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Based on current policies and procedures, Dedicated Emergency Department (DED) medical record review, the hospital's physician and staff interviews; the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

The hospital's DED medical staff failed to provide an appropriate medical screening examination within the capability of the hospital's DED for an individual who presented for evaluation for an emergency medical condition in 1 of 39 sampled patients (Patient #3).

~ Cross refer to §489.24(a) and (c) Medical Screening Exam, Tag A2406.

Based on hospital policy review, closed DED (Dedicated Emergency Department) medical record reviews, on-call schedules review, physician interview and staff interview, the hospital's DED failed to provide an appropriate Medical Screening Examination (MSE), within the capability of the hospital's emergency department, including ancillary services (on-call orthopedic spine surgery) routinely available to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 39 sampled DED patients who presented to the hospital for evaluation and treatment of severe, escalating back pain and symptoms of possible cauda equina (Patient #3).

The findings include:

Review of the Hospital's "EMTALA COMPLIANCE, INCLUDING PATIENT TRANSFERS..." policy in place at the time of Patient #3's visit, reviewed/revised 05/15, revealed "...Emergency services and care, including an appropriate Medical Screening Examination, will be provided to individuals who 'come to the emergency department' and request examination or treatment of a medical condition, as defined in this policy. A Medical Screening Examination will be done to determine if an Emergency Medical Condition exists....'Emergency Medical Condition' or 'EMC' means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain....such that the absence of immediate medical attention could reasonable be expected to result in:...Placing the health of the individual....in serious jeopardy....Serious impairment to bodily functions....Serious dysfunction of any bodily organ or part....'Medical Screening Exam' or 'MSE' means examinations, tests, studies, monitoring, and procedures that are appropriate given the individual's presenting signs and symptoms and reasonably calculated to determine if an EMC is present, including ancillary services routinely available to the emergency department....'Stable' or 'Stabilized' means that no material deterioration of the individual's condition is likely, within a reasonable medical probability, to result from or occur during the transfer of the individual. In other words, the EMC that caused the individual to seek care is Stable, even though the underlying condition may still exist....When medically appropriate, a MSE will include consultation with the on-call physician. ..."

DED record review, on 07/11/2018, revealed Patient #3, a 72 year old, presented to the Emergency Department on Tuesday 04/17/2018 at 1241. Review of ED Triage, on 04/17/2018 at 1249, revealed " ...Stated Complaint 'since last of March having severe back plan leg ain (sic, pain), loosing (sic) bowel and bladder control' onset of loose (sic) of control Monday. ..." Triage document review revealed Patient #3 was assigned an acuity of 2. Review of a pain assessment at 1247 revealed "Pain Present ...Yes" but did not reveal a pain score. Review of a Physician Assistant (PA) note, at 1252, revealed " ...This is a 72-year-old female, past medical history of spondylosis (Painful condition of the spine), sciatica (pain affecting back, hip, and outerside of leg caused by compression of spinal nerve), s/p (status post) kyphoplasty (painful condition of the spine) and epidural approximately one week ago, presenting to the ED with persistent worsening low back pain radiating to her left lower extremity with persistent numbness and tingling. Patient states this is worst when she is ambulatory. Today she states she became incontinent of her urine prompting her to some (sic) into the ED. Denies any saddle anesthesia....Physical Exam ....General: Alert, no acute distress ....Neuro: A/Ox4 (alert and oriented to person, place, time, situation), no focal neurological deficits noted. ..." Review revealed Patient #3's procedure/surgical history included " ...lamaectomy (sic) x2 ....T 12 surgery. ..." Review of blood lab Results, collected at 1320, showed an abnormal WBC of 20.8 (Reference Range [RR] 4.1-10.7).

