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Based on observation, interview, and record review, the hospital failed to comply with the regulatory requirements for EMTALA for one of 21 patients, when:

The hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [EMC] exists) within the capability of the hospital's emergency department (ED) for one of 21 patients (Patient (Pt) 1) when Pt 1 was brought in by caretaker on 12/9/24 at 3:45 p.m. with chief complaint of increasing severity of abdominal pain for four days and not eating except for popcorn. Pt 1 was known to have a genetic intellectual disability and was triaged with an Emergency Severity Index (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient's condition and the resources needed, ESI 1 is the most serious, in order to prioritize care) of 3. Physician Assistant (PA) did not begin an evaluation until 7:06 p.m. (over 3 hours from first triaged) and did not conduct a physical examination of the abdomen, the source of the chief complaint. PA ordered a urine test and blood laboratory tests. Two hours later at 9:08 p.m., Medical Doctor (MD) 1 examined Pt 1 and immediately recognized the probable EMC and ordered a CT which indicated sigmoid volvulus (twisted colon). At 10:39 p.m. patient was intubated and put on a mechanical ventilator. On 12/10/22 at 2:20 a.m. (almost 11 hours after first being seen), patient was emergently taken to OR for Left sigmoid colectomy (removal of colon) and on 12/12/22, a right hemicolectomy (removal of colon) was done.

These failures resulted in the PA not conducting a physical examination of the abdomen, delay in recognizing the emergent nature of symptoms and could have contributed to delay in surgical intervention and outcome of Pt 1.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner.

Based on interview and record review, the hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [EMC] exists) within the capability of the hospital's emergency department (ED) for one of 21 patients (Patient (Pt) 1) when Pt 1 was brought in by caretaker on 12/9/24 at 3:45 p.m. with chief complaint of increasing severity of abdominal pain for four days and not eating except for popcorn. Pt 1 was known to have a genetic intellectual disability and was triaged with an Emergency Severity Index (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient's condition and the resources needed, ESI 1 is the most serious, in order to prioritize care) of 3. Physician Assistant (PA) did not begin an evaluation until 7:06 p.m. (over 3 hours from first triaged) and did not conduct a physical examination of the abdomen, the source of the chief complaint. PA ordered a urine test and blood laboratory tests. Two hours later at 9:08 p.m., Medical Doctor (MD) 1 examined Pt 1 and immediately recognized the probable EMC and ordered a CT which indicated sigmoid volvulus (twisted colon). At 10:39 p.m. patient was intubated and put on a mechanical ventilator. On 12/10/22 at 2:20 a.m. (almost 11 hours after first being seen), patient was emergently taken to OR for Left sigmoid colectomy (removal of colon) and on 12/12/22, a right hemicolectomy (removal of colon) was done.

These failures resulted in the PA not conducting a physical examination of the abdomen, delay in recognizing the emergent nature of symptoms and could have contributed to delay in surgical intervention and outcome of Pt 1.

