HospitalInspections.org

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Based on record review and interview the facility failed to abide by the provider's agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.
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Based on a record review of 20 patients and interview, it was discovered that Facility A failed to provide a complete and accurate medical screening examination (MSE) for 1 of the 28 (Patient #1) whose records were reviewed. Patient #1 is a 31-year-old male patient with a history of diabetes mellitus and anxiety. Patient #1 presented on 12/07/2024 at 3:11 PM with complaints verbalized by Patient #1 as dizziness and confusion. Facility A failed to medically assess Patient #1 or provide screening of his blood glucose levels. Facility A failed to follow its policy regarding MSEs.
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Cross refer A2406.
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Based on record reviews and interviews, Facility A failed to maintain a written policy for On-Call Providers that outlined:
1. How emergency services would be available to meet the needs of individuals with emergency medical conditions (EMCs).
2. It is not documented whether the hospital permits on-call providers to have simultaneous duties. If so, a clear delineation of on-call physician responsibilities should be documented.
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Findings:
Document Review:
A review of Facility A's Medical Staff Rules and Regulations, last reviewed and implemented on 02/22/2024 had one mention of "on-call physicians" found on page 21 of 21:
" ...C. Consultations in the Emergency Department:
The ER physician may request consultation with various specialties on the Medical Staff as needed. When a request for consultation to the ER is made, the on-call physician should respond to the emergency department within 60 minutes of the request ..."
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There was no mention of "on-call physicians" found during a review of Facility A's Medical Staff Bylaws, last reviewed and implemented on 02/22/2024.
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Policy Review:
A review of the facility policies revealed that Facility A does not have an On-call Policy and referred this surveyor to its "EMTALA" and "Scope of Service - Emergency and Inpatient Services" policies. They read as follows:
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Facility A's Scope of Service - Emergency and Inpatient Services policy, last reviewed and effective on 10/2023, stated on page 1 of 7:
" ...An on-call list of Internal Medicine Physicians and/or Hospitalists is maintained for inpatient admissions ..."
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Facility A's EMTALA Policy, last reviewed and effective on 09/2023, stated on page 9 of 13:
" ...H. Physicians On-Call
1. The Hospital must maintain a list of physicians who are on-call for duty after the initial medical screening examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. The list must include the names of individual physicians on call; the name of a physician group or practice is not sufficient.
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2. The Hospital has the discretion to maintain the on-call list in accordance with the resources available to the Hospital, including the availability of on-call physicians. In determining on-call responsibilities, the Hospital will consider all relevant factors, including the number of physicians on staff in a particular specialty, other demands on these physicians, and the frequency with which individuals typically require services of on-call physicians.
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3. A determination as to whether an on-call physician must physically assess the individual in the emergency department is the decision of the treating Emergency Department physician.
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4. If a physician on the on-call list is called by the Emergency Department physician to provide emergency screening or treatment, the physician must respond within a reasonable time in accordance with the time established in the Hospital Medical Staff by-laws. If the physician refuses or fails to arrive within the required response time the chain of command should be initiated in an effort to obtain treatment for the emergency patient. If the individual is required to be transferred as a result of the on-call physician's failure to appear, the Hospital is required by EMTALA to document in the medical record the name and address of the physician who failed to appear. See Reporting Obligations section. Transfers that result from an on-call physician refusal shall be referred to peer review for evaluation in accordance with the Hospital Medical Staff by-laws ..."
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Interviews:
On 02/03/2025 at 3:59 PM, Facility A's Market Chief Executive Officer (CEO), Staff #4, was asked about On-call Policies. Staff #4 stated that there were no policies for on-call physicians at this facility. Staff #4 stated that the facility had specialists on duty 24/7 that could be conferred with if needed, but only have Internal Medicine or Hospitalists on-call for emergent coverage as needed. This was confirmed by Facility A's Hospital Compliance Officer, Staff #3.
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On 02/04/2025 at 7:43 AM, Staff #4 was asked again to clarify if the facility had an On-Call Policy. This Surveyor was directed to a paragraph in the EMTALA Policy regarding on-call and a sentence in the Scope of Service - Emergency and Inpatient Services Policy. Staff #4 stated that there was no separate On-Call policy. This was again confirmed by Staff #3.
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Based on record review and interview, Facility failed to maintain a complete and accurate central log and follow its policy when their December 2024 ED Log/Transfer Log was reviewed and it was discovered that of the 715 patients, there were 9 patients (Patient #1 and Patients #21 through #28) did not have a documented time of arrival and 2 of the 9 patients (#28 and #29) had no date documented.