Review of a physician note, signed at 2158, revealed " ...The patient is a 72-year-old female who presents to the emergency department for evaluation of lower back pain with radiation to the left lower extremity and spontaneous/ unintentional loss of bowel and bladder control. Remote history of kyphoplasty and prior history of laminectomy. Patient actually has an appointment with (name) neurosurgical and spine this Friday but states that she developed these new neuro findings and spoke with the office who has recommended evaluation in the emergency department....States she got an epidural nerve block last week with minimal improvement ....Review of Systems ....NEUROLOGICAL: Back pain with radiation to the left lower extremity MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness ....Physical Exam ....Neuro: alert and oriented, moves all extremities spontaneously, 5/5 strength in the bilateral lower extremities, deep tendon reflexes preserved, ambulatory slowly but independently ....Medical Decision Making ....Differential diagnosis: Lumbar radiculopathy, cauda equina Plan... CBC demonstrates leukocytosis but no anemia or bandemia. Sed rate normal. Chemistry within acceptable limits and urinalysis without evidence of an infection. MRI of the T and L-spine has been ordered. MRI of the T-spine without abnormal cord signal or findings to suggest deficit. Discussed this patient's case with Dr. (last name) who will follow-up on results and determine disposition. ..." DED record review revealed a note at 2041 that a post void bladder scan was done that stated " ...Post Void Bladder Scan Volume Instrument ....0 mL ....Post Void Residual ....Done." Review of a L Spine MRI result, at 2150, revealed " ...Reason For Exam...back pain with LLE (Left Lower Extremity) radiation and loss of bowel/bladder control ....IMPRESSION: ... 2. Multilevel lumbar spondylotic changes, most pronounced at L (Lumbar) 4-5 with moderate severe canal with moderate to severe right and severe right neural foraminal stenosis. ..."
Review of an ED Physician note, signed 04/18/2018 at 0027, revealed " ...Medical Decision Making This patient was signed out to me by (physician name) of (sic) the end of his shift pending MRI LSpine. Essentially the patient has a history of back pain and follows with (Name) neurosurgery has appointment scheduled for this Friday. She came to the ED because she has been having worsening back pain with with (as written) radiation symptoms in the left leg without weakness or paresthesia. She is having some urinary incontinence. On exam patient has no neurologic deficit. Muscle strength is equal for the bilateral upper and lower 70s (as written). Patellar reflex is equal bilaterally and sensation is intact in all dermatomes of the lower cavities. Patient was signed out due to pending MRI of the L-spine. I did review the results and discuss this case with Dr. (first and last name) who is on-call for neurosurgery. Essentially these findings are 'normal' for patient of her age and do not require emergency or urgent decompression. He recommended outpatient follow-up....As with any illness or injury other clinical impressions are possible and may arise as the illness or injury progress. Due to this, instructions were given to return at any time if the illness or injury gets worse. Assessment/Plan Back pain with left-sided radiculopathy. ..."
DED record review revealed a request for "Consult Only", dated 04/17/2018 at 2326, for "L4-L5 severe canal stenosis with back pain, leg pain and urinary retention ...." Record review did not reveal any documentation from the consulting MD. Further record review revealed, on 04/18/2018 at 0045, a notation was made that "Pt (Patient) and family requesting to speak to patient rep (representative) and to speak with MD and neurosurgery.... MD is in room to speak with family. Further DED record review revealed a note called "ED Discharge/ Transfer/Expired" which stated " ....D/C - NO EMC Identified, STABLE at time of disposition decision. ..." Record review indicated Patient #3 was discharged via wheelchair on 04/18/2018 at 0205.

Review of an Office Note/ History and Physical by a PA, dated 04/19/2018 at 1030 (approximately 32.5 hours after discharge from the ED), revealed " ...(Patient #3) ....presents today with severe pain. Her leg pain is greater than her back pain. Her pain is 10/10. She states that since March 30, 2018, she has had back pain that radiates into the left hip, buttocks, into the left groin, and down into her lateral foot. She denies any trauma or injury. Within the last 2-3 days, she has presented with vaginal numbness with rectal and stool incontinence. She does work for a pain management doctor and she did receive a lumbar epidural steroid injection for pain within the last couple of days but it has not helped. She has had 2 MRIs. She has one from (Name) and another that was done yesterday when she presented to the emergency room at (Hospital Name). They discharged her home and her daughter was concerned still with her symptoms and contacted her PCP who then referred her to come and see us this morning. ..." Review revealed a Physical Exam was done. The Neurological Exam stated that the sensation on the right and left was normal, upper extremity coordination on right and left was normal, and lower extremity coordination on right and left side was normal. The Musculoskeletal exam stated the lower extremity muscle strength on the right was decreased and on the left indicated foot drop. Lower extremity muscle tone was recorded as normal on both sides. "Motor and other Tests" on the left side indicated " ...Hoffman's ....absent ....Clonus ....absent ....SLR ....positive ....Toe Walk ....abnormal ....Heel Walk .... abnormal ....Additional Findings: She has decreased sensation of her whole leg on the left side, left anterior lateral thigh into the lateral calf into her whole foot ....IMPRESSION 72-year-old female with grade 1-2 spondylolisthesis at L4-5 with degenerative disc disease at L5-S1 with cauda equina symptoms (serious condition caused by something compressing spinal nerve roots-considered a surgical emergency) ....Assessment/Plan ....1 ....Lumbar back pain with radiculopathy affecting left lower extremity ....2 ....Foot drop, left foot ....3 ....Back pain with radiation ....We will direct admit the patient to (hospital name) to our service for a STAT laminectomy L4-5 by (physician name) ....She will be leaving our office to go directly to patient registration at (hospital name). ..." Review of the Discharge Summary revealed Patient #3 was admitted to the hospital on 04/19/2018 at 1425, an EKG was done at 1515, and surgery was performed the same day. Review of the "Operative - Procedure Report" revealed " ...Postoperative Information 4/19/2018 20:15:00 Preoperative Diagnosis: lumbar stenosis, cauda equina syndrome, lumbar spondylolisthesis. Postoperative Diagnosis: lumbar stenosis, cauda equina syndrome, lumbar spondylolisthesis, lumbar facet cyst. Procedure: Redo Bilateral Lumbar 4/5 Hemilamintomy and Medial Facetectomy for Decompression and removal of facet cyst (left side approach) ....Post-Op Condition: Guarded ....Description of operation: ...During our contralateral exposure we did find severe impingement on the thecal sac and identified an enormous compressive cyst which was removed. ..." Further review of the Discharge Summary revealed " ...Hospital Course ...She was direct admitted for urgent surgical intervention for cauda equine syndrome with planned redo lumbar 4/5 decompensation ....Surgery was without complication....findings at surgery consistent with facet cyst. ..." Review revealed Patient #3 was discharged 04/20/2018 at 1552.

