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Based on interview and record review, the hospital failed to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. This failure had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.
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Findings:

1. The hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for six of 20 sampled patients (Patients 1, 11, 12, 15, 16, and 19). Cross reference to A2407.

2. The hospital failed to ensure the ED staff completed the EMTALA Transfer Form when transferring one of 20 sampled patients (Patient 14) to other facility. Cross reference to A2409.

Based on interview and record review, the hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for six of 20 sampled patients (Patients 1, 11, 12, 15, 16, and 19) as evidenced by:

1. The ED staff did not ensure the pain management for Patients 1, 11, 12, 15, 16, and 19 as per the hospital's P&P.

2. The ED staff did not conduct the reassessments, including the vital signs every four hours for Patient 19 as per the hospital's P&P.

These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. Review of the hospital's P&P titled Pain Management dated October 2021 showed the following:

* When pain is present, a detailed assessment shall be performed to include the following parameters:
- Pain intensity
- Pain quality
- Location
- Onset, duration, variation, and patterns
- Alleviating and aggravating factors
- Present pain management regimen and its effectiveness
- Use of any Complementary and Alternative Medicine (CAM) for pain management
- Patient's pain goal (including pain intensity and goals related to function, activity, and quality of life)

* Reassessment will be done as indicated by persistence of pain, initiation of potentially painful procedures, changes in medical status, and/or after any interventions provided for pain management (pharmacological/non-pharmacological interventions). The following will be reported immediately to the Provider:
- Uncontrolled pain
- Pain intervention that do not achieve patient's pain goal in a timeframe appropriate to the intervention
- New or worsening pain
- Adverse effects of pain medication

a. Review of Patient 1's closed medical record was initiated on 8/29/24. Patient 1's medical record showed Patient 1 arrived in the ED on 8/20/24 at 1700 hours.

Review of the ED Triage/Intake dated 8/20/24 at 1726 hours, showed Patient 1 had pain to the head and the patient's pain level was seven out of 10 (on a scale of 0 to 10 with 0 = no pain and 10 = worst possible pain). However, further review of Patient 1's medical record failed to show Patient 1's pain goal.

Review of the physician's order dated 8/20/24 at 1734 hours, showed to administer acetaminophen (a pain medication) 650 mg by mouth.

Review of the Medication Administration Record showed on 8/20/24 at 1802 hours, Patient 1 was administered with acetaminophen 650 mg by mouth.

However, further review of Patient 1's medical record failed to show documented evidence of reassessing the patient's pain after administering the acetaminophen to the patient as per the hospital's P&P.

b. Review of Patient 11's closed medical record was initiated on 8/29/24. Patient 11's medical record showed Patient 11 arrived in the ED on 6/25/24 at 0937 hours.

Review of the Vital Signs dated 6/25/24 at 1006 hours, showed Patient 11 had abdomen pain and the patient's pain level was five out of 10. However, further review of Patient 11's medical record failed to show Patient 11's pain onset, duration, variation, patterns, alleviating and aggravating factors, and pain goal were assessed. In addition, there was no documented intervention for the pain until Patient 11 had no answer for a call at 2003 hours.

c. Review of Patient 12's closed medical record was initiated on 8/29/24. Patient 12's medical record showed Patient 12 arrived in the ED on 8/20/24 at 1526 hours.

Review of the ED Triage/Intake dated 8/20/24 at 1532 hours, showed Patient 12 had the right flank pain and the patient's pain level was 10 out of 10. However, further review of Patient 12's medical record failed to show Patient 12's pain onset, duration, variation, patterns, alleviating and aggravating factors, and pain goal were assessed. In addition, there was no documented intervention for the pain until Patient 12 had no answer for calls at 1640 hours.

d. Review of Patient 15's closed medical record was initiated on 8/30/24. Patient 15's medical record showed Patient 15 arrived in the ED on 7/19/24 at 1011 hours.

