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Based on policy review, medical record review and interview, the facility failed to provide an appropriate medical screening exam for 2 of 20 (Patient #1 and #11) sampled patients, and failed to appropriately transfer 1 of 5 (Patient #11) sampled patients requiring a higher level of care.

The findings included:

1. Medical record review revealed Patient #1 presented to Hospital #1's Emergency Department (ED) on 1/15/2025 at 8:20 PM with a chief complaint of back pain- non-traumatic. A Medical Screening Examination (MSE) was initiated on 1/15/2025 at 9:00 PM by Physician #1. Physician #1 documented Patient #1 presented to the ED with back pain from his shoulders to his buttocks and had a history of Multiple Myeloma (a type of cancer that forms in the white blood cells called plasma cells). Patient #1 denied falls and reported no other illnesses. Patient #1's family reported the patient fell the day prior to arrival to the ED. Patient #1 reported a pain score of 8 out of 10 (7-10 being severe pain). Physician #1 ordered a computed tomography (CT - a non-invasive medical imaging procedure that uses xrays to create detailed pictures of the inside of the body) scan of the chest, abdomen and pelvis. The CT scan findings revealed diffuse bony metastatic (the spread of cancer cells from the primary site to other parts of the body) disease related to known multiple myeloma, T6 (the sixth thoracic vertebrae in the spine located just below the level of the shoulder blades) and T7 (the seventh thoracic vertebra in the spine located roughly in the middle of the spine) destruction-stable, mild right middle lobe infiltrate (an area of increased density on a chest x-ray that affects one or more lobes of the lungs; (possible causes are infection, inflammation, fluid accumulation or cancer), ascending aortic aneurysm (a bulge or enlargement in the part of the aorta that carries blood from the heart up toward the head), prominent pulmonary artery (an enlargement of the major blood vessel that carries oxygen-poor blood from the heart to the lungs), bilateral renal cysts (fluid-filled sacs that can form on or inside both kidneys) and prostatic enlargement. Physician #1 documented the ED course as the CT scan without acute findings; and there was no lymphadenopathy (swelling of the lymph nodes) on exam, and the patient was known with metastatic multiple myeloma. Patient #1 was on Gabapentin (a medication given to relieve nerve pain) and a Fentanyl (a man-made opioid used to treat chronic severe pain; 100 times more powerful than morphine) patch. Prescription for Lortab (a medication that relieves moderate to intense pain) 5 milligrams (mg) was provided and the patient was to follow up with his primary care physician (pcp). The patient's discharge diagnosis was documented as multiple myeloma and back pain. The patient's discharge disposition was home and his discharge condition was documented as stable. Patient #1's pain score continued at an 8 out of 10 at 9:54 PM. Patient #1 was administered Hydrocodone-Acetaminophen (Lortab) 5-325 mg by mouth at 9:54 PM. Patient #1 was discharged and departed the ED at 10:08 PM, 14 minutes after he received Lortab for pain. There was no lab work ordered or drawn to further assess Patient #1's condition related to the complaint of severe back pain. There was no reassessment of the patient's pain to determine if Patient #1's pain level had increased, decreased, or unchanged after receiving the pain medication, lortab. The hospital failed to ensure Patient #1 received a complete and appropriate MSE.

Cross Refer to A-2406.

2. Medical record review revealed Patient #11 presented to Hospital #1's ED on 10/5/2024 at 4:02 PM with a chief complaint of pregnancy greater than 20 weeks. Patient #11 complained of abdominal cramping and vaginal spotting for 1 day. Patient #11 was 31 weeks pregnant. Fetal Heart Tones (FHT - the sound of the baby's heartbeat in the womb using a handheld ultrasound device or electronic fetal heart monitor) were assessed at 4:28 PM with results of 144 beats per minute (the normal fetal heart rate is between 110 and 160 beats per minute). A MSE was initiated on 10/5/2024 at 4:34 PM by Physician #2. Physician #2 documented Patient #11 was 31 weeks gestational age (the number of weeks that have elapsed since the first day of a woman's last menstrual period; used to determine the expected due date) and presented with complaints of lower abdominal/pelvic crampy pain associated with vaginal bleeding and described as mild amount and light red in color. Patient #11 was also concerned she had not experienced any fetal movement during the day. Patient #11 did feel fetal movement when the ED Registered Nurse (RN) evaluated her for FHTs. Patient #11's pain score was a 7 out of 10. The examination of Patient #11's abdomen revealed palpable (able to be felt) fetal movement. Physician #2 documented the ED course as symptomatology concerning for possible pre-term labor with respect to light vaginal bleeding and lower abdominal pain. Physician #2 documented Patient #11 was hemodynamically stable (a patient has a stable blood flow, blood pressure and heart rate) with noted fetal movement and fetal heart tones. Patient #11 was documented as "Not in eminent labor...Patient is stable for being transferred". Physician #2 discussed Patient #11 with the Obstetrician (OB) on call. Patient #11 was instructed to go straight to Hospital #2 for a full evaluation and non-stress fetal monitoring.

