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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag 2406 - Applicability of Provisions of this Section (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction. Based on interviews and document review, the facility failed to ensure patients received a medical screening exam (MSE) according to facility policy. Specifically, the facility failed to ensure patients presenting to the facility with a potential emergency medical condition (EMC) were medically screened according to facility policy.

Tag 2407 - Necessary Stabilizing Treatment for Emergency Medical Conditions (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either-- (i) Within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. Based on interviews and document review, the facility failed to ensure patients presenting to the emergency department (ED) with an emergency medical condition (EMC) received stabilizing treatment according to facility policy. This failure impacted five of 22 patients' medical records reviewed.

Based on interviews and document review, the facility failed to ensure patients received a medical screening exam (MSE) according to facility policy. Specifically, the facility failed to ensure patients presenting to the facility with a potential emergency medical condition (EMC) were medically screened according to facility policy. This failure impacted eight of 20 patients' medical records reviewed. (Patients #1-4, #7, #16, #17, and #19) (Cross-reference C-2407)

Findings include:

Facility policies:

According to the Emergency Medical Treatment and Labor Act (EMTALA) policy, any patient who comes to the hospital requesting emergency services will receive an MSE to determine whether an emergency medical condition (EMC) exists. Services provided under this policy shall be provided regardless of the patient ' s diagnosis and shall be the same for all individuals who present with the same signs and symptoms. The MSE is the process to determine whether or not an EMC exists. Such screening must be done within the facility's capabilities and the capabilities of available personnel and may range from a simple process involving only a brief history and physical examination to a complex process that involves performing ancillary studies and procedures. The MSE includes both a generalized assessment and a focused assessment based on the patient ' s chief complaint. An MSE is not an isolated event but is an ongoing process which involves continued monitoring according to the patient ' s needs until the patient is stabilized. The ED physician on duty shall be responsible for the general care of all patients presenting themselves to the ED.

According to the Standards of Practice of Care policy, assessments reflect changes in patients' condition and are appropriately charted and communicated. Patients' response to treatment and interventions is reflected in the electronic medical record (EMR). The nursing process is used to reflect the patients' current conditions and treatment plans, which includes evaluation of patient response to interventions and outcomes. The patients will be continually assessed for changes and progress toward meeting outcome goals and discharge objectives. Fundamental ED nursing interventions for class I patients include vital signs taken every 15 minutes two times then every 30 minutes and for class II patients, vital signs taken every 30 minutes two times then every two hours. For class III patients, vital signs are taken on admission, post-intervention, and/or discharge. Vital signs will be repeated if not within normal limits. Vital signs will be repeated after administration of medications with potential side effects. Patient response to medical and nursing interventions is evaluated and documented.

Reference:

According to the Colorado Code of Regulations (CCR) for Emergency Medical Services (EMS) Scope of Practice, medical supervision of the EMS provider in a clinical setting must be provided by a medical supervisor who is a Colorado licensed physician or registered nurse licensed in good standing, trained and experienced in the acts and skills for which supervision is being provided, knowledgeable about the maximum skills, acts, or medications that an emergency medical technician (EMT) or paramedic are authorized to perform, and immediately available and physically present at the clinical setting where the care is being delivered to provide oversight or guidance to the EMS provider during the performance of medical acts.

1. The facility failed to ensure patients presenting to the facility for an EMC received an MSE per facility policies.

A. Medical record review

i. A review was conducted of Patient #16's medical record which revealed Patient #16 had presented to the ED on 7/29/24 after a suicide attempt from overdosing on alcohol and acetaminophen. On 7/29/24 at 9:50 a.m., the RN documented the first assessment, an ED Triage and Assessment. Although Patient #16 was at the facility until 7/30/24 at 9:15 a.m. (23 hours and 35 minutes later), the medical record failed to reveal another RN assessment of the patient. This gap in patient assessment was in contrast to an interview conducted on 8/13/24 at 5:09 p.m. with chief nursing officer (CNO) #3 during which they stated reassessments were performed at least once every shift and at shift change to ensure nurses observed and responded to changes in patient condition.

