HospitalInspections.org

Based on review of the Hospital's Emergency Department (ED) logs, PCC management report visit listing summaries, review of medical records, policy review and staff/family interviews, it was determined the Hospital failed to comply with the provider agreement as defined in ?489.20 and ?489.24.

The findings included:

a. The Hospital failed to maintain accurate documentation in the ED logs of patients presenting to the ED. See A2405 for specifics.

b. The Hospital failed to provide a medical screening examination that was, within reasonable clinical confidence, sufficient to determine whether or not an Emergency Medical Condition (EMC) existed. See A2406 for patient specifics.

c. The Hospital failed to ensure the patient's emergency medical condition was stabilized prior to discharge/transfer. See A2407 for patient specifics.

d. The Hospital failed to provide an appropriate transfer of patients seeking emergency medical treatment. See A2409 for patient specifics.

Based on policy review, medical record review, review of the ED logs, PCC management report visit listing summaries and staff/patient interviews, the Hospital failed to maintain accurate, complete documentation in the ED logs of patients who presented for emergency services. The findings included:

1. Review of the policy titled "Emergency Department: ER Log" indicated if a patient presented to another department and made a request for examination in the ED, the patient would receive a MSE to determine the existence of an EMC. When this occurred the patient visit would be logged into the ED log. This policy had not been reviewed since September 2003.
2. Review of the EHR for an outpatient clinic documentation on 2/4/10 at 8:29 AM indicated patient #13 presented to the clinic 'as a walk in'. The progress note indicated "they signed in at 8:29 and apparently went back to the ED where they originally presented with concerns and upset that they were not seen immediately. They returned with (patient advocate) at 9:01 AM. Her grandfather states that he wanted her "in the emergency roon (sp)" but they wouldn't (sp) let her in."
a. Review of the PCC Management Reports Visit Listing Summary Page for the walk-ins on 2/4/10 did not show the patient presented to the hospital as a walk-in.
b. Review of the ED (hand written) log did not show the patient listed for 2/4/10.
3. Review of the ED logs (hand written) and the PCC Management Reports Visit Listing Summary Page did not consistently record the same time of arrival of patients to the hospital. Examples:
a. Patient #28-2/3/10-ED log time 1230 (12:30 PM) -PCC listing time 1324 (1:24 PM)
b. Patient #29-2/4/10-ED log time 1642 (4:42 PM) -PCC listing time 1633 (4:33 PM)
c. Patient #30-2/5/10-ED log time 1555 (3:55 PM) -PCC listing time 1616 (4:16 PM)
d. None of the times for the patients listed on the PCC listing for 2/6/10 matched the times listed for these patients in the ED log.
e. Not all the patients on the PCC listing were seen in the ED but the listing did not indicate what ESI category these patients had been triaged as or the patient's disposition.
4. In an interview with the Director of Nursing (A) on 9/8/10 at 2:35 PM she indicated she did not think there was a log for the triage nurse to show the patients (walk-ins) that were triaged as an ESI 4 and ESI 5 who did not go to the ED for care. She indicated walk-ins and their disposition "should be logged".
5. In an interview with patient #26 he/she indicated after a request for ED services on 5/11/10, he/she was directed to clinic, even after a second request in the clinic area for ED services.
a. Review of the ED log for 5/11/10 did not show patient #26 presented directly to the ED.
b. Review of the PCC Management Reports Visit Listing Summary Page for the walk-ins on 5/11/10 showed patient #26 came to the triage /registration area at 10:58 AM. This log did not show the triage level, reason for visit or disposition. The log did not show if the patient had a prior appointment or he/she was a walk-in patient.
c. Review of the Outpatient EHR did not show if the patient had requested to be seen in the ED.
6. Review of the ED log for 7/30/10 showed patient #27 had initially arrived at 1110 (11:10 AM) and was triaged at ESI 4 for complaints of asthma. The ED log indicated "returned to ER 1750 (5:50 PM) over 6 ? hours later but there was no second entry in the ED log at this time.

Based on observations, medical record reviews, policy/administrative record review and staff/family interviews, it was determined the Hospital failed to provide an appropriate medical screening exam (MSE) for eleven of 30 sample patients (#4, #5, #6, #8, #9, #10, #11, #13, #15, #21 and #23) who presented to the Emergency Department (ED) to determine whether or not the patient had an emergency medical condition (EMC).

Findings included:

1. Review of the policy titled "Emergency Department: ER Log" indicated if a patient presented to another department and made a request for examination in the ED, the patient would received a MSE to determine the existence of an EMC. When this occurred the patient visit would be logged into the ED log. This policy had not been reviewed since September 2003.

