HospitalInspections.org

Based on patient, family and staff interviews, ED log, medical record and policy review, it was determined that the hospital failed to ensure that Patients # 16, 17, and 37 (of 21 sampled patients who presented to the emergency department seeking care) received an appropriate medical screening examination (MSE) that made use of the hospital's capabilities; failed to ensure that Patients # 17 and 37 received further medical evaluation and treatment as required to stabilize their emergency medical condition; and failed to ensure that Patient # 44 did not experience a delay in medical examination and treatment in order to inquire about payment.



These failures resulted in Patient #16 leaving the hospital ' s off-campus emergency department and traveling 9.5 miles (16 minutes) to the main campus to receive examination and treatment; a delay in activation of the Stroke Protocol preventing Patient # 17 from receiving thrombolytic medication to treat an acute stroke; Patient # 37 leaving the ED to go to another hospital to receive a rapid assessment for the presence and severity of post-tonsillectomy bleeding (a high risk condition that can be life threatening); Patient # 44 coreced into making a payment to prevent care from being stopped; and placed all patients at risk for deterioration of their health and wellbeing as a result of an undetected or untreated emergency medical condition.

Based on patient interview, staff interviews, and the hospital's emergency department (ED) log/Obstetrics Department (OB) log, the hospital's administrative staff failed to ensure hospital ED staff maintained a complete ED log for 1 of 21 patients reviewed (Patient #16) who presented to the ED seeking medical care on 5/2/24.

Failure to maintain a complete log resulted in the possibility of the hospital staff inability to track the care provided to each individual who comes to the hospital seeking care for a potential emergency medical condition (EMC).

Findings include:

1. Review of Policy "Triage of OB Patient in the Emergency Department," last revised 5/23 revealed in part:

a. "< (less than) 20 Weeks gestation with any chief complaint: Registered to the Emergency Department (ED) and triaged according to the ED Policy and Procedure..."

b. " > (greater than) 20 Weeks gestation with OB related chief complaint: OB related chief complaints may include: Abdominal cramps/pain, contractions, vaginal bleeding, leaking fluid, decreased fetal movement, headache with hypertension, epigastric pain, hypertension (SBP > 140 and/or DBP > 90)...Patients will be triaged to labor and delivery...The main ED will notify the OB charge RN or RN in the OB ED and provide patient name, care provider's name (if available), due date/weeks' gestation, and chief complaint."

2. On 5/8/24 at 9:00 AM, during an interview, Patient #16 reported the patient went to hospital's West campus ED on 3/31/24 (sometime before 5:00 PM) with a complaint of back pain and the patient was also 7 months pregnant. The patient explained the patient went to an urgent care clinic to be seen initially. The provider at the clinic reportedly told the patient that the patient could be in labor and to go to the hospital's West campus to be seen. Patient #16 arrived at the ED, the patient approached the receptionist. The receptionist retrieved a wheelchair for the patient to sit and the receptionist told the patient they would call up to the OB department. The receptionist placed a call, spoke with someone, and then advised the patient that OB staff were in the middle of a delivery and it would be a few minutes for someone to come retrieve the patient. Patient #16 waited in the ED lobby with family. The receptionist informed the patient that staff called from the OB floor and advised the patient to go to the hospital's downtown campus (approximately 20 minute drive) to be seen. When the patient arrived at the hospital's downtown campus, the ED staff reported the patient could have been seen at the West campus ED and they were not sure of the reason why the patient was sent downtown.

3. Review of the West campus hospital ED and OB logs, dated 3/31/24, revealed Patient #16 was not identified in the logs.

4. On 5/7/24 at 1:30 PM, during an interview, Staff L Patient Access Associate (PAA-ED registration staff at the West campus) recalled Patient #16 presented to the ED triage desk stating they had back pain and needed to be seen. Staff L PAA explained Patient #16 reported being sent to the ED by the patient's provider. Staff called upstairs to the OB department inquiring about the patient needing to be seen. OB staff reported they were in the middle of a delivery and it would be a few minutes. Staff L PAA reported, a few minutes later, staff from the OB department called back to the ED triage desk and told staff to send Patient #16 to the main (downtown) campus. Staff L PAA explained that patients that OB staff registered patients that went to the OB department. Hospital staff do not register OB patients in the ED area unless they were treated in the ED for unrelated OB issues.

5. On 5/7/24 at 4:00 PM, during an interview, Staff K ED RN (triage nurse at the West campus) reported Patient #16 presented to registration and asked to be seen. Registration staff came to the door and asked Staff K what they should do with the OB patient. Staff K ED Triage Nurse advised registration staff to call the OB department if the patient was more than 20 weeks pregnant. Staff K ED Triage Nurse reported they heard registration staff place the call the OB Department. Staff K ED Triage Nurse explained when they later asked registration staff what happened to Patient #16, registration staff reported that OB staff called down and told the patient to go to Methodist downtown. Staff K ED Triage Nurse reported that if an OB patient needed to be seen upstairs in the OB department, the OB staff registered the patient in their log.

Based on medical record review, hospital policy review, patient interview, family interview and staff interviews, the Acute Care Hospital's administrative staff failed to ensure the Emergency Department (ED) staff provided, within the hospital's capabilities, a timely and appropriate medical screening examination (MSE) to 3 of 21 sampled patients (Patient #16, #17 and #37) seeking emergency medical treatment at one of the hospital's 3 campuses.

Failure to provide an appropriate and timely MSE to all patients presenting to the ED seeking medical care placed patients at risk for an undetected emergency medical condition.

Hospital Capabilities: The acute care hospital had three campuses (Iowa Methodist "Downtown," Methodist West, and Iowa Lutheran). Between the three campuses, the hospital had a Dedicated ED (DED) on each campus. The Methodist West campus had 15 emergency department exam rooms. The Iowa Methodist "Downtown" campus had 26 emergency department exams rooms, plus 12 additional pediatric emergency department exam rooms in a separate emergency department area. The Methodist West and Iowa Lutheran campuses had Level III Trauma designations, while Iowa Methodist Medical Center "Downtown" had a Level I Trauma center designation. The Iowa Methodist Medical Center "Downtown" Emergency Department had a dedicated pediatrics DED (and associated children's hospital) known as "Blank Children's Hospital (under the same CCN)." Each DED was staffed with at least a physician as the provider on duty, along with a mix of additional physician assistants and nurse practitioners providing coverage to each department.

The hospital, across all campuses, had 24 hour on-call, specialists and surgeons, and imagery testing (CT, MRI scans).

The Methodist West location offered OB services and the Iowa Methodist "Downtown" Blank hospital offered Level IV OB and Neonatal nursery level care. The Iowa Methodist "Downtown" campus had 45 Labor & Delivery rooms. The Methodist West campus had 24 obstetrical rooms.

Findings include:

1. Review of policy, "Transfer and Emergency Examination-EMTALA," last revised 9/21, revealed in part:

a. " ...Medical Screening Examination-The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an individual who has come to the Dedicated Emergency Department, has or does not have an Emergency Medical Condition ..."

b " ...Medical Screening Procedure- Initial Assessment When an individual requests examination or treatment, the patient registrar will notify an Emergency Department nurse of the individual's arrival and will inform such nurse of the individual's complaints and symptoms, as well as any observations made by the registrar. Individuals who arrive at Unity Point Hospital Des Moines (UPHDM) by either ground or air ambulance will be examined by a nurse upon arrival ...."

c. " ...Medical Screening Procedure-Examination -The individual shall be examined according to Emergency Department protocol and procedures. The Medical Screening Examination provided shall be within the Capability and Capacity of the UPHDM hospital's Emergency Department (including ancillary services routinely available to the emergency department). The Medical Screening Examination shall be recorded in the individual's medical record ...."

