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ST VINCENT HEALTHCARE 1233 N 30TH ST BILLINGS, MT 59101 June 7, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag A2406 - Medical Screening Exam Until Individual Is Stabilized

Based on interviews and record review, the facility failed to comply with the Medicare provider agreement as defined in 489.24 related to the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. Specifically, the facility failed to ensure that the patient's chief complaint was followed throughout the continuum of care and ensure the patient was stabilized at the time of discharge from the Emergency Department. This deficiency affected 1 (#1) of 20 patients on two separate visits to the Emergency Department.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to provide an adequate medical screening exam per 489.24(a). Specifically, the facility failed to ensure that the patient's chief complaint was followed throughout the continuum of care and ensure the patient was stabilized at the time of discharge from the Emergency Department. This deficiency affected 1 (#1) of 20 patients on two, same day, separate visits to the Emergency Department. Findings include:

AMBULANCE RECORD:
A review of the non-facility owned ambulance record showed the call was received on 5/4/16 at 4:07 p.m., and the ambulance arrived with the patient at the Emergency Department at 5:08 p.m. The documentation included a note of possible stroke, CVA, TIA, with right sided weakness and migraine along with vital signs which were called ahead to the hospital from the ambulance. A Los Angeles Prehospital Stroke Screen (LAPSS) was conducted to determine if a stroke had or was occurring which was inconclusive.

POLICY REVIEW:
A review of the facility's triage policy showed all ambulance patients will be triaged to appropriate areas of treatment per the CS and/or ED Physician. The Primary RN and/or CS will initiate and complete the triage process. The process for the rooming tech/RN places all patients with an acuity level (ESI) of 1, 2, and 3 on a bedside monitor including ECG, blood pressure, and pulse oximeter monitoring devices.

The ESI Level 3-(Urgent) neuro/altered mental status included known seizure (without increased or recent seizure activity.) The ESI Level 2-( Emergent) neuro/altered mental status included seizures (new onset or continuous). Upon the first visit, patient #1 presented to the Emergency Department via ambulance with potential stroke like symptoms and seizures (new onset or continuous), and was triaged at ESI Level 3 although fit the ESI Level 2 triage per facility policy. At the second visit, patient #1 was triaged at an ESI 3.

EMERGENCY DEPARTMENT VISIT #1:
A review of patient #1's emergency department record, dated 5/4/16 at 5:12 p.m., showed the patient presented for evaluation of a new onset seizure; after the initial incident of a seizure where bystanders witnessed and reported the event lasted less than a minute, with generalized tonic-clonic movements. The patient reported a headache and generalized weakness and no history of a seizure prior to that occurrence.

The patient was given a physical assessment which was within normal limits. Staff member L, MD, wrote in the medical note the patient received fluids and morphine for pain control. The tests recorded did not show abnormality and the findings were discussed with the patient. Staff member L wrote the patient's symptoms may have been secondary to alcohol withdrawal and did not feel that the patient needed further admission or evaluation.

Patient #1 was administered 4 mg of Zofran intravenously at 5:51 p.m. for nausea, and 4 mg/ml intravenous morphine on 5/4/16 at 5:52 p.m. for pain. Patient #1 was then administered 8 mg of intravenous morphine on 5/4/16 at 7:08 p.m.; there was no evidence vital signs were taken for the patient after 7:00 p.m., and after the second dosage of morphine. The patient's pain level was assessed at 7:08 p.m. at a 5/10 and described as aching and acute, and re-assessed at 7:24 p.m., with a pain level of a 3/10 and described as aching and acute. The patient was given discharge instructions related to Adult Seizure on 5/4/16 at 7:09 p.m. The ED disposition showed at 7:26 p.m., the patient would be discharged to the Community Crisis Center (CCC) by a hospital security guard dropping him off. The CCC is within 5 blocks of the hospital.

The patient was discharged on [DATE] at 7:31 p.m., to home or self care with final diagnoses of Nausea, Nicotine Dependence, Homelessness, Unspecified convulsions, and Allergy status to analgesic agent status. The medical record showed the patient's left hand intravenous IV, which was initiated by ambulance staff prior to admission, was removed at 7:32 p.m.

There was no evidence in the record that a continum of care took place between the ambulance's report of CVA/TIA, and the ED's medical screening exam.