Review of the ED Triage/Intake dated 7/19/24 at 1054 hours, showed Patient 15 had rectal pain and the patient's pain level was 10 out of 10. However, further review of Patient 15's medical record failed to show Patient 15's pain onset, duration, variation, patterns, alleviating and aggravating factors, and pain goal were assessed. In addition, there was no documented intervention for the pain until Patient 15 had no answer for calls at 1320 hours.

e. Review of Patient 16's closed medical record was initiated on 8/30/24. Patient 16's medical record showed Patient 16 arrived in the ED on 7/25/24 at 1415 hours.

Review of the ED Triage/Intake dated 7/25/24 at 1430 hours, showed Patient 16 came to the ED for leg pain. The ED Triage/Intake showed the Pain Assessment section showing the preferred pain tool was the numeric rating scale. However, further review of Patient 16's medical record failed to show documented evidence of pain assessment and management.

f. Review of Patient 19's closed medical record was initiated on 8/30/24. Patient 19's medical record showed Patient 19 arrived in the ED on 7/13/24 at 1216 hours.

Review of the ED Triage/Intake dated 7/13/24 at 1225 hours, showed Patient 19 had chest pain and the patient's pain level was four out of 10. However, further review of Patient 19's medical record failed to show Patient 19's pain onset, duration, variation, patterns, alleviating and aggravating factors, and pain goal were assessed.

Review of the Vital Signs dated 7/13/24 at 2121 hours, showed Patient had chest pain and the patient's pain level was four out of 10. However, there was no documented intervention for the pain until Patient 19 signed the AMA at 2220 hours.

2. Review of the hospital's P&P titled Triage and Medical Screening Examination dated November 2023 showed triage priority is based on the router nurse's perceived urgency of a patient's need for medical evaluation and/or treatment following initial assessment. Patient acuity is determined at the time of triage in accordance with the Emergency Severity Index (ESI).

Review of the hospital's P&P titled Nursing Documentation dated November 2023 showed patients in the waiting room must have a reassessment completed a minimum of every two hours for ESI level 2, four hours for ESI level 3, and every 8 hours for ESI levels 4 and 5.

Review of Patient 19's closed medical record was initiated on 8/30/24. Patient 19's medical record showed Patient 19 arrived in the ED on 7/13/24 at 1216 hours.

Review of the ED Triage/Intake dated 7/13/24 at 1225 hours, showed Patient 19's vital signs were taken and the patient was triaged with the acuity level (or ESI level) "3."

Review of the Medical Screening Exam dated 7/13/24 at 1236 hours, showed Patient 19's ESI level was "3."

Review of the Vital Signs dated 7/13/24 at 1957 hours (seven hours and 32 minutes later), showed Patient 19's vital signs were taken.

On 8/29/24 at 1348 hours, Clinical Nursing Director 1 was interviewed. When asked, Clinical Nursing Director 1 stated patient whose acuity level was with ESI level 3, should be assessed every four hours, including the vital signs.

On 8/30/24 at 1300 hours, the above findings were shared and verified with Clinical Nursing Director 1.

Based on interview and record review, the hospital failed to ensure the ED staff completed the EMTALA Transfer Form when transferring one of 20 sampled patients (Patient 14) to other facility. This failure had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving ED services.

Findings:

Review of Patient 14's closed medical record was initiated on 8/30/24.

Patient 14's medical record showed Patient 14 came to the ED on 8/20/24, and was transferred or discharged to other facility on 8/22/24 at 1807 hours.

On 8/30/24 at 1300 hours, Clinical Nursing Director 1 was interviewed. When asked, Clinical Nursing Director 1 stated the transfer form should be completed hospital-wide, including the ED. Patient 14's transfer form was requested. However, Clinical Nursing Director 1 stated she was not able to locate the form.

On 8/30/24, Clinical Nursing Director 1 verified Patient 14's transfer form was missing in Patient 14's medical record.

Review of the EMTALA Transfer From showed the following:

"I acknowledge that I have been informed of the risk and consequences potentially involved in the transfer, the possible benefits of continuing treatment at this hospital, and the alternative (if any) to the transfer I am requesting. I hereby release the attending provider, any other providers involved in the patient's care, the hospital and its agents and employees, from all responsibility for ill effects which may results from the transfer."