HospitalInspections.org

Based on policy and procedure review, medical record review, emergency medical services (EMS) report review, staff and physician interviews, the hospital failed to provide an appropriate medical screening exam to determine whether or not an emergency medical condition existed for 3 of 26 emergency department patients records reviewed (Patient #26, Patient #3, and Patient #1).

The findings included:

~cross refer to Stabilizing Treatment, Tag A 2406.

Based on facility policy review, medical record review, emergency medical services (EMS) report review, staff and physician interviews, the facility failed to provide an appropriate medical screening exam to determine whether or not an emergency medical condition existed for 3 of 26 emergency department patients records reviewed (Patient #26, Patient #3, and Patient #1).

The findings included:

Review of facility policy, EMTALA - Medical Screening and Treatment of Emergency Medical Conditions, effective 12/02/2021, revealed, "... DEFINITIONS... I. Emergency Medical Condition means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity... such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual... in serious jeopardy; b. Serious impairment to bodily functions... L. Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists... Depending on the patient's presenting symptoms, the Medical Screening Examination may range from a simple process... to a complex process that also involves performing ancillary studies and procedures..."

Review of facility policy, Triage & Classification System, effective 12/2021, revealed,"...C. An ED (Emergency Department) Registered Nurse is responsible for assigning an acuity level to each patient based on history, physical assessment, and sound clinical decision-making skill... E. All patients, at will, will be triaged and provided with an emergency medical screening examination according to established policy and procedure..."

Review of facility policy, Nursing Documentation of Patient Care in the Emergency Department, last revised 08/2022, revealed,"...V. Patients arriving by ambulance will have documented in the nursing record any treatments/interventions performed prior to arrival, e.g. IVs including amount of fluid, location, size if known, oxygen therapy, pulse ox monitoring, any medications administered, cervical collars, backboard, etc..."

Review of facility policy, Discharges from the Emergency Department, last revised 08/2022, revealed, "... If the patient chooses to leave Against Medical Advice (AMA) they will be asked to sign the Against Medical Advice form only if they identify they are leaving. The Emergency Department physician should inform the patient of his/her risk in deciding to leave AMA including threat to limb or life... This form, plus documentation, will remain a part of the patient's medical record. In the event the patient refuses to sign the form, the refusal will be documented on the form and in the patient's ED record..."

1. VISIT #1

Review of (named) County EMS run report dated 08/28/2022 revealed local EMS received a 911 call for Patient #26 for a "sick person." Review revealed the chief complaint was "right leg shaking/pain" and the secondary complaint was "hyperglycemia (high blood sugar)." Review of the History of Present Illness revealed,"... The patient was alert and oriented and stated that his leg is weak, hurting and shaking and has been for a week. While vital signs were being assessed he also added that he has been super thirsty for about a month and urinating a lot. The patient was found to be normocardic (normal heart rate), normotensive (normal blood pressure), with a normal RR (respiratory rate) and SPO2 (pulse oximetry) but did have a sugar of 502 (HX (history) of DM2 (Diabetes Mellitus Type 2)... Upon arrival to the ER the patient was assisted into a wheelchair and taken to triage. He was left at the front nurses desk and a report was given to the triage nurse. Signatures were obtained..."