The ED disposition for Patient #11 was documented as home. The Discharge instructions included go straight to Hospital #2. Patient #11 left the ED at Hospital #1 on 10/5/2024 at 5:53 PM per personal vehicle.

Patient #11 had presented to Hospital #1 with symptoms of possible pre-term labor. There was no lab work ordered or drawn. There was no ultrasound ordered or performed. In addition, there was no documented assessment of Patient #11's cervical dilation or effacement. Hospital #1 failed to ensure Patient #11 received a complete and appropriate MSE for herself and the unborn baby. Hospital #1 failed to order a transfer to Hospital #2, a facility with a higher level of care, and allowed Patient #11 to be discharged from Hospital #1's ED, via personal vehicle, with instruction to go to Hospital #2.

Cross Refer to A-2406 and A-2409.

Based on policy review, medical record review and interview, the facility failed to provide a complete or appropriate medical screening exam (MSE) to determine if an Emergency Medical Condition (EMC) exists for 2 of 20 (Patient #1 and #11) sampled patients who presented to the facility's Emergency Department (ED) seeking medical care.

The findings included:

1. Review of the facility's "EMTALA [Emergency Medical Treatment and Labor Act]- Definitions and Terminology" policy (7/13/19) revealed, "...Emergency Medical Condition...For all individuals- A medical condition manifesting itself by acute signs and symptoms of sufficient severity (including severe pain...) such that the absence of immediate medical attention could reasonably be expected to result in either...placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy...serious impairment to bodily functions...or serious dysfunction of any bodily organ or part ...Labor means...The process of childbirth beginning with the early or latent phase of labor and continuing through delivery of the placenta. A woman experiencing contractions is in "true labor" unless a physician or other Qualified Medical Person certifies that, after a reasonable time of observation and examination, the woman is in "false labor" and there is no Emergency Medical Condition...Medical Screening Examination means: An examination conducted by a QMP [qualified medical person] of a sufficient nature to determine whether or not an Emergency Medical Condition exists. The examination is non-discriminatory and consistent for all patients with the same signs and symptoms, and is provided without regard to the patient's payer status. A Medical Screening Examination includes ancillary services routinely available to the ED [Emergency Department], including tests, procedures, and the services of on-call physicians ..."

Review of the facility's "EMTALA - Medical Screening Examination" policy (1/6/23) revealed, "...Medical Screening Examination Requirement... Any individual presenting to the hospital or ED and requesting emergency care will receive a MSE within the capabilities of the Hospital to determine whether or not an Emergency Medical Condition exists. These capabilities include the utilization of ancillary services, diagnostic methods and specialist physicians routinely available to the hospital and the ED.... The MSE must be the same for all individuals presenting with the same condition..."

Review of the facility's "OB [obstetrics] Delivery in Emergency Department" policy (8/9/23) revealed, "...The physician will provide a medical screening to all obstetrical patients presenting to Emergency Department..."

2. Medical record review revealed Patient #1 presented to Hospital #1's ED on 1/15/2025 at 8:20 PM with a chief complaint of back pain non-traumatic. Patient #1 was an 87 year old who presented to the ED via Emergency Medical Services (EMS) from his home. Patient #1 reported "terrible back pain" that began the morning prior to arrival. Patient #1 reported a pain level of 8 out of 10 on a 0-10 pain scale (0 being no pain and 10 being the most severe pain).

A MSE was initiated on 1/15/2025 at 9:00 PM by Physician #1. Physician #1 documented Patient #1 presented to Hospital #1's ED with back pain from his shoulders to his buttocks and had a history of Multiple Myeloma (a cancer of plasma cells-plasma cells are a type of white blood cells in the bone marrow). Patient #1 denied falls and reported no other illnesses. Patient #1's family reported the patient fell the day prior to arrival to the ED (1/14/2025).

