HospitalInspections.org

The survey team conducted an on-site, unannounced Emergency Medical Treatment and Labor Act (EMTALA) investigation for complaint NE00080181 as directed by the Centers for Medicare & Medicaid Services (CMS) Regional Office staff. The EMTALA investigation ended on November 11, 2016. The hospital was not operating in compliance with the EMTALA Commitments Relevant to section 1867 Responsibilities (42 CFR 489.20 (1)) and (42 CFR 489.24(a)). The CMS Kansas City Regional Office notified the hospital Chief Executive Officer that an immediate jeopardy (IJ) conditions existed on 11/9/16 at 4:15 pm. The determination for the IJ was based upon record reviews and staff interviews which revealed the emergency department (ED) did not provide patient # 7 with an examination after learning her physician had directed her to go to the nearest hospital to receive an examination for her complaints of a headache and leg pain, and an elevated blood pressure during her pregnancy which culminated in a cesarean section five days prior. Without performing an examination, the ED physician directed the patient to another hospital for an examination. Please refer to citations at A2406 for further details regarding patient # 7.

Based on record review, review of the facility Emergency Treatment and Labor Act (EMTALA) policies, staff and provider interviews the facility failed to provide and document in the medical record an appropriate Medical Screening Examination (MSE) for 2 of 20 sampled patients (Patient 7 and 10). The total sample size was 20. Findings are:

A. Record review of the facility policy titled "Transfer and Emergency Examination" last revised 10/2015 under section titled "Procedures" directs staff that for any individual who comes to the Emergency Department (ED) and requests an examination and/or treatment that an "appropriate medical screening examination is to be provided (including ancillary services routinely available to the Emergency Department) to determine whether or not an emergency medical condition exists." The policy further states that the MSE is to be performed by a Physician, Physician Assistant (PA) or Advanced Practice Nurse Practitioner (APRN).

B. Interview with the facility Administrator on 10/31/16 at 2:30 PM revealed that the Administrator received a call from Hospital B stating that they thought they needed to report an EMTALA violation related to Patient 7 who did not receive an examination prior to being told to come to Hospital B for care on 10/23/16. The administrator revealed there was no medical record or documentation related to Patient 7 being in the ED or that the emergency department (ED) physician provided an examination.

In an interview on 10/31/16 at 2:20 PM ED physician B said that Patient # 7 came into the hospital on 10/23/16 and said her physician had directed her to go to the nearest hospital because she had a " headache and pain in her left leg, " and that 5 days prior she had delivered a baby by Cesarean Section (surgical opening into the abdomen/ uterus to deliver baby) at Hospital B. Physician B stated patient # 7 told her that she had an elevated blood pressure during her pregnancy. Physician B said she recalled that she asked patient # 7 a few questions about her headache and looked at her legs for evidence of a deep vein blood clot. Physician B stated that she did not want the patient billed for the visit and "told her I could do a further workup here or I can send you to hospital B. Physician B stated "I wanted her to be evaluated by someone that does OB [Obstetrical services)]. Physician B said the patient left with her mother and went to Hospital B.

In an interview on 10/31/16 at 3:40 PM, registered nurse (RN) E recalled Patient 7 came to the nurses ' desk on 10/23/16 and asked to be seen. RN E took the patient to a room used for ED patients and checked her blood pressure which was high. RN E recalled that Physician B came in and talked with the patient, looked at her incision and checked the pulses in her legs. RN E confirmed there was no documentation of the patient ' s visit. RN E said she recalled that physician B said they were not going to create an ED chart so she would not be billed for the visit, "we are going to send her to hospital B ' s Emergency Room." RN E confirmed that staff did not contact hospital B to let them know patient # 7 would be arriving without having received a medical screening examination at Callaway District Hospital.

