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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag 2406: Applicability of Provisions of this Section (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction. Based on interviews and document review, the facility failed to ensure patients received a medical screening exam (MSE) according to facility policy. Specifically, the facility failed to ensure patients presenting to the facility with a potential emergency medical condition (EMC) were medically screened according to facility policy. This failure impacted seven of 22 patients' medical records reviewed.

Tag 2407: Necessary Stabilizing Treatment for Emergency Medical Conditions (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either-- (i) Within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. Based on interviews and document review, the facility failed to ensure patients presenting to the emergency department (ED) with an emergency medical condition (EMC) received stabilizing treatment according to facility policy. This failure impacted one of seven patients who were assessed in the ED and discharged home.

Based on interviews and document review, the facility failed to ensure patients received a medical screening exam (MSE) according to facility policy. Specifically, the facility failed to ensure patients presenting to the facility with a potential emergency medical condition (EMC) were medically screened according to facility policy. This failure impacted seven of 22 patients reviewed. (Patients #2, #4, #7, #8, #13, #15, and #21)

Findings include:

Facility policies:

According to the Medical Screening Examination (MSE) policy, all individuals presenting to the Emergency Department (ED) and requesting medical treatment are entitled to a medical screening examination. The MSE will be performed regardless of race, color, national origin, or financial status. An MSE is the screening of sick, wounded, or injured persons in the emergency department to determine whether the person has an emergency medical condition. The MSE will include but not be limited to the chief complaint, vital signs, mental status showing evidence of abnormalities, general appearance showing the patient looks sick, skin looks poorly perfused, signs of dehydration, and ability to walk. Potential emergent patient examples may include vital signs including a temperature over 99° Fahrenheit (F), heart rate under 60 or over 100, blood pressure under 90 or over 150 systolic (the phase of the heartbeat when the heart muscle contracts and pumps blood), acute pain over five on a zero to ten scale, acute chest pain, acute abdominal pain, any abnormal mental/psychiatric status presenting with suicidal or homicidal ideation, gestures, or agitation, or patients under the age of five or over 65.

According to the Admission Policies and Patient Care in the ED policy, all patients admitted to the ED will be seen by a provider and have a face sheet (summary of patient's information) generated. All such patients will be triaged (given a preliminary assessment) into the system by the ED provider. Any patient who presents to the ED for care will be provided an MSE.

According to the Policies of the Emergency Department policy, the reason is to stabilize and care for acutely ill and injured patients, to provide care on a continuous basis once entered into the system, to provide quality care of the patient and family within the scope of capability, to be aware of the patients' clinical and personal needs and meeting them with rapid response, to provide adequately trained personnel and a safe environment at all times. The ED was open at all times to ill or injured patients so that the patients' condition could be assessed. The hospital and medical staff are responsible for ensuring that emergency care meets the general standards of care. Emergency patient care shall be guided by written policies and shall be supported by appropriate procedure manuals and reference materials. There shall be written policies concerning the extent of treatment carried out in the ED. A control register shall be kept by the ED. The register shall contain at least the name, date, and time of arrival and departure, with a control number of each patient served. Reports of laboratory test results shall be made available promptly to the practitioner providing emergency care. There shall be a mechanism for notifying and recalling patients who require additional or repeat laboratory studies.

According to the Standards of Nursing Practice-ED policy, Emergency Nursing Practice is the nursing care of individuals of all ages with perceived physical and/or emotional alterations which are undiagnosed and may require prompt intervention. The scope of nursing practice in an emergency setting encompasses nursing activities which are directed toward health problems of various levels of complexity. A rapidly changing physiological and/or psychological status, which may be life-threatening, requires assessment and supportive care.

According to the Cardiac Monitor-Reasons for Placement in the ED policy, patients to consider for cardiac monitoring are all older (30 years or above), diabetics (high blood sugar), especially if complaining of abdominal pain or chest pain, previous heart and/or lung disease, any abnormal blood pressure, pulse, respiratory rate, pulse oximetry (measurement of oxygen) less than 88% or adult with fever over 103°F, shortness of breath (SOB), weakness, dizziness, syncope (fainting), altered consciousness or elderly patient with a history of a fall, abnormal lab, edema (swelling), abdominal pain, bleeding or anemia (lack of ability to carry oxygen to the tissues), chest pain, seizure (sudden, uncontrolled burst of electrical activity in the brain), substance use including alcohol intoxication, hypothermia (under 94°F), or multiple traumas.

