Based on interview and record review, the hospital failed to abide by the provider's agreement that required a hospital to comply 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, citing 1 of 1 patient (Patient #1) that presented in the emergency department (ED) the morning of 11/14/16 and returned to the ED the night of the same day. Findings included: Cross Refer to Tags 2406, 2407, and 2409

Based on interview and record review the hospital failed to provide an appropriate medical screening to 1 of 1 patient (Patient #1) that presented in the emergency department (ED) the morning of 11/14/16 and returned to the ED the night of the same day. Findings included: Patient #1 presented in the ED on 11/14/16 at 11:02 AM. Personnel #11 conducted a "rapid assessment" at 11:07 AM and noted "Patient states he has fallen twice today and that his right knee keeps going out on him." The EMS (Emergency Medical Services) Patient Care Report dated 11/14/16 reflected Patient #1's chief complaint was "right knee pain/weakness and right elbow laceration." At 11:32 AM right knee x-rays were conducted as ordered. At 11:58 AM the result of the "Radiology-Knee, 3 view RT (right)...no acute findings." Physician #7 noted in the "HPI (History of Present Illness) Chief Complaint Fall, Extremity pain...Location lower extremity left, Quality aching, Severity: onset Moderate, Severity: current Moderate ..." Physician #7 did not address the problems of the right knee. At 11:05 AM Personnel #11 noted the patient was covered with feces and urine. Personnel #11 noted the EMS concerns about Patient #1's poor living conditions and that the patient was unable to take care of himself, the wife could not take care of the patient. Patient #1 needed maximum help in "moving" and with ADLs (activities of daily living). Physician #7 did not address these issues. Patient #1's current circumstances was not reported to case management. The EMS Patient Care Report dated 11/14/16 reflected Patient #1 had Diabetes. Patient #1 had a blood sugar of 414 (via finger stick). Physician #7 did not address this problem. Patient #1's blood sugar was not rechecked in the ED and there was no order for blood work. Patient #1 initially verbalized pain level of 10 in the scale of 1 to 10 (10 being the highest level of pain) during the nursing initial assessment. Personnel #11 noted the pain could be alleviated by pain medication. Physician #7 did not address Patient #1's pain management. Physician #7 did not identify Patient #1's current home medications. The medical record did not reflect Patient #1's home medications and/or if the patient was compliant with his medication regimen. In an interview on 03/27/17 at 1:50 PM and 03/28/17 at 10:00 AM, Personnel #1 was informed of the above findings and confirmed the findings.

Based on interview and record review the hospital failed to provide stabilizing treatment to 1 of 1 patient (Patient #1) that presented in the emergency department (ED) the morning of 11/14/16 and returned to the ED the night of the same day. Findings included: Patient #1 presented in the ED on 11/14/16 at 11:02 AM. Physician #7 did not re-evaluate Patient #1. Patient #1 had unresolved issues which was noted by nursing staff. Physician #7 did not address these unresolved issues. Noted unresolved patient issues were the following: 1) Patient #1 was unable to take care of himself. His wife could not take care of him. He had problems with "moving" and needed maximum assistance. He needed help with the ADLs (activities of daily living). 2) Patient #1 lived in poor living conditions. Problems #1 and #2 were not reported to case management which was available. Case management had the ability of assisting Patient #1. 3) Patient #1 had Diabetes. The EMS Patient Care Report reflected Patient #1's blood sugar was checked in the ambulance. The result was 414 which was considered high. The blood sugar was not rechecked in the ED and/or laboratory test was not ordered for Patient #1. 4) Patient #1 had a pain level of 10 during the initial nursing assessment at 11:07 AM. Upon reassessment at 12:14 PM, Patient #1 verbalized his pain level was a 7 and could be alleviated with pain medication. There was no order for Patient #1's pain management. 5) Physician #7 did not identify Patient #1's home medications. Physician #7 did not know if Patient #1 was compliant or not with his medication regimen. There was no home medication list found in Patient #1's medical record. In an interview on 03/27/17 at 3:00 PM and 03/28/17 at 11:30 AM, Physician #7 stated the day Patient #1 presented in the ED it was very busy. He stated he "missed documenting" Patient #1's re-evaluation. Physician #7 stated he saw Patient #1 about 3 times. Physician #7 stated he did not order pain medications because more than likely Patient #1 did not want pain medications. Physician #7 stated he did not receive report from the nursing staff about the above patient issues. In an interview on 03/28/17 at 2:25 PM, Personnel #13 was asked if case management services was provided in the ED. She replied that they do. Their names, phone numbers, and daily on-call list were available at the secretary's desk. She explained if they received a report, for example like Patient #1, she would have talked to the nurse and physician to find out what was going on with the patient. She would have talked to Patient #1 and would "offer resources and explore all options in order to have a safe discharge."

