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Based on observation, interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#14) and failed to ensure stabilization for one patient (#26) of 27 Emergency Department (ED) records reviewed from 09/2023 through 07/2024. The hospital failed to conspicuously post signs in the Labor and Delivery Unit specifying the rights of individuals with respect to examination and treatment for emergency medical conditions, and information indicating whether or not the hospital participated in the Medicaid program in the Labor and Delivery Unit. These failed practices had the potential to cause harm to all patients who presented to the ED and Labor and Delivery Unit seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 2,213. The hospital's Labor and Delivery average monthly triage (process of determining the priority of a patient's treatment based on the severity of their condition) census over the past six months was 564.

Findings included:

Review of the hospital's undated policy titled, "EMTALA," showed:
- It is the hospital policy to provide patients with emergency medical care that meets or exceeds the requirements of EMTALA.
- Individuals who come to the ED and request an examination, or treatment will receive an appropriate MSE.
- It is unacceptable to transfer or discharge a patient with an EMC to a physician's office for evaluation and/or treatment.
- When an individual is determined to have an EMC, the hospital will provide necessary examination and treatment to stabilize the patient within the capabilities of staff and facilities available at the hospital.
- The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether an EMC exists. The use of such ancillary services will be based on the qualified personnel's clinical assessment of the patient and the need for those ancillary services, including specialty consults.
- Once the determination is made that the individual has an EMC, the hospital must provider further examination or treatment as may be required to stabilize the medical condition or transfer the individual to another medical facility.

Review of the hospital's undated policy titled, "Assessment of the Obstetrical (relating to childbirth and the processes associated with it) Triage Patient," showed all patients shall receive a MSE that includes providing necessary testing and services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic.

Review of the hospital's undated policy titled, "Radiology (a variety of medical imaging/x-ray [test that creates pictures of the structures inside the body-particularly bones] techniques used to diagnose or treat diseases)/ED Discrepancy Policy," showed:
- A Radiologist (medical doctor that specialize in diagnosing and treating injuries and diseases using medical imaging) will interpret films between the hours of 7:00 AM and 6:00 PM Monday through Friday, 7:00 AM to 2:00 PM on Saturdays and 7:00 AM to 12:00 PM on Sundays. For procedures performed outside of coverage hours or when a radiologist is unavailable, the following procedure will be followed.
- The Attending (a medical doctor who is responsible for the overall care of a patient in a hospital) ED physician will review x-rays and leave preliminary treatment notes in the electronic medical system (EMR).
- If they agree, the report will be dictated.
- If there is a discrepancy in the interpretation, the radiologist will notify the ED staff/physician to follow-up with the patient appropriately.
- The Radiologist will then dictate the report and include the ED staff member's name and when he/she spoke with this staff member.
- The ED physician will review the patient's chart and determine whether the discrepancy impacted the patient's care; if so, the appropriate action (notify patient, notify primary physician, modify treatment, etc.) will take place and be noted in the EMR.


Please refer to 2402, 2406 and 2407 for further details.



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Based on observations and interview, the hospital failed to conspicuously post signs in the Labor and Delivery Unit specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMCs), and information indicating whether the hospital participated in the Medicaid program. These failures had the potential to affect all patients that presented to the Labor and Delivery unit for emergency medical treatment. The hospital's Labor and Delivery Unit average monthly triage (process of determining the priority of a patient's treatment based on the severity of their condition) census over the past six months was 564.

Findings included:

Observation on 07/01/24 at 11:30 AM, in the Labor and Delivery Unit, showed no Emergency Medical Treatment and Labor Act (EMTALA) signage at the registration desk, waiting room or patient rooms. The one triage room had two EMTALA signs.

During an interview on 07/01/24 at 11:30 AM, Staff B, Women's and Pediatrics Program Director, stated that patients were examined and treated for EMCs in the Labor and Delivery Unit patient rooms in addition to the one triage room. She agreed there was no EMTALA signage in the registration area, waiting room or patient rooms.

Based on interview, record review, and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#14) out of 27 Emergency Department (ED) records reviewed from 09/2023 to 07/2024. This failed practice had the potential to cause harm to all patients who presented to Progress West Hospital seeking care for an EMC.

Review of the hospital's undated policy titled, "EMTALA," showed:
- It is the hospital policy to provide patients with emergency medical care that meets or exceeds the requirements of EMTALA.
- Individuals who come to the ED and request an examination, or treatment will receive an appropriate MSE.
- When an individual is determined to have an EMC, the hospital will provide necessary examination and treatment to stabilize the patient within the capabilities of staff and facilities available at the hospital.
- The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether an EMC exists. The use of such ancillary services will be based on the qualified personnel's clinical assessment of the patient and the need for those ancillary services, including specialty consults.
- Once the determination is made that the individual has an EMC, the hospital must provide further examination or treatment as may be required to stabilize the medical condition or transfer the individual to another medical facility.

