HospitalInspections.org

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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.
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Based on record review and interview, the facility failed to provide a complete emergency medical screening examination for one of 20 (Patient #1) patients whose records were reviewed. Patient #1 presented to the emergency department (ED) at Facility A on 08/18/2023, with a headache, dizziness, and weakness. Patient #1's physical exam did not include a neurologic examination to determine if an emergency medical condition (EMC) was present. Patient #1 arrived at Facility B the following day on 08/19/2023, for continued symptoms of a headache for one week, fatigue, right facial droop, and right-sided weakness for 10 days. Patient #1 was determined to have a recurrent brain tumor at Facility B and was directly admitted to the Intensive Care Unit (ICU) for an emergency medical condition (EMC).
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Cross Reference to:
Tag A-2406 - 42 CFR §489.24 (a) (c) Appropriate Screening Examination.
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Based on record review and interview, the facility failed to provide a complete emergency medical screening examination for one of 20 (Patient #1) patients whose records were reviewed. Patient #1 presented to the emergency department (ED) at Facility A on 08/18/2023, with a headache, dizziness, and weakness. Patient #1's physical exam did not include a neurologic examination to determine if an emergency medical condition (EMC) was present. Patient #1 arrived at Facility B the following day on 08/19/2023, for continued symptoms of a headache for one week, fatigue, right facial droop, and right-sided weakness for 10 days. Patient #1 was determined to have a recurrent brain tumor at Facility B and was directly admitted to the Intensive Care Unit (ICU) for an emergency medical condition (EMC).
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Findings include:
Medical Record Review at Facility A
On 08/18/2023, at 3:57 PM, Patient #1, a 51-year-old male, arrived at the emergency department (ED) of Facility A with chief complaints of headache, dizziness, and weakness. The triage nurse, Staff #7, noted during the triage assessment at 3:57 PM that Patient #1 had "flu-like symptoms since Saturday ...feeling weak and tired since Saturday .... getting worse headache, body aches, and loose stools." The triage notes also documented under "Symptoms" that Patient #1 had "dry cough, fever, shortness of breath, fatigue, nausea/vomiting, diarrhea, headache, body aches, chills." An examination by Staff #5 (the treating ED physician) was initiated at 4:40 PM. Within The History of Present Illness (HPI) that was initiated on 08/18/2023, at 4:40 PM, Staff #5 noted that Patient #1 had been "stuck in the heat" last week and "feels like he got dehydrated". The "Review of Systems" from the same HPI did not annotate that there were signs of dehydration, document an examination of the neck, note any cough, fever, or chills. The triage nurse, Staff #7, noted during the triage assessment at 3:57 PM that Patient #1 had "flu-like symptoms since Saturday ...feeling weak and tired since Saturday ....getting worse headache, body aches, and loose stools." The triage note also documented under "Symptoms" that Patient #1 had "dry cough, fever, shortness of breath, fatigue, nausea/vomiting, diarrhea, headache, body aches, chills." A review of the document titled "MSE- Medical Screening Exam: Emergency Medical Condition" completed on 08/18/2023 by Staff #5 noted, "Emergent Condition Exist. There was no documented neurological assessment and Patient #1's orientation (an assessment to indicate if the patient was aware of person, place, time and situation) was not addressed. There were no additional laboratory studies and imaging that may have been required following the neurological examination to further rule out neurological conditions.
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Laboratory studies were performed and resulted on 08/18/2023 at 5:00 PM, which showed mild dehydration with an elevated blood urea nitrogen (BUN) of 21 mg/dL (normal range is 7 - 18 mg/dL) and an elevated creatinine of 1.4 mg/dL (normal range is 0.60 - 1.30 mg/dL). A urinalysis was ordered however urine was not collected during this visit. Patient #1 had normal vital signs recorded during his triage assessment by nursing on 08/18/2023, at 3:57 PM. No EKG was obtained to rule out arrhythmia, acute coronary syndrome (ACS), or myocardial infarction (MI).
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Patient #1 was discharged by Staff #5 on 08/18/2023, at 5:41 PM with a diagnosis of viral syndrome (refers to symptoms caused by a virus). After the discharge orders were written orders to administer Norco 7.5-325 mg for pain on 08/18/2023, at 7:05 PM and for intravenous (IV) fluids, 1000 mL of Normal Saline 0.9% at a rate of 999 mL per hour. A second set of vital signs were obtained on 08/18/2023, at 7:12 PM in preparation for discharge. There was no intake or output documentation to monitor effectiveness of the IV fluids for Patient #1's dehydration. Patient #1 was discharged on 08/18/2023, at 7:12 PM. The total time Patient #1 spent in the ED was 213 minutes.
