HospitalInspections.org

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Based on record review and interview the facility failed to abide by the provider's agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.
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Based on a record review and interview, Facility A failed to provide an appropriate medical screening examination (MSE) for 1 of the 20 (Patient #1) whose records were reviewed. Patient #1 was a 60-year-old male with known history of peripheral artery disease (PAD) for which he is taking the blood thinner Coumadin. Patient #1 had presented twice to Facility A's emergency department (ED). An appropriate medical screening exam was not completed for Patient #1 during either visit. Patient #1 presented to Facility B where he spent 8 days as an inpatient being treated for the following diagnoses: coagulopathy, hematuria, symptomatic anemia, supratherapeutic international normalized ratio (INR), acute kidney injury, dehydration, bilateral arm pain, acute urinary tract infection (UTI), and elevated creatinine kinase (CK).
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Cross refer A2406.
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Based on a record review and interview, Facility A failed to provide an appropriate medical screening examination (MSE) for 1 of the 20 (Patient #1) whose records were reviewed. Patient #1 was a 60-year-old male with known history of peripheral artery disease (PAD) for which he is taking the blood thinner Coumadin. Patient #1 had presented twice to Facility A's emergency department (ED). An appropriate medical screening exam was not completed for Patient #1 during either visit. Patient #1 presented to Facility B where he spent 8 days as an inpatient being treated for the following diagnoses: coagulopathy, hematuria, symptomatic anemia, supratherapeutic international normalized ratio (INR), acute kidney injury, dehydration, bilateral arm pain, acute urinary tract infection (UTI), and elevated creatinine kinase (CK).
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Findings:
Patient #1 Record Review for the first ED visit on 07/27/2023:
Patient #1 arrived at Facility A's emergency Department (ED) at 3:50 PM on 07/27/2023, with chief complaints of right leg and lower back pain that has been ongoing for 5 days. At 4:06 PM, Patient #1 was assigned a priority level 3 (meaning Urgent - not life threatening) during triage by the ED RN, Staff #7. Staff #7 noted that Patient #1 was "here" (in this ED) 2 days ago due to concerns about scratches to his legs, was "discharged home with antibiotics and was returning today due to generalized weakness in legs" and is also complaining of "bruising on arms from IV sticks from previous visit". Staff #7 noted that Patient #1's pain level was "severe" at a rating of 10/10.
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Patient #1 was seen by an ED Physician, Staff #13 at 4:13 PM. Staff #13 noted Patient #1 was a "60-year-old male with a (past medical history) PMH of PAD presenting for "right leg and lower back pain ongoing for five days with no relief. (Patient #1) Was seen at (Facility A) two days ago with no relief of pain. Patient (#1) notes he has been having increasing difficulty urinating recently. Patient (#1) has taken nothing at home for pain." Suprapubic tenderness and tenderness to palpation of the right sacroiliac (SI) joint were noted on physical examination with normal vital signs. The differential diagnoses noted were for "abrasion, sprain, strain, sciatica, urinary tract infection (UTI), and obstructive uropathy."
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The MDM (medical decision making) stated the following:
"Patient (#1) was examined and evaluated. Patient (#1)'s physical exam was significant for some mild bruising from the IV site in the right antecubital fossa region. There was no pulsatile bleeding or any hard signs. A tight dressing was applied. After about 20 to 30 minutes of the dressing being applied it was removed and it was still oozing some, but the dressing had moved in a way that it was not actually putting pressure on the IV site. At this point a TXA (tranexamic acid - a synthetic lysine analog that acts as an antifibrinolytic agent to encourage clotting) soaked gauze was applied with a new dressing. At this point patient was going to be discharged since the bleeding was minor, however, patient (#1) started complaining of right-sided chest pain that was sharp and he was concerned and wanted to be checked out for this. He reported he was insidious symptoms coming out of nowhere without any obvious exacerbating or rating factors. At this point I decided not to discharge him and order CBC, BMP, troponin and EKG. This was Dorsey to my shift the patient had to be signed out to oncoming ED provider to follow-up on work-up."
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At 4:47 PM, Staff #18, an ED licensed vocational nurse (LVN), applied a lidocaine patch to the SI joint of the right hip on Patient #1 (for right hip pain at level 5/10).
At 5:20 PM the report for x-rays of the right hip and pelvis were received. There were no fractures, dislocations, or advanced arthritic changes identified.
"Impression:
No acute osseous findings or advanced arthritic changes on right hip radiograph with AP (anterior posterior) pelvis.
