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Based on record review and interview, Hospital B failed to enforce its policy to ensure compliance with 42 CFR 489.24 for one of one patient (Patient #1). Patient #1 had been admitted to Hospital B from Hospital A to provide stabilizing treatment to an emergency medical condition. The patient was in pain, and unable to walk. Discharge with Home Health Charity was recommended. Although Patient #1 refused to leave the hospital and struggled to stand up, he was discharged from Hospital B four days after admission still in severe pain, unable to walk and with high blood pressure. Within three hours of the Hospital B discharge, Patient #1 sought emergency care at Hospital A again. Patient #1 was assessed to have a severe spinal canal compromise with sensory loss in both legs, the same condition he had when he was tranferred to Hospital B. Patient #1 was in danger of permanently losing his bladder function. The patient underwent decompression surgery at Hospital A and was discharged three days later after the provision of an stabilizing treatment to an emergecy medical condition. Patient #1 was able to stand, walk, and had intact sensation in his legs.

Cross refer to A2407 and A 2409

Based on record review and interviews, the hospital (Hospital B, Medical Center of McKinney), after admitting one of one patient (Patient #1) to the hospital's inpatient unit, failed to stabilize the emergency medical condition in that Patient #1 was discharged home in severe pain and with high blood pressure. The required surgical intervention for the emergency medical condition of this uninsured patient was not provided. Therefore, the patient was not admitted to the hospital in good faith. The patient returned to Hospital A's Emergency Department (ED) to seek further care and was admitted. The required surgical intervention for the emergency medical condition was performed within three hours after discharge from Hospital B.

Findings included:

Hospital A ED Physician Report dated 04/25/14 at 11:14 by Hospital A, Personnel MD #15, noted that Patient #1 was previously treated for low back pain prior to presentment at the hospital. The patient had been unable to walk, defecate, or urinate for a few days prior to presentment. Magnetic Resonance Imaging (MRI) reflected "...severe impingement at L4-L5..."

Patient' #1's admitting diagnoses dated 04/25/14 at 16:31 by Hospital A Personnel MD #15 included Back Pain, Disc Herniation, Cauda Equina, and Chronic Back Pain. The patient was accepted at Hospital B for "neurosurgical emergency."

Hospital A's ED Clinical Summary dated 04/25/14 at 16:32 by Hospital A, Personnel #19, noted that Patient #1 left Hospital A's ED to be transferred to Hospital B. Patient #1's discharge information included Cauda Equina Syndrome, a neurosurgical emergency (http://www.aans.org).

Hospital B's ED Provider Report dated 04/25/14 at 17:46 by Hospital B, Personnel #9, reflected Patient #1 was transferred from Hospital A with complaints including back pain and numbness and tingling in both legs. Patient #1 was unable to walk or stand up.

Hospital B's patient data information sheet noted Patient #1 was uninsured and did not have a primary or family physician.

The History and Physical Exam dated 04/25/14 at 22:39 by Hospital B, Personnel MD #12, noted Patient #1 had Chronic Back Pain with Radiculopathy (pinched nerve).

Brief Consultation Note dated 04/25/14 at 21:29 by Hospital B, Personnel MD #11, noted the patient had "...acute on chronic back pain..." and bulging discs in the lower back.

Hospital B, Personnel MD #1,2 noted on 04/27/14 at 16:43 that Patient #1 was "...probably not a surgical candidate..." and noted social services involvement for "...home health charity."

Hospital B's Case Management Report dated 04/28/14 at 15:45 reflected Patient #1 was not scheduled for surgery and "...has been told he may follow up as an outpatient." The document noted that Patient #1 "...refused to leave the hospital stating he is unable to walk...continues to complain of severe pain and became tearful...struggled to stand up...charity pending."

Hospital B Personnel MD #12's discharge summary dated 04/28/14 at 11:42 noted Patient #1's condition at discharge was "fair, improved." Follow up appointments included a primary care physician and "...neurosurgery as recommended."