In an interview on 10/31/16 at 3:50 PM, the Medical Chief of Staff, Physician A stated the hospital administrator contacted physician B on 10/24/16 and physician B emailed a note describing her interaction with Patient 7 on 10/23/16. Physician A stated that physician B ' s email is the hospital ' s only documentation related to patient # 7 being in the facility on 10/23/16. Physician A stated that physician B documented in the email that the Assessment/Plan for patient # 7 was "HTN [Hypertension] vs. pre-eclampsia " (disorder of pregnancy characterized by high blood pressure and a large amount of protein in the urine. Complications can include seizure, stroke, liver damage, kidney injury. An elevation of blood pressure can occur during the first week postpartum attributable volume expansion and fluid mobilization). Physician A stated it "looked like [name of Patient 7] could have had an Emergency Medical Condition" based on the patient ' s history of pre-eclampsia and timing of delivery. Physician A related that if this had been his patient in the ED the MSE would have included laboratory testing to check liver enzymes, platelet count, and protein in the urine. Physician A stated that these tests along with checking the patient ' s vital signs would help a physician to determine if the patient had an emergency medical condition.

Review of Patient 7's medical record from Hospital B revealed the patient arrived on 10/23/16 at 6:22 PM. The documentation revealed after going to Callaway District Hospital the patient arrived at Hospital B with an extremely high blood pressure. Hospital B provided patient # 7 with an examination and treatment of her abnormal blood pressure.


C. Review of Patient # 10's medical record revealed the patient was seen in the ED on 8/20/16 at 2:01 PM and discharged at 5:30 PM. Advanced Practice Nurse Practitioner APRN C conducted the examination and ordered blood tests. Patient # 10 was diagnosed with Nausea and Vomiting, Dehydration, Hypokalemia (low potassium), headache and viral syndrome. The patient received Intravenous (IV) fluids and medications including potassium during his visit. At discharge his vitals were stable and his headache had improved.

Patient # 10 returned to the ED at 10:05 PM (4 hours and 35 minutes later) complaining of a Headache. The medical record did not contain evidence that patient # 10 received an examination. The provider, APRN C was on duty, but failed to document an examination. The APRN gave orders for IV fluids and pain medication. The patient discharged at 12:30 AM on 8/21/16.

Phone interview with APRN C on 11/1/16 at 2:15 AM revealed that the APRN had examined the patient but since nothing changed the nurse told the APRN that documentation was not needed so she did not document any contact with the patient.

An unannounced onsite EMTALA (Emergency Medical Treatment and Labor Act) investigation began on 10/27/16 and continued through 11/2/16.

Based on record review of the facility EMTALA policies, staff interview and medical staff interviews the facility failed to perform a Medical Screening Examination (MSE) for 2 of 20 sampled patients (Patient 7 and 10) to determine if the patienst had an Emergency Medical Condition (EMC) requiring stabilizing treatment and transfer.

Patient 7 had a potential EMC related to elevated Blood Pressure (BP) and a history of Pre-eclampsia, a dangerous complication related to pregnancy. A nurse and physician spoke with the patient while she was in the ED on 10/23/16. The patient did not recieve an examination before being sent to a nearby hospital for treatment and evaluation. Patient 10 was seen on 8/20/16 with dehydration and received a MSE and treatment for dehydration. The patient returned to the ED 4 hrs and 35 minutes later with similar symptoms but a worsening headache. The medical record did not contain evidence that the practitioner examined the patient. These findings have the potential to place all patients coming to the ED at risk of failure to receive an adequate screening examination to ensure the patient does not have an EMC requiring stabilizing treatment. This places the patients in immediate jeopardy to their health and safety. The facility sees on average, 58 patients per month over the past 6 months.

Findings are:

A Interview with the facility Administrator on 10/31/16 at 2:30 PM revealed that the Administrator received a call from Hospital B stating that they thought they needed to report an EMTALA violation related to Patient 7 who presented to their emergency department (ED) after leaving Callaway District Hospital without having received an examination on 10/23/16. The administrator revealed there was no medical record or documentation related to Patient 7 being in the ED on 10/23/16.