On 7/29/24, the RN notes documented vital signs at 11:10 a.m., 1:57 p.m. (two hours and 47 minutes later), 3:30 p.m. (one hour and 33 minutes later), and 5:00 p.m. (one hour and 30 minutes later). The 3:30 p.m. and 5:00 p.m. vitals failed to reveal an assessment of Patient #16's BP. The next assessment of Patient #16's vital signs was on 7/30/24 at 3:45 a.m., 10 hours and 45 minutes after the last set of vital signs were assessed, and 13 hours and 48 minutes after the BP was last assessed. On 7/30/24 at 9:15 a.m., Patient #16 was discharged. The medical record failed to reveal an assessment of the vital signs between 7:00 a.m. and 9:15 a.m. which was in contrast to an interview conducted on 8/12/24 at 4:57 p.m., during which RN and ED Manager (Manager) #2 stated RNs obtained discharge vitals no less than an hour before discharge to ensure the patients' conditions had not changed.

This lack of assessment, including RN reassessments and vital signs, in a patient with behavioral health and medical concerns, revealed an inappropriate MSE which was in contrast to the EMTALA policy which read, patients presenting to the ED received an MSE to determine whether an EMC existed. An MSE was not an isolated event but an ongoing process which involved continued monitoring according to the patient ' s needs until the patient was stabilized.

ii. A review was conducted of Patient #17's medical record which revealed Patient #17 had presented to the ED for suicidal and homicidal ideations (thoughts) on 6/10/24. On 6/10/24 at 3:17 a.m., the RN Triage Assessment documented Patient #17's ED intake. Although Patient #17 was at the facility until 6/11/24 at 9:45 a.m. (30 hours and 28 minutes later), the medical record failed to reveal another RN assessment of the patient. This gap in patient assessment was in contrast to an interview conducted on 8/13/24 at 5:09 p.m. with chief nursing officer (CNO) #3 during which they stated reassessments were performed at least once every shift and at shift change to ensure nurses observed and responded to changes in patient condition.

On 6/10/24 at 9:42 p.m., the RN Rounding Comments documented Patient #17 was agitated, in pain, and had requested pain medication. On 6/11/24 at 12:23 a.m., the physician notes documented Patient #17 complained of general diffuse pain and requested olanzapine (helps regulate mood, behavior, and thoughts) and gabapentin (relieves nerve pain), however, there was a concern for additive effects (a combined unintended effect that occurs when two or more medications are administered together) with the gabapentin so Patient #17 would be given olanzapine and was then to be reassessed.

The Medication Administration Record (MAR) documented olanzapine was administered to Patient #17 on 6/10/24 at 9:42 p.m. On 6/11/24 at 6:27 a.m., the RN Rounding Comments documented Patient #17 slept after the administration of medication. The record failed to reveal a follow-up assessment of Patient #17 in accordance with the physician's note.

On 6/11/24 at 9:22 a.m., the physician note documented Patient #17 had baseline postsurgical ankle pain and had been given ibuprofen (a non-steroidal anti-inflammatory medication). The MAR documented ibuprofen was given on 6/11/24 at 9:21 a.m. The record failed to reveal a thorough assessment or follow-up assessment of Patient #17's pain.

This lack of assessment, including RN reassessments and a thorough assessment of pain, in a patient with behavioral health and medical concerns, revealed an inappropriate MSE which was in contrast to the EMTALA policy which read, patients presenting to the ED received an MSE to determine whether an EMC existed. An MSE was not an isolated event but an ongoing process which involved continued monitoring according to the patient ' s needs until the patient was stabilized.

iii. A review was conducted of Patient #2's medical record which revealed Patient #2 had presented to the ED for lateral tibial plateau fracture (a break of the larger leg bone below the knee that breaks into the knee joint itself) on 7/3/24. At 11:17 a.m., the RN note documented Patient #2's blood pressure (BP) was 172/113 (normal is 120/80) and pain was 5/10. At 12:25 p.m. (one hour and eight minutes later), the RN administered an intramuscular (IM) injection of ketorolac (NSAID) for pain. At 12:30 p.m. (five minutes after the pain medication was administered), Patient #2 was discharged. The medical record failed to reveal an assessment of Patient #2's pain after the administration of the pain medication or before discharge. The medical record also failed to reveal a reassessment of Patient #2's vital signs, including BP, before they were discharged.