Findings
During a concurrent interview and record review on 2/11/25, at 10:40 a.m., with the Emergency Department Director (EDD) and RN Shift Manager of ED (SM 1), Pt 1's "Electronic Medical Record [EMR]," dated 12/9/22 was reviewed. The triage form indicated Pt 1 was triaged at 3:45 p.m. and assigned an ESI Level of 3. EDD stated, the nurse who triaged Pt 1 no longer works at the hospital. Review of the document "ED Note-Physician," dated 12/9/22, at 7:06 p.m. by PA 1, indicated Pt 1 was seen by PA 1 at 7:06 p.m. The note indicated, " ...Chief Complaint: Cough and n[nausea]/v[vomiting]/diarrhea x[for] 4 days ... 55-year-old male with some sort of developmental disorder brought in by caregiver today with complaints of nausea, vomiting, diarrhea and some lower abdominal pain that began earlier this afternoon. Caregiver states the symptoms started after eating some popcorn at the movie theater earlier today. He endorses 3 episodes of vomit thus far. Caregiver has attempted to administer some medications, but patient has been unable to take them without wanting to vomit ..." The ED Physician's Note indicated Pt 1 had a past medical history, "Developmental disorder (Patient Stated)". The ED Physician's Note indicated, "Physical Exam: ... General: Alert, no acute distress. Head: normocephalic/atraumatic [normal head with no signs of injury] Eyes: EOMI [Normal eye movement] Respiratory: Respirations are non-labored Psychiatric: Cooperative. ... " No physical exam of the abdomen was indicated. Review of the document "ED Note-Physician," dated 12/9/22, at 9:08 p.m. by MD 2, indicated Pt 1 was seen by MD 2 at 7:06 p.m. The note indicated, Pt 1 " ... with hx [history] developmental disorder, presents with cough, nausea, vomiting, and diarrhea x 4 days." MD 2 performed a physical exam including the abdomen. The note indicated, "His initial exam demonstrated abdominal discomfort and some distention without rebound or other peritoneal signs. CT [scan] of the abdomen and pelvis with contrast was ordered. Patient deteriorated during ED course, vital signs were checked and he became poorly responsive with labored breathing, as a result he was emergently intubated without complication. CT of abdomen and pelvis with contrast results were later received which demonstrated sigmoid volvulus with significant fecal retention [constipation]. General surgery was contacted, and ... quickly replied to evaluate patient in case. Patient also became hypotensive [low blood pressure], despite IV [intravenous - through the vein] fluid bolus of 2 L [liters] normal saline. Levophed [medication used to increase blood pressure] was added after which time he appeared to maintain ... stability. ... patient will be admitted to intensive care unit."

During an interview on 2/11/25, at 2:56 p.m., with the Emergency Medical Director (EMD), EMD stated he was aware of Pt 1's hospital visit. EMD stated, there was a delay in the MSE and we should try to see the patient as soon as possible. EMD stated, there has been much improvement since 2022.

During a concurrent interview and record review on 2/12/25, at 3:30 p.m., with PA 1, Pt 1's "Electronic Medical Record [EMR]," dated 12/9/22 was reviewed. PA 1 stated, he barely recalled patient as it had been some time. PA 1 stated, he remembers it was busy because of COVID and not like that now. Review of the document "ED Note-Physician," dated 12/9/22, at 7:06 p.m. PA 1 stated, it does not appear he did an abdominal exam of the patient. PA 1 stated, he probably should have done a physical exam of the abdomen as it was the primary complaint of the patient. PA 1 stated, when talking with caregiver of patient, it can be hard to determine the patient's symptoms as the information can be subjective.

During a concurrent interview and record review on 2/13/25, at 10:00 a.m., with MD 1, Pt 1's "Electronic Medical Record [EMR]," dated 12/9/22 was reviewed. MD 1 stated, he had reviewed the record and his notes. MD 1 stated, MSE (being initiated) over three hours is not normal as the goal is (within) 30 mins. MD 1 stated, he reviewed the labs that had been ordered by the PA 1 and stated they were nonspecific and did not prompt a level of concern. MD 1 stated, he did not see the patient at 7:09 p.m. but at 9:08 p.m. as the time auto populated in his note. MD 1 stated Pt 1 was difficult to understand because he is Assyrian and developmentally delayed, and caregiver made it difficult to determine patient's specific complaints. MD 1 stated, after the exam, he ordered the CT scan at 9:24 p.m. MD 1 stated, he did not see anything that would have notified him earlier of Pt 1's decompensation at 10:40 p.m. MD 1 stated, abdominal pain was waxing and waning and intermittent. MD 1 stated, overall outcome would have probably been the same.