Review of the hospital's undated policy titled, "Radiology (a variety of medical imaging/x-ray [test that creates pictures of the structures inside the body-particularly bones) techniques used to diagnose or treat diseases]/ED Discrepancy Policy," showed:
- A Radiologist (medical doctor that specialize in diagnosing and treating injuries and diseases using medical imaging) will interpret films between the hours of 7:00 AM and 6:00 PM Monday through Friday, 7:00 AM to 2:00 PM on Saturdays and 7:00 AM to 12:00 PM on Sundays. For procedures performed outside of coverage hours or when a radiologist is unavailable, the following procedure will be followed.
- The Attending (a medical doctor who is responsible for the overall care of a patient in a hospital) ED physician will review x-rays and leave preliminary treatment notes in the electronic medical system (EMR).
- If they agree, the report will be dictated.
- If there is a discrepancy in the interpretation, the radiologist will notify the ED staff/physician to follow-up with the patient appropriately.
- The Radiologist will then dictate the report and include the ED staff member's name and when he/she spoke with this staff member.
- The ED physician will review the patient's chart and determine whether the discrepancy impacted the patient's care; if so, the appropriate action (notify patient, notify primary physician, modify treatment, etc.) will take place and be noted in the EMR.

Review of Patient #14's medical record, dated 01/01/24, showed:
- At 12:16 PM, he was an 87-year-old male who arrived at the ED and reported, right sided chest and epigastric (the upper part of the abdomen just below the rib cage) abdominal pain.
- His past medical history was aortic stenosis (narrowing of the valve in the large blood vessel branched off the heart), asthma (a chronic lung disease which makes breathing difficult), bladder cancer, dementia (a loss of thinking abilities and memory), high cholesterol and high blood pressure. He was seen in the ED on 12/30/23 and diagnosed with a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra) and given a prescription for antibiotics.
- At 12:28 PM, his vital signs (VS, measurements of the body's most basic functions: blood pressure (BP) normal between 90/60 and 120/80; pulse/heartbeats (HR) normal 60 to 100 per minute and respiration rate (RR) normal 12 to 20 breaths per minute) were HR-112, RR-20, BP 161/97. His oxygen saturation (SAO2, measure of how much oxygen is in blood, normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) was 93%.
- At 1:01 PM, his electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed an irregular heartbeat.
- At 1:18 PM, his blood work showed sodium (a mineral in the blood or body fluid, normal is 135-145) was 126, his chloride (a type of electrolyte in the blood, normal is 97-110) was 86, blood urea nitrogen (BUN, blood test that specifies kidney function, normal is 6-25) was 33, alanine transaminase (ALT, an enzyme found mostly in the liver, normal is 7-55) was 6, lipase (an enzyme the body uses to break down fats, normal is 10-99) was 124, troponin (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 22) was 39 and white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood, normal is 3.8-9.9) was 8.6.
- At 2:07 PM, he was seen by a provider. His assessment showed he presented with epigastric discomfort and was spitting up bile (fluid in the digestive system) like fluid.
- At 2:15 PM, his VS were SAO2-96% and HR-95.
- At 2:24 PM, Intravenous (IV, in the vein) fluids were administered for hyponatremia (a condition when low salt levels in the blood cause an abnormally low level of body fluids).
- At 2:53 PM, his repeat troponin was 32.
- At 3:00 PM, his VS were HR-109, RR-26, BP-141/96 and SAO2-92%.
- At 3:35 PM, his disposition was set to discharge. His discharge diagnosis was adverse drug reaction (ADR, unwanted or harmful reaction after the administration of a drug)
to the antibiotic (Bactrim) prescribed for the UTI, drug induced acute pancreatitis (inflammation of the pancreas) and hyponatremia.
- At 3:51 PM, IV antibiotics were given.
- At 4:00 PM, his VS were HR-104, BP-147/103 and SAO2-96%.
- At 4:30 PM, he was discharged home with instructions to follow up with his primary care doctor as needed.
- At home his family witnessed him fall and found a large amount of coffee ground vomit (indicates old blood in the gastrointestinal tract) around the patient.
- On 01/01/24, at 11:56 PM, he arrived at the ED in cardiac arrest (when the heart suddenly and unexpectedly stops pumping). There was dark red blood vomit in his throat.
- On 01/02/24, at 12:06 AM, Patient #14 was pronounced dead.

During an interview on 07/08/24 at 1:52 PM, Staff KK, ED Medical Director, stated that symptoms of pancreatitis were epigastric pain, nausea and vomiting. Any level of increased lipase indicated pancreatitis. Lipase was also increased with diet and alcohol intake. He only considered imaging when he suspected pancreatitis was related to an infectious source. Suspicion of an infectious source was if a patient had a "significantly increased white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) with a left side shift (an increased number of immature cells in the blood).

