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Based on observation, interview and document review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 (special responsibilities of Medicare hospitals in emergency cases), specifically the failure to complete an appropriate medical screening exam on 1 (#1) of 20 patients, resulting in the potential for less-than-optimal outcomes

1. Failure to complete an appropriate medical screening exam. (See tag A-2406)

Based on observation, document review and interview the facility failed to A) ensure an appropriate medical screening exam was performed for 1 out of 5 patients reviewed with a chief complaint of abdominal pain from a total sample of 20 and B) failed to ensure individuals performing medical screening examinations were determined qualified by hospital bylaws resulting in the potential for less-than-optimal outcomes for all patients seeking emergent care. Findings include:

A)
Review of the medical record for Patient #1, the patient of concern, revealed he was a 07-year-old male who had two recent visits to the emergency department (ED). During visit A patient #1 arrived at the ED via private car at 1555 on 05/29/2022 with a chief complaint of vomiting and abdominal pain. Review of the triage noted on 5/29/2022 at 1559 revealed patient had been vomiting all day with some abdominal pain. The record indicated Patient #1 was placed in a room at 1714 and the first contact with a provider (Staff L) was at 1717. Nursing note indicated Patient #1 was given Zofran 4 milligrams (mg) (medication to treat nausea) orally at 1731. Nursing Notes indicated Patient #1 did have emesis while in the ED at 1812. Nursing note revealed the "Pediatric Assessment Triangle" (type of pediatric assessment) was completed at 1733. A Group A Strep test (swab of the throat to test for Strep infection) was completed and resulted as negative. Review of the record did not reveal physician orders for any other testing for Patient #1, nor was any other testing completed. ED physician note (Staff L) revealed a history of present illness to include that Patient #1 was seen 10 days prior for a sore throat and fever with a negative Strep test, now presents with complaints normal day the day prior with mild sore throat, but in the night developed nausea, vomiting, and generalized abdominal discomfort with decreased oral intake. Review of systems documented positive for nausea, vomiting, and abdominal pain. Physical Exam indicated dry mucous membranes. There was no assessment of Patient #1's abdomen documented in the physician note, or in any other documentation by the Staff L during the visit by Patient #1 on 5/29/2022. The patient was discharged home on 5/29/2022 at 1940 with a diagnosis of vomiting and a prescription for Zofran. During Visit B, Patient #1 returned via private car on Wednesday, 06/01/2022 at 1709. Triage at 1713 with complaints documented per mother as abdominal pain, vomiting since 0400 Sunday and still unable to keep anything down. Pain was rated as a 10/10. No pediatric assessment was documented. Patient #1 was assigned SSI (Emergency Severity Index) acuity level 3. The next documentation at 2129 indicated Patient #1 left without being seen.

Review of another facility ED (Facility B) medical record for Patient #1, revealed Patient #1 arrived in the Emergency Department on 6/1/2022 at 2158. Triage completed at 2207 revealed Patient #1's chief complaint was abdominal pain onset 0400 Sunday 5/29/2022, worse with movement. Patient #1 was assessed and found to have dry, cracked lips. Medical screening exam was completed at 2307. Laboratory studies, ultrasound exam was completed with results documented of elevated white blood cell count and questionable appendicolith (a calcified deposit within the appendix) versus non-compressible bowel. Patient #1 was given pain medication, intravenous fluids and transferred to the care of a pediatric surgeon at Facility C at 0135.

Review of Facility C (pediatric hospital) medical records for Patient #1 revealed a general surgeon history and physical dated 6/2/2022 at 0306 which indicated Patient #1 had diagnosis to include diffuse peritonitis and a history consistent with ruptured appendicitis. Recommendation for laparoscopic appendectomy and anticipation of 3-5 days of antibiotics. Patient #1's medical record did reveal he underwent surgery laparoscopic appendectomy with postoperative diagnosis to include perforated peritonitis (inflammation of the peritoneum, typically caused by bacterial infection either via the blood or after rupture of an abdominal organ). He was treated in the pediatric intensive care unit with intravenous antibiotics and pain medications and was still an inpatient at the time of the survey.

In an interview on 06/09/2022 at 1125, Staff O stated she remembered Patient #1, who came in on 5/29/2022. Patient #1 was a young boy who presented with parents complaining of nausea, vomiting and belly pain for a couple of days. Mom was concerned about the child getting dehydrated. Staff O stated Patient #1 did receive Zofran (anti-nausea medication) and then an oral liquid challenge was completed (liquids are given by mouth to see if the patient will keep them down without vomiting). Patient #1 did have an episode of emesis while in the ED. No testing was completed, and no IV fluids were given. Staff O said Patient #1 was discharged home with his parents.

In an interview on 06/08/2022 at 1627, Staff N (ED triage RN) stated she did not recall Patient #1's visit on 6/1/2022, but after review of the medical record stated he came in with abdominal pain and vomiting. Staff N stated Patient #1 was assigned an SSI (Emergency Severity Index - a triage told used in Emergency Departments) of 3 which meant he was stable. She said optimally it would be great if they could go back in 15 minutes, but they cannot. Staff N said she cannot take the stress of patients having to wait in the waiting room. There just are not enough beds for the number of patients coming in for treatment.

