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Based on record reviews and interviews, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department (ED) for 1 of 20 sampled patients (Patient #1). On 12/17/19, the Centers of Medicare and Medicaid Services determined that the hospital's failure to provide an appropriate medical screening examination constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements.

Finding:

On 10/13/19 at 12:50 PM, Patient #1, who was involved in a motorcycle accident, presented to the ED of Hospital A as a "Code Green" which means as a trauma patient.

At 12:54 PM, the patient was initially seen by the ED Physician who documented that patient had received Fentanyl (a pain medication) on route to the hospital; he/she was moaning and screaming; it was difficult to determine if he/she had back pain on palpitation as the patient was screaming and yelling the entire time; he/she had two separate lacerations on the right lower leg; and he/she had abrasions on his/her abdomen.

Documentation on the "Consultation Notes", by the Trauma Surgeon, indicated the following: the patient complained of "pain everywhere"; he/she had a two centimeter (cm) laceration lateral to the right knee and a five cm laceration lateral to the right calf; the wounds which required irrigation and suturing; and he/she had the following diagnostic tests: bloodwork; Computed tomography (CT) scans of the brain, cervical spine, chest, abdomen and ankle; and x-rays of the pelvis, chest, right tibia and right fibia. These diagnostic tests showed no fractures or acute injuries.

Further documentation in the record indicated that patient was given Dilaudid, a pain medication, at 1:00 PM, 1:52 PM, 2:00 PM, 2:52 PM, and 3:00 PM and Versed, a benzodiazepine medication, at 1:52 PM.

At 2:26 PM, the ED Nurse #3 documented the following, "Patient expressed concerns with discharge as [he/she] felt that "my legs are too weak to walk". Provider in room X2 to discuss that there were no findings on CT or XR [x-ray], labs normal. Provider educated patient that [he/she] was being discharged. Pt. [patient] refused to move from stretcher to wheelchair for discharge X 1.5 hours. Staff (2) were able to eventually assist patient into the wheelchair. Staff brought pt [patient] out to curb to meet his/her [husband/wife] for ride home. Pt [patient] then refused to move from wheelchair to truck stating "it is too far up for me to get in". Pt states that [his/her] legs are too weak and needs a car that is lower to get into. Pt's [patient's] [husband/wife] to call cab to transport home pt [patient]."

At 3:07 PM, the ED Physician documented the course of treatment; that the patient's spouse informed him "that the patient traditionally has a very low threshold for pain tolerance"; "I certainly agree with this"; the "patient screamed and yelled the entire time [he/she] was in the emergency department"; he/she was "very hesitant to even sit up"; "at this point, there is absolutely no indication for admission"; and [he/she] will be discharged.

On 10/13/19 at 3:45 PM, Patient #1 was discharged and wheeled outside the ED doors.

On 10/15/19, Patient #1 presented to the ED of another hospital (Hospital B). The ED Physician, at Hospital B, documented at 2:32 AM that the patient was in the back of a pickup truck facing down, the family were unable to get him/her out of the truck once home; and the patient spent the next 24 hours in the same position in the back of the truck. Upon presentation to the ED of Hospital B, multiple emergency medical service personnel and fire department personnel assisted with getting the patient out of the truck. He/She had multiple open wounds, ecchymosis (bruising), deep tissue tenderness, and any movement of his/her legs produced severe pain. The patient was diagnosed with rhabdomyolysis. Rhabdomyolysis is a serious syndrome due to a direct or indirect muscle injury and it results from the death of muscle fibers and release of their contents into the bloodstream. The patient continued to have pain with movement of his/her right leg. On 10/17/19, an x-ray was ordered which revealed a right midshaft femur fracture. The patient was transferred back to Hospital A, the hospital he/she initially presented to on 10/13/19, so that he/she could have surgery on his/her leg.

