Adventhealth Ottawa

“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: 47234 Based on document review, record review, policy review and interview the Hospital failed to ensure the emergency medical treatment and labor act (EMTALA) requirements were met by failing to perform an appropriate medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed and failing to provide stabilizing treatment for patients who presented to the emergency department (ED) seeking medical care. Failure to provide an appropriate MSE and stabilizing treatment places patients at risk for unidentified emergency medical conditions resulting harm and injury up to an including death. Findings Include: The hospital failed to perform an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 1 of 20 patients (Patient 1) who presented to the emergency department (ED) seeking medical care. (Refer to tag A2406) The hospital failed to provide stabilizing treatment for 1 of 20 patients (Patient 1) who presented to the emergency department seeking medical care. (Refer to tag A2407)”

“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: 47234 Based on record review, policy review, document review and interview the Hospital failed to perform an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 1 of 21 patients (Patient 1) who presented to the emergency department (ED) seeking medical care. The hospital’s failure to perform an appropriate MSE has the potential for patients to be discharged with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the person’s condition, including harm and death. Findings Include: Review of a hospital policy titled “CR-115 EMTALA Emergency Medical Treatment and Active Labor Act” policy reviewed date 09/26/24, showed, “ ...Compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) and provide guidelines by which the AdventHealth (AH) Ottawa will provide a Medical Screening Examination (MSE) performed by Qualified Medical Personnel (QMP) to any individual who presents to the Emergency Department, regardless of his or her race, disability, creed, sex, age, color, national origin, insurance coverage or ability to pay for services ... ...If Qualified Medical Personnel determine that the patient is experiencing an Emergency Medical Condition, the Hospital will provide (i) further medical examination or treatment available within the capabilities of the Hospital required to stabilize the Emergency Medical Condition; and/or (ii) an Appropriate Transfer of the individual to another medical facility... ...Medical Screening Examination” means the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. A MSE is not an isolated event. It is an ongoing process that may begin, but typically does not end, with triage...” Review of a hospital policy titled, “TR-109 Guidelines for Management of the Head Injured Adult Patient” review 02/13/24 showed “ ...PURPOSE: To provide guidelines for the management of the adult patient (18 yrs or older) experiencing traumatic head injury ...PROCEDURE/GUIDELINES: Initial Assessment & Management of the Head Injured Patient A. Perform primary assessment including vital signs, oxygen saturation and an initial Glasgow Coma Score (GCS) which can assist in determining the severity of the brain injury: 1. Mild (GCS score 13-15) ... J. Obtain labs as warranted, including a blood glucose level. Perform necessary diagnostic test including CT or other imaging as warranted ...Monitor for signs of increased ICP [intracranial pressure-pressure in the skull indicating brain injury] ...Prompt transfer to a facility that can provide traumatic brain injury care ...Common Injury in the Severe Head Injured Patient ...Increased ICP includes ...Nausea and vomiting ...” Review of a hospital policy titled “TR-100 Trauma Activation Plan” policy review date 09/06/24 showed, “ ...POLICY: A multidisciplinary Trauma Response Team will be used in an effort to provide coordinated, complex care to patients with multiple-system or major injury. Trauma Team activation criteria: ... The below criteria require Level 2 Code Trauma Activation with the ED physician as the Team Leader ...Fall from any height if anticoagulated older adult, and injury suspected above the clavicles ...High energy mechanism with one of the following: ... Anticoagulation or bleeding disorder ...Elderly considerations for traumatic injuries; Emergency physician discretion (consider extremes of age, i.e., the risk of injury death increases after age 55 years) ... Trauma Lab Panel ...a. CBC [Complete Blood Count] (group of blood test that measure the number and size of the different cells in your blood) b. Basic metabolic panel (BMP)(measures eight different substances in your blood) c. Lactic acid (chemical your body produces when your