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Based on interview, record review and policy review the hospital failed to follow its policies and procedures when they failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#3) and ensure that an emergency medical condition (EMC) was stabilized for two patients (#3 and #24) of 24 Emergency Department (ED) records reviewed from 10/01/24 through 06/16/25. These failed practices 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, "EMTALA Guidelines," revised 03/05/24, showed:
- All patients shall receive a MSE that includes providing all necessary testing and diagnostics to determine whether or not an EMC exists.
- A MSE should include an assessment and evaluation, a brief general history, as well as any history related the patient's chief complaint. An appropriate examination including the presenting complaint, potentially affected systems and known chronic conditions should also be included.
- The results of any diagnostic tests and the resulting diagnosis must be assessed and validated.
- Required medical staff documentation includes all of the elements of the MSE including observations and diagnostic test results that support a conclusion that an EMC does or does not exist. EMTALA defines "stabilized" as when no material deterioration of the condition is likely, within reasonable probability, to result or occur during the transfer of the patient.
- The hospital must not transfer or discharge patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient.

Review of the hospital's policy titled, "Guidelines Regarding MSEs," reviewed 02/28/24, showed:
- The MSE will be sufficient, based on the capability of the hospital, to permit the hospital to decide whether or not the individual has an EMC.
- Appropriate examination, including the presenting complaint, potentially affected systems, and known chronic conditions must be completed as part of the MSE.
- Required medical staff documentation includes all of the elements of the MSE including observations and the diagnostic test results that support a conclusion that an EMC does or does not exist.
- Results of any diagnostic tests and the resulting diagnosis must be assessed and validated. Assessment is an ongoing process which determines the patient's status at any given time while the patient is being evaluated and treated.
- When an EMC is determined to exist, continuing stabilizing and evaluative care will be rendered within the capabilities of the hospital.

Please refer to 2406 and 2407 for further details.

Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they 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 (#3) of 24 Emergency Department (ED) records reviewed from 10/01/24 through 06/16/25.
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, "EMTALA Guidelines," revised 03/05/24, showed:
- All patients shall receive a MSE that includes providing all necessary testing and diagnostics to determine whether or not an EMC exists.
- A MSE should include an assessment and evaluation, a brief general history, as well as any history related the patient's chief complaint. An appropriate examination including the presenting complaint, potentially affected systems, and known chronic conditions should be included.
- The results of any diagnostic tests and the resulting diagnosis must be assessed and validated.
- Required medical staff documentation includes all of the elements of the MSE including observations and diagnostic test results that support a conclusion that an EMC does or does not exist. EMTALA defines "stabilized" as when no material deterioration of the condition is likely, within reasonable probability, to result or occur during the transfer of the patient.
- The hospital must not transfer or discharge patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient.

Review of the hospital's policy titled, "Guidelines Regarding MSEs," reviewed 02/28/24, showed:
- The MSE will be sufficient, based on the capability of the hospital, to permit the hospital to decide whether or not the individual has an EMC.
- Appropriate examination, including the presenting complaint, potentially affected systems, and known chronic conditions must be completed as part of the MSE.
- Required medical staff documentation includes all of the elements of the MSE including observations and the diagnostic test results that support a conclusion that an EMC does or does not exist.
- Results of any diagnostic tests and the resulting diagnosis must be assessed and validated. Assessment is an ongoing process which determines the patient's status at any given time while the patient is being evaluated and treated.
- When an EMC is determined to exist, continuing stabilizing and evaluative care will be rendered within the capabilities of the hospital.

