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Based on interview, record review, and policy review, the facility failed to comply with the conditions of participation outlined in §489.24(a)(1)(i): The facility failed to provide an appropriate MSE (medical screening examination) by a qualified medical provider for 3 (#s 5, 11 and 17) failed to inform and document the risks and benefits of refusing an examination and treatment for 2 (#s 5 and 11) of 20 sampled patients who presented for emergency care.

Findings Include:

Review of a facility policy titled, Passport Emergency Room Services, dated 10/26/17, showed:

"Policy: It is the policy of Granite County Medical Center, in compliance with the federal COBRA Law, that the hospital emergency room provide a Medical Screening Examination to all who present themselves at their facility to determine if the patient has an emergent condition."

Review of a facility policy titled, Emergency Transfer Protocol, dated 10/26/17, showed:

"Policy: It is the policy of Granite County Medical Center to provide 'emergency services and care' within the capability of the facility and staff to any individual who requests services, examination, or treatment ... 5. Refusal of Treatment or Transfer: a. Should any patient who comes to the Medical Center seeking emergency treatment refuse further medical examination and treatment or refuse a transfer to another medical facility, he or she (or a person acting on the patient's behalf) shall be informed of the risks and benefits to the patient ..."

-Patient #5 presented to the facility seeking medical care on 12/24/23. The facility did not provide a MSE for patient #5 and did not require signed documentation by his guardian showing she had been informed of the risks and benefits of leaving the hospital prior to receiving a MSE by a qualified medical provider. (Refer to 2406)

-Patient #11 presented to the facility seeking medical care on 4/2/24. The facility did not provide a MSE for patient #11 and did not require signed documentation showing she had been informed of the risks and benefits of leaving the hospital prior to receiving a medical screening evaluation by a qualified medical provider. (Refer to 2406)

-Patient #17 presented to the facility on 5/13/24 with complaints of pain between her shoulder blades that made it hard for her to breath. In triage, the patient had an elevated blood pressure and low blood oxygen saturation of 88% (normal is greater than 92%). Pain medication and a muscle relaxer was administered to the patient with some improvement. However, the patient continued to have pain at discharge, and the MSE did not include further evaluation of the patient's ongoing pain, along with the presenting low blood oxygen level and high blood pressure, to determine whether the patient was experiencing an emergency medical condition. (Refer to 2406)

Based on interview and record review the facility failed to provide an appropriate MSE (Medical Screening Examination) for 3 patients (#s 5, 11, and 17) and failed to obtain signed AMA (Against Medical Advice) forms including explanation of risks of leaving the hospital AMA for 2 (#s 5 and 11) of 20 sampled patients who presented for emergency care. Findings include:

1) Record review of patient #5's electronic medical showed, patient #5 presented to the facility on 12/24/23 seeking care for upper respiratory illness and requesting testing for COVID. There was no evidence within the medical record that a qualified medical provider examined patient #5 on 12/24/23 to determine if an emergency medical condition existed. The electronic medical record lacked a signed AMA form explaining the risks of leaving the hospital AMA.

During an interview on 6/13/24 at 11:36 a.m. staff member I stated he was the nurse working when patient #5 came to the ED (Emergency Department) on 12/24/23. Staff member I said the patient's mother called prior to arrival asking for a COVID test for the patient and said she told him the patient was having symptoms of an upper respiratory infection. Staff member I said he phoned the provider, and the provider told him to order the COVID test and call her when the patient arrived. Staff member I said he obtained the specimen and sent it to the laboratory for analysis. When the results were complete, he told the mother the test was negative and then called the provider. Staff member I stated the mother told him the COVID test was all she wanted and left with the patient before the provider could arrive. Staff member I said he usually would get an AMA form and have the patient or guardian sign it. He said he was not sure why there was not one in the chart. He stated, "they must not have scanned it into the medical record." Staff member I said, "I should have made a note or something showing I talked to her about the risks of leaving AMA, but I don't think I did that."

During an interview on 6/6/24 at 11:41 a.m., staff member H said the normal procedure to follow when a patient presented to the ED would be for the nurse to take the patient back to the ED and get the triage information. Then, they should call the provider if they aren't already in the facility, to come see the patient. She said usually she would assess the patient before she ordered any tests, but in this case on 12/24/23 with patient #5, the nurse called and asked if he could order the COVID test for the patient. She told him that would be ok, but to call her when the patient arrived at the facility. She said the nurse did not call until the test result was back, and then he called her to say the mother of the patient had already left with the patient. Staff member H said she did not get an opportunity to provide an MSE for patient #5 because the patient was gone before she could arrive at the facility.

2) Record review of patient #11's electronic medical record showed patient #11 presented to the facility on 4/2/24 seeking care for severe pain. There was no evidence within the electronic medical record that a qualified medical provider examined patient #11 to determine if an emergency medical condition existed. The electronic medical record lacked a signed AMA form explaining the risks of leaving the hospital AMA. The nurse's note showed the patient "did not want to wait for an ambulance ride."

During an interview on 6/5/24 at 5:30 p.m., staff member B said the nurse who wrote the note in patient #11's chart was not available for interview. Staff member B said she was unsure what the nurse meant when she wrote the patient did not want to wait for an ambulance and left before she was seen by the provider. Staff member B said there was no AMA form available for patient #11 for the ED visit on 4/2/24.