cells break down carbohydrates) d. Protime/INR [Prothrombin Time] (test to find out if your blood is clotting normally) e. PTT [Partial Thromboplastin Time](blood test looks how long it takes blood to clot) ...” Review of a hospital policy titled, “NSG-SOP-100 ED Emergency Department Patient, Care of the” review date 09/06/24, showed, “ ...The standard of care (SOC) is initiated for all patients across the lifespan, newborn to geriatric, presenting for care in the Emergency Department (ED), and will establish minimal expectations for nursing assessment, intervention and documentation ...Code Trauma shall be activated per Administrative Policy: 01.16.01 Trauma Activation Plan ...Glascow Coma Scale (GCS) shall be obtained on all patients with trauma related complaints and with any reports of head injury, as well as reassessed hourly or more often as patient condition warrants ...Reassess patient vital signs 1. Adults based on ESI Level a. Level 1-3, every 30 minutes ...The RN shall reassess the following, as appropriate to patient condition ...4. Neurological checks default to: every hour if stable, or more frequently per physician order or patient condition 5. Patients shall be reassessed for response to medications based on medication and route ...DEFINITION (S): ... Geriatrics age is 65 years of age and older ...” Patient 1 Review of Patient 1’s medical record showed a 73-year-old presented to emergency room on 07/18/24 at 7:47 AM with chief complaint of back, facial pain and bleeding lip after falling in the bathroom. Given a triage acuity level 3 (meaning a patient has an urgent condition and needs quick attention but can wait up to 30 minutes for treatment). Review of “Prehospital Care Report” dated 07/18/24 at scene 7:13 AM showed “ ...Patient report: I was leaning down to use the bathroom and I lost my balance and fell. I hit my face on the sink. I didn’t lose consciousness. I do take blood thinners though ...” Review of “ED Provider Notes” dated 07/18/24 at 8:04 AM showed, “[Patient 1] is a 73 y.o. female who presents to the ED with a chief complaint of fall. Patient (sic) she was getting up out of a chair unfortunately fell forward striking the sink with her face and falling to the ground. She does complain of some mild neck and lower back pain however states she is chronic back pain that appears just maybe a little bit worse she did suffer a superficial abrasion to her upper lip has some swelling to the upper lips as her teeth feel normal to her. She did not lose consciousness. Presents here by ambulance in C-collar. Patient is on Eliquis [medication used to thin the blood]...” Review of “Physical Exam” dated 07/18/24 at 8:04 AM, showed, “...Skin: warm, dry. Social abrasion (superficial injury) to patient’s upper lip with swelling upper lip and chin without bony tenderness dentition (condition of teeth) is intact ... Gastrointestinal (digestive system): soft, non-distended, no tenderness, no guarding ...” Review of “ED Care Timeline” 07/18/24, showed the following: 8:37 AM “ ...Medication Given ondansetron (Zofran) (prevents nausea and vomiting) injection 4 mg - Dose: 4 mg; Route: Intravenous (into a vein also called IV) ...” 9:29 AM “ ...Medication Given ondansetron (Zofran) injection 4 mg - Dose: 4 mg; Route: Intravenous ...” 9:29 AM “ ...Emesis (vomit) Output/Assessment Unmeasured Emesis Occurrence: 1 Emesis Amount: Medium ...” 9:34 AM “ ...ED Quick Updates; Free Text: Changed clothes and up to WC [wheelchair]. Waiting on ride home from daughter ...” 9:34 AM “ ...Discharge Education Patient Teaching: Discharge instructions reviewed Learner: Patient; Family ...” 10:43 AM “ ...Medication Given ondansetron (Zofran) injection 4 mg - Dose: 4 mg; Route: Intravenous ...” 11:12 AM “ ...Patient Discharged ...” Review of “After Visit Summary” dated 07/18/24, showed “ ... follow up with family physician within 7-10 days. ice (sic) and rest. Return to ER for segment (sic) worsening of pain persistent headache or vomiting new symptoms or concerns ...ondansetron ODT (Zofran-ODT) 4 MG disintegrating tablet; Instructions: Take 1 tablet (4 mg total) by mouth every 6 (six) hours if needed for nausea or vomiting ...” During an interview on 10/01/24 at 2:45 PM, Patient 1’s family member (F1) stated “ ...When I arrived to the ER, they were giving her discharge instructions. She was actively vomiting; at that time they told me it was due to pain medication. I was worried since she was on blood thinners even though she had a negative CT scan (Computer Tomography) that she could be having a slow bleed. After I took her home, she still continued to vomit, and she was unable to keep any liquids down including water or medications. So, we left to go to another ER around 4:30 PM or 5:00 PM where she was admitted