2. Review of nursing staff minutes dated 7/26/10 indicated that if a patient presents stating that they are an emergency or want to be seen in ER, they must be seen in ER. Once a MSE is conducted by a medical provider it can be determined if they are emergency or non-emergency. A non-emergency patient can then be sent to outpatient or scheduled for a later appointment.
3. These minutes included an attachment titled "the Medical Screening Examination Requirement" which indicated the following:
a. Initial first impressions (triage), especially of a cursory nature with only vital signs and presenting complaint to guide the triage, cannot be the basis of a medical screening examination.
b. The hospital needs to document and maintain records for every triage interaction.
c. Triage was never intended to reach a diagnosis and cannot be substituted for a MSE. Even minor presenting symptoms or complaints may turn out to be a medical emergency.
d. The section regarding "Triage Out of the Emergency Department" indicated a cautionary note that referral to another care setting such as a clinic and the substitution of non-physician or QMP performance of a MSE to rule out an EMC has the risk of EMTALA violations.
4. Review of the hospital's policy titled "Triage Policy" indicated all patients presenting for care without an appointment or planned visit would be triaged according the Emergency Severity Index (ESI), an emergency department (ED) triage algorithm. This policy indicated the triage nurse would assess the patient and assign the ESI number.
a. The policy indicated patients triaged as ESI 1 or ESI 2 would be taken to the emergency room with 'hand-off' to the ED nurse and/or provider.
b. The policy did not indicate how the ESI 3 level patient would be handled (in ED or in an outpatient clinic setting).
c. The policy indicated patients who are triaged by the nurse as ESI 4 (semi-urgent) or ESI 5 (non-urgent) would be referred to one of the outpatient clinic teams and not the ED.
d. The triage policy indicated a patient would be triaged at an ESI of 4 (semi-urgent) when the patient's presenting condition had a low potential for deterioration or complications.
This triage policy fails to ensure all patients who present to the hospital for emergency services receive a MSE by a Qualified Medical Provider to determine the presence of an EMC and the need for stabilizing treatment.
5. Review of the policy titled "Medical Screening Evaluations" indicated the following:

"4. Medical Screening Examination (MSE): the process required to reach, with reasonable clinical confidence that a medical emergency does or does not exist."

"III. Policy: B: In accordance with the Medical Staff Bylaws, Rules and Regulations, a medical screening examination may be completed by a medical doctor, physician assistant, or certified nurse practitioner."

"V. Procedure/Instructions/Operations Information: B: Initial Triage will be completed by Nursing staff (triage is not equivalent to a MSE, but determines the order in which individuals will be seen."

6. In an interview on 9/8/10 at 10:30 AM with a registration clerk (E), she indicated if a patient with an appointment presented at the registration area, he/she was given a green slip/pass and directed to the clinic area. If the patient did not have an appointment the patient was screened in the 'triage' area and sent to either the ED or one of the clinic areas. This was confirmed by the nurse doing triage assessments at this time.

This system of emergency triage shifts patients with a possible EMC away from the ED setting and creates the potential for delays in examination and/or treatment of an EMC. Patients sent from this triage area to a clinic setting would not have received a MSE to rule out an EMC and the need for stabilizing treatment.

7. In a telephone interview with an anonymous family member on 10/1/10 at approximately 9:00 AM, she indicated she had taken her child into the hospital ED on 9/23/10 and the nurse in the triage area indicated to her, before an examination or triage assessment, the child was not an emergency and she needed to make an appointment. The family member indicated she was directed to leave the ED and go to the front of the hospital to registration to get an appointment. When she insisted her child be seen in the ED she was told again the child was not an emergency. She indicated she was told this without the nurse or anyone doing a triage assessment or even taking the child's temperature. She indicated, only after she became upset and insisted on ED services, did the ED staff examine the child.
8. In an interview on 9/9/10 with a security guard (F), he indicated staff and patients were not allowed to enter through the ED entrance (during hours the clinic registration was open) but were directed to the hospital's front entrance. He indicated if a patient requested ED services or "looked sick" on the monitors (i.e. with complaints of shortness of breath, dizziness or chest pain) they were brought in through the ED entrance.
9. Observation of the front entrance did not show the outside area was marked as an emergency entrance.