References:

According to the Cardiac Routine Order Set, nursing interventions: place the patient in a monitor bed and obtain vital signs every 15 minutes four times, and then if stable, may change to every 30 minutes to one hour depending on the patient's acuity.

According to the Security Officer Job Description, the security officer protects the life and property of all persons on the facility premises and patrols buildings and grounds. Responds to security needs of facility personnel, visitors, and patients. Their duties and responsibilities include providing a visible deterrent to crime and prohibited activities by patrolling the buildings and grounds, responding quickly and effectively to emergent and non-emergent situations, ensuring that only authorized persons are admitted onto the premises, responding to emergency calls for assistance to control disorderly conduct or combative patients, patrolling buildings, grounds, and parking areas, demonstrates knowledge of the principles of growth and development over the lifespan, and excelling in verbal communication in diffusing volatile situations.

1. The facility failed to ensure patients presenting to the hospital with a potential EMC were medically screened according to facility policy.

A. Medical Records and Security Surveillance Reports

i. A review of medical records and a Security Surveillance Report revealed Patient #21 presented to the facility with a potential emergency medical condition, waited more than 10 hours in the facility lobby, was removed from the facility by security staff although the patient presented in an altered state, and was provided an MSE only after being found outside once removed from the facility, still in an altered state.

a. A review of Patient #21's medical record revealed Patient #21 was a 65-year-old who presented to the ED on 12/1/23 at 12:40 a.m. for altered mental status. The physician's note revealed Patient #21 was dropped off in the lobby on 11/30/23 around 2:20 p.m. by the state patrol and the patient was first observed sitting in the lobby at 8:00 p.m. The note further revealed that ED staff had security "confront" Patient #21 after the other patients had been discharged from the ED.

b. A review of a Security Surveillance Report revealed Patient #21 was seen in the facility lobby by an ED nurse on 11/30/23 at 8:00 p.m. and on 12/1/23 at 12:00 a.m. According to the security report, on 12/1/23 at 12:00 a.m., security was called and Patient #21 was asked to leave the facility. Patient #21 left and sat outside where security again "confronted" them before it was determined Patient #21 needed to be seen in the ED as they appeared mentally altered. The report revealed Patient #21 was brought to the ED where they were admitted and then later admitted to the inpatient unit for further treatment. The follow-up to the report revealed CNO #7 was informed of the incident and security staff were counseled to be more attentive to unusual situations. The follow-up education provided to security staff was requested and an interview on 3/6/24 at 9:27 a.m. with quality and risk director (Director) #9 revealed this education was provided to the security officers verbally and no written documentation of the counseling could be provided.

In contrast to the Security Surveillance Report which revealed security asked Patient #21 to leave the facility on 12/1/23 at 12:00 a.m. and then found Patient #21 outside a short time later where Patient #21 was "confronted again" and determined to have alterations in their mental status, the physician's note stated security brought Patient #21 to the ED after "confronting" them in the lobby. The physician's note revealed the patient was provided care in the ED at 12:40 a.m. and was then admitted to the intensive care unit (ICU) at 8:06 a.m. for treatment of altered mental status.

Also in contrast to the Security Surveillance Report, the nursing general assessment note written upon admission to the ED revealed Patient #21 told security they were late for an appointment when security originally encountered Patient #21, and then Patient #21 walked out the door. The nursing note read Patient #21 was later discovered outside cold and not making sense and was then brought into the ED by security. The nursing assessment revealed Patient #21's temperature was 96.3°F with a pulse rate (PR) of 103.

The medical record review and security report was in contrast to the MSE, the Admission Policies and Patient Care in the ED, and the Policies of the Emergency Department policies which read, all individuals who presented to the ED were entitled to an MSE to determine the presence of an emergency medical condition. The reason was to stabilize and care for acutely ill and injured patients and the ED was open to ill or injured patients so that the patients' conditions could be assessed.

This security report was also in contrast to the Security Officer Job Description which read, the security officer protected the life of all persons on the facility premises.

ii. A review of medical records revealed Patient #2 was not provided with an appropriate MSE based on their presenting symptoms and past medical history.