The lack of ongoing assessment, including for pain and vital signs, revealed an inappropriate MSE which was in contrast to the EMTALA policy which read, patients presenting to the ED received an MSE to determine whether an EMC existed. An MSE was not an isolated event but an ongoing process which involved continued monitoring according to the patient ' s needs until the patient was stabilized.

iv. A review was conducted of Patient #1's medical record which revealed Patient #1 had presented to the ED for wrist fracture (broken bone) after a motor vehicle accident (MVA) on 7/23/24. At 1:41 p.m., the RN triage assessment documented Patient #1 rated their pain as four out of 10, with 10 being the worst possible pain. At 2:50 p.m. (one hour and nine minutes after triage), the RN administered ibuprofen (a nonsteroidal anti-inflammatory (NSAID)) to Patient #1. At 5:03 p.m. (two hours and 13 minutes after the pain medication was administered), Patient #1 was discharged. The medical record failed to reveal an assessment of Patient #1's pain after the administration of pain medication or before discharge.

The lack of ongoing assessment for pain revealed an inappropriate MSE which was in contrast to the EMTALA policy which read, patients presenting to the ED received an MSE to determine whether an EMC existed. An MSE was not an isolated event but an ongoing process which involved continued monitoring according to the patient ' s needs until the patient was stabilized.

v. A review was conducted of Patient #3's medical record which revealed Patient #3 had presented to the ED for lateral tibial plateau fracture on 7/30/24. At 10:54 a.m., the RN note documented Patient #3 rated their pain 6/10. At 12:32 p.m. (an hour and 38 minutes later), the RN documented only Patient #3's pulse rate, respiratory rate, and oxygen saturation and the patient was discharged at 12:34 p.m. The medical record failed to reveal a reassessment of Patient #3's pain or BP before they were discharged.

The lack of ongoing assessment, including for pain and blood pressure, revealed an inappropriate MSE which was in contrast to the EMTALA policy which read, patients presenting to the ED received an MSE to determine whether an EMC existed. An MSE was not an isolated event but an ongoing process which involved continued monitoring according to the patient ' s needs until the patient was stabilized.

vi. A review was conducted of Patient #4's medical record which revealed Patient #4 had presented to the ED for a lateral tibial plateau fracture after an MVA on 6/21/24. At 6:45 p.m., the RN note documented Patient #4 rated their pain 10/10. During Patient #4's stay in the ED from 6:33 p.m. to 11:30 p.m. (four hours and 57 minutes in duration), they were given Dilaudid (a narcotic pain medication used to treat moderate to severe pain) at 7:19 p.m., 8:53 p.m., and 10:37 p.m.). They were also given acetaminophen/hydrocodone (another narcotic pain medication for moderate to severe pain) at 9:16 p.m. The RN notes in the Medication Administration Record (MAR) documented that the narcotic pain medications were "effective," but the medical record failed to reveal a thorough assessment of the severity and quality of Patient #4's pain in response to the pain medications (administered between 7:19 p.m. and 10:37 p.m.) before they were discharged at 11:30 p.m.

The lack of a thorough and ongoing pain assessment revealed an inappropriate MSE which was in contrast to the EMTALA policy which read, patients presenting to the ED received an MSE to determine whether an EMC existed. An MSE was not an isolated event but an ongoing process which involved continued monitoring according to the patient ' s needs until the patient was stabilized.

vii. A review was conducted of Patient #7's medical record which revealed Patient #7 had presented to the ED for tachycardia (high heart rate) on 7/10/24. At 9:39 p.m., the ED Assessment documented an EMT had performed Patient #7's assessment with the RN's cosign documented in the medical record on 7/11/24 at 6:08 a.m. (eight hours and 29 minutes later). There was no further evidence in the medical record to verify if the RN was physically present to provide oversight at the time of the EMT's assessment.

The medical record failed to reveal medical supervision of the EMT during this patient assessment which was in contrast to the CCR for EMS Scope of Practice which read, medical supervision of the EMS provider was provided by a provider or RN who was immediately available and physically present to provide oversight or guidance during the performance of medical acts.