In an interview on 10/31/16 at 2:20 PM physician B said that Patient 7 came into the hospital on 10/23/16 and said her physician had directed her to go to the nearest hospital because she had a " headache and pain in her left leg, " and that 5 days prior she had delivered a baby by Cesarean Section (surgical opening into the abdomen/ uterus to deliver baby) at Hospital B. Physician B stated patient # 7 told her that she had an elevated blood pressure during her pregnancy. Physician B said she recalled that she asked patient # 7 a few questions about her headache and looked at her legs for evidence of a deep vein blood clot. Physician B stated that she did not want the patient billed for the visit and "told her I could do a further workup here or I can send you to hospital B." Physician B stated "I wanted her to be evaluated by someone that does OB [Obstetrical services]." Physician B said the patient left with her mother and went to Hospital B.

In an interview on 10/31/16 at 3:40 PM, registered nurse (RN) E recalled Patient 7 came to the nurses ' desk and asked to be seen. RN E took the patient to a room used for ED patients and took her BP which was high. RN E recalled that Physician B came in and talked with the patient, looked at her incision and checked the pulses in her legs. RN E confirmed there was no documentation of the patient ' s visit. RN E said she recalled that physician B said "we aren ' t doing an incident on her, we are going to send her to hospital B ' s Emergency Room." Staff did not contact hospital B to let them know patient # 7 would be arriving without having received a medical screening examination at Callaway District Hospital.

In an interview on 10/31/16 at 3:50 PM, the Medical Chief of Staff physician A stated the hospital administrator contacted physician B on 10/24/16 and physician B emailed a note describing her interaction with Patient 7 on 10/23/16. Physician A stated that physician B ' s email is the hospital ' s only documentation related to patient # 7 being in the facility on 10/23/16. Physician A stated that physician B documented in the email that the Assessment/Plan for patient # 7 was "HTN [Hypertension] vs. pre-eclampsia " (disorder of pregnancy characterized by high blood pressure and a large amount of protein in the urine. Complications can include seizure, stroke, liver damage, kidney injury. An elevation of blood pressure can occur during the first week postpartum attributable volume expansion and fluid mobilization). Physician A stated it "looked like [name of Patient 7] could have had an Emergency Medical Condition" based on the patient ' s history of pre-eclampsia and timing of delivery. Physician A related that if this had been his patient in the ED the MSE would have included laboratory testing to check liver enzymes, platelet count, and protein in the urine. Physician A stated that these tests along with checking the patient ' s vital signs would help a physician to determine if the patient had an emergency medical condition.

Review of Patient 7's medical record from Hospital B revealed the patient arrived on 10/23/16 at 6:22 PM. The documentation revealed the patient arrived after having gone to Callaway District Hospital for care. Further documentation showed Hospital B provided patient 7 with an examination and treatment of her extremely elevated blood pressure.

B. Review of Patient 10's medical record showed the patient was seen in the ED on 8/20/16 at 2:01 PM and discharged at 5:30 PM. Advanced Practice Nurse Practitioner (APRN) C conducted the MSE and orded laboratory testing during the visit. The patient was diagnosed with Nausea and Vomiting, Dehydration, Hypokalemia (low potassium), headache and viral syndrome. The patient received Intravenous (IV) fluids and medications including potassium during his visit. At discharge his vitals were stable and his headache had improved.

Patient # 10 returned to the ED at 10:05 PM (4 hours and 35 minutes later) complaining of a worsening Headache. The medical record did not contain evidence that APRN C conducted a MSE.


In a phone interview on 11/1/16 at 2:15 AM, APRN C stated that s/he examined the patient but since nothing changed the nurse told the APRN that MSE documentation was not needed.

C. Review of the facility policy titled "Transfer and Emergency Examination" last revised 10/2015 under section titled "Procedures" directs staff that for any individual who comes to the Emergency Department (ED) and requests an examination and/or treatment that an "appropriate medical screening examination is to be provided (including ancillary services routinely available to the Emergency Department) to determine whether or not an emergency medical condition exists." The policy further states that the MSE is to be performed by a Physician, Physician Assistant (PA) or Advanced Practice Nurse Practitioner (APRN).

D. Review of Medical Staff Bylaws last approved 1/9/12 identified the Qualified Medical Professional as a physician, a physician assistant, or an advanced practice registered nurse. The QMP determines if the patient has an EMC.