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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 Active Labor Act (EMTALA) requirements.

FINDINGS

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

Tag 2406: (c) Appropriate Medical Screening. Based on interviews and document review, the facility failed to provide an appropriate Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to ensure a medical screening examination appropriate to the individual's presenting signs and symptoms was conducted to rule out a medical emergency in one of one patients who presented to the emergency department (ED) with abdominal pain and returned to the ED the same day (Patient #1).

Based on interviews and document review, the facility failed to provide an appropriate Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to ensure a medical screening examination appropriate to the individual's presenting signs and symptoms was conducted to rule out a medical emergency in one of one patients who presented to the emergency department (ED) with abdominal pain and returned to the ED the same day (Patient #1).

Findings include:

Facility policy:

According to the Medical Screening Exam policy, the term emergency medical condition (EMC) means:

A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in -ii. serious impairment to bodily functions, or iii. serious dysfunction of any bodily part;

Therefore, an appropriate MSE must be reasonably calculated to identify EMCs and be the exact same level of standard screening provided to all patients who present with substantially similar complaints.

Therefore, the MSE will be the responsibility of either the Emergency Department Physician (EDP), Nurse practitioner (NP), or Physician Assistant (PA) on duty in the Emergency Department, or other qualified physician on medical staff who is present to evaluate the patient.

In performing the MSE the EDP, NP, PA or other physician on medical staff member will provide an evaluation that permits them to decide based on clinical judgment whether a. further evaluation and treatment are necessary for stabilization, b. admission is necessary because the patient ' s condition appears to be medically unstable or, c. the patient may be safely referred to the private physician for outpatient follow-up.

The MSE must contain the following elements:
a. ER Record and log entry into the electronic medical record
b. Vital Signs
c. Oral History
d. Focused physical exam of affected system
e. Physical exam of potentially affected systems or known chronic conditions
f. Discharge or transfer Vital Signs
g. Any ancillary testing necessary to R/O presence of legally defined EMC.

1. The facility failed to ensure a medical screening examination appropriate to the individual's presenting signs and symptoms was conducted to rule out a medical emergency.

A. Medical record review revealed Patient #1 presented to the emergency department (ED) on 6/21/22 at 11:38 a.m. and discharged home at 6:57 p.m. Patient #1 returned to the ED at 9:46 p.m. (three hours later), was placed on comfort care at 12:34 a.m. on 6/22/22 and expired at 12:49 a.m.

a. Review of the medical record for Patient #1's second visit revealed she presented to the ED on 6/21/22 at 9:46 p.m. Patient #1 was diagnosed and treated for abdominal pain, sepsis (a potentially life-threatening condition that occurred when the body's response to an infection damages its own tissues), metabolic acidosis (too much acid in the body fluids), shock (critical condition brought on by the sudden drop in blood flow through the body), acute kidney injury and elevated lactic acid level (byproduct when the body breaks down carbohydrates to use for energy when oxygen levels are low).

The medical record revealed Patient #1 had a high white blood cell count of 12.65 K/uL, which had doubled from the first visit, an ultrasound revealed intra-abdominal free fluid in the right upper quadrant and the patient's blood pressure was hypotensive (low blood pressure) at 90/47. A computerized tomography (CT) scan (a series of X-ray images taken from different angles around the body) was ordered, but Patient #1 vomited and aspirated (inhaled vomit) before the CT could be performed. Patient #1 then expired in the ED at 12:49 a.m. on 6/22/22.

b. Review of the medical record for Patient #1's initial ED visit on 6/21/22, revealed she presented to the ED at 11:38 a.m. via ambulance with a chief complaint of syncope (medical term for fainting or passing out, caused by a temporary drop in the amount of blood that flows to the brain).

Physician #3 documented a note on 6/21/22 at 11:52 a.m., which read, Patient #1 presented to the ED after a syncopal episode. Physician #3's note read, Patient #1 complained of dizziness while driving home prior to the syncopal episode. Physician #3 documented the ambulance crew reported a low blood pressure of 69/35 and had placed an intravenous line (IV) and started intravenous fluids prior to arrival to the ED. Physician #3 documented in the ED Patient #1 complained of mid abdominal pain and constipation and had reported her last bowel movement occurred ten days ago.

