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Based on staff interview, medical record review, and facility policy and procedure review, the hospital failed to provide an appropriate medical treatment screening exam and stabilizing treatment for two (2) out of 20 patient charts reviewed: Patients #1, #17.

Findings Include:

Cross Refer to findings at A-2406 and A-2407 for the facility's failure to provide appropriate medical treatment.

During exit conference on 02/17/2022 at 4:00 p.m. with the Chief Executive officer, Chief Nursing Officer, Emergency Department/Intensive Care Director, Labor and Delivery Manager, and Human Resources Director survey findings were discussed and no further documentation was submitted for review.

This standard is not met based on staff interview, medical record review, and facility policy and procedure review, the hospital failed to provide a thorough medical screening examination for two (2) out of 20 patient charts reviewed: Patients #1, #17.

Findings Include:

Patient #1:

A phone interview on 02/16/2022 at 10:55 a.m. with patient #1 revealed she had three (3) visits (12/27/2021,12/31/2021, 01/23/2022) to the Emergency Department (ED) at facility #1. Patient #1 reported on her first visit 12/27/2021, she came in for severe pain and bleeding and was diagnosed with an ectopic pregnancy and was given an injection of Methotrexate and discharged home with instructions to follow up on 12/30/2021 with her Obstetrician /Gynecologist (OBGYN). Patient #1 said she returned to the ED on 12/31/2021 related to pain continuing in her abdomen after the treatment for an ectopic pregnancy and was having some ear pain and low-grade fever. Patient #1 reported the Emergency Department (ED) physician did another ultrasound at this time, drew lab work, and completed a COVID-19 test. Patient reported she was positive for COVID-19 test at this time. Patient #1 reported she was discharged home and told to follow up with her OBGYN at her scheduled appointment. Patient #1 said she visited the ED again on 01/23/2022 for lightheadedness, dizziness, continued lower abdominal pain, and a concern she may be bleeding internally related to the ectopic pregnancy. Patient #1 reported she only had lab work done and no other testing or examinations were performed, and she was told to see her OBGYN the following day. Patient #1 reported on 01/26/2022 the pain became unbearable, so she went to the ED department at a different hospital, facility #2. Patient #1 reported the physician told her, "she was in bad shape and needed surgery". Patient #1 reported she had a six (6) centimeter (cm) blood clot in her fallopian tube from the ectopic pregnancy and had to have emergency surgery to remove her fallopian tube and clean out all the blood. Patient #1 reported the physician told her "she was messed up and could have died, and he was concerned about the care she had received prior to coming to facility #2." Patient #1 reported she was discharged on 01/29/2022 with a drain in her surgical site and now sees another OBGYN. Patient #1 reported she is very concerned and upset that no one ever actually checked her at her OBGYN clinic and that on her last visit to hospital #1 on 01/23/2022 the physician in the ED refused to consult OBGYN and did not do a thorough examination, only lab work. Patient stated, "All of this could have been prevented if they would have just done their job."

An interview on 02/16/2022 at 3:00 p.m. with ED Physician, Doctor of Osteopathy (DO) (on duty 01/23/2022 who treated patient #1) revealed he felt like this wasn't an emergent situation. The ED Physician reported Patient #1 was scheduled to be seen the next day 1/24/2022 by her OBGYN. The ED Physician said the patient reported she had been followed closely by her OBGYN over the past month. The ED Physician reported there is no protocol for low hemoglobin and hematocrit or ectopic pregnancy because they are treated per provider judgement. The ED Physician stated, "if there were all those protocols there would have been no need for me to go to medical school." The ED Physician reported the patient told him her pain was better than it was three (3) days prior to the ED visit. The ED Physician reported he did not consult an obstetrician (OB) physician or order an ultrasound because nothing indicated she needed that. The ED Physician reported her hemoglobin and hematocrit were low, but orthostatic blood pressures were normal which indicated no major blood loss.

