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 record review and interview, the facility failed to provide an appropriate emergency medical screening examination (MSE) for one of 20 (Patient #1) patients whose records were reviewed. Patient #1 presented to the facility's emergency department (ED) three times. The first ED visit was on 11/11/2023 at 11:55 AM with complaints of a fall at home with right leg weakness following a recent Lumbar 4-Lumbar 5 transforaminal lumbar interbody fusion (a spinal fusion surgery that treats lower back pain and other conditions by joining two or more vertebrae in the spine) on 10/25/2023. The second ED visit was on 11/30/2023 at 11:00 AM with complaints of pain that did not respond to his prescribed pain medications. The medications included hydrocodone, methocarbamol, and gabapentin. Patient #1 also reported drainage from his surgical site. The third ED visit was on 12/02/2023 at 3:26 PM with complaints of increasing back pain, hip pain, abdominal pain, and pelvic pain and having had surgery recently. None of these three ED visits contained an appropriate MSE that was sufficient to rule out emergency medical conditions (EMCs) for Patient #1.
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Cross Reference to:
Tag A-2406 - 42 CFR §489.24 (a) (c) Appropriate Screening Examination.
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Based on record review and interview, the facility failed to provide an appropriate emergency medical screening examination (MSE) for one of 20 (Patient #1) patients whose records were reviewed. Patient #1 presented to the facility's emergency department (ED) three times. The first ED visit was on 11/11/2023 at 11:55 AM with complaints of a fall at home with right leg weakness following a recent Lumbar 4-Lumbar 5 transforaminal lumbar interbody fusion (a spinal fusion surgery that treats lower back pain and other conditions by joining two or more vertebrae in the spine) on 10/25/2023. The second ED visit was on 11/30/2023 at 11:00 AM with complaints of pain that did not respond to his prescribed pain medications. The medications included hydrocodone, methocarbamol, and gabapentin. Patient #1 also reported drainage from his surgical site. The third ED visit was on 12/02/2023 at 3:26 PM with complaints of increasing back pain, hip pain, abdominal pain, and pelvic pain and having had surgery recently. None of these three ED visits contained an appropriate MSE that was sufficient to rule out emergency medical conditions (EMCs) for Patient #1.
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Findings include:
Medical Record Review for 11/11/2023 Emergency Department (ED) Visit #1:
Patient #1, a 53-year-old male, presented to the emergency department (ED) on 11/11/2023 at 11:55 AM after a fall the night before (11/10/2023). His pertinent history included a recent Lumbar 4-Lumbar 5 transforaminal lumbar interbody fusion on 10/25/2023. The documented chief complaints were a fall at home with right leg weakness since yesterday (11/10/2023) and back pain that would not resolve while being two weeks post-operative. Staff #5 documented that Patient #1 had a "full range of motion to bilateral lower extremities" at the time of this ED visit.
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Vital signs were documented on 11/11/2023 at 11:00 AM, 12:04 PM, 12:21 PM, 12:30 PM, 1:30 PM, 2:00 PM, and 4:00 PM.
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On 11/11/2023 at 12:08 PM, Staff #5, the treating ED physician noted that after a fall last night at home, Patient #1 reported that, "He felt a loss of sensation of his RLE (right lower extremity)" and that "he has pain radiating down his R (right) side and foot numbness. He (Patient #1) is afraid he re-injured his back." It was further documented that Patient #1 "is postoperative from back surgery done 10/25/2023."
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Morphine 10mg (intramuscularly) IM was administered for pain on 11/11/2023 at 1:00 PM.
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On 11/11/2023 at 12:19 PM, Staff #5 documented that he consulted with Staff #6, Neurosurgery, about Patient #1's case. It was recommended to Staff #5 that if a CT of the lumbar spine was reassuring and the hardware is intact, the patient could call on Monday to the Neurosurgery office for further follow-up.
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The last documented pain level for Patient #1 was at level 8 of 10 at 1:01 PM on 11/11/2023.
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A CT of the lumbar spine was completed at 1:43 PM showing "no concerning focal lesions."
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On 11/11/2023 at 3:53 PM, Staff #5 documented a plan for follow-up with Neurosurgery as an outpatient and that the referrals had been made with the understanding he should return to the ED for any new or worsening symptoms.
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The treating physician, Staff #5, did not document an appropriate history to include Patient #1's surgery on 10/25/2024. Staff #5 did not document in the medical record a "review of systems" nor did he document an appropriate physical exam.
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There were no laboratory studies obtained by Staff #5 (such as a full white count, C-reactive protein (CRP), or a procalcitonin level) noted within the patient record that was provided. It is unknown if an infection had started at this time. The physician, Staff #5, did not ask whether Patient #1 had infectious symptoms such as fever or chills.

