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Based on clinical record review, policy review and staff interview, the hospital failed to adopt and enforce policies to ensure compliance with the Emergency Medical Treatment and Labor Act (EMTALA) requirements at 42 CFR 489.20 and 489.24, as evidenced by failure to provide an appropriate Medical Screening Exam (MSE) to determine the extent of an emergency medical condition (EMC), and to provide care and treatment to relieve or eliminate such condition. In addition, if such condition required services that were not available at Hospital A, the hospital failed to implement a transfer to a hospital with the necessary services available. This failure affected 1 of 20 sampled patients (Patient #1).

The findings included:

Based on clinical record review, policy review and interview conducted on 08/06/24 and 08/07/24, Hospital A failed to provide an appropriate medical screening exam to Patient #1, who presented to the Emergency Department (ED) seeking medical care for facial pain, swelling, and dental abscess.
Patient #1 was discharged from Hospital A and then presented to the ED at Hospital B, 49 minutes after being discharged from Hospital A, with the same symptoms, The patient was subsequently diagnosed with Facial Cellulitis, Parapharyngeal swelling, Dental abscess and Leukocytosis, requiring specialty consultations, inpatient admission, surgical intervention and a long course of intravenous antibiotic therapy.

Cross Refer to evidence of noncompliance at A2406.

Based on policy review, record review, and interview, the hospital failed to substantiate the provision of emergency services for 1 of 20 sampled patients (Patient #1) as evidenced by failure to perform an appropriate Medical Screening Exam (MSE) to determine if a medical condition existed, and if so to provide care and treatment to relieve or eliminate the condition.

The findings included:

Review of the hospital's policy, titled, EMTALA, {Emergency Medical Treatment and Labor Act], last revised 08/03/22, documented, in part:
"Hospital will provide an individual with an appropriate Medical Screening Examination within the Capability of Hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an Emergency Medical Condition exists, regardless of the individual's ability to pay, when: (a) there has been a request for medical care by an individual within a Dedicated Emergency Department; (b) an individual requests emergency medical care on Hospital Property, other than in a Dedicated Emergency Department; or (c) a Prudent Layperson Observer would recognize that an individual in a Dedicated Emergency Department or on Hospital Property requires emergency treatment or examination, though no request for treatment is made."


Clinical record review conducted on 08/06/24 and 08/07/24 revealed Patient #1 presented to the Emergency Department (ED) on 03/14/24 at 1:50 PM seeking care for complaint of "right-side facial pain and swelling, the patient was diagnosed with dental abscess and was given antibiotic. Patient states getting worse".

The patient was triaged at 1:59 PM as a priority 4, non-urgent. The vital signs noted temperature 98.6, pulse 106, respiration 18, blood pressure 125/70, oxygen saturation 97% and pain level 5 of 10.

The Medical Screening Exam (MSE) conducted on 03/14/24 at 2:06 PM documented a History of Present Illness (HPI) as, "the patient presents with facial pain and swelling for the past few days. Patient denies any fever, chills, nausea, vomiting, chest pain, shortness of breath or any other chief complaint or trauma. The onset was just prior to arrival. The course duration of symptoms is constant. The character of symptoms is pain. The degree of pain at present is none. The exacerbating factor is none. The relieving factor is none. Risk factors consist of none. Prior episodes none and therapy today none."

It was noted the nursing triage notes contained minimal information, did not address previous procedures, length of time of the symptoms, when the antibiotic therapy was started and why the patient felt it was getting worse.

The MSE included a physical examination, as follows: Ear/Nose/Mouth/Throat negative except as documented in HPI.
Surgical history noted no active procedure history items have been selected or recorded.
Physical examination documented Ear/Nose Mouth and Throat: tympanic membranes clear.
The differential diagnosis noted Facial pain and Sinusitis.
Patient #1 received Morphine and Clindamycin and blood workups included a complete blood count, chemistry and blood cultures.
Laboratory results indicated elevated white blood count 16.76 (normal range is 4.5-10.5) and elevated liver function.
Patient #1 was discharged home on 03/14/24 at 5:43 PM with prescription for pain medicine and follow up with oral surgeon.

The physical exam documented many non-pertinent findings that were within normal limits. The area of focus based on the patient complaint noted EAR/NOSE/MOUTH/THROAT findings as tympanic membranes clear. There is no other documentation regarding the swelling of the face, degree of swelling, mouth or tongue examination, drainage or pain.

Review of the Provider reexamination noted at 3:26 PM, documented, "patient verbalizes feeling much better at this time. Patient requesting to go home. Advised immediately return to ED if signs and symptoms return or worsen".
The record documented the provider ordered Antibiotic and blood cultures at the same time, 3:26 PM; Morphine was ordered at 4:00 PM; and additional blood work was ordered at 4:19 PM. The acuity level was updated to urgent.

It was documented that Patient #1 left the ED on 03/14/24 at 5:43 PM with a prescription for pain management and follow up instruction with an oral surgeon. There were no vital signs or pain reassessment upon discharge.

Patient #1 left Hospital A on 03/14/24 at 5:43 PM and presented to Hospital B on 03/14/24 at 6:32 PM, approximately 18.5 miles away. At Hospital B, Patient #1 received a Medical Screening Exam at 6:41 PM, an hour later. Patient #1 was diagnosed with facial cellulitis, complicated right mandibular infected dental implant with facial space involvement, and significant leukocytosis, pain level noted to be 10 of 10. Patient #1 was subsequently admitted for specialty consultations, intravenous antibiotic therapy and incision and drainage.

The investigation ascertained the medical screening exam completed at Hospital A did not identify the degree of Patient #1's medical condition requiring diagnostic imaging and specialty consultations to alleviate the condition.

Interview with the Emergency Department Medical Director (ED MD) on 08/06/24 at 1:48 PM revealed in general, complaints of dental pain do not require imaging, unless there are significant findings. There are risks associated with imaging and radiation exposure. The provider will look for evidence of Ludwig, abscess formation, or fluid collection. In addition, the providers do a general assessment to include does the patient looks ill, do they have abnormal vital signs, it is a comprehensive decision. In most cases, tooth infections need to be treated with antibiotic, and a drill.

The ED MD reviewed Patient #1's clinical record and explained the care provided was in accordance to the patient's presentation. The assessment did not indicate deep infection of the face, no significant findings are hinted on in the chart and explained the elevated white blood cell count is not a definite sign of infection, but it means stress to the body. The Medical Director agreed with the care provided.

Interview with the Advanced Registered Nurse Practitioner (ARNP), who examined Patient #1, was conducted on 08/07/24 at 8:33 AM. The ARNP reviewed the record for Patient #1 and had limited recollection. The patient presented with dental pain, he performed a physical examination and stated that he charts by exception, he did not document swelling or edema or any other significant findings, if any abnormal signs are seen he would have documented it. The ARNP also explained he typically does not order blood work for dental pain complaints, he believes the patient wanted the blood work, and that is why it was done. He did not recall the patient asking for imaging studies or advising the patient to seek medical care at another hospital, the patient was discharged home with prescriptions and follow up care with an oral surgeon.

The investigation determined Hospital A failed to provide an appropriate medical screening exam to Patient #1 resulting in a secondary visit to the ED at another hospital (Hospital B) within 49 minutes of discharge.