Closed medical record review on 09/14/2022 of Patient #26 revealed a 47-year-old male who presented to the ED via ambulance on 08/28/2022 at 1340. Review of the (named) EMS (Emergency Medical Services) Hand Off Notes dated 08/28/2022 revealed, "... Numbness R (right) leg, high sugar...Vital Signs: 1315 - HR (Heart Rate): 96, BP (Blood Pressure): 119/82, SaO2 (Pulse Oximetry): 99%, Resp (R/Respirations): 18, GCS (Glasgow Coma Scale - scoring system used to describe the level of consciousness, 15 is considered normal): 15, Glu (Glucose): 502 (normal range 70-100)... (group home nurse contact phone number)..." Review of the Nursing Triage Assessment at 1352 by Registered Nurse (RN) #7 revealed, "... Stated Complaint: Numbness R Leg... Pt (patient) presented to ED via EMS and is placed in triage with c/o (complaint of) RLE (right lower extremity) pain since Monday. Pt states he got an abilify (antipsychotic medication) shot and has had pain and shaking in leg since injection. Pt states the pain is getting worse and he can't walk on it. No other s/s (signs/symptoms) noted at this time, no signs of distress, vss (vital signs stable), a/o (alert/oriented) to pt baseline...Priority (ESI/acuity level - 1 is the most urgent, 5 is the least urgent): 4...Pain: 10/10 (Numerical scale - 1 - least pain, 10 - most pain)..." Medical record review revealed Patient #26 was seen by the provider at 1426. Review of the Emergency Provider Record by Medical Doctor (MD) #6 signed on 08/29/2022 at 1949 revealed,"...Chief complaint: Right lower extremity pain... History of Present Illness (HPI): 47-year-old male with right lower extremity shaking and discomfort. Symptoms began and (sic) shortly after receiving and (sic) Abilify injection 1 week ago. Persistent since. He has had this injection previously without any issues. Denies anything different otherwise. Denies any trauma or strain. Review of Systems: Review of systems is negative unless otherwise noted in HPI (History of Present Illness)...MDM (Medical Decision Making): ... Possibly dystonic (involuntary muscle contractions) reaction although this is typically less common isolated to an extremity. He was given Cogentin (anti-tremor medication) and Benadryl (antihistamine medication) with some improvement but not complete resolution. Will have him try p.r.n. (as needed) Benadryl. He needs to follow up with his psychiatric provider..."

Review of ED Notes at 1630 by RN #7 revealed, "Eloped." Medical record review revealed Patient #26 was dispositioned as "Left Prior to MSE" and "Elopement after Seen" at 1640. Medical record review failed to reveal documentation or assessment of Patient #26's blood glucose. Medical record review failed to reveal a nursing assessment or review of risks and benefits prior to departure.

VISIT #2

Review of (named) County EMS run report dated 08/29/2022 revealed local EMS received a 911 call for Patient #26 for "breathing problems." Review revealed the chief complaint was "hyperglycemia (high blood sugar)." Review of the History of Present Illness revealed,"... Pt complains of his blood sugar being high. Aid (sic) in the home reports that he was seen yesterday at hospital for a FSBS (finger stick blood sugar) of 507. However, he was discharged home with no changes. Pt was placed on ETCO2 (End-tidal carbon dioxide - helps measure ventilation/carbon dioxide levels) which revealed deep hypocarbia (reduced carbon dioxide in the blood - usually due to hyperventilation). Pts (sic) is also tachycardia at 120; sinus. Pt FSBS reads High on our equipment. IV access was established... fluid bolus of NS (normal saline) was started... arrived at (named facility) where the pt was unloaded and brought inside. Pt was taken to ED... Pt care/report was given to (named RN)..."

