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Based on (the Hospital's) Rules and Regulations review, policy reviews, and medical record review, the hospital failed to comply with 42 CFR §489.24 Special Responsibilities of Medicare Hospitals in Emergency Cases and the related requirements at §489.20 (l), (m), (q), and (r), which pertain to the Federal Emergency Medical Treatment and Labor Act (EMTALA).

The findings include:

1. The hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 23 sampled DED patients (#3) who presented to the hospital for evaluation and treatment of an EMC.

~ Cross refer to §489.24(r) and §489.24(c) Medical Screening Examination - Tag A2406.

Based on closed medical record review, policy and procedure review, the facility staff failed to provide an appropriate medical screening examination that was within the capability of the hospital's dedicated emergency department (DED) to include ancillary services routinely available to the DED to determine whether or not an Emergency Medical Condition (EMC)existed for 1 (#3) of 23 sampled patients who presented to the hospital for an evaluation and treatment of am EMC.



The findings include:

Review of facility policy (on March 15, 2016) EMTALA: General Guidelines (reviewed facility 8/2014) revealed " ...POLICY: ...C. All Individuals seeking medical treatment on the hospital property will receive a Medical Screening Examination by Qualified Medical Personnel as outlined in the Medical Staff Rules and Regulations to ascertain whether an Emergency Medical Condition exists. If there is a condition such that a ' prudent layperson ' would believe the individual is suffering from an Emergency Medical Condition, a Medical Screening Examination shall be performed ...DEFINITIONS...d. Emergency Medical Condition - shall mean a medical condition manifesting itself by acute symptoms of sufficient severity (including pain, psychiatric disturbances, alcohol or drug intoxication, and/or symptoms of substance abuse), such that the absence of immediate medical attention could reasonably be expected to result is: 1. Placing the health of an individual ...in serious jeopardy; 2. Serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part ...g. Medical Screening Examination - shall mean such an examination conducted within the capability of the (named facility) emergency Department, including the use of appropriate ancillary services that are routinely available to (named facility), as will reasonable disclose the presence or absence of an Emergency Medical Condition. A Medical Screening Examination is not an isolated event; rather it is an ongoing process; however not all Medical Screening Exams must be equally extensive, rather they must be commensurate with the individual ' s condition and request for examination or treatment. The Medical Record must reflect continued monitoring according to the patient ' s needs which must continue until the patient is Stabilized or appropriately transferred, as defined by EMTALA ... "

Closed medical record review conducted on 03/15/2016 for Patient #3 revealed a 72 year old female who presented to Hospital A's DED on 2/21/2016 at 1919 ambulatory from home with chief complaint "tingling in arms, throat closing." Review revealed the patient was triaged by RN #1 (Registered Nurse) at 1921, with vital signs documented as follows: Temperature (T) 96.9, Pulse (P) 111 (normal pulse 60-100), Respirations (R) 19, Blood Pressure (BP) 189/84 ( Adult normal BP 120/80), Pulse Ox (oxygen saturation) 97%, and pain reported as "0" (on scale from 0-10 with 10 being the worst pain), and was 5'2" and weighed 134 pounds. Further review of the triage RN note revealed "...PT (patient) C/O (complains of) NUMBNESS AND TINGLING IN THROAT. PT STATES 'I FEEL LIKE MY THROAT IS CLOSING'."

Review of the DED RN #2 note documented 2/21/16 at 2040 revealed "Patient reports that while trimming rose bushes this morning she began to have some tightness of her throat and L (left) arm tingling. Patient states she stopped thinking she had overexerted herself and rested for awhile and the feeling went away. Patient states once feeling better she finished her yard work. Later she and her husband went to the grocery store and she began having tightness in her chest, throat, and back. Once again the symptoms subsided. While cooking dinner the tightness in her throat began and the decision to come to the ER was made. Patient in NAD (no acute distress) and VSS (vital signs stable). Patient has no noted neurological deficits at the time of assessment. Will continue to monitor closely."

