HospitalInspections.org

Based on observation, staff interview, review of medical record and review of Emergency Department Log and hospital's policy and procedure, the facility's did not effectively enforce and implement its Emergency Department (ED) policies and procedures to ensure that all individuals presenting in its ED have initial clinical screening evaluation (Triage) upon arrival at the hospital to determine their priority for medical screening evaluation.

Findings include:

1. During the tour of the facility's ED on 10/1/2013 at approximately 10:15 AM, it was observed that patients seeking treatment are directed to the Intake Registration Clerk for a "mini" registration before they are triaged.

At interview with an Intake Registration Clerk on 10/02/13 at 9:00 AM, she stated that mini registration is limited to entering the patient ' s name, date of birth and reason for the ED visit in the computer. The information is immediately available to the Triage Nurse. However, upon review of the Emergency Department log, it was noted that there were several patients with disposition listed as " left without being seen " , and the diagnosis listed as " left without being seen " . A review on 10/2/13 of a sample of patients (MR # 3, 4 and 5) who left without being seen revealed the following:

MR #3 is a 19-year-old patient with unknown medical history who walked in to the ED on 7/26/13. The patient record contained an Emergency Room Treatment Consent form dated on 7/26/2013 at 12:32:10 AM and a copy of the Patients ' Right ' s forms dated 7/26/2013 at 12:58 AM. However, the patient did not have an initial clinical assessment as the chief complaint and vital signs were not documented in the record.

On 7/26/2013 at 03:02 AM, the physician noted that patient was called a few times with no response. The disposition was noted as left without notifying staff. This patient waited over two hours without an initial clinical screening. The patient's chief complaint was unknown and it could not be determined if the patient needed a timely medical screening examination.

MR #4 is a 61- year-old patient that arrived in the facility's Emergency Department (ED) on 6/3/2013 at 19:40. The triage nurse documented the following: arrival time -19:42; triage time - 22:04; and waiting room time - 22:07. The chief complaint was "assaulted, cut to right palm" . It was noted that the patient's vital signs were not taken. On 6/3/2013 at 21:11, the physician noted "the patient was not treated by me and no Doctor/Patient relationship was established". The patient's disposition was documented on 6/3/2013 at 22:05 as "left without being seen" . This patient was not triaged and the reason for the visit was not documented prior to the patient's departure from the ED which was more than two hours later.

In MR #5 is an 84-year-old patient with history of cellulitis and hypertension who presented to the ED on 06/19:13 at 11:26 AM with chief complaint of difficulties walking. It was noted that the patient was triaged on 06/19/2013 at 11:41 and assigned an acuity level of 4 (Emergency Severity Index IV). There were no vital signs documented for the patient in accordance with the facility's triage policy that required that initial patient assessment should include vital signs. The record indicted that this patient left without being seen by a physician on 06/19/2013 at 21:15; this disposition was entered almost 10 hours after triage.

The Facility's Triage Assessment policy revised on 4/12 states that patients waiting to be seen are reassessed every 30 minutes. There was no indication that the patient in MR # 5 was reassessed according to this triage policy.

At interview with the Director of the Emergency Department on 10/2/2013 at 14:30, he reported that the facility was unable to prevent patients from walking out. He also stated that the patients leaving without medical screening were often the ones seeking medication. There was no evidence presented by the ED Director to validate this conclusion.

Based on tours of the Emergency Department, it was determined the hospital failed to ensure conspicuous display of signs that specify the rights of patients to examination and treatment of emergency conditions and for women in labor in accordance with Section 1867.

Findings include:

Tour of the Emergency Department on 10/01/13 at approximately 11 AM revealed there was only one sign posted by the registration boot in the ED specifying the rights of individuals with emergency medical condition and women in labor who come to the ED for health care services. The facility did not post signs conspicuously in multiple sections of the ED where they are likely to be noticed by individuals entering, awaiting or receiving care in the ED. There were no signs in the ambulatory and ambulance entrances; no signs were observed in the waiting room, and treatment areas.

The lack of signage in designated areas was witnessed by the ED Director and Chief Operating Officer on 10/01/13 at 11:15 AM.

Based on medical record and the facility Emergency Department log and medical record, it was determine that the facility did not ensure that its Central Log (Emergency Department log) was complete and accurate. This deficiency was noted in four applicable medical records reviewed.

Finding includes:

The review of ED log on 10/01/13 for the months of March 2013, June 2013, July 2013 and August 2013 found gaps and missing disposition in the log.
For example: The ED log for the month of March 2013 lacked two dispositions of patients evaluated on 3/09/2013.
The June 2013 ED log lacked disposition and the chief complaint of four patients seen in the ED on 6/05/2013.