The lack of RN assessment revealed an inappropriate MSE which was in contrast to the EMTALA policy which read, patients presenting to the ED received an MSE to determine whether an EMC existed. Such screening was done within the capabilities of available personnel.

viii. A review was conducted of Patient #19's medical record which revealed Patient #19 had presented to the ED for third-trimester bleeding on 7/30/24. At 1:38 a.m., the ED Assessment documented an EMT had performed Patient #19's assessment with the RN's cosign documented in the medical record on 7/30/24 at 6:36 a.m. (five hours and 58 minutes later). There was no further evidence in the medical record to verify if the RN was physically present to provide oversight at the time of the EMT's assessment.

The medical record failed to reveal medical supervision of the EMT during this patient assessment which was in contrast to the CCR for EMS Scope of Practice which read, medical supervision of the EMS provider was provided by a provider or RN who was immediately available and physically present to provide oversight or guidance during the performance of medical acts.

The lack of RN assessment revealed an inappropriate MSE which was in contrast to the EMTALA policy which read, patients presenting to the ED received an MSE to determine whether an EMC existed. Such screening was done within the capabilities of available personnel.

B. Interviews

i. On 8/7/24 at 1:00 p.m., an interview was conducted with RN #1. RN #1 stated every patient in the ED received an initial assessment. They stated they used the emergency severity index (ESI) to determine acuity which guided the frequency of patient reassessment. RN #1 stated reassessments were also performed based on changes in condition, specific needs, and after every intervention. They stated they obtained vitals in patients with an ESI of 1 or 2 every five minutes at first then modified the frequency based on provider orders.

RN #1 stated if a patient was in the ED for over an hour, the patient would have at least two sets of vitals in their medical record. They stated the discharge process involved ensuring patients had stable vitals within 15 minutes of discharge. RN #1 stated ensuring discharge vitals were taken, and at that patient's baseline, was important to ensure patients were stable and safe for discharge.

This was in contrast to the medical records for Patients #2, #3, and #16 which did not reveal the assessment of all vital signs before discharge.

RN #1 stated pain was assessed using a pain scale. They stated pain reassessments were performed 15 minutes after the administration of intravenous (IV) medications and 45 minutes after oral medications. RN #1 stated if patients still had elevated levels of pain after receiving pain medications, the nurse informed the provider and considered additional comfort measures. They stated if pain was not reassessed, there was a risk of uncontrolled pain and pain crisis.

This was in contrast to the medical records for Patients #1, #2, #3, #4, and #17, which did not reveal a reassessment of pain.

ii. On 8/12/24 at 4:03 p.m., an interview was conducted with RN #5. RN #5 stated they evaluated pain at the time of triage using a pain scale. They stated they re-evaluated pain and included vital signs in this reassessment as the vitals could indicate the patients' pain was not adequately controlled. RN #5 stated pain reassessments performed after medication interventions, including for non-narcotic medications, included taking vital signs every hour and a determination of the medication's efficacy. They stated vital signs outside of normal limits could indicate uncontrolled pain or anxiety. RN #5 stated obtaining vital signs and reassessing patients after the administration of pain medications was important to ensure pain was addressed and to ensure patients were not experiencing side effects from the medications. They stated for instance, narcotic pain medications such as Dilaudid and Vicodin, could result in respiratory distress (trouble breathing) and NSAID medications like Toradol had the potential for liver and gastric pain.

RN #5 stated vital signs were to be taken per assigned acuity and at a minimum, three times per shift. They stated RN assessments were performed constantly and documented in the RN Rounding Notes. RN #5 stated frequent patient assessment was important as more acutely ill patients were more medically unstable with the potential for fast and acute change.

iii. On 8/7/24 at 1:26 p.m. and 8/12/24 at 4:57 p.m., interviews were conducted with RN and ED Manager (Manager) #2. Manager #2 stated patients were assessed by RNs during the triage process. They stated RNs were responsible for performing all assessments as this was not within the EMT scope of practice, which was in contrast to the medical records for Patients #7 and #19.

Manager #2 stated RN reassessments were triggered by any medical interventions. They stated for patients kept in the ED over 12 hours, they expected an RN assessment at the beginning of each shift and in response to changes in condition. Manager #2 stated the RN assessments and reassessments were important to ensure nurses knew their patients as knowing the patient was essential to providing quality medical care and providing interventions in response to changes in condition. Manager #2 also stated pain was assessed at triage and after any medical interventions. They stated this reassessment was important to know if the interventions were successful at reducing or controlling patients' pain levels.

