HospitalInspections.org

Based on review of medical staff rules and regulations, review of facility policy, review of facility diversion logs, review of the Emergency Department (ED) Central Log, review of the Health Alert Network report (public health's notification system for rapidly disseminating alerts, updates, and advisories to local, state, and federal partners), medical record review and interview, the facility failed to provide a Medical Screening Examination for 21 patients who presented to the Emergency Department (ED), and failed to provide an appropriate transfer for 1 patient (#39) who presented to the ED for care and was transferred by Emergency Medical Services (EMS) of 44 ED patients reviewed.

The findings include:

On 1/21/2024, the facility was placed on ED diversion related to ED Provider services were unavailable. During the time frame for 1/22/2024-1/25/2024 at 7:00 PM, 21 patients presented to the ED requesting medical treatment. The patients did not receive a nursing triage or a medical screening examination by a licensed medical provider. The facility had a 'Diversion Log' which did not have a patient name to identify those patients who presented to the ED. One of the 21 patients (#39) was transported by Emergency Medical Services (EMS) from Facility A to Facility B on 1/23/2024 for treatment.

Refer to C-2406 and C-2409.

Based on review of facility policy, review of facility diversion logs, review of Emergency Department (ED) Central Logs and interview, the facility failed to ensure all patients who presented to the ED were placed on the ED Central Log for 21 patients (#24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, and #44) who presented to the ED of 44 ED patients reviewed.

The findings include:

Review of the facility's policy "Emergency Medical Treatment and Patient Transfers" dated 3/8/2017 showed, "...Emergency Department Log: the hospital shall maintain a central log on each individual who comes to the Emergency Department seeking assistance...and indicate whether the individual refused treatment...or was transferred, admitted and treated, stabilized and transferred, or discharged. In the event the patient's name is not obtained, the patient shall be listed as a John/Jane Doe even if the patient leaves before entering the Emergency Department..."

Review of a facility handwritten document titled "Diversion Log" showed 21 patients presented to the ED between the dates of 1/21/2024-1/25/2024. The patient names were not included on the "Diversion Log". These patients were not listed on the ED Central Log. The patients were as follows:
* Patient #24 arrived in the ED on 1/21/2024 at 11:30 PM with complaint of neck pain.
* Patient #25 arrived in the ED on 1/22/2024 at 1:30 AM with complaint of a high fever.
* Patient #26 arrived in the ED on 1/22/2024 at 3:00 AM with complaint of a possible kidney
stone.
* Patient #27 arrived in the ED on 1/22/2024 at 9:04 AM with complaint of a panic attack.
* Patient #28 arrived in the ED on 1/22/2024 at 9:26 AM with complaint of a fall.
* Patient #29 arrived in the ED on 1/22/2024 at 11:56 AM with complaint of a head laceration.
* Patient #30 arrived in the ED on 1/22/2024 at 12:04 PM with complaint of wrist pain.
* Patient #31 arrived in the ED on 1/22/2024 at 2:55 PM with complaints of a cough and not
feeling well.
* Patient #32 arrived in the ED on 1/22/2024 at 3:10 PM with complaint of psychiatric
evaluation.
* Patient #33 arrived in the ED on 1/22/2024 at 3:55 PM with complaint of a fall.
* Patient #34 arrived in the ED on 1/22/2024 at 4:19 PM with complaint of chest pain.
* Patient #35 arrived in the ED on 1/22/2024 at 9:23 PM with complaint of intoxication.
* Patient #36 arrived in the ED on 1/23/2024 at 7:00 AM with complaint of wrist pain.
* Patient #37 arrived in the ED on 1/23/2024 at 2:01 PM who stated they "needed a
wheelchair."
* Patient #38 arrived in the ED on 1/23/2024 at 8:30 PM with complaints of nausea and
vomiting.
* Patient #39 arrived in the ED on 1/23/2024 at 9:45 PM with complaints of shortness of
breath and chest pain. The facility called 911 for the patient and EMS transported the patient
to another facility.
* Patient #40 arrived in the ED on 1/24/2024 at 5:25 PM with complaint of a right thumb
laceration. The patient had stated they were going to an urgent care.
* Patient #41 arrived in the ED on 1/25/2024 at 6:36 AM with no complaint documented.
* Patient #42 arrived in the ED on 1/25/2024 at 8:25 AM with complaint of shortness of
breath.
* Patient #43 arrived in the ED on 1/25/2024 at 1:52 PM with complaint of shortness of breath.
The facility offered to call 911 for the patient but the patient declined.
* Patient #44 arrived in the ED on 1/25/2024 at 6:20 PM with complaint of a psychiatric
evaluation.