MEDICAL RECORD REVIEW:

Review of medical records for eleven of 30 patients seen in the ED after the Hospital alleged compliance with EMTALA regulations (date of alleged compliance 10/22/09) revealed the following:
1. Review of the EHR for an outpatient clinic documentation on 2/4/10 at 8:29 AM indicated patient #13 presented to the clinic 'as a walk in'. The progress note indicated "they signed in at 8:29 and apparently went back to the ED where they originally presented with concerns and upset that they were not seen immediately. They returned with (patient advocate) at 9:01 AM. Her grandfather states that he wanted her "in the emergency roon (sp)" but they wouldn't (sp) let her in. "
a. Review of the PCC Management Reports Visit Listing Summary Page for the walk-ins on 2/4/10 did not show the patient presented to the hospital at the walk-in registration. Review of the ED (hand written) log did not show the patient listed for 2/4/10. Although the family member indicated he had initially requested ED services and again indicated he wanted ED services at the pediatric clinic, the patient was not taken to the ED.
b. The patient was seen in the pediatric clinic and diagnosed with pneumonia and asthma. The EHR progress note did not indicate if the patient's vital signs (including temperature) had been taken in the clinic although it was noted the patient had a "fever all night". The EHR indicated the patient "Brightens after Tylenol and takes fluid". The record did not indicate the dose of Tylenol given or if fluids were oral or intravenous or the amount taken. There was no indication on the clinic progress note of any antibiotics given to the patient.
c. There was no evidence the patient's vital signs and oxygen saturation levels were evaluated.
d. Patient #13 returned to the ED on 2/5/10 at 0847 (8:47 AM) with continued fever and vomiting. The patient required IV fluids on this ED visit due to his/her hypovolemia. The patient was originally triaged as ESI 4 and then the triage level was changed to "3", with no documentation of the reason for the change. Triage assessment showed a temperature of 101.3 degrees and a stated pain level of 10/10.
e. The patient received IV fluids but there was no documentation of the total amount of fluids given to the patient.
2. Patient #23 presented to the ED on 1/20/10 with complaints of shortness of breath after choking on a piece of pork chop. Although the patient denied the presence of a bone in the pork chop, no radiological studies were conducted to determine possible blockage. The MSE did not indicate if the QMP examined the patient's throat. See A2409 for patient specifics regarding appropriate transfer.
3. Patient #9 presented to the ED on 1/26/10 at 1420 (2:20 PM) with complaints of headache (stated level of 6 of 10) and facial numbness. The patient was transferred with possible stroke or Bell's palsy. The QMP did not provide any radiological or baseline laboratory studies to determine need for emergency treatment to stabilize the patient prior to transfer and reduce the long term effects of either condition. See A2409 for patient specifics regarding appropriate transfer.
4. Patient #15 presented to the ED on 3/15/10 with complaints of left-sided abdominal pain, pain with urination and nausea/vomiting. The patient was triaged at the ESI level of 3 but this was changed to ESI 4 with no notation of the reason for this change. Although the triage nurse had indicated the patient complained of pain with urination, the QMP indicated denial of dysuria (painful or difficult urination). The QMP did not document the time of the MSE on the ER record or in the EHR.
a. The patient also presented to the ED on 5/19/10 with complaints of head cold and bilateral ear pain (stated level of 6-7 of 10). Although the patient was triaged and given the triage level of ESI 5, no basic nursing assessment, including vital signs, was conducted to accurately determine this ESI level or the patient's status.
b. The patient again presented to the ED on 7/30/10 at 1235 (12:35 PM) with complaints of a head cold and difficulty breathing, stated pain level of 8/10 and "pain in middle of chest". The patient was not monitored or reassessed until he/she was called at 1712 (5:12 PM) almost 5 hours later. A diagnosis of "head cold, sore throat' was indicated although there was no evidence the QMP had conducted a MSE exam. The patient was also given "Aftercare Discharge Instructions" without adequate ED services. The ER record showed the patient left without being seen.
5. Patient #10 presented to the ED on 4/18/10 at 1512 (3:12 PM) with complaints of urinary frequency and pain with urination. The patient arrived in the ED at 3:12 PM but was not triaged until 1712 (5:12 PM) two hours later and the MSE was not conducted until 1830 (6:30 PM), over three hours after presenting to the ED.