Hospital A provided surveyors with a document titled "Investigatory report regarding pt [patient] [patient's initials] seen here on 10-13-19". This document contained information from interviews conducted between 10/22/19 and 10/28/19 with four nurses and three undated email statements from three nurses. The document indicated the following:
- ED Nurse #1 stated that she had informed the ED Physician that the patient needed to be admitted in her opinion as the patient was not able to move well.
- ED Nurse #2 stated the patient complained of leg weakness not right leg pain.
- ED Nurse #3 had stated that the Physician Assistant (PA) had asked the Trauma Surgeon to x-ray the patient's right leg but she declined; the PA was suturing the patient leg and he/she complained of pain when he moved it; the patient was not specific about pain but complained of weakness.
- ED Nurse #4 had send an email indicating that she was asked to assist a patient in front of the ER; she was told the patient had been outside for three hours; patient was refusing at this time to help stand as he/she stated his/her lower leg hurt due to his/her stitches.
- ED Nurse #5 had sent an email indicating that the patient was refusing to transfer to wheelchair from trauma stretcher, option of social admit was discussed with the ED physician; he was informed that the patient would likely not be accepted for admit; patient transferred from the stretcher to the wheelchair with moderate assistance; and the Nursing Supervisor was informed of the situation.
- ED Nurse #7 had sent an email that indicated multiple staff attempted to lift the patient so he/she could stand multiple times but failed due to the fact the patient refused to assist and repeatedly braked feet against staff, forcing himself/herself back onto the ground; each time the patient was asked why he/she was unable to stand he/she stated "I just can't"

As of 10/31/19, there was no further evidence provided to surveyors to indicate that any changes may have been considered or implemented after the hospital's investigatory report.

On 10/28/19 at 11:10 AM, surveyors reviewed the video footage, for 10/13/19, which captured the area outside ED. The following was observed:
- At 4:04 PM, the patient, who was dressed in a hospital gown, was wheeled outside.
- Between 4:10 PM and 7:00 PM, there were multiple attempts, by staff, to help the patient into a truck and then a cab
- While sitting on the edge of the cab frame, the patient was lowered to the ground.
- Between 7:00 PM and 7:23 PM, the patient remained on the ground.
- At 7:24 PM, the patient was lifted, via EMS Lift Sheet [used for transfer] and the assistance of ten individuals, into the back seat of a truck.

On 10/28/19 at 12:04 PM, ED Nurse #1 was interviewed regarding Patient #1's ED visit on 10/13/19. The Nurse stated that the ED Physician was called back in due to the difficulty getting the patient in a wheelchair at the time of discharge and the patient complained of general all over pain.

On 10/28/19 at 12:22 PM, ED Nurse #2 was interviewed regarding Patient #1's ED visit on 10/13/19. The Nurse indicated the following:
- About 4:00 PM, ED Nurse #2 saw the patient when he/she was ready for discharge.
- "This was a difficult vehicle for anyone to get into and, after 1.5 hours, the patient was still complaining that the right lower leg hurt." ED Nurse #2 stated, "[Patient #1] was screaming, but not crying, and angry about the right lower leg." ED Nurse #2 stated, "Upon trying to assist the patient, the patient stated, "I can't stand due to the pain in the right lower leg." ED Nurse #2 stated that the patient would not stand and showed no effort to stand.

On 10/28/19, at 12:46 PM, the ED Physician was interviewed regarding Patient #1's ED visit on 10/13/19. The ED Physician stated that when Trauma was questioned about the need for an x-ray of the patient's femur the Trauma Surgeon didn't feel it was necessary; "The patient didn't want to participate in any part of the care...didn't want to move anything ...all [he/she] did was scream ...the patient screamed all the time and it was difficult to assess pain."

On 10/29/19 at 9:00 AM, ED Nurse #3 was interviewed regarding Patient #1's ED visit on 10/13/19. The Nurse stated the following:
- "I remember Patient #1...alert and oriented and had a lot of pain in the right leg ...patient described it as painful but also weak."
- When asked why the patient was screaming a lot, ED Nurse #3 stated, "Patient was in pain ...adrenaline rush and patient was scared...the [patient's spouse] described the patient's behavior as typical."
- "I was there with the Trauma PA (Physician Assistant) while getting ready to suture the lacerations and the patient complained of pain when positioning the right leg."
- "The patient did not want to put any pressure on the right leg due to weakness and the patient acted in pain."
- The patient's pain was assessed at 2:02 PM at a level 8.
- "When preparing [Patient#1] for discharge the patient had concerns which is why I asked the ED physician for help."
- "The ED Physician stated that trauma staff had cleared the patient, so we needed to discharge...it took 1.5 hours to get the patient into the wheelchair ...the patient told me "I can't step on that leg."
- Two staff members asked the ED Physician if the patient should be admitted and asked for a delay in the discharge and the delay was denied.
- "I was in the room when the PA said that the Surgeon would be asked to x-ray the femur and then the PA left and then returned we were told that the surgeon did not want an x-ray."