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Findings:
Document Review:
The December 2024 ED Log/Transfer Log was reviewed in detail. There were 715 Patients listed on the December 2024 log. Of the 715 patients, there were 9 patients (Patient #21 through #29) noted to have "LWBS (left without being seen) Before Triage". Of the 9 patients who "LWBS Before Triage", there were 5 (Patient #1, #22, #23, #24, #25, and #28) who did not have a documented time of arrival. Of the 9 patients who "LWBS Before Triage", there were 2 patients (#28 and #29) who had no date documented. These findings are also contrary to Facility A's EMTALA Policy. For 2 of the 9 patients (Patient #26 and #27) who "LWBS Before Triage", there was no documentation in a medical record, but a "ED Central Log" portion was attached by Facility A to the medical record.
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Policy Review:
Facility A's EMTALA Policy, last reviewed and effective on 09/2023, stated on page 2 - 3 of 13:
" ...D. "Central Log" is a documented list of each individual who comes to the emergency department seeking assistance, whether or not that person refused treatment, was refused treatment, or was transferred, admitted and treated, stabilized and transferred or discharged.
E. "Dedicated Emergency Department"(DED) is defined as any department or facility of the Hospital, regardless of whether it is located on or off the main Hospital campus, that meets at least one of the following requirements:
1. It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department;
2. It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously schedule appointment; or
3. During the calendar year immediately preceding the calendar year in which a determination under this Section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment ..."
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and on page 6 - 7 of 13:
" ...B. Central Log
1. The Hospital must maintain a central log of individuals who come to the emergency department seeking examination and/or treatment for an emergency medical condition (including psychiatric conditions). All individuals who present for examination or treatment in the emergency department must be entered into the Central Log, even if they leave prior to triage or MSE.
2. The log shall include the individual's name, date, time, chief complaint/diagnosis, and their disposition, which should indicate if the patient was:
a. Admitted
b. Discharged
c. Transferred
d. Refused MSE or stabilizing treatment
e. Was refused treatment
f. Left without being seen (LWBS/LWOBS)
g. Eloped or Left Against Medical Advice (NOTE: Documentation should indicate if the emergency medical condition was stabilized or was unstabilized upon admission, discharge, or transfer.)
3. If a presenting individual left prior to completing the initial registration, an ED staff member should document, if the individual's first and last name and DOB is not known, a description of the individual into the designated event/incident reporting system.
4. The Hospital may keep its central log in an electronic format but has the discretion to maintain the central log in a form that best meets the needs of the Hospital.
5. The central logs must be available in a timely manner for surveyor review and must be kept as required in the Records Retention Schedule, but not less than five (5) years from the date of disposition of the individual who sought examination or treatment for a medical condition from the DED.
6. The central log should also include any additional information as required by state law ..."
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Interview:
On 02/06/2025 at 10:04 AM, Facility A's Market Chief Executive Officer (CEO), Staff #4, was asked if the December 2024 ED/Transfer Log was complete as provided to the Surveyors. Staff #4 confirmed that it was.
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Based on a record review of 20 patients and interview, it was discovered that Facility A failed to provide a complete and accurate medical screening examination (MSE) for 1 of the 28 (Patient #1) whose records were reviewed. Patient #1 is a 31-year-old male patient with a history of diabetes mellitus and anxiety. Patient #1 presented on 12/07/2024 at 3:11 PM with complaints verbalized by Patient #1 as dizziness and confusion. Facility A failed to medically assess Patient #1 or provide screening of his blood glucose levels. Facility A failed to follow its policy regarding MSEs.
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Findings:
Medical Record Review for Patient #1 at Facility A:
Patient #1 is a 31-year-old patient with a history of diabetes mellitus and anxiety. A patient record was provided for Patient #1 with the date (12/17/2024), time (9:11 AM), and attending Emergency Department (ED) physician (Staff #5) name documented. There were no assessments or treatments documented. The ED Registered Nurses (RNs) on duty at the time Patient #1 presented were (Staff #6) and (Staff #4). Patient #1 is documented on the ED Log with a disposition of "LWBS (left without being seen) Before Triage".
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Medical Record Review for Patient #1 at Facility B:
A patient record was provided for Patient #1. The record stated that Patient #1 arrived on 12/17/2024 at 9:36 AM by car. The triage notes at 9:42 AM reflected that "Pt (Patient #1) reports history of sleep apnea and did not wear machine last night and reports he woke up having dizziness and disoriented. Pt (Patient #1) reports was seen at (Facility A) and was "kicked out" because of his dog. Pt (Patient #1) reports dizziness and anxiety."