a. A urinalysis showed large amounts of blood and protein as well as a urine glucose of 1000 mg/dL. No urine culture was performed to ensure the antibiotic ordered would be adequate and appropriate treatment.
b. No further evaluation of the high levels of urine glucose was evident in the MSE. The patient had a history of diabetes mellitus and noncompliance but there was no further evaluation of the patient's blood glucose levels. Hyperglycemia (high levels of glucose in the blood) may impact the urinary system. Prior studies on 3/22/10 showed a fasting blood glucose of 406 mg/dL (high) and a high HgbA1C of 12.4 % (the test HgbA1C is used to rule out diabetes or monitor diabetic treatment).
c. There was no evaluation of the patient's current medication regime by the nurse or the QMP.
6. Patient #21 presented to the ED on 12/22/09 with complaints of back and leg pain after a fall, urinary frequency, confusion, increased thirst and increased blood sugar. Laboratory studies showed the patient had a severe urinary tract infection (urosepsis).
The Mid-Level QMP consulted with the physician on call regarding the care of the patient. This physician recommended the QMP check the patient's CPK and serum ketones. These recommendations for further evaluation were not implemented by the QMP and the patient was transferred to another area hospital for "inpt (inpatient) IV anbx (antibiotics) and IV fluids". See A2407 for patient specifics regarding stabilizing treatment. See 2409 for patient specifics regarding appropriate transfer.
7. Patient #5 presented to the ED via ambulance on 1/14/10 at 2330 (11:30 PM) with complaints of a possible assault with head injuries (stated pain level of 8/10) and possible loss of consciousness.
a. Although an assault patient with possible head injuries has a potential for deterioration or complications, the patient was triaged as ESI 4.
b. After the initial evaluation of the patient's vital signs and neurological status, no further evaluation was evident prior to discharge to Detox.
c. The patient also had an elevated blood alcohol level (BAL) of 322 but no further evaluation was evident to ensure BALs were not increasing or the patient did not have alcohol poisoning or other drugs/chemicals which could impact his/her treatment and care. The patient was transferred to a detoxification (Detox) unit one hour and fifteen minutes after initial presentation to the ED.
d. No radiological studies were conducted to evaluate the extent of a possible head injury.
e. The patient was transferred to a detoxification center at 0045 (12:45 AM) but there was no treatment/re-evaluation of the patient's pain level.
f. The patient was discharged to "detox", which is a drug and alcohol center. The patient was discharged to this center via police escort. Review of the discharge form to the Detox center did not show the treatment given for the patient's wounds, risks/benefits of the transfer and did not show the patient's consent for this transfer.
g. In an interview with the Director of Nursing (A) on 9/15/10 at 1:50 PM she confirmed the detox center was a separate provider from the hospital but was unsure of the protocol for such transfers.
h. In an e-mail from the DON on 9/16/10 she indicated the patients sent to the Detox Center were not transferred but discharged and then only transported to the center by the Detox driver. She indicated if medications were prescribed, the medication was given to the patient. If unable to stabilize the patient, a transfer would be made to a higher level of care.
8. Patient #8 presented to the ED on 1/26/10 at 1420 (2:20 PM) with complaints of headache (stated level of 6 of 10) and facial numbness. The patient was transferred with possible stroke or Bell's palsy. The QMP did not provide any radiological or baseline laboratory studies to determine the need for emergency treatment to stabilize the patient prior to transfer. See A2409 for patient specifics regarding lack of appropriate transfer.
9. Patient #4 presented to the ED on 1/24/10 at 11:27 AM with complaints of severe head and neck pain (stated pain of 10/10). The patient received an injection of Morphine at 1245 (12:45 PM) over one hour later but there was no reassessment of his/her current pain level when the medication was given.
a. The EHR indicated a diagnosis of headache and pseudotumor cerebri. The patient had complained of photophobia. According to information from Mayo Clinic, pseudotumor cerebri occurs when the pressure inside the skull (intracranial pressure) increases for no obvious reason with symptoms that mimic those of a brain tumor. The increased intracranial pressure associated with pseudotumor cerebri can cause swelling of the optic nerve and result in vision loss. No evaluation of possible increase in intracranial pressure was evident in the medical record.