On 10/29/19 at 9:15 AM, the ED Nurse Manager was interviewed. The ED Nurse Manager stated, "With my experience working in the Emergency Room, it is common practice if there is an injury on a limb, the limb is x-rayed above the injury."

On 10/29/19 at 10:33 AM, the ED Physician was again interviewed via telephone and the following information was obtained:
- The ED Physician was asked if there was a thorough examination and assessment of Patient #1 when the nurse was having difficulty with the discharge and the Physician stated, "yes". He stated, "yes ...I do a thorough job...at the time it appeared as there were no injuries so what was keeping [the patient] from discharge...Trauma stated she was cleared."
- He was asked if the patient should have been discharged. The ED Physician stated, "You have to ask yourself what is keeping the patient here ...there were no injuries ...the [spouse] told us that the patient had a low threshold for pain ...no specific part of the body was identified by the patient as where the pain was."
- The ED Physician was asked if the patient was ever asked if the right leg was in pain. The ED Physician stated, "The patient could have said that sometime when I was in the room ...the patient did so much yelling and screaming ...the patient never said the right leg hurts ...the Trauma Service would have been the ones to keep the patient."
- He stated, "I asked the PA if the femur was going to be x-rayed and the PA said that the Trauma Surgeon said no femur x-ray should be ordered." The ED Physician stated, "[the Trauma Surgeon] is the one to make that decision..I could override that decision but why would I...it is a working trust and [the Trauma Surgeon] said no. Hindsight is 20/20'."

On 10/29/19 at 11:00 AM, the Trauma Physician Assistant [PA] was interviewed regarding Patient #1's ED visit on 10/13/19. The PA stated the following:
- He was at the foot of the stretcher and examined the patient's pedal pulses
- "The patient complained of pain throughout and it was difficult to localize it...I did suture with the aid of [named the Trauma Surgeon]...I did ask [named Trauma Surgeon] if a right femur x-ray was appropriate as the patient was in excruciating pain and the degree with which he/she reacted during my manipulation of that leg...I felt it was appropriate...[named the Trauma Surgeon] stated that [named the Trauma Surgeon] did not feel a femur x-ray was warranted...even though I may disagree, I defer to my attending regarding these decisions."

On 10/29/19 at 1:35 PM, the Trauma Surgeon was interviewed. The Surgeon stated the following:
- She recalled treating the a patient on 10/13/19 after an accident.
- The patient had pain everywhere.
- She did not recall specific areas of pain.
- There were multiple x-rays ordered which were all negative.
- When asked if she recalled anyone questioning the the need for a right femur x-ray, she did not recall anyone asking for that.
- She was asked again about anyone mentioning a right femur x-ray, as the ED Physician and the Trauma PA recalled asking for an x-ray of the femur and again she stated that she [Surgeon] had no recollection of that at all. The Trauma Surgeon stated that after they completed the suturing of the laceration, [Surgeon] turned the case over to [ED Physician].

On 10/31/19 at 9:44 AM, ED Nurse #4 was interviewed via telephone. The Nurse stated stated that Patient #1 stated, "My stitches hurt and my lower leg hurts and I just can't stand up."

On 10/31/19 at 11:09 AM, Patient #1 was interviewed. The patient stated the following:
- She felt that the hospital discharged him/her too early.
- "They were told numerous times that there was something wrong... but they kept saying that I was medically cleared...I told them about the pain in my right leg...I told them I could not bear weight on my right leg, and they said they didn't care, you are discharged."
- A female Nurse came to say that the cops were being called because it was taking too long to get into the truck.
- "They literally rolled me into a sheet and threw me in the truck...every time I moved it hurt."