Physician #1 documented on the physical examination that Patient #1 had "...no acute distress, [Patient #1 was] alert and oriented...Musculoskeletal: Moves all extremities equally..."

Physician #1 ordered a Computed Tomography (CT-imaging test that helps healthcare providers detect diseases and injuries) scan of the chest, abdomen and pelvis without contrast [contrast are dyes that are injected into the body to highlight specific areas to aide viewing]. The CT performed on 1/15/2025 was compared to a previous CT scan results from 7/1/2024. The CT scan findings revealed diffuse bony metastatic disease (cancer cells spread from the original tumor to the bones) related to known Multiple Myeloma, T6 and T7 (vertebrae of the thoracic spine) destruction-stable, mild right middle lobe infiltrate (may cause poor ventilation and may be caused by infection or inflammation), ascending aortic aneurysm (bulge in the aorta; aorta is the main blood vessel through which oxygen and nutrients travel from the heart to organs in the body), prominent pulmonary artery (suggested pulmonary hypertension; pulmonary hypertension is a type of hypertension that affects arteries in the lungs and the heart), bilateral renal cysts (abnormal growth-usually non cancerous, located in or on the kidneys) and prostatic enlargement (prostate gland larger than normal). The findings on the 1/15/2025 CT scan report were stated as not being significantly changed since the prior CT report dated 7/1/2024.

Physician #1 documented Hospital #1's ED course for Patient #1 as follows, "...evaluated for back pain from his Thoracics to his lower lumbar. No reported injury. Differential diagnosis includes but is not [limited] to: New metastatic lesion, compression fracture [occurs when one or more bones in the spine weaken or crumple], degenerative disc disease [a condition of the spine in which the discs between the vertebrae lose the cushioning, fragmentation and herniation related to aging]. Sent for CT of the chest/ab [abdomen]/pelvis without contrast. CT scan without acute finding. Patient has an aortic aneurysm that is actually decreased in size from prior evaluation. No lymphadenopathy [swollen lymph nodes] noted on exam. Does have known metastatic multiple myeloma. Already on gabapentin [medication used for nerve pain] and fentanyl patch [used to treat severe pain]. Have provided prescription for Lortab [opioid used to treat moderate to severe pain] 5 mg [milligrams]. Patient follow-up PCP [primary care physician]...Discharge Diagnosis: Multiple myeloma, Back pain...ED Disposition: Home; Patient condition: stable..."

Review of Patient #1's vital signs on 1/15/2025 at 9:54 PM revealed the pain score continued at an 8 out of 10. Patient #1 was administered Hydrocodone-Acetaminophen (generic name for Lortab) 5-325 mg by mouth at 9:54 PM. The ED Disposition revealed Patient #1 was discharged "Home" on 1/15/2025 at 10:08 PM, 14 minutes after receiving pain medication. Hospital #1 failed to re-assess Patient #1 to see if the pain medication had relieved Patient #1's pain.

In an interview on 1/29/2025 at 7:30 AM, ED Registered Nurse (RN) #1 stated she remembered Patient #1. ED RN #1 stated Patient #1's main complaint was back pain and generalized pain. Patient #1 denied falling though both family members present during the ED visit stated the Patient fell the previous day. ED RN #1 stated one of the family members wanted Patient #1 to be given specific intravenous pain medication, Dilaudid, and wanted him to stay in the hospital for pain control. ED RN #1 stated Patient #1 was already on Fentanyl and Gabapentin. ED RN #1 stated Patient #1 was given Lortab for break through pain (a sudden increase in pain that may occur in patients who already have chronic pain from cancer, arthritis or other conditions) and also a prescription for Lortab to take at home. Patient #1 was instructed to discuss further chronic pain management with his oncologist (physician specializing in cancer treatment) at his appointment the following morning after his ED visit (1/16/2025). ED RN #1 verified no lab work was ordered or performed.

In an interview on 1/29/2025 at 8:00 AM, Physician #1 verified he was Hospital #1's ED provider for Patient #1. Physician #1 stated Patient #1 came in with back pain and history of Multiple Myeloma. Physician #1 stated, "Scans were done...can't remember exactly how many, but no new acute findings...scanned the entire spine for sure...the patient was already on chronic pain medication along with Gabapentin...we gave him a Lortab and gave him a script [prescription] to help with breakthrough, till he could see his Oncologist, which I believe was the next day...we don't provide long term chronic pain management..." Physician #1 stated, "...he had no other complaints, other than pain...we did what was needed..."

