Saint Luke’s East Hospital

“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: 15697 Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#3) of 33 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy titled, “Patient Transfers and Emergency Medical Treatment and Labor Act (EMTALA), GA-063,” dated 09/21/22, showed: - All persons receive an appropriate MSE within the hospital’s capability to determine whether or not an EMC exists. - EMC means and manifests itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, or serious impairment to bodily functions, serious dysfunction of any bodily organ or part. - MSE refers to the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an EMC exists. - A MSE must be done within the facility’s capability and available personnel. Review of the hospital’s policy titled, “Pain Management, PC-010,” dated 02/24/23, showed: - Patients will be assessed for pain at the time of admission or initial assessment to include location and character of pain, appropriate pain scale, the numerical rating that represents the patients pain intensity or the pain scale rating. - Severe pain (seven to 10) dominates the senses and significantly disables the ability to perform Activities of Daily Living (ADL, daily self care activities, such as bathing, dressing and eating) and interferes with sleep and conversing requires effort. - Ongoing pain scale assessments for ED patients will be assessed on admission and discharge from the department and as needed. - Self-report of pain shall be considered the single most valuable indicator of pain. Review of Patient #3’s ED medical record showed: - The patient was a 52-year-old female who presented to the ED on 06/16/24 at 8:02 PM. - She complained of rectal pain, constipation and generalized abdominal pain. She verbalized that she had used over the counter (OTC) medications without any relief and that her last bowel movement was three days ago. She reported her physician had sent her to the ED to rule out peri rectal (the tissue surrounding the rectum) abscess (collection or pocket of thick fluid caused by an infection) or a small bowel obstruction (a blockage in the small intestine that prevents food, liquid, gas, and stool from passing through normally). - Triage (process of determining the priority of a patient’s treatment based on the severity of their condition) was completed at 8:59 PM. - She scored her pain at an eight on a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible). - On 06/17/24, at 1:37 AM, laboratory work was ordered that included a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) urinalysis (a laboratory examination of a person’s urine), lactate test (test that measures level of lactic acid [an acid produced in muscle tissue cells and red blood cells during strenuous exercise], normal levels are less than 1.0 mmol/L). - She was placed in an ED room at 1:38 AM (5 hours and 36 minutes after her arrival to the ED). - At 1:38 AM. a computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan of the abdomen and pelvis with contrast (substance injected into an intravenous [IV, within a vein]) line that causes the particular organ or tissue under study to be seen more clearly) was ordered. - At 1:45 AM, Staff R, Advanced Practice Registered Nurse (APRN), completed a history and physical examination. - At 2:07 AM, lab results were normal. - At 2:48 AM, an IV was inserted and nausea medication was ordered. - At 2:49 AM, a CT scan of the abdomen with contrast was completed. - The CT scan showed liquid stool within the majority of the colon, colitis (inflammation of the inner lining of the colon) of the descending colon (a part of the large intestine that stores stool and helps absorb water and electrolytes from digestive materials) and proctitis (inflammation of the anus and the lining of the rectum). No visualized perianal (situated in or infection the area around the anus) or perirectal (the rectal space which is the last part of the large intestine where stools are stored before leaving the body) fluid collections (that could indicate an abscess). - She was treated with hydrocortisone (a steroid, used to treat inflammation) suppositories (medication inserted in the rectum) and recommended to follow-up with gastroenterology (GI, branch of medicine concerned with the structure and diseases of the stomach and intestines). - Patient #3 was agreeable to the discharge plan. She was encouraged to return to the ED for any worsening symptoms. She verbalized understanding of discharge instructions, and all questions were answered. - At 3:59 AM, Patient #3 was provided with a copy of the discharge instructions, her CT scan results, a referral to a GI specialist, and a prescription for hydrocortisone 25 milligrams (mg) suppository two times per day. Review of Patient #3’s ED medical record from Hospital B, dated 06/18/24, showed: - She presented to Hospital B’s ED on 06/18/24 at 8:15 PM. - Her chief complaint was constant rectal pain, that had gradually worsened with an initial onset of five days prior. - She stated that the pain was dull, aching and was located on her rectum with painful bowel movements. - Lab results showed an increased white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) of 17,000, normal range is 4,100 to 11,100 otherwise labs were normal. - CT scan of abdomen and pelvis showed a 3.6 centimeter (cm) perirectal abscess. - She was admitted to Hospital B with admission orders for patient to have nothing per mouth (NPO), IV antibiotics, IV fluids, pain, and nausea medication. - A colorectal (pertaining to or involving the colon and rectum) surgery consult was ordered. During a telephone interview on 08/07/24 at 7:59 AM, Staff Q, Registered Nurse (RN), Hospital A, stated that Patient #3’s ED visit was due to complaints of abdominal pain and constipation. Her doctor sent her to be evaluated for a small bowel obstruction or possible abscess. Patient #3 was assessed at a level three triage, (urgent but non-life threatening). She was stable, her pain score was normal, and she did not ask for pain medication. After she received nausea medication, she seemed comfortable. The ED was busy that night, so it took some time to get her seen. She had lab work and a CT scan. She received verbal and written discharge instructions and verbalized her understanding. She was then discharged. During a telephone interview on 08/07/24 at 10:15 AM, Staff R, APRN, Hospital A, stated that Patient #3 came in for abdominal pain and constipation. Her physician wanted to rule out a bowel obstruction versus constipation. She received a CT scan, which gave a better picture of the internal abdomen. The CT scan showed proctitis and a GI consultation was recommended. Patient #3 received discharge instructions, agreed with the instructions and all her questions were answered.”