In addition, for the months of June 2013 and July 2013, several entries in the log on 6/25, 6/19, 6/21, 7/29, 7/23, 7/11, and 7/5 indicated the patient's disposition as "registration". The correct dispositions of these patients were not noted in the ED log.

For example:
The ED log listed the disposition for the patient in MR # 6 as left without being seen. In reviewing the medical record, it was noted that the patient had a medical screening examination and the patient signed out against medical advice. The disposition in the log was incorrect.
The following patients' dispositions were listed as " Registration" : MR # 7, 8 and 9 .

MR # 7 was reviewed on 10/2/2013. This is a 69 year old patient with a medical history significant for asthma who presented to the ED on 6/18/2013. The patient was treated and discharged home; however, the ED log noted " registration as the disposition.

MR # 8 was reviewed on 10/2/2013. This is an 85 year old who presented to the Emergency Department on 6/21/2013 with a chief complaint of chest pain. The patient was admitted following evaluation in the ED. However, the disposition of the patient on log was " registration " .

Similarly, MR #9 is a 44-year-old patient who was treated in the ED on 6/25/2013 for back pain and discharged home. However, the log listed the disposition as registration.

Based on interviews, the review of medical records and other documents it was determined the facility failed to ensure that every patient presenting to the Emergency Department receives a Medical Screening Examination (MSE) to determine if a an emergency medical condition exist. Specific reference is made to the lack of an appropriate medical screening examination in 2 of 32 patients (MR #1 and 2) reviewed; the patients presented to the Emergency Department with complaints of medical symptoms and left the Emergency Department without being evaluated by the physician.

Findings include:

1. MR #1 is a 49 year-old female who arrived in the Emergency Department on 9/11/13 at 23:55 with complaint of back pain. There was no triage assessment of the patient upon arrival in the Emergency Department in accordance with ED Triage Assessment policy that states "the triage nurse will categorize each patient upon arrival to the Emergency Department into Emergent, Urgent and Non-Urgent". There was no information or assessment entered into the patient's triage record.

At interview with triage nurse on 10/2/13 at 9:00 AM, she stated the patient at triage presented documents that were reviewed by the physician which showed she had a recent back surgery at another hospital. The nurse reported that the physician told the patient that her physician at the other hospital was well known to her and she will refer her back to the facility where she had her surgery for continued treatment. The nurse stated that the patient became angry snatched her documents from her and left the Emergency Department. She added that the patient refused triage despite encourage from her and the physician.

Upon interview with the ED physician on 10/2/13 at 9:30 AM, she stated she vaguely remembers the patient but recollects a female patient that came into the ED with a walker complaining of back pain. She stated she questioned if the patient was in pain because she was demanding for immediate pain management and an MRI to evaluate her spine. The physician stated she reviewed the documents presented by the patient and immediately recognized the patient's physician at the other facility whom she stated was a good doctor and did not believe that this physician did not provide adequate pain management for the patient. The physician said she asked the patient if she wanted to go to the other facility; she further explained that "I was going to offer to send her to her doctor at the other facility but it seems she did not want to go there". The patient was informed that the facility had capability for x-ray and CT scan but not MRI. She stated that the patient became very angry and refused triage and medical screening examination.

However, at interview with the patient on 10/1/13 at 12:45 PM, she stated the physician accused her of seeking narcotics prior to triage and stated that "I will not give you any pain medication". She further stated that the physician said "I cannot help you, go back to the hospital where you had your surgery" .

The triage nurse and the physician interacted with the patient but failed to document their interaction with the patient. The physician did not conduct a medical screening examination to determine if an emergency condition existed and the suggestion by the physician to refer the patient to another hospital prior to a triage assessment was premature and deterred the patient from receiving treatment of her medical condition.

MR #2 is 40-year-old male who presented to the Emergency Department on 9/8/13 at 18:28. The triage assessment on 9/8/13 at 18:39 revealed the patient complained of right sided chest pain radiating to the right side and nervousness. The patient's medical history was significant for high cholesterol, hypertension and cancer. Vital signs at triage were as follows: Temperature 98.50 Fahrenheit, Pulse 122, Respiration 22, Blood Pressure 105/70 and SPo2 98%. The patient reported a pain level of 8 on a scale of 1-10. The patient was triage as non- urgent and sent to the Waiting Room to await medical screening evaluation. At 22:01, the triage nurse documented the patient left the Emergency Department without being seen.

At interview with the ED Director on 10/2/13 at 1300 regarding the lack of timely medical screening examination, he stated the patient should have been seen more quickly and should not have been triaged as "Non-Urgent" . The physician stated that an electrocardiogram should have been obtained immediately after triage to determine the nature of the chest pain.

