HospitalInspections.org

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Based on a review of documentation and interview, the facility failed to ensure medical records documented information necessary to monitor the patient's condition in 2 of 20 patients whose records were reviewed (Patient #1 and Patient #8). The facility nurses failed to:
1. Document on Patient #1 a "PO Challenge" (testing of the patient's ability to tolerate an oral intake) that was pertinent to knowing the status of the patient's medical condition.
2. Document appropriately on Patient #8 who left against medical advice (AMA).
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Findings:
Patient #1 Medical Record Review for 04/23/2025 Emergency Department (ED) Visit:
A 4-year-old male (Patient #1) arrived at 7:43 AM - Patient #1 arrived as a walk-in patient with chief complaints of abdominal cramping, nausea, vomiting, and diarrhea. The medical screening examination began at 7:45 AM by Staff #9, the ED Provider. The physician notes included:
"Several episodes of emesis this morning no antiemetics given will trial antiemetic and p.o. challenge (A "PO challenge" is a way to assess a patient's ability to tolerate food and drink. It's often used to determine if a patient can safely return home after an illness, especially when there's a risk of dehydration or other complications from not being able to eat or drink.)."
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The physician later documented: "ED Course: Other. Child was given multiple antiemetics and tolerating p.o. (oral intake) without emesis at the time of discharge she he has a benign abdominal exam."
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There was no "PO Challenge" found in the nursing documentation and no
intake or output documented for Patient #1.
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By failing to document a "PO Challenge", there was no documented evidence that the patient was safe for discharge home.
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Patient #8 Medical Record Review for 11/01/2024 ED Visit:
A 32-year-old female (Patient #8) arrived as a walk-in patient at 2:10 AM with chief complaints of shortness of breath (SOB) and chest pain.; The triage began at 2:22 AM. An ESI level 3 (Urgent: Stable patients requiring multiple resources to investigate or treat, such as lab tests and imaging. Examples include abdominal pain, high fever with cough, or persistent headache.) was assigned. The medical screening exam began at 2:24 AM. The physician noted that the patient was getting angry and upset with x-ray tech, then became hostile with physician. The physician noted that the patient wanted to leave against medical advice (AMA), that the risks were explained, and that nursing should provide discharge information to the patient. Nursing documented that the patient left AMA at 2:54 AM and was given discharge instructions but did not state that the potential risks and consequences had been discussed with Patient #8. The patient left AMA at 3:02 AM. The AMA form was not found during the medical record review. The facility was asked to do a larger search for the document, but it could not be produced. Policy was not followed.
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Policy Review:
Facility A's "ED Assessment and Reassessment" policy version 5, last reviewed and implemented on 02/25/2025 stated on page 2 of 2:
" ...12. RN will complete appropriate nursing records on ED patients. LPN's and/or other licensed provider can assist in gathering data related to this process ..."
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Facility A's "Leaving Against Medical Advice - ED - Version 3" policy, last reviewed and implemented on 01/27/2025 stated on page 1 of 2:
" ...Purpose:
I. Policy:
A. When a patient leaves the Emergency Department against medical advice (AMA), the medical record should reflect exactly what treatment and instructions were advised, with thorough documentation. All patients indicating the desire to leave against medical advice shall be provided an AMA form to sign ...
II. Procedure:
B. The Registered Nurse and/or physician shall discuss and document, with the patient and/or family, the potential risks and consequences that may occur if the patient leaves prior to the physician discharging the patient ...
D. The Registered Nurse shall provide instructions to the patient to follow up with his/her family physician or return to the Emergency Department if his/her condition worsens ...
E. If the patient refuses to sign the form, complete the form except for the patient's signature, write across the signature area that the patient refuses to sign and have a second witness sign the form ..."
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Policy Review:
Facility A's "ED Assessment and Reassessment" policy version 5, last reviewed and implemented on 02/25/2025 stated on page 2 of 2:
" ...12. RN will complete appropriate nursing records on ED patients. LPN's and/or other licensed provider can assist in gathering data related to this process ..."
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Interviews:
An interview with the Treating Physician (Staff #9) was conducted on 05/28/2025 at 10:10 AM. Staff #9 indicated that he was verbally told by nursing that a PO challenge had been completed. Staff #9 indicated that he did not know where the PO challenge should have been documented. Staff #9 indicated that no emergency medical condition (EMC) was identified in Patient #1 and that Patient #1 had no signs or symptoms of hypoglycemia or any other EMC during his ED visit at Facility A.
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An interview with the Chief Quality Director (Staff #2) was conducted during the investigation beginning on 05/27/2025 at 1:15 PM. Staff #2 was asked where a PO challenge should be documented. Staff #2 indicated that it should be found in the nursing notes. The medical record for Patient #1 was reviewed again. Staff #2 could not locate any nursing notes by either of the treating RN's (Staff #7 or Staff #8) documenting the PO challenge that was indicated by the treating physician, Staff #9.
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An interview with one of the treating Registered Nurse (RN) (Staff #8) was conducted on 06/03/2025 at 11:19 AM. Staff #8 indicated that she was not the primary nurse for Patient #1. Staff #8 indicated that a PO challenge should have been documented by marking the orders for it as complete and later documented in the nursing notes.
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An interview with one of the treating Registered Nurse (RN) (Staff #7) was conducted on 06/03/2025 at 11:28 AM. Staff #7 indicated that he was the triage nurse and not the primary nurse for Patient #1. Staff #7 indicated that a PO challenge should have been documented under interventions in the nursing notes.
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Based on record review and interview the facility failed to abide by the provider's agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.

