Pratt Regional Medical Center

“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: 46640 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 ensure a central log was maintained and failed to perform an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) exists for a patient who presented to the emergency department seeking emergency medical care for an emergency. Failure to maintain a central log and perform an appropriate MSE places patient at risk for harm and injury up to an including death. Findings Include: Review of a policy titled, “EMTALA (Emergency Medical Treatment and Active Labor Act)”, revised 8/01/22, showed “ ... [The Hospital] shall, within its Capabilities, provide each person who Comes To The Emergency Department an appropriate Medical Screening Examination to determine whether the individual has an Emergency Medical Condition and provide necessary Stabilizing Treatment ...A. MEDICAL SCREENING EXAMINATION (1) Mandatory Medical Screening Examination. The purpose of the Medical Screening Examination is to determine whether or not an Emergency Medical Condition exists. PRMC e, through its Qualified Medical Personnel, a Medical Screening Examination to each individual who: (a) Comes to PRMC’s Dedicated Emergency Department without a scheduled appointment for outpatient services, and not pursuant to a physician or allied health professional’s order for continuous outpatient care or treatment, and: ...III. if no request is made, it is determined by the Dedicated Emergency Department personnel, using a prudent layperson standard, that based upon the individual’s appearance or behavior, the individual needs an examination or treatment for a medical condition ...(c) A nurse may perform a nursing assessment as part of a Medical Screening Examination and report those results to the Qualified Medical Personnel making the final determination of whether an Emergency Medical Condition exists ...C. EMERGENCY DEPARTMENT DOCUMENTATION ... (2) Emergency Department Central Log. The Emergency Department shall maintain a central log of all individuals Coming to The Emergency Department ... Each entry in the central log maintained at the Emergency Department ... Review of policy titled “Triage”, revised 04/04/23, showed, “ ...PROCEDURE 1. The Emergency Department RN should always be the first medical representative to interact with the patient after entering the hospital. A. All patients who present to the Emergency Department should have their condition evaluated by a RN. B. A patient should wait no longer than a few minutes after arrival at the Emergency Room for the initial evaluation ...” The hospital failed to ensure a central log was maintained for 1 of 20 individuals (Patient 1) who presented to the emergency department (ED) seeking emergency medical care. (Refer to A2405) The hospital failed to perform an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) exists for 1 of 20 patients (Patient 1) who presented to the emergency department (ED) seeking emergency medical care. (Refer to A2406)”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 46640 Based on policy review, document reviews, and interviews, the hospital failed to ensure a central log was maintained for 1 of 20 patients (Patient 1) who presented to the emergency department (ED) seeking emergency medical care. These failures have the potential to affect all patients presenting to the ED. Findings Include: Review of a hospital document titled, “ER [Emergency Room] log with chief complaint,” dated 06/03/24, failed to show Patient 1 on the log on the date of the alleged incident of 04/07/24. Review of surveillance video dated 04/07/24 showed Patient 1 presented to the ED at approximately 5:46 PM. Further review of surveillance video dated 04/07/24 from a camera titled Switchboard PVC-city showed the following: 05:56:18 PM Central Daylight Time (CDT), Staff E, Registration Clerk (RC), seated at Emergency Department (ED) Registration desk and a male individual (identified by Staff E, RC, as Patient 1’s spouse) walked into the Emergency Department. 05:56:39 PM (CDT), Patient 1’s spouse approached the registration desk and engaged in conversation with Staff E, RC. (No audio is available) Staff E continued to look down and appeared to be eating. Patient 1’s spouse got Staff E’s attention and the two conversed for approximately 1 minute when Staff E pointed to the lobby. Patient 1’s spouse walked away and then returned to the registration desk moments later. Staff E pointed to the west side of the lobby. 05:58:01 PM (CDT) Patient 1’s spouse exited the sliding ED entrance doors pushing a wheelchair. Staff E, RC, resumed eating. 05:59:13 PM (CDT) Patient 1’s spouse is seen in the reflection of the glass window pushing a wheelchair back into the ED lobby with a person, identified during an interview as Patient 1, by Staff E. 06:01:25 PM (CDT) Patient 1’s spouse approached the ED registration desk and pointed towards the west side of the waiting room where he wheeled Patient 1. Staff E shook her head from left to right at this time then Patient 1’s spouse walks back over to the west side of the lobby. 