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Medical Record Review for 11/30/2023 Emergency Department (ED) Visit #2:
On 11/30/2023 at 11:00 AM, Patient #1 presented to the ED with complaints of pain that did not respond to his prescribed pain medications. The medications included hydrocodone, methocarbamol, and gabapentin. Patient #1 also reported drainage from his surgical site.
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There was a "Sepsis Predictive" score obtained on 11/30/2023 at 11:20 AM documenting a score of 8. A "Sepsis Predictive" score is considered high risk if the score is 2 or higher. A "Sepsis Predictive" score uses a combination of clinical parameters like heartrate, respiratory rate, blood pressure, white blood cell count, lactate level, and mental status assessments.
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On 11/30/2023 at 11:18 AM, the treating ED physician, Staff #13, documented that Patient #1 had uncontrollable lumbar back pain and was post-surgery on Monday (11/27/2023) and had been discharged on 11/29/2023. Staff #13 noted that Patient #1 had pain that radiated down his legs and was synchronous with his heartbeat and was worsening and was associated with profuse sweating. Staff #13 did not assess for cord compression, spinal epidural abscess, osteomyelitis, or discitis.
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At 11:28 AM, the triage nurse, Staff #14 documented that the skin around the surgical incision was warm when touched and noted a small amount of drainage on the dressing. The initial vital signs at 11:28 AM demonstrated tachycardia (a heartrate above 100 beats per minute) and relative hypotension (a blood pressure less than 90/60 in an adult) when compared to blood pressures and heartrate on previous visits. Patient #1 had a heart rate of 112 and a blood pressure (BP) of 96/70. Patient #1 was afebrile and not hypoxic.
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There was a "Sepsis Predictive" score obtained on 11/30/2023 at 11:35 AM of 60.1.
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There was a "Sepsis Predictive" score obtained on 11/30/2023 at 11:50 AM of 46.7.
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There was a "Sepsis Predictive" score obtained on 11/31/2023 at 12:01 PM of 46.7.
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There was a "Sepsis Predictive" score obtained on 11/31/2023 at 12:16 PM of 26.
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Staff #13 ordered a CBC (complete blood count) and a BMP (basic metabolic panel) on 11/30/2023 and the results were posted at 12:25 PM. Patient #1 was found to have a leukocytosis (a condition where a person has a high white blood cell count (WBC), typically more than 11,000 white blood cells per microliter (mcl) of blood in adults) with a WBC of 11.72 WBC/mcl and a slightly elevated anion gap.
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There was a "Sepsis Predictive" score obtained on 11/31/2023 at 12:31 PM of 5.3.
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There was a "Sepsis Predictive" score obtained on 11/31/2023 at 12:46 PM of 4.1.
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There was a "Sepsis Predictive" score obtained on 11/31/2023 at 1:01 PM of 4.1.
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There was a "Sepsis Predictive" score obtained on 11/31/2023 at 1:17 PM of 2.3.
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There was a "Sepsis Predictive" score obtained on 11/31/2023 at 1:31 PM of 2.3.
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No documented lab results for lactic acid to screen for sepsis were obtained. There were no documented lab results for an ESR (eosinophil sedimentation rate) or CRP (c-reactive protein) which could have assessed for a spinal infection. There was no EKG (electrocardiogram) ordered for Patient #1's documented tachycardia and report of profuse sweating to rule out an arrhythmia. The MSEs (medical screening examinations) were inappropriate as it did not adequately rule out other EMCs (emergency medical conditions).
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Medical Record Review for 12/02/2023 Emergency Department (ED) Visit #3:
On 12/02/2023 at 3:26 PM, Patient #1 presented to the ED with complaints of increasing back pain, hip pain, abdominal pain, and pelvic pain and having had surgery recently. Patient #1 was seen in the same ED 2 days before this visit for severe back pain and at that time had a mild leukocytosis.
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Vital signs were obtained on 12/02/2023 at 3:36 PM noting tachycardia and a pulse rate of 110. No EKG to rule out other emergency medical conditions (EMCs) such as acute coronary syndrome could be located within the provided patient record.
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The treating ED physician, Staff #5, documented on 12/02/2023 at 3:39 PM that Patient #1's family reported a bump near the incision and that Patient #1 felt a bulge in his stomach with pain that awakened him from sleep. Staff #5 documented that Patient #1 was in acute distress but did not document whether there was warmth, fluctuance, or induration to the site. Patient #1 was taking gabapentin, Robaxin, and hydrocodone without relief. Staff #5 did not document asking Patient #1 about fevers, chills, or night sweats.
