HospitalInspections.org

Based on medical record review, policy/procedure review, and staff interviews, the hospital administrative staff failed to enforce policies/procedures requiring staff to provide a complete Medical Screen Exam (MSE) by not completing a physical assessment when the patient presented to the Emergency Department (ED), requesting emergency care for one (Patient #21) of 30 patient records reviewed between 2/1/14 through 9/3/14.

Failure to enforce the hospital's MSE policy and provide proper stabilizing treatment can result in patients leaving the ED with an undetected Emergency Medical Condition (EMC), potentially leading to a delay in life saving treatment or death.

Findings include:

Review of the hospital policy/procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA," effective 12/2013, revealed in part... "II. 5. MSE- Minimally includes vital signs, patient history, physical exam and any necessary ancillary testing."

Review of Patient #21's ED medical record dated 8/12/14 at 8:43 PM revealed:
On the History of Present Illness:
a. Review of Systems: Unable to perform Review of Systems.
b. Physical Exam: Vital signs documented
Physical Exam
Psychiatric: His affect is appropriate. He is not agitated, aggressive or hyperactive. Cognition and memory are impaired. He expresses impulsivity and is non communicative.
c. ED Course: Narration: Chart was reviewed, noted prior admissions and evaluations for the same. The most recent was 2 days ago. I discussed the case with Practitioner A, (Psychiatrist) who advised to give Haldol 10mg IM- (intramuscularly), discharge and follow up with primary psychiatrist the next day. I reviewed the results and plan of care with the patient and/or family, if present. At this point the patient is stable for outpatient management. Return precautions and follow up instructions were discussed and patient discharged in stable condition.

No physical assessment documented in the medical record.

During an interview on 9/3/14 at 8:30 AM, Practitioner C, DO (Doctor of Osteopathy) stated he did not complete a physical exam for Patient #21 because the patient was agitated when the patient first presented to the ED. Practitioner C said he did not want to get close to the patient when agitated. Practitioner C said later in the visit he observed the patient for the physical exam, but failed to document the exam in the medical record.

During an interview on 9/3/13 at 9:05 AM, Practitioner A stated a physical exam is very important to complete for patient #21 with a diagnosis of aggressive behavior to rule out physical/medical concerns that could cause the aggressive behavior.

During an interview on 9/3/14 at 10:15 AM, Practitioner D, MD (Medical Doctor) stated it is important to complete a physical exam because it is a part of the MSE. The physical exam must be completed to rule out physical problems that could be the cause of the behavioral problems.

Based on a review of policy/procedures, review of medical record documentation, and staff interviews, the hospital failed to provide a proper medical screening exam for 1 of 30 patients who presented to the hospital's Emergency Department (ED) requesting emergency care for one (Patient #21) of 30 patient records reviewed between 2/1/14 through 9/3/14.

Failure to provide a complete medical screening exam in the ED for patients requesting emergency care could result in staff providing inadequate care or ineffective care to treat the EMC and potentially result in condition of the patients declining.

Findings include:

Review of the hospital policy/procedure titled "Emergency Medical Treatment and Active Labor Act (EMTALA," effective 12/2013, revealed in part... "II. 5. MSE- Minimally includes vital signs, patient history, physical exam and any necessary ancillary testing."

Review of Patient #21's ED medical record dated 8/12/14 at 8:43 PM revealed:
On the History of Present Illness:
a. Review of Systems: Unable to perform Review of Systems.
b. Physical Exam: Vital signs documented
Physical Exam
Psychiatric: His affect is appropriate. He is not agitated, aggressive or hyperactive. Cognition and memory are impaired. He expresses impulsivity and is non communicative.
c. ED Course: Narration: Chart was reviewed, noted prior admissions and evaluations for the same. The most recent was 2 days ago. I discussed the case with Practitioner A, (Psychiatrist) who advised to give Haldol 10mg IM- (intramuscularly), discharge and follow up with primary psychiatrist the next day. I reviewed the results and plan of care with the patient and/or family, if present. At this point the patient is stable for outpatient management. Return precautions and follow up instructions were discussed and patient discharged in stable condition.

No physical assessment documented in the medical record.

Patient #21 was discharged from Hospital A's ED at 10:18 PM with the his caregiver.

Review of Patient #21's medical record from Hospital B [another hospital] revealed the patient presented to Hospital B' ED with the same complaint of aggressive behavior, accompanied by the patient's caregiver, at 10:34 PM on 8/12/14 and the patient was then admitted to Hospital B's behavioral health unit.

During an interview on 9/3/14 at 8:30 AM, Practitioner C, DO (Doctor of Osteopathy) stated he did not complete a physical exam for Patient #21 because the patient was agitated when the patient first presented to the ED. Practitioner C said he did not want to get close to the patient when agitated. Practitioner C said later in the visit he observed the patient for the physical exam, but failed to document the exam in the medical record.

During an interview on 9/3/13 at 9:05 AM, Practitioner A stated a physical exam is very important to complete for patient #21 with a diagnosis of aggressive behavior to rule out physical/medical concerns that could cause the aggressive behavior.

During an interview on 9/3/14 at 10:15 AM, Practitioner D, MD (Medical Doctor) stated it is important to complete a physical exam because it is a part of the MSE. The physical exam must be completed to rule out physical problems that could be the cause of the behavioral problems.