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Abnormal appearance of vascular stent at the right thigh as detailed above. Recent arterial doppler ultrasound showed occlusion of the right CFA (common femoral artery) and SFA (superficial femoral artery) stent."
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At 6:01 PM Staff #18 gave Patient #1 Norco 5/325, 1 tab orally (for lower back pain level 10/10).
At 6:07 PM an indwelling foley catheter was placed (for acute retention/obstruction) per orders written by Staff #19, an ED physician. A lidocaine patch was placed transdermal (for lower back pain level 5/10).
At 6:09 PM a bladder scan was completed on Patient #1 by Staff #8 noting a "bedside POCUS (point of care ultrasound) PVR (post void residual) greater than 700 ml, foley to be obtained". Reevaluation notes by Staff #13 stated the following:
"Labs showing AKI (acute kidney injury), fluids given, no UTI. Patient had relief after 700 straw colored urine drained. Patient feeling better, fitted with leg bag, will d/c (discharge) home with uro (urology) follow up, patient understands and agrees to treatment plan."
"bilateral lower ext (extremity) pulses intact, chronic le (lower extremity) pain, no obvious unilateral swelling or difference in pain to palp (palpation)."
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At 6:01 PM Patient #1 was given Hydrocodone Bitartrate/Acetaminophen (Vicodin) 1 tab (for right hip pain at level 10/10) orally. A second Lidocaine patch was placed transdermal (for right hip pain at level 10/10).
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At 6:29 PM Lab results had the following abnormal results:
Test Results Normal Value
White blood cells 10.38 K/mm3 4.6 - 10.0 K/mm3
Red blood cells 3.7 M/mm3 4.1 - 5.3 M/mm3
Hemoglobin 10.2 gm/dL 12.0 - 17.4 gm/dL
Hematocrit 30% 40 - 50%
Immunoglobulin 1.0% 0 - 0.5%
Lymphocyte 10.8% 15.0 - 40.0%
Granulocytes 7.77 K/mm3 1.40 - 6.50 K/mm3
Immunoglobulin 0.10 K/mm3 0 - 0.03 K/mm3
Lymphocytes 1.12 K/mm3 1.20 - 3.40 K/mm3
Monocytes 1.24 K/mm3 0.10 - 0.60 K/mm3
Sodium 127mmol/L 136 - 144 mmol/L
Chloride 94 mmol/L 102 - 110 mmol/L
Glucose 158 mg/dL 70 - 110 mg/dL
BUN 54 mg/dL 6 - 20 mg/dL
Creatinine 1.9 mg/dL 0.4 - 1.5 mg/dL
BUN/create ratio 28.4 8.0 - 23.0
Creatinine kinase 1351 units/L 21 - 232 units/L
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At 7:19 PM Staff #18 gave Patient #1 a muscle relaxer (Methocarbamol 500mg) orally (for right hip pain).
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At 7:06 PM a urinalysis was resulted noting the following abnormal results:
Test Results Normal Value
Urine appearance turbid clear
Urine blood 3+ negative
Urine protein 50 mg/dL negative
Urine leukocytes trace negative
Red blood cells >100/HPF 0 - 2 RBC/HPF
Mucus 4+ none
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At 7:15 PM Discharge notes by the ED physician were entered (Staff #13).
At 7:23 PM Staff #8 gave Patient #1 a 1-liter IV fluid bolus (for dehydration) as ordered.
At 7:45 PM Discharge notes were entered by the ED RN (Staff #8).
At 7:45 PM, Patient #1 departed the ED following the first visit.
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Patient #1 Record Review for the second ED visit 07/27/2023:
Patient #1 arrived back to Facility A's Emergency Department (ED) at 11:55 PM with a chief complaint of "IV site will not stop bleeding". Patient #1 was roomed, and the triage notes by Staff #10, ED RN, documented, "Patient reported recently being discharged and having to come back to hospital due to inability to stop the bleeding from the IV site. Patient reports being on warfarin and having a history of stroke." The objective assessment (by Staff #10):
"Patient is alert and oriented x4 and speaking in complete sentences. Respirations even and non-labored, patient has limited mobility and uses wheelchair. Patient skin is warm, dry, bruising noted to bilateral arms. Bleeding controlled at this time." Staff #10 also documented, "Ambulatory aid: Crutches/cane/walker" and "Gait/transferring: Weak".
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A medical examination was started by Staff #6, ED Physician at 11:57 PM. Notes included, "60-year-old male presenting because he was bleeding out of his IV site in the right antecubital fossa. Patient was just here tonight and was resting and when he woke up, he had some blood in the bed so he decided to come as he is on warfarin and the bleeding will not stop. He denies fevers, chills, nausea, vomiting, syncope, or any other associated symptoms."
