Integris Health Ponca City

“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: 32662 Based on record review and interview, the facility failed to ensure services were provided per policies and procedures to ensure compliance with the requirements of EMTALA (Emergency Medical Treatment and Labor Act) for one (Pt # 1) of 6 patients reviewed. This failed practice had the potential to place hospital staff, including medical staff, at risk of failure to uphold responsibilities under the EMTALA requirements. Crossreferenced: See 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: 32662 Based on record review and interview, the facility failed to ensure: 1. an appropriate medical screening examination was conducted for patients presenting to the ED requesting an examination of a medical condition for 1 (Pt # 1) of 10 patient records reviewed and 2. This failed practice had the potential to delay needed lifesaving treatment to all patients who present to the ED. Findings A review of a hospital policy/procedure titled, “EMTALA - Medical Screening/Stabilization” was reviewed by surveyor and read in part: “Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor. Such screen must be done within the Hospital’s capabilities and available personnel, including on-call physicians. The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient’s needs and continue until the patient is either stabilized or appropriately transferred. The Hospital must apply, in a non-discrinatory manner and regardless of ability to pay, a screening process that is reasonably calculated to determine whether an Emergency Medical Condition exists.” A review of a second hospital policy/procedure titled, “G2 A EMTALA - Medical Screening/Stabilization” read in part: “4. The Medical Screening Examination includes both a generalized assessment and a focused assessment based on the patient’s chief complaint, with the intent to determine the presence or absence of an Emergency Medical Condition.” Policy showed an effective date of November 2003 and no date entered for date revised.” Pt #1 A review of the ED records documented arrival date of 12/11/23 at 4:55 pm with complaints of “passed out prior to arrival.” Medical history positive for diabetes, hypertension, history CVA, history kidney cancer s/p nephrectomy, history neck cancer. Patient’s chief complaint was patient getting ready to shower this afternoon and suddenly passed out. Patient reported consciousness regained after EMS came to their home. Patient reported not feeling good. A review of the ED exam showed lungs with sonorous breath sounds but no discrete wheeze, rales, or rhonchi. On an ED record titled, “Nurse Documentation,” RN #1 documented the following vital signs: 12/11/23 at 4:57 pm B/P 105/63, pulse 59, resp 15, pulse ox 97% on RA. On the same ED record, RN #2 documented the following vital signs: 12/12/23 at 2:00 am B/P 158/75, pulse 57, resp 16, pulse ox 92% on 2LNC 12/12/23 at 2:30 am B/P 166/80, pulse 57, resp 10, pulse ox 97% on 2L NC 12/12/23 at 3:00 am B/P 164/78, pulse 59, resp 14, pulse ox 95% on 2L NC 12/12/23 at 3:30 am B/P 150/80, pulse 59, resp 10, pulse ox 97% on 2L NC 12/12/23 at 4:00 am B/P 160/80, pulse 67, resp 13, pulse ox 95% on 2L NC 12/12/23 at 4:49 am B/P 158/102, pulse 70, resp 14, pulse ox 97% on 2L NC The ED record did not specify additional interventions for the increased blood pressure beginning 12/12/23 at 2:00 am which remained elevated at discharge on 12/12/23 at/around 4:49 am. A review ED clinical documentation titled, “Order Sheet” showed a D-Dimer ordered 12/11/23 with results of 1173.0 reviewed 12/11/23 at 7:14 pm and interpreted as “abnormal.” Documentation showed normal range for this lab to be 0-500. Continued review of the ER record showed no evidence that the critical D-Dimer was adressed by medical screening. A review of “ED Nurse Documentation” showed administration of DuoNeb on 12/11/23 at 10:50 pm, 12/12/23 at 2:26 am, and 12/12/23 at 4:27 am as well as MethylPrednisone (Solu-Medrol) on 12/12/23 at 1:23 am, and 4:25 am. The critial lab value (D-Dimer of 1173.0) along with patients presentation with shortness of breath, difficulty breathing, decreased oxygen saturation, and need for oxygen could be an indicator that a pulmunary embois was present. The lack of follow-up to this critical lab showed a thorough medical screening did not occur in light of patient’s complaints of shortness of breath, coughing up sputum associated with blood, and continued administration of medication to help patient breath and relieve symptoms (Solu-Medrol and DuoNeb). A review of the ED Physician Documentation completed by Physician #1 on 12/12/23 at 6:42 pm showed care was transferred to Physician #2 at 7:00 pm. On the “ED Physician Documentation” record, Physician #2 documented at 7:00 pm on 12/11/23 patient was entered into observation status to establish the need for admission to discuss proper disposition to maximize pain control while awaiting sputum result, and discussion of the case with the oncology team at Hospital #2 and determined: 1. the patient had an extensive metastatic risk and the oncological team was planning on performing an MRI of the spine; 2. the patient had a known mass in his upper lobe that was s/p biopsy which was inconclusive. 3. Patient was on antibiotics, symptoms worsening and patient was begining to cough up sputum associated with blood. 4. A chest CT confirmed a complex mass that was growing in size and was cavitary. Documentation continued by Physician # 2 that patient received medication to help him breath and to relieve symptoms (Solu-Medrol and DuoNeb) with breating and coughing as well as multiple doses of Dilaudid for comfort and made attempts to transfer patient to Hospital #2. A Chest X-Ray completed by the hospital on 12/11/23 at 7:21 pm documented in part: “2. mild depression of the anterior lucent lesion isuper endplate of T5. This could be assessed with MR if felt clinically indicated. 