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Based on interviews policy and procedure review, and record review it was determined the hospital failed to adhere to their provider agreement under CFR §489.20 (l) of the provider's agreement requiring that hospitals comply with 42 CFR §489.24, Special Responsibilities of Medicare Participating Hospitals in Emergency Cases. (cross refer to A 2406).
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Based on medical records (MR) review, Policy and Procedure review, Ophthalmology on-call schedule review, and staff interviews, it was determined that an individual who came to the hospital's emergency department (ED) with presenting signs and symptoms of an eye complaint with severe eye pain, the hospital failed to monitor and meet the needs of the patient while waiting in the ED for approximately greater than eight hours. The hospital failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's ED, including ancillary services routinely available to the ED to determine whether or not an emergency medical condition (EMC) existed for one (#1) of 20 sampled ED cases reviewed. The patient returned to the ED two days later where it was determined the patient had an EMC, which placed the patient at risk for vision loss.

The findings include:

The facility's policy titled "Medical Screening Exam" (examination), Effective Date: 6/08/2011, Revised Date: 11/2020, Reviewed Date 10/21 was reviewed. The policy revealed in part, "IV Policy: A. It is the Policy of Halifax Health to provide emergency treatment to all patients presenting to the ED according to the guides set by the Emergency Treatment Medical and Active labor Act (EMTALA) ...All patients presenting to the ED for evaluation and treatment will receive a Medical Screening Exam (MSE). The MSE is to determine if the patient has an EMC (Emergency Medical Condition) ... V. Procedure: B. The MSE is performed by a QMP (Qualified Medical Person) ...E. Medical Screening Exam Inclusion Criteria ...4. ...eye complaints.

A medical record review revealed Patient #1 presented to the ED on 2/5/22 at 0849 with "L(left) eye complaint." The patient was triaged (system used in healthcare community to categorize patients based on the severity of their injuries) by a registered nurse (RN staff member G) at 0931 and the patient was noted to have spontaneous eye movement with decreased vision to the left eye and reported oozing of puss since 1700 on 2/4/22. Patient #1 reported his pain level was a 10 on a 1-10 scale (10 being most severe level), and he was assigned an Emergency Severity Index (ESI- 5 level ED triage algorithm that sorts patient into 5 groups from 1 (most urgent) to 5 (least urgent) based on predicted acuity and resources needed) severity level 3.

Patient #1's Vital Signs were listed as Temperature: 98. 1; Pulse rate: 88; Respirations -16; and Blood Pressure 158/82 -H (high). According to the MR the patient's Status was listed as "Discharge "on 2/6/2022 at 0941. There was no entry in the MR to indicate that on 2/5/2022 Patient #1 received a Medical Screening Examination on 2/5/2022. Patient #1 sat in the ED waiting lobby for approximately greater than 8 hours on 2/5/22 without treatment for complaint of left eye severe pain, and reported by patient decreased vision.

The medical record lacks any other entries to support that Patient #1 was ever reassessed or otherwise monitored by the ED staff. At 1641 the RN went to the ED waiting room to call Patient #1 back to see the Advanced Practice Registered Nurse (APRN), however the patient was no longer found to be in the ED waiting room.

The facility's on-call schedule dated February 2022 for Ophthalmology was reviewed. The on-call schedule verified that on February 5, 2022, an ophthalmology physician was on call when Patient #1 presented to the hospital. The on-call schedule verified the hospital had the capability to provide ancillary services of the Ophthalmologist when he presented to the hospital's ED on February 5, 2022.

A review of the hospital's Emergency Severity Index (ESI) revealed that an acuity level 3 required "many resources." The ESI revealed resources were listed as labs, imaging, intravenous fluids, intravenous, intramuscular, or nebulized medications, specialty consultation, and simple or complex procedures.

A review of the medical record revealed Patient #1 again presented to the ED on 2/7/22 at 1746 as instructed by his retinal specialist for cultures and treatment. The patient's pain level was noted to be an 8 and his left conjunctive was normal in appearance with a small amount of white/yellow draining from the area. An MSE was performed, and the patient was found to have an EMC. The retinal surgeon ophthalmologist came to see patient in the ED and drew vitreous fluid cultures from the left eye and prescribed oral antibiotics as well as topical regimen. Patient #1's diagnosis was purulent endophthalmitis ( rare but severe form of ocular (eye) inflammation due to infection ...that can lead to irreversible visual loss if not treated properly and timely) grade 3.

On 2/22/23 at approximately 10:00 AM, an interview was conducted with RN (staff member G), and she confirmed she was not aware of when Patient #1 had left the ED.

On 2/21/23 at approximately 3:45 PM, an interview was conducted with the ED Nurse Manager regarding the triage and MSE process. He relayed that the process is for a patient to receive a triage and then await a mid-level practitioner or a physician to conduct an MSE. He confirmed the hospital did not have any protocols for nursing staff to perform any rounds or additional vital signs for patients waiting in the ED.

The facility failed to ensure that their policies and procedures were followed as evidenced by failing to ensure that an appropriate medical screening examination was provided to Patient #1 who presented to the ED with presenting signs and symptoms of left eye severe pain and patient reported decreased vision to that eye.