Review of ED Central Logs for 1/21/2024-1/25/2024 showed the 21 patients were not listed on the ED Central Log.

During an interview on 1/30/2024 at 1:35 PM, the Registration Supervisor stated when patients came to the ED during the diversion, the staff were told to ask the patient why they came to the ED and assist the patients as needed. They documented the patients on the ED diversion log.

During an interview on 1/30/2024 at 1:15 PM the ED Nurse Manager confirmed the patients were listed on a 'Diversion Log' and not placed on the ED Central Log.

Based on review of medical staff rules and regulations, review of facility policy, review of facility diversion logs, review of Emergency Department (ED) Central Log, review of the Health Alert Network report (public health's notification system for rapidly disseminating alerts, updates, and advisories to local, state, and federal partners), medical record review and interview, the facility failed to provide a Medical Screening Examination for 21 patients (#24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, and #44) who presented to the ED of 44 ED patients reviewed.

The findings include:

Review of the Medical Staff Rules and Regulations dated 3/2004 showed, "...any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. Generally, an "emergency medical condition" is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child..."

Review of the facility's policy "Emergency Medical Treatment and Patient Transfers" dated 3/8/2017 showed, "...Coming to the Emergency Department...any individual on hospital property [including the parking lot or campus] requesting an examination or treatment...Medical Screening Examination: when an individual comes to the Emergency Department of the hospital, or any location on hospital property...and a request is made on the individuals behalf for a medical examination or treatment, an appropriate medical screening examination, within the capabilities of the emergency department...shall be provided to determine whether an emergency medical condition exists...An Emergency Department Provider shall perform medical screening examinations. An Emergency Department provider on duty shall be responsible for the general care of all patients presenting themselves to the Emergency Department..."

Review of the facility's policy "Scope of Services" revised 8/23/2021 showed, "...Emergency Department...Staffed 24 hours a day, 7 days a week, 365 days a year (24/7/365) with a physician and a minimum of 2 licensed personnel...Any patient presenting to the Emergency Department for care will be evaluated and treated...All services provided by [named facility] will be evaluated on an ongoing basis to ensure the needs of the patients and community are being met to the highest capabilities of the facility..."

On 1/21/2024, the facility posted a sign on the ED and EMS entrance which stated, "...attention, [Facility A] is currently on diversion status and can not accept patients for the next several hours. We apologize for the inconvenience..."

