Pampa Regional Medical Center

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 28421 Based on review of documentation, it was determined that 1 of 23 patients (Patient #21) did not receive an appropriate Medical Screening Exam prior to discharge from the emergency department. Findings were: Facility policy entitled “EMTALA-Compliance with the Emergency Medical Treatment and Active Labor Act” (last revised 3/16, last approved 10/21) stated in part “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). This exam should be done in a non-discriminatory way ... Pampa Regional Medical Center will provide emergency services and care without regard to an individual’s race, ethnicity, national origin, citizenship, age, sex, sexual orientation, preexisting medical condition, physical or mental handicap, insurance status, economic status or ability to pay for medical services, except to the extent that a circumstance such as age, sex, preexisting medical condition, or physical or mental handicap is medically significant to the provision or appropriate medical care to the patient.” On 12/13/23, Patient # 21 arrived at the emergency department requesting nebulizing treatment with complaints of cough, congestion, and shortness of breath (SOB). Patient #21’s triage vital signs at 9:42 pm included high pulse (118), high blood pressure (BP 208/157), and decreased oxygen saturation at 92% on Room Air (RA). Patient #21 refused labs, but there was no documentation of discussion of risks of refusal. Patient #1’s last set of vital signs at 10:35 pm continued to be abnormal: BP 206/157, pulse 101, oxygen saturation 92% RA. There was no documentation of determination of severity of asthma exacerbation and the patient’s abnormal vital signs were not addressed. Patient #21 was not provided an appropriate MSE, as there was no continued assessment of systems. On 12/15/23, Patient #21 presented to the ED with severe SOB. The ordered EKG (electrocardiogram) was not documented or scanned into the chart. Patient had elevated troponin level and MI (myocardial infarction/heart attack) was not ruled out prior to the transfer. Patient had elevated WBC and was not given antibiotics or IV fluids prior to transfer.”

“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: 28421 Based on review of documentation, it was determined for 1 of 23 ED patients reviewed (Patient #21), the facility failed to: A. ensure Patient #21 was stable and appropriate for transfer; and B. obtain a written request by the individual (or their represtantive) or ensure a physician signed a certification detailing benefits outweighed the risks of the transfer. Findings were: Facility policy entitled “EMTALA-Compliance with the Emergency Medical Treatment and Active Labor Act” (last revised 3/16, last approved 10/21) stated in part “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). This exam should be done in a non-discriminatory way ... Pampa Regional Medical Center will provide emergency services and care without regard to an individual’s race, ethnicity, national origin, citizenship, age, sex, sexual orientation, preexisting medical condition, physical or mental handicap, insurance status, economic status or ability to pay for medical services, except to the extent that a circumstance such as age, sex, preexisting medical condition, or physical or mental handicap is medically significant to the provision or appropriate medical care to the patient.” On 12/15/23, Patient #21 presented with chest pain and respiratory distress via EMS (Emergency Services/Ambulance) to the ED after becoming unrresponsive at home. This was Patient #21’s third time to visit the ER in 4 days; Patient #21 was diagnosed with influenza B on their first visit to the ED on 12/11/23. EMS attempted intubation; a king tube (airway management device) was placed instead. In the ED, the physician orders for Patient #21 included: labs, urine, arterial blood gas, chest x-ray (CXR), and EKG; an endotrachial tube, gastric tube, and foley catheter were placed. Patient #21 had elevated troponin levels, d dimer, white blood cell count, and lactic acid level; Patient #21’s CXR revealed right middle lobe pneumonia. Patient #21 was treated for possible angioedema (swelling under the skin) with medications (epinephrine, solu-medrol, famotidine, and benadryl) but was not treated for sepsis (no antibiotics or IV (intravenous) fluids) with no documentation why these were not given. Although Patient #21’s troponin level was elevated, which could indicate heart attack (MI), the ordered EKG was not documented nor scanned into the chart. Patient #21’s elevated d dimer could indicate pulmonary embolism (PE), but Patient #21 did not receive a CT (computed tomography scan) to rule out PE. Further, there was no documentation of a written request of transfer indicating the patient was aware of the risks and benefits of the transfer; nor did a physician sign a certification that contained a summary of the risks and benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweighing the increased risks to the individual from being transferred.”