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Based on facility policy review, review of laboratory staffing schedules, review of laboratory employees' time punches, medical record review, and interviews, the facility failed to provide an appropriate medical screening exam (MSE) and failed to provide stabilizing treatment for 1 ED patient (Patient #1) with abdominal pain of 30 ED patients reviewed.

The findings include:

Patient #1 presented to Facility A's ED on 2/26/2021 at 1:58 PM with a complaint of epigastric pain, nausea, and vomiting. The patient rated her pain as an 8 (on a scale from 1 to 10, with 10 being the worse pain). The ED physician ordered an abdominal x-ray on Patient #1, but no other diagnostic tests were ordered. Patient #1 was discharge from Facility A with a diagnosis of Acute Gastroenteritis with Acute Constipation. Patient #1 presented to Facility B's ED on 3/2/2021, where diagnostic tests were ordered including laboratory tests and a Computed Tomography (CT) of the Abdomen. The patient was diagnosed with Acute Appendicitis at Facility B and was transferred to Facility C (children's hospital) where an appendectomy was performed on Patient #1 on 3/3/2021.

Please refer to A-2406 for failure to provide MSE.

Please refer to A-207 for failure to provide stabilizing treatment.

Based on facility policy review, medical record review, review of laboratory employee time punches, and interviews, the facility failed to provide an appropriate medical screening exam (MSE) for 1 Emergency Department (ED) patient (Patient #1) with abdominal pain of 30 ED patients reviewed.

The findings include:

Review of Facility A's policy titled "Emergency Medical Treatment and Patient Transfer (EMTALA)" revised 2/2020 showed "...When an individual comes to the Emergency Department of the hospital, or to any location on the hospital property...and a request is made on the individual's behalf for a medical examination or treatment, an appropriate medical screening examination, within the capabilities of the emergency department (including ancillary services routinely available to the emergency department), shall be provided to determine whether an emergency medical condition exists..."

Review of Facility A's policy titled "SCOPE OF SERVICES" revised 6/2021 showed services provided by the facility included "...Emergency Department...Any patient presenting to the Emergency Department for care will be evaluated and treated. If the patient requires services not available at [Facility A], the ED provider will initiate a transfer to a facility with such services available..."

Medical record review of a Nurse's Triage note dated 2/26/2021 at 1:58 PM showed Patient #1 presented to Facility A's ED with complaint of abdominal pain, nausea, and vomiting since 9:00 AM (4 hours 58 minutes prior to arrival). The patient reported last vomiting episode was approximately 15 minutes prior to arrival to the ED. She described her pain as stabbing, localized to the abdominal area, and rated the pain level as 8/10 (10 being the worst possible pain). The patient did not have a fever, heart rate was 78 (normal range 60-100) beats per minute, respirations were 20 (normal range 12-20) breaths per minute, and the blood pressure (BP) was 152/102 (ideal BP 120/80) upon arrival to the ED. There was no documentation to indicate blood was collected for diagnostic studies.

Medical record review of an ED Provider's Note at Facility A dated 2/26/2021 at 2:05 PM showed Patient #1 complained of acute (severe and sudden) abdominal pain with abdominal distention, nausea, and vomiting. Physical exam showed the patient had tenderness in the epigastric area (stomach) and the patient's condition was deemed emergent (calling for prompt or urgent action) by the ED provider. Continued review showed an abdominal x-ray was done. Further review showed no documentation further diagnostic studies were done to determine the cause for the patient's abdominal pain.

Medical record review of a radiology report of an Abdominal X-Ray at Facility A dated 2/26/2021 showed "...Non-obstructed bowel-gas pattern with air and stool seen scattered throughout the colon..."

Patient #1 was discharged from Facility A's ED on 2/26/2021 at 2:53 PM with diagnoses of Acute Gastroenteritis (inflammation of the stomach and intestines) with Acute Constipation (difficulty having a bowel movement). The patient was instructed to take a laxative, to follow-up with her personal physician in 3 days, and to return to the ED as needed.

Review of laboratory employee time punches at Facility A dated 2/26/2021 showed the laboratory was not staffed with a medical laboratory technician (MLT) (performs all levels of laboratory testing) from 6:00 AM-6:00 PM. Patient #1 was in the ED from 1:58 PM-2:53 PM.

