Transylvania Regional Hospital, Inc.

“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: 33790 Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24. Findings included: 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) to determine whether or not an emergency medical condition existed for 1 of 25 sampled DED patients (Patient #1). Cross refer to C2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 33790 Based on policy review, medical record reviews and staff and provider interviews, the hospital failed to ensure a thorough medical screening (MSE) was provided that was within the capability of the hospital’s Dedicated Emergency Department (DED) to determine whether or not an emergency medical condition (EMC) existed for 1 of 25 sampled DED patients (Patient #1). The findings included: Review of the hospital policy titled “EMTALA - Medical Screening Examination and Stabilization...”, last approved 11/10/2023, revealed “...C. Extent of the MSE: 1. Determine if an EMC exists. The hospital must perform an MSE to determine if an EMC exists.... 2. Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event.... 3. An on-going process. The individual shall be continuously monitored according to the individual’s needs until it is determined whether or not the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred. ...” DED medical record review, on 11/19/2024, revealed Patient #1 arrived to the hospital DED on 05/29/2024. Review of the ED Triage Note, at 1712 revealed Patient #1 was brought in by EMS [Emergency Medical Services - ambulance] after taking a handful of metoprolol [medication that can treat high blood pressure], possibly 40 pills in a suicide attempt. Patient #1 was assigned an acuity of 2 [on a scale of 1-5 with one being the most severe acuity and 5 the least acute] Initial vital signs revealed a heart rate of 74 and respiratory rate of 18 with a pain score of 0, no pain. A Suicide Risk Assessment was completed at 1712 with a high risk level obtained. Patient #1’s blood pressure [BP] at 1724 was 195/88. Review of a PA [Physician Assistant] note, signed at 2102, revealed “...79-year-old female history of anxiety and depression.... hypertension [high blood pressure], atrial fibrillation [heart rate irregularity] on Xarelto [can treat and prevent blood clots], takes metoprolol extended release....daily presents to the ER by EMS after concerns that the patient took approximately 39 tablets of her 50 mg metoprolol.... at 1940 this afternoon as an attempt to harm or kill herself. Patient admits to this and though she is vague denying suicidal ideation she does state ‘I just wanted to get away from my (family member)’.” Review of a “Psychiatric Evaluation Note”, on 05/30/2024 at 0859, revealed “...Patient reports stomach pain (ED staff informed). ...” Review of an “ER Report” by MD #3, service date 05/30/2024 0713 revealed an Addendum note that indicated, “...on May 30, 2024 18:07:12 .... Notified by nursing patient was having abdominal pain. Evaluated her. She notes she may have had some tumors in her belly. Subsequent CT scan [Computed Tomography - type of imaging] performed showing no acute pathology but showed some fibroids. Also noted a thickened gallbladder recommended ultrasound. This was performed showing no evidence of acute cholecystitis [inflammed gallbladder]...Blood pressure was elevated on my evaluation of the patient but she is in significant discomfort in her abdomen. I gave her Norco [hydrocodone, prescription pain med to treat moderate to severe pain] as well as ibuprofen [treats pain and inflammation] and repeat vital signs pending. She is clear for psychiatric admission. ...” An “ER Report” by MD #4, signed 05/30/2024 at 2233 revealed “...Accepted care.... at 6 PM this evening. Patient has been in the emergency department now for greater than 24 hours.... Apparently today developed some abdominal pain. CT scan showed fibroids in her uterus and also showed thickened gallbladder. Follow-up ultrasound showed cholelithiasis [gallstones] without cholecystitis. Psychiatry saw the patient and were concerned about patient’s significantly elevated blood pressure. Dr. [name of MD #3] felt this likely was related to pain.... She has no chest pain or shortness of breath. She has no lightheadedness or dizziness. She was given 1 tab of hydrocodone without any change in her pain. She also received her gabapentin around 415. Her blood pressure continued to run in the 180s, likely related to pain. Will try to address her pain again. Going to give her 1.25 mg of droperidol. I reviewed her EKG.... I do think the benefits of droperidol and a small dose outweigh the risks at this point.... Still think our best approach initially is to treat her acute on chronic abdominal pain as this certainly may be driving some of her elevated blood pressure. [space] Reevaluated at 7 PM. Patient resting comfortably. Still complains of some lower abdominal pain which seems to be chronic related to her fibroids...” Review revealed Patient #1 was accepted to the Hospital B mental health facility and was transported out at 2120 on 05/30/2024. Review of the DED record did not reveal thorough evaluation of the cause of the patient’s abdominal pain. Record review revealed a CT and ultrasound were completed but did not reveal adequate laboratory testing or description of the evolving abdominal pain that appeared to be intense enough that it could be impacting blood pressure. Record review did not reveal detailed documentation of repeat abdominal examinations or descriptions of the pain. No troponin or repeat troponin was noted after the abdominal pain to evaluate for acute coronary syndrome, no urinalysis to evaluate for a potential UTI and no lipase to evaluate for potential pancreatitis in a patient with gallstones and abdominal pain. Review of the Hospital B records revealed Patient #1 was transported to Hospital B’s Mental Health Campus. Review of an “ED Report” dated 05/30/2024 at 2322 revealed “...79-year-old female was seen at [Hospital A], intentional overdose with beta-blocker that occurred greater than 24 hours ago. The patient had been medically cleared. However was at that hospital having abdominal discomfort, blood pressure was remaining elevated....Apparently upon arriving to [Hospital B Mental Health Campus] the patient ‘fell out of the van’ and had decreased LOC [level of consciousness] so she was brought here [Hospital B Emergency Department] ....” The report noted “... patient will be admitted here for medical clearance, at which point psychiatry can be consulted for behavioral health admission. ...” Patient #1 was admitted for medical clearance, was discharged from Hospital B’s inpatient care 06/02/2024, was transported to Hospital B’s Mental Health campus and subsequently discharged home on 06/07/2024. Telephone interview with MD #3 on 11/20/2024 at 1405 revealed Patient #1 complained of abdominal pain. A CT was done which showed fibroids. Cholecystitis was also ruled out. Interview revealed Patient #1 continued to have hypertension. She was in pain so the thought was to treat the pain and see if it brought the BP down. Interview revealed MD #3 saw in the medical record where Patient #1 had decreased responsiveness upon arrival to the psychiatric facility but did not recall anything while at Hospital A that would have caused it. Interview revealed droperidol could be sedating, but the patient received a small dose.”