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Based on document review and staff interview, it was determined the Hospital failed to provide a Medical Screening Examination and treatment was not delayed to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24.

Findings include:

1. The hospital failed to ensure patients who did come to the Emergency Department were provided an appropriate medical screening examination within the capability of the hospital's emergency department. See deficiency at A-2406

2. The hospital failed to ensure treatment was not delayed. See deficiency at A-2408

Based on document review and interview, it was determined for 1 of 20 (Pt #1) patients who presented to the Emergency Department (ED) seeking treatment, the hospital failed to provide an appropriate medical screening to determine within reasonable clinical confidence whether an emergency medical condition existed. This has the potential to affect all patients who presented to the hospital and requested a medical screening examination (MSE) with 36,000 patient visits per year in the Emergency Department (ED) and 1808 patient visits in the Labor and Delivery.

Findings include:

1. The policy titled "Transfer and Emergency Examination- EMTALA (Emergency Medical Treatment and Labor Act/revised by hospital 4/22)" was reviewed on 12/13/22. The policy noted "IV. Indications for Medical Screening ... B. Conditions to be Referred for Prompt Screening Registration of an individual should not be post-phoned and the following areas shall be notified without delay whenever the condition of the individual warrants' immediate notification... Emergency Department... h) eye injury."

2. The policy titled "Emergency Severity Index Triage Guideline" (reviewed by hospital 11/6/22) was reviewed on 12/13/22. The policy noted "The Emergency Severity Index (ESI) is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent). ESI is used to assess patient acuity based on their presentation in the ED and the expected level of care the patient will require... C. Arriving patients with wait times... 1. Nurse and tech (technician) may need to interchange who will arrive the patients, due to the current needs of the ESI area. They should work as a team to ensure that the patients ESI is completed."

3. Pt #1 DOS: 11/6/22
Diagnosis: Cornea Ulcer Left Eye. The record was reviewed on 12/13/2022. The record noted Pt #1 arrived to the ED via car on 11/6/22 at 11:53 AM; was triaged at 12:54 PM, 61 minutes after arrival and a blood pressure of 170/101 (normal blood pressure reading is less than 120/80) was noted; assigned an ESI score of 3 (urgent); taken to ED roomed at 2:11 PM, 77 minutes after triage, a blood pressure reading of 199/103 and the first pain assessment was conducted which Pt #1 reported as a 10 (worst possible pain); and the MSE was conducted at 2:45 PM. The record lacked documentation a past medical history and a review of current medications were conducted. The record lacked documentation of why there was a delay in treatment, why the abnormal blood pressures were not reported to a qualified medical professional or a past medical history was assessed.

4. Pt #1 DOS: 11/10/22
Diagnosis: Persistent Left Eye Pain. The record was reviewed on 12/13/2022 at 12:50 PM. The record noted an initial blood pressure reading of 172/98 and a reassessment of the blood pressure was not conducted prior to discharge, lacked a pain assessment and a past medical history and a review of current medications were not assessed. The record noted Pt #1 complained of constant pain which radiated into his/her skull and a headache which not symptoms previously reported by Pt #1. The record lacked documentation vision was assessed or a slit lamp test was conducted (microscopic evaluation of internal structure) and noted "Dilated left pupil, left conjunctive is erythematous and mildly edematous, mild left periorbital edema, no overlying skin findings to the left periorbital tissues (external exam)... Patient seen here by ophthalmology less than a week ago for similar symptoms that have not changed or worsened." The on-call ophthalmologist (MD#5) was consulted, although could not see the patient because "... they are unable to do so secondary to the patient insurance status." Pt #1 was discharge without a complete and accurate medical screening examination.