During an interview on 07/03/24 at 8:56 AM, Staff U, Registered Nurse (RN), stated that Patient #14 complained of right sided epigastric pain. He was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation). The decision to order imaging was provider driven. Pancreatitis was treatable at home. She was not present when Patient #25 came into the ED for cardiac arrest.




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Based on interview, record review, and policy review, the hospital failed to ensure that emergency medical conditions (EMC) were stabilized for one patient (#26) out of 27 Emergency Department (ED) records reviewed from 09/2023 through 07/2024, when they were discharged with unstable medical conditions. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for and Emergency Medical Condition (EMC).

Review of the hospital's undated policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)," showed:
- The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether an EMC exists. The use of such ancillary services will be based on the qualified personnel's clinical assessment of the patient and the need for those ancillary services, including specialty consults.
- When an individual is determined to have an EMC, the hospital will provide necessary examination and treatment to stabilize the patient within the capabilities of staff and facilities available at the hospital.
- Once the determination is made that the individual has an EMC, the hospital must provide further examination or treatment as may be required to stabilize the medical condition or transfer the individual to another medical facility.

Review of the hospital's undated policy titled, "Radiology (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases)/ED Discrepancy Policy," showed:
- A Radiologist (medical doctor that specialize in diagnosing and treating injuries and diseases using medical imaging) will interpret films between the hours of 7:00 AM and 6:00 PM Monday through Friday, 7:00 AM to 2:00 PM on Saturdays and 7:00 AM to 12:00 PM on Sundays. For procedures performed outside of coverage hours or when a radiologist is unavailable, the following procedure will be followed.
- The Attending (a medical doctor who is responsible for the overall care of a patient in a hospital) ED physician will review x-rays (test that creates pictures of the structures inside the body-particularly bones) and leave preliminary treatment notes in the electronic medical system (EMR).
- If they agree, the report will be dictated.
- If there is a discrepancy in the interpretation, the radiologist will notify the ED staff/physician to follow-up with the patient appropriately.
- The Radiologist will then dictate the report and include the ED staff member's name and when he/she spoke with this staff member.
- The ED physician will review the patient's chart and determine whether the discrepancy impacted the patient's care; if so, the appropriate action (notify patient, notify primary physician, modify treatment, etc.) will take place and be noted in the EMR.

Review of Patient #26's medical record, dated 01/12/24, showed:
- At 1:27 AM, he was a 55-year-old male who arrived at the ED and reported, "abdominal pain that started a couple of hours ago, nausea and vomiting."
- At 1:47 AM, his pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was eight out of ten.
- At 2:01 AM white blood cell count (normal is 3.8-9.9) was 14.2.
- At 3:06 AM and 4:07 AM, he was given IV Zofran (medication for the treatment of nausea).
- At 3:42 AM, the abdominal and pelvis CT scan results per ED physician was "clinically correlates to presenting symptoms of gastroenteritis."
- At 4:09 AM, he was given IV Pepcid (a medication that treats excess stomach acid or heartburn) and oral Bentyl (medication to treat irritable bowel syndrome [IBS, ongoing disorder of the colon which includes diarrhea, cramping and abdominal pain].
- At 5:04:26 AM, he was seen by the ED provider. his review of systems was positive for fever, chills and nausea.
- At 5:04:40 AM, his disposition was set to discharge.
- At 5:16 AM, his pain scale assessment was seven out of ten.
- At 5:34 AM, he was given oral Zofran.
- At 5:47 AM, he was discharged home with instructions to return to the ED if he developed focal abdominal pain or was unable to tolerate oral intake.
- At 10:39 AM, A Radiologist called the ED Provider to report an abdominal and pelvis CT report discrepancy of suspected acute appendicitis (inflammation of the appendix [a small tube-shaped part that is joined to the intestines on the right side of the intestines]).
- At 2:42 PM, he returned to the ED and reported he was seen 12 hours ago and received a call to come back in for re-evaluation for possible appendicitis.
- At 7:00 PM, Patient #26 underwent an appendectomy (surgical removal of the appendix).

Although requested the hospital did not provide an interview with Staff NN, Physician. She provided care to Patient #26 during his initial visit on 01/12/24.

During an interview on 07/09/24 at 10:15 AM, Staff MM, RN, stated that Patient #26 continued with pain at discharge. He performed a pain assessment, and the patient stated seven out of ten. "Two minutes later" an order was written to discharge the patient home. He informed the provider of the patient's continued pain.

During an interview on 07/03/24 at 2:11 PM, Staff LL, Physician, stated that a critical discrepancy was when the radiologist (medical doctor that specialize in diagnosing and treating injuries and diseases using medical imaging) believed the patient needed to be notified as soon as possible of the discrepancy to prevent a negative outcome. In the case of a critical discrepancy the radiologist who noted the discrepancy called the patient directly. A discrepancy that was not considered to be "critical" was placed on the discrepancy tracker and the ED provider was responsible to contact the patient.



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