An interview on 2/17/2022 at 10:05 a.m. with Registered Nurse (RN) #1 after review of Patient #1's medical record, confirmed the hemoglobin and hematocrit were not critical and Patient #1's orthostatic blood pressures were normal at the 01/23/2022 ED visit. RN #1 reported normally the patient would go to surgery if the ectopic pregnancy was diagnosed in the ED, but the OBGYN was consulted and that they had decided to give the Methotrexate instead on the 12/27/2021 ED visit.

An interview on 02/17/2022 at 12:55 p.m. with the ED Director revealed he remembered giving the patient Methotrexate on 12/27/2021 ED visit because they don't do that very often. The ED Director reported he has seen both surgical and medical treatment of ectopic pregnancy with patients. The ED Director reported in this case at the ED visit on 01/23/2022 the patient already had an appointment the next day,1/24/2022, and lab values weren't critical and vital signs were within normal limits, so she was referred to her Obstetrician for her follow-up the next day 01/24/2022.

A review of the medical record revealed Patient #1 presented to the Emergency Department (ED) on 12/27/2021 at 2:29 a.m. with complaints of vaginal bleeding. The ED physician ordered a Complete Blood Count (CBC), Human Chorionic Gonadotropin (HCG) Quantitative, Type and screen, Urinalysis (UA) with Culture, if indicated, and an Obstetrical Ultrasound (OB) transvaginal. The medical record review revealed Patient #1 had abnormal lab results as follows hemoglobin 11.8, hematocrit 36.0, HCG revealed 7408 which gives proximate gestation of one - two (1-2) months, and all the other lab results were within normal limits. Medical record review revealed the ultrasound was consistent with an ectopic pregnancy per the ED physician's report. The record review of physician notes revealed the OBGYN was consulted at 7:09 a.m. and at 7:16 a.m. ordered Methotrexate Sodium 100 milligrams (mg) per intramuscular injection (IM), the patient was given Methotrexate Sodium100 mg IM per the registered nurse (RN) at 7:30 a.m. as ordered by the ED physician. The patient was discharged from the ED at 8:10 a.m. with discharge instructions to follow up with her OBGYN on Thursday, December 30, 2021, and return to the ED if she has any problems or worsening symptoms. Patient was given prescriptions for Acetaminophen-hydrocodone Bitartrate 325 mg-5 mg take one (1) every 6 hours as needed and Naprosyn 375 mg take one (1) three (3) times a day.

A record review of Patient #1's second visit to the ED on 12/31/2021 revealed the patient arrived on 12/31/2021 at 7:45 p.m. The medical screening revealed the patient was complaining of continued left lower quadrant abdominal pain, left ear pain, and a sore throat. The record review revealed the ED physician ordered diagnostic test as follows: HCG Quantitative, Strep A screen, Ultrasound OB Complete, and COVID-19 test. The medical record review revealed the following test results: Strep test negative, COVID-19 polymerase chain reaction (PCR) positive, HCG results indicated that the patient's HCG increased to 11,582 from 7408 on 12/27/21 after receiving Methotrexate on 12/27/2021. The medical record review of the Ultrasound revealed the patient had left sided ectopic pregnancy in the same position as the previous ultrasound and was negative for intrauterine pregnancy. The physician's note from 12/31/2022 visit revealed the ED physician consulted the OBGYN who stated " ...the findings are promising. Patient's pain is controlled with her home Hydrocodone and Naprosyn. OBGYN follow up on Monday as scheduled...". The medical record review revealed the patient was discharged from the ED at 11:45 p.m. with discharge instructions to follow up with the OBGYN on Monday, continue home medications, Zyrtec tablet one (1) twice (2) daily, encourage fluids, Tylenol or Advil for pain or fever and if symptoms fail to improve or get worse return to the ED promptly.

