Intermountain Health Platte Valley Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48269 Based on document review and interviews, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements. FINDINGS 1. The facility failed to meet the following requirements under the EMTALA regulations: Tag 2406: MEDICAL SCREENING EXAM §489.24(a)(c) - (a) Applicability of Provisions of this Section c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. Based on document review and interviews, the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA). Specifically, the facility failed to provide a medical screening exam for a patient who experienced sepsis (a life-threatening condition when the body’s immune system has an overwhelming response to infection). (Patient #1)”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48269 Based on document review and interviews, the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA). Specifically, the facility failed to provide a medical screening exam for a patient who experienced sepsis (a life-threatening condition when the body’s immune system has an overwhelming response to infection). (Patient #1) Findings include: Facility policies: The Emergency Medical Treatment and Labor Act (EMTALA) policy read, its purpose was to ensure the facility complies with the requirements of the federal EMTALA regulations. Stabilized with respect to an Emergency Medical Condition (EMC) means to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to occur. It is the policy of the facility that if it is determined that the individual has an EMC, the facility will provide the individual with such further medical examination and treatment as required to stabilize the EMC within the capability and capacity of the facility. If an EMC is determined to exist, the facility shall provide any necessary stabilizing treatment or an appropriate transfer. The Emergency Department Triage and Throughput policy read, all patients presenting for care will receive a medical screening exam (MSE) by the Emergency Department (ED) provider in addition to their triage exam. Triage is the initial assessment and sorting of patients, not a location. The registered nurse (RN) will assign an ESI (emergency severity index) level based on ENA (Emergency Nursing Association) ESI criteria and judgment of the triage nurse. The RN will perform an initial evaluation. The RN will document assessments and reassessments periodically during the patient’s stay. Reassessments will occur according to ESI level: ESI-1 at least every 30 minutes; ESI-2 at least every one hour; ESI-3 - ESI-5 at least every two hours. ED triage and practices will be a topic of department performance improvement plans. Indicators include but are not limited to, triage scoring practices and reassessment practices. Reference: According to the National Institutes of Health (NIH), Systemic Inflammatory Response Syndrome (SIRS), 5/29/23, retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK547669/#:~:text=Objectively%2C%20SIRS%20is%20defined%20by,CO2%20less%20than%2032%20mmHg SIRS is defined as any two of the following criteria: body temperature above 100.4 Fahrenheit (F) or below 96.8 F, heart rate greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute, and white blood cell (WBC) count greater than 12000 or less than 4000 /microliters or over 10% immature WBC. 1. The facility failed to provide a medical screening exam for a patient who experienced sepsis. A. Document Review i. Medical record review revealed Patient #1 was brought to the ED by ambulance on 1/7/25 at 4:23 a.m. with a chief complaint of severe low back pain. Patient #1 was discharged at 11:00 a.m. with a diagnosis of back spasms (sudden involuntary muscle contractions). Additional medical record review revealed Patient #1 returned to the ED less than 24 hours later on 1/8/25 at 6:41 a.m. with chief complaints of back and neck pain, dizziness, and shortness of breath (SOB). Patient #1 was diagnosed with sepsis and an epidural abscess (a collection of pus that forms in the space between the spinal cord and the bones of the spine, causing permanent neurological damage, spinal cord injury, and death). Further, the record revealed Patient #1 was transferred to another facility at 10:45 a.m. for spine surgery and hospitalization. Further review of the medical record revealed the following: a. Review of Patient #1’s medical record revealed upon initial arrival to the ED on 1/7/25, Patient #1’s initial vital signs included a blood pressure (BP) 150/96 (normal range is less than 120/80), heart rate 111 (normal range 60 - 100 beats per minute), respiratory rate 22 (normal range 12 - 20 breaths per minute), and temperature 97.8 F (normal range 97 F - 99 F). Patient #1’s pain level was documented as 10/10 and described as a sudden onset of shooting pain. The record revealed no sepsis screen in the documentation. Patient #1 was triaged as an ESI-3 (a triage system tool score indicating an urgent condition requiring prompt but not immediate attention). Additionally, documentation revealed Patient #1’s past medical history was significant for atrial fibrillation (irregular heartbeat), diabetes, and osteomyelitis of the right hand. b. The