HospitalInspections.org

Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare-participating hospitals in emergency cases as evidenced by:

A2406: Medical Screening Examination: for 6 of 21 patients, the hospital failed to ensure attempts were made to encourage patients waiting in the Emergency Department (ED) lobby who had lab work and/or imaging procedures results outside of normal reference range (based on standards for normal reference range) to stay and receive a medical screening examination. Patients #1, #8, #11, #14, #17, and #21 had lab work and imaging procedures conducted while they were waiting in the lobby of the Emergency Department. The results of the lab work and/or imaging procedures were outside of the normal reference range, and there were no attempts to communicate to those patients and encourage them to stay for a complete MSE (medical screening examination) in spite of the long wait times.

Based on reviews of clinical records, policies and procedures, hospital documents, logs and records, and staff interviews, it was determined for 6 of 21 patients, the hospital failed to ensure attempts were made to encourage patients waiting in the Emergency Department (ED) lobby who had lab work and/or imaging procedures results outside of normal reference range (based on standards for normal reference range) to stay and receive a medical screening examination. Patients #1, #11, #14, #17, #20, and #21 had lab work and imaging procedures conducted while they were waiting in the lobby of the Emergency Department. The results of the lab work and/or imaging procedures were outside of the normal reference range, and there were no attempts to communicate to those patients and encourage them to stay for a complete MSE (medical screening examination) in spite of the long wait times.

Findings include:

The hospital's policy and procedure titled, "EMTALA-Medical Screening Examination and Stabilization Treatment," included: "An appropriate MSE will be offered to individuals on the Campus of Banner Hospitals with a Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested, or, in the absence of such a request, whose appearance or behavior would cause a prudent layperson observer to believe that such individuals need an emergency examination or treatment...An MSE will be conducted to determine whether the Patient has an EMC (emergency medical condition). The Hospital will conduct a consistent MSE, in the nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuous monitoring based upon the Patient's needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred."

The hospital's "Emergency Department Standards of Care" revealed triage assessments completed by Registered Nurses (RN's) were to include the assignment of an Emergency Severity Index (ESI) score from 1 to 5 with an ESI 1 score requiring immediate life-saving interventions and ESI 5 requiring no resources needed. An ESI 2 score was defined as: "High-risk situation or confused/lethargic/disoriented or severe pain distress." Reassessments, "Occurs according to the patient's clinical presentation or any significant clinical event with the minimum requirements as follows...ESI 2 = Documented reassessments every 1 hour until hemodynamically stable, then minimally every 4 hours or per admitting unit standard of care."

The hospital provided three different documents that addressed patients who left the ED without examination, treatment, and/or transfer as follows:

1. The policy and procedure titled, "EMTALA - Medical Screening Examination and Stabilization" included: "...1. If an individual or his/her Representative has refused examination/treatment or Transfer, the following will occur: a. The individual will be informed of the Hospital's obligations under the EMTALA law, and the willingness of the Hospital to provide a (sic) MSE and render Stabilizing Treatment. b. The risks and benefits of refusing Stabilizing Treatment are explained by the physician or QMP (qualified medical person). c. The Refusal of Treatment or Transfer form is signed, indicating what aspects of care are refused, the risks of refusal and the reasons for the refusal. If the individual/Representative refuses to sign, documentation relative to the above is noted in the medical record along with the steps taken to try to secure the written informed refusal. 2. If an individual leaves without examination, attempts will be made to locate the individual in the Hospital. The Hospital will document information on any known individual who chooses to leave without examination...."

2. The policy and procedure titled, "Leaving the Hospital Against Medical Advice, Left Without Treatment, Refusal of Treatment/Transfer or Missing patients" included the following definitions: "...Against Medical Advice (AMA): refers to patients who request to be discharged from the hospital before the completion of treatment or contrary to the advice of the attending physician. This includes all inpatients, observation, outpatients, and patients in the Emergency Department or Obstetric Department that are in the process of receiving or having already received a Medical Screening Exam (MSE)...Elopement / Missing Patient: a patient leaves without staff knowledge. Elopement refers to the patient's departure from the facility without notifying staff or being discharged which may place the patient at risk of injury or death...Left Without Treatment (LWOT): refers to patients who leave the hospital after requesting to be seen in the Emergency Department / OB department, but prior to receiving a medical screening exam...."

