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Based on policy reviews, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings included:

Based on medical record reviews and physician and staff interviews, hospital staff failed to provide stabilizing treatment within the capability of the hospital's Dedicated Emergency Department (DED) for one (1) of 27 sampled Dedicated Emergency Department patients (Patient #7).

~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2407

Based on medical record reviews and physician and staff interviews, hospital staff failed to provide stabilizing treatment within the capability of the hospital's Dedicated Emergency Department (DED) for one (1) of 27 sampled Dedicated Emergency Department patients (Patient #7).

The findings included:

Medical record review on 05/24-25/2022 revealed Patient #7, a 49-year-old male, arrived to the DED on 09/06/2021 at 1248 by private vehicle with an arrival complaint of "Possible covid; SOB (shortness of breath), sore throat". "ED Care Timeline" review revealed Triage started at 1308 . Review of the ED Triage Note' revealed "Pt (Patient) reports exposure to covid and now he has sob (shortness of breath)." At 1309, Timeline review revealed vital signs were taken with a temperature of 100.5, pulse 109, respirations 20 and blood pressure 135/73. Review further revealed an oxygen saturation of 92% and a pain score of 4. A "Focused Assessment" by nursing at 1310 revealed "Airway ...Within Defined Limits ....Breathing ....Within Defined Limits ....Circulation ....Within Defined Limits ....Disability ....Within Defined Limits." Patient #7 was assigned an acuity of "3-Urgent". The "ED Provider Note" date of service 09/06/2021 at 1321 noted " ...presents to the ED ....with ....cough, congestion, fever and nausea x 4 days. Pt had exposure to (family members) who are COVID positive .....Presenting symptoms: congestion, cough, and fever ....no ear pain, no fatigue, no rhinorrhea [runny nose] and no sore throat Severity: Moderate Onset quality: Sudden Timing: Constant Progression: Worsening ....Associated Symptoms: no arthralgias ([joint pain), no headaches, no myalgias (muscle pain), no neck pain, no sinus pain, no sneezing and no wheezing Associated symptoms comment: + (positive for) nausea ....Review of Systems: Constitutional: Positive for fever .... HENT (head, ears, nose, throat): Positive for congestion .... Respiratory: Positive for cough. Negative for shortness of breath and wheezing. Cardiovascular: Negative for chest pain. Gastrointestinal: Positive for nausea ....Physical Exam ....Constitutional: General: He is not in acute distress. Appearance: He is well-developed. He is not toxic-appearing ....Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm .... Pulmonary: .... Pulmonary effort is normal. No tachypnea (fast breathing), accessory muscle usage or respiratory distress. Breath sounds: Normal breath sounds ....XR (x-ray) CHEST AP PORTABLE Preliminary Result 1. Multifocal peripheral groundglass opacities moderate in severity 2. Commonly reported imaging features of Covid-19 pneumonia are present .....Labs reviewed COVID-19 AND INFLUENZA A/B PCR - Abnormal; Notable for the following components ....SARS-COV-2 Positive ....Will refer for monoclonal AB ([antibody) therapy given HTN (hypertension), start on PO (oral) Zofran for nausea ....Clinical Impression: 1. COVID-19 ....ED Disposition ....Discharge Stable. ..." Review of the ED Care Timeline revealed Patient #7 received Zofran orally at 1334 and Tylenol orally at 1335. Timeline review revealed vital signs were taken at 1457 with a pulse of 94, respirations 20 and blood pressure 141/75. Review did not reveal a temperature or pulse oximetry taken at that time. Review of an ED Nursing Note at 1457 revealed "Patient discharged from emergency department with all belongings and given 1 prescription ...and instructed on medication use. Patient educated on all discharge instructions from provider. Patient verbalized understanding." Patient #7 was discharged home from Hospital A at 1457. Record review did not reveal evidence of any further pulse oximetry testing, with or without exertion, after the initial 92% was obtained, did not reveal a repeat temperature after the Tylenol and did not reveal any laboratory testing except testing for COVID-19 and flu.

Interview on 05/25/2022 at 1140 with RN #1 revealed the RN took the discharge vital signs on Patient #7. Interview revealed the RN saw in the medical record that he did not document a pulse oximetry reading at discharge. Interview revealed it should be documented in a flow sheet. RN #1 stated if he got a pulse he would have also seen a pulse oximetry reading. Interview revealed the RN felt "relatively confident" he used a rolling machine to take the vital signs and stated that if the patient's oxygen saturation was in the 80s he thought he would have noticed, noted that in the record and notified the physician.

Interview with RN #2 on 05/25/2022 at 1208 revealed RN #2 did not recall the patient's ED visit. Interview revealed that if a patient was hooked up to continuous pulse oximetry it would typically show in the medical record but would show as unverified. Interview revealed a level 3 patient should have vital signs every hour.

