HospitalInspections.org

Findings were:

1. Cross refer to A2406 as it relates to failure of the facility to perform an appropriate medical screening for a patient presenting to the Emergency Department.

2. Cross refer to A2407 as it relates to failure of the facility to provide stabilizing treatment for a patient presenting to the Emergency Department.

Based on review of Medical Staff By-laws/Rules and Regulations, policies and procedures, physician written statement, physician assistant written statement, staff written statement, and staff interviews, it was determined that the facility failed to provide a medical screening, for one of 21 (#21) patients presenting to the emergency department (ED) on 12/11/10.

Findings were:

A phone interview was conducted with employee #3 at 11:15 am on 12/22/10. The interviewee stated that he/she worked in the ED as a unit secretary on 12/11/10 and was at the nursing station, when patient #21 arrived, via EMS with police escort. The interviewee stated the EMS staff and a police officer entered the ED with the patient. The patient was on the transport stretcher. The patient was sitting up with his/her hands cuffed behind him/her. The interviewee stated that the ED was very busy at the time of the patient's arrival and all the rooms were occupied. He/she recalled that the patient was extremely agitated and spoke loudly. An ED nurse (employee #2) talked with the police officer and questioned if the patient was under arrest. The police officer informed the nurse that the patient was not in custody, and the hand cuffs were for the safety of the EMS staff. The interviewee stated that EMS staff moved the patient back into the ED entrance bay due to the heavy patient traffic flow. The decision to move the patient was made by the EMS staff. The ED employees did not request that the patient be moved. The interviewee recalled that the ED charge nurse (employee # 1) was aware of the patient's arrival. He/she was trying to discharge or admit patients to in-patient status as quickly as possible, in a effort to provide ED rooms, for the patient and other patients awaiting treatment. The patient's drivers license was provided as identification. The interviewee was not able to obtain information from the computer system related to a recent ED visit. The interviewee stated that approximately twenty (20) minutes later the police officer returned to the desk. He/she instructed the EMS driver that they were leaving and would take the patient to another hospital. The interviewee was not aware of ED staff talking with the police or EMS staff prior to departure, to encourage them not to leave and to explain the risk involved with leaving the emergency department prior to receiving a medical screening and stabilizing treatment.

An interview with the employee #2 was conducted at 10:10 a.m. on 12/22/10 in the Administration conference room. The interviewee stated that he/she was assigned to work in team triage with the physician assistant on 12/11/10. His/her primary responsibility was to initiate protocols for patients. The interviewee was unaware of the exact time (sometime in the late afternoon) of patient #21's arrival at the ED. He/she recalled that the ED was extremely busy. He/she remembered talking with an emergency medical technician (EMT) at the front desk. The EMT informed the interviewee that they had not called ahead to alert the ED of their impending arrival. The interviewee checked the system and determined that a room assignment had not been made for the patient. The charge nurse (employee #1) returned to the desk. The charge nurse talked with the EMT. He/she informed the EMT that the ED was extremely busy, and he/she would find a room for the patient as soon as possible. The interviewee stated that he/she then started assisting with patient discharges in an effort to expedite room availability for patients. The interviewee confirmed that he/she was aware that the patient was in the ambulance entrance vestibule. He/she did not have any contact with the patient, and was not aware of any ED staff completing an assessment of the patient. When the interviewee returned to the front desk approximately twenty (20) minutes later the police officer was confrontational requesting that the staff call the patient's physician. The police officer was unable to provide the physician's name or other information related to the patient's previous admission to the facility. The police officer walked back into the ambulance entrance vestibule. An EMT walked into the ED and stated that they were leaving, and were going to take the patient to a "real hospital". The interviewee confirmed that he/she did not encourage the EMT not to leave or explain the risk involved with leaving the emergency department prior to receiving a medical screening examination and stabling treatment.

A written statement was provided by the registered nurse (employee #4) assigned to ED triage at the time of the patient arrival on 12/11/10. The statement revealed that the employee was busy triaging other patients at the time of patient #21's arrival at the ED. The employee confirmed that he/she did not have any contact with the police officer, EMS staff or patient. He/she did not provide a triage assessment and was not aware of any assessment completed prior to the patient's departure.