Medical record review from Facility B showed Patient #1 presented to Facility B's ED on 3/2/2021 with complaint of abdominal pain, nausea, and vomiting (onset 5 days ago 2/26/2021).

Medical record review of a laboratory report dated 3/2/2021 showed a Complete Blood Count (CBC/blood test) was performed for Patient #1 at Facility B with the following abnormal results:
White blood cells 12.73 (reference range 3.0-15.0)
Neutrophils% 75.2 (reference range 37.0-72.0)
Lymphocytes% 14.2 (reference range 20.0-50.0)
Neutrophils# 9.58 (reference range 1.50-7.0)

Medical record review of a Computed Tomography (CT) scan of the Abdomen and Pelvis at Facility B dated 3/2/2021 showed the patient had Acute Appendicitis (a serious medical condition in which the appendix becomes inflamed and painful).

Patient #1 was transferred by Facility B via ambulance to Facility C on 3/2/2021 for further evaluation and surgery.

Medical record review from Facility C showed Patient #1 arrived by ambulance from Facility B on 3/3/2021 where the patient was evaluated and admitted with a diagnosis of Acute Appendicitis and Acute Vomiting.

Medical record review of an Operative Report at Facility C dated 3/3/2021 showed a "...Laparoscopic Appendectomy (appendix removed), difficult..." was performed on Patient #1. The postoperative diagnoses were Ruptured Appendicitis and Obesity.

During a telephone interview on 6/22/2021 at 9:25 AM, the complainant (Patient #1's mother) stated Patient #1 presented to Facility A's ED on 2/26/2021 (Friday) due to "...severe stomach pain and vomiting..." The patient's mother stated Physician #1 evaluated the patient and wanted an intravenous line (IV) started, but after 2 unsuccessful attempts by the nurse "...the doctor said to forget it..." The complainant stated Patient #1 did not have laboratory studies or a CT scan performed at Facility A. Further interview revealed Patient #1 was discharged home with a prescription for a stool softener and was told to follow-up with her primary care provider (PCP) in 3 days. The patient's mother stated Patient #1's pain continued to worsen so the patient went to the PCP's office on 3/2/2021 and was told by the PCP that the patient needed a CT scan. The PCP advised Patient #1's mother to take her to Facility B's ED for a CT scan. Continued interview revealed Patient #1 had laboratory studies and a CT scan at Facility B which showed the patient had appendicitis. The patient was transferred to Facility C where she had an appendectomy.

During an interview and review of Patient #1's medical record on 6/22/2021 at 2:00 PM, the ED Nurse Manager at Facility A confirmed a CT scan nor laboratory studies were performed for Patient #1 during the patient's ED visit on 2/26/2021.

During an interview on 6/23/2021 at 1:15 PM, the Radiology Director (Facility A) stated the CT scanner was not functioning on 2/26/2021 and any patient needing a CT scan prior to 5/15/2021 was transferred to another facility. The facility's CT scanner had not been working since 1/19/2021.

During an interview on 6/24/2021 at 11:15 AM, Physician #1 at Facility A stated Patient #1 had only been having symptoms for 15 minutes prior to arrival to Facility A's ED. The Physician stated the abdominal x-ray showed Patient #1 was constipated. Physician #1 stated he based the need for diagnostic testing on the patient's appearance and the patient's reported symptoms and "...I look at the patient and films and see what needs to be ordered..." Physician #1 instructed Patient #1 to follow-up with her PCP in 3 days and to return to the ED if there were no improvement in her symptoms. Physician #1 confirmed diagnostic studies were not performed for Patient #1 while she was in Facility A's ED.

During an interview and review of the laboratory staffing schedules and laboratory staff time punches on 6/24/2021 at 11:41 AM, with the Laboratory Manager at Facility A, the Laboratory Manager confirmed the laboratory was not staffed with a MLT from 6:00 AM-6:00 PM on 2/26/2021 and the facility was unable to perform Complete Blood Counts (CBC/blood test) on site when a MLT was not present. The Laboratory Manager stated Chem 8 (blood test), troponin levels (blood test), lactic acid (blood test), and ABG's (blood test for respiratory status) could be performed using iSTAT (device to test blood at the bedside) by the ED nurses when the laboratory was not functioning at full capacity (no MLT) and any other blood tests, such as a CBC, would be taken to a nearby facility (closest facility was 1 hour from Facility A) by a courier.

