HospitalInspections.org

Based on review of records and staff interviews, the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability and capacity of the hospital's emergency department (ED) for an individual (Patient #1) who presented to the hospital's emergency department by emergency medical services (EMS). The hospital failed to provide an appropriate medical screening examination for Patient #1's identified emergency medical condition (possible overdose) to determine whether or not an emergency medical condition existed. The patient left the ED without receiving a medical screening examination by a qualified medical person.

Refer to findings in tag A-2406.

Based on patient and hospital records and staff interviews, the hospital failed to provide a medical screening exam (MSE) to an individual coming to the emergency department (ED) for 1 (Patient #1) of 20 pediatric patients who came to the emergency department. Patient #1 presented in the ED via emergency medical services (EMS) but did not receive a MSE before being transported to another hospital.
The hospital had two opportunities. They did not perform a MSE on Patient #1 when he arrived by ambulance at the ED. They did not stop EMS from taking Patient #1 out of the hospital before performing a MSE.
The facility had the capability and capacity to provide a MSE.

The findings included:

1. Review of the hospital's Emergency Services Outside of Clinical Areas policy and procedure (revised 10/2013, reviewed 11/2018) revealed the intent to establish appropriate response in compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA). The policy included:
"3. EMTALA begins when an individual presents on hospital property..." and
"3.2 Has a request made on the individuals behalf for examination or treatment for what may be an emergency medical condition..."
The Procedure included:
"4. If the patient assessment reveals no emergency medical condition, the medical screening exam should be documented and filed in a permanent patient medical record."

A review of the hospital's EMTALA staff in-service presentation (undated) showed on page 4: " EMTALA simply means:
That any and all patients who presents to the Emergency Department (or on hospital grounds),
That request assistance for a possible emergent medical condition,
Must at minimum, receive a medical screening by a qualified medical professional and,
If needed, receive stabilization and an appropriate transfer if necessary".

2. A review of hospital records for Patient #1 showed a few demographics. The problem list noted: "Never reviewed".

The ED notes documented:
"Call received from EMS in route with a 15 year old who deliberately ingested 48 Anti-Depressants
Dr. [ED physician] attempted twice to contact EMS to re-direct them to [the local children's hospital] since this was a child. No response from EMS.
At [4:21 p.m.] EMS arrived on our property with the child and brought him in via stretcher with his mother and LCSO [Lee County Sheriff's Office] who had Baker Acted the child.
At [4:23 p.m.] Dr. [ED physician] spoke with EMS staff and explained that in the future, when it is a child that they know would have to be admitted, they should just go directly to [the local children's hospital].
At [4:25 p.m.] the LCSO left the facility after giving the Baker Act papers to our staff member [staff name].
At [4:34 p.m.] [staff name] house supervisor was in ED speaking with EMS staff. A conversation took place.
At [4:37 p.m.] EMS left the facility with the child to take him to [the local children's hospital] ."
(The Baker Act is the Florida statute that authorizes an involuntary mental health examination.)

Additional notes included: "Feb 23 [4:39 p.m.] Patient dismissed" and "[city] EMS transporting pt. to [the local children's hospital] peds"

3. In an interview on 4/1/19 at 9:10 a.m., the Risk Manager said she did an investigation on this case. She said on 2/23/19 at 4:21 p.m., Patient #1 arrived by ambulance at the hospital ED. The patient was on a stretcher in the hall in the ED. The doctor told the EMS staff "in the future" send pediatrics to Children's Hospital if they need admission. This hospital does not admit pediatrics. The doctor then went to the emergency room to do a MSE on Patient #1, but the patient was not in the room. Nurse Staff A told the doctor EMS took Patient #1 out of the hospital and left. The Risk Manager said when she reviewed the video tape of this incident she observed Nurse Staff A and Nurse Staff B watching EMS leave the hospital with the patient. The hospital staff did not stop EMS so the doctor could perform a MSE on Patient #1.

4. In an interview on 4/1/19 at 1:28 p.m., the ED Physician said he told EMS "in the future" if a pediatric patient needs admission to the hospital, take him to the children's hospital. He left to go see another patient when "someone" told him EMS were taking Patient #1 out of the hospital. He went to the EMS and asked them if "crossing the threshold" was "against protocol" (referring to the EMTALA regulations). The EMS staff said it was all right, and they left the hospital with Patient #1. The physician said he did not try to stop the EMS so he could perform a MSE on the patient.

5. On 2/23/19 the hospital had 37 in-patients and 88 ED visits.

Review of the hospital's website (https://www.lehighregional.com/Our-Services/Emergency-Medicine.aspx) revealed:
"Emergency Medicine
We can handle everything from lacerations to life-threatening injuries.
When you have a medical emergency, you can count on the team at [hospital name]. We offer 24-hour emergency room services led by trained emergency medicine physicians who are supported by compassionate medical and professional staff. Our emergency room is easy to access and features comfortable surroundings. We are backed by the full resources of an integrated health system offering the latest medical technology and diagnostic capabilities for adults and children."

6. Review of the EMS record for 2/23/19 involving Patient #1 included: "Pt [patient] states approx an hour prior to EMS arrival, he had taken approx 48 Lamictal pill because he was mad at mother and wanted to hurt himself..." At the hospital, "upon arriving at [hospital], Dr. [ED physician] advised that pt needs to be transported to [the local children's hospital]. Dr. [ED physician] and House Supervisor, [name], states that seeing pt has not been triaged into hospital, this unit could transport to [the local children's hospital] and had directed this unit to do so. As a result, this unit had loaded pt up and began to transport pt to [the local children's hospital]..."

7. Review of Patient #1's record from the local children's hospital showed he was admitted after overdosing on Lamictal (an anticonvulsant) on 2/23/19. He was in the pediatric intensive care unit until he was medically cleared and transferred to a medical floor. He was discharged to a Baker Act facility on 2/25/19.