2. Patient #17 medical record review and family interview revealed the following:

a. On 6/3/24 at 1:00 PM, during an interview, a family member reported the patient complained of weakness and an inability to lift themselves out of the bathtub. Family called 911, and emergency medical services (EMS) took the patient to the hospital's downtown campus ED. Family reported they arrived at the hospital at 1:00 PM; they found the patient sitting unaccompanied, in a wheelchair in the ED waiting room. Per family interview, Patient #17 appeared lethargic, a little sleepy, slightly disoriented, sitting hunched over and the patient's head was down. The family member recalled the patient told them that the patient's left side was losing more sensation 15-20 minutes after the family member's arrival at the ED. The family reported that there were approximately 25-35 additional people in the ED waiting area. A hospital staff (Patient Care Technician-PCT) came out and took the patients' blood pressure two or three times while the patient was in the ED waiting room. The family member reported that the first time the PCT took the patient's blood pressure, the patient told the PCT that they could not feel their left side. The PCT stated she would mention the concern to staff. The family member reported "a gal" came out to take the patient to get some blood work completed between 3-5 PM. The patient told the female staff person that got the patient for blood work about not being able to feel the left side. The PCT came and took VS again and patient #17 again stated that the patient could not feel the left side and felt worse. The family member reported that at about 7:00 PM that night, hospital staff wheeled the patient into an exam room. Fairly soon after the patient got into the exam room, hospital staff took the patient for a CT scan.

b. On 1/8/24 at 11:57 AM, Patient #17 arrived at the hospital ED by ambulance emergency medical services (EMS) with a complaint of syncope (brief loss of consciousness). The EMS trip report indicated the patient had the following abnormally high blood pressures (BPs) : 176 (systolic)/72 (diastolic) at 11:22 AM; 167/86 at 11:30 AM; 203/148 at 11:40 AM; 185/149 at 11:47 AM; and 169/64 at 11:53 AM.

c. On 1/8/2024 at 12:17 PM, Staff W ED RN initiated triage. At 12:19 PM, Staff W ED RN documented, vital signs (VS) as follows: temperature 36.4 degrees Celsius (C), 97.5 degrees Fahrenheit (F); heart rate 67 beats per minute (bmp); respiratory rate (RR) 16 breaths per minute; oxygen saturation (O2 Sat) 98% on room air; blood pressure (BP) 138/109 millimeters of mercury (mmHg). Patient #17 denied any pain.

d. On 1/8/24 at 12:19 PM Staff W ED RN documented Patient #17 reported to have been sick for the past four weeks and today was too weak to get out of bed to go to a doctor appointment. Patient #17 reported being unable to eat much, or at all, and thought they lost quite a bit of weight.

e. On 1/8/2024 at 4:03 PM Staff S ED PCT documented the following VS: temperature 36.3 degrees C, 97.4 degrees F; HR 70 pm; O2 sat 99% on room air; BP 152/80.

f. On 1/8/2024 at 6:25 PM, Staff S ED PCT documented the following VS: temperature 36.3 degrees C, 97.4 degrees F; HR 70; RR 16; O2 sat 97% on room air; BP 180/106 mmHg. Staff S ED PCT noted she notified the triage nurse of Patient #17's elevated BP reading, 180/106.

g. On 1/8/24 at 6:54 PM, Staff Y ED RN documented they placed Patient #17 in a fast track (FT) room. ED staff ordered labs including complete blood count (CBC) with differential, complete metabolic panel (CMP), urinalysis (UA), respiratory film array panel and Covid testing.

h. On 1/8/24 at 6:56 PM, Staff Y ED RN documented a neurological assessment and determined the patient was displaying stroke-like symptoms including arm drifting, slurred or inappropriate words; talking like the patient's mouth was full of food, left hand grip weak, left foot dorsiflexion and plantar flexion weak and decreased left lower extremity sensation (symptoms indicative of a stroke). Staff Y ED RN documented the patient failed the stroke screening assessment and the nurse ordered the patient to be nothing by mouth (NPO) and ordered a bed-side swallow study.

i. On 1/8/2024 at 7:00 PM, Staff Y ED RN documented vital signs which included an elevated blood pressure of 182/98.

j. On 1/8/2024 at 7:20 PM, Staff T ED ARNP and documented that around 11:00 AM today (1/8/24) the patient noticed weakness in left arm and leg. The patient's family member said the patient was quite a bit worse than over the past several weeks. The patient stated the patient could not make a fist or lift the patient's left leg; the left leg felt heavy.

k. On 1/8/24 at 7:40 PM, Staff T ED ARNP completed the stroke scale and placed orders for chest x ray and computed tomography (CT) of the head with contrast, stroke alert only, CT angiography of the head.

l. At 7:42 PM Staff Y ED RN documented Stroke Activation by Staff T ED ARNP.

m. On 1/8/24 at 7:51 PM, hospital staff completed the CT of head and CT angiography.

n. On 1/9/24 at 7:57 AM, Staff X Hospitalist documented Patient #17's history (hx) of diabetes mellitus type 2 (DM 2), obstructive sleep apnea (OSA), gastroesophageal reflux disorder (GERD), hypertension (HTN), cerebral vascular accident (CVA), anxiety/depression, benign prostatic hypertrophy (BPH) and noted Patient #17 admission on 1/8/24 with bilateral strokes. They further noted Patient #17 presented following four weeks of weakness with acute worsening of left-sided weakness. A head computed tomography (CT) was unremarkable. Computed tomography angiography (CTA) of the head and neck showed no large vessel occlusion (LVO) but noted multifocal areas of mild to moderate arterial narrowing of the posterior circulation. A magnetic resonance imaging (MRI) showed infarct (stroke) of the right pons, left posterior limb of the internal capsule/left anterior thalamus, left temporal periventricular parenchyma. Patient was on Plavix prior to arrival; Aspirin was added to the regimen.

o. On 1/9/24 at 3:06 PM, Staff HH Neurologist documented Patient # 17's history of a right corona radiata ischemic stroke, memory problems, under control diabetes, hypertension and hyperlipidemia. Staff HH Neurologist noted Patient #17 presented to the ED for evaluation of left-sided weakness. The patient's last well known normal was 11:00 AM on 1/8/2024. Staff HH Neurologist documented Patient #17 was out of the window for thrombolytics. A CTA (scan) of the head and neck showed no evidence of LVO (large vessel occlusion). An MRI showed Patient #17's brain demonstrated acute to subacute infarct in right pons, left posterior limb of internal capsule/anterior thalamus and left temporal periventricular parenchymal. Staff HH Neurologist noted Patient #17 scored 10 on the National Institute of Health Stroke Scale (NIHSS)(subtle left facial droop, left arm and leg drift, sensory changes). Patient #17 took Plavix prior to admission. Staff HH Neurologist, ordered the following:
- P2Y12 platelet function assay and Transesophageal Echocardiogram (TEE) for further evaluation
- Continued dual antiplatelet therapy (DAPT) for the time
- Continued Atrovastatin (medication to lower blood cholesterol levels) 80 mg orally nightly
- Follow-up P2Y12 results
- Allowed permissive hypertension with goal LDL (type of blood cholesterol level)<70 and HbA1c (type of blood test related to blood sugar levels)<7
- Physical therapy (PT), occupational therapy (OT) and speech therapy (ST)
-Stroke education
He further noted Patient #17 likely needed a 30-day cardiac event monitor at discharge and follow up with Neurology would occur the next day.

3. During an interview, on 5/8/24 at 2:30 PM, Staff W ED RN explained the different levels of triage, noting patients were given a triage level 1-5, 1 being the highest acuity level and 5 being minor. Staff W/ED RN, recalled triaging Patient #17 and determined an acuity level 3 due to weakness. Patient #17 was returned to the waiting room following triage. ED staff should have checked Patient #17's VS every two hours based on the identified acuity level 3 per Staff W.

