Vanderbilt Clarksville 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: 35244 Based on policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) with an Emergency Medical Condition (EMC) were provided an appropriate and ongoing Medical Screening Examination (MSE) and stabilizing treatment for 1 of 20 (Patient #1) sampled patients reviewed. The findings included: Medical record review revealed Patient #1 presented to the ED of Hospital #1 on 8/2/2024 at 6:38 AM by private vehicle. A triage assessment beginning at 6:40 AM documented the chief complaint as chest pain with inspiration. Patient #1’s chest x-ray performed on 8/2/2024 revealed the following, “Basal opacity [hazy area] is demonstrated on the lateral view could represent atelectasis (complete or partial collapse of a lung or a section of a lung) or pneumonia. A computed tomography angiography (CTA) of the chest (a test that combines a CT scan with an injection of contrast material to create images of blood vessels and tissues ) revealed, “1. Positive study showing bilateral segmental branch emboli [blood clot] in the lower lobes, left greater than right. 2 ...groundglass opacity [hazy gray areas] in the posterior left lower lobe suspicious for small territory pulmonary infarct [pulmonary infarct occurs when a lung artery becomes blocked and lung tissue may begin to die].” There was no documentation of Patient #1’s pain being reassessed following the administration of the pain medication and prior to discharge to see if the pain medication was effective. Discharging prescriptions were documented as Eliquis Starter Pack 5 milligram tablets (anticoagulant/blood thinner) and to follow up with a Primary Care Provider (PCP) within 1-2 days. Patient #1 was discharged from the ED on 8/2/2024 at 9:44 AM. There was no documentation of vital signs (including pain assessment) being obtained within an hour of Patient #1’s discharge. There was no documentation ED Provider #1 or nursing staff reassessed Patient #1’s pain at any time after the initial pain assessment in triage on 8/2/2024 at 6:40 AM when Patient #1 rated his pain as a “10” (worst possible pain). There was no documentation ED Provider #1 or nursing staff reassessed Patient #1’s pain after Patient #1 received Toradol 30 mg IV which was administered 17 minutes prior to Patient #1 being discharged and leaving the ED. Cross Refer to A2406 and A2407.”

“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: 30070 Based on policy review, medical record review, Emergency Medical Services (EMS) documentation review, and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical attention were provided an appropriate and ongoing Medical Screening Examination (MSE) for 1 of 20 (Patient #1) sampled patients reviewed. Specifically, the facility failed to reassess Patient #1’s vital signs and pain as part of his ongoing MSE to assess if inpatient or outpatient therapy was needed. The findings included: 1. Review of the facility’s “Emergency Medical Treatment and Active Labor Act (EMTALA)” policy (2/5/21) revealed, “...Emergency Medical Condition (EMC) means: A medical condition manifesting 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...Placing the health of the individual...in serious jeopardy...Serious impairment to bodily functions...Serious dysfunction of any bodily organ or part...Medical Screening Examination (MSE) 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...Such screening must be performed by qualified medical personnel...and within the hospital’s capacity and capability. The MSE is an ongoing process, and the medical records must reflect continued monitoring based on the patient’s needs and must continue until the patient is either stabilized, admitted to inpatient care, or appropriately transferred...The MSE 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 EMC...The ED physician or QMP [qualified medical personnel] on duty shall be responsible for the general care of all patients presenting themselves to the ED and remains with the ED physician until the patient’s private physician or an on-call specialist assumes that responsibility, the patient is appropriately discharged, or the patient arrives at the receiving hospital following appropriate transfer...” Review of the facility policy “Emergency Services Standards of Care Policy” (revision date 12/2/2023), revealed, “ ...PURPOSE: To identify the procedure for vital signs assessment in Emergency Services ...A Complete set of vital signs includes ...Pain will be assessed and documented as a part of vital signs in triage. ...ESI Level 3, 4, or 5 will have vital signs documented approximately ever 4 hours ...Patients should have repeat vital signs documented with approximately 1 hour after administration of medications that affect the cardiovascular, respiratory, peripheral-vascular, or thermoregulatory systems depending on the medication’s onset of action ...Vital Signs shall be reassessed and documented within 60 minutes of departure from the ED [Emergency Department] for all patients - admitted, transferred, or discharged ...” 