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Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires hospitals comply with 42 CFR §489.24, special responsibilities of Medicare hospitals in emergency cases as evidenced by 1) failure of the hospital to ensure an appropriate medical screening examination was provided to each patient presenting to the emergency department to determine whether or not an emergency medical condition existed in 1 (#15) of 20 (#1- #20) reviewed medical records of patients presenting for evaluation (See findings under tag A-2406); and 2) failure of the hospital to ensure a transferred patient was certified as stable and the transfer was to a facility with the capability to meet the medical needs of the patient in 1 (#20) of 7(#1-#5, #19, #20) reviewed patient transfer records from a total of 20 reviewed records (See findings under tag A-2409).

Based on record review and interview, the emergency department failed to ensure each patient received an appropriate screening medical examination. The deficient practice is evidenced by failure of the emergency department staff to address nausea and vomiting 1 (#15) of 20 (Patients #1-#20) reviewed records of patients who presented to the emergency department with compaints of shortness or breath and weakness.
Findings:

Review of the emergency department record for Patient #15 revealed the patient presented on 11/11/2024 at 12:15 p.m. with complaints of "shortness of breath, weakness, swelling to his ankles since last night, denies chest pain." The patient was triaged at 12:19 PM and assigned an Emergency Severity Indes (ESI) of 3. Triage vital signs included temperature 98.2 degrees Fahrenheit, blood pressure (!)187/111 millimeters of mercury (mmHg), pulse 91 beats per minute (bpm), respirations 22/ minute, and SPO2 97 %.

Review of the "History of Present Illness" for Patient #15 revealed in part, " a past medical history of hypertension, diabetes presents to ER today with complaints of shortness of breath, bilateral leg swelling. Calf tenderness to the left calf. Patient denies chest pain at this time. Patient also reports he has weakness as well as nausea. Patient reports he cannot keep his medicine down this morning due to nausea. Blood pressure in triage 187/111. Patient reports 2 months ago he was evaluated by [name removed] cardiology for similar physical feelings. Patient reports he was compliant with all prescription medications at this time."

Further review of Patient #15's history failed to reveal a reconciliation or list of routine home medications.

Review of the "Physical Examination" was significant for left calf tenderness.

The workup included EKG, radiology and blood studies. The EKG, chest x-ray, CTA of chest (non-coronary), and ultrasound of the left thigh and calf were all normal. Significant abnormal findings from the studies included the following results:
Carbon Dioxide (CO2)- 19 milliequivalents per liter (mEq/L) [normal 20-29 mEq]
Total Protein- 8.5 grams per deciliter (g/dL) [normal 6.0- 8.5 g/dL]
Alkaline Phosphatase- 39 international units per liter (IU/L) [normal 48- 121 IU/L]
Aspartate Aminotransferase (AST)- 64 units per liter (U/L) [normal less than or equal to 40 IU/L]
Hemoglobin 13.5 grams per liter (g/L) [indicated to be low]
Hematocrit 37.5% [indicated to be low]
D dimer 2.04 milligrams per liter (mg/ L) [normal range <0.50]
Anion Gap- 19 milliequivalents per liter (mEq/ L) [normal range 8-12 mEq/L]

Review of the medical record revealed no acknowledgement or further assessment of the elevated anion gap and slightly low CO2 despite the presentation of nausea in a known diabetic. Further review of the record failed to reveal an oral challenege of liquids to assess Patient #15's nausea and inability to tolerate oral intake including daily medications.

Review of the orders and medication administration revealed Patient #15 was only administered the contrast for the imaging study.

Review of the emergency provider's note at the time of discharge revealed, "Patient stable at time of discharge in no acute distress. No life threatening illnesses were found during ER visit today. Patient was instructed to follow-up with PCP or other recommended specialist within the next 48- 72 hours. Patient was instructed to return to ER immediately for any worsening symptoms or concerning symptoms. All discharge instructions discussed with patient, and patient agrees to comply with discharge instructions given today."