A physical exam by Physician #3 was documented on 6/21/22 at 11:52 a.m., revealed Patient #1's abdomen was not distended, was soft, mild discomfort, no guarding, hypoactive, but normal-pitched bowel sounds and had no palpable masses or organ enlargement. Physician #3's note read, upon rectal exam, Patient #1 had a moderate amount of firm but mobile stool and no obvious impaction.

Further review of Patient #3's medical record revealed an initial blood pressure of 61/34 upon arrival to the ED on 6/21/22 at 11:52 a.m. and thirteen additional episodes of hypotension, examples included:

i. 73/38 at 12:06 p.m.

ii. 72/30 at 12:56 p.m.

iii. 74/33 at 1:57 p.m.

At 12:06 p.m. Registered Nurse (RN) #5 documented a gastrointestinal flowsheet which revealed Patient #1's abdomen was distended, tender and firm and Patient #1 reported cramping and constipation. RN#5 further documented Patient #1's last reported bowel movement was on 6/11/22, ten days prior to arrival to the ED. A neurological flowsheet documented at the same time revealed a note by RN #5 which noted vertigo/dizziness; syncope and lethargy.

A review of physician orders in Patient #1's medical record revealed a comprehensive metabolic panel (CMP) and complete blood count (CBC) were performed, but no other laboratory studies were conducted.

There was no evidence in the medical record of additional orders for laboratory tests or evidence additional laboratory tests were discussed with Patient #1 or her family.

Review of Patient #1's medical record revealed RN #5 documented Patient #1's condition as:

i. At 12:13 p.m., level of consciousness was slightly drowsy, easily aroused and had abdominal cramping.

ii. At 1:00 p.m., Patient #1 rated her abdominal pain 10/10.

iii. At 1:12 p.m., level of consciousness was drowsy and lethargic and pain was rated as 8/10 .

Further review of the medical record revealed Patient #1 received a dose of fentanyl (pain medication) 25 mcg via IV at 12:28 p.m. and second dose of 25 mcg IV at 12:55 p.m.

At 2:59 p.m., RN#1 documented Patient #1 required a two RN assist to the bedside commode .

Further review of the medical record revealed Physician #3 ordered a mineral oil and glycerin water enema and continued to focus on concerns of constipation. The enema was administered at 4:59 p.m. No stool was produced following this enema.

At 6:47 p.m. RN #1 documented a road test (toleration of walking) had been conducted with Patient #1. She further documented Patient #1's symptoms as dizzy and that Patient #1 did not want to walk, yet once up, Patient #1 was steady and able to walk with a cane.

At 6:57 p.m. in a discharge note, RN #5 documented Patient #1 was discharged to home with family via wheelchair.

Upon further review of the medical record, there was no evidence of orders for imaging such as computed tomography (CT), x-rays or additional laboratory or diagnostic testing to rule out a medical emergency to include differential diagnoses. There was also no evidence that imaging or specific further laboratory or diagnostic testing was discussed between the facility staff and Patient #1 or her family members.

B. Interviews

a. On 9/21/22 at 10:31 a.m., an interview was conducted with Physician #2. Physician #2 stated he recalled having cared for Patient #1 during her return visit to the ED. Physician #2 stated he did not have a lot of insight into what happened during her first visit. He stated when he examined Patient #1 when she returned to the ED on the evening of 6/21/22, she was clearly dying.