06:01:40 PM (CDT) Staff E picked up the telephone receiver. During an interview on 06/04/24 at 9:00 AM, Staff D, Senior Systems Administrator, stated that no outgoing calls were made from the registration desk on 04/07/24 that coincide with the video surveillance footage. An incoming call is noted from another department. 06:02:05 PM (CDT) Patient 1’s spouse walked out of the ED lobby pushing Patient 1 in the wheelchair. 06:06:09 PM (CDT) Patient 1’s spouse pushed an empty wheelchair back into the ED lobby. Patient 1 and Patient 1’s spouse arrived at the hospital ED on 04/07/24 at 05:56:18 PM and exited at 06:02:57 PM (approximately 6 minutes later). No other patients or visitors were observed in the lobby during this time. Review of hospital census at the time of the event showed there were no patients in the ED receiving services. Current staffing at the time of this event was one provider, four Registered Nurses (RN) and one Registration Clerk (RC). No staff was visualized evaluating Patient 1 nor assisting Patient 1 into the ED lobby despite multiple conversations initiated by Patient 1’s spouse with Staff E. During an interview on 06/04/24 at 1:32 PM, Staff E, ED RC, stated that she recalled this patient and stated that yes it was [Patient 1 and spouse]. She went on to state, “the spouse came in and wanted us to check his wife’s blood pressure (BP) so they could decide if they wanted to go on to [Hospital 2]. I told him we don’t do BP checks in the ED unless they check in. I told him he could use the BP machine in the lobby. He went and got her a wheelchair and brought her into the ED lobby and used the machine. Then he wanted me to give him advice as to whether he should check into the ER here and I told him I can’t give advice. She never came over to the desk. He said he did not need help bringing her in. I was frustrated he wouldn’t bring her over to the desk so I could ask her what she needed. I didn’t register her or put her on the log.” When asked if she notified any ED staff on duty of a patient in the lobby with a possible medical emergency that needed to be seen she stated, “I think I called back there, I’m sure I did.” When asked with whom she spoke with she was unable to recall. During an interview on 06/04/24 at 2:27 PM, Staff I, RN, stated that she did not recall the patient or any information regarding this event. She stated administration changed the protocol years ago that BP check only are not allowed in the ED and the patient is instructed to check their own on the machine unless they register to be seen. During an interview on 06/04/24 at 10:06 AM, Staff F, RN, stated, “all I know is I was told they just wanted to check their blood pressure after they used the bathroom and then they were going to just go on to [Hospital 2] to be seen. I never saw this patient...””

“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: 46640 Based on policy review, document review, surveillance video review, and interview the Hospital failed to perform an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) exists for 1 of 20 patients (Patient 1) who presented to the emergency department (ED). The hospital’s failure to perform an appropriate MSE has the potential to place patients at risk for an unidentified Emergency Medical Condition (EMC), and a delay in treatment leading to deterioration of the patient’s condition, including harm and/or death. Findings Include: Patient 1 Review of surveillance video dated 04/07/24 showed Patient 1 presented to the ED at approximately 5:46 PM. Further review of surveillance video dated 04/07/24 from a camera titled Switchboard PVC-city showed the following: 05:56:18 PM Central Daylight Time (CDT), Staff E, Registration Clerk (RC), seated at ED Registration desk and a male individual (identified by Staff E, RC, as Patient 1’s spouse) walked into the Emergency Department. 05:56:39 PM (CDT), Patient 1’s spouse approached the registration desk and engaged in conversation with Staff E, RC. (No audio is available) Staff E continued to look down and appeared to be eating. Patient 1’s spouse got Staff E’s attention and the two conversed for approximately 1 minute when Staff E pointed to the lobby. Patient 1’s spouse walked away and then returned to the registration desk moments later. Staff E pointed to the west side of the lobby. 05:58:01.423 PM (CDT) Patient 1’s spouse exited the sliding ED entrance doors pushing a wheelchair. Staff E resumed eating. 05:59:13 PM (CDT) Patient 1’s spouse is seen in the reflection of the glass window pushing a wheelchair back into the ED lobby with a person, identified during an interview as Patient 1, by Staff E. 06:01:25 PM (CDT) Patient 1’s spouse approached the ED registration desk and pointed towards the west side of the waiting room where he wheeled Patient 1. Staff E shook her head from left to right at this time then Patient 1’s spouse walks back over to the west side of the lobby. 