Review of a facility handwritten document titled "Diversion Log" showed 21 patients presented to the ED between the dates of 1/21/2024-1/25/2024. The patient names were not included on the Diversion Log. These patients were not listed on the ED Central Log. The patients were as follows:
* Patient #24 arrived in the ED on 1/21/2024 at 11:30 PM with complaint of neck pain.
* Patient #25 arrived in the ED on 1/22/2024 at 1:30 AM with complaint of a high fever.
* Patient #26 arrived in the ED on 1/22/2024 at 3:00 AM with complaint of a possible kidney
stone.
* Patient #27 arrived in the ED on 1/22/2024 at 9:04 AM with complaint of a panic attack.
* Patient #28 arrived in the ED on 1/22/2024 at 9:26 AM with complaint of a fall.
* Patient #29 arrived in the ED on 1/22/2024 at 11:56 AM with complaint of a head laceration.
* Patient #30 arrived in the ED on 1/22/2024 at 12:04 PM with complaint of wrist pain.
* Patient #31 arrived in the ED on 1/22/2024 at 2:55 PM with complaints of a cough and not
feeling well.
* Patient #32 arrived in the ED on 1/22/2024 at 3:10 PM with complaint of psychiatric
evaluation.
* Patient #33 arrived in the ED on 1/22/2024 at 3:55 PM with complaint of a fall.
* Patient #34 arrived in the ED on 1/22/2024 at 4:19 PM with complaint of chest pain.
* Patient #35 arrived in the ED on 1/22/2024 at 9:23 PM with complaint of intoxication.
* Patient #36 arrived in the ED on 1/23/2024 at 7:00 AM with complaint of wrist pain.
* Patient #37 arrived in the ED on 1/23/2024 at 2:01 PM who stated they "needed a
wheelchair."
* Patient #38 arrived in the ED on 1/23/2024 at 8:30 PM with complaints of nausea and
vomiting.
* Patient #39 arrived in the ED on 1/23/2024 at 9:45 PM with complaints of shortness of
breath and chest pain. The facility called 911 for the patient and EMS transported the patient
to another facility.
* Patient #40 arrived in the ED on 1/24/2024 at 5:25 PM with complaint of a right thumb
laceration. The patient had stated they were going to an urgent care.
* Patient #41 arrived in the ED on 1/25/2024 at 6:36 AM with no complaint documented.
* Patient #42 arrived in the ED on 1/25/2024 at 8:25 AM with complaint of shortness of
breath.
* Patient #43 arrived in the ED on 1/25/2024 at 1:52 PM with complaint of shortness of breath.
The facility offered to call 911 for the patient but the patient declined.
* Patient #44 arrived in the ED on 1/25/2024 at 6:20 PM with complaint of a psychiatric
evaluation.

Review of the facility's electronic medical records showed no medical records for the following patients: #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43 and #44.

Review of an EMS Run Report for Patient #39 dated 1/23/2024 9:50 PM showed EMS was requested by 911 to respond to [Facility A] for a patient with complaints of shortness of breath and chest pain. The patient was outside the ED and ambulated to the ambulance. The patient stated his heart was racing and he was dizzy when standing up. The patient's vital signs were obtained, an intravenous (IV) line was started and a 12 lead EKG was performed. The patient was given Aspirin (blood thinner) 324 milligrams (mg) orally and the patient refused sublingual Nitroglycerin (medications used to treat chest pain). The patient was transported nonemergent to (Facility B's) ED.

During an interview on 1/29/2024 at 10:40 AM the Chief Executive Officer (CEO) stated the facility was on ED diversion starting on 1/21/2024. The ED was on diversion until 1/25/2024 at 7:00 PM. A sign was placed on the ED entrance doors to notify patients they were unable to provide ED services.

During an interview on 1/29/2024 at 1:10 PM the ED Medical Director confirmed all patients who present to the ED for treatment, should receive a medical screening examination by a licensed medical provider.

During an interview on 1/30/2024 at 9:45 AM, the CEO confirmed the ED did not have ED provider coverage starting 1/21/2024 and ended 1/25/2024 at 7:00 PM. All patients who presented after 1/22/2024 at midnight were told the ED was on diversion and would be referred to another facility, their Primary Care Provider, or offered 911 services. Those patients who presented to the ED did not receive a medical screening examination related to the ED diversion.

During an interview on 1/30/2024 at 1:40 PM Licensed Practical Nurse (LPN) #1 stated there was not an ED provider in the ED while the ED was on diversion. The staff were told tell the patients there was not a provider and the staff could call 911 for any patients who needed assistance. LPN #1 confirmed there were no patients evaluated in the ED during the ED diversion.