4. During an interview, on 5/8/24 at 9:30 AM, Staff S ED PCT explained patients were assigned an acuity level following triage. Patient's assigned a level 3 acuity and sent to the waiting room required vitals completed every two hours. Staff S/ED PCT, further explained if the ED was busy with 30 or more patients, staff prioritized by acuity level and completed higher levels first. If extremely busy, staff should call back to the shift lead to request help to ensure everyone received appropriate care and vital signs. If a patient had a different or additional complaint VS should be taken and reported to the triage nurse.

A review of daily patient census and staffing schedule revealed the total patient census for the ED on 1/8/24 was 118 patients. From 11:00 AM until 4:00 PM, while Patient #17 waited in the ED, 20 patients arrived.

Review of Patient #17's medical record, dated 1/8/24, revealed an approximately 3.5 hour void in documentation of VS on Patient #17.

5. During an interview, on 5/14/24 at 10:00 AM, Staff Y ED RN recalled staff brought Patient #17 to a Fast Track (FT) bed. Staff Y reported they noted changes with Patient #17's VS, specifically elevated BP and neurological assessment for stroke symptoms. Staff Y ED PCT informed Staff T ED ARNP of the concerns. Staff Y ED RN, recalled they took Patient #17 to obtain a CT, and the CT was positive. Staff T ED ARNP, then called the stroke alert. Patient #17 was outside of the window to receive Thrombolytics (TPA) therapy. Staff Y ED RN, stated "Patient #17 then moved to a room for higher acuity level of care."

6. During an interview, on 5/7/24 at 11:30 AM, Staff T ED ARNP recalled examining Patient #17 in a FT bed and asking Staff U ED Physician, to further evaluate the patient. Patient #17 was moved to a room for higher acuity level of care in the ED. Staff T ED ARNP and Staff U ED Physician, called the stroke alert at 7:42 PM, and Staff U ED Physician, became the primary physician, implementing stroke protocol. Patient #17's care was turned over to internal medicine, as the patient was admitted to the hospital.

7. During an interview, on 5/7/24 at 1:05 PM, Staff U ED Physician recalled being asked to verify findings on Patient #17 and speak with the patient and family. Staff U ED Physician became involved in Patient #17's care and moved the patient into a room around 7:00 PM, due to his higher acuity level.

8. During an interview, on 5/8/24 at 8:10 AM, Staff X Physician of Internal Medicine recalled they saw patient #17 the second day, following Staff P admitted the patient. They explained standing orders for a typical stroke protocol included imaging, management of BP, platelet therapy, and anticoagulation therapy. Patient #17 had Bilateral strokes during inpatient admission, while waiting for rehab therapy recommendations and admission. A bed request was put in at the time of admission, but they could not recall if the patient had left the ED yet. Staff X Physician, could not confirm the patient boarded in the ED while waiting for a bed to become available in therapy and a rehab admission.

9. During an interview, 5/14/24 at 3:00 PM, Staff HH Neurologist recalled they saw Patient #17 and, as a supervising physician, also oversaw resident notes. Staff HH Neurologist, further recalled confusion amongst the staff and physicians regarding exact time of onset Patient #17's symptoms of dizziness and confusion. Patient #17 arrived at the ED reporting symptoms had been on-going for days to weeks prior. Staff HH Neurologist, explained TPA therapy should be initiated within a 4.5 hours' time frame, unless the exact time of symptom onset was known. Due to ongoing weakness and not knowing the actual onset of symptoms, the decision to initiate TPA therapy was difficult. The patient's report of four weeks of symptoms put Patient #17 outside the TPA therapy window.

10. Review of Policy "Triage of OB Patient in the Emergency Department," last revised 5/23 revealed in part:
a. ..."Policy Statement: Obstetric patients presenting to the main Emergency Department (ED) will be screened and referred or treated with the appropriate interventions as early as possible ..."
b. > 20 Weeks gestation with OB related chief complaint:
c. OB related chief complaints may include: Abdominal cramps/pain, contractions, vaginal bleeding, leaking fluid, decreased fetal movement, headache with hypertension, epigastric pain, hypertension (SBP > 140 and/or DBP > 90).
d. Patients will be triaged to labor and delivery at Methodist West (MWH) or the Obstetric Emergency Department (OBED) at Iowa Methodist Medical Center (IMMC).
c. The main ED will notify the OB charge RN at MWH or the RN in the OBED at IMMC and provide patient name, care provider's name (if available), due date/weeks' gestation, and chief complaint.
d.. If a patient presents to the Iowa Lutheran Hospital (ILH) ED the OB stat RN and their primary OB provider should be notified to determine appropriate plan of care/disposition.
e. If the patient does not have an established OB provider, and presents to the ILH ED, the East Des Moines Family Medicine resident should be consulted ..."

11. Patient #16 medical record review, patient and staff interviews revealed the following:

a. On 5/8/24 at 9:00 AM, during an interview, Patient #16 reported the patient went to hospital's West campus ED on 3/31/24 (sometime before 5:00 PM) with a complaint of back pain and the patient was also 7 months pregnant. The patient explained the patient went to an urgent care clinic to be seen initially. The provider at the clinic reportedly told the patient that the patient could be in labor and to go to the hospital's West campus to be seen. Patient #16 arrived at the ED, the patient approached the receptionist. The receptionist retrieved a wheelchair for the patient to sit and the receptionist told the patient they would call up to the OB department. The receptionist placed a call, spoke with someone, and then advised the patient that OB staff were in the middle of a delivery and it would be a few minutes for someone to come retrieve the patient. Patient #16 waited in the ED lobby with family. The receptionist informed the patient that staff called from the OB floor and advised the patient to go to the hospital's downtown campus (approximately 20 minute drive) to be seen. When the patient arrived at the hospital's downtown campus, the ED staff reported the patient could have been seen at the West campus ED and they were not sure of the reason why the patient was sent downtown.

b. On 5/7/24 at 1:30 PM, during an interview, Staff L Patient Access Associate (PAA-ED registration staff at the West campus) recalled Patient #16 presented to the ED triage desk stating they had back pain and needed to be seen. Staff L PAA explained Patient #16 reported being sent to the ED by the patient's provider. Staff called upstairs to the OB department inquiring about the patient needing to be seen. OB staff reported they were in the middle of a delivery and it would be a few minutes. Staff L PAA reported, a few minutes later, staff from the OB department called back to the ED triage desk and told staff to send Patient #16 to the main (downtown) campus. Staff L PAA explained that patients that OB staff registered patients that went to the OB department. Hospital staff do not register OB patients in the ED area unless they were treated in the ED for unrelated OB issues.

c. On 3/31/24 5:00 PM- Patient #16 arrived at Iowa Methodist Downtown, ED, by private car and went directly to the OB Department.

d. On 3/31/24 6:00 PM, Staff N, Certified Nurse Midwife (CNM) ARNP, documented the following assessment of Patient #16: "...28 weeks pregnant with estimated delivery date of 6/23/24. History of polycystic ovarian syndrome, postpartum depression, migraines, IVF (in vitro fertilization). Assessed the patient in OB ED Triage... (Patient #16) presented today for evaluation of back pain. Pain started worsening last week, did not improve with chiropractor, stretching or yoga. "(Patient #16) has a hx (history) of back pain due to injury at the age of 13 but today she is having a hard time with movement, rating pain 8/10. Pain is across the lower back and radiates over to the right side. Denies any obstetrical complaints. The patient states that the baby moves as usual. She denies contractions. Denies vaginal bleeding or loss of fluid. No dysuria (difficulty with urination). BP 121/74 (within normal limits)."

e. On 3/31/24 7:32 PM, documentation noted, Staff O RN provided discharge education to Patient #16.

f. On 3/31/24 7:32 PM Staff N CNM, ARNP- documented "Discharge Note- Treatment- Fetal Non-Stress Test obtained- reactive (Fetal Heart Rate 125 bpm, no uterine contractions, no accelerations, no decelerations), UA within normal limits, Flexeril (muscle relaxant medication) given, 2 Norco (pain medication) given. Plan- Pt (patient) was given an additional Norco Rx (prescription) to take tonight, physical therapy consulted and education given to follow up, the patient is to call the OB office in the morning, stay hydrated, rest, and use a heat pack as needed..."