The hospital failed to ensure a thorough medical screening was conducted based on following:
- The patient had received pain medication; however, was described as having "excruciating pain" and reacted when his/her right leg was manipulated during examination.
- The patient was unable to move well and it took 1.5 hours for the patient to move from the stretcher to the wheelchair.
- The PA and the ED Physician questioned the need for an x-ray of the patient's right femur; however, this was not ordered.
- The patient was described as not wanting to put any pressure on his/her right leg due to weakness and "the patient acted in pain".
- The patient expressed concerns with discharge as he/she felt that his/her "legs are too weak to walk".
- The patient stated "I can't step on that leg."
- Video footage indicated that the patient was wheeled out of the ED doors at 4:04 PM and it took until 7:24 PM to get the patient into a vehicle. The patient had to be assisted, via a lift sheet and ten individuals, into the back seat of a truck.
- There was no evidence, in the record, that a reassessment of the patient was conducted after the patient continued to have difficulty with movement and pain.

On 12/17/19, the Centers of Medicare and Medicaid Services determined that the hospital's failures constituted an immediate jeopardy situation.

Based on record reviews and interviews, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department (ED) for 1 of 20 sampled patients (Patient #1). On 12/17/19, the Centers of Medicare and Medicaid Services determined that the hospital's failure to provide stabilizing treatment constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements.

Finding:

On 10/13/19 at 12:50 PM, Patient #1, who was involved in a motorcycle accident, presented to the ED of Hospital A as a "Code Green" which means as a trauma patient.

At 12:54 PM, the patient was initially seen by the ED Physician who documented that patient had received Fentanyl (a pain medication) on route to the hospital; he/she was moaning and screaming; it was difficult to determine if he/she had back pain on palpitation as the patient was screaming and yelling the entire time; he/she had two separate lacerations on the right lower leg; and he/she had abrasions on his/her abdomen. Diagnostic tests, including Computed tomography (CT) scans and x-rays, showed no fractures or acute injuries.

Further documentation in the record indicated that patient was given Dilaudid, a pain medication, at 1:00 PM, 1:52 PM, 2:00 PM, 2:52 PM, and 3:00 PM and Versed, a benzodiazepine medication, at 1:52 PM.

At 2:26 PM, the ED Nurse #3 documented the "Patient expressed concerns with discharge as [he/she] felt that "my legs are too weak to walk".

At 3:07 PM, the ED Physician documented the course of treatment; that the patient's spouse informed him "that the patient traditionally has a very low threshold for pain tolerance"; "I certainly agree with this"; the "patient screamed and yelled the entire time [he/she] was in the emergency department"; he/she was "very hesitant to even sit up"; "at this point, there is absolutely no indication for admission"; and [he/she ] will be discharged.

On 10/13/19 at 3:45 PM, Patient #1 was discharged and wheeled outside the ED doors.

On 10/15/19, Patient #1 presented to the ED of another hospital (Hospital B). The ED Physician, at Hospital B, documented at 2:32 AM that the patient was in the back of a pickup truck facing down, the family were unable to get him/her out of the truck once home; and the patient spent the next 24 hours in the same position in the back of the truck. Upon presentation to the ED of Hospital B, multiple emergency medical service personnel and fire department personnel assisted with getting the patient out of the truck. He/She had multiple open wounds, ecchymosis (bruising), deep tissue tenderness, and any movement of his/her legs produced severe pain. The patient was diagnosed with rhabdomyolysis. Rhabdomyolysis is a serious syndrome due to a direct or indirect muscle injury and it results from the death of muscle fibers and release of their contents into the bloodstream. The patient continued to have pain with movement of his/her right leg. On 10/17/19, an x-ray was ordered which revealed a right midshaft femur fracture. The patient was transferred back to Hospital A, the hospital he/she initially presented to on 10/13/19, so that he/she could have surgery on his/her leg.