Hospital B clinical documentation records dated 04/29/14 at 10:45 reflected Patient #1 complained of a pain level of 8 on a 1 to 10 pain scale (10 being the highest level of pain). At 12:17, Patient #1 rated his pain level a 9 on the pain scale of 1 to 10. The notes reflected the physician denied another dose of Dilaudid (pain medication) "...and will not provide any further narcotic medication as the patient is discharged..." The clinical documentation reflected Patient #1's blood pressure readings were 181/92 at 07:23 and 192/97 at 11:17. The notes timed at 12:45 reflected Patient #1 had high blood pressure and received medication. Patient #1 "...refused BP [blood pressure] recheck and was discharged off the unit." Patient #1 left at 12:45 in "stable condition."

Hospital B's Patient Referral Emergency Department Policy PC.PP.108 dated 02/2014 reflected the purpose to ensure Hospital B "...complies with the intent of EMTALA and other related federal/state/local regulations in providing care to patients who present to the Emergency Department."

Hospital B's EMTALA Texas Transfer Policy PC.PP.104 dated 05/2013 noted that "the transfer of an individual shall not consider/insurance status, economic status or ability to pay for medical services..."

Hospital B's Pain Management Policy PC.PP.104 dated 03/2014 noted "...severe pain corresponds to pain scale of 7-10..."

Hospital A Personnel MD #15 ED Physician Record Final Report dated 04/29/14 at 15:52 reflected Patient #1 was "...unable to walk due to the pain..." and unable to void. Patient #1 was admitted to the hospital with diagnoses including Cauda Equina Syndrome, Emergency.

Hospital A's MRI spine report dated 04/29/14 at 16:43 by Hospital A Personnel MD #14 noted "...no significant change has occurred since prior examination."

Patient #1's History and Physical reports dated 04/29/14 at 19:51 by Hospital A Personnel MD #13 reflected the patient had a "severe lumbar spinal stenosis with cauda equine [equina] syndrome."

The Final Report of Consultation dated 04/29/14 at 19:34 by Hospital A Personnel MD #16 reflected Patient #1 had "...severe spinal canal compromise...a dense sensory loss around the perineal area...and both lower extremities...may have permanently lost bladder function at this point."

Hospital A's Preliminary Discharge Summary dated and signed by Hospital A Personnel MD #13 on 05/09/14 at 18:14 reflected Patient #1's discharge diagnoses included Cauda Equina Syndrome with Cauda Equina Compression, Urinary Retention, Urinary Tract Infection, and Hypertension. Decompression laminectomy surgery was performed on 04/30/14. After the surgery Patient #1 was able to void without catheterization and "up and walking..." Patient #1 was discharged on 05/02/14 with the ability to "...stand and walk...raise his legs against gravity...[and] has intact sensation in his lower extremities bilaterally."

Based on record review and interviews, Hospital B failed to stabilize an emergency medical condition for one of one patient (Patient #1) in that the patient had been admitted with severe back pain and inability to walk. The patient was discharged home four days later although still in severe pain and hypertensive. Patient #1 sought emergency care at Hospital A and was admitted for emergency neurosurgical intervention within three hours of discharge from Hospital B.


Findings included:

Hospital A ED Physician Report dated 04/25/14 at 11:14 by Hospital A Personnel MD #15 noted Patient #1 was treated for low back pain. The patient had been unable to walk, defecate, or urinate for a few days. Magnetic Resonance Imaging (MRI) reflected "...severe impingement at L4-L5..."

Patient' #1's admitting diagnoses dated 04/25/14 at 16:31 by Hospital A Personnel MD #15 included Back Pain, Disc Herniation, Cauda Equina, and Chronic Back Pain. The patient was accepted at Hospital B for "neurosurgical emergency."

Hospital A's ED Clinical Summary dated 04/25/14 at 16:32 by Hospital A Personnel #19 noted Patient #1 left Hospital A's ED to be transferred to Hospital B. The patient's discharge information included Cauda Equina Syndrome, a medical emergency (http://www.aans.org).

Hospital B's ED Provider Report dated 04/25/14 at 17:46 by Hospital B Personnel #9 reflected Patient #1 was transferred from Hospital A with complaints including back pain and numbness and tingling in both legs. Patient #1 was unable to walk or stand up.

