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Based on document review and interview, it was determined that the Hospital failed to ensure compliance with CFR 489.24.

Please refer to: A-2406 and A-2407.

A. Based on document review, observation and interview, it was determined the hospital failed to ensure medical screening exams (MSE) are conducted by individual(s) deemed qualified by hospital By-Laws and/or Rules and Regulations.

Findings include:

1. On 8/5/15 at 11:00 AM, the Medical Staff Bylaw revised 8/12/14 were reviewed. The Bylaws did not include individual(s) approved to perform MSEs.

2. On 8/7/15 at 11:45 AM, hospital staff provided six binders titled Rules and Regulations containing approximately 5,000 pages. According to hospital staff, the contents of the binders did not include the individual (s) approved to perform a MSE.

3. On 8/5/15 at 1:15 PM, an interview was conducted with the Administrative Director of Nursing Services (E #6). E #6 stated neither the Bylaws nor Rules and Regulations included the individual(s) approved to perform a MSE in the ED.


B. Based on document review and interview, it was determined, for 1 of 10 clinical records reviewed (Pt. #1), the hospital failed to provide an appropriate medical screening examination.

Findings include:

1. On 8/7/15 at 2:45 PM, a nursing practice and skill document titled, "Pain Assessment: "Using the Numeric Pain Rating Scale", provided by the Administrative Director of Nursing Services (E #6), was reviewed. E #6 stated this pain rating scale is used by the whole hospital. The document included, "The 11 point numeric scale of 0 - 10 contains the following anchors: 0 = no pain; 10 = worst possible pain. Inadequate assessment of pain is a barrier to its management and relief of pain. Effective analgesic management of pain requires an evaluation with a reliable and valid measurement tool to translate subjective information into objective measures..."

2. On 8/7/15 at 10:15 AM, hospital ED policy titled: "Triage Procedure in the Emergency Department", revised 4/16/12, was reviewed. The policy included, "Appendix C - Patient Care Protocols - Abdominal Pain Protocol - Upper Abdomen Female - Saline lock [venous access], CBC [complete blood count], CMP [comprehensive metabolic panel], Amylase/Lipase [pancreatic test], UA [urine analysis]/Dip, and UHCG [pregnancy test]."

3. On 8/7/15 at 12:50 PM, hospital policy No. 950-1610-001.02, titled, "Licensed Physician Assistant, Request or Allied Staff Duties", revised 12/5/08, was reviewed. The policy required, "3. Services Provided: The services provided by the licensed physician assistant shall be limited to services that the supervising physician generally provided in the normal course of his/her clinical medical practice."

4. On 8/5/15 between 9:00 AM and 11:00 AM, Pt. #1's clinical record was reviewed. Pt. #1 was a 46 year old female, transported to the ED by ambulance on 6/15/15 at 9:19 PM, with a complaint of abdominal pain. Patient #1 received 100 mcg of Fentanyl (pain medication) in the ambulance. Pt. #1 was triaged in the Emergency Department (ED) at 9:25 PM and prioritized as urgent. Vital signs taken at 9:29 PM were: blood pressure 132/85, respirations 20, pulse 102, temperature 96.3, oxygen saturation on room air 98%, and pain level 7 of 10.

5. On 8/5/15 at 12:25 AM, an interview was conducted with the Physician Assistant (PA) (E #1) who cared for Pt. #1 on 6/15/15. E #1 stated Pt. #1 had "belly pain" and had been vomiting. Pt. #1 was calm when she arrived and received Fentanyl in the ambulance. During Pt. #1's exam, Pt. #1 was not complaining when her abdomen was palpated. E #1 estimated Pt. #1's pain level to be at 3 or 4, but did not ask. A pain assessment using the hospital's 0 - 10 pain scale was not utilized.

6. On 6/15/15 at 9:42 PM, a E #1 ordered laboratory blood tests including, CBC, CMP, and Lipase. E #1 did not order a UA or UHCG, as required by hospital policy.