Hospital A provided surveyors with a document titled "Investigatory report regarding pt [patient] [patient's initials] seen here on 10-13-19". This document contained information from interviews conducted between 10/22/19 and 10/28/19 with four nurses and three undated email statements from three nurses. The document indicated the following:
- ED Nurse #1 stated that she had informed the ED Physician that the patient needed to be admitted in her opinion as the patient was not able to move well.
- ED Nurse #2 stated the patient complained of leg weakness not right leg pain.
- ED Nurse #3 had stated that the Physician Assistant (PA) had asked the Trauma Surgeon to x-ray the patient's right leg but she declined; the PA was suturing the patient leg and he/she complained of pain when he moved it; the patient was not specific about pain but complained of weakness.
- ED Nurse #4 had send an email indicating that she was asked to assist a patient in front of the ER; she was told the patient had been outside for three hours; patient was refusing at this time to help stand as he/she stated his/her lower leg hurt due to his/her stitches.
- ED Nurse #5 had sent an email indicating that the patient was refusing to transfer to wheelchair from trauma stretcher, option of social admit was discussed with the ED physician; he was informed that the patient would likely not be accepted for admit; patient transferred from the stretcher to the wheelchair with moderate assistance; and the Nursing Supervisor was informed of the situation.
- ED Nurse #7 had sent an email that indicated multiple staff attempted to lift the patient so he/she could stand multiple times but failed due to the fact the patient refused to assist and repeatedly braked feet against staff, forcing himself/herself back onto the ground; each time the patient was asked why he/she was unable to stand he/she stated "I just can't"

As of 10/31/19, there was no further evidence provided to surveyors to indicate that any changes may have been considered or implemented after the hospital's investigatory report.

On 10/28/19 at 11:10 AM, surveyors reviewed the video footage, for 10/13/19, which captured the area outside ED. The following was observed:
- At 4:04 PM, the patient, who was dressed in a hospital gown, was wheeled outside.
- Between 4:10 PM and 7:00 PM, there were multiple attempts, by staff, to help the patient into a truck and then a cab
- While sitting on the edge of the cab frame, the patient was lowered to the ground.
- Between 7:00 PM and 7:23 PM, the patient remained on the ground.
- At 7:24 PM, the patient was lifted, via EMS Lift Sheet [used for transfer] and the assistance of ten individuals, into the back seat of a truck.

On 10/28/19 at 12:04 PM, ED Nurse #1 was interviewed regarding Patient #1's ED visit on 10/13/19. The Nurse stated that the ED Physician was called back in due to the difficulty getting the patient in a wheelchair at the time of discharge and the patient complained of general all over pain.

On 10/28/19 at 12:22 PM, ED Nurse #2 was interviewed regarding Patient #1's ED visit on 10/13/19. The Nurse indicated the following:
- About 4:00 PM, ED Nurse #2 saw the patient when he/she was ready for discharge.
- "This was a difficult vehicle for anyone to get into and, after 1.5 hours, the patient was still complaining that the right lower leg hurt." ED Nurse #2 stated, "[Patient #1] was screaming, but not crying, and angry about his/her right lower leg." ED Nurse #2 stated, "Upon trying to assist the patient, the patient stated, "I can't stand due to the pain in the right lower leg." ED Nurse #2 stated that the patient would not stand and showed no effort to stand.

On 10/28/19, at 12:46 PM, the ED Physician was interviewed regarding Patient #1's ED visit on 10/13/19. The ED Physician stated that when Trauma was questioned about the need for an x-ray of the patient's femur the Trauma Surgeon didn't feel it was necessary; "The patient didn't want to participate in any part of the care...didn't want to move anything ...all [he/she] did was scream ...the patient screamed all the time and it was difficult to assess pain."

On 10/29/19 at 9:00 AM, ED Nurse #3 was interviewed regarding Patient #1's ED visit on 10/13/19. The Nurse stated the following:
- "I remember Patient #1...alert and oriented and had a lot of pain in the right leg ...patient described it as painful but also weak."
- When asked why the patient was screaming a lot, ED Nurse #3 stated, "Patient was in pain ...adrenaline rush and patient was scared...the [patient's spouse] described the patient's behavior as typical."
- "I was there with the Trauma PA (Physician Assistant) while getting ready to suture the lacerations and the patient complained of pain when positioning the right leg."
- "The patient did not want to put any pressure on the right leg due to weakness and the patient acted in pain."
- The patient's pain was assessed at 2:02 PM at a level 8.
- "When preparing [Patient#1] for discharge the patient had concerns which is why I asked the ED physician for help."
- "The ED Physician stated that trauma staff had cleared the patient, so we needed to discharge...it took 1.5 hours to get the patient into the wheelchair ...the patient told me "I can't step on that leg."
- Two staff members asked the ED Physician if the patient should be admitted and asked for a delay in the discharge and the delay was denied.
- "I was in the room when the PA said that the Surgeon would be asked to x-ray the femur and then the PA left and then returned we were told that the surgeon did not want an x-ray."

