HospitalInspections.org

Based on interview and record review, the hospital failed to ensure 2 of 20 patients (Patient #3 and Patient # 7) who presented in the emergency department:

A. Were not given a proper medical screening exam;

Cross Refer to Tag A2406 -§489.24(a) and 489.24(c) Medical Screening

Based on interview and record review, the facility failed to ensure a patient presenting to the Emergency Department (ED) had an appropriate medical screening exam to evaluate for potential emergent conditions and/or following a change in condition for 2 (Pt # 3 and #7) of #20 patient records reviewed.

This deficient practice had the likelihood to affect all patients of the facility.

Findings included:

On 10/20/2021 the medical record (MR) for patient #7 was reviewed and revealed the following. Pt #7's MR began on 2/17/2021 in the Emergency Department (ED) at 14:49 (2:49 pm). A medical screening exam (MSE) was conducted by Staff #7 and it was determined pt #7 was five (5) days positive for COVID-19 without symptoms. Pt #7 confirmed, he had lost electricity and water during the severe cold weather, and couldn't stay in his home alone. He had called for an ambulance to take him to the hospital.

Staff #7 prescribed Zithromax, Mucinex, Decadrone, and acetaminophen for pt. #7. He could not be discharge because he had no safe place to be discharged to and no safe way to get there. He was placed in a patient room on the medical surgical unit for compassionate care until his home regained electricity and water utilities. Pt #7 was never discharge from the ED and was never admitted to the in patient unit.

A review of the RN notes indicated on 2/18/2021 at 1800 (6:00 pm). "Pt moved to RM (room) ccu#5 (Critical care unit for staffing purpose and COVID diagnosis) at this time..."

The RN staff continued to document on pt #7 and at 2245 Hrs, the RN documented the following: "Pt called out, walked into room to find pt sitting on the floor with head bleeding". "Pt states I woke up and had to pee real bad, so I got up and went to the toilet to pee. I lost my balance and fell hit my head on the floor. pt was found had blood on forehead and left side of head. Blood cleaned bleeding from wound in center of forehead. Patient assisted to bed and vitals signs's taken, 121/64 (BP), 122 HR (heart rate), 22 (respirations), oxygen (O2) saturation (sat) 94%. HR is rapid between 122-161 at this time. Wound dressed with pressure applied. Pt oriented x 4, PERLA (pupils equal round light accommodation)."

A review of the RN timeline of documented notes for the patients unwitnessed fall with head injury, revealed there was no documentation of notification of the physician on call at the time the patient was found and treated for the fall. A late entry that was entered and authenticated by the House Supervisor (Staff #15) was identified on an addendum page. The entry read; "2/18/2021 Late entry-2250. Pt awake alert post fall. Dr _______ (#16) notified, pt only complaint of headache. Dr ______(Staff #16) ordered neuro checks every 1 hour times 4 hours and then every 4 hours, notify if changes".

Review of pt #7 medical record revealed on 2/19/2021 at 10:45 am, ED physician #7 had documented, "I was just informed that this patient (#7) was taken to a room on the floor last night but is still an ER (emergency room) patient because he wasn't really admitted". "I was also informed he fell last night and injured his head but nothing was done about it. His vitals signs are stable. I have now ordered a CT scan of his head and cervical spine to rule out injury."



41831

Findings included:

A review of the ED record revealed Patient #3 was a 47-year-old male who presented to the Emergency Department (ED) and a proper medical screening exam to evaluate for possible emergent conditions was not performed on 07/15/21 and 09/11/21.

This deficient practice had the likelihood to cause harm in all patients presenting to the ED.

Findings include:

A review of documentation from an ED visit 7/15/21 for Patient # 3, revealed the following:

ED Chief Complaint: 07/15/2021 arrived 8:43 PM

"Pt complained of pain/pressure in his lower abdomen and foul smelling urine. Pt is a dialysis pt and states he missed dialysis x 1 week but went yesterday. Pt self caths and states output has only been 100-150 ml and is dark, orange color."

ED Provider Notes: 07/15/2021 8:58 PM - (Staff # 7)

"Chief Complaint: "Pt complained of pain/pressure in his lower abdomen and foul smelling urine. Pt is a dialysis pt and states he missed dialysis x 1 week but went yesterday. Pt self caths and states output has only been 100-150 ml and is dark, orange color."