Closed medical record review on 09/14/2022 of Patient #26 revealed a 47-year-old male who presented to the ED via ambulance on 08/29/2022 at 0733 (14 hours, 53 minutes after Visit #1). Review of the Nursing Triage Assessment at 0740 revealed, "... Stated Complaint: High BGL (blood glucose level)... Pt presents via Ems from his home for a c/c (chief complaint) of high BGL and n/v (nausea/vomiting). Pt's BGL was HI enroute by EMS. Pt is noted to be confused but reports n/v and chest pain on arrival. Pt has noted kussmaul respirations (fast, deep breaths that occur in response to metabolic acidosis). Pt is tachypneic as well. Pt's BGL read >500 (greater than 500) on our glucometer. Pt received 500 mL (milliliters) bolus by EMS enroute... Priority (ESI/acuity level - 1 is the most urgent, 5 is the least urgent): 3...Vital Signs: BP: 137/67, HR: 122, R: 33, SaO2: 97%, Temperature: 36.6 C/97.9 F, Pain: 4 (FACES scale - 1 - least pain, 10 - most pain)..." Review of Glucose laboratory result at 0750 revealed a value of 938. Review of ED notes at 0817 revealed, "...witnessed tonic clonic seizure (type of seizure that involves a loss of consciousness and violent muscle contractions) noted at 0748 lasted for 10 sec (seconds) second seizure noted at 0803 tonic clonic lasting 10-15 sec. Pt postictal (post seizure state usually with confusion) afterwards..." Review of the Emergency Provider Record signed 08/29/2022 at 0904 revealed, "... past medical history of hypertension hyperlipidemia and diabetes, unclear if he is on insulin or not presents (sic) brought in by EMS for evaluation of altered mental status rapid breathing and hyperglycemia... Presentation concerning for diabetic ketoacidosis (serious diabetes complication when excess ketones are in the bloodstream)... Patient activated as a sepsis alert given CBC (complete blood count) of 18 (normal white blood cell (WBC) range 3.8-10.7, high value indicates infection) with tachycardia...Patient will need admission to the ICU..." Medical record review revealed Patient #26 was transferred to an outside facility on 08/29/2022 at 1235.

Interview on 09/16/2022 at 1139 with EMT #8 revealed he was the paramedic that rendered care to Patient #26 on 08/28/2022. Interview revealed that Patient #26 was picked up from a group home and that the nurse gave the patient a sheet of paper with his medications and contact information to take to the hospital. Interview revealed EMT #8 was concerned about Patient #26's high blood sugar findings and highlighted it during handoff to the Triage Nurse (RN #7). Interview revealed that the Triage Nurse (RN #7) was informed that Patient #26 was a diabetic and took medications for it. Interview revealed that in addition to the oral report, the Triage Nurse (RN #7) was given a written handoff report [(named) EMS Hand Off Notes].

Request on 09/14/2022 for Interview with RN #7 revealed that he was a contract nurse and that his last day was 09/14/2022 per facility Director of Risk on 09/15/2022 at 0915.

Request on 09/14/2022 for Interview with MD #6 revealed that he was unavailable per facility Director of Risk on 09/15/2022 at 1520.

Interview on 09/15/2022 at 1604 with Nurse Manager (NM) #5 revealed the expectations for travel and permanent staff nurses was the same. Interview revealed that the triage nurse was expected to document the patient's stated complaint and any findings from EMS. Interview revealed that the blood glucose of 502 from Patient #26's first visit to the Dedicated Emergency Department (DED) should have been documented in the medical record and reported to the medical provider. Interview revealed that an AMA form should be completed for patients that inform staff that they wanted to leave prior to discharge. Interview revealed NM #5 clarified that the documentation was not clear as to how Patient #26 departed back to his group home on Visit #1. Interview revealed that NM #5 was present when Patient #26 returned on 08/29/2022. Interview revealed that Patient #26 was critically ill and needed ICU-level care. Interview revealed that the ICU's staffed beds were full of patients and the ED physician decided to transfer Patient #26 to a different facility.

Interview on 09/16/2022 at 1200 with MD #2 revealed the expectation of the ED medical providers to respond to a blood glucose level of 500 and provide treatment with intravenous fluids, laboratory workup, and insulin. Interview revealed that it was possible that findings, like Patient #26's blood glucose from EMS, to get lost in handoff between the EMS to RN to ED provider. Interview revealed the EMS handoff sheet was not always available for the provider to review, but they have access to what the nurses document in the electronic medical record. Interview revealed the medical providers were dependent on the triage nurses to capture the handoff from EMS and document it within the medical record. Interview revealed if the blood glucose value was not documented in the medical record by the RN, then the provider may not have been aware of the value.