2. Medical record review revealed Patient #1 presented to the ED of Hospital #1 on 8/2/2024 at 6:38 AM by private vehicle. A triage assessment beginning at 6:40 AM documented the chief complaint as chest pain with inspiration. Triage vital signs were as follows: Temperature- 99.1 degrees Fahrenheit. Oxygen Saturation (oxygen in the blood stream)- 93 percent (normal 95 - 100) on room air. Pain Assessment- 10, worst possible pain, location: back. Patient #1 was given an acuity level of “3” (an emergency severity index (ESI) rated 1-5, with 1 being a critical patient requiring continuous monitoring; level 3 ESI indicates the patient’s medical condition is urgent and should be seen by the medical provider within 30 minutes). A Medical Screening Examination (MSE) was initiated on 8/2/2024 beginning at 6:45 AM by ED Provider #1. ED Provider #1 documented, “The patient presents with chest pain and Patient is a 36-year-old male who presents with left posterior chest wall pain that is worse with deep breath. Does endorse a cough although it is difficult to get anything up. The onset was 1 days ago...Review of Systems...Cardiovascular symptoms: Chest pain...” Review of Patient #1’s physical examination revealed Patient #1 had decreased breath sounds in the left lower lobe of the lung. The following laboratory testing was performed on Patient #1 on 8/2/2024 at 6:58 AM: Complete Blood Count (CBC), Prothrombin Time (PT) with international normalized ratio (INR) (measures how many seconds for a clot to form in a blood sample), Complete Metabolic Profile (CMP), and Troponin (measure heart muscle damage). The results from the laboratory testing revealed the follwing: White Blood Count was elevated at 13.59 (normal range 4.6-10.20). D-Dimer (checks for blood clotting problems) was elevated at 1.13 (normal range 0-0.49). The other results from the laboratory testing were documented as unremarkable. Patient #1’s chest x-ray performed on 8/2/2024 revealed the following, “Basal opacity [hazy area] is demonstrated on the lateral view could represent atelectasis (complete or partial collapse of a lung or a section of a lung) or pneumonia.” A computed tomography angiography (CTA) of the chest (a test that combines a CT scan with an injection of contrast material to create images of blood vessels and tissues ) revealed, “1. Positive study showing bilateral segmental branch emboli [blood clot] in the lower lobes, left greater than right. 2 ...groundglass opacity [hazy gray areas] in the posterior left lower lobe suspicious for small territory pulmonary infarct [pulmonary infarct occurs when a lung artery becomes blocked and lung tissue may begin to die].” ED Provider #1 ordered the following medications for Patient #1 while in the ED on 8/2/2024: Lovenox (anticoagulant/prevents blood clots) 80 milligram (mg) injection (ordered at 9:15 AM and administered at 9:27 AM) and Toradol (pain medication) 30 mg via intravenous (IV) push (ordered at 9:21 AM and administered at 9:27 AM). ED Provider #1 ordered pain medication 2 hours 36 minutes after seeing Patient #1 who rated his pain as a 10 (worst possible pain). The pain medication was administered at 9:27 AM which was 17 minutes prior to Patient #1 being discharged and leaving the ED. There was no documentation of Patient #1’s pain being reassessed following the administration of the pain medication and prior to discharge to see if the pain medication was effective. Further review of Patient #1’s MSE documented, “Reviewed labs and radiology with patient. CTA does show evidence of bilateral PEs [Pulmonary Embolism - blood clots], no evidence of heart strain...Discussed starting outpatient blood thinners with outpatient follow-up. Patient does not have a primary care provider, but is starting a new job in 2 days where he has insurance on day 1, states that he will follow-up starting next week. Discussed with patient signs symptoms return to the ER [emergency room] for..” Patient #1’s discharge diagnosis was documented as Bilateral Pulmonary Embolism. Discharging prescriptions