Manager #2 stated for patients with a history of suicidal ideation and intentional overdose, they expected frequent vital signs, for example, blood pressure was to be taken every 15 minutes, and an assessment was to be performed of the patient's level of orientation and consciousness. This was in contrast to the medical record for Patient #16, who had presented for suicidal ideation and intentional overdose, which did not reveal frequent monitoring of vital signs. Manager #2 also stated the risks of not addressing vital signs outside of normal limits, for example an elevated blood pressure, included a stroke (lack of oxygen to the brain tissue). Manager #2 stated if a patient had a BP in the 110s, the RNs notified the provider to understand what interventions were necessary.

Manager #2 stated discharge vitals were obtained an hour or less before discharge if the patients were stable. They stated if the vital signs were out of range at this time, the provider was notified, interventions were performed, and the patient was reassessed. Manager #2 stated this process of assessing and reassessment was important to ensure patients received the necessary medical care to address an EMC.

iv. On 8/13/24 at 5:09 p.m., an interview was conducted with chief nursing officer (CNO) #3. CNO #3 stated patient assessments and reassessments were performed at least once every shift and at shift change which was important to ensure there was a documented baseline for comparison in case of a change in condition. CNO #3 stated they also expected to see reassessments performed with any change in condition. They stated vital signs were taken at triage, at shift change, with any change in condition, and at discharge. CNO #3 stated reassessments were necessary to catch subtle changes in condition which could worsen exponentially if not caught early.

CNO #3 stated EMTs were not able to perform patient assessments as this was not within their scope of practice or training which was in contrast to the medical records for Patients #7 and #19. They stated there was a risk the EMTs might miss significant patient findings due to a lack of knowledge and training.

CNO #3 stated pain assessments were performed at triage and 30 minutes after an intervention. They stated pain assessment, including quantifying pain, was important to ensure interventions effectively addressed pain. CNO #3 stated RNs assessed all vitals, including pain prior to discharge. They stated discharge assessments and vitals were important to ensure the chief complaint had been addressed and resolved and there were no changes in condition.

v. On 8/7/24 at 4:00 p.m. an interview was conducted with ED physician (Physician) #4.
Physician #4 stated medical screening exams were performed on patients in the ED to determine the presence of life-threatening conditions. They stated an initial evaluation was necessary to understand the patient's condition and a reevaluation was important to understand if the patient had improved or had changes. Physician #4 stated an RN reassessment was based on acuity and may not be necessary. However, Physician #4 stated they expected RNs to assess vitals at triage and discharge. They stated this was important for quality patient care as the physicians integrated the information from the nurses into their patient assessments.

Physician #4 stated they reassessed pain after pain medications were administered although this may not have been documented in the medical record. They stated their goal was for pain to decrease by at least 50 percent during their time in the ED. Physician #4 stated, however pain was a subjective measurement and they validated the patients' scoring of their pain with a physical exam and observation so there was not necessarily a correlation between a pain score and a medical intervention.

Based on interviews and document review, the facility failed to ensure patients presenting to the emergency department (ED) with an emergency medical condition (EMC) received stabilizing treatment according to facility policy. This failure impacted five of 22 patients' medical records reviewed. (Patients #1-4 and #17)

Findings include:

Facility policies:

According to the Emergency Medical Treatment and Labor Act (EMTALA) policy, any patient who comes to the hospital requesting emergency services is entitled to and will receive a medical screening examination (MSE) to determine whether an EMC exists. Patients who are determined to have an EMC shall be provided with stabilizing treatment and transferred, admitted, or discharged. Services shall be the same for all individuals who present with the same signs and symptoms. All persons with an EMC shall receive further examination and treatment, within the capabilities of the staff and facilities to stabilize the patient. Patients with an unresolved EMC shall not be discharged unless the patient is "stable for discharge." For patients with an unresolved EMC, the patient is stable for discharge when it is determined by the physician that the patient's continued care could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions.