“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: 15697 Based on interview, record review and policy review, the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for one patient (#3) of 33 Emergency Department (ED) records reviewed. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy titled, “Patient Transfers and Emergency Medical Treatment and Labor Act (EMTALA), GA-063,” dated 09/21/22, showed: - All persons receive an appropriate medical screening examination (MSE) within the hospital’s capability to determine whether or not an EMC exists. - If an EMC is found to exist, the Hospital will stabilize or transfer the patient in accordance with EMTALA. - EMC means and manifests itself by acute symptoms of sufficient severity, (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in serious impairment to bodily functions. - Stabilized, with respect to an EMC, ensures that no material deterioration of the patient’s condition is likely, within reasonable medical probability. Review of the hospital’s policy titled, “Pain Management, PC-010,” dated 02/24/23, showed: - Patients will be assessed for pain at the time of admission or initial assessment to include location and character of pain, appropriate pain scale, the numerical rating that represents the patients pain intensity or the pain scale rating. - Severe pain (seven to 10) dominates the senses and significantly disables the ability to perform Activities of Daily Living (ADL, daily self care activities, such as bathing, dressing and eating) and interferes with sleep and conversing requires effort. - Ongoing pain scale assessments for ED patients will be assessed on admission and discharge from the department and as needed. - Self-report of pain shall be considered the single most valuable indicator of pain. Review of Patient #3’s ED medical record, dated 06/16/24, showed: - She was a 52-year-old female who presented to the ED at 8:02 PM, with chief complaints of rectal pain, constipation with last bowel movement over nine days prior, no longer passing gas and generalized abdominal pain. - She reported that her physician had sent her to the ED to rule out peri rectal (the tissue surrounding the rectum) abscess (collection or pocket of thick fluid caused by an infection) or a small bowel obstruction (a blockage in the small intestine that prevents food, liquid, gas, and stool from passing through normally). - Triage (process of determining the priority of a patient’s treatment based on the severity of their condition) was completed at 8:59 PM. - She scored her pain at an eight on a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible). - On 06/17/24, at 1:37 AM, laboratory work was ordered. - At 1:38 AM, a computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan of the abdomen and pelvis with contrast (substance injected into an intravenous [IV, within a vein]) line that causes the particular organ or tissue under study to be seen more clearly) was ordered. - At 1:45 AM, Staff R, Advanced Practice Registered Nurse (APRN), completed a history and physical examination, no rectal exam was completed. - At 2:07 AM, lab results were normal. - At 2:48 AM, an IV was inserted and nausea medication was administered. - At 2:49 AM, a CT scan of the abdomen with contrast was completed. - The CT scan showed liquid stool within the majority of the colon, colitis (inflammation of the inner lining of the colon) of the descending colon (a part of the large intestine that stores stool and helps absorb water and electrolytes from digestive materials) and proctitis (inflammation of the anus and the lining of the rectum). No visualized perianal (situated in or affecting the area around the anus) or perirectal (the rectal space which is the last part of the large intestine where stools are stored before leaving the body) fluid collections (that could indicate an abscess). - She was treated with hydrocortisone (a steroid, used to treat inflammation) suppositories (medication inserted in the rectum) and recommended to follow-up with gastroenterology (GI, branch of medicine concerned with the structure and diseases of the stomach and intestines). - At 3:59 AM, Patient #3 was provided with a copy of the discharge instructions, her CT scan results, a referral to a GI specialist, and a prescription for hydrocortisone 25 milligrams (mg) suppository two times per day. During a telephone interview on 08/07/24 at 7:59 AM, Staff Q, Registered Nurse (RN), stated that Patient #3’s ED visit was due to complaints of abdominal pain and constipation. Her doctor sent her to be evaluated for a small bowel obstruction or possible abscess. Patient #3 was assessed at a level three triage, (urgent but non-life threatening). She was stable, and she did not ask for pain medication. After she received nausea medication, she seemed comfortable. The ED was busy that night, so it took some time to get her seen. She had lab work and a CT scan. She received verbal and written discharge instructions and verbalized her understanding. She was then discharged. During a telephone interview on 08/07/24 at 10:15 AM, Staff R, APRN, stated that Patient #3 came in for abdominal pain and constipation. Her physician wanted to rule out a bowel obstruction versus constipation. She received a CT scan, which gave a better picture of the internal abdomen. The CT scan showed proctitis and a GI consultation was recommended. Patient #3 received discharge instructions, agreed with the instructions and all her questions were answered. Review of Patient #3’s ED medical record from Hospital B, dated 06/18/24, showed: - She presented to Hospital B’s ED on 06/18/24 at 8:15 PM. - Her chief complaint was constant rectal pain, that had gradually worsened with an initial onset of five days prior. - She stated that the pain was dull, aching and was located on her rectum with painful bowel movements. - Lab results showed an increased white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) of 17,000 normal range is 4,100 to 11,100, otherwise labs were normal. - CT scan of abdomen and pelvis showed a 3.6 centimeter (cm) perirectal abscess. - She was admitted to Hospital B with admission orders for patient to have nothing per mouth (NPO), IV antibiotics, IV fluids, pain, and nausea medication. - A colorectal (pertaining to or involving the colon and rectum) surgery consult was ordered.”