12. Review of Patient #37, a pediatric patient, medical record revealed the following:

a. On 5/1/24 at 9:30 PM, Staff CC ED RN and Staff BB ED RN documented the following: "Arrive to Methodist West ED via private vehicle...chief complaint post-op problem (Patient #37) underwent a tonsillectomy and adenoidectomy (T&A) on 4/22/24 by pediatric Ear Nose and Throat (ENT) physician...Patient woke up covered in blood on 4/30 (4/30/24) and the ENT physician told them if the bleeding stops that is okay, but if reoccurred to come to the ED. Patient woke up again tonight (5/1/24) covered in blood. Bleeding from the throat has stopped since the patient arrived in the ED. Family reports no new spitting up of blood."

b. On 5/1/24 at 9:46 PM, Staff CC ED RN and Staff BB ED RN documented a triage assessment on Patient #37 as follows: vital signs (VS) were heart rate (HR) 142 beats per minute (bpm- elevated), respirations 22 per minute, BP- 99/58, oxygen saturation level of 100%, wt (weight)-25 lbs (pounds), temp 98.6 (degrees Fahrenheit).

c. On 5/1/24 10:56 PM, ED staff documented, "Family signed Refusal of Medical Screening Exam; "too long of wait for treatment".

d. On 5/8/24 at 4:00 PM, during an interview, a family member reported they asked a person at the front desk how long of a wait it would be, and the front desk told the family member there was a 3 to 4 hour wait for a bed (exam room). The family member asked a nurse if they should take the patient to another hospital, as they had been told by the ENT surgeon that the patient needed to be seen immediately. The nurse (identified as Staff BB ED Triage Nurse) informed the family that they could not tell the family member to take the patient to another hospital, encouraged them to stay, but expressed her understanding that a 3 to 4 hour wait was too long for a child. The family member confirmed they signed a form to refuse treatment.

e. On 5/1/24 11:26 PM Patient #37 arrived at a second hospital ED, Hospital SS via private vehicle.

f. On 5/1/24 at 11:30 PM, Staff RR, ED RN, Triage Note-"(Patient #37) had tonsillectomy/adenoidectomy and tubes placed 4/22/24 with pediatric ENT Staff PP. Last night, the patient had a little bleeding but stopped, tonight the patient had another episode of bleeding that was worse."

g. On 5/2/24 at 12:48 AM, Staff QQ ED Physician documented the following: "(Patient #37) presented after tonsils and adenoids removed on 4/22/24, late last night (Patient #37) had a small amount of post tonsillar bleeding, resolved spontaneously, seems to be doing fine, tolerating P.O. (by mouth) today, took Ibuprofen, however this evening woke after another episode of bleeding, blood in the naris (nose), large blood clot was spit out of the mouth, however bleeding is now stopped, recommended to go to the emergency department by Ear Nose and Throat (ENT) for evaluation and potentially IV fluids. Previous treatment: outpatient surgery. Post op course: Fluctuating. Incision complaints: moderate Bleeding. Risk factors consist of age. Therapy today: none. MSE completed."

PLAN: "(Patient #37) with post tonsillar bleed, appears not to be bleeding currently, will keep an eye on (Patient #37) in the ED, patient appears pale, recommendation from ENT to get IV(intravenous) fluids, will place IV, do screening blood work (complete metabolic profile (CMP), complete blood count (CBC) with differential) and give Dextrose 5% and Sodium Chloride 0.9% with Potassium Chloride 20 milliequivalents per liter (mEq/L) per 1000 mL(milliliters)- 250 cc(cubic centimeters) bolus."

h. On 5/2/24 4:15 AM Staff QQ ED Physician documented Physician Notes as follows: "Patient with no further bleeding in the emergency department however is profoundly anemic with hemoglobin 7.3 (normal 11.5-13.5; indicative of anemia or low blood volume), discussed with ENT and will admit to PEDS (pediatric) Hospitalist, type and screen pending, ENT will see in the a.m. and reevaluate."

i. On 5/2/24 at 4:28 AM, Staff PP ENT documented the following progress notes: "(Patient #37) was admitted earlier this morning with a postoperative bleed. We are evaluating Patient #37 today to assess how they have done over the course of the day. Patient #37 has been doing quite well and has had no further bleeding. There have been no concerns regarding their airway since admission. I spoke to the family a couple of nights ago and noted that Patient #37 had a brief bleed at that time, but we had followed up that morning and they had no further issues. It was only in the middle of the night that they began bleeding again at which time the family brought them in. Again, the last 12 hours have been uneventful. Patient 37 has had no further bleeding or concerns. Patient #37 is feeding and doing quite well. We will monitor them overnight and see how Patient #37 does. If there is no further bleeding tomorrow depending on how they are feeling and the family is comfortable, we will start considering discharge home. Order for Pediatric Admission placed."

13. During an interview, on 5/9/24 at 8:10 AM, Staff BB ED RN (West campus ED triage nurse), recalled the patient. Staff BB reported they recalled that "it was a very busy evening" and they believed "the wait times were getting to be long". Staff BB reported the patient had a little bit of blood on their pajamas or in their hair. Family said the bleeding had stopped. Staff BB did not remember seeing the patient bleeding. The family never asked for a tissue or notified staff that the bleeding had started again. Staff BB explained that if the patient's condition worsened, she would have called the charge nurse to direct Staff BB to get the patient seen immediately by a provider. Staff BB, did ask the charge nurse what acuity level the patient should be, and Staff BB reported the charge nurse told her a Level 3. Level 3 would be brought back before a Level 4 patient. Since the waiting room was busy there was a PCT rounding for the patient's vitals. The PCT documents those vitals in the patients' electronic records. When asked if they explained to the family that the patient had a possible EMC and should stay and let the patient to be seen, Staff BB responded that they encouraged them to stay to see a provider. When the family asked how long it would be before the patient could be seen, Staff BB reported they told the family that wait times were always changing and they could not provide that information. Staff BB reported they explained the Refusal of Medical Treatment form and had a family member sign it.

14. During an interview, on 5/9/24 at 8:40 AM, Staff CC ED RN (West Campus ED Triage nurse), recalled Patient #37 and recalled that night (5/1/24) being horribly busy. Staff CC ED RN explained there were a lot of patients boarding (in the ED) and no beds were opening up. Staff CC ED RN recalled the family came up to the desk voicing their frustration, because their provider told them to rush the child in and then they had to wait for their child to be seen. The family said they were going to take the patient to a different ED. Staff CC ED RN reported that Staff BB explained that Patient #37 needed to be seen, but if they were leaving they could sign the Refusal of Medical Exam form. The family did sign the form. Staff CC ED RN did not recall staff stating a time frame for the wait to be seen by a provider. Staff usually state that they cannot give an estimate of the time frame, and patient were taken into the ED rooms according to their acuity level.
The Hospital failed to provide Patient #16, #17 and #37 with a timely and appropriate MSE. Patient #16, a pregnant patient, presented to the ED on 3/31/24 with back pain. Patient #16 was sent to another ED location on the hospital's campus without a triage and screening exam. Patient #17 presented to the ED on 11/24/2023 with weakness and stroke symptoms. Hospital ED staff sent Patient #17 to the ED waiting area while the patient's symptoms got increasingly worse. Patient #17 remained in the ED waiting area for 7 hours, and did not receive an examination by a healthcare provider until more than 7 hours after arriving at the ED. Patient #37, a pediatric patient, presented to the ED with family on 5/1/24 with post surgical bleeding. The family left with Patient #37 without being seen by a provider due to long wait times and fear for their child's imminent health.

