Knapp 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: 21935 Based on record review and interview, the facility failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. Specifically, the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital’s emergency department to determine whether an emergency medical condition (EMC) existed for 1 of 1 patient (Patient #1) reviewed that presented to the emergency department (ED) November 11, 2023 with respiratory complaints. Patient #1 was a 3 week, premature infant (born at 35 weeks) that presented to the ED with respiratory distress; cough, congestion and reports of low oxygen saturation levels of 86%, and did not receive an appropriate and thorough MSE to include necessary assessments and diagnostics. Patient #1 was discharged without stabilization when O2 levels were last documented at 86% (below normal range). As a result, Patient #1 did have an EMC of hypoxic respiratory failure with respiratory distress that could lead to complete respiratory failure, including death. There were also risk factors and signs of sepsis, which could lead to septic shock, organ failure, and death. Refer to A-2406 - §489.24(a) Medical Screening Examination for specific evidence.”

“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: 21935 Based on review of documentation and interview, the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital’s emergency department to determine whether an emergency medical condition (EMC) existed for 1 of 1 patient (Patient #1) reviewed that presented to the emergency department (ED) November 11, 2023 with respiratory complaints. Specifically, Patient #1 was a 3 week, premature infant (born at 35 weeks) that presented to the ED with respiratory distress; cough, congestion and reports of low oxygen saturation (O2) levels of 86%, and did not receive an appropriate and thorough MSE to include necessary assessments and diagnostics. Patient #1 was discharged without stabilization when O2 levels were last documented at 86% (below normal range) and approximately 4 hours later Patient #1 was seen at another facility’s ED with apnea episodes (when breathing stops) requiring resuscitation. As a result, Patient #1 did have an EMC of hypoxic respiratory failure with respiratory distress that could lead to complete respiratory failure, including death. There were also risk factors and signs of sepsis, which could lead to septic shock, organ failure, and death. Findings included: Review of Complaint Intake, TX00479931 dated 11/27/2023 indicated Patient #1 was a 3 week old infant that was a “preemie” born at 35 weeks and taken to the facility’s ED for RSV (Respiratory Syncytial Virus). Patient #1 was discharged and the parents told that she could not be transferred to another hospital. Patient #1 was released with 78% oxygen readings, and later that evening, she stopped breathing, and they barely made it to another hospital in another city. Patient #1 should have been transferred because they knew her oxygen was in the 70’s. Review of the EMTALA Policy: Compliance with the Emergency Medical Treatment and Active Labor Act (last revised 3/20/19): 1. On 2nd paragraph page 1 of 5: “Any individual who “comes to the hospital emergency department” requesting examination or treatment shall be provided with an appropriate Medical Screening Exam (MSE). This MSE will determine whether an individual has an actual Emergency Medical Condition (EMC)” 2. Under Procedure: page 3 of 5 section 3: “MSE: A medical screening examination is offered to any individual who presents for an examination or treatment of a medical condition. The MSE is a continuous process reflecting ongoing monitoring in accordance with an individual’s needs.” Review of the Vital Signs Policy: Last revised 4/92, Last reviewed 12/2021. On page 1 of 1 under procedures line 6 it states: “ 6. Vital signs must be taken before patient is discharged.” Review of Texas Board of Nursing Registered Scope of Practice https://www.bon.texas.gov/practice_scope_of_practice_rn.asp which defines the legal scope of practice for registered nurses: “.....Professional nursing involves: A. the observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes.....” Review of Patient #1’s complete medical record from Hospital A revealed the following; in part: 1.) A medical treatment record review of three-week-old female patient who presented to the emergency department at Knapp Medical Center on November 11, 2023, at 7:23 pm via car. Chief complaint documented on page 5 of 61 Reason for visit documented by emergency department (ED) nurse on 11.11.2023 at 7:39 pm was “cough, nasal congestion.” The documented Visit Diagnosis by ED physician on 11.11.2023 at 10:18pm was” RSV (acute bronchiolitis due to respiratory syncytial virus) primary and Hypoxemia.” The ED disposition documented on page 5 of 61 at 11.11.2023 at 10:17pm by ED physician patient was discharged. Condition “stable.” Comment: “Patient discharged to home/selfcare. Condition at discharge: “Stable” The ED Care timeline pages 8-15 of 61 describes the chronological timeline of care the patient received while in the emergency department and who provided care. The patient received respiratory treatment and was monitored by a respiratory technician (RT) and assigned nurse. The patient last reassessed by the ED physician at 10:17 pm on November 11, 2023, at this time the patient Sao2 (arterial oxygen saturation) was 98% at room temperature. Discharged orders were placed at this time. The 3 week old patient