HospitalInspections.org

Intake #TN000028518

Based on policy review, review of the Dedicated Emergency Department (DED) central log and interview, it was determined the hospital failed to maintain a central log on individuals who came to the DED seeking medical treatment that included the patient's name, treatment and disposition for 3 of 21 (Patients #1, 5 and 15) sampled patients with record reviews and for 3 of 3 random patients (Random Patients #1, 2 and 3) selected from the central log for the month of August 2011.
Refer to A 2405

Based on review of the hospital's By-laws Rules and Regulations, policy review, medical record review and interview, it was determined the hospital failed to ensure all patients presenting to the dedicated emergency department (DED) received an appropriate medical screening examination (MSE) according to hospital policies and within the capabilities of the hospital to determine if a medical emergency existed for 3 of 21 (Patients #1, 9 and 21) sampled patients and ensure an MSE was performed timely 1 of 21 (Patient 15) sampled patients.
Refer to A 2406

Based on policy review, medical record review and interview, it was determined the hospital failed to ensure patients who presented to the hospital's dedicated emergency department (DED) and chose to leave without treatment were explained the risk and benefits of leaving without treatment and signed the Against Medical Advice (AMA) form for 5 of 21 (Patients #17, 18, 19, 20 and 21) sampled patients.
Refer to A 2407

Based on policy review, review of the Dedicated Emergency Department (DED) central log and interview, it was determined the hospital failed to maintain a central log on individual who came to the DED seeking medical treatment was included the patient's name, treatment and disposition for 3 of 21 (Patients #1, 5 and 15) sampled patients with record reviews and for 3 of 3 random patients (Random Patients #1, 2 and 3) selected from the central log for the month of August 2011.

The findings included:

1. Review of the hospital's policy, "Emtala Policy", documented, "...A central log will be maintained and include all patients who present to the DED requesting medical assistance... The elements of the log...should contain at a minimum: 1. Date and time of arrival 2. Name, age and sex of patient 3. Presenting complaint 4. Disposition 5. Date and time of discharge."

2. Medical record review for Patient #1 documented the patient presented to the DED on 8/15/11 at 0851 with complaints the cast on the patient's right arm was tight causing pain rated a 10 on a scale of 1 - 10 with 10 being the most painful. There was no documentation the patient's name, treatment and disposition had been included on the central log dated 8/15/11.

Medical record review for Patient #5 documented the patient presented to the DED on 7/11/11 at 1255 with complaints of suicidal ideation and depression. There was no documentation the patient's name, treatment and disposition had been included on the central log dated 7/11/11.

Medical record review for Patient #15 documented the patient presented to the DED on 7/22/11 at 2031 with complaints of right arm pain rated a 10 on a scale of 1 - 10 with 10 being the most painful. There was no documentation the patient's name, treatment and disposition had been included on the central log dated 7/22/11.

3. Review of the central log dated 8/4/11 documented Random Patient #1 presented to the DED on 8/4/11 at 1537 with complaints of head cold and back pain. There was no documentation on the central log whether the patient was transferred, admitted, treated, stabilized or discharged.

Review of the central log dated 8/4/11 documented Random Patient #2 presented to the DED at 1645 with complaints of rectal problems. There was no documentation on the central log whether the patient was transferred, admitted, treated, stabilized or discharged.

Review of the central log dated 8/8/11 documented Random Patient #3 presented to the DED at 1301 with complaints of abdominal pain. There was no documentation on the central log whether the patient was transferred, admitted, treated, stabilized or discharged.

4. During an interview on 8/16/11 at 4:30 PM, the Director of Quality Management verified the above findings.

Based on review of the hospital's By-laws Rules and Regulations, policy review, medical record review and interview, it was determined the hospital failed to ensure all patients presenting to the dedicated emergency department (DED) received an appropriate medical screening examination (MSE) according to hospital policies and within the capabilities of the hospital to determine if a medical emergency existed for 3 of 21 (Patients #1, 9 and 21) sampled patients and ensure an MSE was performed timely 1 of 21 (Patient 15) sampled patients.

The findings included:

1. Review of the hospital's By-laws Rules and Regulations documented, "...When a patient presents to [name of hospital] seeking treatment, a MSE will be done in accordance with the Emergency Medical Treatment and Active Labor Act..."

Review of the hospital's policy entitled, "Emtala Policy" documented, "All patients presenting to [name of hospital] Dedicated Emergency Department will be evaluated through a triage system and receive an appropriate medical screening exam..."