Based on medical record review, hospital policy review, family and staff interviews, the Hospital's administrative staff failed to ensure emergency department (ED) staff provided appropriate and timely stabilizing treatment for 2 of 21 sample patients (Patient #17 and Patient #37) that had an emergency medical condition (EMC) and presented to the ED seeking medical care from 12/1/23 to 5/1/24.

Failure to provide all patients with the appropriate and timely stabilizing treatment placed patients at risk for a worsening emergency medical condition and at a potential risk for death.

Findings include:

1. Review of policy, "Transfer and Emergency Examination-EMTALA," last revised 9/21, revealed in part:

. " ... Stabilize-To provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from, or occur during, the transfer of the individual from a facility; or with respect to a woman in Labor, to deliver (including the placenta)" ...
"...Medical Screening Examination in Emergency Department ..."

2. Patient #17 medical record review and family interview revealed the following:

a. On 6/3/24 at 1:00 PM, during an interview, a family member reported the patient complained of weakness and an inability to lift themselves out of the bathtub. Family called 911, and emergency medical services (EMS) took the patient to the hospital's downtown campus ED. Family reported they arrived at the hospital at 1:00 PM; they found the patient sitting unaccompanied, in a wheelchair in the ED waiting room. Per family interview, Patient #17 appeared lethargic, a little sleepy, slightly disoriented, sitting hunched over and the patient's head was down. The family member recalled the patient told them that the patient's left side was losing more sensation 15-20 minutes after the family member's arrival at the ED. The family reported that there were approximately 25-35 additional people in the ED waiting area. A hospital staff (Patient Care Technician-PCT) came out and took the patients' blood pressure two or three times while the patient was in the ED waiting room. The family member reported that the first time the PCT took the patient's blood pressure, the patient told the PCT that they could not feel their left side. The PCT stated she would mention the concern to staff. The family member reported "a gal" came out to take the patient to get some blood work completed between 3-5 PM. The patient told the female staff person that got the patient for blood work about not being able to feel the left side. The PCT came and took VS again and patient #17 again stated that the patient could not feel the left side and felt worse. The family member reported that at about 7:00 PM that night, hospital staff wheeled the patient into an exam room. Fairly soon after the patient got into the exam room, hospital staff took the patient for a CT scan.

b. On 1/8/24 at 11:57 AM, Patient #17 arrived at the hospital ED by ambulance emergency medical services (EMS) with a complaint of syncope (brief loss of consciousness). The EMS trip report indicated the patient had the following abnormally high blood pressures (BPs) : 176 (systolic)/72 (diastolic) at 11:22 AM; 167/86 at 11:30 AM; 203/148 at 11:40 AM; 185/149 at 11:47 AM; and 169/64 at 11:53 AM.

c. On 1/8/2024 at 12:17 PM, Staff W ED RN initiated triage. At 12:19 PM, Staff W ED RN documented, vital signs (VS) as follows: temperature 36.4 degrees Celsius (C), 97.5 degrees Fahrenheit (F); heart rate 67 beats per minute (bmp); respiratory rate (RR) 16 breaths per minute; oxygen saturation (O2 Sat) 98% on room air; blood pressure (BP) 138/109 millimeters of mercury (mmHg). Patient #17 denied any pain.

d. On 1/8/24 at 12:19 PM Staff W ED RN documented Patient #17 reported to have been sick for the past four weeks and today was too weak to get out of bed to go to a doctor appointment. Patient #17 reported being unable to eat much, or at all, and thought they lost quite a bit of weight.

e. On 1/8/2024 at 4:03 PM Staff S ED PCT documented the following VS: temperature 36.3 degrees C, 97.4 degrees F; HR 70 pm; O2 sat 99% on room air; BP 152/80.

f. On 1/8/2024 at 6:25 PM, Staff S ED PCT documented the following VS: temperature 36.3 degrees C, 97.4 degrees F; HR 70; RR 16; O2 sat 97% on room air; BP 180/106 mmHg. Staff S ED PCT noted she notified the triage nurse of Patient #17's elevated BP reading, 180/106.

g. On 1/8/24 at 6:54 PM, Staff Y ED RN documented they placed Patient #17 in a fast track (FT) room. ED staff ordered labs including complete blood count (CBC) with differential, complete metabolic panel (CMP), urinalysis (UA), respiratory film array panel and Covid testing.

h. On 1/8/24 at 6:56 PM, Staff Y ED RN documented a neurological assessment and determined the patient was displaying stroke-like symptoms including arm drifting, slurred or inappropriate words; talking like the patient's mouth was full of food, left hand grip weak, left foot dorsiflexion and plantar flexion weak and decreased left lower extremity sensation (symptoms indicative of a stroke). Staff Y ED RN documented the patient failed the stroke screening assessment and the nurse ordered the patient to be nothing by mouth (NPO) and ordered a bed-side swallow study.

i. On 1/8/2024 at 7:00 PM, Staff Y ED RN documented vital signs which included an elevated blood pressure of 182/98.

j. On 1/8/2024 at 7:20 PM, Staff T ED ARNP and documented that around 11:00 AM today (1/8/24) the patient noticed weakness in left arm and leg. The patient's family member said the patient was quite a bit worse than over the past several weeks. The patient stated the patient could not make a fist or lift the patient's left leg; the left leg felt heavy.

k. On 1/8/24 at 7:40 PM, Staff T ED ARNP completed the stroke scale and placed orders for chest x ray and computed tomography (CT) of the head with contrast, stroke alert only, CT angiography of the head.

l. At 7:42 PM Staff Y ED RN documented Stroke Activation by Staff T ED ARNP.

m. On 1/8/24 at 7:51 PM, hospital staff completed the CT of head and CT angiography.

n. On 1/9/24 at 7:57 AM, Staff X Hospitalist documented Patient #17's history (hx) of diabetes mellitus type 2 (DM 2), obstructive sleep apnea (OSA), gastroesophageal reflux disorder (GERD), hypertension (HTN), cerebral vascular accident (CVA), anxiety/depression, benign prostatic hypertrophy (BPH) and noted Patient #17 admission on 1/8/24 with bilateral strokes. They further noted Patient #17 presented following four weeks of weakness with acute worsening of left-sided weakness. A head computed tomography (CT) was unremarkable. Computed tomography angiography (CTA) of the head and neck showed no large vessel occlusion (LVO) but noted multifocal areas of mild to moderate arterial narrowing of the posterior circulation. A magnetic resonance imaging (MRI) showed infarct (stroke) of the right pons, left posterior limb of the internal capsule/left anterior thalamus, left temporal periventricular parenchyma. Patient was on Plavix prior to arrival; Aspirin was added to the regimen.

o. On 1/9/24 at 3:06 PM, Staff HH Neurologist documented Patient # 17's history of a right corona radiata ischemic stroke, memory problems, under control diabetes, hypertension and hyperlipidemia. Staff HH Neurologist noted Patient #17 presented to the ED for evaluation of left-sided weakness. The patient's last well known normal was 11:00 AM on 1/8/2024. Staff HH Neurologist documented Patient #17 was out of the window for thrombolytics. A CTA (scan) of the head and neck showed no evidence of LVO (large vessel occlusion). An MRI showed Patient #17's brain demonstrated acute to subacute infarct in right pons, left posterior limb of internal capsule/anterior thalamus and left temporal periventricular parenchymal. Staff HH Neurologist noted Patient #17 scored 10 on the National Institute of Health Stroke Scale (NIHSS)(subtle left facial droop, left arm and leg drift, sensory changes). Patient #17 took Plavix prior to admission. Staff HH Neurologist, ordered the following:
- P2Y12 platelet function assay and Transesophageal Echocardiogram (TEE) for further evaluation
- Continued dual antiplatelet therapy (DAPT) for the time
- Continued Atrovastatin (medication to lower blood cholesterol levels) 80 mg orally nightly
- Follow-up P2Y12 results
- Allowed permissive hypertension with goal LDL (type of blood cholesterol level)<70 and HbA1c (type of blood test related to blood sugar levels)<7
- Physical therapy (PT), occupational therapy (OT) and speech therapy (ST)
-Stroke education
He further noted Patient #17 likely needed a 30-day cardiac event monitor at discharge and follow up with Neurology would occur the next day.

