Saint Francis Bartlett 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: 53332 Based on policy review, medical record review, and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical evaluation and treatment were provided an appropriate Medical Screening Examination (MSE) for 1 of 21 (Patient #1) sampled patients that were reviewed. The findings included: Patient #1 presented to the Hospital on 04/27/2025 at 5:07 PM via personal vehicle with complaints of continued pelvic pain that worsens with movement and certain positions changes with some relief from tramadol (controlled medication used to treat moderate to severe pain) and Motrin (medication for pain). Patient #1 was triaged at an Emergency Severity Index (ESI - triage method to prioritize patients based on their acuity) of “4” which means classification of Stable (patients at this level are stable and only need one resource for their care, such as a simple lab test or a prescription). Patient #1’s chief complaint is pelvic pain that has continued from previous ED visit on 4/22/2025. Patient #1 stated during the 4/27/2025 ED visit she had an appointment scheduled with the cancer clinic in five days from the date of the ED visit. Patient #1 was discharged home 4/27/2025. Cross Refer to 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: 53332 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 appropriate Medical Screening Examination (MSE) for 1 of 21 (Patient #1) sampled patients that were reviewed. The facility failed to adequately assess and perform a Medical Screening Examination (MSE) on Patient #1’s continued lower abdominal pain to determine if a Emergency Medical Condition (EMC) existed. The findings included: 1. Review of the facility’s “Emergency Medical Treatment and Labor Act of 1986 (EMTALA)” policy (09/15/2022) revealed, “...Emergency Medical Condition (EMC): A 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 individual’s health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs...Medical Screening Examination (MSE) (is the) screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist... will provide an appropriate MSE within the capability of (the hospital) to any individual coming to the Dedicated Emergency Department...(and) will provide an individual who is determined to have an Emergency Medical Condition further medical examination and treatment as is required to stabilize the Emergency Medical Condition including admission for inpatient care, or arrange an appropriate transfer of the individual to another medical facility with the capability to provide the stabilizing care...” 2. Medical record review for Patient #1 revealed an admission date of 4/22/2025 at 3:08 PM. Her ultrasound demonstrated a multiloculated right ovarian cystic mass (a fluid-filled sac inside the ovary that is divided into multiple smaller compartments by thin walls). Patient #1 was discharged on 4/22/2025 at 6:30 PM with a diagnosis of Ovarian Cyst and a recommendation to follow-up with obstetrician/gynecologist (ob/gyn- a physician who specializes in women’s reproductive health, pregnancy, and childbirth) for further evaluation and treatment. 3. Patient #1 again presented to the Hospital on 04/27/2025 at 5:07 PM via personal vehicle with chief complaint of pelvic pain. Patient #1 stated she was diagnosed with a “large ovarian mass 5 days ago here [at this hospital]” Patient #1 stated she had an appointment scheduled [at her obstetrician/gynecologist (ob/gyn) - physician who specializes in women’s reproductive health, pregnancy, and childbirth], but it was not for another 5 days, and the pain in the pelvis was worse with movement and certain positions. Patient #1 reported taking Tramadol (controlled medication used to treat moderate to severe pain) and Motrin (medication for pain) with some relief. She stated the pain was worse first thing in the morning time. Patient #1 was triaged with an Emergency Severity Index (ESI - triage method to prioritize patients based on their acuity) of “4” which means classification of Stable (patients at this level are stable and only need one resource for their care, such as a simple lab test or a prescription). Patient #1 stated pain of 10 out of 10 (using a pain scale where 0 is no pain and 10 is the worse pain ever the patient ever experienced). A Medical Screening Examination (MSE) was initiated on 04/27/2025 at 5:10 PM by the Physician Assistant (PA). The PA’s exam revealed Patient #1 experienced tenderness when the PA palpated the suprapubic area (lower central region of the abdomen, located just above the pubic bone and below the navel) and right lower quadrant of the abdomen. On 04/27/2025 at 6:01 PM, Patient #1 was administered Ketorolac (medication used to treat moderate to severe pain) 30 milligrams (mg), oxycodone 5 mg (medication used to treat severe pain) and ondansetron (medication used to treat nausea) 8 mg. The PA documented on 04/27/2025 at 5:29 PM Patient #1’s workup was complete, and she would be discharged home with pain medication. There