Caromont 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: 40299 Based on policy review, medical record review, and physician interviews, the hospital failed to comply with 42 CFR §489.24. The findings included: 1. The hospital failed to ensure a thorough medical screening examination was provided that was within the capability of the hospital’s Dedicated Emergency Department (DED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) existed for one of 31 sampled Emergency Department (ED) patients (Patient #23). ~ Cross refer to Medical Screening Exam - Tag A2406.”

“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: 40299 Based on policy reviews, medical record reviews and provider interview, the hospital failed to ensure a thorough medical screening examination was provided that was within the capability of the hospital’s Dedicated Emergency Department (DED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) existed for one of 31 sampled Emergency Department (ED) patients (Patient #23). The findings include: Review of the hospital’s “Emergency Medical Treatment and Labor Act (EMTALA)” policy last revised 10/2023 revealed “ ... When an individual presents or is brought to any Emergency Department of (Named Hospital) and a request is made on the individual’s behalf for examination and treatment of a medical condition, a physician, nurse practitioner (NP), physician assistant (PA) or certified nurse midwife (CNM) provide a medical screening examination within the capabilities of the hospital including ancillary services routinely available to the Emergency Department, for the purpose of determining the presence or absence of an emergency medical condition ...” Review of the medical record revealed Patient #23 was a 21-year-old female who presented on 12/07/2023 at 0815 to the DED of Hospital A with a complaint of “Abdominal Pain.” Review of the Triage note at 0817 revealed “Pt (patient) cussing staff, stating she has no idea how far pregnant she is maybe due in Jan. (January).” The Chief Complaint was updated at 0818 to “Abdominal Pain (Approx (approximately) 8 (eight) months preg (pregnant) (no prenatal care).” Patient #23 was transported to L&D at 0838. Review of the Nurse note at 0838 revealed “Pt seems nervous and anxious.”The Nurse note at 0913 revealed “When pt was asked about where she lives, Pt states, ‘I live wherever I am. And I am alive.’ Medical Record documentation revealed the ED COURSE: Patient presented to OB ED for evaluation of Abdominal pain during pregnancy in third trimester. Patient was verbally combative in Main Emergency Department (ED), cursing and yelling. On arrival to OB ED unit, patient was initially responsive to questions but appeared confused. She stated that she came to the hospital due to abdominal pain; however, she was not able to describe this pain or point to location of pain. When asked questions regarding pain, patient would stare straight ahead, not make eye contact, and not respond to questions...MD notified of patient status, ... recommended that after OB evaluation patient present back to Main ED for psych evaluation. 0900 Management called to unit to discuss POC (plan of care) ...0945 RN informed CNM (Certified Nurse Midwife) that patient was unresponsive to PHQ (patient health questionnaire) questions. 0950 Consulted nurse manager in ED regarding a POC for this patient. Spoke to ... RN on phone, she said she will consult to (sic) ... MD regarding how to facilitate psych evaluation on this patient. 1000 Social worker at bedside to see patient. 1020 patient removed EFM monitors from her abdomen, she refused to having to have them placed back on her abdomen 1108 Pt [patient] to radiology for ultrasound, transporter ... to stay with patient while in ultrasound. 1200 Patient back from ultrasound. 1230 Called ... MD, ... informed him of my concern regarding patient’s mental status and ability to comprehend instructions, ... informed him that I felt uncomfortable discharging her...if I was able to clear obstetrically as she is here by herself and I did not feel that she would be able to comprehend and follow discharge instructions. He stated that he would not be able to eval patient on OB triage unit as it was not a secure location for psych eval. He recommended that we have her present to Main ED for eval. I voiced my concern that patient would not willingly present back to Main ED for eval. He said that if the Main ED staff was able to transport patient to OB ED without any issue then he did not see why there would be an issue with my staff transporting patient back to Main ED. I told him that I was concerned that patient would become combative with my staff if we were to attempt to transport her to Main ED. POC was made for Main ED staff to coordinate with security for patient transport back to Main ED. I was NOT given any verbal orders to restrain patient to our unit, or any verbal orders for patient sitter ... MD did NOT mention anything regarding lack of capacity orders either. 