3. Documentation in the hospital's "Emergency Department Standards of Care" revealed three documented attempts will be made to find unobserved patients who left without treatment (LWOT). For patients who notify staff of their intent to leave prior to the MSE, staff is directed to have the patient or their legal representative sign the "LWOT form 1419."

Patient #1:

Patient #1 presented to the ED of Banner University Medical Center Tucson (Hospital #1) on 07/23/2021 at 3:34 p.m. and was triaged at 3:57 p.m. The patient's chief complaint was: "Pt had a CT scan today that showed right hydronephrosis and kidney blockage. The patient's reported pain level was "8" on a scale of 0 to 10 with 0 being no pain and 10 being unbearable pain. A physician's note a 4 p.m. included the following:

"S (subjective): Patient reports two weeks of right flank pain with the scan that shows 12 mm stone.
O (objective): Exam: Patient is awake, alert. Speaking clearly and cogently. No respiratory difficulty.
A/P (assessment plan): There are currently no available rooms in the emergency department. As there are no rooms currently available, the patient will wait for a room in the lobby. The patient requires further workup to exclude any emergent causes of symptoms...."

Blood was drawn at 6:30 p.m. for lab work ordered by the physician. The patient's vital signs were obtained by a Certified Nursing Assistant (CNA) at 10:44 p.m. There was no documentation of the status of the patient after that time. The patient was logged out of the electronic medical record on 07/24/2021 at 5:52 a.m., a period of approximately 12.5 hours after the patient arrived. There was no documentation of a nursing reassessment or complete MSE performed prior to the patient leaving.

Patient #1 presented to Hospital #2 on 07/24/2021 at 12:40 p.m. and received a medical screening exam at 12: 56 p.m. The physician documented the patient had a 12 mm stone in the right ureter according to the CT scan performed at Banner the prior day. The physician's documentation included: "...12mm obstructing stone with hydronephrosis...Urine shows infection...The patient will be admitted...." The patient underwent stent placement.

Patient #8:

Patient #8 presented to the ED on 07/20/2021 at 5:28 p.m. The patient was triaged at 5:36 p.m. with a chief complaint: "...pressure moving up the abdomen to throat and nose, palpitations over last few days. Reports (sic) pressure over chest. Hx myocardial bridge, acid reflux. The patient was assigned an acuity score of "2." A "Physician Triage Exam" performed at 5:55 p.m. included:

"S: The patient presents with lower abdominal pain is (sic) rating (sic) up into the chest & into the throat to the nostrils. The patient with a history of leukemia and has a myocardial bridge. Advised to come in by his cardiologist.
O: Exam: Patient is awake, alert. Speaking clearly and cogently. No respiratory difficulty.
A/P: There are currently no available rooms in the emergency department. As there are no rooms currently available, the patient will wait for a room in the lobby. The patient requires further workup to exclude any emergent causes of symptoms...."

An EKG was performed at 5:51 p.m. The print-out of the EKG included: "Abnormal ECG...Probably Left Ventricular Hypertrophy...Unconfirmed Diagnosis." A handwritten note at the top of the form included: "No STEMI (ST-Segment Elevation Myocardial Infarction) ...Repeat q 30." It was signed by an ED physician and dated 7-20-21. There was no documentation that the EKG was repeated. Blood was drawn at 6:10 p.m. for lab work, and a chest x-ray was performed at 5:59 p.m. which revealed "mild cardiomegaly. No failure or pneumonia." The patient was documented to have "Eloped (left unannounced)" on 7/21/2021 at 2:42 a.m. There was no documentation of the patient's condition from the initial triage to the documentation that the patient eloped approximately nine hours later. Staff #4 reported the EKG was not repeated because the physician did not write an order.