First Provider Contact Date and Time: 07/15/2021 8:58 PM

HPI -

"Wants Foley catheter placed; chronic problem. Thinks "I have a UTI."

"Review of Systems:

Constitutional: No fevers, No chills, No sweats. Morbid obesity;

Eye: No recent visual problems;

ENT: No ear pain, No nasal congestion, No sore throat;

Respiratory: No shortness of breath, No cough;

Cardiovascular: No Chest pain, No palpitations, No syncope;

Gastrointestinal: No nausea, No vomiting, No diarrhea;

Genitourinary: No hematuria;

Hema/Lymph: No bruising tendency, No swollen lymph glands;

Endocrine: No excessive thirst, No excessive hunger;

Musculoskeletal: No back pain, No neck pain, No joint pain, No muscle pain, No decreased range of motion;

Integumentary: No rash, No pruritus, No abrasions;

Neurologic: Alert & oriented X 4;

Psychiatric: No anxiety, No depression"


Physical Exam

Vitals & Measurements

"T: 36.8 °C (Oral) HR: 82(Peripheral) RR: 22 BP: 168/74 Sp02: 91% BMI: 49 Pain Score: 8 02 Therapy: Room air

General: Alert and oriented, well nourished, No acute distress;

Eye: PERRL, EOMI, Normal conjunctiva;

HENT: Normocephalic, clear tympanic membranes, Normal hearing, moist oral mucosa, No scleral icterus, No sinus tenderness;

Neck: Supple, non-tender, No carotid bruits, No JVD, No lymphadenopathy;

Lungs: Clear to auscultation and percussion, Non-labored respiration;

Heart: Normal rate, Regular rhythm, No murmur, No gallop, No edema;

Breast: No lumps, No bumps, No scars, Normal nipples;

Abdomen: Soft, non-tender, non-distended, Normal bowel sounds, No masses;

Musculoskeletal: Normal range of motion and strength, No tenderness, No swelling Skin: Skin is warm, dry and pink, No rashes, No lesions;

Neurologic: Awake, alert and oriented X4, CN II-XII intact;

Psychiatric: Cooperative, appropriate mood and affect"

Medical Decision Making:
"This is a chronic issue; either UTI and/or urinary retention."

Procedure
No Qualifying Data

"Assessment/Plan
1. UTI - Urinary tract infection N39.0

Orders:
Discharge Patient, 07/15/21 21:20:00 CDT
Patient Education
Urinary Tract Infection, Adult
Antibiotic Medicine, Adult
Follow Up
"Follow up with Primary Care Within 3 to 5 days""

A review of the ED Record for 7/15/21 revealed no diagnostic testing such as laboratory tests to include blood work or urinalysis were completed on the patient at this visit.

Further review of the ED Record for 7/15/21 revealed the patient was given one dose of Rocephin 1000 mg Intramuscular and discharge instructions for an "adult antibiotic" however there was no documentation found for the specific antibiotic the patient was given and there was no documentation found the patient was given a prescription for antibiotics, only to follow up with the provider in 3-5 days. The patient was discharged between 9:54 PM and 10:25 PM per the documentation.


A review of documentation from an ED visit on 9/11/21 for Patient # 3, revealed the following:

"ED Chief Complaint: 09/11/21 7:18 PM

Back Pain

ED Provider Notes: 09/11/2021 7:22 PM - (Staff # 5)

"Back Pain"

First Provider Contact Date and Time: 09/11/21 7:22 PM

HPI
"Patient presents to the ER via EMS with complaints of acute on chronic back pain, reports it began hurting Monday after he was released from the hospital at Methodist, reports it has been hurting every single day since he came home from Houston Methodist after having his left hand amputated at the wrist. Reports he was receiving Norco and Dilaudid last week in the hospital which were very effective for his pain, he was prescribed some Norco by the surgeon, however, has not been able to afford to get medications. Patient also reports he makes no urine, has end-stage kidney failure, is scheduled for dialysis 3 times per week, his last dialysis was Saturday a week ago while he was in the hospital Houston Methodist, has not been to his dialysis appointments this week because his truck is broken down and he has not been able to find anyone who can give him a ride."