Hospital B's patient data information sheet noted Patient #1 was uninsured and did not have a primary or family physician.

The History and Physical Exam dated 04/25/14 at 22:39 by Hospital B Personnel MD #12 noted Patient #1 had Chronic Back Pain with Radiculopathy (pinched nerve).

Brief Consultation Note dated 04/25/14 at 21:29 by Hospital B Personnel MD #11 noted the patient had "...acute on chronic back pain..." and bulging discs in the lower back.

Hospital B Personnel MD #12 noted on 04/27/14 at 16:43 that Patient #1 was "...probably not a surgical candidate..." and noted social services involvement for "...home health charity."

Hospital B's Case Management Report dated 04/28/14 at 15:45 reflected Patient #1 was not scheduled for surgery and "...has been told he may follow up as an outpatient." The document noted that Patient #1 "...refused to leave the hospital stating he is unable to walk...continues to complain of severe pain and became tearful...struggled to stand up...charity pending."

Hospital B Personnel MD #12's discharge summary dated 04/28/14 at 11:42 noted Patient #1's condition at discharge was "fair, improved." Follow up appointments included a primary care physician and "...neurosurgery as recommended."

Hospital B clinical documentation records dated 04/29/14 at 10:45 reflected Patient #1 complained of a pain level of 8 on a 1 to 10 pain scale (10 being the highest level of pain). At 12:17, Patient #1 rated his pain level a 9 on the pain scale of 1 to 10. The notes reflected the physician denied another dose of Dilaudid (pain medication) "...and will not provide any further narcotic medication as the patient is discharged..." The clinical documentation reflected Patient #1's blood pressure readings were 181/92 at 07:23 and 192/97 at 11:17. The notes timed at 12:45 reflected Patient #1 had high blood pressure and received medication. Patient #1 "...refused BP [blood pressure] recheck and was discharged off the unit." Patient #1 left at 12:45 in "stable condition."

Hospital B's Patient Referral Emergency Department Policy PC.PP.108 dated 02/2014 reflected the purpose to ensure Hospital B "...complies with the intent of EMTALA and other related federal/state/local regulations in providing care to patients who present to the Emergency Department."

Hospital B's EMTALA Texas Transfer Policy PC.PP.104 dated 05/2013 noted that "the transfer of an individual shall not consider/insurance status, economic status or ability to pay for medical services..."

Hospital B's Pain Management Policy PC.PP.104 dated 03/2014 noted "...severe pain corresponds to pain scale of 7-10..."

Hospital A Personnel MD #15 ED Physician Record Final Report dated 04/29/14 at 15:52 reflected Patient #1 was "...unable to walk due to the pain..." and unable to void. Patient #1 was hospital admitted with diagnoses including Cauda Equina Syndrome, Emergency.

Hospital A's MRI spine report dated 04/29/14 at 16:43 by Hospital A Personnel MD #14 noted "...no significant change has occurred since prior examination."

Patient #1's History and Physical reports dated 04/29/14 at 19:51 by Hospital A Personnel MD #13 reflected the patient had a "severe lumbar spinal stenosis with cauda equine [equina] syndrome."

The Final Report of Consultation dated 04/29/14 at 19:34 by Hospital A Personnel MD #16 reflected Patient #1 had "...severe spinal canal compromise...a dense sensory loss around the perineal area...and both lower extremities...may have permanently lost bladder function at this point."

Hospital A's Preliminary Discharge Summary dated and signed by Hospital A Personnel MD #13 on 05/09/14 at 18:14 reflected Patient #1's discharge diagnoses included Cauda Equina Syndrome with Cauda Equina Compression, Urinary Retention, Urinary Tract Infection, and Hypertension. Decompression laminectomy surgery was performed on 04/30/14. After the surgery Patient #1 was able to void without catheterization and "up and walking..." Patient #1 was discharged on 05/02/14 with the ability to "...stand and walk...raise his legs against gravity...[and] has intact sensation in his lower extremities bilaterally."