HospitalInspections.org

Findings were:


1. Cross refer to A2406 as it relates to failure of the Emergency Department to perform an appropriate medical screening for a patient presenting to the Emergency Department.

2. Cross refer to A2407 as it relates to failure of the facility to provide stabilizing treatment for a patient presenting to the Emergency Department.

Based on review of policies and procedures and staff interviews, it was determined that the facility failed to establish a medical record for a patient (#1) presenting to the emergency department (ED) on 10/25/10 requesting medical care.

1. An interview was conducted with employee #2, on 11/09/10, at 10:10 a.m., in the Administration Conference Room. The interviewee stated that he/she worked as an ED registrar on 10/25/10 and was at the registration counter when patient #1 arrived at the ED. He/she recalled that the patient arrived in the morning and walked up to the registration counter accompanied by his/her spouse. The patient informed the interviewee that he/she had fallen at home and hit his/her head and that his/her private physician wanted him/her to have a CT scan done. The interviewee confirmed that the patient did not provide a physician order for the requested CT scan. The interviewee stated that the patient was concerned about having to wait, because the ED appeared very busy. He/she inquired if the test could be performed at the Healthcare System's Urgent Care Facility. The interviewee checked with other ED employees and informed the patient that the the Urgent Care Facility had radiology services, and a CT scan could be done there. The interviewee confirmed that he/she did not obtain patient information, an entry was not made on the central log related to the patient presentation to the hospital, the ED triage nurse, ED charge nurse and ED physician were not informed of the patient's presentation prior to the patient leaving the ED without treatment, and a medical record was not initiated for the patient.

2. The hospital's Plan for the Provision of Patient Care required that the medical record be initiated at the point of entry to the facility. The Emergency Department registration area was to gather the necessary demographic information on patients who present themselves or who are presented to the ED for triage/treatment. All patients presenting to the ED facility are rendered services without distinction to race, color, national origin, handicapping condition,age or ability to render payment.

3. An interview with the Risk Manager on 11/09/10 at 1:00 p.m. in the Administration Conference Room revealed that the facility had initiated an investigation of the incident. The interviewee confirmed that there was no evidence that the patient had contact with any ED employee except the registration clerk. He/she also confirmed that the patient name and required information had not been entered in the central log, a medical record had not been initiated, triage, medical screening, and stabilizing treatment was not provided by the ED staff.

A written statement provided by the facility's Risk Manager outlined the following steps that have been or will be taken to prevent a recurrence of the incident:

1. The registrar involved in the incident was interviewed and she was instructed that patients should have a MSE when they present to the Emergency Department. She was also advised that patients should be entered into the log and Emergency Department staff advised when a patient desires to leave without being treated.

2. The Emergency Department manager addressed EMTALA training in the staff meeting.

3. The Risk Manager, Director of Patient Financial Services, Patient Registration Manager, and Director of Performance Improvement met on November 5, 2010. The decision was made at that meeting to form an "EMTALA Task Team". The task team will include members from multiple disciplines that will take steps to correct any deficiencies noted by Centers for Medicare and Medicare Services( CMS).

4. Directors and Managers will receive education on EMTALA on December 8, 2010.

5. Education will also be provided to Patient Financial Services, Patient Registration, Emergency Department Nursing Staff, Volunteer Staff, and Security Staff. Our goal is to complete this training by December 15, 2010.




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Based on review of policies and procedures, facility documentation, the emergency department central log, and staff interview, it was determined that the facility failed to maintain a central log on each individual (#1) who came to the emergency department (ED) seeking treatment