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The physical exam noted by Staff #6 noted, "Upper extremity/M/S: right antecubital fossa has an area of ecchymosis that is not expanding, no pulsatile bleeding, mild oozing of blood". (There was no gait or mobility assessment for the leg weakness documented.)
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07/28/2023:
At12:06 AM a triage assessment was initiated by Staff #9, ED RN.
At 12:43 AM a hand-off Report between Staff #9 and Staff #10 noted "visible seeping of the Coban".
At 12:43 AM a dressing change to Patient #1's old IV site using hemastat (hemostatic dressings include a substance/agent such as chitosan or celox - agents to promote rapid blood coagulation) by Staff #9 and Staff #13 was documented.
At 1:25 AM verbal orders were given by Staff #13 to Staff #9 for oral Ativan 1 mg.
At 1:29 AM the Ativan was given by Staff #9 to Patient #1 for pain scale rating of 8/10 (pain location was not documented).
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At 1:59 AM physician notes documented:
"Clinical Impression
Primary Impression: BLEEDING FROM IV SITE
Secondary Impressions: Chest pain"
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At 2:40 AM Hydrocodone Bitartrate/Acetaminophen 7.5/325 mg/1 tablet was given per orders to Patient #1 by Staff #9 for pain scale rating of 8/10 (pain location was not documented).
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At 3:35 AM CBC and CMP results included the following abnormal findings:
Test Results Normal Value
Red blood cells 3.0 M/mm3 4.1 - 5.3 M/mm3
Hemoglobin 8.3 gm/dL 12.0 - 17.4 gm/dL
Hematocrit 24% 40 - 50%
Granulocytes 75.1% 45.0 - 75.0 %
Immunoglobulin 1.2% 0 - 0.5%
Lymphocyte 9.8% 15.0 - 40.0%
Granulocytes 7.05 K/mm3 1.40 - 6.50 K/mm3
Immunoglobulin 0.11 K/mm3 0 - 0.03 K/mm3
Lymphocytes 0.92 K/mm3 1.20 - 3.40 K/mm3
Monocytes 1.19 K/mm3 0.10 - 0.60 K/mm3
Sodium 130mmol/L 136 - 144 mmol/L
Chloride 97 mmol/L 102 - 110 mmol/L
Glucose 177 mg/dL 70 - 110 mg/dL
BUN 46 mg/dL 6 - 20 mg/dL
Creatinine 1.53 mg/dL 0.4 - 1.5 mg/dL
BUN/create ratio 30.1 8.0 - 23.0
(The hemoglobin and hematocrit are noted to be dropping. A follow-up CK (creatinine kinase) was not obtained. Patient #1's CK was notes as 1,351 units/L during the previous ED visit on 7/27/2023 (21 - 232 units/L).)
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At 3:40 AM Patient #1's leg pain rating was documented as 3/10.
At 4:05 AM Patient #1's leg pain rating was documented as 8/10.
At 4:11 AM an EKG was ordered and obtained. The EKG noted "normal sinus rhythm, T-wave abnormality, consider inferior arterial ischemia, abnormal EKG".
At 4:38 AM a Troponin was normal at 17.
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At 5:07 AM, discharge orders were presented to and signed by Patient #1.
At 5:18 AM, Discharge notes by Staff #9 (ED RN) documented "Patient condition assessment: improved Ongoing signs/symptoms: bleeding has subsided post dressing change"
At 5:19 AM, Patient #1 departed the ED.
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(There was no evaluation for cord compression obtained for Patient #1 who presented on his first ED visit with complaints of back pain, leg pain. Patient #1 was found to have acute urinary retention with hematuria during his first ED visit and a foley catheter was placed. Patient #1 complained of bruising and had a Hgb of 10.2 which dropped to 8.3 gm/dL by the time of his second ED visit. There was no measurement of clotting time, such as an international normalized ratio (INR) obtained on Patient #1 who takes Coumadin for a history of PVD and presented he presented a second time with complaints of bleeding that would not stop at the IV site from the first visit. There were no clear medical notes that all potential emergency medical conditions (EMCs) were properly assessed for. There were no serial troponins or repeated EKGs obtained (per AHA Guidelines) for chest pain were not obtained to rule out acute coronary syndrome (ACS).)