were documented as Eliquis Starter Pack 5 milligram tablets (anticoagulant/blood thinner) and to follow up with a Primary Care Provider (PCP) within 1-2 days. Patient #1 was discharged from the ED on 8/2/2024 at 9:44 AM. There was no documentation of vital signs (including pain assessment) being obtained within an hour of Patient #1’s discharge. There was no documentation ED Provider #1 or nursing staff reassessed Patient #1’s pain at any time after the initial pain assessment in triage on 8/2/2024 at 6:40 AM when Patient #1 rated his pain as a “10” (worst possible pain). There was no documentation ED Provider #1 or nursing staff reassessed Patient #1’s pain after Patient #1 received Toradol 30 mg IV which was administered 17 minutes prior to Patient #1 being discharged and leaving the ED. 3. Review of Emergency Medical Services (EMS) #1 trip report dated 8/2/2024 revealed, “...Dispatch Priority...Priority 1 (Critical)...PSAP [Public Safety Answering Point - a dispatch center that handles emergency calls and directs them to the appropriate emergency services] Call...21:53:36 [9:53 PM]...Patient Contact Made...21:54:25 [9:54 PM]...22:04 [ 10:04 PM] Pain...10 [worst possible pain]...22:06 [10:06]...Signs & [and] Symptoms...Chest pain (cardiac)(Primary)...Chest pain on breathing...Cough...Shortness of breath...Weakness...[EMS mobile unit] was dispatched to a residence on [Patient #1’s address street name] for a male with difficulty breathing...Patient is a 36 yr [year] old male complaining of chest pain and SOB [shortness of breath] for 36-48 hrs [hours]. Was seen at [Hospital #1] and diagnosed with Pulmonary Embolism and suspected pneumonia. Was discharged 20 hrs ago [actual time was approximately 12 hours] with prescription for eliquis. Was not able to find a pharmacy that could fill it he claimed until Monday morning [8/2/2024 was on a Friday]. Claims that his symptoms are worsening and he feels he cannot catch his breath. Complaining of dizziness, chest that is a stabbing sensation to the chest and epigastrum [upper middle area of the abdomen], headache, and transient [passing quickly into and out of existence] shortness of breath...Patient exhibited a dry non-productive cough, and shortness of breath after 4-5 words. Assessment findings remain unchanged for duration...Report called via public service too [Hospital #1 ED]. On arrival to destination patient was checked in at desk. Long wait time for a bed...Emergency Room...At Destination...22:38:26 [10:38 PM]...Pt. [patient] Transferred...23:15:00 [11:15 AM - 37 minutes after arrival to the ED]...” 4. Medical record review revealed Patient #1 returned to the ED at Hospital #1 on 8/2/2024 at 10:41 PM via ambulance. ED Provider #2 initiated a MSE beginning at 10:42 PM and documented Patient #1 had been discharged home earlier in that same day and instructed to fill his anticoagulation (medication) prescription. ED Provider #2 documented, “ ...He [Patient #1] states he was not able to fill his anticoagulation and he feels like his chest pain and shortness of breath are getting worse.” A Triage assessment documented at 11:08 PM revealed Patient #1 complained of worsening shortness of breath since released from the ED earlier in the day. Patient #1 was given an acuity level of “2” (level 2 ESI indicates a high-risk condition that could become life threatening and should be seen by the medical provider within 15 minutes). Patient #1 reported constant pain to the left back and chest with a pain scale rating of “8” [severe pain]. ED Provider #2 transferred care to ED Provider #3 on 8/3/2024 at 1:00 AM. ED Provider #3 ordered morphine (strong pain medication) 4 mg IV push stat (immediately) on 8/3/2024 at 3:08 AM (4 hours 26 minutes after first being seen by a medical provider). The morphine was administered to Patient #1 by Licensed Practical Nurse (LPN) #1 on 8/3/2024 at 3:15 AM. There was no documentation ED Provider #3 addressed or reassessed Patient #1’s pain which he rated as an “8”. A repeat CTA was performed on 8/3/2024 at 4:34 AM with the results, “...IMPRESSION: 1. Pulmonary embolism involving segmental branches of bilateral lower lobar arteries. 2. Wedge shaped, peripheral, sub-pleural soft tissue density in left lower lobe_likely infarct. 