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Patient #1 had an intracranial mass that was previously diagnosed at Facility A during an admission on 01/01/2018. Additionally, Patient #1 had a return visit on 01/31/2018, documenting a brain abscess at Facility A. Due to a change in the electronic medical record systems, Patient #1's medical history pertaining to prior brain abscess diagnosis for the two past admissions was not available for Staff #5 to review as part of Patient #1's past medical history during his ED visit on 08/18/2023 to have incorporated it into his MSE.
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Medical Record Review at Facility B
On 08/19/2023, at 3:29 PM, Patient #1 arrived at the emergency department (ED) of Facility B with chief complaints documented as stated by Patient #1 of "Pain- Head (Headache x 1 week, fatigue, right facial droop, and right-sided weakness x 10 days)". A physical examination was initiated on 08/19/2023, at 3:40 PM by Staff 5B, the ED medical Provider. Laboratory studies were collected on 08/19/2023, at 3:51 PM. The tests included creatinine kinase (CK), BNP (b-type natriuretic peptide), Troponin level (a cardiac marker), CMP (complete metabolic panel), and Urinalysis (UA) with microscopic examination if indicated. A CBC (complete blood count) was ordered 17 minutes later. An electrocardiogram (EKG) was also ordered at that time.
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On 08/19/2023, at 3:52 PM, Norco 10-325 mg and Fioricet 50-325-40 mg was ordered by Staff #9B, another ED physician. On 08/19/2023, at 3:53 PM, a computed tomography (CT) angiogram of the head and neck was ordered.
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On 08/19/2023, at 4:01 PM, the EKG was obtained and showed normal sinus rhythm, a normal EKG. On 08/19/2023, at 4:02 PM, intravenous (IV) fluids, 1000 mL of Normal Saline 0.9% at a rate of 999 mL per hour were ordered and initiated. IV Zofran 4 mg was also given.
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Abnormal laboratory findings were documented on 08/19/2023, at 4:13 PM:
Monocytes elevated at 1.15 k/uL (normal range is 0 - 0.51 1.15 k/uL).
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Abnormal laboratory findings were documented on 08/19/2023, at 4:24 PM:
Urinalysis color amber, normal color is yellow.
Protein elevated at 30 mg/dL, normal is 0 mg/dL.
Glucose elevated at 50 mg/dL, normal is 0 mg/dL.
Ketones elevated at "trace", normal is 0 mg/dL.
Urobilinogen elevated at 2.0 mg/dL, normal is 0.1 - 1.0 mg/dL.
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Abnormal laboratory findings were documented on 08/19/2023, at 4:31 PM:
Glucose elevated at 128, normal is 74 - 100 mg/dL.
Albumin low at 3.4 g/dL, normal is 3.5 - 5.2 g/dL.
A/G (albumin to globulin) ratio low at 0.83, normal is 1.00 - 1.80.
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On 08/19/2023, at 4:46 PM, a CT of the head had findings and impression as follows:
"Findings: there is a mass within the right basal ganglia, measuring approximately 16 mm with surrounding vasogenic edema, and effacement of the right lateral ventricle. There is a leftward midline shift of 6 mm. no hydrocephalus. No head bleed. Visualized paranasal sinuses are clear."
"Impression:
Mass within the right basal ganglia, with mass effect and midline shift. Follow-up MRI with and without contrast may be of benefit."
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On 08/19/2023, at 4:44 PM, a CT angiogram of the head and neck had the findings and impression as follows:
"Findings:
Head: There is a mass within the right basal ganglia, measuring 15 x 21 x 27 mm. surrounding vasogenic edema with effacement of the right lateral ventricle and some midline shift. No hydrocephalus. There is a normal course, caliber, and enhancement of the circle of Willis including the ACA (anterior cerebral artery), MCA (middle cerebral artery), PCA (posterior cerebral artery), vertebral basilar junction, and intracranial portions of the ICA (internal carotid artery). There is no large vessel cut off, intraluminal filling defects, or appreciable aneurysms."
"Impression:
Neck: No hemodynamically significant stenosis.
Head: No acute abnormalities of the circle of Willis. Right intracranial mass. Follow-up MRI with and without contrast may be of benefit."
An MRI of the brain with and without contrast were ordered on 08/19/2023, at 5:07 PM.
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On 08/19/2023, at 5:08 PM, Morphine 4mg IV was ordered to be given every 15 minutes as needed for pain. It was given on 08/19/2023, at 5:12 PM. On 08/19/2023, at 5:20 PM, Fioricet 50-325-40 mg was administered. On 08/19/2023, at 5:08 PM, Keppra 1,000 mg IV was ordered as a one-time dose. On 08/19/2023, at 5:46 PM, Decadron 10 mg IV was ordered as a one-time dose. The IV Keppra was given on 08/19/2023, at 6:03 PM and the IV Decadron was given on 08/19/2023, at 6:04 PM. On 08/19/2023, at 6:11 PM, another dose of Morphine 4mg IV was given. On 08/19/2023, at 6:12 PM, the decision for admission to the hospital's Intensive Care Unit (ICU) from the ED, condition noted as "fair".