Interview with MD #3 on 05/25/2022 at 1650 revealed MD #3 did not recall Patient #7 but reviewed the record. Patient #7's x-ray, interview revealed, showed COVID pneumonia, which was "typical" for patients with COVID-19 and not indicative of a need to admit a patient. Interview revealed Patient #7's pulmonary effort was normal. In evaluating a patient, MD #3 indicated, he looked at the physical presentation. Interview revealed additional labs were not as important if not admitting a patient, that the decisions were based on what the physician observed in the patient in front of him. Interview revealed he gave Patient #7 Tylenol and Zofran and ordered monoclonal antibody therapy as an outpatient at an urgent care. MD #3 stated there was a process in place for urgent care to call the patient and set up the appointment. MD #3 further stated the facility tried to contact the patient on the 7th (next day) and left a voicemail. Interview revealed the sooner the monoclonal antibodies could be given the better but that their hospital did not have that capability in September. The patient, interview revealed, was referred to an urgent care center for the monoclonal antibody therapy. MD #3 further stated that if concerned the physician would have the patient stand and walk and check the pulse oximetry but may or may not document it. Interview revealed MD #3 did not see anything he would have done differently, that Patient #7's vital signs did not indicate a need for admission and the patient was set up for the best follow-up available at the time. Interview revealed it would have been routine to get a repeat oxygen saturation prior to discharge but not necessarily a repeat temperature.

Interview with the ED Nurse Manager on 05/26/022 at 0942 revealed discharge vital signs should include pulse oximetry and temperature.

Interview with the Chief Medical Officer on 05/26/2022 at 1155 revealed during the time of Patient #7's visit the facility was seeing COVID pneumonia patients every day that were not admitted. Interview revealed Patient #7 presented as a typical COVID patient and most patients had no adverse outcomes, would go home and do well. Interview revealed COVID was rampant at that time. The patient was young with a 100.5 temperature and they would not do an EKG (electrocardiogram), but would give good follow-up and tell the patient what to look for at home. Further interview revealed the CMO would "not be shocked" to hear if it was said that pulse oximetry in the 80s with COVID was the new 90s. Interview revealed isolated readings of 88-89% did not necessarily warrant oxygen based on presentation but at 87% he would not send a patient out without exploring home oxygen..

Medical record review revealed Patient #7 arrived to Hospital B on 09/07/2021 at 0912 (approximately 18 hours 15 minutes after discharge from Hospital A). At 0917 the presenting complaint was noted as "..Patient states: 'I have been short of breath.' States he was diagnosed with COVID yesterday....His O2 sats (oxygen saturation) were in the 70s initially.... Patient has a Covid pneumonia and he is hypoxic (low oxygen in the tissues). We gave him Decadron (steroid- treat inflammation) ....the patient will be admitted to the hospitalist service where he will receive remdesivir (medication treatment for COVID-19) and the new anti-Covid IV drug as well. ..." Review of the "HISTORY AND PHYSICAL EXAMINATION", dictated 09/07/2021 at 1241, revealed " ...(Name of Patient #7)....presents to the Hospitalist Service with shortness of breath. He has a significant medical history of a recent diagnosis of COVID-19 ....Yesterday he went to (name of Hospital A) ER and tested positive for COVID and was released. He came to the Emergency Department today for treatment with monoclonal antibodies, but was noted to be too hypoxic to receive them and was sent to the ER for evaluation. In the Emergency Room on arrival, he was 84% on 2 liters, but his oxygen was as low as the 70s.... Chest x-ray was done and revealed pneumonia....ASSESSMENT AND PLAN: 1. Acute hypoxic respiratory failure secondary to coronavirus disease 2019 pneumonia ....2. Abnormal electrocardiogram .... 6. Disposition: the patient will be admitted... ." Record review revealed Patient #7 was transferred back to Hospital A on 09/11/2021.

Review of the History and Physical for Patient #7 at Hospital A, date of service 09/11/2021 at 2120, revealed " ...(Patient #7).... accepted in transfer from (Hospital B) ....Chest x-ray revealed pneumonia and he was admitted to the hospital with Covid pneumonia and hypoxia. His status continued to deteriorate he was intubated placed on the ventilator ....Principal Problem: Pneumonia due to COVID-19 virus Active Problems: Acute respiratory failure with hypoxia. ...." Review of the Discharge Summary, dated 10/22/2021, revealed " ...10/22/2021: ...patient....passed away at 0528 hrs. (hours) from cardiac arrest. ..."

In summary, Patient #7 arrived to the DED of Hospital A on 09/06/2021 at 1155 with a chief complaint of shortness of breath, a presenting temperature of 100.5 and pulse oximetry of 92% on room air. The patient received a COVID-19 and Flu test which was positive for COVID-19. Patient #7 was discharged from the DED at 1457. Prior to discharge, there was no documentation of further pulse oximetry readings, either at rest or on exertion, no evidence of another temperature check and no additional laboratory testing while in the DED. Patient #7 arrived to Hospital B's DED the next morning, 09/07/2021 at 0912, initially for monoclonal antibodies, however was "noted to be too hypoxic to receive them... ." Patient #7 was admitted to Hospital B where he was later placed on a ventilator and on 09/11/2021 was transferred back to Hospital A. Patient #7 expired on 10/22/2021.