During a telephone interview on 6/24/2021 at 5:25 PM, Registered Nurse (RN) #1 at Facility A stated she recalled Patient #1 was in mild distress. RN #1 attempted to start an IV and obtain labs but was unsuccessful. RN #1 notified Physician #1 she was having difficulty starting the patient's IV and obtaining blood work. RN #1 stated Physician #1 told her not to worry about starting an IV or obtaining blood for laboratory studies. The RN stated patients in need of a CT scan had to be transferred to another facility because the CT scanner was not functioning during that time.

Based on facility policy review, medical record review, review of laboratory staff time punches, and interviews, the facility failed to provide stabilizing treatment for 1 Emergency Department (ED) patient (Patient #1) with abdominal pain of 30 ED patients reviewed.

The findings include:

Review of Facility A's policy titled "Emergency Medical Treatment and Patient Transfer (EMTALA)" revised 2/2020 showed "...When an individual comes to the Emergency Department of the hospital, or to any location on the hospital property...and a request is made on the individual's behalf for a medical examination or treatment, an appropriate medical screening examination, within the capabilities of the emergency department (including ancillary services routinely available to the emergency department), shall be provided to determine whether an emergency medical condition exists... Stabilizing Treatment for Emergency Medical Conditions and Women in Labor...If it is determined through a medical screening examination that an emergency medical condition exists...emergency department personnel shall: Provide such further medical examination and treatment as may be required to stabilize the medical condition..."

Review of Facility A's policy titled "SCOPE OF SERVICES" revised 6/2021 showed services provided by the facility included...Emergency Department...Any patient presenting to the Emergency Department for care will be evaluated and treated. If the patient requires services not available at [Facility A], the ED provider will initiate a transfer to a facility with such services available..."

Medical record review of a Nurse's Triage note at Hospital A dated 2/26/2021 at 1:58 PM showed Patient #1 presented to Facility A's ED with a complaint of abdominal pain, nausea, and vomiting since 9:00 AM (4 hours 58 minutes prior to arrival) and the patient reported last vomiting episode was approximately 15 minutes prior to arrival to the ED. Patient #1 described the her pain as stabbing, localized to the abdominal area, and rated the pain level as 8/10 (10 being the worst possible pain). The patient did not have a fever, her heart rate was 78 (normal range 60-100) beats per minute, respirations were 20 (normal range 12-20) breaths per minute, and the blood pressure (BP) was 152/102 (ideal BP 120/80) upon arrival to the ED. There was no documentation to indicate blood was collected for diagnostic studies.

Medical record review of an ED Provider's note at Facility A dated 2/26/2021 at 2:05 PM showed Patient #1 complained of acute (severe and sudden) abdominal pain with abdominal distention, nausea, and vomiting. Physical exam showed the patient had tenderness in the epigastric area (stomach) and the patient's condition was deemed emergent (calling for prompt or urgent action) by the ED provider. Continued review showed an abdominal x-ray was done, but no further diagnostic studies were done to determine the cause for the patient's abdominal pain.

Medical record review of an Abdominal X-ray report at Facility A dated 2/26/2021 showed Patient #1 had a "...Non-obstructed bowel-gas pattern with air and stool seen scattered throughout the colon..."

Review of laboratory employee time punches at Facility A dated 2/26/2021 showed the laboratory was not staffed with a medical laboratory technician (MLT) (performs all levels of laboratory testing) from 6:00 AM-6:00 PM. Patient #1 was in the ED from 1:58 PM-2:53 PM.

Patient #1 was discharged from Facility A's ED on 2/26/2021 at 2:53 PM with diagnoses of Acute Gastroenteritis (inflammation of the stomach and intestines) with Acute Constipation (difficulty having a bowel movement). The patient was instructed to take a laxative, to follow-up with her personal physician in 3 days, and to return to the ED as needed.

Medical record review from Facility B showed Patient #1 presented to Facility B's ED 3/2/2021 with complaint of abdominal pain, nausea, and vomiting (onset 5 days ago 2/26/2021).

