLE erythema, swelling. Labs...leukocytosis-WBC 16...Patient #1 presentation most consistent with possible LLE DVT. Plan: US Doppler Venous and arterial bilateral STAT. Strict OGES warnings given..."

At 5:49 PM, Findings of US Doppler Venous DVT BLE indicated "1. Deep venous thrombosis (DVT) identified. Thrombus identified throughout the Left lower extremity venous system. No right-sided DVT.
Left Lower Extremity:
Common femoral vein: Occlusive thrombus.
Cephalad greater saphenous vein: Occlusive thrombus.
Cephalad profunda femoral vein: Occlusive thrombus.
Femoral vein: Occlusive thrombus.
Popliteal vein: Occlusive thrombus.
Deep calf veins: Occlusive thrombus."

At 8:16 PM, Vascular Surgery Consult Note reflected "Assessment/Plan...The cause of her thrombus may be pregnancy related as there is no evidence of any other provocations. No need for surgical interventions. Continue observation. Serial pulse checks. Heparin drip..."

Patient #1 was admitted on 05/22/21 at 11:55 PM for "indication for care in labor and delivery, antepartum and DVT (deep vein thrombosis) in pregnancy." The patient was eventually discharged on 05/27/21.