06:01:40 PM (CDT) Staff E picked up the telephone receiver. During an interview on 06/04/24 at 9:00 AM, Staff D, Senior Systems Administrator, stated that no outgoing calls were made from the registration desk on 04/07/24 that coincide with the video surveillance footage. An incoming call is noted from another department. 06:02:05 PM (CDT) Patient 1’s spouse walked out of the ED lobby pushing Patient 1 in the wheelchair. 06:06:09 PM (CDT) Patient 1’s spouse pushed an empty wheelchair back into the ED lobby. Review of video surveillance footage dated 04/07/24 from the camera titled Switchboard Main Campus Back Entrance showed the following: 05:56:23 PM (CDT) Patient 1’s spouse entered the ED Lobby and approach the registration desk. 05:57:57 PM (CDT) Patient 1’s spouse walked over and looked at the automatic blood pressure (BP) machine (a machine that measure the pressure of blood in the body) that is placed in the ED lobby for BP checks. He then exited the ED lobby door to the exterior foyer taking a wheelchair with him. 05:59:07 PM (CDT) Patient 1’s spouse pushed Patient 1 into the ED lobby and took Patient 1 over to the automatic BP machine. Patient 1 appears pale, frail, unkempt and appeared sick. 05:59:31 PM (CDT) Patient 1’s spouse made two attempts to assisted her to stand without the wheelchair being locked. Patient 1 was seen sitting at the BP machine and then stood and was unsteady when she returned to the wheelchair. 06:01:19 PM (CDT) Patient 1’s spouse is seen walking over to the ED registration desk while Patient 1 remained in the wheelchair by the BP monitoring machine. 06:01:38 PM (CDT) Patient 1 remained in the wheelchair with her hand resting on her head and appeared visibly sick. 06:02:09 PM (CDT) Patient 1’s spouse exited the ED lobby door to the outside and then returned to the lobby. 06:02:57 PM (CDT) Patient 1’s spouse returned to the ED lobby and then pushed Patient 1 out the ED lobby doors and returned the wheelchair at 06:06:08 PM (CDT). Patient 1 and Patient 1’s spouse arrived at the hospital ED on 04/07/24 at 05:56:18 PM and exited at 06:02:57 PM (approximately 6 minutes later). No other patients or visitors were observed in the lobby during this time. Patient 1 was not registered on the ED log and there was no medical record to review. The hospital failed to perform an appropriate MSE. Review of hospital census at the time of the event showed there were no patients in the ED receiving services. Current staffing at the time of this event was one provider, four Registered Nurses (RN) and one Registration Clerk (RC). No staff was visualized evaluating Patient 1 nor assisting Patient 1 into the ED lobby despite multiple conversations initiated by Patient 1’s spouse with Staff E. During an interview on 06/04/24 at 1:32 PM, Staff E, ED RC, stated that she recalled this patient and stated that yes it was [Patient 1 and spouse]. She went on to state, “the spouse came in and wanted us to check his wife’s blood pressure (BP) so they could decide if they wanted to go on to [Hospital 2]. I told him we don’t do BP checks in the ED unless they check in. I told him he could use the BP machine in the lobby. He went and got her a wheelchair and brought her into the ED lobby and used the machine. Then he wanted me to give him advice as to whether he should check into the ER here and I told him I can’t give advice. She never came over to the desk. He said he did not need help bringing her in. I was frustrated he wouldn’t bring her over to the desk so I could ask her what she needed. I didn’t register her or put her on the log.” When asked if she notified any ED staff on duty of a patient in the lobby with a possible medical emergency that needed to be seen she stated, “I think I called back there, I’m sure I did.” When asked with whom she spoke with she was unable to recall. During an interview on 06/04/24 at 2:27 PM, Staff I, RN, stated that she did not recall the patient or any information regarding this event. She stated administration changed the protocol years ago that BP check only are not allowed in the ED and the patient is instructed to check their own on the machine unless they register to be seen. During an interview on 06/04/24 at 10:06 AM, Staff F, RN, stated, “all I know is I was told they just wanted to check their BP after they used the bathroom and then they were going to just go on to [Hospital 2] to be seen. I never saw this patient ...” Review of Patient 1’s, Hospital 2 medical record dated 04/07/24 at 7:35 PM, showed Patient 1 an 81 year old female arrived at the ED seeking medical treatment for a cough/cold/congestion. Patient 1 received an MSE and treatment was provided for Pneumonia (lung infection), Urinary tract infection and atrial fibrillation (irregular heart rhythm).”