An interview with employee #1 was conducted at 3:00 p.m. on 12/21/10 in the Administration conference room. The interviewee stated that he/she was the ED Charge Nurse at the time of patient #21's arrival at approximately 4:40 p.m. on 12/11/10. He/she recalled that the ED was extremely busy with critical patients at the time of the patient arrival. He/she was not at the desk when the EMS staff and police officer entered the ED with the patient. When he/she returned to the front desk the patient was in the bay area of the ambulance entrance, and he/she was yelling loudly. The interviewee never saw the patient inside the ED. The interviewee talked with EMS staff, determined that the patient was a psychiatric patient, in hand cuff for safety due to his/her violent behavior, and the patient was not under arrest. The interviewee told the EMS staff that it would take a few minutes to arrange for a room for the patient and left the area to facilitate locating and preparing an available room. When he/she returned to the desk with the room assignment the EMS staff, police officer and patient were gone. The interviewee confirmed that he/she did not have any contact with the patient and a nursing assessment was not completed. He/she was unaware of the EMS staff's decision to leave the hospital prior to the departure and was unable to encourage them to stay or inform them of the risk of leaving the facility prior to receiving medical screening and treatment.

Written statements provided by the physician and physician assistant providing coverage in the ED on 12/11/10 at the time of patient #21 arrival confirmed that they did not see the patient and there was no medical screening and/or stabilizing treatment provided.

Review of facility policy #2014 entitled "Transfer Activities In Accordance With COBRA/EMTALA Legislation" last revised 5/08 revealed that it is the policy of the hospital to provide a medical screening examination by a qualified medical person to any person presenting on hospital grounds and seeking care. If it is determined that the individual has an emergent medical condition, the Hospital will provide the individual with such further medical examination and treatment as is required to stabilize, within the capability of the Hospital, or arrange for appropriate transfer of the individual.

Review of the Medical Staff Rules and Regulations Section 4: Emergency Department 4.2 Medical Screening 4.2.1 revealed that qualified medical personnel may perform a medical screening exam (MSE). In the Emergency Department the physician, or a Certified Nurse Practitioner or Physician Assistant in consultation with the physician may perform MSE. In Labor and Delivery the Registered Nurse or Certified Nurse Midwife may perform the MSE in consultation with the physician.

Interview at 1:00 p.m. on 12-22-10 and written documentation provided by the facility's risk manager (employee #6) revealed that when the possible violation was brought to his/her attention an immediate internal investigation was initiated. The facility's security department was able to identify and provide surveillance pictures. The pictures identified the EMS ambulance in the ambulance bay on 12/11/2010 at 4:25:55 p.m. The EMS staff off- loaded the patient on a stretcher at 4:26:58 p.m. The camera surveillance inside the ED was angled only to show the nurses station. At 4:28:33 p.m., the EMS staff was observed at the nurses station desk. At 4:49:05 p.m., the EMS staff was observed speaking with the unit secretary (employee #3). At 4:53:33 p.m., the EMS staff and the police officer were observed at the nurses station. At 4:56:07 p.m., the EMS staff and the police officer were observed with the patient on a stretcher in the ambulance bay approaching the ambulance to leave. The risk manager confirmed that the camera surveillance pictures indicated that the EMS staff, police officer and patient were at the ED for approximately 30 minutes prior to leaving the facility. He/she also confirmed that the facility had failed to provide a triage assessment, medical screening and stabilizing treatment for the patient.
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The following Corrective Action Plan was initiated by the facility:

1. Communicated expectations regarding EMS patients and delays in off-loading. Due Date Immediately

2. Place extra stretcher adjacent nurse's station #1 for off-load capability. Due Date 12/17/2010

3. Revise EMTALA educational content. Due Date 12/22/2010

4. EMTALA education already mandatory for new employees. Due Date n/a

5. Mandatory EMTALA education for all charge nurses. Due Date 12/31/20110

6. Mandatory EMTALA education for all employees. Due Date 1/14/2011

7. EMTALA education annually. Will explore submitting DCI as required department module. Due Date 3/31/2011

8. Review ED policies to determine if additions or corrects regarding triage or EMTALA are needed. Due Date 1/31/2011

9. Obtain EMTALA Answer Book to keep in ED as reference resource. Due Date 12/17/2010

10. Establish a 2nd triage float nurse position to process any patients received via EMS and waiting for bed assignment. Due Date Recruiting

11. EMTALA educational opportunity by the Executive VP of Legal Counsel with invitations to medical staff and mandatory attendance by ED nursing and medical leadership. Due Date 1/31/2011

12. Create an Emergency room EMTALA policy. Due Date 1/31/2011

13. Schedule meeting with Clayton County EMS leadership to review incident and opportunities to improve. Due Date 1/31/2011

Based on review of Medical Staff by-laws/Rules and Regulations, policies and procedures, physician written statement, physician assistant written statement, staff written statement, and staff interviews, it was determined that the facility failed to provide stabilizing treatment, for one of 21 (#21) patients presenting to the emergency department (ED) on 12/11/10.