1. An interview was conducted with employee #2, on 11/09/10, at 10:10 a.m., in the Administration conference room. The interviewee stated that he/she worked as an ED registrar on 10/25/10 and was at the registration counter when patient #1 arrived at the ED. He/she recalled that the patient arrived in the morning and walked up to the registration counter accompanied by his/her spouse. The patient informed the interviewee that he/she had fallen at home and hit his/her head and that his/her private physician wanted him/her to have a CT scan done. The interviewee confirmed that the patient did not provide a physician order for the requested CT scan. The interviewee stated that the patient was concerned about having to wait, because the ED appeared very busy. He/she inquired if the test could be performed at the Healthcare System's Urgent Care Facility. The interviewee checked with other ED employees and informed the patient that the the urgent care facility had radiology services, and a CT scan could be done there. The interviewee confirmed that he/she did not obtain patient information, an entry was not made on the central log related to the patient presentation to the hospital, the ED triage nurse, ED charge nurse and ED physician were not informed of the patient's presentation prior to the patient leaving the ED without treatment, and a medical record was not initiated for the patient.

2. The central log was reviewed for 10/25/10. The log lacked documentation related to the above presentation of patient #1 to the ED.

3. Documentation provided by the facility's Risk Manager revealed that the hospital began to use a new computerized system to document ED visits on 10/19/10. The system also provided the log required for ED visits. The facility was currently in the process of updating policy to reflect the changes in their process. The facility's Registration Manager provided the following details of the process now in use.

1. Patient presents to Triage desk upon arrival, requesting to be seen.
2. Registrar presents a sign-in slip (demographic information for identification purposes only) and consent for treatment forms to patient for completion (process to change in near future).
3. Upon completion of the forms, patient returns to registrar, who then quick-registers them in the HMC HIS (Healthcare Information System) and applies arm band.
4. Registrar asks the patient to return to waiting room (unless triage nurse is available) and then "pulls" patient into Medhost system from HIS.
5. If a patient presents in distress, registrar immediately calls nurse or tech to assess the patient (before steps 2-4).
6. Patient is triaged and if a bed is available, the patient is is taken directly to the back. If a bed is not available, the patient is returned to the waiting room until called.
7. Once the patient is taken to the room, a medical screening must take place (and be documented in Medhost by physician) before complete financial registration can be done.

4. An interview with the Risk Manager, on 11/09/10, at 1:00 p.m. in the Administration Conference Room, revealed that the facility had initiated an investigation of the incident. The interviewee confirmed that there was no evidence that the patient had contact with any ED employee except the registration clerk. He/she also confirmed that the patient name and required information had not been entered in the central log, a medical record had not been initiated, triage, medical screening, and stabilizing treatment was not provided by the ED staff.


A written statement provided by the facility's Risk Manager outlined the following steps that have
been or will be taken to prevent a recurrence of the incident:

1. The registrar involved in the incident was interviewed and she was instructed that patients should have a MSE when they present to the Emergency Department. She was also advised that patients should be entered into the log and Emergency Department staff advised when a patient desires to leave without being treated.

2. The Emergency Department manager addressed EMTALA training in the staff meeting.

3. The Risk Manager, Director of Patient Financial Services, Patient Registration Manager, and Director of Performance Improvement met on November 5, 2010. The decision was made at that meeting to form an "EMTALA Task Team". The task team will include members from multiple disciplines that will take steps to correct any deficiencies noted by CMS.

4. Directors and Managers will receive education on EMTALA on December 8, 2010.

5. Education will also be provided to Patient Financial Services, Patient Registration, Emergency Department Nursing Staff, Volunteer Staff, and Security Staff. Our goal is to complete this training by December 15, 2010.

Based on review of Medical Staff By-laws/Rules and Regulations, policies and procedures physician written statement, and staff interviews, it was determined that the emergency department failed to provide a medical screening, for a patient (#1) presenting to the ED on 10/25/10.