medical record also revealed Patient #1 had lab work drawn, received intravenous (IV) fluids, pain medications, and a CT scan (detailed x-ray which creates cross-sectional images) of the lumbar spine, abdomen, and pelvis. At 5:16 a.m., Provider #2 documented Patient #1 had been tachycardic (rapid resting heart rate >100 beats per minute), had an elevated WBC count of 20.16 (normal range 3.5 - 11.5), neutrophils (immature WBC) 18.46 (normal range 2.0 - 8.0), and lactic acid level (acid produced by the body when oxygen is limited) of 1.9 (normal range 0.5 - 2). Provider #2 also ordered a procalcitonin laboratory test (a protein produced by the body in response to infection) and a urinalysis. Provider #2 documented a hand-off of Patient #1’s care to the daytime ED provider with the additional lab work pending, as well as the need for reassessment of Patient #1’s condition after pain medications and a trial of walking to determine Patient #1’s final disposition. c. At 6:13 a.m., documentation revealed Patient #1’s procalcitonin level was elevated at 0.48 (reference range <0.05). The record revealed this meant a low risk for progression to severe sepsis/septic shock; however, procalcitonin values measured early in systemic infection may still have been low. The record revealed in the workup of sepsis, values <0.5 ng/ml would not have excluded infection. Additionally, the medical record revealed at 7:00 a.m., Patient #1’s vital signs were documented as follows: BP 113/76, heart rate 104, and no respiratory rate or temperature were recorded. At 7:05 a.m., Patient #1’s heart rate was 109; no BP or respiratory rate were recorded at this time. Patient #1’s pain level at 7:05 a.m. was documented as 5 of 10 and described as shooting. Further, documentation at 7:54 a.m. revealed Patient #1 had not tolerated the trial of ambulation well. Documentation revealed Patient #1 was able to take only a few steps without any assistive devices, which was not their baseline. The record read Patient #1 experienced severe back pain during the trial of walking. d. A review of the daytime ED provider’s documentation at 10:45 a.m. revealed Patient #1 had improved significantly after medications, with the most pronounced improvement after the administration of diazepam (a muscle relaxant). Also, the ED provider’s documentation read Patient #1 had no clinical findings consistent with acute infection, imaging was negative, and Patient #1 had walked with some low back pain but it was much improved. At 10:52 a.m., Patient #1 was administered diazepam 2 milligrams (mg) orally and discharged from the ED at 11:00 a.m. The ED provider’s documentation was in contrast to the previous documentation of tachycardia, increased respiratory rate, elevated WBC, elevated neutrophils, elevated procalcitonin, and lactate near the high end of normal. Also, at 7:54 a.m., Patient #1 had not tolerated walking unassisted, which was not their baseline. Furthermore, Patient #1’s BP had not been reassessed since 7:00 a.m., heart rate had not been reassessed since 7:05 a.m., respiratory rate had not been reassessed since 5:17 a.m., and pain level had not been reassessed since 7:05 a.m. This was in contrast to the Emergency Department Triage and Throughput policy, which read ED patients with an ESI-3 should have been reassessed every two hours and with any change in condition. e. Further review of Patient #1’s medical record revealed Patient #1 returned to the ED on 1/8/25 at 6:41 a.m., less than 24 hours after discharge. Patient #1 returned with complaints of back pain, neck pain, dizziness, and SOB. At 6:50 a.m., Patient #1’s VS were documented as follows: BP 173/106, heart rate 150, and temperature 101.2 F. Lab work was drawn, including blood cultures. An EKG at 7:28 a.m. revealed a rapid, irregular heartbeat. Patient #1 was administered a rapid IV fluid bolus of one liter. Lab work revealed WBC 14.77, Procalcitonin 1.21, and lactate 1.9. Results of an MRI of the lumbar spine at 8:35 a.m. revealed a multilevel lumbar epidural abscess. Further documentation revealed at 9:07 a.m., Patient #1 was started on Cardizem (medication to control rapid heart rate and irregular rhythm) IV. At 10:45 a.m., Patient #1 was transferred by ambulance to another facility for spine surgery and treatment of sepsis. B. Interviews i. On 3/20/25 at 8:26 a.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated ED patients received an initial triage assessment and a focused assessment based on the initial complaint. RN #1 stated reassessment in the ED should have occurred every two to four hours, depending on the acuity of the patient. Also, RN #1 stated the only documentation required before an ED patient was discharged was vital signs to ensure nothing had changed with the patient. RN #1 stated they would have documented a set of vital signs before the patient was discharged to ensure no change in the patient’s condition had occurred. This was in contrast to Patient #1’s medical record, which revealed Patient #1 did not have vital signs and pain level reassessed before discharge from the ED. ii. On 3/20/25 at 10:41 a.m., an interview was conducted with Physician #2. Physician #2 stated they provided care for Patient #1 from