Based on record review and interview, the facility failed to provide an appropriate emergency medical screening examination (MSE) for one of 20 (Patient #11) patients whose records were reviewed. Patient #11 presented to the facility's emergency department (ED) with complaints of abdominal cramping, vomiting, and chest pain on 12/1/2024. The patient did not receive further imaging (x-ray) or advanced imaging (CT/CTA) of their chest to rule out emergency medical conditions (EMCs).

Based on record review, facility policy, and interviews, Facility A failed to provide an appropriate transfer for 3 of 20 patients (Patient #7, #11, and #13) whose records were reviewed. Patients #7, #11, and #13 were all transferred with an incomplete memorandum of transfer (MOT). The MOT was missing a summary of risks, benefits, and a signed physician's certification.

Cross Reference:
Tag A-2406 - 42 CFR §489.24 (a) (c) Appropriate Screening Examination.
Tag A-2409 - §489.24 (e)(1) and (2) Appropriate Transfer

Based on record review and interview, the facility failed to provide an appropriate emergency medical screening examination (MSE) for one of 20 (Patient #11) patients whose records were reviewed. Patient #11 presented to the facility's emergency department (ED) with complaints of abdominal cramping, vomiting with blood, and chest pain on 12/1/2024. The patient also endorsed coffee ground emesis and was noted to have medical history of esophagitis and gastritis. The patient did not receive further imaging (x-ray) or advanced imaging (CT/CTA) of their chest to rule out emergency medical conditions (EMCs).


Findings include:
Patient #11, a 76-year-old female, presented to the emergency department on 12/1/2024 at 8:30 AM with complaints of abdominal pain and blood in vomit.
The patient's HPI documented at 12/1/2024 at 9:28 AM (history of the preset illness) indicated, "76-year-old female with history of risks of gastritis, hiatal hernia developed with abdominal pain and hematemesis last night ....Also complaining of substernal chest pain radiating down into her left arm. No known history of coronary artery disease."
Vital Signs documented for the patient from 12/1/2024 at 8:34 PM through 10:32 AM indicated 30-minute interval readings of: 193/87, 176/98, 189/75, 138/83, 187/89, 201/79, and 189/90. The patient's EKG and troponin resulted with normal findings. The patient was diagnosed with an upper GI (gastrointestinal) hemorrhage as noted on the patient's MOT.

ED Physician documentation on 12/1/2024 at 9:34 AM indicated a differential diagnosis of GI bleed, hemorrhagic shock, ACS (acute coronary disease).
At 9:35 AM, the ED course is documented as, "Final Impression Primary 76-year-old female with history of erosive gastritis developed epigastric and sternal pain last night, and multiple episodes of coffee-ground emesis. She is not on blood thinners. She is hemodynamically stable, hemoglobin at baseline, 13.7. She was given a pantoprazole bolus followed by continuous drip. We do not have Gastroenterology on-call today, discussed need for transfer to higher level of care for, family and patient are agreeable."

The medical record does not contain evidence to support that the patient's complaints of chest pain were addressed with a chest x-ray and/or CT (computed tomography) imaging of the chest was not completed to further rule out any additional emergency medical conditions the patient may have been experiencing.

