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Based on interview, and record review, the facility failed to ensure that emergency medical services were provided in accordance with CFR §489.24, the regulations for the Emergency Medical Treatment and Active Labor Act (EMTALA) as evidenced by:

1. The facility failed to document that six of 22 patients (Patients 1, 3, 8, 11, 12, and 13) received ongoing monitoring while awaiting a medical screening exam. (Refer to A 2406)

2. The facility failed to obtain a patient signature on a transfer form for one of 22 patients (Patient 4). (Refer to A 2409)

Based on observation, interview, and record review, this facility's Emergency Department (ED) nursing staff failed to provide ongoing monitoring to assure patient stability when vital signs (VS - blood pressure, pulse, respirations, oxygen levels in the blood, temperature, pain level, and physical assessment) were not reassessed for six of 22 patients (Patients 1, 3, 8, 11, 12, and 13).

These failures had the potential for Emergency Medical Conditions (EMCs) to go undetected and result in a decline in patient status with the potential for negative health outcomes.


Findings:


The Emergency Medical Treatment and Labor Act (EMTALA - known as the "Patient Anti-Dumping Law") is a Federal law that ensures hospitals participating in Medicare programs provide Medical Screening Exams (MSEs) and stabilize patients with an EMC.

A review, of the facility's policy titled, "EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act," dated 8/15/24, indicated that the facility must use its available resources to provide ongoing evaluation and stabilizing treatment as required by law. The policy indicated that any individual who presented to the ED requesting examination or treatment shall be provided with an appropriate MSE which would determine the presence or absence of an EMC.

A review, of the facility's policy titled, "Admission Policy/Emergency Medical Record," dated 8/15/24, indicated that the facility shall comply with the emergency care obligations imposed by EMTALA. All patients presenting to the ED will be registered and receive an MSE by an ED provider. The policy indicated that the MSE was to be performed as soon as possible on patient arrival, and Triage/Intake (an initial assessment to determine the urgency of the presenting problem and treatment resources required) by a Registered Nurse (RN) is not an MSE.

A review, of facility's policy titled, "Triage and Treatment of Patients in the ED," dated 6/25/24, indicated that patients were assessed using Emergency Severity Index (ESI) classifications: ESI Level 2: Patient with a high-risk situation or confused/lethargic/disoriented or severe pain/distress. Nursing staff were directed to reassess patients no less frequently than every hour for four hours, then every two hours if clinically stable. VS assessment was to be current within 30-minutes of discharge. ESI Level 3: Patients with normal VS but requiring many resources: labs, x-ray imaging, intravenous (into a vein), or intramuscular (into a muscle) medications, electrocardiogram (EKG - noninvasive testing that records the heart's electrical activity), or repair of a laceration (cut). The policy directed nursing staff to reassess normal VS at their discretion but no less frequently than every four hours. Nursing staff were directed to reassess abnormal VS no less frequently than every two hours for four hours, then every four hours if clinically stable. VS assessment was to be current within 30-minutes of discharge. The policy indicated that the triage nurse had the primary responsibility for assessing and prioritizing patient needs and expediting patient care.

A review, of facility's policy titled, "Vital Signs (Temperature, Pulse, Respiration, Blood Pressure)," dated 5/23, indicated that VS were to be assessed at minimum once per shift or within the set monitoring frequency standard of the clinical unit within monitoring frequency set by physician order, or using a standing protocol. The policy indicated that all vital signs should be recorded in the electronic medical record (EMR).

1. Patient 1's ED medical record was reviewed. Patient 1's record indicated that he was seen in the ER on 1/23/25 at 11:41 am, with complaints of intermittent slurred speech, balance issues, and headaches for several months. The record indicated that Patient 1 reported an episode of slurred speech for one sentence that morning, witnessed by a family member, and she complained of headache, fatigue, and dizziness. Registered Nurse (RN) G triaged Patient 1 at ESI Level 3. VS taken at 11:42 am, and indicated a blood pressure (BP) of 182/89 (a "hypertensive crisis" per American Heart Association Guidelines, which if not treated could lead to stroke, heart attack, or kidney failure). The record indicated Patient 1 was placed in a room at 1:43 pm.

A document titled, "Discharge Assessment," documented by RN G on 1/23/25 at 4:34 pm, indicated that Patient 1 was waiting to see the provider, "all tests [were] back," and RN G "Recommended patient wait to see if Dr. wants to run additional scans for mini TIAs," (TIA or "mini stroke" - disruption of blood flow to the brain). The record indicated that Medical Doctor (MD) A went to Patient 1's room at 4:29 pm (two hours and 46-minutes after being roomed), but Patient 1 was "gone," and the EKG leads were on the bed. The record indicated that VS were "monitored;" however, VS were not documented between 11:42 am through 4:34 pm (four hours, and 52 minutes).