Physician #2 stated he recalled she had a history of worsening abdominal pain. He stated he did not recall seeing any imaging orders or results from her first visit to the ED on the morning of 6/21/22 when he reviewed her medical record. Physician #2 stated he performed a focused assessment with sonography for trauma (FAST) exam (a type of ultrasound) while waiting for a CT scan to be performed and noted free fluid in Patient #1's abdominal cavity. He stated he ordered a CT scan, while concurrently obtaining labs. He stated on the way to the CT scan, Patient #1 vomited and aspirated and the CT scan was not able to be completed. Physician #2 reported Patient #1's lactate levels were high, her pH levels were low and her mental status was clearly altered indicating sepsis. Physician #2 stated he and Patient #1's family discussed care goals for Patient #1, and her family reported they did not wish for aggressive interventions and agreed to transition Patient #1 to comfort care. Physician #2 reported Patient #1 was provided comfort measures and pain medication per the family's request and she expired in the ED sometime after midnight.

Physician #2 stated the importance of completing a MSE was for providers to determine if a medical emergency existed. He stated for a patient who presented with abdominal pain, it was necessary to determine if a life-threatening condition existed. Physician #2 stated he might order imaging and certain sets of labs depending on several factors to include age, gender and patient presentation. Physician #2 stated his diagnostic investigation would depend on several factors and he would consider patient history, patient's current physical exam, the patient's medical comorbidities, the quality of the patient's abdominal pain, whether the patient had a fever, a fast heart rate, hyper or hypotension (high or low blood pressure), or elevated white blood cells. Physician #2 further stated if a patient presented with new onset abdominal pain, he would order a CT scan. Physician #2 stated for patients older than seventy-five years of age who presented with abdominal pain, he would have been more likely to order imaging to rule out life-threatening conditions.

Physician #2 stated there were risks to patients even after the completion of a thorough medical screening exam, but the risk of not performing a thorough MSE could include missed illnesses, patient condition deterioration, and even death.

b. On 6/21/22 at 2:54 p.m., an interview was conducted with ED medical director (Director) #4. Director #4 stated completing an MSE was important in order to complete the workup the provider determined was appropriate for the patient's condition. \ Director #4 stated for a medical work up in the ED, it always started with ruling out the worst potential things such as ruptured bowel and aneurysm, absent pulses, intestinal ischemia (inadequate blood supply to an organ or part of the body), pain out of proportion to the physical exam, or perforated abdomen. Director #4 stated further stabilizing treatment for a patient with abdominal pain, constipation and hypotension would include: IV fluids, diagnostics with CT scan, determination if the patient was a surgical candidate, or whether the patient would need to be admitted to inpatient.

Director #4 stated he reviewed Patient #1's medical record. He stated in hindsight upon review of the case, during Patient #1's first ED visit, obtaining a lactate level and a CT scan might have been helpful He stated the risk of a diagnosis of abdominal pain and constipation without further work up could include emergencies such as ischemic bowel, ruptured bowel, or death. X

c. On 9/21/22 at 9:01 a.m. an interview was conducted with RN #1. RN #1 reported she did recall caring for Patient #1 on 6/21/22. RN #1 stated Physician #3 was aware of Patient #1's low blood pressure trends. RN #1 stated she recalled an abdominal x-ray had been obtained, but stated she did not remember for certain. She further reported she had concerns regarding Patient #1's hypotension and had administered IV fluids. RN #1 stated Patient #1's blood pressures never fully resolved, but she was able to get her up to ambulate. RN #1 further stated she had conducted an ambulation test with Patient #1 right before Patient #1 discharged to home. RN #1 stated Patient #1 was not symptomatic at discharge, she was able to ambulate and she was not dizzy.

This was in contrast to a flowsheet documentation which revealed on 6/21/22 at 6:47 p.m., during a road test Patient #1 had documented symptoms of dizziness. Patient #1 expressed she did not want to walk, but once up, she was steady and able to walk with a cane.

Review of Patient #1's medical record did not reveal an order or results for an abdominal x-ray.

d. The treating provider for Patient #1 during her first visit to the ED on 6/21/22 declined to interview. On 9/22/22 at 1:45 p.m., an interview with Director of Quality (Director) #6 was conducted. Director #6 stated Physician #1 stated he had offered imaging to the family, but the family declined. On review of the medical record, there is no indication this occurred.