A review of Patient #2's medical record revealed they presented to the ED on 11/23/23 at 5:16 a.m. with a chief complaint of pain with urination, low back pain, and a headache. Nursing notes revealed Patient #2 had a temperature of 99.7°F (normal temperature was 98.6°F), a pulse rate of 99 (normal was 60-100), and pain rated at 10/10. The record revealed Patient #2 had a previous history of kidney stones. Laboratory testing revealed the patient's urine contained blood and was positive for an infectious process. Physician notes revealed the treating physician diagnosed Patient #2 with a urinary tract infection. The physician's note did not reveal the physician had considered kidney stones in the patient's differential diagnosis although Patient #2 had kidney stones in the past, nor had the physician provided a screening exam that would have ruled this diagnosis out.

This review of Patient #2's medical record was in contrast to the MSE, the Admission Policies and Patient Care in the ED, and the Policies of the Emergency Department policies which read, all individuals who presented to the ED and requested medical treatment were entitled to an MSE to determine the presence of an EMC.

iii. A review of medical records revealed Patient #4, Patient #7, Patient #8, Patient #13, and Patient #15 were not assessed at regular intervals as part of their MSE while in the ED.

a. A review of Patient #4's medical record revealed Patient #4 was a 34-year-old who presented to the ED on 1/8/24 at 5:16 p.m. after a suicide attempt (attempting to kill oneself) by overdosing on medication. Nursing notes revealed on 1/9/24, there was a gap in obtaining vital signs from 2:18 a.m. to 7:52 p.m. (17 hours and 34 minutes). There was another gap in obtaining vital signs between 1/9/24 at 7:52 p.m. to 1/10/24 at 5:30 a.m. (nine hours and 38 minutes). Also, nursing notes failed to reveal evidence nursing staff obtained Patient #4's vital signs at the time of discharge. Nursing notes also revealed from 1/8/24 to 1/10/24, there were only two nursing assessments completed for the patient. The discharge assessment revealed the patient was transferred to inpatient care on 1/10/24 at 8:35 a.m. for further mental health treatment.

b. A review of Patient #7's medical record revealed Patient #7 was a 76-year-old who presented to the ED on 2/6/24 at 3:14 a.m. with chest pain. The physician ordered vital signs to be performed per the cardiac routine at 3:37 a.m. Nursing notes revealed the blood pressure (BP) at 3:14 a.m. was 81/57 (normal was 120/80), BP at 3:20 a.m. was 81/57, BP at 3:32 a.m. was 84/51, BP at 3:40 a.m. was 70/48, and the BP at 3:50 a.m. was 101/76. There was then a 24-minute gap between the 3:50 a.m. BP reading and the next at 4:14 a.m., when the BP was 87/58. This review of vital signs was in contrast to the Cardiac Routine Order Set which read, vital signs were to be taken every 15 minutes four times, and then if stable, decreased in frequency.

c. A review of Patient #8's medical record revealed Patient #8 was a 23-year-old who presented to the ED on 9/6/23 at 5:50 a.m. for high blood sugar. Nursing notes revealed the patient had a history of diabetes (inability to maintain blood sugars) and diabetic ketoacidosis (DKA) (the body does not have enough insulin (a hormone that allows blood sugar to enter the cells)) and Patient #8 had self-administered 23 units of insulin before presenting to the ED. Nursing notes revealed the patient's blood glucose (sugar) was over 500 by point of care testing (POCT) glucose (normal 70-106) at 5:57 a.m. and was 574 by lab glucose at 6:16 a.m. The record revealed six units of intravenous (IV) insulin were ordered and administered at 6:31 a.m. At 8:26 a.m., an hour and 55 minutes after the IV insulin was given, Patient #8's blood sugar was 461, which was also a gap of two hours and 10 minutes between the two blood sugar measurements. The patient was given another 10 units of IV insulin at 8:43 a.m.

The nursing notes revealed Patient #8's BP was taken on 9/6/23 at 5:55 a.m., 7:30 a.m., and 8:55 a.m., which was an hour and 35 minutes between the first two readings, and an hour and 25 minutes between the second and third readings. The medical record did not reveal evidence of cardiac monitoring.