was no documentation imaging was obtained during this ED visit to evaluate for ovarian torsion. After Patient #1’s appointment at the cancer clinic, she was admitted to this hospital on 05/08/2025 for an outpatient surgical procedure to remove an ovarian mass. On 05/08/2026 at 4:47 PM, Patient #1 underwent a robotic appendectomy (removal of appendix), robotic right salpingo-oophorectomy (fallopian tube and ovary removal) and a mini laparotomy (surgical procedure that involves making an incision through the abdominal wall to gain access to the abdominal cavity) with removal of a 10 x 8 x 8 centimeter (cm) adnexal mass (a growth, lump, or enlargement that develops in the adnexa of the uterus, which includes the ovaries, fallopian tubes, and nearby connective tissues.) There was obvious torsion (twisting) of the ovary ligament and the appendix was wrapped into that mass. During an interview on 05/12/2026 at 11:00 AM, the Emergency Room (ER) Medical Director revealed, “I reviewed the records and on her first visit she’s having right lower quadrant pain, and so you want to rule out a surgical or emergent cause for the abdominal pain. On her first visit, a CT [computerized tomography] [imaging test that uses X-rays and a computer to create detailed pictures of the inside of your body] was obtained, and it looked like she had an ovarian cyst or mass. So, on the reevaluation a few days later (on 04/27/2025), it looked like after she was given some pain medication, vital signs were stable, and she appeared to be resting comfortably, they discharged her with follow up to the Cancer clinic. It would be up to the discretion of the provider to reorder imaging (CT or ultrasound) at that time, based on the symptoms and physical assessment.””

“EMERGENCY LABORATORY SERVICES CFR(s): 482.27(a)(1) Emergency laboratory services must be available 24 hours a day. This Standard is not met as evidenced by: 53332 Based on review of hospital policy, medical record review, and interview, the hospital failed to report critical laboratory findings in a timely manner for 1 of 3 (Patient #3) sampled patients reviewed. The findings included: 1. Review of hospital policy, “Critical Tests and Alert Values” documented, “Purpose: A process exists where by all laboratory results that fall outside of defined limits are communicated to the responsible licensed caregiver or health professional that can take definitive action... Definitions...Critical Tests- A test defined by the testing department to be critical in nature and is reported to the licensed caregiver or physician, regardless of the result. The following tests are considered critical tests and monitored for timeliness, CBC [Complete Blood Count], Comp [Comprehensive] Metabolic Profile...Procedure: alert values will be called by the lab personal to the appropriate caregiver within 15 minutes of finalizing the test value...Goals are as follows: Lab to nursing, 15 minutes, Nursing to MD, 30 minutes...” Medical record review for Patient #3 documented the patient was admitted on 9/5/2025 at 9:49 AM to the emergency department with chief complaint of intermittent worsening Altered Mental Status, Lower Extremity Edema, and Low Blood Pressure. A CBC was ordered at 10:00 AM and collected at 10:39 AM. The critical lab result was called back to Registered Nurse (RN) at 2:59 PM (4 hours and 20 minutes) by laboratory personnel. The critical results were:Hemoglobin (a protein in the red blood that carries oxygen from the lungs to the body’s tissues and transports carbon dioxide back to the lungs) 5.2 , reference range, 12.0 to 16.0. The Hematocrit (measures the percentage of red blood cells in your body) was 16.2., reference range, 36.0 to 46.0. There was no documentation the emergency department was notified of the critical lab results until 2:59 PM. In an interview on 9/29/2025 at 1:00 PM, the Director of Lab Services provided the policy and procedure for critical tests and alert values. The policy documented “...lab to nursing 15 minutes, nursing to MD [Medical Doctor] 30 minutes...”. When asked about the four-hour delay for Patient #3’s lab, the Director of Lab Services stated, “...that is not a reasonable amount of time...”. In a telephone interview on 9/30/2025 at 11:00 AM, Physician #1 stated “...I remember the sister expressing concern of her discharge. I did a rectal exam on the patient and re-ordered her lab work. I was surprised at it because she did not present with classic pallor and basically looked good. I reversed my course of treatment and cancelled her discharge home and had her admitted to the hospital. I don’t know why her lab was not reported to me...” Physician #1 stated that a delay such as that is not normal and the lab normally calls the ED desk and then that call is given to the Charge Nurse or another Registered Nurse (RN), who then notifies the physician. In an interview on 9/30/2025 at 11:19 AM the Lab Director stated, “there is no explanation for the delay in reporting the critical Hemoglobin and Hematocrit”.”