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2. Closed medical record review on 09/14/2022 for Patient #3 revealed a 54-year-old female who presented via EMS to Hospital A's DED (dedicated emergency department) on 07/11/2022 at 1327 with a stated chief complaint of " ...Pt's vehicle stopped working and pt put the vehicle in neutral to push the car and it started rolling. Pt fell and her back driver tire ran over her left arm. Pt having left arm, hip and bilateral knee pain. Pt states she hit the left side of her head and she does not think she had LOC (loss of consciousness). ..." Review of the DED medical record revealed the patient was triaged as a priority level 3 (urgent) at 1402. Review revealed the patient's pain was recorded as 7 on a scale of 1-10 with 10 the worst pain. Review revealed "Gait not evaluated due to aggravation of bilateral knee pain." Review revealed the patient was discharged and departed the DED at 1831.

Interview on 09/16/2022 at 1025 with Physician Assistant (PA) #23 revealed he was the provider that saw Patient #3 in the DED on 07/11/2022. Interview revealed the PA had reviewed the patient's medical record and did not see documentation that he evaluated the patient's gait. PA #23 stated the patient had multiple joint injuries, did not have any compartmental injuries, had full range of motion and pulses present. Interview revealed an assessment was completed and the patient was offered ortho follow-up with the ortho group on staff at Hospital A. Interview revealed the patient was provided a list for primary care and specialty physicians, information on opioid use, an MD note, and instructions for return precautions.

Interview on 09/15/2022 at 1330 with Paramedic 22 revealed she provided discharge instructions to Patient #3. Interview revealed the discharge instructions were printed and she read over the instructions with the patient. She reported she told the patient to follow-up with (named orthopedic physician) in 1 - 2 days for re-evaluation. The staff member was unable to remember if the patient was ambulatory when she departed and was unable to locate any documentation regarding the ambulation status of the patient at departure.

In summary, Patient # 3 did not have a complete and thorough physical exam; her gait was not assessed and no specific evaluation of the lower extremities was documented/completed.



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3. Patient #1 Visit #1:

Review of a closed DED medial record on 09/13/2022 for Patient #1 revealed a 31-year-old male that presented to the DED on 01/26/2022 at 0904 via EMS with a chief complaint "MVC (motor vehicle crash) Entrapment." Review of the Vital Signs at 0905 revealed a blood pressure of 156/97; a Pulse of 98; a Respiratory rate of 21; an O2 (oxygen) Sat (saturation) of 96 on room air; and a Pain level of 0/10 (scale of 0-10 used to determine severity of pain with 0 being does not hurt/nor pain and 10 being hurts a lot/severe pain). Review of the Rapid Initial Screen Dated 01/26/2022 at 0912 revealed "Patient presents ... from rollover MVC. Patient was entrapped requiring extrication. Patient was face down in water in the back window of car. Patient has a hx (history) of PCP (Phencyclidine - mind-altering drug that may lead to hallucinations) use. Upon extrication, patient became combative requiring a total of 10 mg (milligrams) Versed IM (intramuscular - in the muscle). Patient arrives in restraints without C-collar. Patient responsive to verbal stimuli but does not answer questions appropriately. When asked what happened, patient responds "cops and robbers." Review of the ED Summary revealed Patient #1 was assigned a "Priority: 2 (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute)." Review of the Finger Stick Blood Sugar resulted at 0912 revealed "Blood Sugar Results 140." Review of the Physician note dated 01/26/2022 at 0922 revealed " ... Patient was involved in a rollover MVC. Patient's car was found in the canal ditch, car was upside down, patient (sic) was found near back window with face down, in water. Per EMS patient is known the abuser of street drugs/PCP. Patient also seems intoxicated with alcohol. Patient was combative with them. They used restraints and also had to give Versed (sedative medication). Patient received 5+2+3 IM (intramuscular) Versed. By EMS. Patient was brought to emergency room on nasal cannula. Patient is moving all the extremities, no C-collar placed ... Patient is arousable with the touch stimuli. only words patient stated were 'Police & robbers' ... Physical Exam: Neuro: ... Other (Spontaneous movement of all the extremities noted, patient is able to change position in ED with minimal help. Seems intoxicated and does not follow any commands. Since patient is maintaining airway. We will continue close monitoring) ... 1012 patient is now alert, o x 3 (oriented times three) PATIENT IS REFUSING FURTHER WORK UP AND WOULD LIKE TO GO HOME. PATIENT REMAINED A X O X 3 (alert plus oriented times three) THE PATIENT DEMONSTRATES A NORMAL MENTAL CAPACITY TO MAKE DECISIONS. WE HAVE INFORMED RISKS INVOLVED AND POSSIBLE COMPLICATIONS IN LAYMAN TERMS, THAT MAY/CAN HAPPEN - WHICH INCLUDE BUT ARE NOT LIMITED TO DEATH, COMA, PERMANENT DISABILITY, DELAY IN DIAGNOSIS. PATIENT WOULD STILL LIKE TO LEAVE ... The patient has been advised that they are welcome to return to this hospital, or any other, at any time. 1015 I tried to convince him to get further workup done we also allowed family member to join the discussion. Patient continued to refuse. Family member wants to commit patient. Patient himself denies any suicidal ideation denies any homicidal ideations denies any hallucinations. I tried to convey family member that patient does not meet criteria for IVC (involuntary commitment). And on top of that patient continued to refused (sic) to get workup done. Patient is cooperative ...Disposition Type: AMA (against medical advice) ..." Review of the Nursing Assessment at 1000 revealed " ... Neurological: Oriented x (times) 3, Follows Commands, Moves All Extremities, PERRL (pupils equal round reactive to light) ..." Review of the Complete Blood Count resulted at 1005 revealed an elevated red blood cell count and hemoglobin and a low eosinophil (type of white blood cell). Continued review of the blood laboratory work revealed an elevated total protein and AST (aspartate aminotransferase - enzyme found in the liver). Review of the Nurse Note at 1005 revealed "Pt (patient) is requesting to leave at this time. Pt states he does not want to be here and is ready to go. This RN (Registered Nurse) notified (MD #1) and (MD #1) reported to bedside. (MD #1) explained to the pt that he was not cleared and needed to be admitted to the hospital due to the seriousness of the situation that brought him in. The pt stated 'I am fine. I need my paper to go.' This RN asked the pt orientation questions, to which he responeded (sic) appropriately. Pt stated his name, birthday, location of where he was at, the year, as well as the president. This RN is preparing AMA papers at this time. This RN was notified that family is in the lobby. This RN reqested (sic) sister be brought to the room to speak with the pt and (MD #1)." Review of the Nurse note at 1011 revealed "Pt's sister at bedside at this time with this RN and (MD #1). The sister stated she knew everything that happened and that she wanted the pt committed. (MD #1) explained to the sister, with the pts mother on the phone, that unless the pt was a threat to himself or others, the pt could not be IVC's (sic). The pts sister explained that drugs could kill the pt. (MD #1) explained that unless the pt was using drugs to intentionally harm himself then he couldn't be IVC'd. The pt stated he was just high and did not want to harm himself. The pt repeatedly kept saying, 'get my paper. I am ready to go.' (MD #1) repeated orientation questions to which the pt responded appropriately." Review of the Nurse note at 1012 revealed "Pt's sister asking for time with the pt. Stating the pt will stay and is not going to leave." Review of the Nurse note at 1014 revealed "Pt's Sister told this RN that she was done with the pt and that she was leaving. She stated 'he has done this too many times and he needs help. I am done with him'." Review of the Nurse note at 1020 revealed "AMA paperwork signed at this time by the pt. This RN, along with (RN #10) witnessed pt sign. This RN, along with (MD #1), explained the risk of leaving against medical advice. Pt wishes to proceed with AMA process. This RN provided blue scrubs and yellow socks to the pt." Review of the "Release From Responsibility For Discharge" dated 01/26/2022 at 1020 revealed Patient #1's name was handwritten in the space and Patient #1 had signed the form along with two signatures on the witness lines. Review of the Departure Assessment at 1055 revealed " ... Disposition Type: AMA ... Recognized Date Patient Left: 01/26/2022; Recognized Time Patient Left: 1020; AMA Sheet: Signed; Comment: Witnessed by this RN & (and) (RN #10) ..." Review of the medical record revealed Patient #1 left the hospital on 01/26/2022 at 1020 AMA.