1. An interview was conducted with employee #2, on 11/09/10, at 10:10 a.m., in the Administration Conference Room. The interviewee stated that he/she worked as an ED registrar on 10/25/10 and was at the registration counter when patient #1 arrived at the ED. He/she recalled that the patient arrived in the morning and walked up to the registration counter accompanied by his/her spouse. The patient informed the interviewee that he/she had fallen at home and hit his/her head and that his/her private physician wanted him/her to have a CT scan done. The interviewee confirmed that the patient did not provide a physician order for the requested CT scan. The interviewee stated that the patient was concerned about having to wait, because the ED appeared very busy. He/she inquired if the test could be performed at the Healthcare System's Urgent Care Facility. The interviewee checked with other ED employees and informed the patient that the the Urgent Care Facility had radiology services, and a CT scan could be done there. The interviewee confirmed that he/she did not obtain patient information, an entry was not made on the central log related to the patient presentation to the hospital, the ED triage nurse, ED charge nurse and ED physician were not informed of the patient's presentation prior to the patient leaving the ED without treatment, and a medical record was not initiated for the patient.

2. Review of facility's Emergency Department Policy #11.0, entitled "Leave Without Treatment/Against Medical Advice", effective date May 2003, last reviewed/revised April 2010, revealed that if a patient wishes to leave triage prior to receiving a medical screening, the triage/treatment area nurse will make every attempt to encourage the patient to stay and be seen. The patient will be advised that risks may be involved in leaving without having a medical screening performed.

3. Telephone interviews were conducted on 11/09/10 at 2:15 p.m. with the day shift ED charge nurse for 10/25/10 and at 4:15 p.m. with the day shift ED triage nurse on 10/25/10. Both interviewees confirmed that they were unaware of the patient's presentation to the ED.

4. Review of the Medical Staff Podiatry/Dentist Allied Health Professional Rules and Regulations, current version revised November 2008, revealed the medical screening examination was to be performed by a physician or a mid - level provider (Physician Assistant, Certified Nurse Practitioner, or Certified Nurse Midwife), a Registered Nurse with training and experience in a specialized area (Labor and Delivery - with demonstration of clinical competency in physical assessment of the Obstetrical (pregnant) patient, electronic fetal monitoring, and Obstetrical emergencies), psychiatry, or a master's prepared mental health professional working under the supervision and direction of a physician to determine if a medical emergency exists.

5. A written statement was provided by the physician responsible for day shift coverage of the ED, on 10/25/10. The physician documented that he/she received a call from a physician from the Healthcare System's Urgent Care Facility. The Urgent Care physician advised the ED physician that he/she was sending a patient to the ED that had fallen earlier in the day. The physician felt that the patient needed a CT scan. The urgent care physician also told the ED physician that the patient had been to the hospital earlier that day. The patient was seen upon arrival at the ED by the physician. The patient told the ED physician that she went to the ED earlier that day, and it was busy. The patient asked if a CT scan could be done at Urgent Care and had been told that it could.

6. Review of the medical record for patient #1 revealed that the patient arrived at the facility's ED by emergency medical system (EMS) ambulance at 1:25 p.m. on 10/25/10. The patient had been transferred to the hospital's ED, from the Urgent Care Facility. The nursing triage assessment was completed. The initial vital signs were all within an acceptable range. The patient was seen by the ED physician on arrival, and a history and physical examination was completed by the physician. A CT scan of the patient's head was obtained. The CT scan was read by the radiologist and interpreted as negative. The patient was discharged home in stable condition at 4:21 p.m.

7. An interview with the Risk Manager on 11/09/10 at 1:00 p.m. in the Administration Conference Room revealed that the facility had initiated an investigation of the incident. The interviewee confirmed that there was no evidence that the patient had contact with any ED employee except the registration clerk. He/she also confirmed that the patient name and required information had not been entered in the central log, a medical record had not been initiated, triage, medical screening, and stabilizing treatment was not provided by the ED staff.

A written statement provided by the facility's Risk Manager outlined the following steps that have
been or will be taken to prevent a recurrence of the incident:

1. The registrar involved in the incident was interviewed and she was instructed that patients should have a MSE when they present to the Emergency Department. She was also advised that patients should be entered into the log and Emergency Department staff advised when a patient desires to leave without being treated.

2. The Emergency Department manager addressed EMTALA training in the staff meeting.

3. The Risk Manager, Director of Patient Financial Services, Patient Registration Manager, and Director of Performance Improvement met on November 5, 2010. The decision was made at that meeting to form an "EMTALA Task Team". The task team will include members from multiple disciplines that will take steps to correct any deficiencies noted by CMS.