7. On 8/5/15 at 12:55 PM, an interview was conducted with the Administrative Director of Nursing Services (E #6). E #6 stated she spoke with E #1 regarding the UA and UHCG. E #1 did not order a pregnancy test because Pt. #1 was in her 40s and E #1 did not anticipated any imaging tests needed to be ordered. E #1 did not order a UA because Pt. #1 had upper abdominal pain which didn't warrant a UA.

8. E #1 performed Pt. #1's medical screening exam (MSE) on 6/15/15 at 9:37 PM. However, Pt. #1's MSE documentation was dated 7/3/15 at 10:39 AM (19 days after Pt. #1's ED encounter).

9. E #1's supervising Physician's (MD #1) progress note dated 6/15/15 at 10:03 PM, included, "I was personally available for consultation in the emergency department. I have reviewed the chart and agree with the documentation as recorded by the NP/PA, including the assessment, treatment plan, and disposition." However, E #1's MSE was not documented until 7/3/15 at 10:39AM.

10. On 8/5/15 at 11:50 AM, a phone interview was conducted with MD #1. MD #1 stated he did not see Pt. #1 but was available for the PA (E #1) who examined Pt. #1. MD #1 stated the PA may not have finished her notes that day, because the ED was so busy.

A. Based on document review and interview, it was determined, for 1 of 10 clinical records reviewed (Pt. #1), the hospital failed to ensure pain treatment was provided.

Findings include:

1. On 8/7/15 at 2:45 PM, a nursing practice and skill document titled, "Pain Assessment: "Using the Numeric Pain Rating Scale", provided by the Administrative Director of Nursing Services (E #6), was reviewed. E #6 stated this pain rating scale is used by the whole hospital. The document included, "The 11 point numeric scale of 0 - 10 contains the following anchors: 0 = no pain; 10 = worst possible pain... Inadequate assessment of pain is a barrier to its management and relief of pain. Effective analgesic management of pain requires an evaluation with a reliable and valid measurement tool to translate subjective information into objective measures..."

2. On 8/5/15 between 9:00 AM and 11:00 AM, Pt. #1 ' s clinical record was reviewed. Pt. #1 was a 46 year old female, transported to the ED by ambulance on 6/15/15 at 9:19 PM, with a complaint of abdominal pain. The ambulance record included severe pain measured at 10 of 10, with 10 being the highest level of pain. Pt. #1 was administered Fentanyl, a pain medication and was reassessed in the ambulance with pain improvement to 8 of 10.

3. Pt. #1 was triaged in the ED on 6/15/15 at 9:25 PM, with abdominal pain and prioritized as urgent. Vital signs taken at 9:29 PM were: blood pressure 132/85, respirations 20, pulse 102, temperature 96.3, oxygen saturation on room air 98%, and pain level 7 of 10.

4. Pt. #1 was examined by a physician assistant (E #1) on 6/15/15 at 9:37 PM. (However, E #1 did not document her findings until 7/3/15, nineteen days later.) The notes included Pt. #1 complained of abdominal pain starting 3 hours prior to arrival, "described as sharp and constant." Pt. #1 had been vomiting. Pt. #1's exam included normal findings for all the symptoms, including abdominal - "Soft, normal bowel sounds; non-distended; mild TTP [tender to palpation] over epigastrium and LUQ [left lower quadrant] without rebound or guarding."

5. E #1's orders on 6/15/15 between 9:42 PM and 9:43 PM, included a saline lock (intravenous access), Zofran (treat nausea and vomiting) 4mg intravenous push (IVP), Protonix (treat excessive stomach acid) 40mg IVP, Pepcid (treat heartburn) 20mg IVP, and Ativan (treat anxiety) 1mg IVP. Pain relief medications were not ordered.

6. E #1's progress notes on 6/15/15 at 10:10 PM, included, "Patient screaming that 'I need pain medication' none of these meds are pain meds..."

7. An interview was conducted with E #1 on 8/5/15 at 12:25 PM. E #1 stated Pt. #1 had "belly pain" and had been vomiting. Pt. #1 was calm when she arrived, but was "unhappy" with E #1's "medication choices". E #1 thought Pt. #1's problem was gastroenteritis because of her symptoms and Pt. #1 "appeared healthy" .