The cause of the patient's chest pain and tachycardia were not evaluated prior to the patient's departure at 22:01 which was three hours and seventeen minutes post triage assessment.

Based on staff interview, review of medical record and hospital ' s policy, it was determined that the facility failed to ensure that all transfer requirements were met. Specifically, patients who required transfer for stabilization of their Emergency Medical Conditions were not informed of the risks and benefits of the transfer; the Physicians Certification for each transferred patient did not include a summary of the risks and benefits upon which the transfer was based. This deficiency was noted in five of five medical records reviewed. MR #s 10, 11, 12, 13 and 15.

Findings include:

MR # 10 was reviewed on 10/2/2013. It was noted that this 54 year old patient was brought to the facility ' s Emergency Department (ED) by ambulance on 7/14/2013 at 12:06. The chief complaint was abrasion to face/forehead; the patient fell off his bicycle. The CT scan of the head revealed multiple fractures of anterior wall frontal sinuses, roof left orbit and left nasal bone. X- rays revealed fractures of the neck and 4th and 5th metacarpal bones. This patient was transferred to another facility. The transfer summary form indicated that the patient ' s condition was unstable but the expected medical benefits of transfer outweigh potential risks associated with the transfer.

There was no evidence the patient or a legally responsible person acting on the individual's behalf was provided written information on the risks and benefits of the transfer. The Consent for transfer form located in the record did not list the name of the physician who informed the patient of the need for the transfer. The consent form indicated that the reason for the transfer was neurological services; however, there was no documentation in the record that this patient would need neurosurgical services. The form also indicated the patient would require other services but the other required service was not documented. The physician certification did not contain a summary of the risks and benefits of the transfer.

MR # 11 was reviewed on 10/2/2913. This is a 60-year-old patient that was brought to the facility ' s ED by ambulance on 7/28/2013 with a chief complaint that the patient " passed out at home " . The patient ' s past medical history was significant for high cholesterol, stroke, diabetes, hypertension and chronic renal failure. The patient was diagnosed of intracranial bleed and transferred to another facility.

The transfer summary form noted that the patient's condition was unstable but the expected medical benefits of the transfer outweigh potential risks associated with the transfer. There was no documented evidence that the patient was informed of the risk and benefits of the transfer. The consent form for transfer to another facility did not indicate the physician who informed the patient of the transfer.

MR # 12 was reviewed on 10/2/2013. It was noted that this 49- year-old patient walked into the facility ' s ED on 7/6/2013 at 18:15 with chief complaint of head trauma. The patient had a CT of the head with contrast which revealed that the patient sustained multiple areas of contusions to frontal, right temporal and Lt cerebellar. This patient was transferred to a trauma center at another facility. The transfer summary indicated that the patient ' s condition was stable for transfer. It was noted that the sending facility did not list the documents sent with the patient during the transfer. There was no documented evidence that the reason for transfer to another facility was discussed with the patient

MR #13 was reviewed on 10/2/2013. It was noted that this 21-year-old with history of depression and anxiety presented to the ED on 7/1/2013 at 16:15 with a chief complaint of overdose of Lexapro and Tylenol. On 7/1/2013 at 18:06, the medical physician noted that psychiatric services was paged and a psychiatrist would see the patient in the morning of the next day; however, a psychiatric consultation report was found in the patient ' s record. It was noted that the Transfer summary form indicated that the patient ' s condition was stable and the reason for the transfer was for psychiatric service not provided at the facility. However, the Involuntary Admission Application form indicated that the patient was suicidal. The psychiatric who evaluated the patient did not complete the transfer summary form or certified on the form that the patient ' s condition was stable for the transfer. The patient or patient ' s legal representative was not informed of the transfer and the risks and benefits upon which the transfer was based were not documented on the Physician Certification form.

Similar findings were noted in a patient, MR # 14 who presented with a psychiatric history. This is a 61-year-old patient with medical history of cardiac disease, diabetes, hypertension and psychiatric history who presented to the ED on 6/6/2013 at 8:35. The chief complaint was aggressive behavior. The patient underwent medical screening examination and was determined to be medically stable. On 6/6/2013 at 9: 46 AM, the nurse noted that the psychiatrist was contacted for evaluation of the patient. The patient was transferred to another facility on 6/6/2013 at 11:37. However, the psychiatric assessment was not located in the record. The Involuntary Admission Application form indicted the patient needed a psychiatric facility for evaluation and treatment. The patient was not evaluated by a psychiatrist and deemed stable for transfer. There was no evidence that the risks and benefits of the transfer were discussed with the patient/representative. The Physician Certification did not include a summary of the risks and benefits upon which the transfer was based.