A medical record review of Patient #1's third visit to the Emergency Department (ED) on 1/23/2022 revealed the patient arrived by private vehicle at 8:06 a.m. with complaints of lightheadedness and dizziness. The patient's vital signs were obtained at 8:20 a.m. and were within normal limits. The medical record review of the ED Physician's report revealed the patient complained of " ...abdominal pain, lightheadedness, and concerns for the fact that she may be "bleeding internally" ..." A review of the ED physician's assessment dated 1/23/2022 revealed the patient had abdominal tenderness to the left lower quadrant and to the right lower quadrant. The medical record review revealed the ED Physician ordered diagnostic tests as follows: complete blood count (CBC), HCG quantitative, orthostatic blood pressure's (B/P) and urinalysis (U/A) with culture if indicated. Patient #1 test results were as follows: Red Blood Cell Count (RBC) has decreased from 4.32 on 12/27/2021 to 3.35 on 01/23/2022, Hemoglobin (Hgb) has decreased from 11.8 on 12/27/2021 to 9.2 on 01/23/2022, Hematocrit (Hct) has decreased from 36.0 on 12/27/2021 to 27.9 on 01/23/2022, Platelets have increased from 303 on 12/27/2021 to 449 on 01/23/2022, and Human Chorionic gonadotropin (HCG) quantitative has decreased from 7408 on 12/27/2021 to 677.8 on 01/23/2022. A review of the ED Physician assessment/notes revealed the physician discharged patient to home to follow up with her OBGYN the next day,1/24/2022. The medical record review revealed there was no documented evidence of an OBGYN consult made on this visit or a comparable ultrasound completed. The medical record revealed the patient was discharged at 10:23 a.m. with instructions to follow up with her specialist as scheduled and return if symptoms get worse.

A review of the medical record obtained from Hospital #2 revealed the patient went for evaluation on 01/27/2022 and was admitted to the hospital on 01/27/2022 with a diagnosis of left ectopic pregnancy, failed medical management. Review of the history and physical dated 01/27/2022 revealed the patient had an ultrasound on 01/27/2022 which indicated the patient had a 6 centimeter (cm) adnexal mass and was counseled on the need for a diagnostic laparoscopy and possible left salpingectomy/oophorectomy and evacuation of the hematoma.

Review of the consultation note from 01/27/2022 revealed the patient had a ruptured left ectopic pregnancy. The medical record review of the surgical notes revealed the hematoma was evacuated, and the left fallopian tube was removed. A medical record review of the discharge summary revealed the patient was discharged home on 01/29/2022 with diagnoses of anemia, hemoperitoneum due to rupture of the left tubal ectopic pregnancy and ruptured ectopic pregnancy.

Review of facility policy entitled "Emergency Department Triage Policy" (Reviewed/Revised 9/28/2016) revealed " ...URGENT ...3. A rule-out ectopic pregnancy when patient is hemodynamically stable ...".

Patient #17:

An interview at 12:05 p.m. on 2/16/2022 with the Chief Clinical Officer (CCO) confirmed the medical record for Patient #17 did not have documented evidence of a medical screening examination by the physician or nurse practitioner. She also confirmed the medical record did not contain documentation of contact with the patient from 12:33 p.m. to 5:13 p.m.

An interview at 12:55 p.m. on 02/17/2022 with the Nursing Director of the Emergency Department (ED) confirmed there is no documented evidence of a medical screening examination completed by the physician or nurse practitioner on Patient #17 and no documentation of contact with patient #17 from 12:33 p.m. to 5:13 p.m. on 01/23/2022 when it was determined that the patient walked out.

Review of medical record for Patient #17 reveals the patient entered the facility at 12:18 p.m. on 01/23/2022 with complaint of dental pain, acuity level 4, and the triage process started at 12:33 p.m. with triage nurse completing vital signs and history. The next documentation noted in the patient's medical record was at 5:13 p.m. on 1/23/2022, stating, "patient's name called x three (3), with no response," per the Emergency Department Technician (ED Tech). "Patient walked out." per Emergency Department Admissions.

