HospitalInspections.org

Based on document review and medical record review the Critical Access Hospital (CAH) failed to follow their provider agreement and CAH policies and procedures to provide an adequate medical screening exam (MSE) to determine whether the patient had an emergency medical condition (EMC) for one of 20 sampled patients (Patient 10) who came to the emergency department (ED) seeking treatment from 03/02/19 through 10/15/19.

Failure of the CAH to perform an appropriate medical screening exam for every patient presenting to the ED has the potential for patients to have unidentified emergency medical conditions (EMCs) and delay necessary stabilizing treatment which could place patients at risk for further complications or even death.

Findings include:

Review of the CAH Medical Staff By-Laws and an addendum to the By-Laws showed in part that the registered nurse at Sabetha Community Hospital, Inc. is responsible for conducting the "preliminary" medical screening examination in the emergency room. The disposition of the patient's care is at the discretion of the attending physician or the physician on call."

Review of the undated policy "Medical Screening Exam," states "Upon arrival all patients requesting evaluation or treatment in the emergency department will receive an "assessment" by the RN on duty." The findings of the nurse's "assessment" will be reported to the physician, physician's assistant, or the nurse practitioner, who will direct the medical care of the patient ..."

Review of the medical record (EMR) showed, Patient 10 presented to the Sabetha Emergency Department (ED) on 10/14/19 at 9:02 PM after falling 10-15 feet from a tree stand. Registered nurse E documented the patient complained of pain in her back and right elbow which she rated a 4 on a scale of 1-10, 10 being the most severe pain. Further documentation showed the patient denied hitting her head or losing consciousness. At 9:04 PM nurse E documented patient # 10's blood pressure was 116/77 (normal range 120/80 - 140/90) and her heart rate was 96 beats per minutes (normal resting heart rate is 60-100 beats per minute). At 9:11 PM nurse E notified the physician who did not come to the ED. At 9:34 PM nurse E documented she instructed patient 10 to take ibuprofen 600-800 mg every 6-8 hours as needed for pain and to watch for numbness and tingling in her hands, legs, and feet. "Also watch for bloody urine or other symptoms of tiredness or fatigue." "Use ice for comfort." And to "call Doctor [name] for a follow up." Further documentation showed a second set of vital signs prior to patient 10 departing the ED - blood pressure of 98/66, a heart rate of 89 and a pain level of 4.

The next day on 10/15/19 at 7:37 AM, physician D documented an addendum in the medical record indicating that patient 10 "was in a tree stand and the strap broke and it tipped over last evening." Further documentation showed the patient walked in to the ED "without difficulty or limp." The nurse "gave her a screening exam and reported to me that the patient did not have any significant injuries to report." The patient complained of "elbow pain, but was able to freely move her elbow." The patient complained of "back pain, but had good ROM (range of motion), mobility and appeared very comfortable." The patient had a negative ROS (review of symptoms) otherwise." "It was her assessment (nurse E) that she (patient 10) had bumps and bruises and is experiencing soreness." "For that reason, I asked her to give explicit instructions about care, when to call or return." "We will follow up with her by phone today and ask her for an office visit to revisit her symptoms." At 8:30 PM on 10/15/19 nurse E documented in patient 10's medical record indicating the patient had clear and unlabored breath sounds, warm, dry skin, was neurologically intact, had a soft, non-tender abdomen and clear yellow urine on 10/14/19. Additional information was added to the medical record on 10/16/19 at 1:21 PM which indicated the patient did not have any musculoskeletal abnormalities on 10/14/19.

During an interview on 10/21/19 at 9:55 AM, Physician D stated he specifically asked nurse E if she thought the patient's injuries warranted him coming in to the ED and the nurse said no. She also said that she did not think I needed to come in and perform an exam. He then stated, "knowing what I know now I would have come in to examine this girl." Staff D, MD stated he received an oral report over the phone regarding this patient, he did not see the written documentation of the nurse's assessment until the next morning. He also stated he had given explicit instructions to the nurse regarding education of the patient.

Based on record review, interview, and policy review the Critical Access Hospital (CAH) failed to provide an appropriate medical screening examination (MSE) within its capability, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for one of 20 medical records reviewed (Patient 10). Failure to provide an appropriate medical screening examination delays care and places patients at risk for leaving the ED with an undetected emergency medical condition placing them at risk for complications and deterioration in their medical condition or even death.

Findings include:

Review of the undated policy "Policy for Emergency Room Care," states "In accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA), anyone presenting to the Emergency room or any part of the hospital campus requesting assistance will receive a medical screening examination. This examination will be performed by a physician, APRN (advance practice registered nurse), PA (physician assistant) or by the RN (registered nurse) on duty at the time per Sabetha Community Hospital bylaws. The Medical Screening Exam (MSE) will include assessment of vital signs. history of present illness and physical examination. The nurse will then contact the physician if he/she is not present with information about the patient. The physician will determine if the condition is emergent and will respond by coming into the hospital or giving the nurse orders over the telephone at any time the nurse feels the patient's condition is emergent or has deteriorated he/she has the right and responsibility to request that the physician, APRN or PA present to the Emergency Room to see the patient.

During an interview on 10/21/19 at 9:00 AM, Staff C, Director of Nurses (DON), stated that the CAH was unable to provide a policy that defined the specific training that was required for an RN to be considered qualified to perform an MSE. She said all the facility could provide were the policies from the Medical By-Laws, the policy for the MSE and the RN job description. None of these policies defined the required training for the nurse to provide an MSE.