Medical record review of a laboratory report at Facility B dated 3/2/2021 showed a Complete Blood Count (CBC/blood test) was performed for Patient #1 with the following abnormal results:
White blood cells 12.73 (reference range 3.0-15.0)
Neutrophils% 75.2 (reference range 37.0-72.0)
Lymphocytes% 14.2 (reference range 20.0-50.0)
Neutrophils# 9.58 (reference range 1.50-7.0)

Medical record review of a Commuted Tomography (CT) scan of the Abdomen and Pelvis report at Facility B dated 3/2/2021 the patient had Acute Appendicitis (a serious medical condition in which the appendix becomes inflamed and painful).

Medical record review from Facility C showed Patient #1 arrived by ambulance from Facility B on 3/3/2021 where the patient was evaluated and admitted with diagnoses of Acute Appendicitis and Acute Vomiting.

Medical record review of an Operative Report at Facility C dated 3/3/2021 showed a "...Laparoscopic Appendectomy (appendix removed), difficult..." was performed on Patient #1. The postoperative diagnoses were Ruptured Appendicitis and Obesity.

During a telephone interview on 6/22/2021 at 9:25 AM, the complainant (Patient #1's mother) stated Patient #1 presented to Facility A's ED on 2/26/2021 due to "...severe stomach pain and vomiting..." Physician #1 evaluated the patient and wanted an intravenous line (IV) started. The complainant stated the nurse left the bedside to find another nurse to start the IV after 2 unsuccessful attempts. When the nurse returned to the bedside, she told the complainant "...the doctor said to forget it..." The complainant stated Patient #1 did not have laboratory studies or a CT scan performed at Facility A. Further interview revealed Patient #1 was discharged to home with a prescription for a stool softener and was told to follow-up with her primary care provider (PCP) in 3 days. Patient #1's pain continued to worsen so she went to her PCP's office on 3/2/2021 and was told she needed a CT scan. The PCP advised Patient #1's mother to take her to Facility B's ED for a CT scan. Continued interview revealed Patient #1 had laboratory studies and a CT scan at Facility B which showed the patient had appendicitis. The patient was transferred to Facility C where she had an appendectomy.

During an interview and review of Patient #1's medical record on 6/22/2021 at 2:00 PM, the ED Nurse Manager confirmed neither a CT scan nor laboratory studies were performed for Patient #1 during the patients ED visit on 2/26/2021.

During an interview on 6/23/2021 at 1:15 PM, the Radiology Director at Facility A stated the CT scanner was not functioning on 2/26/2021. The Radiology Director stated patients in need of a CT scan prior to 5/15/2021 were transferred to another facility. The facility's CT scanner had not been working since 1/19/2021.

During an interview on 6/24/2021 at 11:15 AM, Physician #1, stated Patient #1 had only been having symptoms for 15 minutes prior to arrival to Facility A's ED. Physician #1 stated an abdominal x-ray showed Patient #1 had constipation. Physician #1 stated he based the need for diagnostic testing on the patient's appearance and the patient's reported symptoms. "...I look at the patient and films and see what needs to be ordered..." Physician #1 instructed Patient #1 to follow-up with her PCP in 3 days and to return to the ED if there were no improvement in her symptoms. Physician #1 confirmed neither blood work nor a CT was performed for Patient #1 while in Facility A's ED.

During an interview and review of the laboratory staffing schedules and laboratory staff time punches on 6/24/2021 at 11:41 AM, with the Laboratory Manager at Facility A, the Laboratory Manager stated the laboratory was not staffed with a MLT from 6:00 AM-6:00 PM on 2/26/2021. The Laboratory Manager confirmed the facility was unable to perform Complete Blood Counts (CBC/blood test) on site when a MLT was not present. Chem 8 (blood test), troponin levels (blood test), lactic acid (blood test), and ABG's (blood test for respiratory status) could be performed using iSTAT (device to test blood at the bedside) by the ED nurses when the laboratory was not functioning at full capacity (no MLT). Any other blood test, such as a CBC, would be taken to a nearby facility (closest facility is 1 hour from Facility A) by a courier.

During a telephone interview on 6/24/2021 at 5:25 PM, Registered Nurse (RN) #1 stated she recalled Patient #1 was in mild distress. RN #1 stated she attempted to start an IV and obtain labs but was unsuccessful. RN #1 notified Physician #1 she was having difficulty starting the patient's IV and obtaining blood work. RN #1 stated Physician #1 told her not to worry about starting an IV or obtaining blood for laboratory studies. The RN stated patients in need of a CT scan would have been transferred to another facility because the CT scanner was not functioning during the time Patient #1 was in the ED.