HospitalInspections.org

Based on document review and interview, it was determined the Hospital failed to ensure compliance with 42 CFR 482.24.

Findings include:

1. The Hospital failed to provide a medical screening exam, including reassessment of patients while waiting for medical screening by a qualified practitioner, to determine if an emergency medical condition existed. See citation at A-2406.

Based on document review and interview, it was determined that for 3 of 11 clinical records (Pt. #1, Pt. #3, and Pt. #7) reviewed for patients seeking care in the Emergency Department (ED), the Hospital failed to provide a medical screening exam, including reassessment of patients while waiting for medical screening by a qualified practitioner, to determine if an emergency medical condition existed.

Findings include:

1. On 3/2/2022, the Hospital's EMTALA Guidelines for Emergency Services (reviewed by the Hospital on 11/2021) was reviewed and included, "... All patients presenting to (Name of the Hospital) Emergency Department ... requesting emergency care, must be accepted and evaluated... All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call service within the capability of the Hospital to reach a diagnosis ... (MSEs) should include at minimum the following ... Patient triage record; vital signs; History and physical exam of the affected systems and potentially affected systems; Exam of known chronic conditions; Necessary testing to rule out emergency medical conditions ... Complete documentation of the medical screening ..."

2. On 3/2/2022, the Hospital's document titled, "General Patient Care Triage Policy" (reviewed by the Hospital on 4/2020) included, " ... 1. Triage is the screening of patients to determine their relative priority for treatment; 2. The registered nurse will evaluate and categorize each patient upon arrival to the Emergency Department into Resuscitative (Level 1), Emergency (Level 2), Urgent (Level 3), Semi-urgent (Level 4) or Routine categories (Level 5). 3. All patients who request care must be medically screened by a physician ... 7. Patients who presents to the ED for triage ... will be assigned an acuity level based on their medical history, vital signs, age, and clinical presentation ...10. In order to improve patient care, specific protocols have been established and approved by the Medical Director for patients presenting to the Emergency Department with the following ... m. Vomiting/Diarrhea: Orthostatic (lying, sitting, and standing) (vital signs), (Point of Care) glucose (blood sugar check), CBC (complete blood count), Chem 8 (blood chemistry testing for electrolytes), UA (urinalysis) ... Procedure ... During the Emergency department visit, patients will be reassessed by nursing staff every 3 hours ..."

3. On 3/2/2022, Pt. #1's clinical record was reviewed. Pt. #1 came to the Hospital's ED (emergency department) on 1/17/2022. The clinical record included:

- A face sheet indicated that Pt. #1's reason for the ED visit was swelling in hands/face for one week, diarrhea, and no taste.

- E #1's (ED Triage Registered Nurse/RN on 1/17/2022, Day Shift) progress note, dated 1/17/2022, indicated that Pt. #1 arrived at the Hospital on 1/17/2022 at 9:19 AM, and the triage screening started at 9:52 AM. The note included, " ...(Pt. #1's statement) swollen hands (for) 1 week, diarrhea ... Temperature (97.6 degree Fahrenheit/normal); Pulse 109 beats per minute/bpm (normal 60-100); Respirations 20 bpm (normal); Blood Pressure/BP 157/113 (normal BP 120/80); with a pain intensity of 3 (0-10 pain scale: 0 no pain, 10 severe) (location of the pain was unknown)." Pt. #1 has a history of heart disease/surgery, congestive heart failure (heart enlargement), and diabetes. There was no assessment regarding the extent or severity of Pt. #1's swelling.

- E #1's emergency severity index/ESI classification for Pt. 1 was a level 3, which indicated that Pt. #1's condition was urgent. (ESI is a five-level ED algorithm: Level 1 requires immediate life-sustaining measures through 5 for stable patients).

- E #2's (ED Charge Nurse on 1/17/2022, Night Shift) progress note, dated 1/17/2022 at 10:00 PM included, "(Pt. #1) called to be seen by a physician with no answer." At 11:20 PM, E #2 called Pt. #1 to see the physician with no answer. There was no reassessment for Pt. #1 from 9:52 AM through 10:00 PM (12 hours and 8 minutes).

- No laboratory testing conducted other than testing for COVID-19.

- Pt. #1 did not receive a complete medical screening examination.

4. The clinical record of Pt. #3 was reviewed on 3/1/2022. Pt #3 presented to ED (emergency department) via ambulance on 2/22/2022 at 1:48 PM. The clinical record included:

-A face sheet indicated that Pt.#3's chief complaint of Lupus Flare-up (auto-immune disease).

- Pt #3's ED Triage Assessment dated 2/22/22 at 2:28 PM, included, " ... presents to ED with c/o (complaint of) generalized pain from Lupus. Patient reports a medical history of ...crohn's disease (infammatory bowel disease) sickle cell, lupus ... Temperature 98.0, Pulse 90, Respirations 20, Blood Pressure 132/89 ... Pain 9 on scale of 0-10 (7-9-severe pain) ..."

- At 7:20 PM, 8:50 PM, and 9:33 PM, "Patient called to be seen by physician with no answer. Pt.#3's ESI classification was a level 3. The clinical record lacked documentation of a reassessment or medical screening for Pt. #3. There was no documentation of any lab work or diagnostic testing or pain management from 2:48 PM through 7:28 PM (4 hours and 40 minutes).

5. The clinical record of Pt. #7 was reviewed on 3/1/2022. Pt #7 presented to ED (emergency department) via ambulance on 1/17/2022 at 7:51 AM. The clinical record included:

-A face sheet indicated that Pt.#7's chief complaint of Chest Pain.

- Pt #7's ED Triage Assessment dated 1/17/2022 at 7:52 AM, included, "... Chest pain on and off for 2 days, radiating to right arm and right wrist ... Temperature 98.0, Pulse, Respirations 20, Blood Pressure 169/86 ... Pain 5 on scale of 0-10 (0 = no pain, 5= moderate pain)..."

- At 7:35 PM, 11:30 PM, and on 1/18/2022 at 12:02 AM, "Patient called to be seen by physician with no answer. Pt.#7's ESI classification was a level 3. The clinical record lacked documentation of a reassessment or medical screening examination for Pt. #7 from 7:52 AM through 7:35 PM (11 hours and 42 minutes).

6. On 3/1/2022 at approximately 1:20 PM, a telephone interview was conducted with MD #1 (ED attending physician on 1/17/2022). MD #1 said that if a patient has facial swelling, the patient would need to be seen right away. MD #1 stated that she would expect the nurse to monitor and evaluate a patient to ensure that the patient's condition is not deteriorating. To complete the medical screening examination process, MD #1 said that monitoring and evaluation by the nursing staff are essential.

7. On 3/2/2022 at approximately 8:45 AM, an interview was conducted with an ED RN (E #2). E #2 stated, "After a patient is triaged, and the patient is in the waiting room, the nurse will reassess the patient about every 3-4 hours. If the acuity assigned is a 2 or 3, the patient should be reassessed every 3-4 hours and an MSE should be done as soon as possible."

8. On 3/2/2022 at approximately 9:35 AM, an interview was conducted with MD #2 (Medical Director, Emergency Department). For Pt. #1, MD #2 said that the process for conducting the medical screening examination did not happen. MD #2 stated that the physician completes the medical screening examination to identify if a patient has an emergency medical condition.