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Medical provider notes at 9:57 AM stated "(Patient #1) is a 31 y.o. male with anxiety who presents to the ED c/a dizziness and panic attack. Patient (#1) states he has a history of sleep apnea and did not wear machine last night and reports being dizzy and disoriented. Patient (#1) reports he was seen at (Facility A) but was kicked out because of his dog. Patient (#1) states that he takes Propranolol. Patient voices no other complaints at this time." The notes reflected a review of systems and physical exam that reflected that Patient #1 had normal attention and perception and a mood and affect that were normal. The Differential Diagnosis included acute anxiety, panic attack, and dehydration.
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The review of Patient #1's medical history documented anxiety, depression, and diabetes mellitus.
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At 10:42 AM documentation of a recheck on Patient #1 by the medical provider stated "Upon patient reassessment, patient is feeling better and resting comfortably in no distress. Discussed findings and reviewed discharge instructions with patient. Discussed follow-up and return precautions. Patient understands and is agreeable to the plan." The final diagnosis was acute anxiety.
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At 10:06 AM, Patient #1 received Ativan 2mg orally. Patient #1 was discharged from the ED at 11:22 AM.
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Policy Reviews:
Facility A's STAT Light Policy, last reviewed and implemented on 07/2024, stated on page 2 of 3:
" ...B. Examples of presenting patient complaints/conditions and/or obvious signs that shall dictate when the STAT Light is to be used (not an all-inclusive list):
1. Stroke
a. Weakness
b. Numbness
c. Tingling to one side of the body
d. Dizziness
e. Difficulty speaking/ slurred speech
f. Sudden/ severe headache
g. Sudden changes in vision ..."
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and on page 2 of 3:
" ...6. Other
a. Confusion or changes in mental function ..."
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and on page 3 of 3:
" ...C. Upon activation of the STAT Light by staff in the front-office, the device will emit an audible and visual indicator in the Emergency Department clinical area. It will remain active until clinical personnel have arrived to the patient in distress, for an immediate assessment(s) and interventions.
D. The STAT light shall not be discontinued until appropriate clinical staff have responded to the patient in need ..."
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Facility A's Medical Staff Rules and Regulations, last reviewed and implemented on 02/22/2024, stated on page 14 of 21:
" ...A medical screening examination sufficient to detect the presence of an emergency medical condition or active labor will be performed by qualified medical personnel, which will be a Doctor of Medicine or osteopathy, nurse practitioner, or physician assistant. The attending physician is ultimately responsible for screening examinations. If, after the screening examination, in the best medical judgment of the provider, the patient is not in active labor and no emergency medical condition is present, the patient will be treated, referred or transferred according to internal Emergency Department or Ambulatory Services procedures and appropriate standards of medical practice. Where the patient is transferred to another facility, appropriate documentation will be sent with the patient ..."
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Facility A's EMTALA Policy, last reviewed and effective on 09/2023, stated on page 1 of 13:
" ...The purpose of this policy is to set forth policies and procedures for the Hospital's use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA), as noted in Sections 1866 and 1867 of the Social Security Act, 42 U.S.C. Section 1395dd, which obligates hospitals to provide medical screening, stabilizing treatment and transfer of individuals with emergency medical conditions or women in labor regardless of ability to pay ..."
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and on page 2-3 of 13:
" ...DEFINITIONS ...
C. "Comes to the Emergency Department." For purposes of this policy, an individual is deemed to have "come to the emergency department" if the individual:
1. Presents to the "Dedicated Emergency Department", or on the "Hospital Property", and:
a. requests examination or treatment for a medical condition; or
b. has such a request made on their behalf of the individual; or
c. In the absence of such a request by or on behalf of the individual, the appearance or behavior of the individual would cause a prudent layperson observer to believe that the individual needed examination or treatment for medical condition; ..."
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and on page 3 of 13:
" ...1."Medical Screening Examination" or "MSE" means the screening process required to determine with reasonable clinical confidence whether an "emergency medical condition" does or does not exist ..."
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Interviews:
On 02/04/2025 at 9:53 AM, the assigned Emergency Department Registered Nurse (ED RN) (Staff #6) during Patient #1's visit on 12/17/2024 confirmed that Facility A's process should have included a medical screening on all patients who presented to the Emergency Department (ED). Staff #6 confirmed that Facility A's process was not followed for Patient #1.
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On 02/04/2025 at 9:43 AM, another ED RN (Staff #10) on duty during Patient #1's visit on 12/17/2024 confirmed that Facility A's process should have included a medical screening on all patients who presented to the Emergency Department (ED). Staff #10 confirmed that Facility A's process was not followed for Patient #1.
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On 02/04/2025 at 10:45 AM, Facility A's Medical Director (Staff #8) confirmed that Facility A's process should have included a medical screening on all patients who presented to the Emergency Department (ED). Staff #10 confirmed that Facility A's process was not followed for Patient #1.
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