3. During an interview, on 5/8/24 at 2:30 PM, Staff W ED RN explained the different levels of triage, noting patients were given a triage level 1-5, 1 being the highest acuity level and 5 being minor. Staff W/ED RN, recalled triaging Patient #17 and determined an acuity level 3 due to weakness. Patient #17 was returned to the waiting room following triage. ED staff should have checked Patient #17's VS every two hours based on the identified acuity level 3 per Staff W.

4. During an interview, on 5/8/24 at 9:30 AM, Staff S ED PCT explained patients were assigned an acuity level following triage. Patient's assigned a level 3 acuity and sent to the waiting room required vitals completed every two hours. Staff S/ED PCT, further explained if the ED was busy with 30 or more patients, staff prioritized by acuity level and completed higher levels first. If extremely busy, staff should call back to the shift lead to request help to ensure everyone received appropriate care and vital signs. If a patient had a different or additional complaint VS should be taken and reported to the triage nurse.

5. A review of daily patient census and staffing schedule revealed the total patient census for the ED on 1/8/24 was 118 patients. From 11:00 AM until 4:00 PM, while Patient #17 waited in the ED, 20 patients arrived.

Review of Patient #17's medical record, dated 1/8/24, revealed an approximately 3.5 hour void in documentation of VS on Patient #17.

6. During an interview, on 5/14/24 at 10:00 AM, Staff Y ED RN recalled staff brought Patient #17 to a Fast Track (FT) bed. Staff Y reported they noted changes with Patient #17's VS, specifically elevated BP and neurological assessment for stroke symptoms. Staff Y ED PCT informed Staff T ED ARNP of the concerns. Staff Y ED RN, recalled they took Patient #17 to obtain a CT, and the CT was positive. Staff T ED ARNP, then called the stroke alert. Patient #17 was outside of the window to receive Thrombolytics (TPA) therapy. Staff Y ED RN, stated "Patient #17 then moved to a room for higher acuity level of care."

7. During an interview, on 5/7/24 at 11:30 AM, Staff T ED ARNP recalled examining Patient #17 in a FT bed and asking Staff U ED Physician, to further evaluate the patient. Patient #17 was moved to a room for higher acuity level of care in the ED. Staff T ED ARNP and Staff U ED Physician, called the stroke alert at 7:42 PM, and Staff U ED Physician, became the primary physician, implementing stroke protocol. Patient #17's care was turned over to internal medicine, as the patient was admitted to the hospital.

8. During an interview, on 5/7/24 at 1:05 PM, Staff U ED Physician recalled being asked to verify findings on Patient #17 and speak with the patient and family. Staff U ED Physician became involved in Patient #17's care and moved the patient into a room around 7:00 PM, due to his higher acuity level.

9. During an interview, on 5/8/24 at 8:10 AM, Staff X Physician of Internal Medicine recalled they saw patient #17 the second day, following Staff P admitted the patient. They explained standing orders for a typical stroke protocol included imaging, management of BP, platelet therapy, and anticoagulation therapy. Patient #17 had Bilateral strokes during inpatient admission, while waiting for rehab therapy recommendations and admission. A bed request was put in at the time of admission, but they could not recall if the patient had left the ED yet. Staff X Physician, could not confirm the patient boarded in the ED while waiting for a bed to become available in therapy and a rehab admission.

10. During an interview, 5/14/24 at 3:00 PM, Staff HH Neurologist recalled they saw Patient #17 and, as a supervising physician, also oversaw resident notes. Staff HH Neurologist, further recalled confusion amongst the staff and physicians regarding exact time of onset Patient #17's symptoms of dizziness and confusion. Patient #17 arrived at the ED reporting symptoms had been on-going for days to weeks prior. Staff HH Neurologist, explained TPA therapy should be initiated within a 4.5 hours' time frame, unless the exact time of symptom onset was known. Due to ongoing weakness and not knowing the actual onset of symptoms, the decision to initiate TPA therapy was difficult. The patient's report of four weeks of symptoms put Patient #17 outside the TPA therapy window.

11. Review of Patient #37, a pediatric patient, medical record revealed the following:

a. On 5/1/24 at 9:30 PM, Staff CC ED RN and Staff BB ED RN documented the following: "Arrive to Methodist West ED via private vehicle...chief complaint post-op problem (Patient #37) underwent a tonsillectomy and adenoidectomy (T&A) on 4/22/24 by pediatric Ear Nose and Throat (ENT) physician...Patient woke up covered in blood on 4/30 (4/30/24) and the ENT physician told them if the bleeding stops that is okay, but if reoccurred to come to the ED. Patient woke up again tonight (5/1/24) covered in blood. Bleeding from the throat has stopped since the patient arrived in the ED. Family reports no new spitting up of blood."

b. On 5/1/24 at 9:46 PM, Staff CC ED RN and Staff BB ED RN documented a triage assessment on Patient #37 as follows: vital signs (VS) were heart rate (HR) 142 beats per minute (bpm- elevated), respirations 22 per minute, BP- 99/58, oxygen saturation level of 100%, wt (weight)-25 lbs (pounds), temp 98.6 (degrees Fahrenheit).

c. On 5/1/24 10:56 PM, ED staff documented, "Family signed Refusal of Medical Screening Exam; "too long of wait for treatment".

d. On 5/8/24 at 4:00 PM, during an interview, a family member reported they asked a person at the front desk how long of a wait it would be, and the front desk told the family member there was a 3 to 4 hour wait for a bed (exam room). The family member asked a nurse if they should take the patient to another hospital, as they had been told by the ENT surgeon that the patient needed to be seen immediately. The nurse (identified as Staff BB ED Triage Nurse) informed the family that they could not tell the family member to take the patient to another hospital, encouraged them to stay, but expressed her understanding that a 3 to 4 hour wait was too long for a child. The family member confirmed they signed a form to refuse treatment.

e. On 5/1/24 11:26 PM Patient #37 arrived at a second hospital ED, Hospital SS via private vehicle.

f. On 5/1/24 at 11:30 PM, Staff RR, ED RN, Triage Note-"(Patient #37) had tonsillectomy/adenoidectomy and tubes placed 4/22/24 with pediatric ENT Staff PP. Last night, the patient had a little bleeding but stopped, tonight the patient had another episode of bleeding that was worse."

g. On 5/2/24 at 12:48 AM, Staff QQ ED Physician documented the following: "(Patient #37) presented after tonsils and adenoids removed on 4/22/24, late last night (Patient #37) had a small amount of post tonsillar bleeding, resolved spontaneously, seems to be doing fine, tolerating P.O. (by mouth) today, took Ibuprofen, however this evening woke after another episode of bleeding, blood in the naris (nose), large blood clot was spit out of the mouth, however bleeding is now stopped, recommended to go to the emergency department by Ear Nose and Throat (ENT) for evaluation and potentially IV fluids. Previous treatment: outpatient surgery. Post op course: Fluctuating. Incision complaints: moderate Bleeding. Risk factors consist of age. Therapy today: none. MSE completed."

