Holy Cross Hospital-Jordan Valley

“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: 45710 Based on interview and record review, it was determined that the hospital failed to meet the requirements for EMTALA. Specifically, the hospital did not provide an appropriate medical screening examination (MSE) for one individual who came to the emergency department seeking emergency care. (Patient Identifier: 9) Findings include: The hospital’s policies for emergency medical treatment and active labor act (EMTALA) stated that the hospital will provide an MSE to determine whether an emergency medical condition exists. The MSE is an ongoing process, and the medical record must reflect an ongoing assessment of the patient’s condition. Monitoring must continue until the individual is stabilized or appropriately admitted, transferred or discharged. There should be evidence of this prior to discharge or transfer. The MSE must be documented in the electronic health record (EHR). Review of the Emergency Department (ED) record for patient 9, showed he arrived at the hospital ED accompanied by law enforcement on 6/5/2024 at 4:36 PM, with altered mental status, alcohol abuse with intoxication, and a history of traumatic brain injury (TBI). Documentation showed that patient 9 had multiple abnormal labs including his blood alcohol level, anion gap, and carbon dioxide (CO2, regulates the body’s acid/base balance, impacting overall body function) and was in restraints for approximately 7 hours. The hospital failed to provide an appropriate MSE. Patient 9 had no follow up labs to determine if his abnormal lab results were returning to normal or how the patient’s body was compensating for the abnormal labs, and was never assessed for injury related to physical holds or restraint, or the potential for rhabdomyolysis (a muscle injury which is a life-threatening condition that can occur after an injury or excessive exercise), prior to his discharge. Refer to tag 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: 35223 Based on interview, record review, and policy review, the hospital failed to provide an appropriate medical screening examination (MSE) to determine whether or not an emergency medical condition (EMC) existed for one patient (9) who presented to the hospital for emergency care. Specifically, the hospital failed to determine the cause of the patient’s metabolic acidosis (serious condition that occurs when there is too much acid in the body’s fluids, demonstrated through the elevated anion gap and low CO2 levels), which left untreated could lead to further deterioration and possibly death. Additionally, the hospital did not provide an examination to rule out injury or rhabdomyolysis (a muscle injury which is a life-threatening condition that can happen after an injury or excessive exercise) which may have occurred due to the patient’s aggressiveness, physical holds, or extended time in restraints. Findings Include: The hospital’s policies for emergency medical treatment and active labor act (EMTALA) stated that the hospital will provide an MSE to determine whether an emergency medical condition exists. The MSE will be performed by a physician, or a Qualified Medical Person (QMP) as designated by the Medical Executive Committee and the governing body. Medical records should contain documentation such as medically indicated screenings, tests, mental status, impressions, and diagnoses (supported by a history & physical (H&P), laboratory and other tests), as appropriate. The hospital EMTALA policies further stated that the MSE is an ongoing process, and the medical record must reflect an ongoing assessment of the patient’s condition. Monitoring must continue until the individual is stabilized or appropriately admitted, transferred or discharged. There should be evidence of this prior to discharge or transfer. The MSE must be documented in the electronic health record (EHR). Review of a law enforcement report dated 6/5/2024 showed law enforcement responded at approximately 3:20 PM, to a residence where Patient 9 was residing. Patient 9 was found with numerous medications on his bedside table, multiple empty bottles of vodka, could not stand up safely, was swaying while walking and used the walls to steady himself. He had bloodshot eyes, smelled of alcohol, and law enforcement believed he was not safe to himself. During attempts to assist the patient in transport to the hospital, he became rigid, resisted officers, and was pushed up against a wall and taken to the ground before transport. Upon arrival to the hospital, Patient 9 refused to respond to the nurse or physician, was verbally aggressive with law enforcement, and would attempt to stand and posture towards the officer and staff. The patient required a physical hold by the officer and hospital security for approximately 45 minutes, until the patient was sedated and placed in restraints. On 6/27/2024 at 9:30 AM, surveyors interviewed the law enforcement officer that accompanied patient 9. He stated Patient 9 was extremely out of control and highly intoxicated. He stated that Patient 9 was agitated and aggressive, so he stayed in the ED for several hours to assist hospital staff. Review of the Emergency Department (ED) record for Patient 9, showed he arrived at the hospital ED accompanied by law enforcement on 6/5/2024 at 4:38 PM, with altered mental status, alcohol abuse with intoxication, and a history of traumatic brain injury (TBI). In triage, the patient’s