Patient #1 presented to Hospital #1 on 1/15/2025 at 8:20 PM with severe back pain. Patient #1 was administered pain medication by mouth at 9:54 PM and discharged from the ED at 10:08 PM, 14 minutes after receiving pain medication. There was no reassessment of pain to determine if Patient #1's pain level was improved, and no longer severe. There was no lab work ordered or drawn to further assess Patient #1's condition related to the complaint of severe back pain and a history of Multiple Myeloma. Hospital #1 failed to provide a complete MSE to determine if Patient #1 had an Emergency Medical Condition.

3. Medical record review revealed Patient #11 presented to Hospital #1's ED on 10/5/2024 at 4:02 PM with a chief complaint of pregnancy greater than 20 weeks. Patient #11 complained of abdominal cramping and vaginal spotting for 1 day. Patient #11 was 31 weeks pregnant. Fetal Heart Tones (FHT- the sound of the baby's heartbeat in the womb using a handheld ultrasound device or an electronic fetal monitor) were assessed at 4:28 PM with a result of 144 beats per minute (normal fetal heartbeat is between 110 and 160 beats per minute).

A MSE was initiated on 10/5/2024 at 4:34 PM by Physician #2 at Hospital #1. Physician #2 documented Patient #11 was 31 weeks gestational age (the number of weeks that have elapsed since the first day of the woman's last menstrual period) and presented with complaints of lower abdominal/pelvic crampy type pain. Patient #11 also reported vaginal bleeding described as mild amount and light red in color. Patient #11 reported she had concerns due to not experiencing fetal movement during the day; although fetal movement was noted when the ED RN evaluated for FHTs. Patient #11's pain score was a 7 out of 10 (with 10 being most severe pain). Physician #2 documented a physical examination of Patient #11's abdomen as, "...soft, gravid [pregnant] abdomen...Palpable fetal movement during exam..." Physician #2 documented Patient #11 had established OB care at Hospital #2 and Patient #11 had originally wanted to go to Hospital #2's ED but was concerned about the well-being of the baby with respect to the lack of fetal movement, therefore she decided to come to Hospital #1's ED.

Physician #2 documented the ED course for Patient #11 as follows: "...31 weeks gestational age presents with symptomatology [symptoms] concerning for possible pre-term labor [labor that occurs before 37 weeks of pregnancy] with respect to light vaginal bleeding and lower abdominal pain; reassuringly, patient is hemodynamically stable [blood pressure and heart rate stable] with self aware and physical examination appreciable [for] fetal movement with fetal heart tones. Not presenting with eminent labor. Patient is stable for being transferred [to a higher level of care]. Discussed patient's presentation with on-call OB [named Obstetrician]; patient will be directed to go straight to [named hospital #2] for full evaluation and non-stress fetal monitoring ...ED course: Patient stable for discharge home".

The Discharge diagnosis for Patient #11 was documented as pelvic pain in third trimester of pregnancy (the final stage, lasting from week 22 to 40) and vaginal bleeding in third trimester pregnancy.

Physician #2 at Hospital #1 documented Patient #11's disposition decision as "Home" with patient discharge instructions that revealed, "Go straight to [named Hospital #2] in [named town]". Patient #11 left the ED, in a private vehicle, on 10/5/2024 at 5:53 PM.

Review of the medical record for Patient #11 at Hospital #2 revealed the Patient arrived via private vehicle on 10/5/2025 at 7:35 PM, 1 hour and 42 minutes after leaving Hospital #1. Patient #11 presented to Hospital #2 with the chief complaint of Vaginal Bleeding, Contractions, Decreased Fetal movement and with contractions every 4-6 minutes variable lasting 30 seconds. The patient reported other symptoms that included spotting when wiping and recent intercourse in the last 24 hours. Patient #11 reported fetal movement was initially decreased when presenting to previous Hospital #1; but reported good fetal movement while at Hospital #1's ED and after transfer here (Hospital #2) by private vehicle.