Review of the discharge instructions for Patient #15 revealed at the blood pressure documented at the time of discharge was 176/ 104mm/Hg. Further review of the discharge instructions failed to reveal a list of the home medications for Patient #15 and failed to reveal instructions for taking the home medications if the nausea persisted.

In interview on 12/09/2024 at 1:10 PM, S3EDM verified all of the blood pressure readings for Patient #15 while in the emergency department were elevated and the patient had stated that he was unable to keep his medications down. S3EDM verified the physician did not document the home medications for Patient #15. S3EDM verified the physician did not assess the patient's complaint of nausea, did nothing to ensure the patient would be able to tolerate his medications after returning home.

Based on record review and interview, the hospital failed to ensure a patient with an emergency medical condition was properly transferred as required by the Emergency Medical Treatment and Labor Act (EMTALA). The deficient practice is evidenced by failure of the hospital to ensure a transferred patient was certified as stable and the transfer was to a facility with the capability to meet the medical needs of the patient in 1 (#20) of 7(#1-#5, #19, #20) reviewed patient transfer records from a total of 20 reviewed records.
Findings:

Review of Policy Number OHS.ED.001, "Admission, Discharge and Transfer Guidelines for the Emergency Department," approved 09/14/2023, revealed in part:
"IV.B. Transfer:
1.Patients requesting or in need or transfer to another facility will be deemed stable by the attending physician or designee before transfer can be approved.
a. In situations where the patient is not stable, the benefits of the transfer must outweigh the risks.
2.The transferring physician will document the reason for transfer, accepting physician, method of transfer and care required during transfer."

Review of Policy Number OHS.PTCARE.005, "Emergency Department Transfer of Patients to Another Hospital or Physician," last revised July 2012, revealed in part:
"III. Policy Statements
A.When and evaluation determines that a patient has an emergency the hospital will provide appropriate services within its capabilities until the patient is stabilized (as defined below) or the labor treated baby delivered, the patient is admitted to the hospital or the patient is discharged following completion of all medically- indicated treatment.

B. Medically Necessary patient transfers for patients who have and emergency medical condition prior to the patient being stabilized or who is in labor, will not occur until the physician certification (as defined below) is completed and the transfer is an appropriate transfer (as defined below) unless the patient ( or his appropriate representative) requests the transfer to be effected."

Further review revealed in part:
"D. Indications for Transfer of Stabilized Patient (assumes patient consents to transfer):
1. Patient Care:
a. The patient will receive at the receiving facility the benefit of a more appropriate facility, medical personnel and/or services than are available at Ochsner.
b. The transferring Ochsner facility lacks the capability to care for the patient (the facilities, equipment, and/or medical staff/personnel)."
[and]
"IV.E. The hospital will not transfer a patient with an emergency medical condition which has not been stabilized or a patient who is in labor unless:
1. The patient or a legally responsible person on the patient's behalf requests that the transfer be effected. The request must be in writing, the patient must be advised of the hospital's obligation to provide emergency medical treatment, and the transfer is an "appropriate transfer" to another medical facility.
2. A physician/ APC has certified in writing (Physician Certification) that, based upon the reasonable risks and benefits to the patient and the information then available, the medical risks and benefits reasonably expected from the provision of appropriate medical treatment at the other facility (receiving hospital) outweigh the increased risks to the patient's or unborn baby's medical condition from effecting the transfer.; and the transfer is an "appropriate transfer" to that other medical facility.

F. An appropriate transfer is one in which:
1. The receiving facility has available space and qualified personnel for the treatment of the patient and has accepted the patient, and a physician or other responsible person has agreed to accept the patient prior to transfer and to provide appropriate treatment on arrival of the patient. The sending physician/APC will arrange this aspect of the transfer as a direct physician to physician contact and will exchange clinical information."
[and]
"G. Duties of the Transferring Physician/ APC
1. Prior to transfer, the transferring physician/ APC will secure a receiving physician and hospital that is appropriate for the medical needs of the patient and will accept the responsibility for the patient's medical treatment and hospital care on arrival of the patient. Transferring APC will document transfer acceptance by the receiving physician and hospital."
[and]
"G.5. Prior to patient transfer, the physician / APC who authorizes the transfer will have personally examined and evaluated the patient to determine the patient's medical needs and to assure that the proper transfer procedures are used. "

Review of the emergency department record for Patient #20 revealed the patient presented on 06/12/2024 at 7:20 PM with complaints of "increased blood pressure and heart rate, falling more frequently with restless leg syndrome. Recent med [medication] changes. Abilify was stopped. Started on Zyprexa."