According to the Standards of Practice of Care policy, the nursing process is used to reflect the patients' current conditions and treatment plans and includes evaluating patient responses to interventions and outcomes. Discharge assessments by the registered nurse (RN) include physical status upon discharge and response to treatment. The patients will be continually assessed for changes and progress toward meeting outcome goals and discharge objectives. Patient responses to medical and nursing interventions is evaluated and documented.

1. The facility failed to ensure patients who presented to the ED for care were provided stabilizing treatment or further examinations to determine if stabilizing treatment was necessary prior to discharge.

A. Medical record review

i. A review was conducted of Patient #17's medical record which revealed Patient #17 had presented to the ED for suicidal and homicidal ideations (thoughts of harming or ending the life of oneself or others) on 6/10/24. On 6/10/24 at 9:42 p.m., the RN Rounding Comments documented Patient #17 was agitated, in pain in "multiple places from multiple injuries", and had requested pain medication. The Medication Administration Record (MAR) documented olanzapine (medication used to regulate mood, behavior, and thoughts) was administered to Patient #17 on 6/10/24 at 9:42 p.m. On 6/11/24 at 12:23 a.m., the physician notes documented Patient #17 had complained of general diffuse pain and had requested olanzapine and gabapentin (relieves nerve pain). The physician notes revealed Patient #17 was given olanzapine and would be reassessed at an unspecified time. On 6/11/24 at 6:27 a.m., the RN Rounding Comments documented Patient #17 slept after the medication administration. The record failed to reveal a thorough assessment of Patient #17's pain or a follow-up assessment to determine if the patient required further treatment for the patient's reported pain.

On 6/11/24 at 9:22 a.m., the physician note documented Patient #17 had baseline postsurgical ankle pain and had been given ibuprofen (a non-steroidal anti-inflammatory medication (NSAID)). The MAR documented ibuprofen was given on 6/11/24 at 9:21 a.m. The record failed to reveal a thorough assessment or follow-up assessment of Patient #17's pain to determine if the patient was stable for discharge.

ii. A review was conducted of Patient #3's medical record which revealed Patient #3 had presented to the ED for a lateral tibial plateau fracture (a break of the larger leg bone below the knee which breaks into the knee joint itself) on 7/30/24. At 10:54 a.m., the RN note documented Patient #3 rated their left knee pain 6/10. At 12:30 p.m., the RN note documented Patient #3 rated their upper leg pain 5/10. The patient was discharged at 12:34 p.m. without having had any pain interventions or further assessment of their knee pain. The medical record failed to reveal treatment for Patient #3's pain and evidence of stabilization prior to discharge.

iii. A review was conducted of Patient #2's medical record which revealed Patient #2 had presented to the ED for a lateral tibial plateau fracture on 7/3/24. At 11:17 a.m., the RN Triage note documented Patient #2's blood pressure (BP) was 172/113 (normal is 120/80). The medical record failed to reveal Patient #2's elevated BP was treated or reassessed to ensure Patient #2 was stabilized prior to discharge.

At 11:17 a.m., the RN Triage note documented Patient #2's pain was 5/10. At 12:25 p.m. (one hour and eight minutes later), the RN notes documented the RN administered an intramuscular (IM) injection of ketorolac (NSAID) for pain. At 12:30 p.m. (five minutes after the pain medication was administered), Patient #2 was discharged. The medical record failed to reveal evidence that Patient #2's pain was adequately treated and that they were stabilized prior to discharge.

iv. A review was conducted of Patient #1's medical record which revealed Patient #1 had presented to the ED for a wrist fracture after a motor vehicle accident (MVA) on 7/23/24. At 1:41 p.m., the RN Triage Assessment documented Patient #1 rated their pain as 4/10. At 2:50 p.m. (one hour and nine minutes after triage), the RN administered ibuprofen to Patient #1. At 5:03 p.m. (two hours and 13 minutes after the pain medication was administered), Patient #1 was discharged. The medical record failed to reveal evidence that Patient #1's pain was adequately treated and that they were stabilized prior to discharge.

v. A review was conducted of Patient #4's medical record which revealed Patient #4 had presented to the ED for a lateral tibial plateau fracture after an MVA on 6/21/24. At 6:45 p.m., the RN note documented Patient #4 rated their ankle pain 10/10. At 6:50 p.m., the RN note documented Patient #4 rated their head pain 10/10. During Patient #4's stay in the ED from 6:33 p.m. to 11:30 p.m., they were given Dilaudid (a narcotic pain medication used to treat moderate to severe pain) three times and acetaminophen/hydrocodone (another narcotic pain medication for moderate to severe pain) one time. The RN notes in the MAR documented the narcotic pain medications were "effective" without documentation of pain reduction or stabilization. The medical record failed to reveal evidence that Patient #4's pain was adequately treated and that they were stabilized prior to discharge.