for three to four days and then sent to rehab for approximately 1 1/2 weeks ....” During an interview on 10/01/24 at 4:29 PM, Staff D, Doctor of Medicine (MD), stated that elderly who fall with head injuries on blood thinners would be made a a level 2 for care in the ER, we would get a CT scan, labs, and EKG (electrocardiogram). If the patient was vomiting with a negative head CT scan, I would transfer them to a Trauma Center ... During an interview on 10/02/24 at 8:28 AM, Staff C, Registered Nurse (RN) stated, “ ...A person over the age of 60 or 65 on blood thinners that is a fall from a standing position would be a level 2 trauma. If the patient was vomiting and had a negative CT scan, I would monitor them for a concussion. [Patient 1]’s main thing that she was having was nausea and vomiting and her daughter was concerned when she took her home ...” During an interview on 10/02/24 at 8:58 AM, Staff A, RN, ER Director stated, “ ...Activate a level 2 trauma on any one over the age of 65 on blood thinners that was a fall with a head injury. They would get a CT scan and labs. Nausea and vomiting are sign of a head injury and we would not discharge a person home with nausea and vomiting with a head injury ...” Review of Patient 1’s medical record showed the hospital failed to activated Patient 1 as a level 2 trauma, failed to obtain labs per policy and failed to provide further medical examination within the capabilities of the hospital to determine if an EMC existed. Review of Patient 1’s Hospital B medical record dated 07/18/24 at 5:35 PM, showed that Patient 1 was admitted from Emergency Department for “ ...intractable vomiting (vomiting that is difficult to control) with head injury ...” and discharged on 07/20/24 to rehabilitation hospital for Occupational and Physical therapy for falls.”

“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: 47234 Based on record review, policy review and interview the Hospital failed to provide stabilizing treatment for 1 of 20 patients (Patient 1) who presented to the emergency department seeking medical care. Failure to provide stabilizing treatment has the potential to place patients at risk for deterioration of the emergency medical condition (EMC) causing harm or injury up to and including death. Findings Include: Review of a hospital policy titled “CR-115 EMTALA Emergency Medical Treatment and Active Labor Act” policy reviewed date 09/26/24, showed, “ ...Compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) and provide guidelines by which the AdventHealth (AH) Ottawa will provide a Medical Screening Examination (MSE) performed by Qualified Medical Personnel (QMP) to any individual who presents to the Emergency Department ... If the MSE reveals that the individual has an Emergency Medical Condition (EMC), AH Ottawa will provide treatment to stabilize the emergency condition or transfer to another facility pursuant to this policy ...Necessary Stabilizing Treatment or Transfer. If Qualified Medical Personnel determine that the patient is experiencing an Emergency Medical Condition, the Hospital will provide (i) further medical examination or treatment available within the capabilities of the Hospital required to stabilize the Emergency Medical Condition; and/or (ii) an Appropriate Transfer of the individual to another medical facility. The Hospital may request on-call physicians to assist in providing necessary stabilizing treatment and such on-call physicians shall respond to such request within a reasonable time. ... Guidance on Stabilization: (1) A patient will be deemed Stabilized if the treating physician attending to the patient in the emergency department/hospital has determined, within reasonable clinical confidence, that the Emergency Medical Condition has been resolved. The physician may discharge the patient home, admit him/her to the hospital or transfer the patient to another hospital depending on his/her needs or request (the “Appropriate Transfer” requirement under EMTALA does not apply to this situation since the patient has been stabilized). (3) Under EMTALA, the Hospital is responsible for treating and stabilizing, within its capacity and capability, any individual who presents himself or herself to the Hospital with an Emergency Medical Condition. The Hospital must provide such care until the condition ceases to be an emergency, or until the patient is properly transferred to another facility ...” Review of the hospital’s Medical Staff Bylaws Rules and Regulations, approved August 2024, showed, “ ...The Emergency Department record shall include: ...c. Clinical observations, including results of treatment d. Diagnostic impressions e. Condition of the patient on discharge or transfer ... Patient 1 Review of Patient 1’s medical