Review of the facility's EMTALA Policy, "Emergency Medical Treatment and Labor Act (EMTALA)" No policy number, original date 09/2011, last revision 08/2018 approved by executive committee states "Procedure: 8. Screening Procedures/Triage; "8.2 After triage in the Emergency Department, a medical screening examination will be provided to each patient by either a physician or nurse practitioner on duty in the emergency department ...".

Review of the facility's "Emergency Department Triage Policy", (Reviewed/Revised 9/28/2016) revealed " ...Any patient that is in the waiting room waiting longer than one (1) hour for bed placement that has had an initial triage done, must be re-assessed by the triage nurse and assessment placed in PulseCheck. This will be done on an hourly and as needed (prn) basis ...".

During exit conference on 02/17/2022 at 4:00 p.m. with the Chief Executive officer, Chief Nursing Officer, Emergency Department/Intensive Care Director, Labor and Delivery Manager, and Human Resources Director survey findings were discussed, and no further documentation was submitted for review.

Based on staff interview, medical record review, and facility policy and procedure review the facility failed to provide necessary stabilizing treatment for an emergency medical condition on 01/23/2022 during emergency department (ED) visit for one (1) of 20 patient charts reviewed: Patient #1.

Findings Include:

A phone interview on 02/16/2022 at 10:55 a.m. with Patient #1 revealed she returned to the emergency department (ED) a third (3rd) time on 01/23/2022 with increased pain, lightheadedness, dizziness, and concerns of internal bleeding. Patient #1 reported she only had lab work done and no other testing or examinations were performed, and she asked again about possible internal bleeding but was told to follow up with her Obstetrician /Gynecologist (OBGYN) the next day. Patient #1 reported on 1/26/2022 that her pain became unbearable, so she went to a different hospital, Facility #2. Patient #1 reported the physician told her, "she was in bad shape and needed surgery." Patient #1 reported she had a six (6) centimeter (cm) blood clot in her fallopian tube from the ectopic pregnancy and she had to have emergency surgery to remove the fallopian tube and clean out all the blood. Patient #1 reported the physician told her she "was messed up and could have died." Patient #1 reported she was discharged on 01/29/2022 with a drain in her surgical site. Patient #1 reported the physician was very concerned about the care she had received prior to coming to Facility #2. Patient #1 reported she is very concerned and upset that no one ever actually checked her at her OBGYN clinic and that on her last visit on 01/23/2022 to Hospital #1 the physician in the ED refused to consult OBGYN and did not do a thorough examination, only lab work. Patient stated, "All of this could have been prevented if they would have just done their job." Patient #1 stated she did go to all her follow-up visits (12/30/21, 01/04/2022, 01/7/2022, 01/20/2022, 01/24/2022) with her OBGYN, but they only drew blood each time and she never saw a doctor.

An interview on 02/16/2022 at 3:00 p.m. with ED Physician, Doctor of Osteopathy (DO) (on duty 01/23/2022 who treated Patient #1), revealed he felt like this wasn't an emergent situation for 01/23/2022 ED visit. The ED Physician reported the patient was scheduled to be seen the next day 01/24/2022 by her OBGYN. The ED Physician said the patient reported she had been followed closely by her OBGYN over the past month. The ED Physician reported there is no protocol for low hemoglobin and hematocrit or ectopic pregnancy because they are treated per provider judgement. The ED Physician stated, "if there were all those protocols there would have been no need for me to go to medical school." The ED Physician reported the patient told him her pain was better than it was three (3) days prior to the ED visit. The ED Physician reported he did not consult an obstetrician (OB) physician or order an ultrasound because nothing indicated she needed that. The ED Physician reported her hemoglobin and hematocrit were low, but orthostatic blood pressures were normal which indicated no major blood loss.

An interview on 02/17/2022 at 10:05 a.m. with Registered Nurse (RN) #1, confirmed she did not remember this patient, but reviewed the chart and the hemoglobin and hematocrit were not critical and her orthostatic blood pressures were normal at the 01/23/2022 ED visit. RN #1 reported normally the patient would go to surgery if the ectopic pregnancy was diagnosed in the ED, but the OBGYN was consulted and that they had decided to give the Methotrexate instead on the 12/27/2021 ED visit.