This review of Patient #8's medical record revealed gaps in patient assessment and lack of cardiac monitoring, which was in contrast to the Cardiac Monitor-Reasons for Placement in the ED policy which read, patients to consider for cardiac monitoring included patients with diabetes. The review was also in contrast to the Cardiac Routine Order Set which read, vital signs were to be taken every 15 minutes four times, and then if stable, decreased in frequency.

d. A review of Patient #13's medical record revealed Patient #13 was an 86-year-old who presented to the ED on 1/12/24 at 3:16 p.m. for confusion and weakness. Nursing notes revealed Patient #13's BP was obtained every 15 minutes four times then, starting at 4:00 p.m. when their BP was 163/88, there was a gap of 30 minutes until 4:30 p.m. when BP was 167/116. Then after 6:00 p.m. with a BP of 182/105, there was an hour gap in BP assessment until 7:00 p.m., when the BP was 132/116. At 7:15 p.m. the BP was 178/101, then there was a 50-minute gap in BP until 8:05 p.m. when the BP was 139/116, then another 22-minute gap until 8:37 p.m., when the BP was 168/93.

e. A review of Patient #15's medical record revealed Patient #15 was a 65-year-old who presented to the ED on 1/24/24 at 5:45 p.m. for altered mental status. The physician's note revealed Patient #15 was diagnosed with sepsis during their stay. The nursing assessments revealed staff obtained Patient #15's vital signs on admission and their BP was 61/41 and pulse rate (PR) was 109. Patient 15's BP was taken every 15 minutes from 5:45 p.m. to 8:45 p.m., except from 6:45 p.m. to 7:15 p.m. when there was a 30-minute gap. Then from 8:45 p.m. to 1/25/24 at 3:50 a.m., there were no documented blood pressures for Patient #15. Patient #15's PR was taken on 1/24/24 at 5:45 p.m. and then next taken on 1/25/24 at 3:50 a.m. The only documented temperature for Patient #15 was taken on 1/25/24 at 3:50 a.m.

The medical records for Patient #4, Patient #7, Patient #8, Patient #13, and Patient #15 which revealed missing assessments, including vital signs, were in contrast to the interview with CNO #7 on 2/28/24 at 1:04 p.m. in which CNO #7 stated nurses continuously assessed patients in the ED and these assessments included obtaining vital signs, rechecking blood sugars, and reassessing pain levels.

The medical records for Patient #4, Patient #7, Patient #8, Patient #13, and Patient #15 with gaps in patient assessments were also in contrast to the MSE, the Admission Policies, and Patient Care in the ED, and the Policies of the Emergency Department policies which read, all individuals presenting to the ED were entitled to a medical screening examination which screened sick, wounded, or injured persons to determine the presence of an emergency medical condition. The ED provided quality care and rapidly met the patient's clinical needs.

Additionally, these medical records for Patient #4, Patient #7, Patient #8, Patient #13, and Patient #15 were also in contrast to the Standards of Nursing Practice-ED policy which read, emergency nursing care addressed undiagnosed physical and emotional alterations which required prompt intervention. Nursing activities were directed towards health problems of various levels of complexity with the potential for rapidly changing physiological and/or psychological status. This rapid change could be life-threatening and required assessment and supportive care.

iv. A review of Security Surveillance Reports revealed unhoused individuals were removed from the facility by non-clinical staff prior to determining if the individuals required medical screening examinations for potential emergent medical conditions.

a. A review of a Security Surveillance Report revealed on 1/23/24 at 1:00 a.m., a person wanted to enter the facility to warm up. The report read the person was told by security staff they needed to leave if they did not need medical attention. The follow-up activity from the Security Surveillance Report suggested having ED staff call security for an escort when leaving the facility.

b. A review of a Security Surveillance Report revealed on 12/24/23 at 6:25 a.m., a person was found sleeping in the chapel. The report read the person was told by security staff they could not sleep in the facility and they had to leave if there was no medical reason for them to be present. According to the report, the police arrived to remove this person from the facility. There was no follow-up activity identified.

B. Document review

i. Policies

a. Upon request on 2/27/24 and 2/28/24, the facility was unable to provide a policy providing guidance on patient assessment and reassessment in the ED. On 2/28/24 at 1:04 p.m. and 4:26 p.m., the chief nursing officer (CNO) #7 stated there was not a policy on patient assessment and reassessment in the ED.

