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Based on interview, policy review, and clinical record review the facility failed to ensure: four of 22 patient records reviewed were advised of the risks of leaving the emergency department without receiving a medical screening exam, one of 22 patient records reviewed was stable prior to discharge (A2407), one of 22 patient records reviewed was stable and provided with a medical screening exam within the facility's capability prior to discharge. (A2409) The cumulative effect of these systemic practices affected six of 22 patient records reviewed and is a potential risk to all patients presenting to the facility's emergency room.

Based on clinical record review, policy review and interview, the facility failed to ensure four of 22 patient records reviewed (Patients #1, #2, #10 and #16) were informed of the risks of leaving the emergency department without being assessed or treated, and failed to ensure one of 22 patient records reviewed (Patient #8) was stable prior to discharge while under the influence of drugs.

Findings:

The clinical record review for Patient #1 was completed on 05/01/13. The clinical record review revealed the 38 year old patient came to the emergency department on 04/13/13 at 1:27 A.M. with a chief complaint of chest pain. A nursing note dated 04/13/13 at 1:40 A.M. revealed the patient complained of chest pain, shortness of breath and said the pain was seven out of ten, with ten being the highest possible score. At 3:15 A.M. the nursing note stated the patient's pain was "better" but felt shortness of breath and the patient was given two liters of oxygen. The note did not describe how much "better" the patient's pain was compared to the earlier description of seven on a scale of ten. Further review of the nursing note dated 04/13/13 at 3:40 A.M. stated the patient complained his/her chest felt tight. At 5:15 A.M. the nursing note stated the patient wasn't going to wait any longer and requested copies of the results of his/her laboratory work. The note said the patient was told to go through medical records to obtain that information and the patient left.

There was no documentation to explain why Patient #1 couldn't wait anymore, what interventions were attempted to dissuade the patient from leaving and nothing to indicate that the risks of leaving before being examined by the physician was explained to the patient.

The clinical record review for Patient #2 was completed on 05/01/13. The review revealed the patient presented to triage at 04/13/13 at 1:48 A.M. for a chief complaint of lower dental pain with decay and revealed the patient was given pain medicine at 3:34 A.M. for pain rated as ten out of 10. Review of a nursing note dated 04/13/13 at 4:25 A.M. revealed the pain continued to be rated as ten out of 10, and stated "patient remains to be seen. "

Review of a nursing note dated 04/13/13 at 5:50 A.M. revealed the physician was at the cartside and the patient was hostile to the physician. The note stated the patient said he/she was leaving and was escorted out by security. The record lacked documentation of any explanation to the patient of what the risks of leaving the emergency department were.

On 05/01/13 at 2:20 P.M. in an interview, emergency department Staff Nurse A stated a written form explaining the risks and benefits of leaving the emergency department prior to discharge would only be given if the patient had been seen by the physician. The form would not be given if they had not been examined.

On 05/01/13 at 2:30 P.M. in an interview, emergency department Staff Nurse B also stated he/she would only give a written form explaining the risks and benefits of leaving the emergency department prior to discharge if the patient had been seen by the physician, but not if they had not yet been examined.

Review of the policy entitled "Patient signing own release (AMA from Emergency Department), lasted revised 01/10, was completed on 05/01/13. The review revealed "if the patient chose to leave before examination completed" staff are to "document on record patient 'Left before examination completed'.... Does not require AMA form to be completed. "

However, review of the AMA form completed on 05/01/13 revealed this form indicates the patient has been informed of the risks involved in leaving the emergency department.

The clinical record review for Patient #10 was completed on 05/01/13. The clinical record review revealed the 45 year old patient presented to the emergency department triage on 04/13/13 at 2:34 A.M. with a chief complaint of asthma flare up and left arm pain. A nursing note dated 04/13/13 at 3:14 A.M. stated he/she had a "barky" cough. The record revealed a nursing note dated 04/13/13 at 3:52 A.M. that stated the patient couldn't wait any longer. Review revealed a nursing note dated 04/13/13 at 4:16 A.M. (nearly two hours and 45 minutes later) that stated the patient left against medical advice.

The record lacked documentation revealing why Patient #10 couldn't wait anymore or what interventions were attempted to dissuade the patient from leaving. The record lacked evidence to indicate the risks of leaving before being examined by the physician was explained to patient.