EMERGENCY DEPARTMENT VISIT #2:
Patient #1 returned to the ED at 10:54 p.m. on 5/4/16, roughly 3 hours after the first hospital discharge. A review of patient #1's emergency department patient record of 5/4/16 at 10:54 p.m., showed the patient presented to the ED by way of walk-in with multiple complaints including feeling nauseous. The patient was triaged at an ESI of 3. A physical exam was performed and resulted in no abnormalities or areas of concern from the medical staff. The medical record showed no evidence that an ECG was conducted on the second visit although the policy is to conduct such monitoring when triaged at ESI 3. Staff member H, MD, encourage patient #1 to return to the CCC where acute resources could be found to help him get back to his home. ED notes on 5/4/16 at 11:57 p.m. showed the patient stated he had "no one" in Montana, was offered a ride back to the CCC, drank three glasses of water and was given an oral dose of Zofran for nausea. The patient refused a ride to the CCC and stated he would walk.

Staff member H, MD, gave discharge instructions on 5/4/16 at 11:50 p.m. that showed "drink lots of fluids." History of present illness showed the patient stated the morphine he was given on his previous admission made him sick and very nauseous and that the patient was unsteady on his feet. The patient complained that he was overheating and he needed water. The patient also commented that he did not feel safe being discharged again to the CCC because he was alone and had no way to defend himself on the streets. The only vital signs that were taken on the second visit were recorded on 5/4/16 at 11:42 p.m. His blood pressure was 134/87 and the patient stated he had a pain level of 7/10. An ED plan of care was created at 11:51 p.m. for Pain Goal and Treatment options; no indication for referral was made.

INTERVIEWS:
During an interview on 6/7/16 at 2:44 p.m., staff member B, RN, stated patient #1's ambulance record was from a non-facility ambulance. The record showed the patient had a seizure and during his initial visit, a work-up with multiple tests were done and no concerns were identified. On a return visit, the patient had mentioned he did not have a way home. Staff member B, stated she could not see in the record where he was told to go to the CCC, but that it was a good resource for community needs. Staff member B, stated the patient was offered a ride to the CCC after discharge on the patient's second trip to the Emergency Department which was declined by the patient.

During an interview on 6/7/16 at 3:35 p.m., staff member A, MD, stated the hospital follows the Emergency Medical Treatment and Labor Act (EMTALA) policy. Staff member A, stated once the medical care episode is finished with a patient, care management can get involved. The care management team included social workers that could assist in helping patients with a lack of resources get placement or transportation from the hospital to home or another appropriate setting. The care management team is not available 24 hours a day however. Staff member A, stated once a patient is discharged , they can wait around the hospital for two hours and try to contact friends or family for a ride home. If a patient was unable to access a private ride, the CCC could also be another resource available to patients with limited resources; but, a diagnosis of homelessness or alcohol abuse was a typical requirement for entry. Staff member A, stated the emergency department's physicians would evaluate a patient, get them as sober as possible or stable. Once the patient was good to go, the physician would refer to the CCC. The CCC would provide food, clothing, warmth, care management, and nursing if required, but the patient needed to be medically stable to stay. Staff member A, stated physicians would give a diagnosis of homelessness after consulting with a patient. The consult included a hospital emergency department intake questions such as, where do you live? The hospital intake nurse would ask that question of every patient reporting to the emergency department for billing or resource purposes.

During an interview on 6/8/16 at 4:45 p.m., patient #1 stated he had a history of right sided weakness but had completely lost the use of his right hand and leg during the ambulance transport to the hospital and the ambulance staff was performing tests for stroke. While at the hospital the patient stated he was mistaken for a homeless person and given a diagnosis as homeless. The patient was discharged the first time from the hospital with no resources for transportation or shelter. Patient #1 stated a hospital security guard gave him a ride to CCC which had no vacancy. The patient stated the person working at the CCC gave him a floor mat to lay on but the patient continued to experience adverse symptoms including a burning sensation in his forehead, profuse sweating, nausea and vomiting. The person working at the CCC recommended the patient go back to the hospital. The patient stated he was scared because of his condition, and fearful because he was disoriented and could not defend himself. The patient made it back to the hospital on his own and stated the hospital staff referred to him as a "chronic." Patient #1 stated to staff that he was nauseous and sick, and his head was burning. The patient stated to the physician he did not know what was wrong but repeatedly told the doctor that he was not seeking drugs. The patient stated he was then discharged and told there was nothing they could do for him. The hospital security guard then dropped the patient off in front of a restaurant downtown.

The patient stated he begged the security guard to help him and not leave him, because he felt unsafe related to his condition and again could not defend himself. The patient stated he was still throwing up, and was laying in the grass to cool off because he was hot. The patient stated he found his way back to the CCC and a nurse on duty took his vital signs, and the patient reported his blood pressure was 197/117. The patient stated the nurse at the CCC told him he needed to go to the emergency room and he stated they kept throwing him out. The patient stated he was eventually given a ride home the next day and followed up with his primary care physician a few days later, more tests were done and the physician identified a blood clot and stated it was too late to break the clot up.