PLAN: "(Patient #37) with post tonsillar bleed, appears not to be bleeding currently, will keep an eye on (Patient #37) in the ED, patient appears pale, recommendation from ENT to get IV(intravenous) fluids, will place IV, do screening blood work (complete metabolic profile (CMP), complete blood count (CBC) with differential) and give Dextrose 5% and Sodium Chloride 0.9% with Potassium Chloride 20 milliequivalents per liter (mEq/L) per 1000 mL(milliliters)- 250 cc(cubic centimeters) bolus."

h. On 5/2/24 4:15 AM Staff QQ ED Physician documented Physician Notes as follows: "Patient with no further bleeding in the emergency department however is profoundly anemic with hemoglobin 7.3 (normal 11.5-13.5; indicative of anemia or low blood volume), discussed with ENT and will admit to PEDS (pediatric) Hospitalist, type and screen pending, ENT will see in the a.m. and reevaluate."

i. On 5/2/24 at 4:28 AM, Staff PP ENT documented the following progress notes: "(Patient #37) was admitted earlier this morning with a postoperative bleed. We are evaluating Patient #37 today to assess how they have done over the course of the day. Patient #37 has been doing quite well and has had no further bleeding. There have been no concerns regarding their airway since admission. I spoke to the family a couple of nights ago and noted that Patient #37 had a brief bleed at that time, but we had followed up that morning and they had no further issues. It was only in the middle of the night that they began bleeding again at which time the family brought them in. Again, the last 12 hours have been uneventful. Patient 37 has had no further bleeding or concerns. Patient #37 is feeding and doing quite well. We will monitor them overnight and see how Patient #37 does. If there is no further bleeding tomorrow depending on how they are feeling and the family is comfortable, we will start considering discharge home. Order for Pediatric Admission placed."

12. During an interview, on 5/9/24 at 8:10 AM, Staff BB ED RN (West campus ED triage nurse), recalled the patient. Staff BB reported they recalled that "it was a very busy evening" and they believed "the wait times were getting to be long". Staff BB reported the patient had a little bit of blood on their pajamas or in their hair. Family said the bleeding had stopped. Staff BB did not remember seeing the patient bleeding. The family never asked for a tissue or notified staff that the bleeding had started again. Staff BB explained that if the patient's condition worsened, she would have called the charge nurse to direct Staff BB to get the patient seen immediately by a provider. Staff BB, did ask the charge nurse what acuity level the patient should be, and Staff BB reported the charge nurse told her a Level 3. Level 3 would be brought back before a Level 4 patient. Since the waiting room was busy there was a PCT rounding for the patient's vitals. The PCT documents those vitals in the patients' electronic records. When asked if they explained to the family that the patient had a possible EMC and should stay and let the patient to be seen, Staff BB responded that they encouraged them to stay to see a provider. When the family asked how long it would be before the patient could be seen, Staff BB reported they told the family that wait times were always changing and they could not provide that information. Staff BB reported they explained the Refusal of Medical Treatment form and had a family member sign it.

13. During an interview, on 5/9/24 at 8:40 AM, Staff CC ED RN (West Campus ED Triage nurse), recalled Patient #37 and recalled that night (5/1/24) being horribly busy. Staff CC ED RN explained there were a lot of patients boarding (in the ED) and no beds were opening up. Staff CC ED RN recalled the family came up to the desk voicing their frustration, because their provider told them to rush the child in and then they had to wait for their child to be seen. The family said they were going to take the patient to a different ED. Staff CC ED RN reported that Staff BB explained that Patient #37 needed to be seen, but if they were leaving they could sign the Refusal of Medical Exam form. The family did sign the form. Staff CC ED RN did not recall staff stating a time frame for the wait to be seen by a provider. Staff usually state that they cannot give an estimate of the time frame, and patient were taken into the ED rooms according to their acuity level.
The Hospital failed to provide Patient #17 and #37 with the appropriate stabilizing treatment. Patient #17 presented to the ED on 11/24/2023 with weakness and stroke symptoms. Hospital ED staff sent Patient #17 to the ED waiting area while the patient's symptoms got increasingly worse. Patient #17 remained in the ED waiting area for 7 hours, and did not receive an examination by a healthcare provider until more than 7 hours after arriving at the ED; this resulted in a delay in stabilizing treatment for the patient's EMC. Patient #37, a pediatric patient, presented to the ED with family on 5/1/24 with post surgical bleeding. The family left with Patient #37 without being seen by a provider due to long wait times and fear for their child's imminent health.

Based on document review, policy review and staff interview, the acute care hospital emergency department staff failed to ensure that 1 of 21 patients who presented for emergency medical care (Patient # 44) did not experience a delay in medical examination and treatment in order to inquire about payment and failed to ensure the patient was not unduly discouraged from remaining for further evaluation during the registration process.

Failure to delay requesting payment for the medical care until after the patient had received stabilizing treatment could potentially result in the patient deciding to discontinue receiving stabilizing treatment due to concerns regarding the cost of their medical care. The hospital's administrative staff identified that an average of 287 patients presented to the emergency department each month and requested an emergency medical screening examination and stabilizing treatment.

Findings include:

Review of the policy titled "Transfer and Emergency Examination - EMTALA," revised 9/2021, revealed in part, "Prohibitions on actions discouraging examination or treatment. Hospital and hospital staff will not discourage individuals presenting to the hospital's Dedicated Emergency Department from seeking emergency care or treatment. Hospital staff will not request or demand that Dedicated Emergency Department (DED) patients pay co-pays or any monies prior to receiving screening or treatment for an Emergency Medical Conditions [sic]. Hospital will not allow any debt collection activities either directly by hospital staff or through contracted debt collection entities that would interfere with the provision of any emergency medical care without discrimination.

1. Review of Patient #44's medical record revealed the following on 2/5/24:

a. at 10:04 AM, Patient #44 presented to the hospital's Dedicated Emergency Department (DED) complaining right sided abdominal pain.

b. at 10:05 AM, Registered Nurse (RN) WW began triaging Patient #44 and documented that Patient #44 was complaining of 8 out of 10 (with 10 being the worst pain imaginable) pain in Patient #44's right side.

c. at 10:30 AM, RN XX took Patient #44 to ED Room #4 and continued assessing Patient #44. RN XX documented that Patient #44 had a personal history of kidney stones and was complaining of pain starting on the right side of their back and the pain radiated around towards the front of Patient #44's body.

d. at 10:32 AM, Physician's Assistant (PA) YY assessed Patient #44 and ordered an abdominal/pelvis CT scan and laboratory testing on Patient #44. PA YY also ordered Patient #44 to receive 1,000 ml of intravenous fluids and 15 mg of toradol (a non-steriodal anti-inflammatory pain medication similar to ibuprofen).

e. at 10:45 AM, RN ZZ started an intravenous (IV) line and administered the IV fluids and toradol to Patient #44.

f. at 10:47 AM, Patient #44's medical record indicated that the hospital staff began the registration process.

g. at 11:25 AM, Patient #44 underwent the CT scan. Radiologist AAA (a physician with specialized training to interpret radiology tests) diagnosed Patient #44 with a 3 mm kidney stone in their right ureter (a small tube between the kidney and bladder). Patient #44 also had several other kidney stones in both kidneys.

h. at 11:37 AM, PA YY ordered Patient #44 to receive 50 micrograms of fentanyl (a opioid pain medication) once, 4 mg of ondansetron (a medication to relieve nausea), and an additional 1,000 ml of intravenous fluids. PA YY also ordered that Patient #44 could receive an additional 25 micrograms of fentanyl every hour, as needed, for pain control.

i. at 11:40 AM, RN ZZ administered the ordered medications to Patient #44.

j. at 11:53 AM, Radiologist AAA completed the documentation for Patient #44's CT scan and transmitted the results to PA YY.

k. at 12:41 PM, Patient #44's medical record indicated that the hospital staff completed the registration process.

l. at 1:49 PM, PA YY ordered RN ZZ to administer tamsulosin (a medication to help pass kidney stones) to Patient #44.

m. at 1:53 PM, RN ZZ documented they administered the tamsulosin to Patient #44.

n. at 1:53 PM, the laboratory staff transmitted the results from Patient #44's urinalysis to PA YY.

o. at 1:58 PM, RN ZZ documented that Patient #44's pain had decreased from 8 out of 10 to 4 out of 10, but also documented Patient #44's pain as "High."

p. at 2:14 PM, PA YY ordered the emergency department staff to discharge Patient #44 home.

q. at 2:16 PM, Patient #44's discharge instructions included that PA YY had prescribed Hydrocodone to Patient #44 and that Patient #44 received fentanyl (an opiod pain medication). The discharge instructions contained information on "Opioids Discharge Instructions" that included "Opioids or other medications that contain them include: ... Hydrocone (Norco)..." The Opioids Discharge Instructions indicated that Patient #44 should "Be Cautious. Opioids may affect your judgement and decision making. Do not drive or operate heavy machinery while you take them."

r. at 2:21 PM, RN ZZ administered an additional 25 micrograms of fentanyl, as needed, to Patient #44. RN ZZ discharged Patient #44 home 4 minutes later. RN ZZ did not document Patient #44's pain prior to administering the 25 micrograms of fentanyl, nor did RN ZZ document Patient #44's pain after receiving the fentanyl.

