Lovelace Westside Hospital

“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: 49835 Based on record review and interview the facility failed to meet the Emergency Medical Treatment and Labor Act (EMTALA) to ensure a medical screening exam was done for all patients that present to the Emergency Department. This deficient practice is likely to lead to poor outcomes related to patients not being evaluated when seeking medical care. The findings are: A. The facility failed to perform a medical screening exam. Refer to tag A-2406.”

“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: 49835 Based on record review and interview the facility failed to provide a medical screening examination that ensured an emergency medical condition was not present for 1(P (patient) 3 out of 20 (P1-P20) patients reviewed. This deficient practice could likely result in patients not receiving medical treatment for an emergency medical condition. The finding are: A. During record review of the faciity policy titled “EM001 EMTALA (Responsibilities of Medicare Participating Hospitals in Emergency Cases) - Hospital Compliance with EMTALA” dated 01/23/2020, under section titled Medical Screening Examination (MSE) 1) Policy Statement: stated “A medical screening examination will be offered to any individual who comes to the emergency department”. B. During a review of P3’s chart under Emergency Medical Note it is noted that P3 came to the emergency room on 12/16/2024 at 11:55pm with a chief complaint per mother P3 has been expressing unusaul behavior for over a year with increase paranoia, seeing things that are not there, pacing the house, at night, staring out the window, hardly sleeping, talking to himself and intermitten aggression toward his brother, a couple days ago P3 threatened his brother with a machete. P3 has a history of acute psychosis, recent homicidal ideation, unspecified anxiety disorder and unspecified Methamphetamine use. 1. On 12/17/2024 at 1:53am under ED Triage Note it stated that P3 is waiting for for a Behavioral Health (BH) evaluation to be done in the morning. 2. Under Ed note dated 12/17/2025 at 7:10am a “Suicide Precaution Environmental Risk Reduction Checklist” which includes looking for and removing items that patinet can harm himself with such as sharp objects, cords 18 inches or longer, plastic bag was conducted. 3. During a review of P3’s memergency room medical record dated 12/16/2024, vital signs were not obtained, there is no order written for a behavioral health exam and no mention of contacting a psychiatrist to obtain behavioral health examination. P3 was in the emergency room from 12/16/2024 at 11:55pm to 12/17/2024 at 10:08am when he “jumped up and eloped” this was 10 hours and 13 minutes P3 was in the emergency room waiting for a behavioral health evaluation.”

“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: 49193 Based on record review and interview the facility failed to meet the Emergency Medical Treatment and Labor Act (EMTALA) to ensure stabilizing treatment for 1 patient that presented to the Emergency Department. This deficient practice could affect patients from receiving an appropriate medical screening exam. The findings are: A. The facility failed to perform a medical screening exam. Refer to tag A-2406.”

“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: 46375 Based on record review and interview the facility failed to provide a proper medical screening exam and failed to perform emergent dialysis (Urgent Dialysis) for 1 (P[patient] P1) out of 20 (P1-P20) patients that presented to the Emergency Department. This deficient practice could possibly lead to a decline in patients’ health. Based on record review and interview the facility failed to provide a proper medical screening exam and failed to perform emergent dialysis (process of removing excess water and toxins from the blood) for 1 (P[patient] P1) out of 20 (P1-P20) patients that presented to the Emergency Department. This deficient practice could affect patients from receiving an appropriate medical screening exam. The findings are: A. Record review of the facility’s undated policy titled, “ EM006 EMTALA - On Campus Departments and Hospital Property-CD-Corp” documented, “If an individual is determined to have an Emergency Medical Condition, [Name of Hospital] will provide further examination and treatment necessary To Stabilize the Emergency Medical Condition, within [Name of Hospital’s] Capability and Capacity.” B. Record review of P1’s Medical Record dated 07/03/2024, revealed the following: 1. In the “ED (Emergency Department) Provider Note” it indicated that the patient presented to the ED because the patient needed dialysis. The patient’s presenting oxygen was 91%. Under “Physical Exam. . . Pulmonary” it stated, “Pulmonary effort is normal.” There is no evidence that the provider listened to the patient’s lungs to evaluate for fluid overload (having too much fluid in the body which can lead to fluid in the lungs) since patient had not been dialyzed in two days. There was no diagnostic imaging done to check for fluid in the patient’s lungs which could affect the patient’s oxygen level. Under, “MDM [medical decision making]” it stated “Spoke with Staff (S)12 from RMA (Renal Medicine Associates) nephrology (medical specialty concerned with the kidneys) and stated that he does feel he should be dialyzed as his BUN/Cr is elevated. Pt is aware that he will need to be transferred for dialysis as we do not have a dialysis nurse today. Pt was signed out to oncoming provider pending disposition”. There were no repeat vital signs to re-check the oxygen saturation and no pedal assessment done on the patient. 2. Under “Comprehensive Metabolic Panel (a blood test that measures proteins, enzymes, electrolytes, minerals and other substances in your body)” it indicated a BUN (Toxins in blood, helps determine kidney function) of 79 and a Creatinine (a measure of how well your kidneys are performing their job of filtering waste from your blood) of 10.7 in abnormal ranges. 3. Under lab results it indicated the normal rage for BUN in 6-29 mg/dL (a unit of measure that shows the concentration of a substance in a specific amount of fluid) and for Creatinine is 0.70-1.3 mg/DL. 4. Oncoming (next provider on shift) Provider note dated 07/03/2024, labeled “ED Provider Note” Stated, “BUN and Creatinine are elevated as expected for patient with end-stage renal disease, but did not meet criteria for emergent dialysis. Potassium normal at 4.7. [SA] Via epic chat (electronic chat), I discussed the patient with nephrologist S12. I informed S12 that patient does not meet emergent criteria for dialysis. While I agree his uremia (High level of toxins in the blood due to kidneys inability to filter) will worsen and his potassium will rise until he is dialyzed, he has no physical or lab indications for emergent dialysis today.” C. Review of P1’s Medical Record dated 07/04/2024. 1. Under the section labeled “Chief Complaint” it indicated patient presented to the Emergency Department for dialysis. 2. “Comprehensive Metabolic Panel” it indicated a Potassium of 5, BUN of 107 and a Creatinine of 12.44. D. During an interview with S11, Clinical Staff Member, at 11:17 AM on 08/21/24, S11 indicated signs and symptoms that would indicate a need for emergent dialysis include a patient presenting with altered mental status, confusion, electrolyte abnormalities (have too much or not enough of certain minerals in your body), signs of fluid overload (too much fluid in your body), SOB (Shortness of Breath), Tachycardia (heart rate over 100 beats a minute). Regards to lab values that may require emergent dialysis, the patient Potassium over 5, phosphorus unknown, Magnesium over 3 and BUN of 100 or over.”