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Medical Record Review and Timeline for Patient #1 at Facility B:
July 28, 2023
At 12:28 PM, Patient #1 was admitted, triaged, and medical screening exam initiated by Facility B's ED Physician (Staff #4). Notes included:
"Chief Complaint: Bleeding/Bruising, Arm Pain, and Generalized Body Aches
(Patient #1) is a 60 y.o. male who presents to the ED along with his daughter complaining of bilateral arm pain, swelling, bleeding from recent IV site, and bruising since yesterday. Patient was seen at (Facility A) on 2 occasions yesterday. States that on 1 of those occasions he had urinary retention and had a Foley catheter placed. He has noticed blood in his Foley catheter. Patient also reports that he is currently on Coumadin." The physical exam noted that Patient #1 was "in acute distress, had a foley catheter in place with blood in the tubing, had bruising in bilateral arms with mild oozing from the left antecubital space from a recent IV puncture with was controlled with pressure." "Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Supratherapeutic INR (INR >22) with symptomatic anemia (hgb 7.7) and AKI, treated with IV vitamin K and FFP. Critical care was time spent personally by me on the following activities: Blood draw for specimens, development of treatment plan with patient or surrogate, discussions with consultants, evaluation of patient's response to treatment, examination of patient, ordering and performing treatments and interventions, ordering and review of laboratory studies, ordering and review of radiographic studies and pulse oximetry ..."
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Notes also included, "Summary of workup today:
Labs-WBC 11.8, H&H 7.7 and 23.1, sodium 129, chloride 93, BUN 51, creatinine 1.5, glucose
162, PT greater than 150, INR greater than 22.4, PTT greater than 200, UA showed moderate
leukocyte esterase, slight bacteria, and blood, CK level 1,402, blood type: 0+
Radiology-bilateral upper extremity venous Doppler ultrasound showed no evidence of DVT
Consults-hospitalist
Disposition-admit
Differential Diagnosis including but not limited to: Anemia, coagulopathy, acute
rhabdomyolysis, DVT, acute renal failure, UTI
Acute UTI: acute illness or injury
AKI (acute kidney injury) (CMS/HCC): acute illness or injury
Bilateral arm pain: acute illness or injury
Coagulopathy (CMS/HCC): acute illness or injury
Dehydration: acute illness or injury
Elevated CK: acute illness or injury
Hematuria, unspecified type: acute illness or injury
Hyponatremia: acute illness or injury
Supratherapeutic INR: acute illness or injury
Symptomatic anemia: acute illness or injury
Amount and/or Complexity of Data Reviewed
Independent Historian:
Details: patient's daughter
Labs: ordered.
Discussion of management or test interpretation with external provider(s): Discussed with Dr.
Kang (hospitalist) regarding the patient's presentation/lab/radiology findings, patient admitted under the hospitalist.
Risk
Prescription drug management.
Decision regarding hospitalization."
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At 3:07 PM an ultrasound doppler of the upper extremities noted no evidence of a venous thrombosis involving either upper extremity allowing for non-visualization of portions of the superficial veins."
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At 3:35 PM Staff #4, the treating ED physician explained to nursing that he had ordered a redraw of Patient #1's PT/PTT/INR due to his last PTT being greater than 150. It was noted by Staff #4 that a PTT greater than 200, and an INR greater than 22.4 with active bleeding in the left arm antecubital and hematuria required that he order FFP (fresh frozen plasma), vitamin K via IV.
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At 4:40 PM, Staff #4 spoke to the hospitalist, and it was decided to admit Patient #1 for care.
At 8:52 PM, a renal ultrasound and a right knee x-ray were obtained.
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Some of the abnormal lab findings while in the ED:
Test Results Normal Value
White blood cells 11.8 K/mm3 4.6 - 10.0 K/mm3
Red blood cells 2.74 M/mm3 4.1 - 5.3 M/mm3
Hemoglobin 7.7 gm/dL 12.0 - 17.4 gm/dL
Hematocrit 23.1% 40 - 50%
Sodium 129 mmol/L 136 - 144 mmol/L
Chloride 93 mmol/L 102 - 110 mmol/L
Glucose 162 mg/dL 70 - 110 mg/dL
BUN 51 mg/dL 6 - 20 mg/dL
Creatinine 1.5 mg/dL 0.4 - 1.5 mg/dL
BUN/create ratio 34 8.0 - 23.0
PT >150 11 - 35 seconds
PTT >200 11 - 13.5 seconds
INR >22.4 0.8 - 1.2 seconds
Patient #1 was admitted at 7:39 PM.