5. Pt #1 DOS: 11/12/22
Diagnoses: Subluxation of Lens left eye, Vitreous Hemorrhage left eye, Hyphema left eye, blunt injury to left eye. The record was reviewed on 12/13/2022. The record noted a surgical procedure to repair Pt #1's left eye was conducted on 11/12/22 by MD#1 (Ophthalmologist not in the Group with the On-Call Agreement). The record noted on 11/12/22 the following medications were added to Pt #1's current medication list: Albuterol inhaler 2 puffs with a start date of 12/29/21 and Ascorbic Acid 240 mg last taken 10/28/22. The record noted a past medical history of hypertension was also added to the record on 11/12/22.

6. During a phone interview on 12/13/22 at approximately 1:00 PM, the ED Nurse Practitioner (E#3) "When he/she was brought back (to the ED room on 11/6/22), I saw him and right away got the doctor. I could tell it (eye injury)was bad and he/she was in a lot of pain."

7. During an interview on 12/13/2022 at approximately 4:00 PM, the Chief Clinical Officer (E#2) reviewed Pt #1's record and verbally agreed the patient was not triaged in a timely manner, abnormal findings were not reported to a qualified medical professional, a past medical history and current medications were not assessed and should have been. E#2 verbally agreed there was a change in condition Pt #1's complaints/symptoms on 11/10/22 and should have been evaluated by the on-call ophthalmologist.

Based on document review and interview, it was determined for 1 of 20 (Pt #1) patients record reviewed, the hospital failed to ensure an appropriate medical examination (MSE) was conducted based on the method of payment. This has the potential to affect all patients who presented to the hospital and requested a MSE with 36,000 patient visits per year in the Emergency Department (ED) and 1808 patient visits in the Labor and Delivery.

Findings include:

1. The "On-Call Coverage Agreement" between the hospital and the Ophthalmology group (referred to as Group in the Agreement) dated 4/16/21 was reviewed on 12/13/22. The Agreement noted " ... (b) to make Physicians available with respect to Hospital patients regardless of financial condition, insurance coverage, or ability to pay ... 8.10 No Referral. Nothing contained in this Agreement shall require ... any party to refer any patients to any other party or to use any other party's facilities as a precondition to receiving the benefits set forth herein ... Exhibit B ... 2. Billing ... Group shall bill and collect in a manner consistent with Hospital's policies and procedures (including Hospital's charity care policy) and with the regulations, guidelines, and directives of all applicable federal, state, third party payor, fiscal intermediary and other entities having authority with respect to the manner in which Group may bill and collect for services."

2. Pt #1 Date of Service (DOS): 11/10/22
Diagnoses: Dislocation of intraocular lens and Abrasion of left cornea. The record was reviewed on 12/13/2022. The Emergency Department note dated 11/10/22 by MD#3 noted "Patient was seen in our emergency department on 11/6/22 for similar symptoms.... followed up on an outpatient basis with ophthalmology (on-call ophthalmologist that saw Pt #1 on 11/6/22 ED visit) and was told that his/her insurance would not cover the procedure to relocate his left lens and was referred to providers in Chicago. States he/she tried calling them but was unable to reach prompting his visit here tonight. Pain is constant. Radiates up into his/her skull... headache ... I did discuss the patient's case with the on-call ophthalmologist (MD#5) who will attempt to have his office reach out to this patient to help establish outpatient follow-up as they are unable to do so secondary to the patient's insurance status ... I recommend calling all the large academic institutions to help obtain an outpatient follow-up appointment to get your surgery." The record lacked documentation Pt #1 was discharged from the hospital with a follow-up appoinment for continuation of care.

3. During an interview on 12/13/22 at approximately 4:00 PM, the Chief Clinical Officer (E#2) reviewed the On-Call Agreement between the hospital and the On-Call Ophthalmology Group and stated "The Agreement explicitly spells out that (On-Call Ophthalmology Group) must follow our policies and accept any insurance that we accept. They cannot refuse to treat a patient based on insurance. (MD#2) assumed the care of this patient (Pt #1) while on-call for us therefore, the care must continue with this provider." E#2 verbally agreed Pt #1 should have been discharged with a follow-up plan for continuation of care.