Mercy Walworth Hospital & 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: 50646 Based on record review and interview the facility staff failed to provide stabilizing treatment to patients presenting to the Emergency Department (ED) for treatment as per EMTALA (Emergency Medical Treatment and Active Labor Act) in 1 of 20 medical records reviewed (Pt. #1) in a total sample of 20 medical records reviewed. Findings include: The facility staff failed to perform a medical screening exam sufficient to rule out an emergency medical condition to patients presenting to the ED for treatment as per EMTALA. See Tag C-2406. The facility staff failed to provide stabilizing treatment to patients presenting to the ED for treatment as per EMTALA. See Tag C-2407.”

“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: 50646 Based on record review and interview, facility staff failed to perform a medical screening exam sufficient to rule out an emergency medical condition based on presenting symptoms for 1 of 20 patients (Patient #1). This failure resulted in Patient #1 being discharged with undiagnosed pulmonary emboli (blood clots in lungs). Review of the facility’s policy 15004864, “EMTALA (Emergency Medical Treatment and Active Labor Act) Screening, Treatment, and Transfer of Individuals” dated 02/2024 revealed, “ ...When an individual comes to the ED seeking medical treatment, the hospital must provide an appropriate MSE [medical screening exam] to determine whether the individual has an EMC [emergent medical condition]. The scope of the screening examination is dictated by: (i) the individual’s presenting symptoms; (ii) what is provided for in any relevant Hospital screening policy, procedure or directive; and (iii) what is within the capability of the Hospital’s Dedicated Emergency Department (“ED”) and other departments, including ancillary services and personnel (including on-call personnel) that are routinely available to the ED ... Pt. #1 came into the Emergency Department (ED) on 11/06/2024 at 1:32 PM via ambulance with complaints of acute thoracic back pain that hurts upon inspiration of a breath and right leg swelling for 3 weeks. Pt. #1 had lab work, ultrasound venous duplex of the right leg and CT (Computed Tomography) scan (imaging test) of the abdomen and pelvis without contrast. The test had originally been ordered with contrast along with a CT to rule out a Pulmonary Embolus (PE), but patient refused the tests with contrast as the patient gets hives from contrast. The Ultrasound showed a Deep Vein Thrombosis (DVT) of the right calf muscle vein. Further review of the record revealed that a CTPA (CT pulmonary angiogram-a CT scan that uses dye to look for blood clots in the lungs) was ordered but discontinued at 3:47 PM due to Pt. #1 refusing the contrast even when offered Benadryl 50 mg IV (medication to help prevent reactions to contrast). During an interview on 12/04/2024 at 09:15 AM ED Physician G stated that Pt. #1 came in with thoracic pain and leg pain. ED Physician G wanted to do a CT scan of the lungs to rule out a PE but patient stated they got itchy from contrast dye and even though Benadryl was ordered the patient refused to have the scan so ED Physician G could not rule out a PE. There is no documented evidence in the medical record that the risks and benefits of not having the CT scan completed to rule out Pulmonary Embolus (PE) were discussed with the patient. Patient was discharged on 11/6/2024 at 5:31 PM. During an interview on 11/19/2024 at 09:15 AM, Patient #1’s family member stated that after leaving the facility, family made the decision to take Pt. #1 to a hospital closer to their home. Upon being evaluated at another hospital, Pt. #1 was admitted and was in the hospital for 5 days with bilateral PE’s (Pulmonary Embolus-blood clots in the lungs), was treated for pneumonia and had an interventional radiology procedure to remove the blood clot from the right leg. Pt. #1 was in the hospital from 11/06/2024 until 11/11/2024 when they were discharged home.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 50646 Based on record review and interview, facility staff failed to provide stabilizing treatment within its capability and capacity for 1 of 20 patients (Pt. #1), in a total sample of 20 patients. Review of the facility’s policy 15004864, “EMTAL (Emergency Medical Treatment and Active Labor Act) Screening, Treatment, and Transfer of Individuals” dated 02/2024 revealed, “ ...Stabilize or Transfer. If the physician or QMP (Qualified Medical Personnel) determines that the individual has an EMC, the Hospital must either: i. Stabilize the individual ...ii. Transfer the individual ...” Review of the RN triage note dated 11/06/2024 at 1:26 PM revealed, “Pt arrives by ems (emergency medical service) for reports of acute thoracic back pain that hurts more on inspiration-right leg swelling for 3 weeks.” Pt #1’s Medical Record indicates on 11/06/2024 at 1:45 PM, Vital Signs were: BP: 116/70; HR 97; SpO2 94% Pain Rating 8. Review of the CT Abdomen/Pelvis without IV (Intravenous) contrast report for Pt. #1, dated 11/06/2024 at 3:54 PM revealed, “Abdomen: There are patchy airspace opacities throughout the right lower lobe compatible with pneumonia. There are no pleural effusions within the imaged lung bases.” An addendum was made to the report 11/06/2024 at 6:18 PM, “A second impression should state: Right lower lobe pneumonia.” The original impression read, “No acute intra-abdominal process is identified.” There was no mention in the ED provider note related to findings of pneumonia as documented in the CT Abdomen/Pelvis report. Review of the ED Provider note dated 11/08/2024 at 1:12 PM for ED visit on 11/6/2024 at 1:37 PM revealed, “Pt. #1 had right leg swelling for over a month and 4+ edema. Pt. #1 also had thoracic back/chest pain with inspiration...I was unable to do a CT to rule out PE because patient had a reaction to contrast dye hives. Patient was medically stable upon discharge had a DVT that could be treated with Eliquis (a blood thinner medication) patient was placed on Eliquis. Patient did not meet admission criteria...” Review of the RN discharge documentation dated 11/06/2024 at 5:32 PM revealed, Vital Signs BP 117/71; Pulse 92; SpO2 94%. No Pain Assessment completed prior to discharge. Pt. #1 was given discharge instructions including prescription for Eliquis. There were no instruction given to the patient on pneumonia. No treatment was prescribed for pneumonia. There is no evidence that Patient #1’s thoracic pain was assessed prior to discharge or that instructions were provided on signs/symptoms of potential pulmonary embolism that would require emergent attention. During an interview on 12/04/2024 at 09:15 AM, ED Physician G stated that they were not aware that Pt. #1’s abdominal CT showed pneumonia. When asked how they would treat pneumonia ED Physician G stated that they would place a patient on antibiotics. During an interview on 12/04/2024 at 10:00 AM, ED Physician I stated that the triage nurse came and asked him to see Pt. #1 and their family in the ED waiting room as they had some questions and concerns about Pt. #1’s discharge from the ED when seen by ED Physician G. The relatives who picked Pt. #1 up were concerned because they were afraid s/he would not be compliant with taking the medications prescribed plus Pt. #1 had no money to purchase the medications. ED Physician I offered to see Pt. #1 again in the ED and potentially admit them and place on heparin to treat the DVT. The family decided to not have Pt. #1 seen again at the current hospital but were planning on taking Pt. #1 to another hospital to be seen as it was closer to their home.”