b. The nurse had triaged the patient as ESI 4 (a low potential for deterioration or complications). A medical condition such as pseudotumor cerebri had the potential for patient deterioration or complications.

c. There was no evidence of evaluation of head CT scan or laboratory studies.

d. The patient went to another area hospital on his/her own for evaluation of intracranial pressure and received treatment in the other hospital's ED.

e. The patient returned two days later (1/26/10 at 9:55 AM) with complaints of headache (stated pain of 10/10) and blurred vision. The nurse had triaged the patient as ESI 4 and indicated a history of pseudotumor cerebri. Although the ER Record indicated the patient left without being seen at 1007 (10:07 AM) his/her vital signs were taken at 10:30 (readings not recorded).

f. The patient returned on 1/29/10 at 9:55 AM with continued complaints of headache (stated pain of 10/10) and 'visual disturbances' and sensitivity to light. The nurse triaged the patient again as ESI 4.

10. Patient #6 presented to the ED on 3/27/10 at 0828 (8:28 AM) with complaints of shortness of breath, diaphoretic and elevated blood pressure. An undated/untimed notation from the Medical Director indicated "unable to finish note/visit Provider no longer at facility". Although the patient left with an improvement of his/her vital signs, the MSE was limited with no QMP dictation to show adequacy of the ED evaluation.

a. Although a chest x-ray indicated possible lower lobe pneumonia and the QMP indicated a diagnosis of upper respiratory infection, there was no evidence the patient received any antibiotic for this infection. The report of the chest x-ray indicated it was not reported until 4/7/10. The patient only received an inhaler treatment at this 3/27/10 ED visit.

b. Review of laboratory tests conducted on this ED visit showed the patient's Red Blood Count was low at 2.82 M/uL (normal 4.5-5.9 M/uL), his/her hemoglobin was low at 9.1 g/dL (normal 14-19 g/dL and his/her hematocrit was low at 27.9 % (normal 40.4-46%). These low serum values were not addressed by the QMP.

c. There was no evidence the laboratory studies ordered included a D-Dimer test (D-Dimer may be ordered when a patient has symptoms of Deep Vein Thrombosis, such as leg pain, tenderness, swelling, discoloration, edema; or symptoms of Pulmonary Embolism, such as labored breathing, coughing, and lung-related chest pain.)

d. The patient returned two days later on 3/29/10 for complaints of shortness of breath, sweating and chest congestion. On this ED visit the patient's D-Dimer test was at a critical value of 503 ng/mL (normal 70-255 ng/mL). The patient was transferred to a higher level of care for cardiac symptoms. See A2409 for patient specifics regarding appropriate transfer.

e. Patient #6 also presented to the ED on 4/10/10 after a fall with a laceration of his/her hand and was triaged as ESI 4. The patient was sent to the clinic and did not receive a MSE from the QMP in the ED. In the clinic the patient required x-rays which showed a fracture of the metacarpal shaft and wound care to a hand laceration. The time the patient was seen in the clinic was not recorded.

11. Patient #11 presented to the ED on 2/6/10 at 1336 (1:36 PM) with complaints of shortness of breath and audible wheezing noted. He/she also had a stated pain level of 7 of 10 but there was no evaluation or treatment to address this symptom. The patient had a known history of COPD and asthma. Triage assessment showed low heart rate and increased respiratory rate with audible wheezing. There was no evidence chest radiology or laboratory studies (CBC) were conducted to evaluate the patient's respiratory status.

INACCURATE/INCOMPLETE DOCUMENTATION

1. Review of 30 medical records of patients seen in the ED from January 2010 through the survey showed the use of a form titled "E.R. Record". This form had a section to record the subjective/objective information, final diagnosis and disposition of the patient. Notations of the QMP and of the triage nurse/ED nurse were interspersed in this area of the record, without consistent designation of the author of each notation (i.e. signature/title).
a. Additionally there were two areas for the recording of medications. Medication names were often listed without dose or route indicated. This documentation was often unclear rather the medications were to be given at the time of the ED visit or if the patient was given the medication to take home.
b. Review of ER Records and the EHRs revealed the QMPs did not consistently document the time he/she conducts the MSE (patients #3, #7, #8, #9, #11, #13, #15, #20, #21, #22, #23, and #24).
2. Patient #7 presented to the ED on 4/14/10 at 2128 (9:28 PM) with complaints of low back pain (10 on a scale of 1 to 10). The patient was triaged at a level of ESI 4 and required an injection of Toradol 60 mg for pain management. The QMP did not document the time of the MSE and did not include the dose or route of two medications, Robaxin and Motrin. The nurse administered the medications but did not record any clarification of the dose/route and did not document this medication administration information.
The patient returned on 4/15/10 at 1312 (1:12 PM) with continued complaints of back pain. The triage note indicated an ESI of 5 but there was no documentation of the pain level or the patient's vital signs and he/she left the ED without being seen.
3. Patient #1 presented to the ED on 7/6/10 at 9:04 AM with complaints of difficulty breathing, low back pain and ankle pain. Stated pain level was 10 (scale of 1 to 10) at the time of triage (untimed note).
a. The EHR showed two visit notes, one timed for 9:30 AM and one timed for 8:20 AM. Physical exam information was similar with the same assessment and vital signs noted on each sheet. The History of Present Illness on the EHR contained different data. Medications listed on the two EHR were the same.
b. Interview with administrative staff (C) and review of faxed EHR notes showed the provider had erroneously entered assessment data for another patient on a visit note for patient #1.
c. The ER Record for the 7/6/10 visit showed Tramadol 60 mg was administered at 1011 (10:11 AM) over an hour after the patient presented to the ED. There was no documentation of the pain level (back or ankle) at this time or at the time of discharge from the ED (at 11:22 AM). Although the QMP indicated the patient was discharged home in stable condition there was no indication the treatment given was effective in relieving or lessening of the patient's pain.
4. Patient #22 (5 month old) presented to the ED on 1/20/10 with complaints of fever and red/swollen genital area. The triage assessment did not include any vital signs including a temperature.
5. Review of policies for the ED showed policies were not current as follows:
a. Multidisciplinary Assessment of Patients last reviewed 7/2001.
b. Medical Screening Evaluations last reviewed 2001.
6. Although the hospital conducted various performance improvement reviews of ED documentation and EMTALA issues, many areas continued to show non-compliance. These QA activities were not effective in identifying/correcting the EMTALA issues of MSE, stabilizing treatment and appropriate transfers.