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Procedure/Policy Review:
Facility A's "Emergency Department Protocols" Policy, last reviewed and effective 02/13/2020 stated on page 2 of 12:
" ...Chest Pain
High-moderate risk factor
(age >35, positive CAD risk factors)
o STAT EKG, Cardiac monitor, Pulse ox
o O2 2 liters NC
o IV access
o Initiate Chest Pain ED Orders
o Draw labs and order
o CBC,
o BMP
o Bio Markers X 3
o Nitro sublingual 0.4 mg every 5 min X 3 if SBP >100
o ASA 81mg chewable x 4 tabs
o Bilateral BP's
o Document patient weight
o Chest x-ray 2 view (if unstable do portable) ..."
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And on page 3 of 12:
" ...EKG STAT Protocol
All of the following patients will have STAT EKG done on arrival
o Chest Pain
o All Males and females >16 yo
o Abdominal Pain
o All Males >40
o All Females >50
o Nausea and Vomiting
o All Diabetics
o All Males >40
o All Females >50
o Short of Breath
o All new onset SOB
o All Diabetics
o Known Heart Disease
o Weakness
o New Onset Weakness
o Syncope
o All ..."
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Facility A's "Scope of Service and Treatment, Emergency Department" Policy, last reviewed and effective 04/2021 stated on page 1 of 6:
" ...II. DEFINITIONS:
C. Medical Screening Examination (MSE)- The process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition (EMC) exists or with respect to a woman who could be in labor, whether or not the woman is in labor. Screening is to be conducted to the extent necessary, by physicians and/or other QMP to determine whether an EMC exists.
III. POLICY:
It is the policy at Medical City Arlington that all patients who present for emergency care receive an appropriate Medical Screening Exam regardless of race; gender; religious affiliation; age; ethnic origin; sexual orientation; or financial resources.
The procedures for care and treatment follow approved departmental and hospital standards and applicable state and federal laws.
Emergency Medical Screening exam incorporates pre-hospital care; triage; nursing and physician
assessment; diagnostics; implementation of therapy; specialty consultation, continued observation and admission when indicated; patient and family education; disposition; and referral. Pre-hospital care providers, multiple hospital departments, consulting physicians, and community agencies collaborate with emergency care personnel to coordinate services delivered to the patient and family ..."
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Facility A's "EMTALA - Texas Medical Screening Examination and Stabilization Policy", last reviewed and effective 04/2022 stated on page 1 of 13:
" ...IV. POLICY:
A. An EMTALA obligation is triggered when an individual comes to a dedicated emergency
department ("DED") and:
1. the individual or a representative acting on the individual's behalf requests an examination or
treatment for a medical condition; or
2. a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition.

Such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition ("EMC").
Further, if a prudent layperson observer would believe that the individual is experiencing an
EMC, then an appropriate MSE, within the capabilities of the hospital's DED (including
ancillary services routinely available and the availability of on-call physicians), shall be performed. The MSE must be completed by an individual (i) qualified to perform such an
examination to determine whether an EMC exists, or (ii) with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an
appropriate transfer as defined by and required by EMTALA. Stabilization treatment shall be applied in a non-discriminatory manner (e.g., no different level of care because of age, gender,
disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state or local law) ..."
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And pages 6 - 7 of 13:
C. Extent of the MSE
1. Determine if an EMC exists.
The hospital must perform an MSE to determine if an EMC exists. It is not appropriate to merely
"log in" or triage an individual with a medical condition and not provide an MSE. Triage is not
equivalent to an MSE. Triage entails the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will
be screened by a physician or other QMP.
2. Definition of MSE.
An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The
MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital.
3. An on-going process.
The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer.
4. Judgment of physician or QMP.
The extent of the necessary examination to determine whether an EMC exists is generally within the judgment and discretion of the physician or other QMP performing the examination function according to algorithms or protocols established and approved by the medical staff and
governing board.
5. Extent of MSE varies by presenting symptoms.
The MSE may vary depending on the individual's signs and symptoms:
a. Depending on the individual's presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures ...."
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And page 11 of 13:
" ...H. When EMTALA Obligations End
The hospital's EMTALA obligation ends when a physician or QMP has made a decision:
1. That no EMC exists (even though the underlying medical condition may persist);
2. That an EMC exists and the individual is appropriately transferred to another facility; or
3. That an EMC exists and the individual is admitted to the hospital for further stabilizing
treatment; or
4. That an EMC exists and the individual is stabilized and discharged ..."
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Interviews:
On 09/12/2023 at 12:55 PM, the ED Director (Staff #21) and an ED RN (Staff #20) were interviewed. Staff #21 indicated that the facility process for screening and emergency medical condition processes as defined in policy had been followed by the ED physician.
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