Record review revealed a medical screening examination (MSE) was began 2/21/16 at 1919 by the DED physician MD #1. The DED physician dictated note revealed "...History of Present Illness: 72-year-old female present to ED with complaints of her "throat closing up." Patient was cutting roses this afternoon when she began feeling like her throat was tightening up and had numbness and tingling down her arms. She denies any wheezing, cough or shortness of breath. She denies any new foods or new medications. She has not taken anything for her symptoms. She denies having any pain. Her symptoms have resolved upon examination. She currently has no further complaints. Patient Medication: Hydrochlorothiazide (Oretic- Medication used to treat high blood pressure)) 25 mg PO DAILY 02/21/16, Levothyroxine (Synthroid -medication used when the thyroid does not produce enough of this hormone on its own) 25 mcg PO DAILY @0600 02/21/16. Allergies/Adverse Reactions: Allergies: No Known Allergies Allergy (Verified 02/21/16 19:23). Past Medical History: Thyroid, Hypo. Past Surgical History: Tonsillectomy. Smoking Tobacco Status: Former smoker. Hx Alcohol Use: Yes...Review of Systems: Constitutional: No Complaints. Head: No Complaints. EENT: Other (Throat tingling and tightening up). Cardiovascular: No Complaints. Denies: Chest Pain. Respiratory: No Complaints. Denies: Dyspnea, Cough, Wheezing. GI: No Complaints. Genitourinary: No Complaints. Musculoskeletal: No Complaints. Neurological: Numbness (numbness and tingling). Skin: No Complaints. Psychiatric: No Complaints. Hem/Lym/End: No Complaints. ROS Review: All Other Systems Reviewed & Negative Except as Noted Above. Physical Examination: Constitutional: Normal, Well Developed, Well Nourished. HEENT: PERRL. Neck: Non-tender, Supple. Cardiopulmonary: Normal, RRR. No: Murmur. Lungs: CTA. Chest: Normal. Abdomen: Normal, Soft, Non-tender. No: Distended. Back: Normal, Atraumatic. Extremities: Full ROM. No: Edema. Neurological: Alert and Oriented x 3, CN ll - Xll Intact. Skin: Normal. No: Rash. Psychiatric: Mood (Normal). Treatment: Patient is completely asymptomatic upon examination. She was advised to take Benadryl if this happens again or symptoms return. She is stable for discharge with outpatient follow-up as discussed. Orders: 02/21/16 20:51 Discharge Patient. Medical Decisions: Nurses Notes Reviewed, Discussed w/ Patient, Discussed w/ Family...Med. Records Reviewed (EKG shows sinus rhythm with a rate of 92 beats per minute). Discussed Results, Discussed Need for F/U. Plan: Discharge. Condition: Improved, Stable. Instructions: Allergic Reaction. Referrals: (Primary Care Provider). Additional Instructions: Take Benadryl 25 mg every 6 hours as needed. Ed Status: Ready for Discharge. Clinical Impression: Allergic reaction."

Further closed medical record review revealed an EKG performed 02/21/16 at 20:24, with the following results: Sinus rhythm, nonspecific ST & T wave abnormality, borderline ECG, and was signed by the ED physician, and the patient was discharged to home on 02/21/16 at 2130. The facility failed to ensure that an appropriate medical screening examination was provided for patient #3 on 2/21/2016 when she presented to the DED complaining of left arm tingling and some throat tightness; as evidenced by failing to conduct a medical screening examination that was within the capability of the hospital's emergency department to include the use of ancillary services, laboratory testing, (CK-MB- to detect and monitor heart attacks,Troponin- specific for damage to the heart) or request a cardiology evaluation.

Further closed medical record review revealed patient #3 returned to Hospital A's DED on 02/22/16 at 1104 (13 hours 34 minutes later) by EMS, with reason for visit as "code". The record review revealed the spouse reported finding the patient unresponsive at approximately 9:00 am, initiated cardiopulmonary resuscitative efforts with chest compressions, and EMS transported the patient to the ED in full code status. The ED provider PA #1 documentation revealed "...Medical Decision Making ...EKG reveals a 2 mm ST segment elevation in leads V3 and V4 which is an acute change from EKG performed yesterday consistent with acute ST segment elevation myocardial infarction..." Further record review revealed the patient was stabilized and transferred to Hospital B by EMS transport.


Closed Hospital B medical record review revealed Patient #3 was admitted on 02/22/16 to the CICU (cardiac intensive care unit) with the diagnosis of anterolateral STEMI (Heart Attack- ST Elevation Myocardial Infarction). Procedures performed included coronary angiography and stenting of the proximal to mid LAD. The patient's condition deteriorated, with abnormal EEG results, and the patient was transitioned to comfort care, extubated, and died on 02/26/16.