This review of the medical records which revealed a lack of stabilizing treatment for Patients #1-4 and #17 was in contrast to the EMTALA policy which read, patients with an EMC were provided with further examination and stabilizing treatment until stable for discharge or transferred to another facility.

B. Interviews

i. On 8/7/24 at 1:00 p.m., an interview was conducted with RN #1. RN #1 stated patients with pain were provided with medical interventions including pain medications until the level of pain decreased. RN #1 stated this process was important to reduce pain and stop a pain crisis. RN #1 stated patients were discharged once their symptoms had improved and their vitals were at baseline. They stated ensuring stability at discharge was important for patient safety.

ii. On 8/12/24 at 4:03 p.m., an interview was conducted with RN #5. RN #5 stated patients with pain were treated and stabilized in the ED. They stated reassessment of vital signs was important to ensure pain was treated and blood pressure and oxygen saturation values stabilized, especially after interventions with narcotics (opioid pain medications such as Dilaudid).

iii. On 8/7/24 at 1:26 p.m., an interview was conducted with RN and ED Manager (Manager) #2. Manager #2 stated they expected nurses to reassess pain prior to discharge. They stated patients were assessed before discharge to ensure patients were stable and the medical interventions provided effectively addressed the presenting complaints. Manager #2 stated patient stabilization was necessary to ensure patients did not experience a respiratory (breathing) or cardiac (heart) emergency while at the facility or decompensate after discharge and return to the facility.

iv. On 8/13/24 at 5:09 p.m., an interview was conducted with chief nursing officer (CNO) #3. CNO #3 stated pain assessments were performed at triage and 30 minutes after an intervention. They stated pain assessment, including the quantification of pain with a pain scale, was important to ensure interventions effectively addressed pain. CNO #3 stated they were not sure how patients were considered stabilized if the patients who presented with pain were prescribed pain medication to pick up at the pharmacy after discharge, but were not provided pain medications while at the facility.

CNO #3 also stated RNs assessed all vitals, including pain prior to discharge. They stated reassessments were necessary to catch subtle changes in condition which could worsen exponentially if not caught early. CNO #3 stated discharge assessments, including vitals, were important to ensure the patients' chief complaints had been addressed and resolved and there were no changes in condition. CNO #3 stated they ensured patients were stable before discharge as the patients' conditions could decline if they were not stabilized before discharge.

v. On 8/7/24 at 4:00 p.m. an interview was conducted with ED physician (Physician) #4.
Physician #4 stated they expected the nurses to assess vitals at triage and discharge. Physician #4 stated they reassessed pain after pain medications were administered as they wanted patients' pain to decrease by at least 50 percent during their time in the ED. This statement was in contrast to a review of the medical records for Patients #1-4 and #17 which did not reveal this pain reassessment. Physician #4 also stated pain was a subjective measurement and they validated the patients' pain scores with a physical exam and observation so there was not always a correlation between a high pain score and a medical intervention.

Physician #4 stated stabilizing treatment varied based on the patients' conditions and was case dependent. They stated for patients with fractures, for example, stability was determined by a repeat assessment including vital signs, improvement in pain, and ensuring the patient felt comfortable returning home. This was in contrast to the medical records for Patients #1-4 and #17 which did not consistently reveal pain and vital sign reassessments to determine if additional stabilizing treatment was required prior to discharging from the ED. Physician #4 stated stability at discharge was important to ensure patients had received the necessary interventions to improve their health.

These interviews which revealed inconsistent expectations for and performance of pain and vital signs reassessment to ensure patients were stabilized prior to discharge were in contrast to the EMTALA policy which read, patients with an EMC were provided with further examination and stabilizing treatment until stable for discharge or transferred to another facility.