Findings were:

A phone interview was conducted with employee #3 at 11:15 am on 12/22/10. The interviewee stated that he/she worked in the ED as a unit secretary on 12/11/10 and was at the nursing station, when patient #21 arrived, via EMS with police escort. The interviewee stated the EMS staff and a police officer entered the ED with the patient. The patient was on the transport stretcher. The patient was sitting up with his/her hands cuffed behind him/her. The interviewee stated that the ED was very busy at the time of the patient's arrival and all the rooms were occupied. He/she recalled that the patient was extremely agitated and spoke loudly. An ED nurse (employee #2) talked with the police officer and questioned if the patient was under arrest. The police officer informed the nurse that the patient was not in custody, and the hand cuffs were for the safety of the EMS staff. The interviewee stated that EMS staff moved the patient back into the ED entrance bay due to the heavy patient traffic flow. The decision to move the patient was made by the EMS staff. The ED employees did not request that the patient be moved. The interviewee recalled that the ED charge nurse (employee # 1) was aware of the patient's arrival. He/she was trying to discharge or admit patients to in-patient status as quickly as possible, in a effort to provide ED rooms, for the patient and other patients awaiting treatment. The patient's drivers license was provided as identification. The interviewee was not able to obtain information from the computer system related to a recent ED visit. The interviewee stated that approximately twenty (20) minutes later the police officer returned to the desk. He/she instructed the EMS driver that they were leaving and would take the patient to another hospital. The interviewee was not aware of ED staff talking with the police or EMS staff prior to departure, to encourage them not to leave and to explain the risk involved with leaving the emergency department prior to receiving a medical screening and stabilizing treatment.

An interview with the employee #2 was conducted at 10:10 a.m. on 12/22/10 in the Administration conference room. The interviewee stated that he/she was assigned to work in team triage with the physician assistant on 12/11/10. His/her primary responsibility was to initiate protocols for patients. The interviewee was unaware of the exact time (sometime in the late afternoon) of patient #21's arrival at the ED. He/she recalled that the ED was extremely busy. He/she remembered talking with an emergency medical technician (EMT) at the front desk. The EMT informed the interviewee that they had not called ahead to alert the ED of their impending arrival. The interviewee checked the system and determined that a room assignment had not been made for the patient. The charge nurse (employee #1) returned to the desk. The charge nurse talked with the EMT. He/she informed the EMT that the ED was extremely busy, and he/she would find a room for the patient as soon as possible. The interviewee stated that he/she then started assisting with patient discharges in an effort to expedite room availability for patients. The interviewee confirmed that he/she was aware that the patient was in the ambulance entrance vestibule. He/she did not have any contact with the patient, and was not aware of any ED staff completing an assessment of the patient. When the interviewee returned to the front desk approximately twenty (20) minutes later the police officer was confrontational requesting that the staff call the patient's physician. The police officer was unable to provide the physician's name or other information related to the patient's previous admission to the facility. The police officer walked back into the ambulance entrance vestibule. An EMT walked into the ED and stated that they were leaving, and were going to take the patient to a "real hospital". The interviewee confirmed that he/she did not encourage the EMT not to leave or explain the risk involved with leaving the emergency department prior to receiving a medical screening examination and stabling treatment.

A written statement was provided by the registered nurse (employee #4) assigned to ED triage at the time of the patient arrival on 12/11/10. The statement revealed that the employee was busy triaging other patients at the time of patient #21's arrival at the ED. The employee confirmed that he/she did not have any contact with the police officer, EMS staff or patient. He/she did not provide a triage assessment and was not aware of any assessment completed prior to the patient's departure.

