Covenant 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: 31974 Based on interview and record review, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements. The facility failed to provide an appropriate medical screening examination within the capability of the hospital’s emergency department when 1 of 20 patients reviewed (Patient #1) presented to the Emergency Department (ED) and did not receive an appropriate medical screening examination when presenting on 3/15/24. Refer to 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: 31974 Based on review of documentation, the facility failed to provide an appropriate medical screening examination within the capability of the hospital’s emergency department when 1 (Patient#1) of 20 patients presented to the Emergency Department (ED) on 3/15/24. Findings were: Patient #1 presented to the emergency department with 2 of 4 criteria meeting SIRS (systemic inflammatory response syndrome) criteria and infection. Sepsis screening was not completed as per facility protocol: Facility protocol - Sepsis Algorithm titled “SEPSIS Early Detection and Treatment: Alert to Patient with 2 SIRS (systematic inflammatory response syndrome)... Temp >100.9 or <96.8 HR >90 RR >20 WBC >12K... Diagnosis Order Set: Lactate Blood Cultures CBC (complete blood count) CMP (comprehensive metabolic panel) PT/INR/PTT (coagulation studies) Procalcitonin UA C&S (urinalysis and urine culture & sensitivity) CXR (chest x-ray) Suspect Sepsis initial treatment: COMPLETED WITHIN 3 HRS 1. Measure lactate level 2. Obtain blood cultures prior to administration of antibiotics 3. Administer broad spectrum antibiotics 4. Administer 30 ml/kg for hypotension or lactate 4.0 3/15/24 4:32 PM Patient #1, 5 weeks postpartum, presented to the emergency department - “Patient complaining of left flank pain, fever, headache onset yesterday. Patient denies any difficulty and painful urination. Patient states she had a history of kidney stones before. Patient denies n/v/d (nausea, vomiting, diarrhea).” Vitals: Temp 35.7 degrees Celsius (96.3 degrees Fahrenheit), HR(heart rate) 114, Respirations 17, Blood pressure 124/67, SpO2: 98%. On admission Patient #1 had 2 of 4 criteria meeting SIRS (systemic inflammatory response syndrome) criteria and infection - Temperature 96.3 degrees Fahrenheit and HR 114. Later laboratory results returned with WBC (white blood cells) - 13K. Urinalysis - 51-100 WBC, few bacteria, trace hematuria plus patient #1’s heart rate remained elevated throughout her stay as documented as HR 110 at 6:00 PM and HR 126 at 7:00 PM. The following assessment is noted in the medical chart: MSE: 5:37 PM Constitutional: ...Genitourinary: left flank tenderness. no frequency, no urgency, no hematuria ...Neurological: headache. no paresthesias, no sphincter control loss procedures, no focal weakness..All Other Systems were Reviewed and Found Negative ...Physical Exam: GU left flank tenderness ...Medical Decision Making: Antibiotics and pain medication given. Patient will be discharged home with antibiotics and fluids ...Clinical Impression: Final Diagnosis: Pyelonephritis ...ED Disposition: Discharge, condition stable ...” ED Nurse note 5:45 PM “Patient alert and oriented x 4, complains of left flank pain since yesterday w/ha (with headache) and nausea today. PMHX Kidney stones. Patient reports being post-partum since 2/7/24. Patient denies cough, abdominal pain, dysuria. RR (respiratory rate) easy and non-labored. Abdomen soft and non-tender. Patient reports increase pain to left flank with palpation. Bilateral radial pulses palpable, skin cool, dry, and normal for race. Patient shivering and complains of feeling cold. Patient remains afebrile at this time.” Vital signs 3/15/24 6:00 PM: Temp 36.6 degrees C (97.8 degrees F), HR 110, respirations: 18, blood pressure 121/56, SpO2: 96%. Medications ordered/administered: CefTRIAXone (Rocephin) 1 g (gram) in lidocaine IM 3/15/24 at 6:38 PM, HYDROcodone-acetaminophen (Norco) 5-325 mg po (Orally) dose: 1 tablet at 3/15/24 7:49 PM ondansetron (Zofran) 4 mg po at 3/15/24 6:38 PM. Labs ordered/completed: Urinalysis; Pregnancy, Serum, Qual; CBC with Differential; Comprehensive Metabolic Panel. Medical Decision Making: 3/15/24 6:10 PM: “Patient #1 presented to the Emergency Department for evaluation, and she was triaged to room ED39. I reviewed the nursing notes, and she was evaluated by me. Patient will be discharged home with antibiotics and fluids. History and reduction (sic) given via interpreter who is not a family member the patient is not nauseated she can carry on a biotics (sic) Disposition Clinical Impression: Final diagnoses: Pyelonephritis ED Disposition Discharge Condition Stable” No assessment for sepsis was performed by the physician. Lactate, blood cultures, PT/INR/PTT, Procalcitonin, urine culture or CXR were not ordered by the physician as required by hospital protocol. And no IV fluids were administered. Patient had left flank tenderness on exam - no imaging ordered. History of kidney stones - documentation reflected diagnostics were not completed to rule out hydronephrosis from obstructing urethral stone/s. 30 minutes prior to discharge, Patient #1 reported a 6/10 pain despite the administration of oral medications for pain.”