Review of the hospital's policy, "Triage Guidelines" documented, "The purpose of triage is to expedite patient care, by prompt accurate assessments which prioritize patients into tiers... determining appropriate care for patients' by utilizing the triage guidelines...Level Red Emergent...Cardiac...chest pain...Level Yellow Urgent...requiring evaluation or treatment within a few hours...urgent patients require re-checks by the triage staff every 4 hours..."

2. Medical record review for Patient #1 documented the patient presented to the DED on 8/15/11 at 0839 with complaints he had been shot in the left hand 2 months ago and the left forearm cast was too tight and causing him pain. The patient rated the pain a 10 on a scale of 1 - 10 with 10 being the most painful. At 1030 the nurse documented Case Management escorted the patient to the Ortho clinic for an appointment. There was no documentation the patient received a MSE.

During an interview on 8/16/11 at 10:51 AM the Manager of the Trauma DED verified there was no documentation the patient had received a MSE. The Manager stated, "I think the emergency department physician "just called the Ortho clinic and sent him [the patient] there."

3. Review of the ambulance trip report dated 7/7/11 for Patient #9 documented the ambulance transported the patient as an emergency transport to the hospital's DED at 2030 for complaints of chest pain. The triage nurse documented at 2031 the patient complained of mid-sternal non-radiating chest pain and described a "hot feeling when breathes in." The chest pain was documented a 3 on a scale of 1 - 10 with 10 being the most painful. The triage nurse documented the patient was a Level Yellow - urgent and sent the patient to the waiting room to wait. At 2324 the nurse documented the patient was called to be seen. The nurse documented the patient had left the DED area.

During an interview on 8/16/11 at 12:38 PM, the Chief Nursing Officer (CNO) verified the hospital's policy stated chest pains were to be classified as Level Red - emergent and seen immediately by the physician. The CNO verified there was no documentation of observation of the patient for the 3 hours and 24 minutes the patient had waited in the DED waiting room.

4. Medical record review for Patient #21 documented the patient presented to the hospital's DED on 7/18/11 at 1144. The triage nurse documented the patient's complaint was "psychiatric." There was no documentation the triage nurse performed an assessment of the patient and assigned the patient a classification Level.

On 8/4/11 at 1244 Patient #21 presented again to the DED. The triage nurse documented the patient's complained as "other. " There was no documentation the triage nurse performed an assessment of the patient and assigned a classification Level for the patient to be seen by the physician. The triage nurse documented the patient left the DED on 8/5/11 at 0627 AMA prior to seeing the physician and the patient's departure condition was listed as "serious."

During an interview on 8/16/11 at 4:50 PM the Director of Quality management verified on 7/18/11 and 8/4/11 the triage nurse failed to perform an appropriate assessment and assign a classification Level to the patient.

5. Medical record review for Patient #15 documented the patient arrived to the DED on 7/22/11 at 1913. The triage nurse documented at 2031 the patient presented to the DED to have her right arm "checked out." The patient complained of right arm pain rating the pain a 10 on a scale of 1 - 10 with 10 being the most painful. The triage nurse classified her as a Level Yellow - urgent. There was no other documentation in the medical record for the dates 7/22/11 and 7/23/11. On 7/24/11 at 0620 the nurse documented the patient's vital signs were re-checked for the first time since arrival to the DED on 7/22/11. On 7/24/11 at 1239 the DED physician performed a MSE on the patient.

During an interview on 8/16/11 at 11:18 AM the Director of Quality Management was questioned as to why the patient had waited 3 days for a MSE. The Director of Quality Management stated, "I don't why she wasn't seen."

During an interview on 8/16/11 at 11:18 AM, the CNO was questioned as to why the patient had waited for 3 days for a MSE. The CNO stated, "I don't know, I don't have an answer for that...She should not have waited for 3 days..."

The CNO and Director of Quality Management verified there was no documentation on the Central log or in the patient's medical record as to why Patient #15 waited 3 days to receive an MSE. The CNO verified patients classified as Level yellow - urgent were to be seen within a few hours. The CNO verified the patient should have been assessed by triage every 4 hours while waiting to be seen by the physician. The CNO verified there was no documentation the patient had been assessed by triage every 4 hours from 7/22/11 - 7/24/11.

Based on policy review, medical record review and interview, it was determined the hospital failed to ensure patients who presented to the hospital's dedicated emergency department (DED) and choose to leave without treatment were explained the risk and benefits of leaving without treatment and signed the Against Medical Advice (AMA) form for 5 of 21 (Patients #17, 18, 19, 20 and 21) sampled patients.