4. Directors and Managers will receive education on EMTALA on December 8, 2010.

5. Education will also be provided to Patient Financial Services, Patient Registration, Emergency Department Nursing Staff, Volunteer Staff, and Security Staff. Our goal is to complete this training by December 15, 2010.

Based on review of policies and procedures and staff interviews, it was determined that the facility failed to provide stabilizing, treatment for a patient (#1)presenting to the emergency department (ED), on 10/25/10.

1. An interview was conducted with employee #2, on 11/09/10, at 10:10 a.m., in the Administration Conference Room. The interviewee stated that he/she worked as an emergency department (ED) registrar on 10/25/10 and was at the registration counter when patient #1 arrived at the ED. He/she recalled that the patient arrived in the morning and walked up to the registration counter accompanied by his/her spouse. The patient informed the interviewee that he/she had fallen at home and hit his/her head and that his/her private physician wanted him/her to have a CT scan done. The interviewee confirmed that the patient did not provide a physician order for the requested CT scan. The interviewee stated that the patient was concerned about having to wait, because the ED appeared very busy. He/she inquired if the test could be performed at the Healthcare System's Urgent Care Facility. The interviewee checked with other ED employees and informed the patient that the the Urgent Care Facility had radiology services, and a CT scan could be done there. The interviewee confirmed that he/she did not obtain patient information, an entry was not made on the central log related to the patient presentation to the hospital, the ED triage nurse, ED charge nurse and ED physician were not informed of the patient's presentation prior to the patient leaving the ED without treatment, and a medical record was not initiated for the patient. The employee also provided a written statement regarding the incident.

2. Review of facility Emergency Department policy # ED 21.1, entitled "Scope of Services/Plan of Care", effective date November, 2001, lasted reviewed/revised April 2010, revealed that all patients that present to hospital for a non-scheduled visit and are seeking emergency care shall receive a medical screening exam by an Emergency Department physician, a physician's assistant, the patient's attending physician, or the obstetrical unit. This screening can include testing and on-call services within the capacity of the Medical Center. Support services including clinical laboratory studies and x-rays will be provided to the patient, if deemed necessary. An on-call list of specialty physicians is maintained to assist in provision of care and to assist patients who need follow-up care following their ED visit All necessary definitive emergency treatment will be provided to the patient within the hospital's capabilities. The ED is responsible for the recognition, evaluation, treatment/stabilization and disposition of patients in response to a medical or surgical emergency.

3. An interview with the Risk Manager on 11/09/10 at 1:00 p.m. in the Administration Conference Room revealed that the facility had initiated an investigation of the incident. The interviewee confirmed that there was no evidence that the patient had contact with any ED employee except the registration clerk. He/she also confirmed that the patient name and required information had not been entered in the central log, a medical record had not been initiated, triage, medical screening, and stabilizing treatment was not provided by the ED staff.


A written statement provided by the facility's Risk Manager outlined the following steps that have
been or will be taken to prevent a recurrence of the incident:

1. The registrar involved in the incident was interviewed and she was instructed that patients should have a MSE when they present to the Emergency Department. She was also advised that patients should be entered into the log and Emergency Department staff advised when a patient desires to leave without being treated.

2. The Emergency Department manager addressed EMTALA training in the staff meeting.

3. The Risk Manager, Director of Patient Financial Services, Patient Registration Manager, and Director of Performance Improvement met on November 5, 2010. The decision was made at that meeting to form an "EMTALA Task Team". The task team will include members from multiple disciplines that will take steps to correct any deficiencies noted by CMS.

4. Directors and Managers will receive education on EMTALA on December 8, 2010.

5. Education will also be provided to Patient Financial Services, Patient Registration, Emergency Department Nursing Staff, Volunteer Staff, and Security Staff. Our goal is to complete this training by December 15, 2010.