record showed a 73-year-old presented to emergency room on 07/18/24 at 7:47 AM with a chief complaint of back, facial pain and bleeding lip after falling in the restroom. Given a triage acuity level 3 (a patient has an urgent condition and needs quick attention but can wait up to 30 minutes for treatment). Review of Patient 1’s “Prehospital Care Report” dated 07/18/24 at scene 7:13 AM showed “ ...Patient report: I was leaning down to use the bathroom and I lost my balance and fell. I hit my face on the sink. I didn’t lose consciousness. I do take blood thinners though ...” Review of Patient 1’s “ED Provider Notes” dated 07/18/24 at 8:04 AM showed “[Patient 1] is a 73 y.o. female who presents to the ED with a chief complaint of fall. Patient (sic) she was getting up out of a chair unfortunately fell forward striking the sink with her face and falling to the ground. She does complain of some mild neck and lower back pain however states she is chronic back pain that appears just maybe a little bit worse she did suffer a superficial abrasion to her upper lip has some swelling to the upper lips as her teeth feel normal to her. She did not lose consciousness. Presents here by ambulance in C-collar. Patient is on Eliquis ...” Review of Patient 1’s “Physical Exam” dated 07/18/24 at 8:04 AM, showed, “...Skin: warm, dry. Social abrasion (superficial injury) to patient’s upper lip with swelling upper lip and chin without bony tenderness dentition is intact ... Gastrointestinal (digestive system): soft, non-distended, no tenderness, no guarding ...” Review of “ED Care Timeline” dated 07/18/24, showed the following: 8:37 AM “ ...Medication Given ondansetron (Zofran) (prevents nausea and vomiting) injection 4 mg - Dose: 4 mg; Route: Intravenous (into a vein also called IV) ...” 9:29 AM “ ...Medication Given ondansetron (Zofran) injection 4 mg - Dose: 4 mg; Route: Intravenous ...” 9:29 AM “ ...Emesis (vomit) Output/Assessment Unmeasured Emesis Occurrence: 1 Emesis Amount: Medium ...” 9:34 AM “ ...ED Quick Updates; Free Text: Changed clothes and up to WC [wheelchair]. Waiting on ride home from daughter ...” 9:34 AM “ ...Discharge Education Patient Teaching: Discharge instructions reviewed Learner: Patient; Family ...” 10:43 AM “ ...Medication Given ondansetron (Zofran) injection 4 mg - Dose: 4 mg; Route: Intravenous ...” 11:12 AM, “ ...Patient Discharged ...” Review of Patient 1’s “After Visit Summary” dated 07/18/24, showed “ ... follow up with family physician within 7-10 days. ice (sic) and rest. Return to ER for segment (sic) worsening of pain persistent headache or vomiting new symptoms or concerns ...ondansetron ODT (Zofran-ODT) 4 MG disintegrating tablet; Instructions: Take 1 tablet (4 mg total) by mouth every 6 (six) hours if needed for nausea or vomiting ...” During an interview on 10/01/24 at 2:45 PM Patient 1’s family (F1) stated “ ...When I arrived to the ER, they were giving her discharge instructions. She was actively vomiting at that time they told me it was due to pain medication. I was worried since she was on blood thinners even though she had a negative CT scan (Computer Tomography) that she could be having a slow bleed. After I took her home, she still continued to vomit, and she was unable to keep any liquids down including water or medications. So, we left to go to another ER around 4:30 PM or 5:00 PM where she was admitted for three to four days and then sent to rehab for approximately 1 1/2 weeks ....” During an interview on 10/01/24 at 4:29 PM, Staff D, Doctor of Medicine (MD), stated that, elderly fall with head injury on blood thinners and was vomiting with a negative head CT scan, I would transfer them to a Trauma Center ...” During an interview on 10/02/24 at 8:58 AM, Staff A, RN, ER Director stated, “ .... Nausea and vomiting are sign of a head injury and we would not discharge a person home with nausea and vomiting with a head injury ...” Review of Patient 1’s medical record showed the hospital failed to provided Patient 1 stabilizing treatment for signs and symptoms of a head injury with nausea and vomiting that can indicate possible increased intracranial pressure (ICP) (a rise in pressure inside the skull that can be result of a brain injury) and failed to reassess for response to Zofran medication for nausea and vomiting to determine if patient was stabilized for discharge. Review of Patient 1’s Hospital B medical record dated 07/18/24 at 5:35 PM, six hours and 23 minutes after discharged from [Above Named Hospital], showed, that Patient 1 was admitted from Emergency Department for “ ...intractable vomiting (vomiting that is difficult to control) with head injury ...” and discharged on 07/20/24 to rehabilitation hospital for Occupational and Physical therapy for falls.”