The findings included:

1. Review of the hospital's policy, "Emtala policy" documented, "...Employees dealing with a patient who choose not to wait and/or refuses to discuss his/her decision with the attending physician and decides to leave AMA shall request the patient to sign Leaving AMA Form...If the patient refuses, the staff shall notify the attending physician or designee and document the refusal, date and time on the Leaving AMA Form and place it in the patient's medical record...It is expected, and always preferable, that a Licensed Independent Practitioner (LIP) will explain the risks of leaving AMA; in the absence of availability of an LIP, other caregivers in the clinic, may give patients information on the risks of leaving..."

2. Medical record review for Patient #17 documented the patient presented to the hospital's DED on 7/23/11 at 1318 with complaints of left hand swelling. The triage nurse documented, "ROM [range of motion] limited to pain." The patient was classified as a Level Yellow - urgent. The triage staff documented at 1912 the patient turned in her pager at the triage desk and left the DED. There was no documentation the risks and benefits of leaving before treatment were explained to the patient. An AMA form was not signed nor refusal to sign documented in the patient's medical record.

During an interview on 8/16/11 at 2:02 PM the Director of Quality Management verified there was no documentation the risks and benefits of leaving before treatment had been explained to the patient. An AMA form was not signed nor refusal to sign documented in the patient's medical record.

3. Medical record review for Patient #18 documented the patient presented to the hospital's DED by ambulance on 7/31/11 at 1350 with complaints of having a ceiling collapse on her head. The triage nurse classified the patient as a Level Yellow - urgent. At 2000 the DED nurse documented the patient was walking in the hallway. The nurse documented she informed the patient, "cannot leave unit." The patient stated, "I'm not coming back." The patient's discharge time was documented as 2000. There was no documentation the risks and benefits of leaving before treatment were explained to the patient. An AMA form was not signed nor refusal to sign documented in the patient's medical record.

During an interview on 8/16/11 at 12:54 PM, the Chief Nursing Officer (CNO) verified there was no documentation the risk and benefits of leaving before treatment had been explained to the patient or an AMA form signed nor refusal to sign documented in the patient's medical record.

4. Medical record review for Patient #19 documented the patient presented to the DED on 7/29/11 at 1758 with complaints she had been in a motor vehicle accident at 1600 and now was experiencing a headache and back/ neck pain radiating down the right side of her body. The triage nurse classified the patient as a Level Yellow - urgent. At 1830 the triage staff documented the patient turned her pager in at the triage desk and left the DED. There was no documentation the risks and benefits of leaving before treatment were explained to the patient. An AMA form was not signed nor refusal to sign documented in the patient's medical record.

During an interview on 8/16/11 at 1:53 PM the CNO verified there was no documentation the risks and benefits of leaving were explained to the patient or an AMA form signed nor refusal to sign documented in the patient's medical record.

5. Medical record review for Patient #20 documented the patient presented to the DED on 8/9/11 at 1941 with complaints of frequent urination and forehead/nose pressure. At 2144 the nurse documented the patient's disposition was AMA. There was no documentation the risks and benefits of leaving before treatment were explained to the patient. An AMA form was not signed nor refusal to sign documented in the patient's medical record.

During an interview on 8/16/11 at 1:00 PM the Director of Quality Management verified there was no documentation the risks and benefits of leaving had been explained to the patient or an AMA form signed nor refusal to sign documented in the patient's medical record.

6 Medical record review for Patient #21 documented the patient presented to the hospital's DED on 7/18/11 at 1144. The triage nurse documented the patient's complaint as "psychiatric." The patient turned his pager in at the triage desk and departed at 1900. There was no documentation the risks and benefits of leaving before treatment were explained to the patient. An AMA form was not signed nor refusal to sign documented in the patient's medical record.

During an interview on 8/16/11 at 4:40 PM the Director of Quality Management verified there was no documentation the risks and benefits of leaving had been explained to the patient or an AMA form signed nor refusal to sign documented in the patient's medical record.

On 8/4/11 at 1244 Patient #21 returned to the DED. The triage nurse documented the patient's complaint was "other." The triage nurse documented on 8/5/11 at 0627 the patient "left against medical advice" with the patient's departure condition listed as "serious." There was no other documentation of care or treatment for the patient from the time of presenting to the DED to the time of departure. There was no documentation the risks and benefits of leaving before treatment were explained to the patient. An AMA form was not signed nor refusal to sign documented in the patient's medical record.

During an interview on 8/16/11 at 4:43 PM the Director of Quality Management verified there was no documentation the patient had been triaged/assessed and assigned a classification level to be seen, no documentation the patient received care or treatment from the time the patient had presented to the DED until the time the patient departed, no documentation the risks and benefits of leaving before treatment were explained nor documentation an AMA form had been signed or the patient's refusal to sign documented in the patient's medical record.