Patient #11:

Patient #11 presented to the ED on 11/4/2021 at 4:41 p.m. The patient was triaged at 4:46 p.m. with a chief complaint of: "Pt here because she had blood work this morning and MD called stating blood sugar was 650, Pt 'Hi' in triage. Pt lightheaded, dizzy. Pt normal (sic) takes 30 insulin daily." The patient's blood sugar obtained during triage was '> 600 mg/dl.' The normal reference range documented on the lab results was 70-115 mg/dl. There was no documentation that an MSE was performed, however, there was a physician's order at 4:53 p.m. for "0.9% NaCl (normal saline) bolus and an intravenous (IV) site was placed. There was no documentation that the IV fluids were administered. The patient's blood glucose was "611" as reported on the complete blood count lab work obtained at 7:09 p.m. The lab report included documentation that this was a "critical" result. There was no documentation that any further lab work including blood glucose was obtained after that time. There was documentation by a Patient Care Technician on 11/5/2021 at 2:10 a.m. that the intravenous site was discontinued and nursing documentation at 2:35 a.m. that the patient left without treatment. There was no documentation of the patient's condition from 4:53 p.m. by a physician or other emergency department personnel until 2:10 a.m. when the patient left without treatment. The patient left the ED with a last known blood glucose of 611 and the physician ordered treatment of intravenous fluids was never initiated by the emergency department

Patient #11's ED record was reviewed with the Director of Emergency Services, Staff #4. Staff #4 acknowledged staff were aware the patient was leaving when the IV site was removed at 2:10 a.m., just prior to the patient leaving. Staff #4 was asked if those patients who informed staff that they were leaving were informed of the risks of leaving prior to an MSE, and she responded that they were too busy to pull a physician or nurse from the back to come up and talk to a patient in the lobby.

Patient #14:

Patient #14 presented to the ED on 11/08/2021 at 7:10 p.m. The patient was brought in by ambulance after the home health nurse assessed increased bleeding to a surgical wound on his left foot. The patient was triaged by an RN at 8:08 p.m., who was assigned a Tracking Acuity of 2. A "Physician Triage Exam was documented at 8:22 p.m. which included the following:

"S: The patient presents with L foot pain s/p surgery, bleeding, no drainage, no fevers
O: Exam: Patient is awake, alert. Speaking clearly and cogently. No respiratory difficulty.
A/P: There are currently no available rooms in the emergency department. As there are no rooms currently available, the patient will wait for a room in the lobby. The patient requires further workup to exclude any emergent causes of symptoms."

There was no documentation of a visual assessment of the patient's left foot during the "triage" exam. The ED physician ordered x-rays of the patient's left foot which were completed at approximately 9:52 p.m. Documentation on the imaging report included: "Exam mildly limited secondary to overlying bandages. The findings included: "Constellation of findings highly concerning for osteomyelitis versus Charcot arthropathy with diffuse erosion of the ankle and hindfoot including acute erosions of the tibial plafond, talus, calcareous, and cuboid...."

The patient was documented to have "Eloped" on 11/9/2021 at 1:27 a.m. There was no documentation the patient was reassessed by an RN or an MSE performed prior to the patient leaving. The patient returned to the ED at 3:16 a.m. after tripping on a step at home and sustaining a left ankle fracture with exposed bone. The patient was found to have "substantial anemia" and required two units of blood transfusions in the ED. The patient was taken to surgery at 4:03 p.m. where "gross purulence necrosis to the wound" was found and a below-the-knee amputation performed.

Patient #17:

Patient #17 presented to the ED on 11/12/2021 at 5:56 p.m. The patient was triaged by an RN at 6:16 p.m. who documented the patient's chief complaint as: "Sent by PCP (primary care provider) for transfusion due to low blood count. Feels dizzy and becomes easily short of breath x2 days. Reports very dark stools x 15 days...." A "Physician Triage Exam" was performed at 6:32 p.m. and included:

"S: The patient presents with c/o told she is anemic
O: Exam: Patient is awake, alert. Speaking clearly and cogently. No respiratory difficulty...
A/P: There are currently no available rooms in the emergency department. As there are no rooms currently available, the patient will wait for a room...The patient requires further workup to exclude any emergent causes of symptoms."

