Children’s Hospital Colorado

“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: 47959 Based on interviews and document review, 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 (MSE) for patients who presented to the emergency department (ED) to rule out an emergency medical condition (EMC) in two of two patients reviewed who did not receive an MSE. Tag 2407 STABILIZING TREATMENT §489.24(d) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either-- (i) Within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the 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 follow facility clinical pathways and provide stabilizing treatment for a patient who experienced a stroke.”

“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: 47959 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 (MSE) for patients who presented to the emergency department (ED) to rule out an emergency medical condition (EMC) in two of two patients reviewed who did not receive an MSE. Findings include: Facility policy: The Emergency Medical Treatment and Labor Act (EMTALA) policy read, the emergency department provided an MSE to any individual who came to the emergency department and requested such an examination. The facility provided stabilizing care for an emergency medical condition (EMC) within the facility’s capabilities and capacity. The ED maintained a central log of information on each individual who requested an examination or treatment for a medical condition. The log tracked the care provided to the individuals and documented the individual’s disposition. Reference: The Pediatric Arterial Ischemic Stroke (AIS) Clinical Pathway read, the neurology team responded as soon as possible, performed a stroke scale assessment, and ordered the magnetic resonance imaging (MRI) (a medical imaging test) in addition to an electrocardiogram (EKG) (a medical test that records the electrical activity of the heart), chest X-ray and stat (done urgently) blood tests. The optimal time for the MRI was within 90 minutes. 1. The facility failed to ensure an MSE was provided to patients who presented to the ED and requested care. A. Document Review i. A review of the facility’s EMTALA log was conducted and revealed no evidence that a patient presented to the ED with law enforcement requesting medical clearance during the time frames indicated from the interviews with security operations manager (Manager) #5 and registered nurse (RN) #6. This was in contrast with the EMTALA policy which read, the ED maintained a central log of information on each individual who requested an examination or treatment for a medical condition. ii. A medical record review was conducted for Patient #22. The review revealed Patient #22, who was 19 years old, arrived at the ED on 3/18/25 at 11:42 a.m. with complaints of a migraine headache (severe, throbbing pain in the head). The medical record review revealed staff performed a neurological examination (a series of tests and assessments to evaluate the function of the brain and nervous system) which was documented as within normal limits. The medical record review revealed at 12:04 p.m., Patient #22 was confused, dizzy, and had blurred vision. The medical record revealed at 1:31 p.m., Patient #22 experienced a neurological change in condition and staff called a stroke alert (a notification used to quickly identify and treat stroke patients). The medical record review revealed the medical team who responded to the stroke alert determined Patient #22 needed transferred to a facility that specialized in stroke care and staff set up a transport to the nearest hospital. The medical record review revealed Patient #22 did not transfer to the facility that specialized in stroke care until 2:39 p.m., which resulted in a delay of stroke care for more than an hour for Patient #22. Additionally, the medical record review revealed Patient #22 did not receive stroke care as outlined in the facility’s AIS clinical pathway which read, the neurology team should have responded as soon as possible, performed a stroke scale assessment, and ordered the magnetic resonance imaging (MRI) in addition to an electrocardiogram (EKG), chest X-ray and stat (immediate) blood tests. Upon review of the medical record, there was no evidence of blood work, an EKG, chest X-ray, or MRI conducted after the stroke alert was called. Furthermore, the medical record review revealed there was no stroke assessment scale performed on Patient #22, and no further neurological examinations by the medical team, from 1:31 p.m. through the time when Patient #22 was transferred at 2:39 p.m. In addition, there was no evidence of a consultation by the neurology physician. This was in contrast to the facility’s EMTALA policy which read, the ED should have provided an MSE to any individual who came to the emergency department and requested such an examination. B. Interviews i. On 3/31/25 at 11:10 a.m., an interview was conducted with RN #4. RN #4 stated a physician saw all patients who presented to the ED. RN #4 then stated the ED did not provide medical clearance for patients who went to jail or juvenile detention. RN #4 stated when patients arrived at the facility, a physician performed the MSE, but when law enforcement called the ED before they arrived, they advised law enforcement to route the patients to other facilities for medical clearance. ii. On 4/1/25 at 3:28 p.m., an interview was conducted with Manager #5. Manager #5 stated the facility did not perform medical clearance on patients who went to jail or juvenile detention. Manager #5 stated the facility experienced a recent situation in which a law enforcement officer (LEO) brought in a juvenile patient to the ED and asked for medical clearance before they escorted the patient to a juvenile detention center. Manager #5 stated staff