8. E #1 stated she had ordered Ativan to calm Pt. #1 who was screaming and crying, but Pt. #1 refused to take it. E #1 stated Pt. #1 received Fentanyl (pain medication) in the ambulance. During Pt. #1's exam, Pt. #1 was not complaining when her abdomen was palpated. Most patients in pain have a rigid ridged abdomen, but Pt. #1's abdomen was soft. E #1 estimated Pt. #1's pain level to be at 3 or 4. A pain assessment using the hospital 0 - 10 pain scale was not done. E #1 stated Pt. #1 did not need narcotics and patients requesting narcotics are often "drug seeking". E #1 stated she would have revised the treatment plan had Pt. #1 not left before the lab results were available.

9. On 8/5/15 at 3:05 PM, an interview was conducted with the RN (E #3) who cared for Pt. #1 on 6/15/15. E #3 stated Pt. #1 was in pain and crying. E #3 asked the physician assistant (E #1) for a pain medication order, but E #1 said she wanted to wait for the lab results to return, in case Pt. #1 needed surgery. Pt. #1 wanted to go to another hospital. The charge nurse (E #2) came into the room to calm Pt. #1. Pt. #1 asked for Dilaudid because the medication she received would not help her pain. Pt. #1 walked out of the ED with her husband and with the charge nurse (E #2) following them.

10. The ED record from the other hospital (hospital B) was reviewed on 8/6/15 at 10:00 AM. Pt. #1 arrived to hospital B on 6/15/15 at 11:58 PM and was examined by an ED physician on 6/16/15 at 12:39 AM. Pt. #1's medical screen exam included, " Acute epigastric abdominal pain with nausea and vomiting. " A CT scan dated 6/16/15 at 2:01 AM, included, " CT findings compatible with pancreatitis. " Pt. #1 was admitted, treated with a morphine pump, Duboff feeding tube, and later TPN (intravenous nutrition) because the tube feedings were painful. Pt. #1 was discharged home on 7/3/15 (18 days later) with follow-up instructions.

Based on document review and interview, it was determined that the Hospital failed to ensure compliance with CFR 489.24.

Please refer to: A-2406 and A-2407.

A. Based on document review, observation and interview, it was determined the hospital failed to ensure medical screening exams (MSE) are conducted by individual(s) deemed qualified by hospital By-Laws and/or Rules and Regulations.

Findings include:

1. On 8/5/15 at 11:00 AM, the Medical Staff Bylaw revised 8/12/14 were reviewed. The Bylaws did not include individual(s) approved to perform MSEs.

2. On 8/7/15 at 11:45 AM, hospital staff provided six binders titled Rules and Regulations containing approximately 5,000 pages. According to hospital staff, the contents of the binders did not include the individual (s) approved to perform a MSE.

3. On 8/5/15 at 1:15 PM, an interview was conducted with the Administrative Director of Nursing Services (E #6). E #6 stated neither the Bylaws nor Rules and Regulations included the individual(s) approved to perform a MSE in the ED.


B. Based on document review and interview, it was determined, for 1 of 10 clinical records reviewed (Pt. #1), the hospital failed to provide an appropriate medical screening examination.

Findings include:

1. On 8/7/15 at 2:45 PM, a nursing practice and skill document titled, "Pain Assessment: "Using the Numeric Pain Rating Scale", provided by the Administrative Director of Nursing Services (E #6), was reviewed. E #6 stated this pain rating scale is used by the whole hospital. The document included, "The 11 point numeric scale of 0 - 10 contains the following anchors: 0 = no pain; 10 = worst possible pain. Inadequate assessment of pain is a barrier to its management and relief of pain. Effective analgesic management of pain requires an evaluation with a reliable and valid measurement tool to translate subjective information into objective measures..."

2. On 8/7/15 at 10:15 AM, hospital ED policy titled: "Triage Procedure in the Emergency Department", revised 4/16/12, was reviewed. The policy included, "Appendix C - Patient Care Protocols - Abdominal Pain Protocol - Upper Abdomen Female - Saline lock [venous access], CBC [complete blood count], CMP [comprehensive metabolic panel], Amylase/Lipase [pancreatic test], UA [urine analysis]/Dip, and UHCG [pregnancy test]."