their arrival in the ED until hand-off of care to the day physician at 5:30 a.m. Physician #2 stated symptoms of sepsis included high WBC count, tachycardia, low BP, and fever. Physician #2 recalled Patient #1 had been in a lot of pain, and they were uncertain if the tachycardia was due to the pain or something else. Physician #2 stated Patient #1 had denied any trauma or injury that would have caused the back pain. Physician #2 stated Patient #1 had an oddly elevated WBC, so Physician #2 ordered more lab work before they handed off care to the day provider. Physician #2 stated Patient #1 had atraumatic back pain (back pain with no known injury), and they had been concerned they might have missed an infection like osteomyelitis (infection of the bone), so they had considered ordering an MRI but decided to wait until results of the additional lab tests were available. Provider #2 stated Patient #1 had no risk factors that would suggest an epidural abscess, such as IV drug abuse, recent surgery, diabetes, or being immunocompromised. Provider #2 stated it was important to reassess patients before discharge to ensure they felt better and had a safe discharge plan. Provider #2 stated they would not have discharged a patient who could not keep food down, had abnormal vital signs, or could not walk. iii. On 3/20/25 at 2:39 p.m., an interview was conducted with Physician #3. Physician #3 had conducted a review of Patient #1’s record. Physician #3 stated the red flags for sepsis in Patient #1’s case would have been tachycardia, elevated procalcitonin, and high WBC count. Physician #3 stated an epidural abscess was a rare diagnosis, and an MRI would have been needed to diagnose it. Physician #3 stated Patient #1 did not have risk factors for an epidural abscess, such as IV drug use, recent surgery, diabetes, or an indwelling catheter (a tube that allows urine to drain from the bladder). Physician #3 stated medical decision making in this case had come down to an infection or musculoskeletal issues that caused the SIRS criteria to come up. Further, Physician #3 stated conditions that needed an MRI were not usually emergent; however, an epidural abscess was emergent because the abscess could have been rapidly progressive.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45020 Based on observation, interviews and document reviews, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements. FINDINGS 1. The facility failed to meet the following requirements under the EMTALA regulations: Tag 2408: §489.24(d)(4),(5)(4) Delay in Examination or Treatment.(i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status.(ii) A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section.(iii) An emergency physician or non-physician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section.(iv) Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. Based on document reviews and interviews, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure the registration process did not delay examination and treatment in two of two pregnant patients who sought emergency care. (Patient #10, and #11)”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 45020 Based on document reviews and interviews, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure the registration process did not delay examination and treatment in two of two pregnant patients who sought emergency care. (Patient #10, and #11) Findings include: Facility Policy: The Emergency Medical Treatment and Labor Act (EMTALA) policy read, neither the medical screening exam nor any required stabilizing treatment for an emergent medical condition shall be delayed to inquire about the individual’s insurance status. Under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment. Registration could occur so long as it does not delay or otherwise adversely affect the medical screening exam and/or treatment to stabilize an emergent medical condition. 1. The facility failed to ensure the registration process did not delay examination and treatment for pregnant patients who sought emergency care. a. On 12/18/24 at 10:02 a.m., the financial responsibility form, referred to in the EMTALA policy, was requested. The Agreement for Assignment of Insurance Benefits consent was provided. Review of the Agreement for Assignment of Insurance Benefits consent revealed section one allowed the facility to bill and receive payment from patients’ insurance companies. Section two was a statement of financial responsibility in which patients promised to pay for any service not covered by their insurance company. b. Medical record review revealed Patient #10, who was 34 weeks and 2 days pregnant, arrived at the facility on 12/3/24 at 7:45 a.m. with a chief complaint of cramping and vaginal leaking. Patient #10 signed the Agreement for Assignment of Insurance Benefits consent (financial responsibility form) at 7:53 a.m. Nursing documentation revealed Patient #10’s vital signs were obtained at 7:59 a.m., and a triage assessment was completed at 8:00 a.m. Provider documentation at 9:11 a.m. revealed Patient #10 had preterm premature rupture of membranes (PPROM) (the breaking of the amniotic sac surrounding a baby before 37 weeks of pregnancy