On 12/1/2024 at 9:52 PM, transfer orders were entered for the patient with a reason noted as, "GI- higher level of care."

Policy Reviews:
Facility A's "ESI (emergency severity index) Triage - Version 3" policy, last reviewed and implemented on 11/11/2024, stated on page 1 of 3:
"Acuity levels will be assigned based on the Emergency Severity Index (ESI) algorithm found in Attachments A and B." The attachments (pages 2 and 3) were reviewed, appeared vague, and did not reveal specific meanings for each ESI level. The footnoted ESI levels were found on the NIH (National Institutes of Health) website.
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Facility A's "ED Assessment and Reassessment - Version 5" policy, last reviewed and implemented on 03/04/2025, stated on page 1 of 2:
" ...4. Each patient should have a Medical Screening Examination (MSE) by a physician, physician extender or an RN as approved by
hospital bylaws.
5. The Medical Screening Examination (MSE) may include, but is not limited to diagnostic laboratory testing, cardiac testing,
radiology, and other invasive and non-invasive procedures as indicated to determine the patient's health care or treatment needs ...
...8. The assessment of infants, children, and adolescents begins at triage and is individualized. Refer to Emergency Department pediatric reference manual for required additional assessment ..."
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And on page 2 of 2:
" ...13 In addition, all patients should have vital signs (blood pressure, pulse, respirations, temperature and paan) monitored as
follows:
Pain using appropriate pain scale
Blood Pressure (BP), Heart Rate (HR), Respiratory Rate (RR)
Temperature (Temp)
Pulse OX
Weight
Height
Repeat vital signs q1 hour and/or as appropriate to chief complaint
Repeat assessment q1 hour for level 2-3 patients
Repeat assessment q2 hour for level 4-5 patients
Monitoring as appropriate to chief complaint
All patients on Oxygen will have a respiratory assessment completed and reassessed as necessary
Repeat pain scale per Pain Assessment and Management policy ...
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... 14. Pediatric patients - refer to pediatric manual for guidelines ..."
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Facility A's "Standing Medical Orders - Version 3" policy, last reviewed and implemented on 01/27/2025 stated on page 2 of 2:
" ...2. Abdominal Pain
a. Pulse Ox Continuous
b. CBC, CMP, Lipase, Serum, UA, UPT (if female of childbearing age), PIV saline lock ..."

Facility A's "Medical Staff Rules and Regulations" policy, last reviewed and implemented in November 2021 stated on page 21 of 25:
" ...6.1(a) Screening
(1) Any individual who presents to the Emergency Department of this Hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. Generally, an "emergency medical condition" is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child.
(2) Examination and treatment of emergency medical conditions shall not be delayed in order to inquire about the individual's method of payment or insurance status, nor denied on account of the patient's inability to pay.
(3) All patients shall be examined by qualified medical personnel, which shall be defined as (i) a Physician; (ii) AHPs where permitted by State law and Hospital policy; and (iii) in the case of a woman in labor, a registered nurse trained in obstetric nursing where permitted under State law and Hospital policy.
(4) Services available to Emergency Department patients shall include all ancillary services routinely available to the Emergency Department, even if not directly located in the department ..."

Interviews:
An interview with the Chief Quality Director (Staff #2) was conducted during the investigation beginning on 05/27/2025 at 1:15 PM. Staff #2 indicated Patient #11 was transferred in stable condition.
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Based on record review, facility policy, and interviews, Facility A failed to provide an appropriate transfer for 3 of 20 patients (Patient #7, #11, and #13) whose records were reviewed. Patients #7, #11, and #13 were all transferred with an incomplete memorandum of transfer (MOT). The MOT was missing a summary of risks, benefits, and a signed physician's certification.