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On 12/02/2023 at 6:20 PM, a CT of the abdomen and pelvis with contrast noted "intervertebral body spacer is projecting dorsally from the disc space 10 mm into the right lateral recess, which may impinge upon the traversing right Lumbar 5 nerve root and a new fluid collection in the laminectomy bed".
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On 12/02/2023 at 7:28 PM, Staff #5 consulted Neurosurgery. Staff #5 documented that Neurosurgery recommended pain control with no surgical intervention needed.
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Neurosurgery notes or any notes regarding a Neurosurgery call-back to Staff #5 could not be located within the patient record provided. No labs were ordered with which to follow up on the previous leukocytosis.
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There were no documented labs found for a lactic acid level, which could be used to screen for sepsis in Patient #1, who had been seen two days prior with mild leukocytosis. There were no documented ESR (eosinophil sedimentation rate) or CRP (c-reactive protein) labs to assess for a spinal infection. There was no EKG (electrocardiogram) ordered for Patient #1's documented tachycardia and report of profuse sweating to rule out an arrhythmia. The MSEs (medical screening examinations) was inappropriate as it did not adequately rule out other EMCs (emergency medical conditions).
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There is no assessment for a mass or tenderness during an abdominal exam. There was no evaluation of the pelvic region, scrotum, or perineum relating to Patient #1's complaints of pelvic pain.
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Patient #1 was discharged on 12/03/2023 at 1:15 AM with outpatient follow-up with Neurosurgery. The follow-up was scheduled for 12/12/2023.
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Patient #1 did not have an appropriate MSE. Patient #1 did not have a complete history obtained by Staff #5. The physical exam by Staff #5 was not sufficient to assess for potential EMCs related to Patient #1's back pain, hip pain, abdominal pain, and pelvic pain.
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From 11/27/2023 through 11/29/2023, Patient #1 had an inpatient admission at the same facility to remove the hardware placed during the initial surgery on 10/25/2023 and redo the Lumbar 4 and Lumbar 5 transforaminal interbody fusion.

Policy Review:
The facility's policy titled, " Medical Screening Examinations and Patient Transfers", last reviewed and effective on 10/07/2022, stated on page 3 of 25:
" ...Any person who comes to Hospital Emergency Department (ED) and requests an examination or treatment for a medical condition shall receive an appropriate Medical Screening Examination by a physician or other Qualified Medical Person as defined in Section 5.0, within the Capability of the ED, including ancillary services routinely available to the ED to determine whether or not the person has an Emergency Medical Condition ..."
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And page 10 of 25:
" ... 5) If based upon the screening physician's evaluation, the physician determines that additional specialist services are needed to further assess the patient and these specialists are routinely available to the ED, these services must be utilized. The screening physician shall call the specialist physician on call for the particular medical condition and shall ask him/her to see the patient. Hospital medical staff rules and regulations require the specialist physician to
respond ..."
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Interviews:
An interview with the Emergency Department's (EDs) Risk Manager, Staff #9, was conducted on 04/08/2023 at 12:35 PM. Staff #9 indicated that Patient #1 had placed multiple complaints against the facility and felt that the facility had done an excellent job providing care to Patient #1. Staff #9 was asked if she and the facility had determined that anything was missed upon chart reviews completed by the facility and involved staff. Staff #9 was aware that Patient #1 had developed an infection and felt that the infection was caught in its early stages on 12/21/2023 (when Patient #1 was admitted treating the infection in his spine.)
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Staff #9 was asked if she could explain what the indicators of infection were. Staff #9 replied, An infection could also cause changes in his/her labs. Such as an elevated white blood cell (WBC) count, elevated number of neutrophils, an elevated CRP (C-reactive Protein), or sometimes an elevated sedimentary rate (a test that measures how quickly red blood cells settle at the bottom of a test tube and can indicate inflammation in the body), you know, things like that. The patient could also have a surgical site that was oozing abnormal drainage, like pus draining from the incision and the incision site could be warm to the touch."
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An interview with a nurse practitioner for Neurosurgery, Staff #15, was conducted on 11/06/2023 at 9:08 AM in response to a grievance filed against the facility. Staff #15 indicated that Patient #1 was taking his pain medication incorrectly. Patient #1 was advised by Staff #15 that the Neurosurgery offices would not write a prescription for Norco or anything stronger and advised Patient #1 to seek help from a pain management doctor (whom Patient #1 had previously worked with) for something stronger if he felt it was needed. Staff #15 and Patient #1 agreed to try Tylenol #4 and alternative therapies such as ice and heat. Staff #15 could not be reached for further interviews.
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