Delta County Memorial 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: 50313 Based on 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: A-2406: Medical Screening Exam. (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. Based on interviews and document review, the facility failed to comply with EMTALA. Specifically, the facility failed to provide a medical screening examination (MSE) for a patient who presented to the emergency department (ED) to rule out an emergency medical condition (EMC) according to facility policy. This failure was identified in one of two patients who presented to the facility with a headache. (Patient #17)”

“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: 50313 Based on interviews and document review, the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA). Specifically, the facility failed to provide a medical screening examination (MSE) for a patient who presented to the emergency department (ED) to rule out an emergency medical condition (EMC) according to facility policy. This failure was identified in one of two patients who presented to the facility with a headache. (Patient #17) Findings include: Facility policy: The EMTALA policy read, an MSE shall be performed when an individual comes to the ED and the individual or a representative acting on the individual’s behalf requests an examination or treatment for a medical condition. The MSE must be completed by an individual qualified to perform such an examination to determine whether an EMC exists. Depending on the individual’s presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures. 1. The facility failed to provide an MSE for a patient who presented to the ED with a headache to rule out an EMC. A. Document Review i. Medical record review revealed Patient #17 presented to the ED on 7/11/25 at 11:01 a.m. with complaints of a urinary tract infection, headache, and left upper arm wound. The provider’s note revealed Patient #17 reported having a severe headache, which had returned at approximately midnight. The provider noted the headache was recurrent, and Patient #17 had received medication for the headache during their previous visit. The provider documented Patient #17 had a skin tear on the side of their left elbow from falling the day before after they were discharged from the ED. The provider cleaned and reapproximated (closed) the wound and applied a wound dressing. The provider documented they believed Patient #17’s headache could have been related to their urinary tract infection, and anticipated the symptoms would resolve with successful antibiotic treatment.The provider ordered one dose of intramuscular (IM) ketorolac, which was administered at 12:03 p.m. Patient #17 reported they were unable to take the cephalexin, which had been prescribed the previous day. Patient #17 was discharged home at 12:04 p.m., with a prescription for a new antibiotic, Macrobid, to be taken twice daily for 10 days. There was no evidence the provider assessed whether Patient #17’s pain was typical or atypical for their migraine headaches or if Patient #17 had injured their head in the fall the day before. There was also no evidence the provider performed a neurological exam or ordered imaging to rule out an EMC. ii. Medical record review revealed EMS brought Patient #17 back to the ED five days later on 7/16/25 at 3:02 p.m., with complaints of weakness and not feeling well. Patient #17’s vital signs on arrival included a heart rate of 108 beats per minute (bpm) (normal is 60-100 bpm), and an oxygen saturation of 91% (normal is 95% to 100%) on 6 liters of oxygen via nasal cannula. The nursing assessment revealed Patient #17 had mild weakness in both upper and lower extremities (limbs of the body). Patient #17 had poor fine motor dexterity (muscle coordination used to perform precise, delicate movements) in both upper extremities. As a result, Patient #17 was unable to open a water bottle, hold or take their medications, or tie their own shoes. The provider’s note revealed Patient #17 complained of two days of general malaise (a general feeling of discomfort, illness, or lack of well-being), a headache described as pain at the base of the skull, nausea, and gastrointestinal (GI) upset, including diarrhea. Patient #17 reported they were having difficulty with fine motor tasks, and were unable to open pill bottles or hold a pencil. Additionally, the provider noted Patient #17 was mildly tachycardic (having a heart rate over 100 bpm), had difficulty with activities of daily living (ADLs) such as showering, dressing, undressing, and was unable to cook for themselves. The provider’s physical examination revealed Patient #17 had difficulty with fine motor skills, no focal deficits (specific, localized impairments in neurological function due to damage or dysfunction in a particular area of the brain), and had normal grip strength and sensation. The provider documented Patient #17 appeared to be experiencing a physical decline as opposed to a cognitive decline (loss of mental skills). The provider noted Patient #17 had labs drawn within the past 48 hours, which were