In an interview on 6/14/2022 at 1525, Staff L, ED Physician, stated Patient #1 presented on 5/29/2022 with nausea, vomiting, abdominal pain and a sore throat that night. Staff L said Patient #1 was tachycardic, only had minimal redness in the back of his throat and tested negative for Strep. Staff L reviewed the medical record for Patient #1 and stated, "I cannot locate the abdominal exam". Staff L said he did not know where the abdominal exam was. When queried as to why he did not order any laboratory or radiological exams, Staff L sated if Patient #1 had anything concerning show up on the abdominal exam he would have ordered testing to be done. However, Staff L could not find that he completed an abdominal exam on Patient #1.

In an interview on 6/9/2022 at 1000 Staff B (ED Manager) stated it was hospital policy and her expectation that patients waiting in the ED waiting room were to be re-assessed by nursing every two hours. She said the ED department did have 36 beds and from 0700 to 0900 they have 19 beds open due to census flux and staffing. At 0900 they open to 27 beds. In an interview on 6/8/2022 at 1540, Staff B stated on 6/1/2022 at the time Patient #1 was in the waiting room there were 3 to 4 providers working in the ED. Staff B said it would be her expectation when Patient #1 returned on 6/1/2022 with continued abdominal pain and mother reported no oral intake, that the pediatric assessment form in the EMR (electronic medical record) would have been completed by the triage nurse and a thorough abdominal assessment. This was not documented by Staff N (triage nurse). Staff B also stated it was her expectation that the triage nurse complete the pediatric assessment in the electronic medical record for all pediatric patients presenting in the ED.

In an interview on 06/09/2022 at 1030, ED Medical Director Staff H stated he had no direct involvement with Patient #1's care; however, he had reviewed the medical record. Staff H stated if a patient presented with a complaint of abdominal pain, "I would expect a provider to assess the patient's abdomen" Staff H stated he would also expect the physician to obtain a history of the pain. When queried if Staff H, upon review of the record for Patient #1 for visit of 5/29/2022, was able to find an abdominal assessment by the physician, Staff H stated no. When queried if the emergency department (ED) had adult abdominal pain protocols, Staff H stated he had not looked at the protocols in a while but "I believe so." Staff H stated he did not believe there were any pediatric abdominal pain protocols. Staff H said it is facility policy for patients waiting in the waiting room to be reassessed by nursing every two hours. We try to use every bed available in the ED that we can staff. Staff H stated it is his expectation that all patients waiting in the waiting room be assessed by nursing staff every two hours while waiting to be seen.

During the initial tour of the emergency department on 06/08/2022 at 1130, it was noted that during the triage process, patients initially meet with a registered nurse at a desk next to registration. The registered nurse verbally interviewed the patients. No physical assessment was completed. The patients then went into another room with an emergency room tech, who obtained vital signs. The registered nurse was not present for this portion of the triage process. The patient was then sent back to the waiting room. At no point did the surveyor observe a physical examination of the patients by a registered nurse during the triage process. The registered nurse met with the patients at a desk in the waiting area.

On 06/08/2022 at 1655, review of facility System ED-8 Triage Guidelines for the Emergency Department Policy dated 08/19, patients presenting with a heart rate over 100 and severe pain should be classified as an SSI 2, also patients presenting with severe abdominal pain are classified as SSI 2. The policy indicates that Patients who were classified as SSI 2 were high risk and should not wait to be seen.

On 6/9/2022 at 1150, Review of the facility documentation guidelines, released on March 9, 2022, revealed the electronic medical records system (EPIC) would display when a patient had been in the waiting room for two hours and trigger a new set of vital signs to be completed. The guidelines state "This matches our ED policy".

Review of facility grievances was completed with Staff P, Manager of Patient Relations on 06/09/2022 at 1140. No concerns were identified with the process of the management of patient grievances. There were a high number of grievances filed regarding patient wait times in the emergency department.

Nursing staffing was reviewed on 6/9/2022. Although there were no concerns with nursing to patient bed ratios, it was noted that ED beds are often closed due to decreased staffing levels.

B)
On 6/9/2022 at 0900, Review of the facility Medical Staff Bylaws dated April 14, 2022, a medical screening exam shall be provided by physicians, nurse midwives, or obstetrical RN's with two years experience ..., also by an appropriately credentialed advanced practiced practitioner.

On 6/9/2022 at 0900, Review of the facility EMTALA (Emergency Treatment and Labor Act) policy dated 06/07/02, Covid-19 Pandemic addendum, the facility authorized registered nurses with ED experience to screen patients for the purpose of identification of an emergency medical condition.

In an interview on 06/09/2022 at 1030, ED Medical Director Staff H stated he had not read through the EMTALA policy, but Registered nurses were allowed to redirect patients requesting a Covid-19 test to alternative source for testing without getting a medical screening exam. Staff H stated he was a member of the Medical Executive Committee and did attend the meetings.

In an interview with the Emergency Department Manager on 06/09/2022 at 1000, Staff B stated the facility EMTALA (Emergency medical treatment and labor act) policy addendum did indicate that a registered nurse can complete a medical screening exam on patients presenting for Covid testing without symptoms.