3. Left basal atelectasis...” Further review of the continuing MSE revealed ED Provider #3 assessed Patient #1 and documented on 8/3/2024 at 6:50 AM, “Patient diagnosed with small subsegmental PEs this morning, reportedly was unable to Fill his Eliquis at the pharmacy today came back with worsening chest pain, repeat CTA obtained to determine if this was getting worsening clot burden, patient was given Lovenox, if patient has no worsening clot burden. CTA is about the same he still showing this infarct. however he [Patient #1] is still having significant pain, and does not seem to be likely to pick up his Eliquis today, so we will plan for [high observation - unit that provides more intensive care that a general unit but less than an intensive care unit] to help with pain control and anticoagulation”. ED Physician #3 ordered for Patient #1 to be admitted to the hospital, and Patient #1 left the ED on 8/4/2024 at 8:46 AM with diagnoses including Dyspnea, Chest Pain, and Bilateral Pulmonary Embolisms. In an interview on 8/14/2024 at 9:15 AM, Registered Nurse (RN) #1 verified she saw Patient #1 on his first ED visit on 8/2/2024 at 9:44 AM. RN #1 stated she instructed Patient #1 to get his medication filled and to follow up with his PCP at discharge. RN #1 verified they are supposed to obtain vital signs before a patient discharges. In an interview on 9/3/2024 at 10:34 AM, the Director of Emergency Services stated that if a patient rated his/her pain to be greater than 7 on the pain scale in triage, the triage nurse should let the medical provider know. The Director of Emergency Services stated they would expect the provider to address the patient’s pain. The Director of Emergency Services stated the ED didn’t have a specific policy about how often pain should be assessed except at triage, but they considered pain as the 6th vital sign and for pain to be assessed when vital signs were required to be taken. The Director of Emergency Services stated that performing a pain assessment when taking vital signs was a standard of care. In an interview on 9/3/2024 at 10:34 AM, the Emergency Room (ER) Manager stated they expected for nurses to reassess pain after pain medication was administered. The ER Manager stated that pain should be reassessed within 30 minutes after IV pain medication and within 1 hour after oral pain medication administration. The ER Manager stated they would expect a pain reassessment to include a numerical assessment, and documenting “pain is effective” was an incomplete assessment. Patient #1 presented to the Hospital #1 ED on the morning of 8/2/2024 with a chief complaint of pain. ED Provider #1 did not address Patient #1’s pain which he rated as “10” (worst possible pain) until 2 hours 36 minutes after first seeing the patient. Patient #1 received Toradol 30 mg IV push (ordered at 9:21 AM and administered at 9:27 AM). There was no documentation of a pain assessment following the administration of the pain medication and whether the pain medication was effective. The pain medication was administered 17 minutes before Patient #1 was discharged and left the ED on 8/2/2024 at 9:44 AM. There was no documentation ED Provider #1 or nursing staff reassessed Patient #1’s pain following the intial pain assessment conducted in triage on 8/2/2024 at 6:40 AM when Patient #1 rated his pain as a “10” (worst possible pain). Patient #1 was discharged from Hospital #1 on the morning of 8/2/2024 with instructions to follow-up with his PCP and fill prescription for Eliquis. Hospital #1 allowed Patient #1 to be discharged home, knowing he did not have a PCP to follow-up with and manage his anticoagulation therapy. Hospital #1 failed to obtain Patient #1’s vital signs (which included pain assessment) within an hour of discharge. Hospital #1 did not verify the needed anticoagulation medication (Eliquis) would be available to be filled. Patient #1 was not given instructions at discharge on what to do if unable to obtain the needed anticoagulation medication. Patient #1 presented to the Hospital #1 ED via EMS on 8/2/2024 at 10:41 PM with complaints of worsening chest pain (Patient #1 rated pain as an “8”) and shortness of breath. ED Provider #2 first saw Patient #1 on 8/2/2024 at 10:42 PM and transferred care to ED Provider #3 on 8/3/2024 at 1:00 AM. There was no documentation ED Provider #2 addressed Patient #1’s pain or that ED Provider #2 reassessed Patient #1’s pain following the initial pain assessment conducted in triage on 8/2/2024 at 11:08 PM. ED Provider #3 ordered morphine 4 mg IV push on 8/3/2024 at 3:08 AM (4 hours 26 minutes after first being seen by a medical provider in the ED), and Patient #1 received the morphine at 3:15 AM when Patient #1 rated his pain as an “8”. This was the first documented pain assessment for Patient #1 following the initial pain assessment conducted in triage (4 hours 33 minutes). Cross Refer to A2407.”