3) Review of patient #17's electronic medical record showed the patient arrived at the facility on 5/13/24 seeking emergency medical care for back pain between her shoulder blades that made it hard for her to breath. Patient #17's vital signs taken in triage were significant for high blood pressure and a low blood oxygen level of 88% (normal value is greater than 92%). The provider's documentation showed the patient, who had a history of multiple myeloma diagnosed on 9/26/23, and a history of heart valve replacement, presented with reports of a four-day onset of mild back pain that suddenly became severe while lying in bed the previous night. The pain was reported as constant and was not relieved by over-the-counter medication or changing positions. "Patient reports never having pain like this before. It hurts to move and take a deep breath. Feels sharp and stabbing." The provider notes showed the patient had tachypneic breathing (fast breathing), "grunting in pain with any movement or deep breathing...obvious pain with most actions...any quick breaths or movement causes her to cry out in pain." The patient complained of tenderness to palpation on both sides of her back below her shoulder blades, however, the provider notes failed to show documentation of physical examination of patient #17's spine, neurological examination of patient #17's lower extremities, and did not include patient #17's bowel and bladder continence (important for assessing emergency conditions related to the spine causing back pain). The provider ordered intravenous (IV - in the vein) fentanyl (narcotic medication used for severe pain) for the patient, and noted that it provided "no relief." Nurse documentation showed that eight minutes after the IV fentanyl administration, the patient reported her back pain had not decreased, she was holding her breath and not breathing normal due to the pain. Patient #17 was then administered IV hydromorphone (opioid medication for moderate to severe pain) as ordered by the provider, and 19 minutes later, the patient reported that her pain was improved "as long as I don't move." Nursing documentation showed that a third medication, orphenadrine (muscle relaxant) was ordered by the provider and administered IV, and the patient was immediately assessed as "much more relaxed." The provider documented that the patient was feeling a "little better," but continued to have spasms with movement. The provider discharged the patient home with a diagnosis of "rhomboid (muscles located between the shoulder blades) spasm." However, during the patient's discharge, the nurse noted that when the patient was placed in a wheelchair, "she was in pain again." The nurse notified the provider, then proceeded to discharge the patient with instructions to take the prescribed pain medication (Hydrocodone-acetaminophen) and muscle relaxer (Robaxin) at home. The provider notes did not include a list of differential diagnoses that were considered, evaluation with a chest CT (computerized tomography, a type of imaging that provides a high level of detail of the organs and structures inside the body) for possible aortic dissection (tear in the body's main artery) or pulmonary embolism (blockage of an artery in the lung), which can be associated with the patient's presenting signs and symptoms, or a clear source for the patient's pain, shortness of breath, hypoxia, and hypertension.

Review of patient #17's electronic medical record from another facility showed, patient #17 arrived at their facility on 5/16/24 seeking emergency medical care for continuing pain in her back. Patient #17 underwent a CT of her chest, abdomen, and pelvis. She also had additional laboratory testing. The provider notes showed " ... CT scan however showed multiple myeloma at multiple levels in her thoracic spine as well as in her bilateral femurs. In particular there is a lesion at T6 which causes spinal canal stenosis and I suspect this is the culprit for the patient's pain." Patient #17 was treated with intravenous pain medication and was referred to her multiple myeloma specialist.

During an interview on 6/6/24 at 10:46 a.m., staff member E stated she remembered patient #17. She stated her initial concern was ruling out a cardiac event that could be causing the patients symptoms. She stated, based on her lack of injury and her history of having back pain she decided an x-ray of her spine was not necessary. Staff member E said, "I suppose since she is 82 there could have been a pathologic fracture of the spine but usually there would be pinpoint tenderness or a certain movement that caused the pain. She also had multiple myeloma so possibly she could have had mets (metastasis) to the spine." She said she did not remember if she had a conversation with the patient or her family about admitting her to the facility for pain control but that she knew patient #17 was still in pain when she was discharged and felt that the pain was to be expected with the movement of putting her in the wheelchair and then into the car. Staff member E said she felt patient #17 would do fine at home with the medications she was discharged with once she was home and lying still. Staff member E did not communicate a concern for aortic dissection or pulmonary embolism for patient #17.

During an interview on 6/6/24 at 12:58 p.m., staff member J said she was the nurse who took care of patient #17 on 5/13/24. She said patient #17 was in pain but after she gave the patient intravenous pain medication, she became more comfortable. She said patient #17's daughter asked her if they would admit her for pain control. She told her she did not think they would, but she informed staff member E patient #17 was still in pain when she got her up into the wheelchair to discharge her. Staff member J said Staff member E told her to tell the family to give patient #17 the medications provided as soon as they arrived home and that patient #17's pain should improve once she was home.

During an interview on 6/18/24 at 8:29 a.m. NF2 said she took patient #17 to the facility on 5/13/24 because she was having severe back pain. She said she spoke to the nurse about admitting her to the hospital to control her pain and was told they would not admit her. She said, "I took her home because they clearly were not going to admit her. I couldn't believe they didn't even do an x-ray of her spine. We ended up taking her to [other hospital name] three days later." NF2 said the imaging showed she had multiple myeloma in her spine that was causing her pain. NF2 said patient #17 was treated with radiation but she did not handle the radiation well and died 2 weeks later.

Review of a facility policy titled, Passport Emergency Room Services, dated 10/26/17, showed:

"Policy: It is the policy of Granite County Medical Center, in compliance with the federal COBRA Law, that the hospital emergency room provide a Medical Screening Examination to all who present themselves at their facility to determine if the patient has an emergent condition."

Review of a facility policy titled, Emergency Transfer Protocol, dated 10/26/17, showed:

"Policy: It is the policy of Granite County Medical Center to provide 'emergency services and care' within the capability of the facility and staff to any individual who requests services, examination, or treatment ... 5. Refusal of Treatment or Transfer: a. Should any patient who comes to the Medical Center seeking emergency treatment refuse further medical examination and treatment or refuse a transfer to another medical facility, he or she (or a person acting on the patient's behalf) shall be informed of the risks and benefits to the patient ..."