Based on interview and record review the hospital failed to provide appropriate transfer/discharge of 1 of 1 patient (Patient #1) that presented in the emergency department (ED) the morning of 11/14/16 and was discharged at 2:00 PM. Patient #1 returned to the ED on the same day at 11:19 PM. Findings included: Patient #1 presented in the ED on 11/14/16 at 11:02 AM. The triage notes indicated "Patient states he has fallen twice today and that his right knee keeps going out on him." The initial vital signs at 11:07 AM were as follows: "BP 232/107, Pulse 102, Temp 36.5 (Celsius), Pulse Ox 96, Resp 20." At 12:12 PM Clonidine 0.2 mg tablet per oral was administered as per order. At 12:15 PM Patient #1's vital signs were as follows: BP 241/112, Pulse 101, Temp 97.8 (Fahrenheit), oxygen saturation 98% (room air), and respiration 20. At 12:37 PM Clonidine 0.1 mg tablet per oral was ordered by Physician #7. At 1:08 PM Patient #1's vital signs were as follows: BP 167/80, Pulse 69, Temperature 97.7 (Fahrenheit), oxygen saturation 95% (room air), and respiration 20. At 1:12 PM Personnel #11 held the "Clonidine 0.1 mg tablet per oral due to BP Low, last BP: 167/80 11/14/16 1:08 PM." Besides blood pressure problems, Patient #1 had other medical and social issues that were unresolved during his ED stay. Hereunder were the unresolved treatment and issues prior to discharge at 2:00 PM on 11/14/16: 1) Patient #1 did not receive a re-evaluation from Physician #7. 2) Patient #1 had Diabetes and had a blood sugar level of 141 which obtained in the ambulance. The blood sugar was not rechecked in the ED and/or blood work was not ordered for Patient #1. 3) Patient #1 had a pain level of 10 on a pain scale of 1 to10 during the initial nursing assessment at 11:07 AM. Upon reassessment at 12:14 PM, Patient #1 verbalized his pain level was a 7 and could be alleviated with pain medication. There was no order for Patient #1's pain management. 4) Physician #7 did not identify Patient #1's home medications. Physician #7 did not know if Patient #1 was compliant or not with his medication regimen for hypertension or Diabetes Mellitus. There was no home medication list found in Patient #1's medical record. 5) Patient #1 was unable to take care of himself. He had problems with moving around and needed maximum assistance. Patient #1 lived in poor living conditions. Patient #1 needed help with his activities of daily living. All these issues were not reported to case management which was available. Per ED log, Patient #1 returned to the ED on 11/14/16 at 11:19 PM via ambulance for "change mental/neuro stat" complaint. The "Primary Impression" was "malignant hypertension" and was subsequently admitted . In an interview on 03/27/17 at 3:00 PM and 03/28/17 at 11:30 AM, Physician #7 stated the day Patient #1 presented in the ED it was very busy. He stated he "missed documenting" Patient #1's re-evaluation. Physician #7 stated he saw Patient #1 about 3 times. Physician #7 stated he did not order pain medications because more than likely Patient #1 did not want pain medications. Physician #7 stated he did not receive report from the nursing staff about the above patient issues. In an interview on 03/28/17 at 2:25 PM, Personnel #13 was asked if case management services was provided in the ED. She replied that they do. Their names, phone numbers, and daily on-call list were available at the secretary's desk. She explained if they received a report, for example like Patient #1, she would have talked to the nurse and physician to find out what was going on with the patient. She would have talked to Patient #1 and would "offer resources and explore all options in order to have a safe discharge."