“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: 35244 Based on policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical attention were provided an ongoing assessment in order to determine if an identified Emergency Medical Condition (EMC) had been stabilized within the capabilities of the hospital for 1 of 20 (Patient #1) sampled patients reviewed. The findings included: 1. Review of the facility’s “Emergency Medical Treatment and Active Labor Act (EMTALA)” policy (2/5/21) revealed, “...Stabilized/Stabilization...Stabilized means, with respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility...The following definitions also apply under EMTALA...Stable for Discharge: A patient is stable for discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions; or, the patient requires no further treatment and the treating physician has provided a written documentation of his/her findings...” Review of the facility policy “Emergency Services Standards of Care Policy” (revision date 12/2/2023), revealed, “ ...PURPOSE: To identify the procedure for vital signs assessment in Emergency Services ...A Complete set of vital signs includes ...Pain will be assessed and documented as a part of vital signs in triage...ESI Level 3, 4, or 5 will have vital signs documented approximately ever 4 hours ...Patients should have repeat vital signs documented with approximately 1 hour after administration of medications that affect the cardiovascular, respiratory, peripheral-vascular, or thermoregulatory systems depending on the medication’s onset of action ...Vital Signs shall be reassessed and documented within 60 minutes of departure from the ED [Emergency Department] for all patients - admitted, transferred, or discharged ...” 2. Medical record review revealed Patient #1 presented to the ED of Hospital #1 on 8/2/2024 at 6:38 AM by private vehicle. A triage assessment beginning at 6:40 AM documented the chief complaint as chest pain with inspiration. Triage vital signs were as follows: Temperature- 99.1 degrees, Oxygen Saturation (oxygen in the blood stream)- 93 percent (normal 95 - 100) on room air. Pain Assessment- 10, worst possible pain, location: back. Patient #1 was given an acuity level of “3” (an emergency severity index (ESI) rated 1-5, with 1 being a critical patient requiring continuous monitoring; level 3 ESI indicates the patient’s medical condition is urgent and should be seen by the medical provider within 30 minutes). A Medical Screening Examination (MSE) was initiated on 8/2/2024 beginning at 6:45 AM by ED Provider #1. ED Provider #1 documented, “The patient presents with chest pain and Patient is a 36-year-old male who presents with left posterior chest wall pain that is worse with deep breath. Does endorse a cough although it is difficult to get anything up. He does smoke/vape. The onset [of the chest pain] was 1 day ago...Review of Systems...Cardiovascular symptoms: Chest pain...” Review of Patient #1’s physical examination revealed Patient #1 had decreased breath sounds in the left lower lobe of the lung. The following laboratory testing was performed on Patient #1 on 8/2/2024 at 6:58 AM: Complete Blood Count (CBC), Prothrombin Time (PT) with international normalized ratio (INR) (measures how many seconds for a clot to form in a blood sample), Complete Metabolic Profile (CMP), and Troponin (measure heart muscle damage). The results from the laboratory testing revealed the follwing: White Blood Count was elevated at 13.59 (normal range 4.6-10.20). D-Dimer (checks for blood clotting problems) was elevated at 1.13 (normal range 0-0.49). Patient #1’s computed tomography angiography (CTA) of the chest (a test that combines a CT scan with an injection of contrast material to create images of blood vessels and tissues ) revealed, “1. Positive study showing bilateral segmental branch emboli [blood clot] in the lower lobes, left greater than right. 