During a concurrent interview and record review on 2/13/25, at 10:36 a.m., with MD 2, Pt 1's "Electronic Medical Record [EMR]," dated 12/9/22 was reviewed. MD 2 stated, he did not see the patient but worked with supervising PA 1. MD 2 stated, if the PAs have questions or have something that is complicated, he will help or take the patient himself. MD 2 stated, the physical exam not being documented in "ED Note-Physician," dated 12/9/22, at 7:06 p.m., was problematic. MD 2 stated, for a MSE, he would have done an abdominal exam.

During a concurrent interview and record review on 2/13/25, at 11:05 a.m., with EDD, "Disposition Log", dated 12/9/22, "Multiple Group Schedule", dated 12/22, and "Emergency Department - Daily Staffing Schedule", dated 12/9/22 were reviewed. EDD stated, he was not working at the hospital in 2022 as he started October 2024. EDD stated, 288 patients were seen on 12/9/2022, 80 percent were seen in the waiting rooms and not in the treatment rooms as that was the process. EDD stated, ambulance volume was low but 27 walk outs had occurred, resulting in almost 10 percent which is much higher than now. EDD stated, admissions were low. EDD stated, nursing staffing could be better for the mid shift when the peaks occur. EDD stated, 2 open shifts or missing mid shift providers were noted on the schedule and supply is not matching demand.

During an interview on 2/13/25, at 11:49 a.m., with the Chief Nursing Officer (CNO), the CNO stated, she expects the MSE to be done quickly and no more than 20 minutes. CNO stated, patients should not have to wait a long time to be seen by the doctor. CNO stated, she expected the PA should have touched Pt 1's abdomen as part of the focused assessment when the patient complains of abdominal pain.

During a review of the hospital's policy and procedure (P&P) titled, "MOD COMP-RCC 5.16 EMTALA POLICY," dated 4/24/24, the P&P indicated, " ... PURPOSE: To ensure individuals presenting to Doctor's Medical Center's emergency department receive an appropriate Medical Screening Examination (MSE) and stabilizing treatment or appropriate transfer in accordance with Emergency Medical Treatment and Labor Act of 1986 (EMTALA) ... Doctor's Medical Center will provide an appropriate MSE within the capability of Doctor's Medical Center to any individual coming to the Dedicated Emergency Department, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists... "

During a review of the hospital's policy and procedure (P&P) titled, "Standard of Care Policy [ED 1.04]," dated 1/23/25, the P&P indicated, " ... Any person presenting to the Emergency Department for care will receive a Medical Screening Examination (MSE). ... 2. Patients shall be triaged and ongoing assessment of physical and psychosocial problems of patients within the emergency care system will be performed as evidenced by written or electronic documentation. ... 3. Assessment data is used to determine and prioritize patient care needs and plan of care. ... 4. Data received from the patient, as well as from the patient's family/significant others are included in the assessment ... 5. Patient evaluation is an interdisciplinary process. Assessment data is documented in a common location and shared among disciplines to enhance the continuity of care and decrease duplication of data collection. ..."

During a review of the hospital's P&P titled, "Medical Screening Examination [ED 1.03]," dated 9/28/22, the P&P indicated, " ...State and Federal regulations require the provision of a medical screening examination to all patients presenting to the Emergency Department for care. The medical screening exam may include the provision of ancillary diagnostic services routinely available in the hospital if necessary to determine whether the individual has an emergency medical condition ...The determination of the patient's presenting condition [i.e., emergent, or non-emergent] will be made for each patient. MSE- Each patient may be triaged to determine priority for medical screening. The MSE will be based on the patient's condition and prior history and may include at least the following: a. Patient's chief complaint, age, sex, duration of onset of chief complaint, date and time, level of distress, and any other pertinent medical history. b. Vital signs, general observation, and focused examination. c. Initiation and documentation of any necessary testing, treatments and/or procedures. The scope of the examination is tailored to the patient's presenting symptoms and the medical history of the patient. The MSE is an ongoing monitoring process, which continues until a medical emergency condition is found not to exist or until appropriate steps to stabilize the presenting emergency medical condition begin..."