communicated to the LEO that they needed to transport the patient elsewhere for medical clearance. iii. On 4/1/25 at 4:17 p.m., an interview was conducted with RN #6. RN #6 stated when patients came through the main ED entrance, they went through registration and a triage process. RN #6 stated when patients came through the ambulance entrance accompanied by LEOs, staff escorted the patients directly to a room for triage, the MSE, and registration. RN #6 stated the facility did not provide medical clearance for patients who went to jail or juvenile detention. RN #6 stated there was an incident in January (2025) in which the LEO brought in a juvenile patient and asked for a medical clearance so the patient could go to juvenile detention. RN #6 stated the LEO did not know the ED did not perform medical clearances on patients, so the primary nurse informed them they needed to transport the patient to another facility. RN #6 stated if the LEO had called ahead, staff could have told them not to come to the facility. RN #6 stated the juvenile was in handcuffs and the LEO was asked if the patient was suicidal or homicidal or had any medical needs. RN #6 stated the LEO said the patient had homicidal ideation, but because the LEO laughed a little when they said it, staff did not take them seriously. RN #6 stated they were unsure what medical clearance meant and stated LEOs were not qualified to determine if a patient had a medical condition that required the MSE. RN #6 stated a medical provider performed the MSE on patients to determine if they were safe for discharge to home, but not a jail or juvenile detention center. RN #6 stated the LEO stated the juvenile patient did not need any treatment and did not appear to look sick or in need of attention so the LEO was directed to take the patient to another facility that provided medical clearance. iv. On 4/2/25 at 9:17 a.m., an interview was conducted with RN #7. RN #7 stated they did not know what a medical clearance examination consisted of. RN #7 stated providers were qualified to perform MSEs but did not know about LEOs. RN #7 stated the LEO called their sergeant and was directed to transport the patient to another facility for the medical clearance examination since the facility did not provide the services. RN #7 stated the LEO stated they only wanted medical clearance and denied the patient had suicidal or homicidal ideation. RN #7 stated the patient did not appear in any distress and was quiet and smiling while the LEO and RN talked. RN #7 stated they only looked at the patient during the conversation with the LEO and did not assess the patient during that time. v. On 4/2/25 at 11:23 p.m., an interview was conducted with ED clinical manager (Manager) #8. Manager #8 stated when LEOs called the facility and asked for a medical clearance exam, staff redirected them to other facilities and informed them the facility did not perform these exams. Manager #8 stated when LEOs did not call and showed up with the patient, the facility proceeded with the MSE. Manager #8 stated they recalled a recent occasion where a LEO brought a patient to the ED for medical clearance. Manager #8 stated the LEO and their commander made the decision to take the patient to another facility. Manager #8 stated the facility considered the situation the same as when a patient left without being seen, although the patient had not been registered or recorded on the central EMTALA log. Manager #8 stated they did not know if LEOs were qualified to determine when a patient had a medical condition, however, RN #7 had done an assessment across the room when they looked at the patient and asked why the patient was in the ED and what they needed. vi. On 4/2/25 at 12:32 p.m., an interview was conducted with pediatric emergency medicine physician (MD) #9. MD #9 stated medical clearance meant the patient was determined as stable to be detained and the facility did not provide this service because providers could not determine what kind of detainment or medical care the patient received once they left the facility ED. MD #9 stated they were unaware of a patient who requested medical clearance in January (2025) but any patient who came to the ED for any kind of treatment should have had an MSE. vii. On 4/2/25 at 3:59 p.m., an interview was conducted with RN #1. RN #1 stated when a patient presented to the ED with stroke symptoms, the physician called a stroke alert, which included a physician from the neurology team who responded to the alert and evaluated the patient. RN #1 stated the protocol to treat a stroke included imaging, such as an MRI. RN #1 stated it was the discretion of the physician to follow the AIS clinical pathway for a stroke patient and if the patient was over the age of 18 years old, they transferred the patient to a stroke facility. RN #1 stated the transport for Patient #22 was delayed, so staff called 911 emergency services to transport Patient #22 to another facility. RN #1 stated staff did not follow the AIS clinical pathway for the patient’s stroke symptoms but was unsure of why the pathway was not followed.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 47959 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 follow facility clinical pathways and provide stabilizing treatment for a patient who experienced a stroke. (Patient #22) Findings include: Facility policy: The Emergency Medical Treatment and Labor Act (EMTALA) policy read, the facility provided stabilizing care for an emergency medical condition (EMC) within the facility’s capabilities and capacity. Reference: The Pediatric Arterial Ischemic Stroke (AIS) Clinical Pathway read, the neurology team responded as soon as possible, performed a stroke scale assessment, and ordered the magnetic resonance imaging (MRI) (a medical imaging test) in addition to an electrocardiogram (EKG) (a medical test that records the electrical activity of the heart), chest X-ray and stat (done urgently) blood tests. The optimal time for the MRI was within 90 minutes. 