significantly increasing the risk of preterm birth and potential complications for both mother and baby). c. Medical record review revealed Patient #11, who was 30 weeks and 5 days pregnant, arrived at the facility on 7/31/24 at 8:14 p.m. with a chief complaint of abdominal pain. Patient #11 signed the Agreement for Assignment of Insurance Benefits consent at 8:22 p.m. Nursing documentation revealed Patient #11’s triage assessment was completed at 8:42 p.m, an ultrasound was performed at 9:04 pm. Provider documentation at 9:53 p.m. revealed Patient #11 was stable and discharged. These medical record reviews were in contrast to the EMTALA policy which read, under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment. d. Review of the Admission, Discharge, and Transfer of Emergency Department (ED) Patients policy revealed financial information for ED patients was requested after the medical screening exam had begun. Registration associates could request information from patients to begin the registration process, provided care was not delayed due to inquiry about the patient’s insurance status. e. On 12/17/24 at 9:45 a.m., an interview was conducted with patient access registration (PAR) #1. PAR #1 stated they registered patients in the ED and at the OB unit. PAR #1 stated when patients presented to the OB unit, the staff called Registration to go to the patient. PAR #1 stated they were not to ask patients to sign financial consents before being screened because the patient might want to leave, refuse treatment and could give birth outside of the hospital setting. PAR #1 stated they relied on the nurses to let them know if a patient was in distress and consents were signed at a later time. f. On 12/18/24 at 7:28 a.m., an interview was conducted with PAR #2. PAR #2 stated when a patient presented to the ED, registration had to wait at least 30 minutes until they entered the patient’s room. PAR #2 also stated that the ED patient had to be seen by a medical provider before the registration process, including financial consents were signed. PAR #2 stated when a patient presented to the OB unit the nurse called registration and registration immediately went to the unit. PAR #2 stated this was the process they were trained to follow and was unsure why there was a difference between the ED and OB unit. This was in contrast to the EMTALA policy which read, under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment. g. On 12/18/24 at 8:33 a.m., an interview was conducted with PAR #3. PAR #3 stated registration was notified when a patient presented to the OB unit and an account account was created with the patient’s name and date of birth. PAR #3 stated registration then went to the OB unit, checked with the nurse to make sure the patient was not in active labor and could sign the consents. PAR #3 stated financial consents were included with other consents that were presented to the patients. PAR #3 stated they did not have a clinical background and did not want to delay care for patients who were in labor. PAR #3 stated laboring patients needed to be examined and receive the treatment they required. This was in contrast to the EMTALA policy which read, under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment. h. On 12/18/24 at 9:13 a.m., an interview was conducted with OB registered nurse (RN) #4. RN #4 stated a medical screening was an evaluation which determined if a medical condition needed to be addressed and had been EMTALA training. RN #4 stated nurses and providers determined if pregnant patients had an emergent medical condition. RN #4 stated there were emergent medical conditions that could occur in patients who were greater than 20 weeks pregnant, such as vaginal bleeding, placenta previa (a condition where the placenta implants low in the uterus, partially or completely covering the cervix (the opening of the uterus), decreased fetal movement and decreased fetal heart rate. RN #4 stated pregnant patients needed to be assessed to determine the interventions needed. RN #4 further stated they had seen registration ask patients to sign the consent forms before the patient was put on the fetal heart rate monitor or vital signs obtained. This was in contrast to the EMTALA policy which read, under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment. i. On 12/18/24 at 10:15 a.m., an interview was conducted with OB provider (Provider) #5. Provider #5 stated labor, seizures, severe preeclampsia (blood pressure condition occurring during pregnancy), abruption (when the placenta pulls away from the uterus), fetal demise and fetal low heart rate were examples of emergent medical conditions patients greater than 20 weeks could experience. Provider #5 stated it was important not to delay the medical screening exam for these patients because staff could not determine these emergent medical conditions had occurred and the patients were physically examined. Provider #3 stated patients could be very ill and a monitor was needed to determine the fetal heart rate or if an emergent medical condition needed to be immediately addressed. This was in contrast to the EMTALA policy which read, under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment.”