The facility's on-call schedules verified the facility had capabilities to ensure that an appropriate medical screening examination was provided; as evidenced by ancillary services to include a Orthopedic spine surgeon was on call and available to provide further evaluation and treatment for Patient #3 on 4/17/2018.


Telephone interview, on 07/11/2018 at 1256, with Physician #1 revealed he did the primary medical screening examination on Patient #3. Physician #1 stated the Triage provider (PIT - provider in triage) sees patients first and makes sure they are medically stable. Interview revealed it seemed in triage that the complaints were of a chronic nature. Interview revealed Physician #1's interpretation was the symptoms had been going on for quite a while, there was an exacerbation of symptoms rather than completely new complaints. Physician #1 stated he ordered the MRI because there was adequate information in the history and physical exam to see that Patient #3 needed emergent testing. Physician #1 stated "if memory serves she had some prior foot drop." Interview revealed there was no documentation of foot drop.

Interview with PA #1, on 07/12/2018 at 1000, revealed she was the provider in triage when Patient #3 came to the ED. Interview revealed the PA recalled the medical record from review but did not recall Patient #3. Interview revealed her role is to start testing to get the patient set up for the provider in the back. PA #1 stated Patient #3 was triaged a level 2 because of her bladder incontinence.

Interview on 7/11/2018 at 1540, with Physician #6, the ED physician who discharged Patient #3, revealed the patient was established with a neurosurgery group and came to the ED with worsening pain. Interview revealed that per the daughter the patient had a new symptom of loss of bowel and bladder control. Interview revealed the patient's main complaint was of worsening pain with radiation into her left leg as well as numbness and tingling, but no weakness, and urinary incontinence. At the time Physician #6 came on duty, it was reported they were "waiting on the MRI results." Interview revealed Physician #6 did a head to toe assessment and there was no foot drop, but she was concerned about the urinary incontinence and pain radiating down the patient's leg. Interview revealed she was not concerned about the elevated white blood count, her concern was "neurologic". Interview revealed Physician #6 discussed her concerns with the on call physician, expressed to him this was an elderly patient with new symptoms, including incontinence, and stated she expressed concern for cauda equina. Interview revealed the on-call physician asked about the exam and it showed normal reflexes and no sensory deficit in the legs. Interview revealed Physician #6 was so concerned about the patient that she made sure to go over the back page of instructions with the family. Physician #6 stated she encouraged the patient/family to come back to the ED if any new symptoms developed. Physician #6 stated she did not tell the patient and family that the symptoms were related to the patient's age, although she stated that was what the on-call physician said to her. Physician #6 stated the family voiced concerns the patient already had some of the symptoms listed as reasons to return and Physician #6 stated she understood that. Physician #6 said she told them the paper was for generic symptoms, the patient had been evaluated today, and she encouraged them to come back to the ED if needed. Physician #6, in interview, said she did not request the on call physician to come to the ED to evaluate the patient. Interview revealed Physician #6 was aware the family was upset, but also knew the patient was established with a neurosurgeon and had an appointment scheduled. Interview revealed she did not think Patient #3 needed to be admitted. Physician #6 stated her concerns were with the patient's symptoms, not the physical exam.