3. There is a 10 mm focal lucent lesion in the left side of T4. Uncertain etiology. 4. There is a large masslike consolidation in the right upper lobe with central areas of bonchiectasis and possibly cavitation. 7.5 cm x 7 cm x 6.5 cm. Findings could represent chronic inflammatory mass or less likely a tumor mass. Follow-up recommended.” Documentation showed no MRI completed by Hospital #1. On a document titled, “ED Physician Documentation,” on 12/12/23 at 3:52 am, MD #2 documented a disposition summary that stated: Discharge ordered Location: home Problem: new (12/12/23 3:52 am) Symptoms have worsened (12/12/23 at 3:52) Condition: Improved A review of the ED record showed no improvement in the patient. A physician documentation note dated 12/12/23 at 4:37 am documented the patient could not be transferred to Hospital #2 due to the hospital being on divert status and Hosital #1, where patient was being treated, could not admit patient because patient needed treatment they could not give (bronchoscopy and oncological consultations). Decision was made that patient would be best served by Hospital #2. Hospital #1 also documented belief that pneumonia was likely. Hospital #1 documented family was going to drive patient to Hospital #2 (106.2 miles away or 1 hour and 40 minutes). Documentation showed no continued measures to stabilize patient, no evidence that the hospital maintained the patient on site until an appropriate transfer could be coordinated, no evidence that all necessary screening was complete to rule out absence of an emergency medical condition, no evidence that the facility followed their own EMTALA policies, no evidence that patient was transferred with medical records to the receiving hospital, and no evidence of transfer with qualified staff and transportation equipment.” During an interview with Staff C on 07/02/24 at 12:00 when asked about appropriate screening, Staff C stated: 1.”The patient (Pt #1) needed oncology. We have no oncology services here;” 2. “We would normally call other facilities that can meet patient needs, I don’t know specifically on this patient.””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 32662 Based on record review and interview, the facility failed to ensure: 1. an appropriate transfer for patients presenting to the ED for 1 (Pt # 1) of 10 patient records reviewed and 2. adherance to their own EMTALA policies and procedures for appropriate transfer for Pt #1. This failed practice had the potential to delay needed lifesaving treatment and interventions during transfer to all patients seen in the ED and found to need a higher level of care with appropriate transfer. Findings A review of a hospital policy/procedure titled, “EMTALA - Medical Screening/Stabilization” documented requirments that, “Appropriate Transfer occurs when 1) the transferring Hospital provides medical treatment within its capacity and capability that minimizes the risk to the individiual’s health and in the case of a woman in labor, the health of the unborn child; 2) the receiving facility has the appropriate space and qualified personnel for the treatment of the individual and has agreed to acccept Transfer of the individual and to provide appropriate medical treatment; 3) the transferring Hospital sends to the receiving Hospital all medical records (or copies thereof) related to the Emergency Medical Condition...; and 4) the Transfer is effected through Qualified Medical Personnel and appropriate transportation and equiment, as required, including the use of necessary and medically appropriate life support measures during the Transfer.” Pt #1 A review of the ER record showed Pt #1 received pain medication and medication to help him breath and relieve symptoms prior to patient discharge by ambulation out of the hospital on 12/12/23 at 4:59 am: A document titled, “Order Sheet” showed Hydromorphone (on opiod pain medication that could further reduce respirations for a patient already symptomatic for shortness of breath) was administred on 12/11/23 at 9:26 pm and 10:54 pm and again on 12/12/23 am at 1:40 am, and 4:25 am. The order sheet showed MethylPrednisone administered on 12/12/23 at 1:23 am and 4:25 am and (for breathing) DuoNeb administered on 12/12/23 at 2:26 am and at 4:27 am (breathing). On an ED physician noted dated 12/12/23 at 4:37 am, Physician #2 documented: 1. patient received multiple doses of Dilaudid (Hydromorphone) for comfort; 2. awarness that patient needed additional stabilizing treament; 3. patient was discharged with oxygen and with catheter in place; 4. patient was discharged in care of family, in a POV, with oxygen and a foley catheter in place to receive care at another facility. Documentation showed no evidence that hospital #1 retained patient until medically stabilized, no evidence of acceptance of a receiving hospital with space, no evidence of acceptance of transfer from a receiving hospital, no record that Hospital #1 sent all medical records for Patient #1 to a receiving hospital, no evidence of transfer with qualified personnel and transport equipment, and no evidence that the hospital followed their own policies. During the an interview with Staff ZZ on 07/02/24 at 1200, Staff ZZ stated: 1. “When we call to get a transfer, we may get told facility can’t accept and we will explore other options. I don’t think that was documented in this case. 2. “No.” (when asked if patient left against medical advice).”