Review of the "History of Present Illness," S4MD documented in part, ". . . presents with continued medication issues. Patient suffers from bipolar disorder was recently started on Abilify 2 weeks ago per family. Significant side-effects afer the Abilify which was recently stopped due to side-effects. Patient was shaking, falling, agitated and not sleeping per the family at bedside this p.m. Patient was prescribed Klonipin; has not helped the side effects from the medications. Family was requesting inpatient behavioral health evaluation and further treatment as well."

Review of the vital signs for Patient #20 at the time of presentation revealed:
Blood Pressure- (!)139/99 milimiters of mercury (mm/Hg)
Pulse- (!)123 beats / minute
Respirations- 20 respirations/ minute
Temperature- 97.8 degrees Fahrenheit
SpO2- 97%

Review of the abnormal laboratory studies revealed in part:
Creatinine Phosphokinase (CPK) - 822 units/ liter (U/L) [normal range 20-200U/L]
Potassium- 3.3 millimoles per liter (mmol/L) [normal range 3.5 to 5.2 mmol/L]
Ketones, UA- 3+ [normal is negative]

The electrocardiogram was interpreted by the ED physician. The physician documented:
EKG Readings: (Independently Interpreted)
No STEMI
Normal Sinus Rhythm
No ectopy
Normal conduction;
Normal ST segments
Normal T wave
Normal Axis
Heart Rate in 100's

Vital signs were repeated on 06/12/2024 at 9:24 PM and revealed:
Blood Pressure- (!) 137/93 mm/Hg
Pulse- 104 beats / minute
Respirations- 20 respirations/ minute
SpO2- 96%


On 06/12/2024 at 9:33 PM under "ED Management and Risks of Complication, Morbidity, and Mortality" S4MD documented, "Patient was not doing well since medication changes by Psychiatry. Will admit to inpatient psychiatry for further treatment and evaluation. Medically cleared for psychiatry placement."

Further review of the medical record revealed on 06/12/2024 at 9:40 PM, S4MD entered an order for a" Physician's Emergency Certificate" (PEC). Review of the PEC revealed under mental condition the physician documented, "patient is not psychotic, patient is not violent, and patient has been entirely cooperative in the ER today. Agitated, not sleeping, several medication changes by Psychiatry in the last couple of weeks." He then checked off the boxes for dangerous to self, unwilling, and gravely disabled.

Patient #20 remained in the emergency department waiting for psychiatry placement from 06/12/2024 at 10:28 PM until 06/14/2024 at 5:42 PM

The results of the EKG performed on 06/12/2024 at 8:12 PM were finalized by S7MD on 06/13/2024 at 12:14 PM The final results included:
Sinus tachycardia
Possible left atrial enlargement
Nonspecific ST abnormality
Borderline Abnormal ECG
When compared with ECG of 04/16/1997 at 3:15 PM, T wave inversion now evident in inferior leads
T wave amplitude has decreased in Anterior-lateral leads

Review of the vital signs for Patient #20's pulse remained above 100 beats/ minute beginning at 9:31 AM on 06/13/2024. Review of the vital signs for 06/13/2024 at 5:30 PM revealed:
Blood Pressure- (!)164/108 mm/Hg
Pulse- (!)131 beats/ minute
Respirations- 18 respirations/ minute
SpO2- 97%

On 06/13/2024 at 5:43 PM, S5MD documented, "Patient was transitioned to me at 6:00 AM, awaiting BHU[Behavioral Health Unit] placement. In the afternoon at 2:15 PM patient was noted to be tachycardic and diaphoretic. Repeat blood work was obtained and resulted as normal. Patient is afebrile. Patient had recent discontinuation of Abilify in the last 3 days which may be contributing to withdrawal symptoms. I gave the patient Ativan as well as normal saline [intravenous hydration] and symptoms did not improve. Patient had been transitioned to olanzapine 3 days ago but has not been given it since he was admitted to the emergency room, so his normal dose of olanzapine was given. We will continue workup and monitor until patient's symptoms improve."