3. On 8/7/15 at 12:50 PM, hospital policy No. 950-1610-001.02, titled, "Licensed Physician Assistant, Request or Allied Staff Duties", revised 12/5/08, was reviewed. The policy required, "3. Services Provided: The services provided by the licensed physician assistant shall be limited to services that the supervising physician generally provided in the normal course of his/her clinical medical practice."

4. On 8/5/15 between 9:00 AM and 11:00 AM, Pt. #1's clinical record was reviewed. Pt. #1 was a 46 year old female, transported to the ED by ambulance on 6/15/15 at 9:19 PM, with a complaint of abdominal pain. Patient #1 received 100 mcg of Fentanyl (pain medication) in the ambulance. Pt. #1 was triaged in the Emergency Department (ED) at 9:25 PM and prioritized as urgent. Vital signs taken at 9:29 PM were: blood pressure 132/85, respirations 20, pulse 102, temperature 96.3, oxygen saturation on room air 98%, and pain level 7 of 10.

5. On 8/5/15 at 12:25 AM, an interview was conducted with the Physician Assistant (PA) (E #1) who cared for Pt. #1 on 6/15/15. E #1 stated Pt. #1 had "belly pain" and had been vomiting. Pt. #1 was calm when she arrived and received Fentanyl in the ambulance. During Pt. #1's exam, Pt. #1 was not complaining when her abdomen was palpated. E #1 estimated Pt. #1's pain level to be at 3 or 4, but did not ask. A pain assessment using the hospital's 0 - 10 pain scale was not utilized.

6. On 6/15/15 at 9:42 PM, a E #1 ordered laboratory blood tests including, CBC, CMP, and Lipase. E #1 did not order a UA or UHCG, as required by hospital policy.

7. On 8/5/15 at 12:55 PM, an interview was conducted with the Administrative Director of Nursing Services (E #6). E #6 stated she spoke with E #1 regarding the UA and UHCG. E #1 did not order a pregnancy test because Pt. #1 was in her 40s and E #1 did not anticipated any imaging tests needed to be ordered. E #1 did not order a UA because Pt. #1 had upper abdominal pain which didn't warrant a UA.

8. E #1 performed Pt. #1's medical screening exam (MSE) on 6/15/15 at 9:37 PM. However, Pt. #1's MSE documentation was dated 7/3/15 at 10:39 AM (19 days after Pt. #1's ED encounter).

9. E #1's supervising Physician's (MD #1) progress note dated 6/15/15 at 10:03 PM, included, "I was personally available for consultation in the emergency department. I have reviewed the chart and agree with the documentation as recorded by the NP/PA, including the assessment, treatment plan, and disposition." However, E #1's MSE was not documented until 7/3/15 at 10:39AM.

10. On 8/5/15 at 11:50 AM, a phone interview was conducted with MD #1. MD #1 stated he did not see Pt. #1 but was available for the PA (E #1) who examined Pt. #1. MD #1 stated the PA may not have finished her notes that day, because the ED was so busy.

A. Based on document review and interview, it was determined, for 1 of 10 clinical records reviewed (Pt. #1), the hospital failed to ensure pain treatment was provided.

Findings include:

1. On 8/7/15 at 2:45 PM, a nursing practice and skill document titled, "Pain Assessment: "Using the Numeric Pain Rating Scale", provided by the Administrative Director of Nursing Services (E #6), was reviewed. E #6 stated this pain rating scale is used by the whole hospital. The document included, "The 11 point numeric scale of 0 - 10 contains the following anchors: 0 = no pain; 10 = worst possible pain... Inadequate assessment of pain is a barrier to its management and relief of pain. Effective analgesic management of pain requires an evaluation with a reliable and valid measurement tool to translate subjective information into objective measures..."