C. Interviews

i. On 2/29/24 at 7:53 a.m., an interview was conducted with security officer (Officer) #1. Officer #1 stated they worked in security and trained other security staff. They stated they did not have a clinical background. They stated they patrolled the facility property and grounds to ensure safety. Officer #1 stated they encountered people who were not patients, visitors, or staff, and who did not appear to have a purpose at the facility. Officer #1 stated they asked people they encountered, in the stairwell or chapel for example, if they had a purpose at the facility. They stated if those people became belligerent with security staff and did not state their purpose, Officer #1 knew those people did not have a reason to be at the facility and they were made to leave.

Officer #1 stated they were not trained in recognizing patients with medical or psychological needs although they were trained to ask if people needed help and if they needed to be seen. Officer #1 stated they tried to ask these questions of every person but some people were not receptive to questions about their medical history. Officer #1 stated if officers felt there was a health concern, although they had no clinical training, they directed people to the ED. Officer #1 stated they received Emergency Medical Treatment and Labor Act (EMTALA) training but were not sure how this training applied to their position or responsibilities.

Officer #1 stated there was tension between security staff and the ED staff, including nurses, resulting in a lack of communication which impacted security's ability to keep everyone safe or protect patients. Officer #1 stated security should have had a conversation with Patient #21 assessing their awareness before they were asked to leave. They stated if security had gauged that Patient #21 was not aware of their surroundings, the security staff was to have notified the ED to initiate a medical assessment. Officer #1 stated with regards to other security incidents where security encountered people whom they asked to leave, many unhoused people came to the facility to sleep or warm up. They stated security could not do their job of keeping staff and security safe if these unhoused people remained at the facility. Officer #1 stated there was a risk to people not receiving an MSE for a health need. They stated if people did not receive the necessary medical care, they could leave the facility and die.

ii. On 2/29/24 at 8:32 a.m., an interview was conducted with security supervisor (Supervisor) #5. Supervisor #5 stated they did not have a medical or clinical background although they knew when people needed psychiatric treatment in the ED due to their years of security experience. Supervisor #5 stated some unhoused people entered the facility to stay warm. They stated they expected their officers to ask these people if they had an appointment and be made to leave if there was no appointment. This was in contrast to the Policies of the Emergency Department policy which read, the ED was open at all times to ill or injured patients so that patients could be assessed and did not require appointments.

Supervisor #5 stated security escorted people to the ED for medical care, for instance, if there was a slip and fall in the parking lot. They stated it was the patient and ED staff's responsibility to ensure people received an MSE for medical or psychiatric needs. Supervisor #5 stated there was not a risk to turning patients away if those people were not able to voice their needs.

iii. On 3/4/24 at 3:10 p.m., an interview was conducted with Officer #8. Officer #8 stated they trained the other security officers to ask the nature of someone's purpose at the facility as people were not allowed to enter the facility without having a reason. Officer #8 stated they talked to and asked questions of people to assess if people were ill. They stated when patients were discharged but had not yet left the facility, security would ask these people to leave as they had been medically screened and there was no reason to stay. Officer #8 stated they did occasionally ask if these patients had new medical needs. Officer #8 stated they used their experience in security and history as an emergency medical technician (EMT) and were able to tell when someone was mentally altered. Officer #8 stated they had not received EMTALA training during their employment, which was in contrast to interviews with other security staff and a review of personnel files. They stated the risk of not being familiar with EMTALA was making incorrect assumptions about a person and their medical or psychiatric health.

Officer #8 stated there was tension between security and the staff in the ED which interfered with security's ability to carry out their duties. They stated they had communicated this tension to CNO #7. Officer #8 stated there was a risk to patient safety if ED nurses chose not to communicate or collaborate with security. Officer #8 stated ED staff were not always willing to leave the ED to assess people within the facility or on the grounds outside the ED. They stated if ED nurses were not willing to collaborate with security to assess people outside the ED, this posed a risk to the patient and security staff.

iv. On 2/29/24 at 9:21 a.m. an interview was conducted with registered nurse (RN) #11. RN #11 stated the risk of patients being turned away without having received an MSE was a higher risk of cardiac (heart) and respiratory (breathing) complications and potentially, death.

