HospitalInspections.org

A. Based on document review, and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24.

Findings include:

1. The Hospital failed to document the patient's name on the ED central log and the disposition of the patient. (A 2405)

2. The Hospital failed to provide a medical screening exam for the patient presenting for screening for treatment. (A 2406)

Based on document review and interview, it was determined that for 1 of 20 (Pt #1) Emergency Department (ED) clinical records reviewed of people presenting to the ED for treatment, the Hospital failed to ensure the patient was entered into the central log.

Findings include:

1. Hospital policy entitled, "Emergency Medical Treatment and Transfer," (review March 2015) required, "III. Definitions...(C) 'Hospital Property' means the entire main hospital campus (the physical area immediately adjacent to the hospital's main buildings...located within 250 yards of the main buildings)...IV Procedure...(I) Patient Log. A central log shall be maintained of all individuals presenting requesting emergency services..."

2. The clinical record of Pt #1 was reviewed on 4/21/15. Pt #1 was a 65 year old female that presented to the Hospital's ED on 4/14/15 at 1:03 AM for a complaint of "eval." Nursing documentation at 1:09 AM included, "called no answer."

3. The Registered Nurse (E #1) on duty 11:00 PM on 4/13/15 to 7:00 AM 4/14/15 was interviewed on 4/22/15 at approximately 7:00 AM. E #1 stated, "...Finally she became disruptive in the waiting area and I had to call the police and have her escorted out at approximately 2:59 AM. I was hoping they would arrest her but they did not. She came back into the ED with the paramedics at approximately 3:47 AM. When she got out of the ambulance she said she couldn't breathe and was receiving a nebulizer treatment. When she came back into the ED ambulance bay I did not put her back on the board to be seen and did not let the physician know."

4. The ED log dated 4/14/15 log included that Pt #1 presented to the ED at 1:03 AM with a complaint of "eval", however, lacked documentation of Pt #1's second visit at approximately 3:50 AM on 4/14/15.

5. The Director of Nursing stated during an interview on 4/22/15 at approximately 1:00 PM that the patient was not entered into the ED log for her 3:50 AM visit since the patient did not come into the ED.

Based on document review and interview, it was determined that for 1 of 20 (Pt #1) Emergency Department (ED) clinical records reviewed, the Hospital failed to ensure a medical screening examination was provided to the patient presenting to the ED for treatment.

Findings include:

1. Hospital policy entitled, "Emergency Medical Treatment and Transfer," (review March 2015) required, "III. Definitions...(C) 'Hospital Property' means the entire main hospital campus (the physical area immediately adjacent to the hospital's main buildings...located within 250 yards of the main buildings)...IV. Procedure: (A) Medical Screening Process ...ii. Medical Screening. All individuals who come for emergency services shall receive an appropriate medical screening examination..."

2. The clinical record of Pt #1 was reviewed on 4/21/15. Pt #1 was a 65 year old female that presented to the Hospital's ED on 4/14/15 at 1:03 AM for a complaint of "eval." Nursing documentation at 1:09 AM included, "called no answer."

3. On 4/22/15 the surveillance video dated 4/14/15, of the Hospital's ED and ambulance area was reviewed. The video included at 1:03 AM, Pt #1 was present in the ED and remained there until 2:57 AM when the Chicago Police Department arrived in the ED waiting area. Pt #1 was observed walking out of the ED at 2:59 AM.

4. The Registered Nurse (E #1) on duty at 11:00 PM on 4/13/15 to 7:00 AM 4/14/15 was interviewed on 4/22/15 at approximately 7:00 AM. E #1 stated, "I am very familiar with the patient (Pt #1). Finally she became disruptive in the waiting area and I had to call the police and have her escorted out at approximately 2:57 AM. I was hoping they would arrest her but they did not. She came back into the ED with the paramedics at approximately 3:47 AM. When she got out of the ambulance she said she couldn't breathe and was receiving a nebulizer treatment. When she came back into the ED ambulance bay I did not put her back on the board to be seen and did not let the physician know. I just told the charge nurse. I felt the custody of the patient did not change from the Chicago Paramedics and they would have been the ones to log her in. She was not triaged and did not receive a medical screening examination. She wanted to be taken somewhere else and the ambulance would not take her. When she left the last time around 3:50 AM, she just walked away."

5. The Charge Nurse (E #4) on duty 4/13/15 night shift was interviewed by phone on 4/22/15 at approximately 8:50 AM. E #4 stated, "The triage nurse told me she (the patient) had returned to the ED by ambulance, was belligerent, and walked away from the ambulance bay without coming inside, at approximately 3:50 AM. The paramedics asked me to sign their incident report which I did. All I know is that the patient only got as far as the ambulance bay doors on her second visit. I did not tell the patient she could not come in. I notified the physician a couple of hours later that the patient had been here."

6. The EMS report dated 4/14/15 was reviewed on 4/22/15. The report included, "Called ...for a 65 year old female patient who had just been kicked out of CFMC (Community First Medical Center) for an unknown reason and is CO (complaining) of difficulty breathing due to asthma ...Pt states CFMC will 'kick her out' if she goes there again...crew convinced her to be taken due to her wheezing and slight distress...Pt found to be wheezing and in mild distress...A triage nurse, security guard, and other staff members met crew at door and told the patient she cannot come inside because they threw her out earlier. Pt became upset...ripped the aerosol mask off her face, got up and walked away..."

7. On 4/22/15 the surveillance video dated 4/14/15, of the Hospital's ED and ambulance area was reviewed. The video included at 2:57 AM the Chicago Police Department arriving in the ED waiting area and at 2:59 AM Pt #1 was observed walking out. At 3:47 AM the video identified Pt #1 arriving by ambulance in a wheelchair. At 3:50 AM Pt #1 was observed talking to staff and then leaving the Hospital ambulatory.

8. Pt #1's clinical record lacked documentation of the provision of a medical screening examination during Pt. #1's first visit with the complaint of "eval" on 4/14/15 at 1:03 AM and when she returned at 3:47 AM on 4/14/15 with the complaint of difficulty breathing.

9. The Director of Nursing stated during an interview on 4/22/15 at approximately 1:00 PM that the patient did not come back into the ED at 3:50 AM after exiting from the ambulance.