The ED physician ordered lab work including a Complete Blood Count (CBC); and a Comprehensive Metabolic Panel (CMP) with Type and Screen. The patient was documented to have "Eloped (left unannounced) at 5:06 a.m. on 11/13/2021, a period of eleven hours after the time of arrival. There was no documentation the lab work ordered by the ED physician was obtained; no documentation of reassessment(s) by an RN; and no documentation that an MSE was performed.

Patient #20:

Patient #20 had a history of double lung transplantation in 2018. Documentation in a Transplant Office/Clinic Note dated 11/23/2021 at 9:50 a.m. revealed the patient called and reported his oxygen saturation levels were dipping to 88-90%, a fever of 101.5 degrees Fahrenheit, weakness, and not able to eat. A Transplant Team physician was notified, and the patient was directed to go to Banner UMC Tucson's ED for evaluation. The patient arrived at the ED on 11/23/2021 at 12:54 p.m. and was triaged at 1:54 p.m. with a chief complaint of: "Pt sent by the transplant team. Covid + on Friday. total lung transplant. No vaccine. 94% RA (room air). The patient's temperature at 1:54 p.m. was 37.1 Deg C (98.8 DegF) and his oxygen saturation was 96%. A "Physician Triage Exam" was performed at 2:02 p.m. and included:

"S: The patient presents with h/o double lung transplant, now with COVID +. Not vaccinated. Feels weak.
O: Exam: Patient is awake, alert. Speaking clearly and cogently. No respiratory difficulty.
A/P: There are currently no available rooms in the emergency department. As there are no rooms currently, the patient will wait for a room in the lobby. The patient requires further workup to exclude any emergent causes of symptoms."

A chest x-ray was ordered and performed which revealed: "...Mild left basilar atelectasis...." Blood was drawn for lab work with results outside normal reference ranges documented on the laboratory reports. The patient's vital signs were obtained at 9:30 p.m. at which time the patient's temperature increased to 37.3 DegC (Degrees Celsius) (99.1 DegF) and his oxygenation saturation level decreased to 94%. The patient was documented to have "Eloped (left unannounced) on 11/24/2021 at 5:20 a.m., a period of approximately 16 hours after the arrival. There was no documentation of an RN assessment of the patient's condition while he was in the waiting room.

Another Transplant Office/Clinical Note dated 11/24/2021 at 9:28 a.m. revealed the patient's family member called and reported picking the patient up from the ED at around 1:30 a.m. because he, "...was never seen by a physician." The patient was diabetic and had not eaten the entire day and had to come home to take medications required for his transplant. The patient's oxygen saturation level dropped to the 70's at the time of the call, and the family member called 911. The patient lived in Casa Grande, Arizona which is approximately one hour from Tucson.

The patient was taken to the acute care hospital in Casa Grande (Hospital #3) on 11/24/2021 at approximately 10:15 a.m. where he received a Medical Screening Exam. The ED physician's documentation included: "...The patient...had a lung transplant done in March 2018 who presents emergency department (sic) for evaluation of shortness of breath, cough, and fever. He tested positive for Covid 5 days ago. He is not Covid vaccinated. He states he went to the emergency department at Banner emergency Medical Center Tucson yesterday but did not stay to be seen because there was a prolonged wait. He presented via ambulance today. He arrived in the emergency department he is on a 5 L (Liters) nasal cannula and was satting 86%...The patient will need to be transferred to Banner University Medical Center Tucson where he had his lung transplant...."

The patient was transferred back to Banner University Medical Center Tucson on 11/26/2021, however, his condition continued to deteriorate and he died on 12/3/2021.

Patient #21:

Patient #21 presented to the ED on 6/28/2021 at 2:41 p.m. The nurse's triage notes revealed the patient-reported falling at home four days earlier with progressing numbness, tingling in his hands and legs. The patient also complained of head, neck, and right hip pain. The following Physician Triage Exam was documented at 2:49 p.m. and included:

"S: 53M presenting with fall four days ago, progressive numbness and tingling in hands and legs.
O: Exam: Patient is awake, alert. Speaking clearly and cogently. No respiratory difficulty.
A/P: There are currently no available rooms in the emergency department. As there are no rooms currently available, the patient will wait for a room in the lobby. The patient requires further workup to exclude any emergent causes of symptoms."