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Policy Reviews:
Facility A's "EMTALA Medical Screening" Policy, last revised and implemented in 05/2023, was reviewed. It was noted that it stated on page 2 of 2:
" ...Medical Screening Criteria is as follows:
- An MSE and Stabilizing Treatment, within the capabilities of the Hospital, will be provided to all individuals regardless of their ability to pay. Medical screening and stabilizing treatment will not be delayed to obtain payment or insurance information. Reasonable registration processes, including insurance information, may be followed as long as individuals arc not unduly discouraged from remaining for further evaluation.
- An MSE will be conducted to determine whether the Patient has an EMC. The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient's needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred.
- An MSE will be conducted on minors without waiting for parental consent. Once it is determined that the minor docs not have an Emergency Medical Condition (EMC), staff may await parental consent to conduct a further assessment or treatment.
- Where an individual comes to the Hospital's Dedicated Emergency Department and requests services for a medical condition that is not of an emergency nature, the Hospital will perform such screening as would be appropriate to determine that the individual does not have an EMC. After such determination is made, the person may be directed elsewhere for services ..."
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Facility A's "Emergency Department Protocols", last revised and implemented in 03/2023, was reviewed. It was noted that throughout the two-page document, there is no protocol for stroke or ruling out a stroke based on presenting symptoms.
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Facility A's "Medical Staff Rules and Regulations", last revised and implemented in 01/18/2019, was reviewed. The following was noted on page 5 of 27:
" ...IV Contents of Medical Records
The attending practitioner shall be responsible for the preparation of a complete medical record for each patient. Its content shall be pertinent and current. This record shall include information data, complaint, personal history, family history, history of present illness, review of systems, physical examination, special reports such as consultations, clinical laboratory, radiology and other services, provisional diagnosis, medical or surgical treatment, operative report, pathological findings, progress note, final diagnosis, condition on discharge, summary or clinical resume' and autopsy report, where performed ..." There was no past medical history noted for Patient #1 within the medical record provided.
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Interviews:
An interview with the wife of Patient #1 took place on 10/10/2023, at 5:27 PM. Patient #1's wife stated that something similar happened five years ago. Patient #1's wife stated, "five years ago Facility A did a CT and found a brain mass in a different part of his brain than the current one. That brain tumor caused different symptoms. He just couldn't see right. We never imagined that it would happen again or (Facility A) would not do another CT." Patient #1's wife was asked if she had informed Facility A of the medical history. Patient #1's wife stated that she had not and that she thought that (Facility A) should know since it had happened there (at Facility A).
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An interview with the treating ED Physician (Staff #5) took place on 10/10/2023 at 1:28 PM.
Staff #5 was provided time to review the medical record for Patient #1. Staff #5 indicated that he did not recall the patient at all, but that he felt that he was treating dehydration and that he had ordered a urinalysis (UA) but nursing was unable to collect the UA as Patient #1 could not pee.
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Staff #5 was asked why a computed tomography (CT) scan of the head was not completed on Patient #1 due to his presenting symptoms. Staff #5 indicated that a CT would not be completed on everyone who has a headache and that he did not recall anything else being said that would have merited a CT being obtained. Staff #5 felt that it looked and sounded like (Patient #1) had a viral process for the past 4 days that led to dehydration.
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An interview with the Quality Director for Facility A (Staff #2) took place on the afternoon of 10/10/2023. Staff #2 was asked if she could see any reason in the patient record that indicated to her (in her personal experience) that Staff #5 should have ordered a CT of the head or other testing. Staff #2 indicated that she saw nothing that would indicate to her and that she saw no need (in her professional experience) for Staff #5 to have ordered a CT of the head or further testing. On 10/10/2023 at 6:30 PM, Staff #2 was asked if Facility A was aware that Facility A had diagnosed Patient #1 with a brain tumor by CT scan five years ago. Staff #2 indicated that on 01/01/2018 one of their doctors had diagnosed him with a CT lesion on left occipital region of brain and instructed him to follow up with a Neurologist. Staff #2 further indicated that on a return visit on 01/31/2018 for a very different reason, the record showed a problem or medical history of a diagnosis of Brain Abscess was added to Patient #1's record. Staff #2 did not see that this medical history was disclosed during the August 2023 visit and felt that this was due to a new EMR (electronic medical record) system.
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