A review, of "Emergency Room Provider Documentation" by MD A, dated 1/23/25 at 4:21 pm, indicated that Patient 1 had been "visually seen," in triage; however, Patient 1 "did not receive re-evaluation as planned," because the patient left the facility prior to completion of an MSE. The record indicated, "Plan was admission for TIA versus complex migraines." The record indicated Primary Impression (diagnosis): TIA, Condition: "Guarded" (a serious medical situation where the outcome is uncertain).

During a concurrent observational tour of the ED, and interview, with Director of Performance Improvement (DPI), Chief Nursing Officer (CNO), and ED Manager (EDM) on 6/18/25 at 11:04 am, it was observed that vital sign monitors were at the head of each bed. The CNO stated, that all VS, including BP, should be documented in the patient's health record on reassessment.

During an interview, with CNO, on 6/19/25 at 4:20 pm, the CNO stated a patient with "Monitor," protocol ordered by a provider were to have BP, pulse, and blood oxygen levels continuously monitored using VS monitors at the bedside. The CNO stated, that the VS would be recorded on the monitor but data would not transfer to the electronic medical record, noting, "The nurse must chart the values."

During an interview, with DPI on 6/19/25 at 4:25 pm, DPI acknowledged Patient 1's abnormal VS were not reassessed by nursing staff every two hours for four hours, then every four hours per facility policy for an ESI Level 3 patient.

2. A review, of Patient 3's ED medical record, dated 1/24 to 1/25/25, indicated Patient 3 arrived by ambulance from another hospital for "Cardiology Transfer," at 8:05 pm. RN H triaged Patient 3 in the ED as ESI Level 2 and documented initial VS at 8:22 pm, to include a pulse of 101 (normal 60 to 100), blood pressure of 138/62 (high normal), and blood oxygen levels of 94 percent (mildly low, normal 95 to 100 percent). The record indicated complete sets of VS were next performed on 1/25/25 at 3:05 am (six hours and 43 minutes later), 5:05 am, and 8:40 am. The record indicated Patient 3 was admitted and transferred to a hospital room on 1/25/25 at 2:07 pm, though VS were not reassessed after 8:40 am (five hours, and 27 minutes).

A review, of "Emergency Room Provider Documentation" by MD B, dated 1/24/25, indicated Patient 3 was seen by MD B for an MSE at 8:46 pm. The record indicated Patient 3 was admitted to the hospital for acute diverticulitis (pouches in the colon lining become inflamed/infected) and non-ST-elevation myocardial infarction (NSTEMI - a heart attack that reduces blood flow to the heart).

During an interview, with DPI on 6/19/25 at 4:25 pm, DPI acknowledged Patient 3's VS were not reassessed by nursing staff no less frequently than every hour for four hours, then every two hours (if clinically stable) per facility policy for an ESI Level 2 patient.

3. A review, of Patient 8's ED medical record, dated 2/23 and 2/24/25, indicated Patient 8 arrived in the ED at 9:52 pm, with complaint of abdominal pain. RN E triaged Patient 8 as ESI Level 3 and documented triage VS at 10:14 pm. A review, of records indicated VS were not reassessed after 10:14 pm, the patient waited in the lobby for a room from 9:52 pm, on 2/23/25 until 3:04 am, on 2/24/25 (six hours and 14 minutes), and an MSE was not performed. RN J documented that patient was not in the lobby on 2/24/25 at 3:04 am, 3:34 am, and 4:05 am.

During an interview, with DPI on 6/19/25 at 4:25 pm, DPI acknowledged Patient 8's VS were not reassessed by nursing staff every two hours for four hours, then every four hours per facility policy for an ESI Level 3 patient.


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4. A review of Patient 11's clinical record indicated they came to the ED on 5/16/25, by ambulance with a complaint of high blood pressure.

A review, of an Emergency Medical Services (EMS) Patient Care Report, dated 5/16/25, indicated at 2:34 pm, EMS staff documented Patient 11's blood pressure as 188/124. EMS staff wrote that Patient 11 had lost their prescribed blood pressure medication and stopped taking it four days prior.

A record review, of a nursing Triage Note, dated 5/16/25 at 3:08 pm, indicated RN A documented a blood pressure of 195/135. RN A also wrote that Patient 11 denied any headache or dizziness. Patient 11's ESI Level was three.