Based on medical record reviews, policy/administrative record review and staff interviews, it was determined the Hospital failed to ensure the patient's EMC was stabilized prior to discharge/transfer for seven of 30 patients (#3, #4, #5, #6, #11, #12 and #21) reviewed who presented to the ED for care and services. The findings included:

1. Patient #21 presented to the ED on 12/22/09 with complaints of back and leg pain after a fall, urinary frequency, confusion, increased thirst and increased blood sugar. Laboratory studies showed the patient had a severe urinary tract infection (urosepsis). Laboratory studies showed the patient had an abnormally high urine glucose of 1000, trace of ketones, large amount of blood and bacteria in his/her urine. A Foley catheter was inserted but there was no evidence of a physician order for this procedure.
a. The Mid-Level QMP consulted with the physician on call regarding the care of the patient. This physician indicated the patient would benefit from IV Rocephin 1 Gram and IV fluids. These recommendations for further stabilizing treatment were not implemented by the QMP.
b. The patient was transferred to another area hospital for "inpt (inpatient) IV anbx (antibiotics) and IV fluids". See A2406 for patient specifics regarding MSE. See A2409 for patient specifics regarding appropriate transfer.
c. In an interview with the Medical Staff Director (B) on 9/10/10 he confirmed the hospital had the capacity/capability to provided IV antibiotics and fluids.

2. Patient #4 presented to the ED on 1/24/10 at 11:27 AM with complaints of severe head and neck pain (stated pain of 10/10). The patient received an injection of Morphine at 1245 (12:45 PM) over one hour later but there was no reassessment of his/her current pain level when the medication was given.

a. The EHR indicated a diagnosis of headache and pseudotumor cerebri. The patient had complained of photophobia. According to information from Mayo Clinic, pseudotumor cerebri occurs when the pressure inside the skull (intracranial pressure) increases for no obvious reason with symptoms that mimic those of a brain tumor. The increased intracranial pressure associated with pseudotumor cerebri can cause swelling of the optic nerve and result in vision loss. No evaluation of a possible increase in intracranial pressure was evident in the medical record.

b. The nurse had triaged the patient as ESI 4 (a low potential for deterioration or complications). A medical condition such as pseudotumor cerebri had the potential for patient deterioration or complications.

c. The patient went to another area hospital on his/her own for evaluation of intracranial pressure and received treatment in the other hospital ED.

3. Patient #11 presented to the ED on 2/6/10 at 1336 (1:36 PM) with complaints of shortness of breath and audible wheezing noted. He/she also had a stated pain level of 7 of 10 but there was no evaluation or treatment to address this symptom.
a. The ER record showed under medication section "Albneb-Albuterol and Prednisone." The order did not indicate dosage and there was no indication if the patient received these medications in the ED or if these medications were sent home with the patient with instructions on use.
b. Although the ER record shows the nurse administered a Duoneb treatment there was no assessment of lung sounds before and after the treatment was given.
c. Patient #11 also presented to the ED on 6/18/10 at 2343 (11:43 PM) with a request for a med refill of his/her inhaler (for asthma). The patient had a stated pain level of 7 of 10 but there was no evaluation or treatment to address this symptom. The ER record showed under medication section "Albuterol inh (inhaler)" but there was no indication if the patient received a treatment or was sent home on the medication with instructions on use.
4. Patient #12 presented to the ED on 5/14/10, 5/15/10 and 5/30/10 for complaints of dislocation of the right shoulder.
a. On 5/14/10 the patient had a stated pain level of 10 of 10. There was no evidence the patient's pain was addressed prior to the transfer to another area hospital.
b. On 5/15/10 the patient returned with complaints of another shoulder dislocation and pain 10/10. The patient did not receive any medication for his/her stated pain.
5. Patient #5 presented to the ED via ambulance on 1/14/10 at 2330 (11:30 PM) with complaints of a possible assault with head injuries (stated pain level of 8/10) and possible loss of consciousness. Although an assault patient with possible head injuries has a potential for deterioration or complications, the patient was triaged as ESI 4. The patient was transferred to a detoxification center at 0045 (12:45 AM) but there was no treatment/re-evaluation of the patient's pain level.
6. Patient #6 presented to the ED on 3/27/10 at 0828 (8:28 AM) with complaints of shortness of breath, diaphoretic and elevated blood pressure. An undated/untimed notation from the Medical Director indicated "unable to finish note/visit Provider no longer at facility". See A2406 for patient specifics regarding MSE.
a. Although a chest x-ray indicated possible lower lobe pneumonia and the QMP indicated a diagnosis of upper respiratory infection, there was no evidence the patient received any antibiotic for this infection. The report of the chest x-ray indicated it was not reported until 4/7/10. The patient only received an inhaler treatment at this ED visit.