2 ...groundglass opacity [hazy gray areas] in the posterior left lower lobe suspicious for small territory pulmonary infarct [pulmonary infarct occurs when a lung artery becomes blocked and lung tissue may begin to die].” ED Provider #1 ordered the following medications for Patient #1 while in the ED on 8/2/2024: Lovenox (anticoagulant/prevents blood clots) 80 milligram (mg) injection (ordered at 9:15 AM and administered at 9:27 AM) and Toradol (pain medication) 30 mg via intravenous (IV) push (ordered at 9:21 AM and administered at 9:27 AM). ED Provider #1 ordered pain medication 2 hours 36 minutes after seeing Patient #1 who rated his pain as a 10 (worst possible pain). The pain medication was administered at 9:27 AM which was 17 minutes prior to Patient #1 being discharged and leaving the ED. There was no documentation of Patient #1’s pain being reassessed following the administration of the pain medication and prior to discharge to see if the pain medication was effective. Further review of Patient #1’s MSE documented, “Discussed starting outpatient blood thinners with outpatient follow-up. Patient does not have a primary care provider, but is starting a new job in 2 days where he has insurance on day 1, states that he will follow-up starting next week. Discussed with patient signs symptoms return to the ER [emergency room] for...” Patient #1’s discharge diagnosis was documented as Bilateral Pulmonary Embolism. Discharging prescriptions were documented as Eliquis Starter Pack 5 milligram tablets (anticoagulant/blood thinner) and to follow up with a Primary Care Provider (PCP) within 1-2 days. Patient #1 was discharged from the ED on 8/2/2024 at 9:44 AM. There was no documentation of vital signs (including pain assessment) being obtained within an hour of Patient #1’s discharge. 3. Medical record review revealed Patient #1 returned to the ED at Hospital #1 on 8/2/2024 at 10:41 PM via ambulance. ED Provider #2 initiated a MSE beginning at 10:42 PM and documented Patient #1 had been discharged home earlier in that same day and instructed to fill his anticoagulation (medication) prescription. ED Provider #2 documented, “ ...He [Patient #1] states he was not able to fill his anticoagulation and he feels like his chest pain and shortness of breath are getting worse”. A Triage assessment documented at 11:08 PM revealed Patient #1 complained of worsening shortness of breath since released from the ED earlier in the day. Patient #1 was given an acuity level of “2” (level 2 ESI indicates a high-risk condition that could become life threatening and should be seen by the medical provider within 15 minutes). Patient #1 reported constant pain to the left back and chest with a pain scale rating of “8”. ED Provider #2 transferred care to ED Provider #3 on 8/3/2024 at 1:00 AM. ED Provider #3 ordered morphine (strong pain medication) 4 mg IV push stat (immediately) on 8/3/2024 at 3:08 AM (4 hours 26 minutes after first being seen by a medical provider). The morphine was administered on 8/3/2024 at 3:15 AM. There was no documentation ED Provider #2 addressed Patient #1’s pain which he rated as an “8”. Further review of the continuing MSE revealed ED Provider #3 assessed Patient #1 and documented on 8/3/2024 at 6:50 AM, “Patient diagnosed with small subsegmental PEs this morning, reportedly was unable to Fill his Eliquis at the pharmacy today came back with worsening chest pain, repeat CTA obtained to determine if this was getting worsening clot burden, patient was given Lovenox, if patient has no worsening clot burden. CTA is about the same he still showing this infarct. however he [Patient #1] is still having significant pain, and does not seem to be likely to pick up his Eliquis today, so we will plan for [high observation - unit that provides more intensive care that a general unit but less than an intensive care unit] to help with pain control and anticoagulation”. In an interview on 8/14/2024 at 9:15 AM, Registered Nurse (RN) #1 verified she saw Patient #1 on his first ED visit on 8/2/2024 at 9:44 AM. RN #1 stated she instructed Patient #1 to get his medication filled and to follow up with his PCP at discharge. RN #1 verified they are supposed to obtain vital signs before a patient discharges. In an interview on 8/15/2024 at 5:30 PM, ED Provider #2 verified she saw Patient #1 on his second ED visit on 8/2/2024 and stated, “He was diagnosed with a small blood clot earlier in the day...couldn’t get his meds [Eliquis] filled...Started having some pain and returned to the ED.” In a phone interview on 9/3/2024 at 12:30 PM, ED Provider #3 stated that Patient #1 presented to the ER on 8/2/2024 and had a diagnosis of low risk PE. ED Provider #3 stated Patient #1 returned to the ED later the same day with significant pain. ED Provider #3 stated he would provide some sort of pain control for anyone who presented with pain. ED Provider #3 stated it was a standard or care to address a patient’s pain. Patient #1 presented to the Hospital #1 ED on the morning of 8/2/2024 with a chief complaint of pain. ED Provider #1 did not address Patient #1’s pain which he rated as “10” (worst possible pain) until 2 hours 36 minutes after first seeing the