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Based on interview, document review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#12) of 22 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Findings included:

Review of the hospital's policy titled, "Consolidated Omnibus Budget Reconciliation Act (COBRA)/Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)," reviewed 01/2025, showed:
- An EMC was a condition that manifested itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the health of the person in serious jeopardy, serious impairment to any bodily functions and/or serious dysfunction of any bodily organ or part.
- A MSE was the initial, and on-going, evaluation of the presenting patient conducted by a physician, to include history, physical examination, appropriate testing, completion of appropriate documentation and evaluation of the patient, within the capabilities of the hospital utilizing the facilities routinely available to the ED to determine whether a patient did or did not have an EMC.
- The patient was considered stable in a condition in which no material deterioration was likely to occur from or during transfer, discharge or referral.
- Patients should not be denied evaluation, screening, treatment or stabilization on the basis of their presenting complaint, condition or lack of a physician on the medical staff of the hospital.

Please refer to A-2406 for further details.

Based on interview, document review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#12) of 22 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Findings included:

Review of the hospital's policy titled, "Consolidated Omnibus Budget Reconciliation Act (COBRA)/Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)," reviewed 01/2025, showed:
- An EMC was a condition that manifested itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the health of the person in serious jeopardy, serious impairment to any bodily functions and/or serious dysfunction of any bodily organ or part.
- A MSE was the initial, and on-going, evaluation of the presenting patient conducted by a physician, to include history, physical examination, appropriate testing, completion of appropriate documentation and evaluation of the patient, within the capabilities of the hospital utilizing the facilities routinely available to the ED to determine whether a patient did or did not have an EMC.
- The patient was considered stable in a condition in which no material deterioration was likely to occur from or during transfer, discharge or referral.
- Patients should not be denied evaluation, screening, treatment or stabilization on the basis of their presenting complaint, condition or lack of a physician on the medical staff of the hospital.

Review of Patient #12's medical record showed:
- On 08/05/25 at 3:11 PM, he was a 63-year-old who arrived at the ED with a chief complaint of a potential infection.
- Triage documentation showed he had received radiation (the use of energy waves to diagnose or treat disease) treatment that morning, and since then he had chills and a fever of 102 to 103 degrees Fahrenheit (F). He had spoken to his Oncologist's (a physician who diagnoses and treats cancer) office. The nurse he spoke to instructed him to go to the ED. His VS were obtained and showed a temperature (normal 97.8 to 99 degrees) of 99.8 F, a blood pressure (BP, normal between 90/60 to 120/80) of 150/72 and a HR of 127.
- Lab work was obtained and showed a white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) of 10.9, a carbon dioxide (CO2, a gas produced by exhaling) of 10, anion gap (a test that checks the acid-base balance of your blood) of 23, blood urea nitrogen (BUN, blood test that specifies kidney function) of 41, and creatinine (a test that measure how well your kidneys are working) of 1.42. Urine and blood cultures (a laboratory test to check for bacteria or other germs in a blood sample) were obtained. A urinalysis (a laboratory examination of a person's urine) obtained from his nephrostomy tube (a small, flexible tube inserted directly into a kidney to drain urine) showed he had bacteria and blood present in his urine.
- Physician documentation showed he had chemotherapy (a drug treatment that uses powerful chemicals to kill fast growing cells or cancer in the body) and radiation treatment earlier in the day for bladder cancer that metastasized (the spread of cancer cells from the place where they first formed to another part of the body) to his tailbone. Physician and nursing assessments showed he had a nephrostomy tube in place.
- At 5:00 PM, an antibiotic was administered.
- Discharge instructions showed he was diagnosed with a catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage) associated urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra). He was discharged with a prescription for oral antibiotics and advised that urine and blood cultures would be checked daily for three days. The results would be sent to his Oncologist for further follow up. His Oncologist's on-call provider reviewed the ED findings and was comfortable with him taking antibiotics from home. He was also advised to change his leg bag (a smaller-capacity bag worn on the thigh or calf to collect urine from a urinary catheter) and keep it below his hips to avoid infection.
- At 5:39 PM, he was discharged home. He did not receive IV fluids, IV antibiotics, or additional monitoring.

Review of Patient #12's medical record from Hospital B, showed:
- On 08/31/25 at 7:03 PM, he arrived at the ED with a chief complaint of right sided flank pain (discomfort felt in the area between the ribs and the hip, can indicate infection in the kidney). He had a nephrostomy tube in place. It had been draining less and was difficult to flush. He reported fevers all day. He had just been seen at Hospital A and was referred to Hospital B.
- At 7:10 PM, his VS were obtained and showed a HR of 120 and a temperature of 99.7 F.
- Lab work was obtained and showed a WBC of 12.46. A urinalysis was positive for protein and blood, suspicious for a UTI.
- An abdomen and pelvis computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) showed perinephric fat stranding (swelling in the fat surrounding the kidney) that may have been indicative of pyelonephritis (a life-threatening F
- Physician documentation showed he had a history of bladder cancer and had body aches that began that day. He completed his chemotherapy and radiation two weeks prior. His pain was all over, but worst on his right side, where the nephrostomy tube was. His wife reported that they presented at Hospital A, where no testing was performed, and had a temperature of 102 F.
- He received intravenous (IV, in the vein) fluids and antibiotics in the ED.
- At 11:20 PM, he was diagnosed with pyelonephritis (a life-threatening bacterial infection in the kidneys and urinary tract) and admitted to Hospital B as he met sepsis (life threatening condition when the body's response to infection injures its own tissues and organs) criteria.

During an interview on 09/30/25 at 1:44 PM, Staff H, ED Physician, stated that Patient #12's presentation was consistent with an infection, to include the elevated HR and low-grade fever. He called Patient #12's oncologist and spoke to a Nurse Practitioner (NP, a nurse with advanced clinical education and training) who was the on-call provider. They discussed Patient #12's VS and lab work. They were aware of his elevated BP as well. They felt comfortable discharging him home and would follow up with him. He was also comfortable with the discharge, and felt Patient #12 received a full and complete MSE. There was no additional testing or imaging he felt was necessary. If the Oncologist had wanted more testing, he would have ordered it.

During an interview on 09/29/25 at 11:05 AM, Staff I, Licensed Practical Nurse (LPN), stated that she had been concerned about his HR, and spoke to Staff H, ED Physician, about it. Staff H advised her that it was related to his infection. He also had an elevated BP, but he told her that he had a history of high BP and took medication for it, so she was not concerned. He had a low-grade fever that did not require medication as it was below 100.4 F. VS should be re-checked within 10 minutes of discharge. She remembered that she had re-checked Patient #12's VS but had written them down on the "charge sheet" in the room, which was shredded after the patient left. The VS machines did not automatically save directly to the medical record, they needed to be manually entered. She was certain his HR had improved when he was discharged but could not remember exactly what it was.

During an interview on 09/30/25 at 8:24 AM, Staff J, Registered Nurse (RN), stated that she had not directly cared for Patient #12, but had reviewed and signed off on Staff I's, LPN, documentation and attempted to draw his lab work. She did not have concerns about the care he received. Staff H, Physician, had called Patient #12's Oncologist's office to discuss his care, which was typical for such patients. She agreed it was appropriate to send him home with antibiotics after blood and urine cultures were obtained. If he had needed to be admitted, the hospital could have potentially treated his infection.