"Review of Systems:

Constitutional: Denies fevers chills sweats;

Eye: Denies recent visual problems;

ENT: Denies ear pain, nasal congestion, sore throat;

Respiratory: Denies dyspnea, cough;

Cardiovascular: Denies Chest pain, palpitations, syncope;

Gastrointestinal: Denies nausea, vomiting, diarrhea;

Genitourinary: Denies making any urine at all and he is stage IV kidney failure and currently on dialysis;

Endocrine: Denies excessive thirst, excessive hunger;

Musculoskeletal: Endorses back pain, denies neck pain, joint pain, muscle pain, decreased range of motion;

Integumentary: Denies rash, pruritus, abrasions;

Neurologic: Alert & oriented X 4;

Psychiatric: Denies anxiety, depression"


Physical Exam

Vitals & Measurements
"T: 36.2 °C (Oral) HR: 79(Peripheral) RR: 22 BP: 184/103 Sp02: 81% BMI: 42 Pain Score: 10 02 Therapy: Room air

General: Alert and oriented, obese, no acute distress;

Eye: PERRL, EOMI, Normal conjunctiva;

HENT: Normocephalic, clear tympanic membranes, normal hearing, moist oral mucosa, no scleral icterus, no sinus tenderness;

Neck: Supple, non-tender, no carotid bruits, no JVD, no lymphadenopathy;

Lungs: Clear to auscultation, respirations even and non-labored;

Heart: Normal rate, regular rhythm, no murmur, gallop, edema;

Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no masses, no CVA tenderness;

Musculoskeletal: Normal range of motion and strength, no swelling, week old amputation to left wrist with dressing in place, old BKA to lower right extremity that is well healed, vertebral point tenderness to T10-T12 and L1-L2, no soft tissues tenderness;

Skin: Skin is warm, dry and pink, no rashes, lesions;

Neurologic: Awake, alert and oriented X4, CN II-XII intact;

Psychiatric: Cooperative, flat affect"


Medical Decision Making:
"0900- in to discuss options with patients at this time, discussed potential transfer to some other can do emergency dialysis if he is not dialysis in 1 week, discussed low to bed availability for transfer due to Covid pandemic, discussed limited ability due to supply to perform chemistry panel for patient, ER is currently on divert for critical lab shortage, patient is still mentating well at this point, also discussed the option of treating his pain and allowing him to go home and follow-up for dialysis on Monday as scheduled, also discussed long-term goal and patient states he met want to look at nursing home placement next week, he was previously at Winfield but ultimately back home. After much discussion with patient and Staff #15, the house supervisor, patient has ultimately decided he would like pain medicine for his back and to go back home, states he will follow up with dialysis on Monday as scheduled.

0930- no relief of pain after hydrocodone, patient states pain is actually worse at this time, remains tender to the same area T-10-T-12 as well as L1-L-2, have ordered T and L Spine x-rays, will follow up after that.

0940-patient called out from the room, in the room to speak with patient, he advised he does feel some better, reports he does not want x-rays at his time because he does not feel actually has anything broken in his back, agrees that it is most likely just from laying in the bed and is soreness, discussed with patient if he has pain medication at home, he states he was receiving Norco and Dilaudid at Houston Methodist last week where he had his amputation, had Norco prescribed by the surgeon at discharge, but has not been able to go and pick up the prescriptions because he cannot afford them. Further discussed plan with patient, he states he is feeling some better after Norco, states he just wants to go home at his time, advises he will go to dialysis on Monday as scheduled, encouraged patient to come in to the ER immediately if anything changes, discharge instructions discussed with patient, he verbalized understanding, discharged home via EMS."

Procedure
No Qualifying Data

"Assessment/Plan
1. Back pain M54.9
Norco as prescribed, follow up with PCP, return to ER as needed
Orders:
Discharge Patient 09/11/21 10:20 PM
Patient Education
Chronic back pain"

Further review of the ED Record for 09/11/21 revealed no diagnostic testing to determine if an emergent condition was present since the patient had missed 3 dialysis treatments and had recently undergone surgery. There was no documentation found the ED attempted to contact any other facilities to determine if a transfer could be arranged due to no lab availability. There was no documentation found the ED provider attempted to contact the patient's nephrologist to consult on the patient since he had missed 3 dialysis treatments in a week and the ED was unable to perform diagnostic lab testing. The documentation revealed the patient was discharged home at 10:30 PM, one hour and 12 minutes after arriving.


The facility did not provide a policy regarding medical screening exams.

An interview with Staff #3 and #13 on 10/20/21 confirmed the above findings.