patient. Patient #1 received Toradol 30 mg IV push (ordered at 9:21 AM and administered at 9:27 AM). There was no documentation whether the pain medication was effective. The pain medication was administered 17 minutes before Patient #1 was discharged and left the ED on 8/2/2024 at 9:44 AM. Patient #1 was discharged from Hospital #1 on the morning of 8/2/2024 with instructions to follow-up with his PCP and fill prescription for Eliquis. Hospital #1 allowed Patient #1 to be discharged home, knowing he did not have a PCP to follow-up with and manage his anticoagulation therapy. Hospital #1 failed to obtain Patient #1’s vital signs within an hour of discharge to ensure stabilization. Hospital #1 did not verify the needed anticoagulation medication (Eliquis) would be available to be filled. Patient #1 was not given instructions at discharge on what to do if unable to obtain the needed anticoagulation medication. Patient #1 presented to the Hospital #1 ED via EMS on 8/2/2024 at 10:41 PM with complaints of worsening chest pain (Patient #1 rated pain as an “8”) and shortness of breath. ED Provider #2 first saw Patient #1 on 8/2/2024 at 10:42 PM and transferred care to ED Provider #3 on 8/3/2024 at 1:00 AM. There was no documentation ED Provider #2 addressed Patient #1’s pain. ED Provider #3 ordered morphine 4 mg IV push on 8/3/2024 at 3:08 AM (4 hours 26 minutes after first being seen by a medical provider in the ED), and Patient #1 received the morphine at 3:15 AM. The Hospital #1 ED failed to provide stabilizing treatment by failing to adequately address Patient #1’s pain and reassess vital signs prior to his first discharge from the hospital ED. Cross Refer to 2406.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 33487 Based on policy review, medical record review, and interview, the facility failed to ensure that the nursing service met patient needs related to pain management for 1 of 3 (Patient #5) sampled patients. The findings included: 1. Review of the hospitals “Patient Rights and Responsibilities,” policy dated 11/17/2014, revealed “ ...Each patient is considered a partner in healthcare...encourages respect for the personal preferences ad values of each individual ...Patients have the right to ...Personal privacy, privacy of their health information and to receive a notice of the facility’s privacy practices ...Pain management ...Care or services provided without discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression ...Be free from neglect, exploitation, and verbal, mental, physical, and sexual abuse ...An environment that is safe, preserves dignity and contributes to a positive self-image ...” Review of the hospital’s “Pain Management Program Policy,” policy dated 10/10/2020, revealed “ ...The patient’s self-report of pain is accepted as the most reliable marker of the presence and extent of pain ...Pain will be assessed on initial assessment, an ongoing reassessment of pain is performed on a regular basis utilizing appropriate, reliable, and valid pain assessment tool ...Patient-specific pain management outcomes will be established and I if not achieved will elicit a review and modification of the pain management program ...” 2. Review of the medical record revealed Patient #5 was admitted to the hospital on 6/7/2023 with a diagnosis of Cholecystitis. Review of the Triage Note dated 6/7/2023 at 8:17 PM, revealed, “...Chief Complaint: pt [patient] having bilateral flank pain also mid abdominal pain and feel nauseous pt is also constipated been going on for days ...[heart rate...85]...[blood pressure...125/77]...alert...oriented x 4 [patient understands who they are, where they are, approximate date or part of the day, and what is happening]...Pain Present: Yes actual or suspected pain...Pain location: Abdomen upper, flank...Laterally: Bilateral...Quality: Sharp, tenderness ...Time Pattern: Constant...Numeric Rating at Rest: 10 = Worst possible pain...” There was no documentation the triage nurse notified the medical provider that Patient #5 reported severe abdominal pain. Review of the History of Present Illness Note [Physician Assistant Note] dated 6/8/2023 at 12:46 AM, revealed Patient #5 was a 35-year-old female who presented to the emergency department (ED), “...for nausea and vomiting. Patient reports she was sent over here by her gastroenterologist for a work-up given the amount of pain she is in...Denies any shortness of breath or chest pain. Reports she is having stabbing abdominal pain...” Review of the History and Physical dated 6/8/2023, revealed, “...History of present