2. On 8/5/15 between 9:00 AM and 11:00 AM, Pt. #1 ' s clinical record was reviewed. Pt. #1 was a 46 year old female, transported to the ED by ambulance on 6/15/15 at 9:19 PM, with a complaint of abdominal pain. The ambulance record included severe pain measured at 10 of 10, with 10 being the highest level of pain. Pt. #1 was administered Fentanyl, a pain medication and was reassessed in the ambulance with pain improvement to 8 of 10.

3. Pt. #1 was triaged in the ED on 6/15/15 at 9:25 PM, with abdominal pain and prioritized as urgent. Vital signs taken at 9:29 PM were: blood pressure 132/85, respirations 20, pulse 102, temperature 96.3, oxygen saturation on room air 98%, and pain level 7 of 10.

4. Pt. #1 was examined by a physician assistant (E #1) on 6/15/15 at 9:37 PM. (However, E #1 did not document her findings until 7/3/15, nineteen days later.) The notes included Pt. #1 complained of abdominal pain starting 3 hours prior to arrival, "described as sharp and constant." Pt. #1 had been vomiting. Pt. #1's exam included normal findings for all the symptoms, including abdominal - "Soft, normal bowel sounds; non-distended; mild TTP [tender to palpation] over epigastrium and LUQ [left lower quadrant] without rebound or guarding."

5. E #1's orders on 6/15/15 between 9:42 PM and 9:43 PM, included a saline lock (intravenous access), Zofran (treat nausea and vomiting) 4mg intravenous push (IVP), Protonix (treat excessive stomach acid) 40mg IVP, Pepcid (treat heartburn) 20mg IVP, and Ativan (treat anxiety) 1mg IVP. Pain relief medications were not ordered.

6. E #1's progress notes on 6/15/15 at 10:10 PM, included, "Patient screaming that 'I need pain medication' none of these meds are pain meds..."

7. An interview was conducted with E #1 on 8/5/15 at 12:25 PM. E #1 stated Pt. #1 had "belly pain" and had been vomiting. Pt. #1 was calm when she arrived, but was "unhappy" with E #1's "medication choices". E #1 thought Pt. #1's problem was gastroenteritis because of her symptoms and Pt. #1 "appeared healthy" .

8. E #1 stated she had ordered Ativan to calm Pt. #1 who was screaming and crying, but Pt. #1 refused to take it. E #1 stated Pt. #1 received Fentanyl (pain medication) in the ambulance. During Pt. #1's exam, Pt. #1 was not complaining when her abdomen was palpated. Most patients in pain have a rigid ridged abdomen, but Pt. #1's abdomen was soft. E #1 estimated Pt. #1's pain level to be at 3 or 4. A pain assessment using the hospital 0 - 10 pain scale was not done. E #1 stated Pt. #1 did not need narcotics and patients requesting narcotics are often "drug seeking". E #1 stated she would have revised the treatment plan had Pt. #1 not left before the lab results were available.

9. On 8/5/15 at 3:05 PM, an interview was conducted with the RN (E #3) who cared for Pt. #1 on 6/15/15. E #3 stated Pt. #1 was in pain and crying. E #3 asked the physician assistant (E #1) for a pain medication order, but E #1 said she wanted to wait for the lab results to return, in case Pt. #1 needed surgery. Pt. #1 wanted to go to another hospital. The charge nurse (E #2) came into the room to calm Pt. #1. Pt. #1 asked for Dilaudid because the medication she received would not help her pain. Pt. #1 walked out of the ED with her husband and with the charge nurse (E #2) following them.

10. The ED record from the other hospital (hospital B) was reviewed on 8/6/15 at 10:00 AM. Pt. #1 arrived to hospital B on 6/15/15 at 11:58 PM and was examined by an ED physician on 6/16/15 at 12:39 AM. Pt. #1's medical screen exam included, " Acute epigastric abdominal pain with nausea and vomiting. " A CT scan dated 6/16/15 at 2:01 AM, included, " CT findings compatible with pancreatitis. " Pt. #1 was admitted, treated with a morphine pump, Duboff feeding tube, and later TPN (intravenous nutrition) because the tube feedings were painful. Pt. #1 was discharged home on 7/3/15 (18 days later) with follow-up instructions.