An interview on 02/17/2022 at 12:55 p.m. with the ED Director revealed he remembered giving the patient Methotrexate on 12/27/2021 ED visit because they don't do that very often. The ED Director reported he has seen both surgical and medical treatment of ectopic pregnancy with patients. The ED Director reported, "in this case the patient already had an appointment the next day,01/24/2022 and lab values weren't critical and vital signs were within normal limits, so she was referred to her Obstetrician for her follow-up the next day 01/24/2022."

A medical record review of Patient #1's third (3rd) visit to the Emergency Department (ED) on 01/23/2022 revealed the patient arrived by private vehicle at 8:06 a.m. with complaints of lightheadedness and dizziness. The patient's vital signs were obtained at 8:20 a.m. and were within normal limits. The medical record review of the ED Physician's report revealed the patient complained of " ...abdominal pain, lightheadedness, and concerns for the fact that she may be "bleeding internally" ..." A review of the ED physician's assessment dated 1/23/2022 revealed the patient had abdominal tenderness to the left lower quadrant and to the right lower quadrant. The medical record review revealed the ED Physician ordered labs as follows: complete blood count (CBC), HCG quantitative, orthostatic blood pressure's (B/P) and urinalysis (U/A) with culture if indicated. A review of the medical record revealed that the patient's lab results were as follows: Red Blood Cell Count (RBC) has decreased from 4.32 on 12/27/2021 to 3.35 on 01/23/2022, Hemoglobin (Hgb) has decreased from 11.8 on 12/27/2021 to 9.2 on 01/23/2022, Hematocrit (Hct) has decreased from 36.0 on 12/27/2021 to 27.9 on 01/23/2022, Platelets have increased from 303 on 12/27/2021 to 449 on 01/23/2022, and Human Chorionic gonadotropin (HCG) quantitative has decreased from 7408 on 12/27/2021 to 677.8 on 01/23/2022. A review of the ED Physician's assessment revealed the physician discharged Patient #1 to home and to follow up with her OBGYN the next day, 01/24/2022. The medical record review revealed there was no documented evidence of an OBGYN consult made on this visit or a comparable ultrasound completed. The medical record revealed the patient was discharged at 10:23 a.m. with instructions to follow up with her specialist as scheduled and return if symptoms get worse.

A review of the medical record obtained from Facility #2 revealed the patient went for evaluation on 01/27/2022 and was admitted to the hospital on 01/27/2022 with a diagnosis of left ectopic pregnancy, failed medical management. Review of the history and physical dated 01/27/2022 revealed the patient had an ultrasound on 01/27/2022 which indicated the patient had a 6 centimeter (cm) adnexal mass and was counseled on the need for a diagnostic laparoscopy and possible left salpingectomy/oophorectomy and evacuation of the hematoma.

Review of the consultation note from 01/27/2022 revealed the patient had a ruptured left ectopic pregnancy. The surgical note review revealed the hematoma was evacuated, and the left fallopian tube was removed. A medical record review of the discharge summary revealed the patient was discharged home on 01/29/2022 with diagnoses of anemia, hemoperitoneum due to rupture of the left tubal ectopic pregnancy and ruptured ectopic pregnancy.
Review of facility policy entitled "Emergency Department Triage Policy" (Reviewed/Revised 9/28/2016) revealed " ...URGENT ...3. A rule-out ectopic pregnancy when patient is hemodynamically stable ...13. If an emergency medical condition does exist: 13.1 ...treatment will be initiated as medically appropriate ...including all ancillary services ...to ensure that -13.1.1 The patient's condition is stabilized ...".

During exit conference on 02/17/2022 at 4:00 p.m. with the Chief Executive officer, Chief Nursing Officer, Emergency Department/Intensive Care Director, Labor and Delivery Manager, and Human Resources Director survey findings were discussed and no further documentation was submitted for review.