v. On 3/5/24 at 9:53 a.m., an interview was conducted with RN #14. RN #14 stated they had observed Patient #21 in the front area of the hospital at 8:00 p.m. on 11/30/23 and they had exchanged greetings. They stated security talked to the patient on 12/1/23 at 12:00 a.m. and at this time, Patient #21 stated they had an appointment. RN #14 stated security asked the patient to leave as all clinics were closed at that time. They stated shortly afterward, security found Patient #21 outside cold and exhibiting signs of altered consciousness and brought them into the ED. RN #14 stated Patient #21's care had fallen through the cracks. They stated they did not understand how this patient was left unattended for over 10 hours with no food or water and without any staff being aware that Patient #21 needed help. RN #14 stated Patient #21 could have died if they had a severe medical emergency.

This interview was in contrast to the security report for Patient #21 which read the patient had been seen by an ED RN on 11/30/23 at 8:00 p.m. and again on 12/1/23 at 12:00 a.m. before the patient was asked to leave the facility. This interview was also in contrast to the medical record which read security brought Patient #21 to the ED after security "confronted" them in the lobby without mentioning the patient had been asked to leave the facility.

vi. On 3/4/24 at 2:27 p.m. an interview was conducted with RN #12. RN #12 stated they worked closely with security to ensure patient safety. They stated in their experience, they felt security could have received more training on patient care and de-escalation of aggressive patients. RN #12 stated all patients who entered the ED received an MSE. They stated an MSE was important as the ED physicians needed to perform an assessment to provide a diagnosis and treatment. They stated the risk if a patient was not provided with an MSE or an MSE appropriate to the presenting concerns, was further complications of their presenting health concern or death.

This was in contrast to Patient #2's medical record which did not reveal an MSE that had included kidney stones in the differential diagnosis, Patient #21's medical record which did not reveal an MSE provided to a patient presenting to the facility with altered mental status until 10 hours after arriving, and Patient #4, Patient #7, Patient #8, Patient #13, and Patient #15's medical records which revealed missing assessments during their stay in the ED.

vii. On 2/28/24 at 1:42 p.m. an interview was conducted with RN #6. RN #6 stated the frequency of patient assessments in the ED was decided by the nursing staff based on the patients' complaints, administered medications, and previous vital signs. They stated more acutely ill patients were assessed more frequently which was in contrast to the medical records for Patient #4, Patient #7, Patient #8, Patient #13, and Patient #15 which revealed a lack of assessments during their time in the ED. RN #6 stated RNs used their skills and experience to determine the appropriate frequency of patient assessment and had the support of the ED physicians who were also closely involved in providing patient care. RN #6 stated patients with psychiatric health concerns were assessed at regular intervals to determine changes in condition although there was also not a set schedule on when the assessments would occur.

RN #6 stated nurses in the ED performed POCT to assess blood glucose levels. They stated RNs typically assessed blood glucose every 15-30 minutes in patients with blood sugar imbalances and once the patients were stabilized, they decreased the frequency of assessment. RN #6 stated if patients were given insulin, blood glucose was checked 15 minutes afterward to ensure their blood sugar did not drop below a healthy level. This statement was in contrast to the medical record for Patient #8 which revealed IV insulin was administered at 6:31 a.m. and blood glucose was checked one hour and 55 minutes afterward. At that time, Patient #8's blood sugar was 461 (normal 70-106). RN #6 stated blood sugar imbalances could have resulted in a compromised airway (inability to breathe), putting a strain on the heart, and decompensation (inability of the heart to maintain circulation).

RN #6 stated for patients presenting with urinary complaints, one of the diagnostic tools used by the physicians was imaging, which could have ruled out kidney failure. They stated physicians would sometimes order Toradol (a prescription pain medication) for pain relief in patients with a history of kidney stones. This interview was in contrast to Patient #2's medical record which revealed they were diagnosed with a urinary tract infection (UTI), their pain was acutely elevated at 10/10, and although kidney stones were documented in Patient #2's past medical history, this was not considered in the differential diagnosis.