Review of the hospital's "Patient Care Guideline" for "Trauma Team Activation" showed that a physician and/or mid-level on-call will serve as the trauma team leader. Further documentation showed "Yellow Team Activation" would be triggered by falls in adults greater than 20 feet and greater than 10 feet for children.

Review of the medical record showed, Patient 10 arrived at the Sabetha Emergency Department (ED) on 10/14/19 at 9:02 PM and was discharged from the ED at 09:34 PM. Staff E, Registered Nurse (RN) documented Patient 10 presented to the ED stating, " Patient reports she was in a deer stand (in a tree) earlier today with her boyfriend and the stand fell. Patient reports falling 10 - 15 ft ... " "Triage, Chief Complaint" Back pain, right elbow pain." The medical record also showed Patient 10 diagnoses included Pain in pelvis. Nurse E performed an assessment on admission at 9:04 PM, that included vital signs, pain assessment, height, weight, allergies, trauma mechanism of injury, respiratory (breathing), gastrointestinal (abdomen), genitourinary (bladder), integumentary (skin), neurological (function of the nervous system), pupils, neuromuscular (function of the muscles), psychosocial, coma assessment and oxygenation. Reassessment at 9:34 PM included vital signs, pain assessment, and oxygenation. Nurse E documented she notified Medical Doctor (MD) D at 9:11 PM of Patient 10's arrival in the ED and noted "no provider visit." The medical record lacked evidence of what Nurse E reported to Physician D about Patient 10's assessment that was done at 9:04 PM. Nurse E made a medical record addendum on 10/15/19 at 8:24 PM that included the rapid pain assessment, level of consciousness, respiratory status, neurological assessment and pupil reactions, neurological strengths of bilateral upper and lower extremities, coma scale score, musculoskeletal joint assessment, gastrointestinal, and integumentary systems. The record showed Physician D gave verbal discharge order on 10/14/19 at 9:50 PM to Nurse E 46 minutes after Patient 10 was dismissed from the ED at 9:34 PM on 10/14/19. Physician D signed the verbal orders on 10/15/19 at 7:12 AM. There is no other documentation of orders or communication between Nurse E and Physician D. The medical record did not contain evidence that patient 10 received a medical screening examination sufficient to determine whether an emergency medical condition existed prior to discharge. Given the height and mechanism of the fall, and the patient's complaints of back, elbow and pelvic pain, the patient could have had a serious injury including, but not limited to, intra-abdominal injury, internal bleeding, extremity fractures, spinal fractures, all of which could potentially place the patient's health in serious jeopardy.

Review of a progress note dated 10/15/19 at 7:37 AM, showed Physician D documented, "This 19 y/o female reported that she was in a tree stand and the strap broke and it tipped over last evening. She ambulated into the ER without difficulty or limp. Nurse E gave her a screening exam and reported to me that she did not have any significant injuries to report. She c/o [complained of] elbow pain but was able to freely move her elbow. She complained of back pain, but had good ROM [range of motion], mobility and appeared very comfortable. She had a negative ROS [review of systems] otherwise. It was her assessment that she had bumps and bruises and is experiencing soreness. For that reason, I asked her to give explicit instructions about care, when to call or return. We will follow-up with her by phone today and ask her for an office visit to revisit her symptoms."

Review of a second medical record showed patient 10 presented to a physician's clinic on 10/15/19 at 1:00 PM Documentation in the record showed: ... [Patient 10] is here today stating she fell 25 feet from a tree stand while hunting yesterday, 10/14/19 ..."[Patient 10] states she had just gotten up in the tree stand and the strap broke causing her to fall. She states she hit a small tree on the way down. She has an abrasion on the right side of her back. She landed face first. She got the wind knocked out of her and had trouble breathing initially. She had a headache yesterday, but this has gotten better since taking ibuprofen. She doesn't think she hit her head. No dizziness. No trouble with her vision. Lights do not bother her eyes. She is not more fatigued than normal. Complaining of her neck being sore in the front of her neck. Range of motion is painful. She had chest pain yesterday but none today. She has pain in both groins. It does not hurt to take a deep breath but does hurt to laugh. No pain in her legs or ankles. No blood in her urine. No trouble urinating. She has been taking ibuprofen every 6-8 hours. Mom is concerned that she hasn't eaten anything today. [Patient 10] states she is just not hungry. She appears pale. ... [Patient 10]'s x-rays and lab tests are unremarkable. She likely has a concussion.

During an interview on 10/21/19 at 9:55 AM, Sabetha Community Hospital Physician D stated he specifically asked Nure E if she thought the patient's injuries warranted him coming in to the ED and the nurse said no. She also said that she did not think he needed to come in and perform an exam. He then stated, "knowing what I know now I would have come in to examine this girl." Physician D stated he received an oral report over the phone regarding this patient, he did not see the written documentation of the nurse's assessment until the next morning. He also stated he had given explicit instructions to the nurse regarding education of the patient.

During an interview on 10/21/19 at 2:30 PM Nurse E stated she spoke with Physician D on the night of 10/14/1 and he instructed her on the education he wanted provided to Patient 10 and to perform a follow up assessment. She stated, "I have only had the physician not come in about three times, but I really truly felt in my gut that she was ok. She walked in totally normal, no problems, normal gait. Really, she had no complaint other than a little bit of pain in her lower back."