HospitalInspections.org

Based on document review and interview, it was determined that in 5 of 23 (P7, P8, P9, P10 and P24) medical records (MR) reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide a medical screening exam.

Findings include:

1. See findings cited at 42 CFR 489.24 (1), C2406.

Based on observation and interview, the hospital failed to post conspicuously, a sign specifying the EMTALA rights of individuals with respect to examination and treatment of emergency medical conditions and women in labor in the emergency department (ED) entry, waiting room or other area likely to be noticed by all individuals entering the ED in one hospital.

Findings include:

1. On 1/10/22, during tour of the ED, no EMTALA signage was noted in ED entry, patient waiting area or other conspicuous location of the ED.

2. On 1/10/22, beginning at approximately 7:45 PM, A2, Registered Nurse/Quality, verified the ED did not have EMTALA signage posted.

Based on document review and interview, the hospital failed to prioritize patients for and/or provide a medical screening examination (MSE) to 5 of 23 individuals (P7, P8, P9, P10 and P24) who came to the hospital emergency department (ED) and made request for examination or treatment of a medical condition.

Findings include:

1. Review of the policy titled Triage, Last Revised 1/2021, indicated that upon presenting to the ED, each patient will be triaged as quickly as possible and assigned a level of acuity. Further evaluation such as medical screening and treatment will proceed based on priorities of care/triage categories.

2. The medical record (MR) of patient P7 indicated the patient presented to the ED on 12/16/21 at 1718 hours and LWBS at 2036 hours. The central log/registry and the MR lacked documentation of the patient's chief complaint/purpose of visit. The MR lacked documentation of the individual's presenting signs and symptoms (S&S) having been assessed at the time of arrival at the hospital, in order to prioritize when the individual would be seen by qualified medical personnel (QMP)/triage, and lacked documentation of the patient having received a Medical Screening Examination (MSE).

The MR of patient P8 indicated the patient presented to the ED on 10/17/21 at 1555 hours and LWBS at 1643 hours. The central log/registry and the MR lacked documentation of the patient's chief complaint/purpose of visit. The MR lacked documentation of the individual having been triaged and lacked documentation of the patient having received a MSE.

The MR of patient P9 indicated the patient presented to the ED on 12/24/21 at 1200 hours and LWBS at 1506 hours. The central log/registry and the MR lacked documentation of the patient's chief complaint/purpose of visit. The MR lacked documentation of the individual having been triaged and lacked documentation of the patient having received a MSE.

The MR of patient P10 indicated the patient presented to the ED on 12/17/21 at 1649 hours and LWBS at 1729 hours. The central log/registry and the MR lacked documentation of the patient's chief complaint/purpose of visit. The MR lacked documentation of the individual having been triaged and lacked documentation of the patient having received a MSE.

The MR of patient P24 indicated the patient presented to the ED on 12/16/21 at 2012 hours and LWBS at 2029 hours. The central log/registry and the MR lacked documentation of the patient's chief complaint/purpose of visit. The MR lacked documentation of the individual having been triaged and lacked documentation of the patient having received a MSE.

3. Review of facility complaint follow-up documentation in administrative emails indicated the following:
Email documentation from A1, Chief Nursing Officer (CNO) on 1/4/22 indicated the facility had an ED complaint about a patient having been in the ED waiting room for some time, requested to speak with a supervisor and that the House Supervisor, N1, informed the family member that hospital staff were busy, and they may want to return to ED at another time. A1 indicated he/she spoke with the Supervisor who indicated that was not the situation. A1 indicated the patient who presented to the ED was P7.
On 1/5/22, N1 provided response to A1 which indicated the following: Spoke with the family of P7. They were angry that the patient had yet to be triaged and treated. I did tell them that I did not have a room to bring the patient back into the ER at that time. I did tell them that it would be a long night for them. The family member asked if they should wait and I told him/her that was up to him/her. I did tell them that they had come at the busiest time of the day for the ER and I didn't know if the MD (physician) would even order the treatment for P7. I did tell them the shortest wait time in the ER was between 8-10am most days if they chose to leave and come back. I did not suggest they do so.

4. On 1/10/22, beginning at approximately 6:30 PM, A5, Clinical Informatics, verified MR findings.
On 1/10/22, beginning at approximately 7:45 PM, A3, ED Director, indicated the department did not have documentation of staff assignments per shift, and verified no specific persons were assigned for triage duty per shift.