4. In an interview on 1/29/2025 at 12:05 PM, Hospital #1's ED RN #3 stated in general, she didn't know why there wasn't an ultrasound performed on Patient #11. ED RN #3 stated given Patient #11 was at the hospital in the daytime, and was critical then there would have been an ultrasound technician available at Hospital #1. Hospital #1's ED RN #3 stated if not able to get an ultrasound, they would typically call a hospital with an OB department and see if they would accept a transfer and would send the patient directly to the OB department.

Patient #11 presented to Hospital #1's ED with symptoms of possible pre-term labor. There was no lab work ordered or drawn, no documented assessment of cervical dilation or effacement, and no ultrasound ordered or performed. Physician #2 at Hospital #1 allowed Patient #11 to be discharged from Hospital #1's ED via private vehicle.

Cross Refer to 2409.

Based on policy review, medical record review and interview, the facility failed to appropriately transfer 1 of 5 (Patient #11) sampled patients requiring a higher level of care.

The findings included:

1. Review of the facility's "EMTALA [Emergency Medical Treatment and Labor Act]-Definitions and Terminology" policy (7/31/19) revealed, "...EMTALA means...requires hospitals to provide medical screening, treatment and transfer of individuals with Emergency Medical Conditions [EMC] or women in labor...Labor means: The process of childbirth beginning with the early or latent phase of labor and continuing through delivery of the placenta...Stable for Transfer means: That after providing a Medical Screening Examination [MSE] and stabilizing treatment, the Hospital may facilitate a transfer to another facility (inpatient or outpatient) if the treating physician has determined, within reasonable clinical confidence, that the patient is expected to leave the Hospital and be received at the second facility with no material deterioration in his/her medical condition, and the treating physician reasonably believes the receiving facility has the capability to manage the patient's medical condition and any reasonably foreseeable complication of that condition...Transfer means: The movement of an individual outside the Hospital's facilities at the direction of any person employed by (or affiliated with) the Hospital, including individuals who are referred to hospitals, clinics, or physician offices for immediate care. Transfers include transfers to a higher level of care and transfers requested by the individual..."

2. Medical record review revealed Patient #11 presented to Hospital #1's Emergency Department on 10/5/2024 at 4:02 PM with a chief complaint of pregnancy greater than 20 weeks. Patient #11 complained of abdominal cramping and vaginal spotting for 1 day. Patient #11 was 31 weeks pregnant. Fetal Heart Tones (FHT) were assessed at 4:28 PM with result of 144 beats per minute (normal fetal heart beat is 110 to 160 beats per minute).

A MSE was initiated on 10/5/24 at 4:34 PM by Physician #2 at Hospital #1. Physician #2 documented, "...Discussed patient's presentation with on-call OB [named Obstetrician]; patient will be directed to go straight to [named Hospital #2] for full evaluation and non-stress fetal monitoring ...ED course: Patient stable for discharge home". The Discharge diagnosis for Patient #11 was documented as pelvic pain in third trimester pregnancy and vaginal bleeding in third trimester pregnancy. Physician #2 documented the disposition decision as "Home" with patient discharge instructions, "Go straight to [named Hospital #2] in [named town]". Patient #11 left Hospital #1's ED on 10/5/2024 at 5:53 PM via private vehicle.

3. In an interview on 1/29/2025 at 12:05 PM, Hospital #1's ED Registered Nurse (RN) #2 stated she was confused because the patient's discharge instruction stated to go straight to Hospital #2. Hospital #1's ED RN #2 stated that was "not normal". If a patient was greater than 20 weeks, they could go straight to the OB department when transferred to another hospital. Hospital #1's ED RN #2 stated she did not understand why Patient #11 wasn't transferred to Hospital #2 via ambulance.

In an interview on 1/29/2025 at 12:05 PM, Hospital #1's ED RN #3 stated if a hospital with OB services would accept a transfer, a patient greater than 20 weeks pregnant would be transferred directly to the OB department. Hospital #1's ED RN #3 stated she was a little confused why Patient #11 was instructed to go straight to Hospital #2, and not transferred via an emergency vehicle.

Patient #11 was discharged from Hospital #1's ED on 10/5/2024 at 5:53 PM. Patient #11 needed a higher level of care not available at Hospital #1. Patient #11 required transfer to another facility. Physician #2 did not order a transfer of Patient #11 to a facility with a higher level of care (Hospital #2) by emergency vehicle and allowed Patient #11 to be discharged from Hospital #1's ED in a private vehicle.

Cross Refer to A-2406.