Further review of the record failed to reveal documentation by a physician in the last 12 hours before Patient #20 was transferred to Hospital B.

Review of the RN note from 06/13/2024 at 5:44 PM revealed, "Notified S5MD that received call from BHU [Behavioral Health Unit] stating S8MD wanted patient to be admitted to the 3rd floor to get fluids [intravenous hydration] throughout the night along with benzo [benzodiazepines] then BHU will be willing to take patient in a.m."

Review of the "Medication Administration Record" for Patient #20 on 06/13/2024 revealed nursing staff administered lorazepam 1milligram at 2:51 PM, olanzapine 10 milligrams at 4:45 PM, clonidine 0.3 milligrams administered at 5:49 PM., and clordiazepoxide HCl 50 mg administered at 6:48 PM.

Review of the ordered laboratory studies for 06/13/2024 revealed an abnormal CPK level of 684 U/L [normal range 20-200U/L] reported at 7:14 PM, and an abnormal D dimer level of 12.90 mg/L [normal range <0.50] reported at 7:23 PM.

Computed tomography angiogram (CTA) of the chest (non-cardiac) was also performed on 06/13/2024 and the result was reported at 9:01 PM and revealed in part, "No pulmonary embolism to the segmental level."

On 06/13/2024 at 9:53 PM, new transfer orders were entered for transfer to "medical/psych due to labile vital signs."

On 06/14/2024 at 5:42 AM, Patient #20 was transferred to Hospital B which was not a medical/psychiatric facility as ordered.

Review of the medical record for Patient #20 revealed S6MD ordered the D dimer, CPK, and CTA, but there was no documented acknowledgement of the test results, no differential diagnosis, and no assessment and plan. There was no "Physician Certification" documenting Patient #20 had been stabilized such that within reasonable medial probability, no deterioration of the patient's condition was likely to result from the transfer. There was no documentation that S6MD called the receiving psychiatrist to discuss Patient #20's normal CTA and abnormal creatinine phosphokinase, D dimer, and EKG. There was no documentation to explain why Patient #20 was transferred to a lower level of care when a bed on the behavioral unit at the current hospital was to be available on the same day and was designated for Patient #20's admission.

Review of the medical records from Hospital C revealed emergency transport services transferred the patient from Ochsner St. Anne General Hospital to Hospital B and then to Hospital C. It was noted that Hospital B refused Patient #20 because of a possible seizure in route and sent the patient to the nearest emergency department for evaluation. While at Hospital C, consideration was given to having Patient #20 return to the behavioral unit at Ochsner St. Anne General Hospital when the patient again had an unresponsive episode, coded several times, was intubated and transferred to a critical care unit at Hospital D. At Hospital D it was determined that Patient #20 had a large pulmonary embolism and right lower extremity deep vein thrombosis.

In interview on 12/09/2024 during the chart review between 1:00 PM and 1:10 PM, S3EDM verified she was familiar with the patient and the events that occurred after Patient #20's presentation to the emergency department. S3EDM verified there was no documentation by a physician after 06/13/2024 at 5:43 PM. S3EDM verified after the normal CTA result was released, there were no other studies ordered or repeated in an attempt to determine the significance of the elevated D dimer, creatinine phosphokinase, and changes in the EKG. S3EDM verified the record did not have "Physician Certification" prior to transfer as required by hospital policy. S3EDM verified arrangements had been made to have Patient #20 admitted to the onsite psychiatric unit on the same day Patient #20 was transferred to another psychiatric hospital with no onsite acute care services. S3EDM verified the orders were for transfer to a facility that could provide both medical and psychiatric care.

In interview on 12/12/2024 at 12:00 PM, the Director of Nursing at Hospital B verified the facility did not accept psychiatric patients with complex medical diagnoses and the facility only provided psychiatric services.