On 10/29/19 at 10:33 AM, the ED Physician was again interviewed via telephone and the following information was obtained:
- The ED Physician was asked if there was a thorough examination and assessment of Patient #1 when the nurse was having difficulty with the discharge and the Physician stated, "yes". He stated, "yes ...I do a thorough job...at the time it appeared as there were no injuries so what was keeping [the patient] from discharge...Trauma stated she was cleared."
- He was asked if the patient should have been discharged. The ED Physician stated, "You have to ask yourself what is keeping the patient here ...there were no injuries ...the [spouse] told us that the patient had a low threshold for pain ...no specific part of the body was identified by the patient as where the pain was."
- The ED Physician was asked if the patient was ever asked if the right leg was in pain. The ED Physician stated, "The patient could have said that sometime when I was in the room ...the patient did so much yelling and screaming ...the patient never said the right leg hurts ...the Trauma Service would have been the ones to keep the patient."
- He stated, "I asked the PA if the femur was going to be x-rayed and the PA said that the Trauma Surgeon said no femur x-ray should be ordered." The ED Physician stated, "[the Trauma Surgeon] is the one to make that decision..I could override that decision but why would I...it is a working trust and [the Trauma Surgeon] said no. Hindsight is 20/20'."

On 10/29/19 at 11:00 AM, the Trauma Physician Assistant [PA] was interviewed regarding Patient #1's ED visit on 10/13/19. The PA stated the following:
- He was at the foot of the stretcher and examined the patient's pedal pulses
- "The patient complained of pain throughout and it was difficult to localize it...I did suture with the aid of [named the Trauma Surgeon]...I did ask [named Trauma Surgeon] if a right femur x-ray was appropriate as the patient was in excruciating pain and the degree with which he/she reacted during my manipulation of that leg...I felt it was appropriate...[named the Trauma Surgeon] stated that [named the Trauma Surgeon] did not feel a femur x-ray was warranted...even though I may disagree, I defer to my attending regarding these decisions."

On 10/29/19 at 1:35 PM, the Trauma Surgeon was interviewed. The Surgeon stated the following:
- She recalled treating the a patient on 10/13/19 after an accident.
- The patient had pain everywhere.
- She did not recall specific areas of pain.
- There were multiple x-rays ordered which were all negative.
- When asked if she recalled anyone questioning the the need for a right femur x-ray, she did not recall anyone asking for that.
- She was asked again about anyone mentioning a right femur x-ray, as the ED Physician and the Trauma PA recalled asking for an x-ray of the femur and again she stated that she [Surgeon] had no recollection of that at all. The Trauma Surgeon stated that after they completed the suturing of the laceration, [Surgeon] turned the case over to [ED Physician].

On 10/31/19 at 9:44 AM, ED Nurse #4 was interviewed via telephone. The Nurse stated stated that Patient #1 stated, "My stitches hurt and my lower leg hurts and I just can't stand up."

On 10/31/19 at 11:09 AM, Patient #1 was interviewed. The patient stated the following:
- She felt that the hospital discharged him/her too early.
- "They were told numerous times that there was something wrong... but they kept saying that I was medically cleared...I told them about the pain in my right leg...I told them I could not bear weight on my right leg, and they said they didn't care, you are discharged."
- "They literally rolled me into a sheet and threw me in the truck...every time I moved it hurt."

Based on the above information, the patient continued to complain of pain and leg weakness; demonstrated that he/she could not move positions well, stand, or ambulate; the patient expressed that he/she could not stand because of pain in his/her right and nursing staff inquired about admission or delay in discharge for this patient. However, the decision was made to discharge this patient prior to providing stabilizing treatment for the signs and symptoms the patient continued to exhibit.


On 12/17/19, the Centers of Medicare and Medicaid Services determined that the hospital's failures constituted an immediate jeopardy situation.