The physician ordered imaging studies including a CT scan of the patient's head and neck which was performed at 6:11 p.m. with the following results dictated at 6:29 p.m.: "...At the C4-C5 level, there is a lentiform-shaped hyperdense structure in the spinal canal seen anteriorly, posteriorly, and on the left measuring up to 6 mm in thickness and 1.4 cm...There is a mass effect with a probably mild displacement of the cord to the right...." There was no documentation that the reading radiologist called the critical result to an ED provider. There were no other physician and/or nursing assessments documented in the record after triage and no documentation that the patient was notified of the results of the CT scan and encouraged to stay for a complete MSE in spite of the long wait time. The patient was documented to have "eloped" at 8:21 p.m. on 6/28/2021, approximately 7.5 hours after the arrival.

The patient called the hospital's outpatient Pulmonology Clinic the following day, 6/29/2021, and the clinic note at 12:22 p.m. included: "Pt called in clinic today, sat in ER for 6 hours with no pain meds and was told they were on code purple and did not know how much longer he would be in the ER so he left...." A Nurse Practitioner in the clinic documented at 4:44 p.m.: "Phone call to the patient to advise him that Dr. (pulmonologist) has reviewed his neck CT results with ED attending and patient to return to ED ASAP, ED will be awaiting his arrival. Reviewed concerning findings on neck CT including some cord compression, stressed importance of returning ASAP to avoid further injury/risk of paralysis, patient agreeable to returning to ED at this time...." The patient did return and was admitted for surgery.

An interview was conducted with an attending radiologist, (Staff #4) who acknowledged there was no documentation that the critical results of the CT head/neck scan were called to an ED physician.

A review of the hospital's dedicated ED logs for the period from July 1, 2021, through November 30, 2021, revealed a significant number of patients who left prior to receiving an MSE. Documentation was requested and provided by the hospital of the number of people who left without receiving an MSE. The following is a breakdown of the number of patients who left without treatment (LWOT) during each of those months:

July 2021: Total Volume = 6,249 LWOT = 885
August 2021: Total Volume = 6,603 LWOT = 1389
September 2021: Total Volume = 6,172 LWOT = 1271
October 2021: Total Volume = 5,910 LWOT = 1374
November 2021: Total Volume = 5,658 LWOT = 1231


There was no documentation in Governing Body Meeting Minutes, Medical Executive Meeting Minutes, or Quality Meeting Minutes that abnormal lab work, imaging procedures, and/or other studies were identified by a qualified medical person and communicated to patients waiting in the lobby for a room in the ED and encouraged to stay for an MSE.

The ED Medical Director acknowledged during interviews that the hospital was aware of the above numbers. She explained the inpatient units were full with patients requiring inpatient beds occupying ED rooms. This limited their ability to move the patients in the lobby to ED rooms. She and the ED Nursing Director submitted a "Pilot Plan" to hospital leadership that would be implemented on 12/6/2021 on Mondays, Tuesdays, and Wednesdays. She explained the current process was for a physician up front doing a medical screening exam at the time of a patient's arrival. She said it was a "quick look" to determine whether or not the patient needed immediate medical attention and that she developed a template for the physicians to use. She stated those physicians will order lab work, imaging, and other pertinent tests pertinent to the chief complaint. The Surveyor explained to Medical Staff #1 that the physician documentation in the template did not reflect any physical assessment of the patient and, in fact, stated the patient required further workup to determine if there was an emergent medical condition. Medical Staff #1 was asked what the system was for a physician review of abnormal lab work and/or imaging procedures that were ordered by the up-front physician if the patient was still in the lobby. She responded that results were not reviewed until the patient was assigned and taken back to a room within the ED. She added that the up-front physicians were too busy triaging patients as they come in. She said that even if the results were reviewed, there was not much that could be done because the patient has to be in an ED room in order to start care and treatment.

An interview was attempted with the CEO on 12/2/2021 to discuss what action plan(s) the hospital had developed and implemented to address the high number of patients leaving without treatment for several months prior to the current surge. The CEO did not provide any additional information.