An interview with employee #1 was conducted at 3:00 p.m. on 12/21/10 in the Administration conference room. The interviewee stated that he/she was the ED Charge Nurse at the time of patient #21's arrival at approximately 4:40 p.m. on 12/11/10. He/she recalled that the ED was extremely busy with critical patients at the time of the patient arrival. He/she was not at the desk when the EMS staff and police officer entered the ED with the patient. When he/she returned to the front desk the patient was in the bay area of the ambulance entrance, and he/she was yelling loudly. The interviewee never saw the patient inside the ED. The interviewee talked with EMS staff, determined that the patient was a psychiatric patient, in hand cuff for safety due to his/her violent behavior, and the patient was not under arrest. The interviewee told the EMS staff that it would take a few minutes to arrange for a room for the patient and left the area to facilitate locating and preparing an available room. When he/she returned to the desk with the room assignment the EMS staff, police officer and patient were gone. The interviewee confirmed that he/she did not have any contact with the patient and a nursing assessment was not completed. He/she was unaware of the EMS staff's decision to leave the hospital prior to the departure and was unable to encourage them to stay or inform them of the risk of leaving the facility prior to receiving medical screening and treatment.

Review of facility policy #2014 entitled "Transfer Activities In Accordance With COBRA/EMTALA Legislation" last revised 5/08 revealed that it is the policy of the hospital to provide a medical screening examination by a qualified medical person to any person presenting on hospital grounds and seeking care. If it is determined that the individual has an emergent medical condition, the Hospital will provide the individual with such further medical examination and treatment as is required to stabilize, within the capability of the Hospital, or arrange for appropriate transfer of the individual.

Review of the Medical Staff Rules and Regulations Section 4: Emergency Department 4.2 Medical Screening 4.2.1 revealed that qualified medical personnel may perform a medical screening exam (MSE). In the Emergency Department the physician, or a Certified Nurse Practitioner or Physician Assistant in consultation with the physician may perform MSE. In Labor and Delivery the Registered Nurse or Certified Nurse Midwife may perform the MSE in consultation with the physician.

Interview at 1:00 p.m. on 12-22-10 and written documentation provided by the facility's risk manager (employee #6) revealed that when the possible violation was brought to his/her attention an immediate internal investigation was initiated. The facility's security department was able to identify and provide surveillance pictures. The pictures identified the EMS ambulance in the ambulance bay on 12/11/2010 at 4:25:55 p.m. The EMS staff off-loaded the patient on a stretcher at 4:26:58 p.m. The camera surveillance inside the ED was angled only to show the nurses station. At 4:28:33 p.m., the EMS staff was observed at the nurses station desk. At 4:49:05 p.m., the EMS staff was observed speaking with the unit secretary (employee #3). At 4:53:33 p.m., the EMS staff and the police officer were observed at the nurses station. At 4:56:07 p.m., the EMS staff and the police officer were observed with the patient on a stretcher in the ambulance bay approaching the ambulance to leave. The risk manager confirmed that the camera surveillance pictures indicated that the EMS staff, police officer and patient were at the ED for approximately 30 minutes prior to leaving the facility. He/she also confirmed that the facility had failed to provide a triage assessment, medical screening and stabilizing treatment for the patient.
.
The following Corrective Action Plan was initiated by the facility:

1. Communicated expectations regarding EMS patients and delays in off-loading. Due Date Immediately

2. Place extra stretcher adjacent nurse's station #1 for off-load capability. Due Date 12/17/2010

3. Revise EMTALA educational content. Due Date 12/22/2010

4. EMTALA education already mandatory for new employees. Due Date n/a

5. Mandatory EMTALA education for all charge nurses. Due Date 12/31/20110

6. Mandatory EMTALA education for all employees. Due Date 1/14/2011

7. EMTALA education annually. Will explore submitting DCI as required department module. Due Date 3/31/2011

8. Review ED policies to determine if additions or corrects regarding triage or EMTALA are needed. Due Date 1/31/2011

9. Obtain EMTALA Answer Book to keep in ED as reference resource. Due Date 12/17/2010

10. Establish a 2nd triage float nurse position to process any patients received via EMS and waiting for bed assignment. Due Date Recruiting

11. EMTALA educational opportunity by the Executive VP of Legal Counsel with invitations to medical staff and mandatory attendance by ED nursing and medical leadership. Due Date 1/31/2011

12. Create an Emergency room EMTALA policy. Due Date 1/31/2011

13. Schedule meeting with Clayton County EMS leadership to review incident and opportunities to improve. Due Date 1/31/2011