1246 Message received from ... RN that Main ED staff is coming to get patient to bring her to Main ED. I informed ... that patient has been cleared from an OB standpoint ... 1255 ... I was informed by secretarty (sic) that patient left unit. I myself was never notified of the lack of capacity order placed under ... [MD’s name], nor was my attending physician ... MD or any team member in the OB ED. Our secretary did not notify security when patient left unit, because again we were not aware of lack of capacity order. Main ED was notified at 1256 that patient left unit. Psych then called a code elopement.” Review of the Case Management note at 1000 revealed “LCSW met with patient in patient room...Patient is able to make eye contact, however appears confused and unable to answer yes or no questions. When asked if patient needed anything else patient responded ‘I don’t know’. SW (social worker) to continue to provide support as needed.” The Nurse note at 1038 revealed Patient #23 refused to allow her temperature to be taken orally or under her armpit. The Urine Rapid Drug Screen Test resulted at 1120 resulted an abnormal result being positive for Amphetamine (stimulant drug). Review of Provider Orders placed at 1236 revealed “Lacks Capacity - LACKS CAPACITY TO LEAVE AMA (against medical advice) -AWAITING PSYCHIATRIC EXAM OR CLEARANCE”. Review of the Nurse note at 1255 revealed “Pt walked off unit, stating ‘I have to leave to charge my phone’.” Review of the Provider note at 1357 revealed “ ... contacted by ER RN manager ... about 12 pm that this patient presented to the ER, transferred to OB triage area, but would likely need a psychiatric assessment ... contacted CNM (certified nurse midwife) ... and received description of the scenario including bizarre behavior concerning for possible psychosis, + meth UDS (positive methamphetamine urine drug screen), and no known SI (suicidal ideation)/HI (homicidal ideation) (but poorly cooperative with questions), and that the patient was cleared of OB (obstetric) causes of cc (chief complaint) abdominal pain ... recommend the patient be transferred back to the main ER for psych eval (evaluation) ... advised RN manager of this and requested main ER staff help with transfer/escort back ... suggested a lacks capacity order ... entered ‘Lacks capacity to leave AMA (sic) ... At 1 pm ... was notified the patient had eloped ... recommended to CNM ... that security be called ... contacted the house supervisor to initiate a ‘code elopement’ in effort to return the patient for further assessment. CNM ... was again contacted to assist with physical description of the patient ... did not evaluate this patient.” The disposition was set to “ED Disposition set to Send to L&D (Labor and Delivery). Review of the Provider note at 0831 revealed “ASSESSMENT: Principal Problem: Abdominal pain during pregnancy in third trimester; Active Problems: Substance abuse; Overview: Patient was encouraged to abstain from substances; Left against medical advice; 32 weeks gestation of pregnancy; Methamphetamine abuse; No prenatal care in current pregnancy; Hepatitis C; PLAN: Patient walked out of unit and did not stop when secretary tried to stop her. Main ED was notified, psych called a code elopement.” Interview on 02/08/2024 at 1547 with CNM #7 revealed she remembered Patient #23. Interview revealed it was hard to get Patient #23 to answer questions as she would stare off into space. Patient #23 came in with a complaint of Abdominal pain. Patient #23 was cleared from an OB perspective. CNM #7 was worried Patient #23 would not be able to understand the discharge instructions so she spoke with the Main ED about evaluating Patient #23. The OB unit secretary observed Patient #23 leave and notified me as she was leaving. CNM #7 did not see Patient #23 leave the OB unit. CNM #7 stated a provider from another department (ED) put in an order on Patient #23. “I (CNM #7) do not have time to refresh my screen to look for an order.” Interview revealed it is not in CNM #7’s scope of practice to determine if a patient can make the decision to leave. CNM #7 revealed the Main ED called the elopement code. CNM #7 acknowledged she had EMTALA training, and the role is that every patient that walks through triage door receives a medical screening exam. In summary, Patient #23 was found to have bizarre behavior and possible intoxication with methamphetamine. Staff felt Patient #23 had altered mental status with poor understanding of discharge instructions and needed further neuro and psychiatric evaluation. The Medical Screening Examination lacked appropriate psychiatric evaluation and Patient #23 was allowed to elope from the OB area with staff knowledge.”