Review of Patient #3's medical record, dated 12/08/24, showed:
- On 12/07/24 at 10:37 PM, a 21-year-old presented to the ED with a chief complaint of a cough, vomiting, and "feeling like passing out."
- His past medical history included polycythemia rubra vera (a rare, chronic blood cancer where the bone marrow produces too many red blood cells. This overproduction thickens the blood, potentially leading to complications like blood clots, stroke, or heart attack).
- He was alert, awake, and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time).
- His skin color was ashen and jaundiced (yellowing of the skin or whites of the eyes that may occur if the liver can't efficiently process red blood cells as they break down).
- He reported that he became short of breath with exertion, had slight chest pain, and described his cough as mild.
- Laboratory tests were ordered.
- His examination showed crackles (irregular clicking, popping or rattling lung sounds) in his right lung.
- At 10:48 PM, his blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) was 113/73.
- On 12/08/24 at 12:10 AM, his BP was 87/46, and he received one liter of intravenous (IV, in the vein) fluid.
- At 12:11 AM, his oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) dropped below 90%, and supplemental oxygen was administered.
- At 1:05 AM, a chest 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) scan showed moderate diffuse body wall edema (swelling) and a small amount of free fluid in the abdomen/pelvis that were evidence for fluid overload.
- At 1:12 AM, his BP was 108/71 and his oxygen saturation was 94%. His blood tests showed his cardiac enzymes (proteins that enter the bloodstream when there has been damage to the heart muscle) were elevated.
- At 1:36 AM, he received one liter of IV fluids.
- At 1:42 AM, his BP was 90/44 and his oxygen saturation was 94%.
- At 4:54 AM, Hospital B (an acute care hospital) was contacted regarding his transfer.
- At 5:44 AM, he was accepted for transfer by Hospital B.
- At 6:12 AM, his BP was 78/60.
- At 6:22 AM, an electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) was completed. It showed a heart rate of 117, an incomplete right bundle branch block (condition caused by a blocked electrical pathway in the heart), right atrial enlargement (a condition where the left atrium or right atrium of the heart is larger than would be expected), and right ventricular hypertrophy (a condition where the walls of one or both ventricles of the heart become thicker than normal).
- At 6:33 AM, he received 500 milliliters of IV fluids.
- At 6:42 AM, his BP was 105/39 and his oxygen saturation was 93%.
- At 7:11 AM, his BP was 99/63 and his oxygen saturation was 94%.
- At 7:14 AM, he departed via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) to Hospital B with a diagnosis of polycythemia rubra vera and fluid overload.

Review of Patient #3's EMS report, dated 12/08/24, showed:
- At 7:17 AM, EMS picked up the patient from the ED for transport to Hospital B. His BP was 104/73, his oxygen saturation was 93% and he was receiving supplemental oxygen. He was A&O X 3 and had no complaints of pain or distress.
- At 8:01 AM, EMS arrived at the ED entrance of Hospital B. The patient stated that he was having trouble breathing and became unresponsive. He aroused and spoke to EMS, then became unresponsive again. He briefly responded to a sternal rub (painful pressure applied with the knuckles to the center of the chest of a patient who is not alert to elicit a response).
- At 8:05 AM, EMS brough the patient into the ED and notified staff that the patient was deteriorating. He began agonal breathing (gasping, labored breathing) and his pulse could not be detected.
- EMS and Hospital B staff initiated cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped).
- At 8:21 AM, the patient expired.

Review of Patient #3's Hospital B medical record, dated 12/08/24, showed Patient #3 arrived at 8:05 AM breathless, unresponsive and pulseless with CPR in progress. He expired at 8:21 AM.

During an interview on 06/17/25 at 3:00 PM, Staff H, Physician, stated that Patient #3 was a complicated case. Initial concerns based on blood tests, including elevated cardiac enzymes, was that the patient was dehydrated, and IV fluid administration was the best approach. Patient #3 began having low BPs, which responded to the IV fluids. He had crackles upon admission and his chest CT scan showed evidence of fluid overload, but Staff H canceled the order for a diuretic (medication that promotes the production and excretion of urine) due to Patient #3's low BP. The CT scan did not show evidence of pulmonary edema (an abnormal buildup of fluid in the lungs). Patient #3 appeared to be stable and ready for transport to Hospital B. No other interventions were used to manage this BP. Staff H evaluated the ECG when it was performed, he did not know why and ECG was not done upon Patient #3's arrival and prior to the administration of IV fluids.

During an interview on 06/17/25 at 4:50 PM, Staff M, Medical Director, stated that the hospital did not have a cardiologist (a physician that specializes in the care of your heart and blood vessels) on call. ED staff would attempt to reach a patient's cardiologist if they had one or reach out to other hospitals to discuss a transfer if there was a need.

Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they failed to ensure that an emergency medical condition (EMC) was stabilized for two patients (#3 and #24) of 24 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, "EMTALA Guidelines," revised 03/05/24, showed:
- All patients shall receive a MSE that includes providing all necessary testing and diagnostics to determine whether or not an EMC exists.
- A MSE should include an assessment and evaluation, a brief general history, as well as any history related the patient's chief complaint. An appropriate examination including the presenting complaint, potentially affected systems, and known chronic conditions should be included.
- The results of any diagnostic tests and the resulting diagnosis must be assessed and validated.
- Required medical staff documentation includes all of the elements of the MSE including observations and diagnostic test results that support a conclusion that an EMC does or does not exist. EMTALA defines "stabilized" as when no material deterioration of the condition is likely, within reasonable probability, to result or occur during the transfer of the patient.
- The hospital must not transfer or discharge patients who are potentially unstable if the hospital has the capabilities to provide treatment and care to the patient.

Review of the hospital's policy titled, "Guidelines Regarding MSEs," reviewed 02/28/24, showed:
- The MSE will be sufficient, based on the capability of the hospital, to permit the hospital to decide whether or not the individual has an EMC.
- Appropriate examination, including the presenting complaint, potentially affected systems, and known chronic conditions must be completed as part of the MSE.
- Required medical staff documentation includes all of the elements of the MSE including observations and the diagnostic test results that support a conclusion that an EMC does or does not exist.
- Results of any diagnostic tests and the resulting diagnosis must be assessed and validated. Assessment is an ongoing process which determines the patient's status at any given time while the patient is being evaluated and treated.
- When an EMC is determined to exist, continuing stabilizing and evaluative care will be rendered within the capabilities of the hospital.

Review of Patient #3's medical record, dated 12/08/24, showed:
- On 12/07/24 at 10:37 PM, a 21-year-old presented to the ED with a chief complaint of a cough, vomiting, and "feeling like passing out."
- His past medical history included polycythemia rubra vera (a rare, chronic blood cancer where the bone marrow produces too many red blood cells. This overproduction thickens the blood, potentially leading to complications like blood clots, stroke, or heart attack).
- He was alert, awake, and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time).
- His skin color was ashen and jaundiced (yellowing of the skin or whites of the eyes that may occur if the liver can't efficiently process red blood cells as they break down).
- He reported that he became short of breath with exertion, had slight chest pain, and described his cough as mild.
- Laboratory tests were ordered.
- His examination showed crackles (irregular clicking, popping or rattling lung sounds) in his right lung.
- At 10:48 PM, his blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) was 113/73.
- On 12/08/24 at 12:10 AM, his BP was 87/46, and he received one liter of intravenous (IV, in the vein) fluid.
- At 12:11 AM, his oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) dropped below 90%, and supplemental oxygen was administered.
- At 1:05 AM, a chest 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) scan showed moderate diffuse body wall edema (swelling) and a small amount of free fluid in the abdomen/pelvis that were evidence for fluid overload.
- At 1:12 AM, his BP was 108/71 and his oxygen saturation was 94%. His blood tests showed his cardiac enzymes (proteins that enter the bloodstream when there has been damage to the heart muscle) were elevated.
- At 1:36 AM, he received one liter of IV fluids.
- At 1:42 AM, his BP was 90/44 and his oxygen saturation was 94%.
- At 4:54 AM, Hospital B (an acute care hospital) was contacted regarding his transfer.
- At 5:44 AM, he was accepted for transfer by Hospital B.
- At 6:12 AM, his BP was 78/60.
- At 6:22 AM, an electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) was completed. It showed a heart rate of 117, an incomplete right bundle branch block (condition caused by a blocked electrical pathway in the heart), right atrial enlargement (a condition where the left atrium or right atrium of the heart is larger than would be expected), and right ventricular hypertrophy (a condition where the walls of one or both ventricles of the heart become thicker than normal).
- At 6:33 AM, he received 500 milliliters of IV fluids.
- At 6:42 AM, his BP was 105/39 and his oxygen saturation was 93%.
- At 7:11 AM, his BP was 99/63 and his oxygen saturation was 94%.
- At 7:14 AM, he departed via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) to Hospital B with a diagnosis of polycythemia rubra vera and fluid overload.