2. During an interview on 5/20/2024 at 12:00 PM, Patient #44 revealed that they presented to the hospital complaining of severe right sided abdominal pain, with their family member. The nursing staff and physician's assistant assessed Patient #44 and ordered medication to relieve Patient #44's pain. After the physician's assistant had evaluated Patient #44, and after the nurse had administered fentanyl to Patient #44, a Patient Access Representative (PAR) came into Patient #44's emergency department room and began asking questions. After the PAR updated Patient #44's insurance information, the patient stated,"the patient access person said that I needed to pay $340. I think I said "what?" They said that I needed to pay them $340...I was thinking the ED copay was $50. They kept saying that I needed to pay $340 and that payment needs to be made or care could be stopped. the patient access person said that I needed to pay $340. I think I said "what?" They said that I needed to pay them $340. Since I have had the same insurance for 20 years, I was thinking the ED copay was $50. They kept saying that I needed to pay $340 and that payment needs to be made or care could be stopped. Eventually I paid them the $50 copay I thought I owed. I felt intimidated because they said that they could stop my care."

Then, a nurse came into Patient #44's room. The nurse asked if there was a problem and Patient #44 told the nurse that the PAR staff member insisted that Patient #44 had to pay something. The nurse then said, "welcome to American healthcare. Everyone wants to get paid. The insurance company wants to get paid, the doctor wants to get paid, and the hospital wants to get paid." Patient #44 stated, "She was very bullying. It was nuts... I felt threatened and it wasn ' t appropriate."

3. During an interview on 5/20/24 at 3:25 PM, Patient #44's Family Member, a healthcare professional, revealed that they accompanied Patient #44 to the hospital, as they believed Patient #44 had a kidney stone. After Patient #44 received the first dose of fentanyl, a Patient Access Registration (PAR) staff member knocked on Patient #44's emergency room door. Initially, the system indicated that Patient #44's insurance had expired, but Patient #44's Family Member found an updated insurance card in Patient #44's wallet. Once the PAR entered the updated information in the system, the Family Member reported the hospital's system indicated that Patient #44 "owed an odd amount, like $267.00." The PAR explained that since Patient #44 had testing and other procedures, Patient #44 would owe more than Patient #44 thought. The PAR informed Patient #44 and Patient #44's Family Member that, unless Patient #44 paid at least 10 percent of what the system thought Patient #44 owed, Patient #44's care could be stopped.

Patient #44's nurse came in after the PAR left the room. When Patient #44's Family Member informed the nurse that the PAR demanded payment, the nurse responded, "welcome to American healthcare. Everyone wants paid. The insurance wants paid and the doctor wants paid."

4. Review of Patient #44's "Account History Report," printed on 5/21/24 and provided by the hospital staff, revealed the following information:

a. at 12:56 PM, Patient Access Representative (PAR) UU documented "[Patient's family member] was upset that I asked for signature and payment she said we shouldn't ask for it and paid $50 down towards but I need to bring RN to explain to them process because they were so unhappy about the payment."

b. at 1:09 PM, PAR UU documented that RN ZZ assisted PAR UU with explaining the financial situation to Patient #44 and their family member.

5. Review of the undated presentation slide titled "EMTALA Cornerstone Training Slide" revealed the following, "... providers and staff will not discourage individuals presenting to the hospital's dedicated emergency department from seeking emergency care or treatment. Further review of the document revealed, "Hospital staff will not demand that dedicated emergency department patients pay copays or any monies prior to receiving screening or treatment for emergency medical conditions. Hospital will not allow any debt collection activities either directly by hospital staff, ... that would interfere with the provision of any emergency medical care ..."

6. Review of the undated presentation "Point of Service Collection Training" slides revealed the following,

a. "Collection Opportunities ... Past Balances ... Take this opportunity to educate the patient about their past balances. Ask them what they would like to pay towards the balance."

b. if the patient requested the hospital staff "just bill me," the staff are instructed "Take this opportunity to negotiate if needed." The slide provides the suggested response, "We do require payment on date of service. What can you pay towards the visit today?"

c. if the patient had a past due balance, the staff are instructed to indicate "You have an outstanding balance of ... We accept cash, checks, and all major credit cards."

d. if the patient indicated that they can not pay the full amount the system indicates they need to pay, the staff are instructed to negotiate with the patient, including asking if the patient can pay 50 percent of the amount due. If the patient, the staff are instructed to see if the patient can pay 25 percent of the amount due. If the patient can't pay that amount, the staff are instructed to offer the patient other payment options, including asking "what can you pay towards your visit today?"

e. if the patient indicated they did not have insurance, the staff are instructed to say "the estimate of today's visit will be ... With the same day 20 percent discount, your estimate updates to ... How would you like to take care of that today?"

7. During an interview on 5/20/24 at 4:15 PM, Patient Access Representative (PAR) UU revealed that they registered Patient #44 after PA YY examined Patient #44. During the registration process, PAR UU obtained Patient #44's insurance information and entered it into the hospital's computer system. The hospital's computer system provided an estimate of Patient #44's out of pocket deductible, how much of the deductible Patient #44 had met, and how much Patient #44 still had to pay that year. The system also showed if Patient #44 owed a copay for the emergency department visit.

PAR UU explained that all patients are required to pay the copayment amount for an emergency department visit. PAR UU is required to ask all patients for their copayment amount, explain why the patients owe their copayment, and ask if the patient can make the copayment.

8. During an interview on 5/22/24 at 3:25 PM, Patient Access Manager (PAM) M revealed that PAR UU called PAM M after PAR UU registered Patient #44 and indicated that Patient #44's Family Member was upset that PAR UU had asked Patient #44 to make a payment while Patient #44 was still being treated in the emergency department.

PAM M explained that while registering a patient in the emergency department, the Patient Access staff access the patient's insurance information and create an estimate of how much the patient will need to pay for the emergency department visit, including how much the patient will owe. The Patient Access staff are required to ask the patients for payment of their emergency department visit copayment and any deductibles (amount of money the patient must pay out of their pocket before their health insurance starts paying) during the registration process. After providing the patient with an estimate of the costs from their emergency department visit (while the patient is still in the emergency department room), the Patient Accesses staff are required to ask how the patients would like to pay the anticipated out of pocket costs (which can exceed several hundred dollars).

9. During an interview on 5/22/24 at 3:40 PM, Patient Access Supervisor (PAS) VV revealed that when PAR UU registered Patient #44, PAR UU was required to create an estimate of Patient #44's expected out of pocket costs (which can exceed several hundred dollars) for the emergency department visit and required to ask Patient #44 how Patient #44 wanted to pay the out of pocket costs. The PAR staff received training on scripting how they ask patients for money by asking how the patient would like to pay the estimated amount owed to the hospital or how can the patient take care of the amount owed to the hospital. PAS VV indicated they train the PAR staff to collect money in the emergency department, because the Patient Access group is part of the revenue cycle team, and thus, responsible for helping to collect money owed to the hospital.