b. There was no evidence the laboratory studies ordered included a D-Dimer test (D-dimer may be ordered when a patient has symptoms of Deep Vein Thrombosis, such as leg pain, tenderness, swelling, discoloration, edema; or symptoms of Pulmonary Embolism, such as labored breathing, coughing, and lung-related chest pain.)

c. The patient returned two days later on 3/29/10 for complaints of shortness of breath, sweating and chest congestion. On this ED visit the patient's D-Dimer test was at a critical value of 503 ng/mL (normal 70-255 ng/mL). The patient was transferred to a higher level of care for cardiac symptoms. See A2409 for patient specifics regarding appropriate transfer.

7. Patient #3 presented to the ED on 3/20/10 at 11:14 AM with complaints of stomach cramping (stated pain of 9/10). The patient was diagnosed with paranoia related to drug use and was transferred to another hospital for evaluation.

a. The patient was treated for a urinary tract infection (medication sent home with parent) but the pain was not addressed by the QMP or re-evaluated prior to transfer.

b. The patient's abdominal cramping was felt to be benign due to the evidence of the paranoia but additional history and evaluation would have been needed to rule out possible cause of the abdominal pain.

c. There was an unexplained delay in the time between the medical evaluation and the evaluation by the mental health QMP.

8. Review of policies for the ED showed policies were not current as follows:
a. Emergency Department: ER Log last reviewed 9/2003.

b. Multidisciplinary Assessment of Patients last reviewed 7/2001.

c. Medical Screening Evaluations last reviewed 2001.

d. Patients Rights and Responsibilities last reviewed 1/2007.

e. Do Not Resuscitate (DNR) last reviewed 4/2007.

f. Several policies did not indicate a date of the last review.

9. Although the hospital conducted various performance improvement reviews of ED documentation and EMTALA issues, many areas continued to show non-compliance. These QA activities were not effective in identifying/correcting the EMTALA issues of MSE, stabilizing treatment and appropriate transfers.