Interview, on 07/12/2018 at 0830, with RN #1 revealed she was the discharging nurse and recalled Patient #3. Interview revealed the patient was in pain. Interview revealed it was shooting pain and Patient #3 could not get up and go to the bathroom.

Telephone interview with Physician #4, on 07/11/2018 at 1510, revealed he was on call for consults related to orthopedic spine surgery the night Patient #3 came to the ED. He stated it was a 0200 call for back pain and stenosis. Interview revealed there was no discussion of incontinence on the first call. Physician #4 indicated he reviewed the MRI scans and also knew Patient #3 had a MRI 3 days before. Interview revealed there were chronic changes of stenosis and Physician #4 recommended follow-up as an outpatient. Physician #4 stated he spoke with the ED physician and said it was not an emergent problem, that to have abnormal imaging was normal at 72 years old and stenosis was pretty common. Patient #3, he stated, did not have saddle anesthesia. Physician #4 further stated that on the second call there was some discussion of incontinence. He said based on literature, if not treated in the first 24-48 hours there was no need to rush surgery, no indication that emergent intervention made a difference. Physician #4 stated with the imaging results and no reported saddle anesthesia, there was no acute problem that required emergent surgery. The facility failed to ensure that their policy and procedure were followed as evidenced by failing to ensure that ancillary services that were available to the hospital's ED provided further evaluation and treatment for Patient #3 on 4/17/2018 who presented to the ED with complaint of sever back pain and possible cauda equina. As this resulted in an inappropriate medical screening examination.

Telephone interview with Physician #7, on 07/12/2018 at 1745, revealed Physician #7 was the radiologist who read the MRIs on Patient #3. Interview revealed it was difficult to answer whether further testing or intervention was needed based on the MRI results. Interview revealed at L4-5 level there was moderate to severe narrowing, leaning to severe. Interview revealed there was nothing on the MRI that was obviously emergent, it looked like it could be degenerative changes. Physician #7 stated he did not see the facet cyst on the MRI at L4-5. The finding alone, he stated, may or may not indicate a need for intervention, it had to be added to the clinical picture, the acuity of symptoms.

Interview with PA #2, a provider in the neurosurgery office, on 07/12/2018 at 0930, revealed she recalled Patient #3. Interview revealed the patient's primary care doctor called and said the patient needed to be seen urgently. Interview revealed it was the first time PA #2 had seen the patient and stated Patient #3 was not an established patient with the group. Interview revealed when Patient #3 came into the office, she was crying, was in a lot of pain, had weakness in her leg, decreased sensation of her left leg and thigh, and had left foot drop. Interview revealed Patient #3 also had problems going to the bathroom, had vaginal numbness, and had stool incontinence for the last two-three days. Interview revealed the patient/family stated she had been seen in the ED and the ED did not think she needed to be admitted. Interview revealed PA #2 was concerned about the exam and had Physician #5 come see the patient urgently. PA #2 stated the physician agreed Patient #3 needed surgery that day. Interview revealed PA #2's focus was "on what we can do now to get her better."

Interview on 07/12/2018 at 1140 with Physician #5, revealed he saw Patient #3 in his office on 07/19/2018. Interview revealed that on exam Patient #3 had significant weakness in her left leg, also had foot drop, had saddle anesthesia and both stool and bladder incontinence. The patient was in severe pain in the office. Interview revealed Physician #5 considered Patient #3's situation to be urgent, with severe neurologic findings. Interview revealed the risk of delaying surgery was the neurologic deficits could become permanent or irreversible. The symptoms present in the office, Physician #5 stated, were consistent with cauda equina. Interview revealed MRI image alone is not enough to define the urgency of the situation.

Interview with Physician #2, a Neurosurgeon, on 07/11/2018 at 1445, revealed he did the surgery on Patient #3. Interview revealed Physician #2's partner saw Patient #3 in the office, and because he was leaving town that day, asked Physician #2 to do the surgery. Interview revealed that when seen on 04/19/2018, the patient had back pain, weakness, saddle anesthesia, and bowel and bladder incontinence. Interview revealed the surgery showed a facet cyst which could not be easily seen on MRI. Physician #2 stated it was not seen prior to surgery, it was found during surgery. Interview revealed that fluid could come in and out of those cysts, which could make symptoms better for a time, then worse.