Findings:
Patient #7 Medical Record Review:
Patient #7 was admitted to the ED on 04/23/2025 at 10:37 AM as a walk-in with chief complaints of weakness. Patient #7 was diagnosed with an AVF (arteriovenous fistula) malfunction and weakness. Patient #7 was transferred for an AVF replacement at 9:39 PM. The MOT was reviewed. The risks or benefits were not noted, and the document did not contain a physician signature on the physician's certification. The MOT indicated the reason for transfer was for, "medical necessity/upgrade in care" and that the patient was in "stable condition", however the transfer was an "emergency transfer and the patient's EMC persisted
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Patient #11 Medical Record Review:
Patient #11 was admitted to the ED on 12/01/2024 at 8:24 AM with chief complaints of vomiting and abdominal pain. Patient #11 was diagnosed with a gastrointestinal hemorrhage. The risks or benefits were not noted, and the document did not contain a physician signature on the physician's certification.The MOT indicated the reason for transfer was for "medical necessity/upgrade in care" and that the patient was in "stable condition", however the transfer was an "emergency transfer."
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Patient #12 Medical Record Review:
Patient #12 was admitted to the ED on 12/01/2024 via EMS at 9:29 AM with chief complaints of "feeling weird" like his heart racing. Patient #12 was diagnosed with ventricular tachycardia and atrial fibrillation. The patient was transferred on an amiodarone drip at 1:47 PM. The MOT was reviewed. The risks or benefits were not noted, and the document did not contain a physician signature on the physician's certification. The MOT indicated the reason for transfer was for "medical necessity/upgrade in care" and that the patient was in "stable condition", however the transfer was an "emergency transfer".
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Patient #13 Medical Record Review:
Patient #13 was admitted to the ED on 12/08/2024 via EMS at 5:53 PM with chief complaints of generalized pain. Patient #13 was diagnosed with rhabdomyolysis, acute kidney failure, dehydration, UTI, fall, hypokalemia, and acute ganglionic intercranial hemorrhage. The patient was transferred at 9:09 PM. The MOT was reviewed. The risks or benefits were not noted, and the document did not contain a physician signature on the physician's certification. The MOT indicated the reason for transfer was for "medical necessity/upgrade in care" and that the patient was in "stable condition", however the transfer was an "emergency transfer.". The patient was transferred via "ground ambulance requiring cardiac monitoring capabilities.
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Policy Review:
Facility A's "Transfer" policy version 4, last reviewed and implemented on 11/26/2024 stated on page 3-4 of 7:
" ...C. Physician Certification - If the physician on call issues orders for the transfer of an individual by telephone or radio, those orders shall be reduced to writing in the patient's medical record, signed by the Hospital staff member receiving the order, and countersigned by the physician authorizing the transfer as soon as possible. In addition, a patient transfer certification form must be signed by the Hospital personnel effecting the transfer and the transferring physician. The physician certification shall include a summary of risks of benefits that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient and, in the case of labor, to the unborn child from effecting the transfer ..."

And on page 4 of 7:
" ...2. Transfer Prior to Stabilizing an Individual with an Emergency Medical Condition or a Woman in Labor An individual with an emergency medical condition, or a woman in labor, must be stabilized prior to transfer, unless:
A. The patient, or a legally responsible person acting on the patient's behalf, after being informed of the Hospital's obligations under this policy and of the risks and benefits of transfer, requests transfer to another hospital in writing, or
B. A licensed physician evaluates the individual and signs a certification, which includes a
summary of the risks and benefits, that, based upon the information available at the time of the
transfer, the medical benefits reasonably expected from the provision of the appropriate
medical treatment at another hospital outweighs the increased risks to the patient, or in the case of labor, to the unborn child from effecting the transfer; or ..."
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Facility A's "Transfer or Admission of Trauma Patients - ED" policy version 3, last reviewed and implemented on 01/27/2025 stated on page 1 of 3:
" ...7. A memorandum of transfer will accompany the patient to the receiving facility. (The white copy is sent with patient and the yellow copy is retained and sent to Quality.)
8. If the patient arrives via EMS to (Facility A) and is then transferred to another facility, a copy of the EMS Run Report will be sent with the patient to the accepting facility as available.
9. The consent for transfer is signed by the patient or guardian if the patient is underage or unable to sign for self, or implied consent is evoked if the patient is unresponsive and no family is available.
10. The Emergency Room physician will need to sign the memorandum of transfer.
11. The Memorandum of Transfer, nursing documentation, physician documentation, lab, and radiology studies on a disc will be sent with the patient.
12. When transferring to any hospital the transfer procedure is followed ..."

Interviews:
In an interview with Staff #2, Chief Quality Officer and Staff #3, Quality Coordinator, Staff #2 indicated that all 4 patients (Patient #7, #11, #12, and #13) were discharged in stable condition and the facility policy was to not have the risks and benefits listed or the certification signed by the treating physician if the patients were stable. Staff #2 indicated that all 4 patients (Patient #7, #11, #12, and #13) were stable upon discharge and that their policy was followed.