Based on medical record reviews, staff interview and policy/administrative record reviews, it was determined the Hospital failed to provide an appropriate transfer for seven of 30 patients ( #3, #6, #8, #9, #12, #21, and #23) who presented to the ED seeking emergency treatment. This failure included the failure to ensure use of appropriate emergency equipment and medical staff for the transfer. The findings included:
1. Patient #3 presented to the ED on 3/20/10 at 11:14 AM with complaints of stomach cramping (stated pain of 9/10). The patient was diagnosed with paranoia related to drug use and was transferred to another hospital for evaluation. Review of the transfer sheet indicated (by a check mark) 'other' risk of transfer but did not list risks specific for this patient.
a. Neither the ER record nor the EHR showed the QMP, who was a physician's assistant, had consulted with the physician on call prior to the transfer of the patient. A physician did not sign the certification for transfer until 3/26/10, six days later.
b. The QMP did not time the MSE (no time on ER Record or on the EHR). The discharge note at 1425 (2:25 PM) indicated the patient had been transferred. The patient's vital signs were recorded but no indication of the patient's mental status evaluation (including suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others).
2. Patient #12 presented to the ED on 5/14/10, 5/15/10 and 5/30/10 for complaints of dislocation of the right shoulder.
a. On 5/14/10 the patient had a stated pain level of 10 of 10. The transfer form did not indicate the patient's condition at the time of transfer, risks of transfer, preparation for the transfer, or what copies of pertinent parts of the medical record were sent with the patient. Although the physician on call signed the transfer form, he/she did not date the signature to demonstrate timeliness. There was no evidence the mid-level provider had consulted the physician prior to the transfer. Although the ER record indicated the patient was transferred via ambulance the Out-Of-Hospital Transfer Record indicated the Detox driver took the patient to the receiving hospital.
b. On 5/15/10 the patient returned with complaints of another shoulder dislocation and pain 10/10. The patient was again transferred to another area hospital. Transfer form did not show risks of transfer or the date of the physician's signature of the transfer certification. There was no evidence the mid-level provider had consulted with the physician on call regarding the transfer. The patient did not receive any treatment or medication for his/her stated pain. The medical record is unclear on the exact method and personnel involved in this transfer.
c. On 5/30/10 the patient returned with complaints of another shoulder dislocation and pain 10/10. The patient was again transferred to an area hospital. Transfer form did not show the date of the physician's signature of the certification or evidence the mid-level provider had consulted with the physician on call regarding the transfer.
3. Patient #6 presented to the ED on 3/27/10 at 0828 (8:28 AM) with complaints of shortness of breath, diaphoretic and elevated blood pressure. See A2406 for patient specifics regarding MSE. See A2407 for patient specifics regarding stabilizing treatment. The patient returned two days later on 3/29/10 for complaints of shortness of breath, sweating and chest congestion. The patient was transferred to a higher level of care for cardiac symptoms.
a. The patient had an elevation of troponin levels (1.15 ng/mL with normal levels of 0-.06 ng/mL). Elevated troponin levels may be indicative of a heart attack.
b. On this ED visit the patient's D-Dimer test was at a critical value of 503 ng/mL (normal 70-255 ng/mL). (D-dimer may be ordered when a patient has symptoms of Deep Vein Thrombosis, such as leg pain, tenderness, swelling, discoloration, edema; or symptoms of Pulmonary Embolism, such as labored breathing, coughing, and lung-related chest pain.)
c. Although the troponin levels and D-Dimer levels were elevated and the QMP indicated a diagnosis of congestive heart failure, the patient was transferred to a higher level of care without qualified personnel and transportation equipment, including the use of medically appropriate life support measures to decrease the risk of the transfer. There was no indication the risk of transfer via private car was discussed with the patient or his/her family.
4. Patient #23 presented to the ED on 1/20/10 with complaints of shortness of breath after choking on a piece of pork chop. See A2406 for patient specifics regarding MSE. There is no documentation or evidence the mid-level QMP consulted with the physician on call regarding the care of this patient prior to transfer. The indication of the reason for a greater level of care or indication of why the hospital did not have the capabilities/capacity to provide care for this patient was not evident in the record. The physician did not sign the transfer certification.
5. Patient #21 presented to the ED on 12/22/09 with complaints of back and leg pain after a fall, urinary frequency, confusion, increased thirst and increased blood sugar. Laboratory studies showed the patient had a severe urinary tract infection (urosepsis). See A2406 for patient specifics regarding MSE. See A2407 for patient specifics regarding stabilizing treatment.
a. The Mid-Level QMP consulted with the physician on call regarding the care of the patient. The recommendations from this physician for further evaluation and stabilizing treatment were not implemented by the QMP and the patient was transferred to another area hospital for "inpt (inpatient) IV anbx (antibiotics) and IV fluids".
b. There was no indication why the hospital did not have the capabilities/capacity to provide this inpatient service. The physician did not sign the transfer certification.
c. In an interview with the Medical Staff Director (B) on 9/10/10 he confirmed the hospital had the capacity/capability to provided IV antibiotics and fluids.
6. Patient #8 presented to the ED on 1/26/10 at 1420 (2:20 PM) with complaints of headache (stated level of 6 of 10) and facial numbness. The patient was transferred with possible stroke or Bell's palsy. The QMP did not provide any radiological or baseline laboratory studies to determine the need for emergency treatment to stabilize the patient prior to transfer. Although the physician on call was consulted about the transfer and signed the transfer form, he/she did not date the signature to demonstrate timeliness. The risks of the transfer related to this individual patient were not outline on the transfer form.

7. Patient #9 presented to the ED on 1/26/10 at 1420 (2:20 PM) with complaints of headache (stated level of 6 of 10) and facial numbness. The patient was transferred with possible stroke or Bell's palsy. See A2406 for patient specifics regarding MSE. Although the physician on call was consulted about the transfer and signed the transfer form, he/she did not date the signature to demonstrate timeliness. The risks of the transfer related to this individual patient were not outline on the transfer form.

8. Although the hospital conducted various performance improvement reviews of ED documentation and EMTALA issues, many areas continued to show non-compliance. These QA activities were not effective in identifying/correcting the EMTALA issues of MSE, stabilizing treatment and appropriate transfers.

9. Review of policies for the ED showed policies were not current as follows:
a. Emergency Department: ER Log last reviewed 9/2003.

b. Multidisciplinary Assessment of Patients last reviewed 7/2001.

c. Medical Screening Evaluations last reviewed 2001.

d. Patients Rights and Responsibilities last reviewed 1/2007.

e. Do Not Resuscitate (DNR) last reviewed 4/2007.

f. Several policies did not indicate a date of the last review.