Review of Patient #3's EMS report, dated 12/08/24, showed:
- At 7:17 AM, EMS picked up the patient from the ED for transport to Hospital B. His BP was 104/73, his oxygen saturation was 93% and he was receiving supplemental oxygen. He was A&O X 3 and had no complaints of pain or distress.
- At 8:01 AM, EMS arrived at the ED entrance of Hospital B. The patient stated that he was having trouble breathing and became unresponsive. He aroused and spoke to EMS, then became unresponsive again. He briefly responded to a sternal rub (painful pressure applied with the knuckles to the center of the chest of a patient who is not alert to elicit a response).
- At 8:05 AM, EMS brough the patient into the ED and notified staff that the patient was deteriorating. He began agonal breathing (gasping, labored breathing) and his pulse could not be detected.
- EMS and Hospital B staff initiated cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped).
- At 8:21 AM, the patient expired.
Review of Patient #3's Hospital B medical record, dated 12/08/24, showed Patient #3 arrived at 8:05 AM breathless, unresponsive and pulseless with CPR in progress. He expired at 8:21 AM.

During an interview on 06/17/25 at 3:00 PM, Staff H, Physician, stated that Patient #3 was a complicated case. Initial concerns based on blood tests, including elevated cardiac enzymes, was that the patient was dehydrated, and IV fluid administration was the best approach. Patient #3 began having low BPs, which responded to the IV fluids. He had crackles upon admission and his chest CT scan showed evidence of fluid overload, but Staff H canceled the order for a diuretic (medication that promotes the production and excretion of urine) due to Patient #3's low BP. The CT scan did not show evidence of pulmonary edema (an abnormal buildup of fluid in the lungs). Patient #3 appeared to be stable and ready for transport to Hospital B. No other interventions were used to manage this BP. Staff H evaluated the ECG when it was performed, he did not know why and ECG was not done upon Patient #3's arrival and prior to the administration of IV fluids.

During an interview on 06/17/25 at 4:50 PM, Staff M, Medical Director, stated that the hospital did not have a cardiologist (a physician that specializes in the care of your heart and blood vessels) on call. ED staff would attempt to reach a patient's cardiologist if they had one or reach out to other hospitals to discuss a transfer if there was a need.






Review of Patient #24's medical record, dated 05/15/25, showed:
- She was a 68-year-old with a past medical history of an abdominal aortic aneurysm (an excessive localized enlargement of an artery caused by a weakening of the artery wall), high blood pressure, atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), and pneumonia (infection in the lungs).
- On 05/15/25 at 7:45 PM, she presented to the ED via EMS with a chief complaint of shortness of breath, possible fever and pneumonia. EMS was unable to obtain IV access.
- At 7:48 PM, her BP was 45/29 and the physician was notified.
- At 7:56 PM, an ECG was completed.
- At 7:57 PM, her BP was 102/44.
- At 7:58 PM, a peripheral venous catheter (a thin, flexible tube that is inserted into a vein in an extremity [i.e., arm, hand, leg, or foot] or in a vein in the scalp) was inserted into her ankle.
- At 8:05 PM, one liter of IV fluids was administered.
- At 8:15 PM, her BP was 78/48.
- At 8:27 PM, the physician was at bed side.
- At 8:31 PM, blood tests were drawn including blood cultures (a laboratory test to check for bacteria or other germs in a blood sample), complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and troponin (a type of blood test that measures whether or not a person is experiencing a heart attack).
- At 8:48 PM, her BP was 80/50, she was noted to be diaphoretic (excessive, abnormal sweating), and multiple attempts were made for additional IV access, without success.
- At 8:54 PM, a chest x-ray was completed that showed no acute abnormality.
- At 9:01 PM, the physician was notified of the Patient #24's continued low BP.
- At 9:15 PM, the patient's white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) resulted as 16.3, the normal range was 4.5 to 10.5.
- At 9:16 PM, her BP was 62/28.
- At 9:20 PM, one liter of IV fluids was administered.
- At 9:32 PM, her troponin resulted as 520.8, the normal range was 8.4 to 18.7.
- At 9:49 PM, nursing staff began contacting other hospitals to arrange transfer to a higher level of care.
- At 10:03 PM, Hospital B accepted Patient #24 for transfer.
- At 10:15 PM, ceftriaxone (antibiotic) was administered.
- At 10:16 PM, her BP was 75/39.
- At 10:25 PM, report was called by the nurse to Hospital B.
- At 10:36 PM, her BP was 82/41 and the physician was notified by the nurse of her continued low BP and single IV access. A central line/central venous catheter (long, thin, flexible tube placed in a large vein and the end of the tube sits in a large blood vessel near to or in part of their heart, allowing multiple fluids to be given and blood to be drawn) was suggested.
- At 10:37 PM, family declined placement of a central line and the CT scan of her abdomen.
- At 10:46 PM, her BP was 83/36.
- At 10:40 PM, one liter of IV fluids was administered.
- At 10:50 PM, the patient left the ED via EMS for transfer to Hospital B.