During an interview on 1/30/2024 at 1:45 PM Registration Clerk #1 stated during the ED diversion they were instructed to tell the patients the ED did not have an ED provider, the patients could go to their primary care physicians office, or the staff could assist the patient with calling 911 to be transported to another facility.

During an interview on 1/30/2024 at 1:15 PM the ED Nurse Manager, stated patients who presented to the ED were told the ED was on diversion. The staff offered to assist the patients by calling 911 if needed, but the patients were referred to their Primary Care Provider, an urgent care center, or the patients could go to another facility for care. The ED Nurse Manager confirmed there was no medical provider schedule during the time the ED was on diversion.

During an interview on 1/30/2024 at 2:30 PM the Chief Nursing Officer stated there was no ED provider in the ED for 1/22/2024-1/25/2024 at 7:00 PM. Patients who presented to the ED were informed the ED was on diversion. The CNO confirmed there were 21 patients between 1/21/2024-1/25/2024 who presented to the ED and a nursing triage or medical screening examination was not performed.

Based on review of facility policy, review of an Emergency Medical Service (EMS) Run Report, medical record review and interview, the facility failed to provide an appropriate transfer for one patient (#39) who presented to the Emergency Department (ED) with chest pain of 44 patients reviewed.

The findings include:

Review of the facility policy "Emergency Medical Treatment and Patient Transfers" dated 3/17/2017, showed "...after determining that an individual will be transferred from the Emergency Department...the individual will be transferred in accordance with the following procedures: [1] acceptance by receiving hospital and receiving provider...prior to transfer, the receiving hospital and provider must consent to the transfer of the individual and agree to provide appropriate medical treatment and hospital care [2] the hospital shall provide medical treatment within it's capacity to minimize the risk of transfer to the individuals health..."

Review of an EMS Run Report for Patient #39 dated 1/23/2024 9:50 PM, showed EMS was requested by 911 to respond to [Facility A] for a patient with complaints of shortness of breath and chest pain. The Run Report showed the patient was outside the ED and ambulated to the ambulance, stating his heart was racing and he was dizzy when standing up. The EMS staff obtained the patient's vital signs, an intravenous (IV) line was started and a 12 lead EKG was performed. The patient was given Aspirin (blood thinner) 324 milligrams (mg) orally and the patient refused sublingual Nitroglycerin (medications used to treat chest pain). The patient was transported nonemergent to (Facility B's) ED. The patient was on the facility property and did not receive a nursing triage or medical screening examination.

During an interview on 1/29/2024 at 1:10 PM, the ED Medical Director confirmed all patients who present to the ED for treatment should receive a medical screening examination by a licensed medical provider.

During an interview on 1/30/2024 at 9:45 AM, the Chief Executive Officer confirmed the ED did not have ED provider coverage starting 1/21/2024 and ended 1/25/2024 at 7:00 PM. All patients who presented after 1/21/2024 at 11:30 PM, were told the ED was on diversion and would be referred to another facility, their Primary Care Provider or offered 911 services. Those patients who presented to the ED did not receive a medical screening examination related to the ED diversion.

During an interview on 1/30/2024 at 1:40 PM, Licensed Practical Nurse (LPN) #1 stated there was not an ED provider in the ED while the ED was on diversion. The staff were told to tell the patients there was not a provider and the staff could call 911 for any patients who needed assistance. LPN #1 confirmed there were no patients evaluated in the ED during the ED diversion.

During an interview on 1/30/2024 at 1:15 PM, the ED Nurse Manager confirmed there was no medical provider schedule during the time the ED was on diversion.

During an interview on 1/30/2024 at 2:30 PM, the Chief Nursing Officer confirmed there were 21 patients between 1/21/2024-1/25/2024 who presented to the ED and a nursing triage or medical screening examination was not performed and there was 1 patient (#39) where EMS was called and the patient was transported to another facility.