A record review, of a Nursing Note, dated 5/16/25 at 8:22 pm (over five hours after the triage assessment), indicated that RN B wrote that Patient 11 was, "Not in lobby," and the patient had left without being seen (LWOBS) by a provider.

5. A review, of Patient 12's clinical record indicated they came to the ED on 5/14/25 with a complaint of abdominal pain.

A record review, of a nursing Triage Note, dated 5/14/25 at 6:35 pm, by RN C, indicated Patient 12 had right lower abdomen pain, level nine out of ten on a zero to ten scale (zero being no pain, ten being the worst pain) since the morning, relieved with vomiting. RN C also wrote that patient 12 was given a cup and instructed to provide a urine sample. Patient 12's ESI level was three.

A record review, of a Nursing Note, dated 5/14/25, at 11:11 pm (over four hours after the triage assessment) indicated that RN B wrote that Patient 12 was, "Not in lobby," and the patient had LWOBS by a provider.

6. A review, of Patient 13's clinical record indicated they came to the ED on 5/5/25, with a complaint of being short of breath at rest for one month.

A record review, of a nursing Triage Note, dated 5/5/25 at 2:01 pm, indicated RN D wrote that Patient 13 complained of shortness of breath and was waiting for a heart monitor report from their doctor. Patient 13's ESI Level was three.

A record review, of a Nursing Note, dated 5/5/25 at 6:22 pm (over four hours after the triage assessment) indicated that RN E wrote that Patient 13 was, "Not in lobby," and that Patient 13 had lab work and an x-ray done, but LWOBS by a provider.

During a concurrent interview, and record review, on 6/20/25, at 9:45 am, DPI confirmed there were no nursing assessments, or vital signs documented after triage for Patients 11, 12 and 13.

Based on interview, and record review, the facility failed to ensure a Patient Transfer Acknowledgement (indicating patient had been informed of and understood the reasons/risks of transfer) was signed prior to transfer from the Emergency Department (ED) to another facility for one of 22 sampled patients (Patient 4).

This deficient practice prevented Patient 4 from making an informed decision about whether to accept a transfer that could potentially endanger her health and safety.


Findings:


During a review, of the facility's policy titled, "EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act," dated 8/15/24, it indicated that: 1. Both stable and unstable patients may be transferred safely and systematically to another facility. 2. A Transfer Consent and Acknowledgement/Refusal Form 100-059 was required to be completed and signed by the individual or legally responsible adult. and was to be witnessed by an appropriate employee.

A review, of Patient 4's "ED Visit Summary," dated 2/1/25 at 7:12 pm, indicated that Patient 4 arrived in the facility ED on 1/31/25 at 9:56 am, with "pregnancy complications." Patient 4 complained of 8 out of 10 lower abdominal pain (0 to 10 pain scale, 10 being the worst pain), and cramping and bleeding after [positive] pregnancy test at home.

A review, of Patient 4's "Emergency Room Provider Documentation," dated 1/31/25, indicated that a MSE and was found to have an acute surgical abdomen (abdominal condition requiring urgent surgery) with an acute ectopic pregnancy, (when a fertilized egg implants outside of the uterus), a life-threatening condition requiring immediate transfer to an outside hospital for emergent surgery and higher level of care. Patient 4's diagnoses included ectopic pregnancy, complications of pregnancy, and anemia (a condition where red blood cells are low and adequate oxygen is not carried in the bloodstream to body tissues).

A review, of a document titled, "Certification for Ambulance Transfer," dated 1/31/25, and signed by Registered Nurse (RN) F, indicated that Patient 4 had been diagnosed with an ectopic pregnancy (left), and required transfer to an outside facility with LND (labor and delivery) triage.

A review, of a document titled, "Acute Transfer Physician (Phys) Certification Form - Exhibit (Exh) B," signed by Physician's Assistant (PA) A on 1/31/25 at 1:37 pm, indicated that PA A deemed Patient 4 stable for transfer to a higher level of care/treatment not available at the facility for left ectopic pregnancy. The "Patient Transfer Acknowledgment," portion of the form was blank, unsigned by the patient or a witness to indicate Patient 4 had been informed of, and understood the reasons/risks for transfer.

During concurrent interview, with Director of Performance Improvement (DPI), and record review, of Patient 4's medical records on 6/18/25 at 3:19 pm, the DPI acknowledged that the transfer consent for Patient 4 should have been signed by the patient prior to transfer.