Review of Patient #24's medical record from Hospital B, dated 05/20/25, showed:
- On 05/15/25 at 11:38 PM, she presented to the ED via EMS with a chief complaint of low blood pressure. Norepinephrine bitrate (medication used to treat patients with very low blood pressure) was infusing into her ankle IV. EMS had initiated the medication to support her blood pressure during transfer.
- At 11:42 PM, her BP was 91/57 and the norepinephrine bitrate infusion continued.
- Laboratory testing, an abdominal CT scan, head CT scan, chest x-ray, and antibiotics were ordered.
- The abdominal CT scan indicated an abdominal aortic aneurism, an esophagus (a muscular tube that food travels through from the throat to reach the stomach) mass, and a pelvic mass.
- At 1:03 AM, a central line was placed for administration of norepinephrine bitrate and other medications.
- At 4:34 AM, she was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) for treatment of sepsis (life threatening condition when the body's response to infection injures its own tissues and organs).

Review of the hospital's undated document titled, "SBAR review," showed the hospital received a complaint from Patient #24's daughter concerning her mother's care. The concerns included inadequate venous access, lack of blood pressure support and lack of monitoring. Norepinephrine bitrate was not initiated by hospital staff. EMS initiated the medication during transport to Hospital B. The patient's RN was interviewed, and she stated that she was concerned about the patient's BP and only having a single IV in her ankle. The nursed notified the physician of her concerns and repeatedly updated him of the patient's continued low BP and the need for a central line.

During a telephone interview on 06/17/25 at 5:55 PM, Staff N, RN, stated that Patient #24's BP and lack of IV access was an immediate concern and that she went to the physician multiple times about both issues. IV access for the patient was very difficult and she "felt lucky" to establish an IV in the patient's ankle. She sought assistance from other staff, including calling in the Nurse Manager from home, but they were all unsuccessful. The physician was aware of the IV access issue upon Patient #24's admission to the ED and eventually agreed to place a central line. The family refused the line placement because she was transferring out and they had lost confidence in the care she was receiving.

During an interview on 06/17/25 at 1:40 PM, Staff A, RN Manager, stated that she was called in from home to assist with patient #24. She and other staff members attempted to place an additional IV but were unsuccessful. She discussed central line placement with the physician and set up supplies, but the patient's family did not want to wait any longer and wanted her transferred as soon as possible. She did not know why IV access wasn't addressed by the physician sooner.

During a telephone interview on 06/17/25 at 3:55 PM, Staff K, Physician, stated that Patient #24's BP was a concern but was "moving in the right direction" after she received fluids and antibiotics. He did not initiate any other medications for her blood pressure because she responded to the IV fluids and the antibiotics covered possible sepsis. Hospital B thought she was appropriate for transport. EMS had norepinephrine bitrate if it was needed during transport. In retrospect the patient should have had more access, and a central line would have been preferred.