RN #6 stated regular patient assessment was important, as being at a rural facility, the patient could have waited for transport or a bed to open in a facility that offered a higher level of care. They stated if patients were not reassessed, patients could decompensate; for example, in patients with chest pain, the heart could change from having a normal rhythm to ST Elevation Myocardial Infarction (STEMI) (a heart attack with a completely blocked coronary artery), a patient with abdominal pains could experience a rupture in the intestines, or a patient with altered mental status could lose the ability to breathe and their heart could stop. This interview was in contrast to the medical records for Patient #4, Patient #7, Patient #8, Patient #13, and Patient #15 which revealed a lack of assessments during their time in the ED. This was additionally in contrast to the medical record for Patient #21 who presented with altered mental status and was not assessed by the facility as they were not recognized as needing medical attention.

viii. On 2/28/24 at 1:16 p.m., an interview was conducted with the ED medical director (Medical Director) #2. Medical Director #2 stated patients were assessed by the nurses on a regular basis and the frequency of vitals was determined by the nurses based on the patients' clinical conditions. Medical Director #2 stated the importance of assessment in the ED depended on patients' presenting concerns and all patients did not require the same type and frequency of assessment. They stated the RN assessments did assess and reassess pain as it was important to know if a patient was feeling better or worse. Medical Director #2 stated patients with a history of diabetes and on insulin needed their blood sugar to be rechecked one hour after insulin was administered so that the patients did not develop altered mental status. They stated a patient with Patient #2's presenting concerns was to have been medically screened for kidney stones with imaging. Medical Director #2 stated they were unsure why this imaging was not conducted for Patient #2.

ix. On 2/28/24 at 3:00 p.m. and at 4:39 p.m., interviews were conducted with Physician #3. Physician #3 stated the type and frequency of patient assessments were based on the patients' conditions. They stated their practice was to allow nurses to determine the frequency of these assessments. Physician #3 stated the MSE was important to diagnose patients in the ED. They stated a comprehensive MSE, including the history and physical and labs, provided necessary information for understanding patients' concerns. Physician #3 stated in the case of patients presenting with a psychiatric concern, they could have a medical concern driving their mental health, such as a thyroid imbalance, electrolyte imbalance, or head trauma. Physician #3 stated understanding a patient's history was important for understanding their current health concern and there was a risk to the patient if a comprehensive MSE was not performed.

Physician #3 stated in the example of Patient #2 with their medical history of kidney stones and their presenting symptoms, they would have ordered im

Based on interviews and document review, the facility failed to ensure patients presenting to the emergency department (ED) with an emergency medical condition (EMC) received stabilizing treatment according to facility policy. This failure impacted one of seven patients reviewed who were assessed in the ED and discharged home. (Patient #2)

Findings include:

Facility policies:

According to the Admission Policies and Patient Care in the ED policy, all patients admitted to the ED will be seen by a provider and have a face sheet (summary of patient's information) generated. All such patients will be triaged (given a preliminary assessment) into the system by the ED provider. Any patient who presents to the ED for care will be provided any necessary stabilization or treatment.

According to the Policies of the Emergency Department policy, the reason is to stabilize and care for acutely ill and injured patients, to provide care on a continuous basis once entered into the system, and to provide quality care of the patient and family within the scope of capability, to be aware of patients' clinical and personal needs and meeting them with rapid response, to provide adequately trained personnel and a safe environment at all times. The ED was open to ill or injured patients so that the patients' conditions could be assessed and treatment rendered. The hospital and medical staff are responsible for ensuring that emergency care meets the general standards of care. Emergency patient care shall be guided by written policies and shall be supported by appropriate procedure manuals and reference materials. There shall be written policies concerning the extent of treatment carried out in the ED. A control register shall be kept by the ED. The register shall contain at least the name, date, and time of arrival and departure, with a control number of each patient served. Reports of laboratory test results shall be made available promptly to the practitioner providing emergency care. There shall be a mechanism for notifying and recalling patients who require additional or repeat laboratory studies.

According to the Standards of Nursing Practice-ED policy, Emergency Nursing Practice is the nursing care of individuals of all ages with perceived physical and/or emotional alterations which are undiagnosed and may require prompt intervention. The scope of nursing practice in an emergency setting encompasses nursing activities which are directed toward health problems of various levels of complexity. A rapidly changing physiological and/or psychological status, which may be life-threatening, requires assessment and supportive care.