Interview on 09/14/2022 at 1520 with Nurse Manager (NM) #5 revealed RN #9 and RN #10 are no longer employed with the hospital and are not available for interview.

Telephone interview on 09/15/2022 at 1109 with Medical Doctor #1 revealed he did not remember Patient #1 and that he had reviewed the medical record for Patient #1's first visit to the emergency department on 01/26/2022. Interview revealed Patient #1 was not cooperative. Interview revealed Patient #1 denied SI (suicidal ideation) and HI (homicidal ideation). Interview revealed Patient #1 stated he was "high" and that he does "abuse drugs". Interview revealed Patient #1's statement went along with his clinical presentation. Interview revealed MD #1 reviewed the risk and benefits with Patient #1 and tried to get him to stay and continue care in the ED. Interview revealed Patient #1 did not want to stay and signed out AMA.

Patient #1 Visit #2

Review of a closed DED medial record on 09/13/2022 for Patient #1 revealed a 31-year-old male that presented to the DED on 01/26/2022 at 2251 via EMS with a chief complaint "MVC /PCP use." Review of the ED summary report revealed at 2319 Patient #1 triage was completed and at 2320 it was documented Patient #1 left prior to triage. Review of the Nurse note at 2318 revealed "Pt standing at the doorway looking at his watch. Asked if he wanted to bed (sic) seen. Pt shook his head no. Pt departed at LPT."

Review of Patient #1's 2nd DED visit on 01/26/2022 revealed he arrived via EMS at 2251 (12 hours 31 minutes from 1st visit to the ED) with a chief complaint of MVC/PCP Use. Review of the Nurse note dated 01/26/2022 at 2318 revealed "Pt standing at the door looking at his watch. Asked if he wanted to be seen. PT shook his head no. Pt departed at LPT (left prior to triage). Review of the ED Summary Report revealed " ... Disposition Type: Left Prior to Triage (LPT) ... Recognized Date Patient Left: 01/26/2022; Recognized Time Patient Left: 2320 ..."

Interview on 09/14/2022 at 1520 with Nurse Manager (NM) #5 revealed RN #19 was no longer employed with the hospital and was not available for interview.

Telephone interview on 09/15/2022 at 1138 with Medical Doctor (MD) #2 revealed he was working in the emergency department on 01/26/2022 when Patient #1 came in for his second visit. Interview revealed MD #2 could not recall Patient #1 coming to the ED. Interview revealed MD #2 reviewed Patient #1's medical record for the second visit on 01/26/2022. Interview revealed MD #2 stated it "does not appear he (Patient #1) was triaged." Interview revealed it appeared Patient #1 left prior to triage. Interview revealed MD #2 did not know Patient #1 was brought into the ED and did not see Patient #1.

In summary, Patient #1 presented on 01/26/2022 at 0904 via EMS with a chief complaint "MVC (motor vehicle crash) Entrapment." Patient #1 had a known substance abuse history and appeared intoxicated upon arrival. Patient #1 had altered mental status only responding with "cops and robbers." Patient #1 began to refuse medical care and wanted to leave, while family was wanting him to be admitted and receive treatment/care. Patient #1 signed an AMA form and was allowed to leave. The medical screening exam failed to show an evaluation of Patient #1's mental status and if he was competent to refuse treatment and make the determination to leave AMA. Patient #1 returned to the ED on 01/26/2022 at 2251 via EMS with a chief complaint "MVC /PCP use." Review revealed Patient #1 presented to the ED however left prior to triage. Review revealed for visit #2, Patient #1 did not received a medical screening examination.