normal. Ancillary studies were not performed during Patient #17’s visit to rule out an EMC and no additional vital signs were assessed after the triage vital signs at 3:07 p.m. Patient #17 was discharged at 6:03 p.m. These medical record reviews were in contrast with the EMTALA policy which read, an MSE should have been performed when an individual came to the ED and requested an examination or treatment for a medical condition. Depending on the individual’s presenting symptoms, an appropriate MSE could have involved a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involved performing ancillary studies and procedures such as clinical laboratory tests, CT scans and other diagnostic tests and procedures. B. Interviews i. An interview was conducted on 12/10/25 at 10:44 a.m. with emergency department provider (Provider) #2. Provider #2 stated patients with a history of migraine headaches who presented to the emergency department should have been evaluated to determine if their symptoms were similar to previous migraine headaches. This was in contrast with Patient #17’s medical records on 7/11/25 and 7/16/25, which revealed no evidence the provider had assessed or considered whether Patient #17’s pain was typical or atypical for their migraine headaches. Provider #2 stated if the pain were severe or different than the patient’s typical migraine pain, or if the patient had any neurological deficits or recent falls, a CT scan should have been ordered to determine if the patient had a stroke or a brain mass. Provider #2 stated if a patient over 75 years old presented to the ED with general malaise, recurrent UTI, nausea, gastrointestinal upset, loss of fine motor skills, and a headache, they would have ordered labs, an EKG, and would have likely ordered a CT scan if the patient had a headache with new neurological symptoms. Provider #2 also stated even if a patient had labs drawn within the last 48 hours, they would have ordered labs again because the patient had presented with new symptoms. Provider #2 stated monitoring a patient’s vital signs was also a part of a medical screening examination. Provider #2 stated it was important to assess and trend vital signs to determine if patients were unstable or stable medically. This was in contrast with Patient #17’s 7/16/25 medical record which revealed Patient #17 had presented with general malaise, recurrent UTI, nausea, gastrointestinal upset, loss of fine motor skills, and a headache and the provider did not order labs, an EKG, or imaging. Additionally, vital signs were not reassessed after triage. Additionally, Provider #2 stated the symptoms of a subdural hematoma included headache, vision changes, and vomiting. Provider #2 stated elderly patients were at a higher risk for subdural hematomas. Provider #2 stated if a patient presented to the ED for a headache, then presented the following day with a headache and history of falling, and presented five days later with new symptoms of loss of fine motor skills, continuing headache, nausea, and generally feeling unwell, then the patient should have received a CT scan. Provider #2 stated the risk of not identifying a subdural hematoma included brain herniation (shifting of the brain tissue from one space in the skull to another through folds and openings) and death. Provider #2 stated it was important to conduct a thorough medical screening examination to help identify emergency medical conditions. ii. An interview was conducted on 12/10/25 at 12:58 p.m. with Provider #1. Provider #1 stated if a patient presented to the ED with a severe headache, and a history of chronic migraines, it was important to do a thorough history and physical exam, including a neurological examination. Provider #1 stated it was important to evaluate if the patient’s pain was similar to or different from previous migraines.This was in contrast with Patient #17’s medical records which revealed no evidence providers evaluated whether Patient #17’s headache was similar to or different from previous migraines. Provider #1 stated if a patient presented to the ED multiple times over the course of 10 days, the provider should have reviewed their previous records to determine if the patient’s presenting symptoms had changed and if there were any new neurological findings. If a patient had a history of falling, and reported a loss of fine motor skills, Provider #1 stated the provider should have considered whether the patient needed any imaging. Provider #1 stated if a patient presented to the ED with general malaise, a headache, recurrent UTI, nausea, GI upset, and a loss of fine motor skills, they would have ordered labs and an EKG. If the patient had any changes to their gait or neurological exam, they would have considered ordering imaging. Provider #1 stated there were risks and benefits to ordering imaging for patients. Provider #1 stated with elderly patients, they were less concerned with radiation risks than with a younger patient. Provider #1 also stated if a patient had labs within the last 48 hours, they would have ordered labs and compared the current results to the previous results.”