1. The facility failed to provide stabilizing treatment and follow facility clinical pathways for a patient who experienced a stroke. A. Medical Record Review i. A medical record review was conducted for Patient #22. The review revealed Patient #22, who was 19 years old, arrived at the ED on 3/18/25 at 11:42 a.m. with complaints of a migraine headache (severe, throbbing pain in the head). The medical record review revealed staff performed a neurological examination (a series of tests and assessments to evaluate the function of the brain and nervous system) which was documented as within normal limits.The medical record review revealed the medical screening examination did not include imaging or blood work (blood glucose) to determine the presence of an emergency medical condition and therefore, was incomplete. The medical record review revealed at 12:04 p.m., documentation revealed Patient #22 was confused, dizzy, and had blurred vision. The medical record revealed at 1:31 p.m., Patient #22 experienced a neurological change in condition and staff called a stroke alert (a notification used to quickly identify and treat stroke patients). The medical record review revealed the medical team who responded to the stroke alert determined Patient #22 needed a transfer to a facility that specialized in stroke care and staff set up a transport to the nearest hospital. The medical record review revealed the patient did not receive prompt neurologic imaging and intervention which was important to prevent loss of function, despite the facility’s capacity and capability to treat Patient #22’s condition. Furthermore, the transfer caused a delay in Patient #22’s care and the risks of transfer outweighed the benefits of remaining at the facility. The medical record review revealed Patient #22 did not transfer to the facility that specialized in stroke care until 2:39 p.m., which resulted in a delay of stroke care for more than an hour for Patient #22. Additionally, the medical record review revealed Patient #22 did not receive stroke care as outlined in the facility’s AIS clinical pathway which read, the neurology team responded as soon as possible, performed a stroke scale assessment, and ordered the magnetic resonance imaging (MRI) in addition to an electrocardiogram (EKG), chest X-ray and stat (immediate) blood tests. Upon review of the medical record, there was no evidence of blood work, an EKG, chest X-ray, or MRI conducted after the stroke alert was called. Furthermore, the medical record review revealed there was no stroke assessment scale performed on Patient #22 and no further neurological examinations by the medical team from 1:31 p.m. through the time when Patient #22 was transferred at 2:39 p.m. In addition, there was no evidence of a consultation by the neurology physician. This was in contrast to the facility’s EMTALA policy which read, the facility provided stabilizing care for an emergency medical condition (EMC) within the facility’s capabilities and capacity. B. Interviews i. On 4/2/25 at 3:59 p.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated when a patient presented to the ED with stroke symptoms, the physician called a stroke alert, which included a physician from the neurology team who responded to the alert and evaluated the patient. RN #1 stated the protocol to treat a stroke included imaging, such as an MRI. RN #1 stated it was the discretion of the physician to follow the AIS clinical pathway for a stroke patient and if the patient was over the age of 18 years old, they transferred the patient to a stroke facility. RN #1 stated the transport for Patient #22 was delayed, so staff called 911 emergency services to transport Patient #22 to another facility. RN #1 stated staff did not follow the AIS clinical pathway for the patient’s stroke symptoms but was unsure of why the pathway was not followed. ii. On 4/2/25 at 5:12 p.m., an interview was conducted with RN #2, who stated they were working as the charge nurse during Patient #22’s visit.. RN #2 stated the neurologist stated the patient could not be treated at the facility because the facility was not licensed to treat strokes for patients over 18 years old and needed to transfer the patient to a hospital that treated adult patients. RN #2 stated they normally followed the AIS clinical pathway for any patient who had stroke symptoms while they waited for the transfer to take place. RN #2 did not know the reason why the pathway for Patient #22 was not followed. iii. On 4/3/25 at 8:02 a.m., an interview was conducted with neurology attending physician (MD) #3. MD #3 stated they provided prompt medical intervention such as lab work, EKGs, and MRIs for stroke patients because early interventions prevented further injury to the brain. MD #3 stated the MRI completion goal was 60-90 minutes to confirm a stroke diagnosis and determine if the patient needed medications that dissolved the blood clot that caused the stroke. MD #3 stated the facility had the ability to stabilize stroke patients, but followed the stroke clinical pathway for patients under 18 years old and over 18 years old only if they were a current patient of the facility. MD #3 stated they transferred stroke patients over 18 years old to other facilities that cared for adult stroke patients. The interviews were in contrast to the facility’s EMTALA policy which read, the facility provided stabilizing care for an emergency medical condition (EMC) within the facility’s capabilities and capacity. When asked, the facility was unable to provide a stroke pathway used for patients over the age of 18 years old in the ED.”