heart rate was elevated at 136 (normal range 60-100) beats per minute, and Registered Nurse (RN) 1 documented that the patient was uncooperative and provided little information. Emergency Department Physician (EDP) MD1 documented the patient had reportedly drank several containers of vodka and was found with several pill bottles, including gabapentin (prevents seizures, treats nerve pain, or sometimes used for anxiety or alcohol use disorders) as well as antipsychotics (treatment for mental health disorders) at his residence. He was not forthcoming with answers due to his intoxication, was argumentative, and chemical and physical restraint were applied for the safety of the patient and staff. During his physical examination, EDP MD documented the patient was “unable or unwilling” to provide answers and would not follow commands, was intoxicated and verbally and physically argumentative. Review of the medication administration record showed that between 5:03 PM and 8:34 PM, Patient 9 received eight doses of medications, used alone or in combination, for chemical restraint. Review of the ED Care Timeline showed that between 6:00 PM and 8:50 PM, Patient 9 was placed in, and remained in, hard locking wrist restraints for agitation and combative or aggressive behavior. At 8:50 PM, he remained in hard locking wrist restraints and was also placed in hard locking ankle restraints due to anger and unsafe behavior, and remained in these restraints until 6/6/2024 at 12:00 AM, when he was able to follow directions and was calm. Review of laboratory test results showed Patient 9 had a blood alcohol level of 341 (critical high, 50 is considered the legal driving limit in Utah), a CO2 carbon dioxide level of 12 (low, normal is 23 to 29), and anion gap of 33 (high, normal is 4 to 12). There was no additional testing completed, such as a beta-hydroxybutyrate (BHB) or lactic acid level, to further assess the reason for the acidosis, and to rule out possible sepsis as the cause of the patient’s high heart rate and agitation. There was no venous blood gas (measures the levels of oxygen and CO2 in the blood, to provide information about the body’s acid-base balance) to evaluate for how the patient was compensating for the acidosis, and no creatine phosphokinase (CPK, test to determine injury or stress to muscle tissue) ordered to assess for the risk of the patient developing rhabdomyolysis (a serious medical condition that occurs when muscle tissue breaks down and releases proteins and electrolytes into the bloodstream), which may have been caused by the patient’s aggressiveness and required physical restraint. Review of an email dated 10/17/2024 at 3:46 PM, from EDP MD2 showed the physician confirmed that the patient’s anion gap was “quite” elevated at 33 with a decreased bicarbonate (CO2), indicating that although these results may indicate other diagnoses, the anion gap elevation was “most likely” caused by alcoholic ketoacidosis (life-threatening condition that occurs when someone drinks large amounts of alcohol and has not eaten or has been vomiting) due to the patient’s reported heavy drinking. The patient himself, as well as his girlfriend reported that he was a heavy, frequent drinker. Typically, in otherwise healthy patients with elevated anion gap acidosis who admit to frequent heavy drinking and have evidence of elevated alcohol levels, the patients are rehydrated and watched clinically. EDP MD2 added that Patient 9 had returned to his baseline, was able to self-hydrate, had normal vital signs and had a normal mental status on reevaluation. Therefore, he did not retest the patient’s anion gap (to determine if it was lowering) because there was no protocol to retest and because it was not his typical practice. The medical record did not indicate that the patient was rehydrated or that he was able to self-hydrate in attempts to lower the patient’s elevated anion gap. No further laboratory tests were conducted to ensure Patient 9’s CO2 was within normal range before patient 9’s discharge from the ED. Review of Patient 9’s documented vital signs showed that his heart rate was abnormal, and consistently elevated between 103 and 136 beats per minute (normal 60 to 100). Review of a Safety Plan dated 6/6/2024 showed that Patient 9 developed a safety plan prior to his discharge that included coping strategies to take his mind off of his problems by drinking and riding dirt bikes, along the Jordan River. During an interview on 7/23/2024 at 1:00 PM, RN 2 stated that unsuccessful attempts were made to have Patient 9 picked up by friends and family at discharge, and the patient ordered himself an Uber, and she discharged the patient to himself. Review of a law enforcement report dated 6/6/2024, showed that at 5:43 AM (less than two hours after Patient 9’s discharge), a caller stated someone was attempting to enter her home. Upon law enforcement arrival, Patient 9 was found on the porch of the residence, and the patient’s family member was contacted to pick him up. Review of Patient 9’s discharge summary showed no documented evidence that he was assessed for injury or rhabdomyolysis (a serious medical condition in which damaged skeletal muscle breaks down rapidly, releasing harmful substances into the blood). Additionally, no documented evidence was found regarding patient education for possible restraint injury, for example watching for dark or insufficient urine, pain in muscle, whole body fatigue, and muscle cramps.”