illness: Patient is a 35-year-old African-American female that comes into the emergency room complaining of severe epigastric abdominal pain. She reports nausea and vomiting. She also reports that she has been having episodes of constipation. Patient states that her pain has been ongoing for approximately 2 weeks however it seems to have worsened over time. Patient reports that roughly a year ago she had similar symptoms. At that time she was told that her gallbladder was dysfunctional and may need to be removed. However she never had surgery. Patient was not noted to have elevated LFTs [liver enzymes]. Additionally she was not noted to have elevated white blood cell count. Ultrasound of the right upper quadrant was concerning for gallstones. She has had a laparoscopic Roux-en-Y bypass [surgery through small incisions in the abdomen for the purpose of weight loss] in the past. She does report that symptoms seem to be worse with eating...” Review of the Radiology Results dated 6/8/2023, revealed, “...Gallbladder distention with some internal sludge but no gallstones. No gallbladder wall thickening or pericholecystic fluid is seen. Clinical correlation for signs or symptoms of acalculous cholecystitis still recommended...” Review of the Medication Administration Record revealed Patient #5 received Fentanyl [narcotic] on 6/8/2023 at 12:53 AM. There were no other documented interventions or medications given to address Patient #5’s pain documented from the time that Patient #5 first reported pain at a level of 10 (worst possible pain) on 6/7/2023 at 8:17 PM until Patient #5 received Fentanyl on 6/8/2023 at 12:53 AM (4 hours 36 minutes). Review of the Surgical Documentation revealed Patient #5 was admitted to the hospital and underwent a laparoscopic cholecystectomy (surgical removal of the gall bladder through small incisions in the abdomen) for a distended gall bladder on 6/8/2023. 3. During an interview on 11/2/2023 at 1:10 PM, the Interim Emergency Room Director stated, “...Patient was admitted on 6/7/2023 at 8:02 PM; Triaged on 6/7/2023 at 8:17 PM; seen by a provider on 6/8/2023 at 12:46 AM; meds [medications were ordered] at 12:50 AM and given at 12:53 AM...” When asked why the patient was allowed to remain in pain (from 6/7/2023 at 8:17 PM to 6/8/2023 at 12:53 AM, the Interim Emergency Room Director stated, “...The expectation is if a patient comes in with that pain level, the nurse is to notify the provider...” The Interim Emergency Room Director confirmed there was no documentation that the nurse notified the provider of Patient #5’s reported pain level of 10 (worst possible pain). During an interview on 11/20/2023 at 10:45 AM, the ED Technician [Tech] stated, “...when someone enters the ED, they come to the window and give us their ID [identification such as a driver’s license], and basic information is put into the computer at that time. We try and ask some basic questions about their complaint to determine if they are emergent or not...I print out a face sheet and wrist band for the patient and place them in the waiting room...a paramedic or tech will monitor the waiting room...get vital signs, and any additional complaints a patient might have...will assist in getting the patient’s labs or diagnostic tests after the triage nurse has ordered them...there are nursing protocols for the triage nurse...” During an interview on 11/20/2023 at 11:50 AM, Registered Nurse (RN) #1 confirmed she was an RN in the ED and had worked in the triage nursing role. RN #1 confirmed the triage nurse should report to the medical provider if a patient reported severe pain during the triage assessment. During an interview on 11/20/2023 at 11:58, RN #2 confirmed he was an RN in the ED and had worked in the triage nursing role. RN #2 confirmed the triage nurse should report to the medical provider if a patient reported severe pain during the triage assessment. During an interview dated 11/20/2023 at 1:05 PM, the Physician’s Assistant (PA) stated, “...Sometimes the patient says they have 10/10 pain, but after reviewing their blood pressure and heart rate and talking with the patient, they are really alright...I wasn’t even in the building at 8:00 PM...I arrived to the ED around 9:00 PM...I addressed the pain as fast as I could...There were other clinicians in the ED seeing other patients, and I’m sure they were probably more emergent than she [Patient #5] was at that time...” When asked if he was familiar with the hospital’s pain policy the PA stated, “ ...No, but I am familiar with how to deal with a patient’s pain...””