Reference:

According to the Cardiac Routine Order Set, nursing interventions: place the patient in a monitor bed and obtain vital signs every 15 minutes four times, and then if stable, may change to every 30 minutes to one hour depending on the patient's acuity.

1. The facility failed to ensure patients presenting to the ED with an EMC received necessary and stabilizing treatment according to facility policy.

A. Medical Records

i. A review of medical records revealed Patient #2 was not provided with the appropriate and necessary stabilizing treatment for their EMC.

A review of Patient #2's medical record revealed they presented to the ED on 11/23/23 at 5:16 a.m. with a chief complaint of pain with urination, low back pain, and a headache. Nursing notes revealed Patient #2 had a temperature of 99.7°F (normal temperature was 98.6°), a pulse rate of 99 (normal was 60-100), and pain rated at 10/10. The record revealed Patient #2 had a previous history of kidney stones. Laboratory testing revealed the patient's urine contained blood and was positive for an infectious process. Physician notes revealed the treating physician diagnosed Patient #2 with a urinary tract infection. The physician's note revealed the patient was given ciprofloxacin (an antibiotic) in the hospital and was given a prescription for this same medication to pick up at a pharmacy. At discharge, the patient was instructed to alternate acetaminophen (over-the-counter (OTC) pain medication) and ibuprofen (an OTC pain medication) for pain control. The urine culture, which resulted after the patient had left the hospital, revealed the bacteria present in Patient #2's urine was resistant to ciprofloxacin. The medical record failed to reveal that ED staff had prescribed a more effective antibiotic for Patient #2 to eliminate their bacterial infection or attempted to contact Patient #2 to inform them of the new laboratory results.

This review of Patient #2's medical record was in contrast to the Policies of the Emergency Department policy which read, acutely ill and injured patients were stabilized and treated with rapid and quality care. The facility and medical staff were responsible for ensuring emergency care met the general standards of care. Reports of laboratory test results were made available promptly and there was a mechanism for notifying and recalling patients.

This review of Patient #2's medical record was also in contrast to the Admission Policies and Patient Care in the ED policy which read, all individuals who presented to the ED and requested medical treatment were provided any necessary stabilization or treatment for an EMC.

B. Interviews

i. On 2/28/24 at 12:09 p.m., an interview was conducted with registered nurse (RN) #10. RN #10 stated physicians and nurses in the ED worked closely together and this contact allowed for patients to receive the necessary care.

ii. On 2/28/24 at 1:42 p.m. an interview was conducted with RN #6. RN #6 stated for patients presenting with urinary complaints and a history of kidney stones, physicians would sometimes order Toradol (a prescription pain medication) for pain relief. This interview was in contrast to Patient #2's medical record which revealed although they were diagnosed with a urinary tract infection (UTI), their pain was acutely elevated at 10/10, and although kidney stones were documented in Patient #2's past medical history, pain medications were not provided at the facility.

iii. On 2/28/24 at 3:00 p.m. and at 4:39 p.m., an interview was conducted with Physician #3. Physician #3 stated in the example of Patient #2 with their history of kidney stones and presenting symptoms, the treatment for kidney stones would have included Toradol (pain medication), intravenous (IV) fluids, and Flomax (a medication to help with urination) and potentially, a referral to a urologist. Physician #3 stated Patient #2's urine culture was ordered to ensure the bacteria in the urine was sensitive to the prescribed antibiotic. They stated if the bacteria was resistant to the antibiotic, as Patient #2's culture had determined, the patient was called and a more effective antibiotic was prescribed. Physician #3 stated ensuring all appropriate medical care was provided for an EMC was important as there was no guarantee patients would seek follow-up care.

iv. On 2/28/24 at 1:16 p.m., an interview was conducted with the ED medical director (Medical Director) #2. Medical Director #2 stated if the assessment revealed kidney stones, staff were to have provided pain medication to patients with Patient #2's presenting concerns and history of kidney stones. They stated if kidney stones were revealed on imaging, physicians may have also referred Patient #2 to a urologist. Medical Director #2 stated for Patient #2 and any patient for whom a culture had been obtained, the physician and nurse were to call the patients with the results of their lab tests and call in new prescriptions if needed. Medical Director #2 stated they were unsure why the lab results were not provided to Patient #2.