The clinical record for Patient #16 was reviewed on 05/01/13. The patient presented to the emergency department on 04/23/13 at 2:32 AM with complaints of mid-sternal chest pain that radiates to the left arm and down arm without complaints of shortness of breath. The patient had a family history of heart attack. The patient was triaged at 2:39 AM and an EKG was obtained at 2:43 AM, which was normal. The nurses notes documented at 5:30 AM the patient stated he/she was "tired of waiting" and the staff explained the physician and physician assistant were busy with many emergencies. At 5:45 AM the nurse noted the patient had removed the leads to the cardiac monitor and was standing in his/her room. The medical record lacked documentation the patient was seen by a physician or physician assistant while in the emergency room. The medical record lacked documentation of any patient education regarding discharge instructions or risk of leaving the emergency room without being seen by a physician or receiving treatment. This was verified by Staff A on 05/01/13 at 1:00 PM.


The clinical record review for Patient #8 was completed on 05/01/13. The review revealed the patient presented to triage on 02/12/13 at 8:47 P.M. with a chief complaint of a head ache all day with nausea and vomiting and blood pressure of 133/90 mmHg. The squad report revealed the patient had some slight facial droop to her right.

The clinical record review revealed at 10:15 PM the patient was laughing inappropriately and not following direction well. The nursing note reveals at 12:00AM Narcan (an antidote to opioid overdose) 2 milligram was given slowly. At 12:27 AM the note stated the husband apparently lowered the bedrail for patient to urinate and the patient lowered self to floor. At 12:50 A.M. the patient became belligerent/hostile/aggressive/swinging/scratching personnel. The note stated the patient was lifted to the bed and said he/she needed to urinate. The note stated an adult incontinence brief was replaced after an attempt to use the bedpan. The note continued, "Husband assisting patient to sit on floor and use bedpan to void 200 milliliters urine." Husband transferred patient to wheelchair and hurriedly left the emergency department.

The clinical record review revealed the patient's urine was positive for amphetamines and barbiturates at 11:45 P.M. on 02/12/13.

The clinical record review revealed a physician note dated 02/12/13 at 11:00 P.M. that stated, "Patient appears under the influence of drugs" and at 01:00 A.M. alert and awake with Narcan. The note stated the patient was discharged at 01:00 A.M. The note stated the patient was stable but did not indicate on what basis that decision was made.

The clinical record review revealed on 02/13/13 at 12:27 P.M. the patient returned to the emergency department triage via ambulance with a chief complaint of a change in level of consciousness and a temperature of 102.3 degrees Fahrenheit.

The clinical record review revealed the patient received a computed tomography scan that revealed a physician diagnosis of acute change in mental status and brain mass. (The patient was admitted to the hospital.) On 05/01/13 at 2:00 P.M. the finding was presented to the Director of Emergency services.


21893

Based on interview and clinical record review, the facility failed to ensure one of 22 patient records reviewed (Patient #3) as stable for transfer and provided with a medical screening exam within the facility's capabilities. This presents a potential risk to all patients who present to the emergency department with symptoms of mental illness.

Findings include:

The clinical record review for Patient #3 was completed on 05/01/13. The clinical record review revealed the patient presented to triage on 04/29/13 at 7:46 P.M. with a chief complaint of "mental." The clinical record review revealed a physician's exam note dated 04/29/13 at 7:52 P.M. that stated "sent from jail for exacerbation of schizophrenia. Patient smearing stool on himself. Screaming and talking non-sensically."

Although the facility provides in-patient psychiatric care, the facility has an area within the emergency department dedicated to the mentally ill, and has psychiatrists on call, the clinical record review revealed a transfer request form that stated the patient was being transferred to a psychiatric facility "for further emergent psychiatric evaluation and treatment." The transfer form did not indicate whether the patient was stable, and the physician's notations did not include any documentation to indicate the patient had been re-evaluated or whether the patient was stable.

On 05/01/13 at 2:00 P.M. the Director of Emergency Services was shown Patient #3's record, and during the interview could not explain why the patient needed to be transferred for further psychiatric evaluation. The Director of Emergency Services verified the physician's documentation did not indicate whether the patient was stable at transfer.