remained in the emergency department being monitored and observed by nurse and respiratory technician until the patient physically left from the emergency department at 12:08 am on November 12, 2023, to go home with parents. It was observed in the 3-week-old female patients medical treatment record vital signs taken at 10:30 pm on 11.11.2023 that the patient’s respiration was 19 and SpO2 (peripheral oxygen saturation taken by pulse oximeter) decrease to 78% and a heart rate (HR) of 165. Further review revealed: - vital signs taken at 10:45 pm 11.11.2023 the patient’s SpO2 was documented as 88%, and HR of 153. - vital signs taken at 11:00 pm 11.11.2023 the patient’s SpO2 was documented as 85%, and HR of 162. - vital signs taken at 11:15 pm on 11.11.2023 the patient’s SpO2 was documented as 86%, and HR of 147. In review of the ED care timeline. There were no further vital signs conducted between 11:15 pm until the time the patient left the facility which was documented as 11:53 pm on 11.11.2023. Other documentation in the ED record noted the patient as physically leaving the ED at 12:08 am on 11.12.2023. Upon review of Patient #1’s complete ED medical record; there was no evidence provided that the staff monitoring the baby notified the attending ED physician of the decrease in the 3-week-old patient’s saturated oxygen levels after 10:17 pm on 11.11.2023. There was no evidence a sepsis screening was conducted on the patient during this visit. A full medical screening within the capabilities of the hospital was not conducted before the patient was discharged home. The facility did not transfer the patient to a facility that had the capability of having a pediatrician available who could initiate a septic protocol and care for the infant. 2.) Review of Patient #1’s emergency medical record #2 Hospital B: 3 week old patient was brought to the emergency room at 4:16 am on November 12, 2023 due to apneic episode, shortness of breath, diagnosis : RSV infection, community acquired pneumonia. Patient had 2 episodes of apnea, needed to be resuscitated. Patient treated and admitted. Discharged on November 17, 2023. Interviewed staff #4, Respiratory Services Director at Knapp Medical Center on December 12, 2023 at 4 pm in administration conference room in facility. This staff did not directly provide any treatment to the 3 weeks old patient but reviewed respiratory services notes including respiratory services treatment and monitoring. This staff believed the spO2 reading of the patient after 10:15 pm was low due to sensors not being on the baby’s tiny fingers securely. Staff#4 explained the baby probably was moving around quite a bit. There was no evidence provided if SpO2 levels were confirmed to make sure there was no respiratory issues with the patient. Staff did observe in notes that vital signs were not conducted on patient at least 30 minutes before the 3 week old patient was discharged. Interviewed staff #5, attending emergency physician who provided MSE and treatment for baby on November 11, 2023 at 8:15 pm on December 15, 2023 via telephone. Staff #5 explained the care he provided and interactions with patient’s parents. Staff #5 explained last time he re-assessed the 3-week old patient was at 10:18 pm on 11.11.2023. He saw the 10:15 pm SpO2 reading which was 98% at room temperature. He had ordered treatment for patient and had respiratory services monitor baby. The attending physician explained after his last re-assessment he felt the patient was stable enough to be discharge. He advised parents to take patient to their pediatrician in 2 days. He had the staff monitor the patient a little longer. He explained to the parents that there was no pediatrician at this facility at night. He explained to parents if the patients conditions worsen they could bring patient back to facility but there was no pediatrician at night at Knapp Medical Center. The physician explained to the patients family that they could still admit patient if needed. The ED physician said he advised family that they could take the patient to another facility that had a pediatrician. The parents agreed with the plan. He said from the time of his re-assessment until when the patient finally left the ER none of the staff had notified him about the patient’s declining SpO2’s. Interviewed staff #6, attending nurse who took care of baby on November 11, 2023 at 9:35 am on December 20, 2023 via telephone call. Staff said she could not recall taking care of patient but did review her assessments and notes in the treatment record. Staff observed the SpO2 levels of the baby being lower than the normal of 91% after the 10:15 pm reading on November 11, 2023. She said it was probably due to the 3 week old patient moving around and the sensors not staying in place on the patients small fingers. she said sometimes they place the sensor on the infants ears and when they are squirming around a lot it throws off the readings. She could not confirm in this case if that happened. Staff # 6 could not confirm if there was a confirmatory procedure provided to ensure if the readings were correct or not. The staff could not answer question. The staff #6 could not answer why vitals signs were not conducted on baby at least 30 minutes before they left the emergency department on December 12, 2023. The facility did not transfer the patient to a facility that had the capability of having a pediatrician available who could initiate septic protocol and care for this infant. The patient was discharged to home.”