HospitalInspections.org

1. Based on review of facility policies, document review, medical record review and interview, it was determined the hospital failed to recognize its obligation to provide Medical Screening Examinations (MSE) and stabilizing treatment began when the patient arrived and requested emergency care for 3 of 4 (Patient's #2, #7 and #18) sampled patients who left the Emergency Department (ED) prior to receiving a MSE.
Refer to findings in deficiency A-2406.

2. Based on review of facility policies, document review, medical record review and interview, it was determined the hospital failed to ensure risks and benefits of receiving examination and treatment were provided and written refusal of examination or treatment was sought for 3 of 4 (Patient's #2, #7 and #18) sampled patients reviewed who left the ED prior to examination or treatment.
Refer to findings in deficiency A-2407.

Based policy review, document review, medical record review and interview, it was determined the hospital failed to recognize its obligation to patients began when they arrived to the hospital and requested emergency care. The hospital failed to act on its obligation to ensure a Medical Screening Exam (MSE) was performed for 3 of 4 (Patient's #2, #7 and #18) sampled patients who came to the hospital's Emergency Department (ED) seeking medical care but left prior to receiving examination and treatment.

The findings included:

1. Review of the facility policy, "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy" revealed, "INTRODUCTION: All individuals presenting on Hospital property requesting emergency medical services, individuals presenting to a Dedicated Emergency Department requesting medical services, and patients arriving/presenting via ambulance requesting medical services shall receive an appropriate Medical Screening Examination and Stabilization services... DEFINITIONS:...Comes to the Emergency Department with respect to an individual requesting examination and treatment means the individual is on the Hospital Property... 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... Such screening must be done within the Hospital's capabilities and available personnel... The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either stabilized or appropriately transferred....Triage is a sorting process to determine the order in which patients will be provided a Medical Screening Examination by a physician or Qualified Medical Personnel. Triage is not the equivalent of a Medical Screening Examination and does not determine the presence or absence of an Emergency Medical Condition... Once a patient presents to the Dedicated Emergency Department of the hospital, whether by ambulance or otherwise, the hospital has an obligation to see the patient... A hospital's EMTALA obligations begin when the patient presents at the hospital's Dedicated Emergency Department or on hospital property and a request is made for examination or treatment of an emergency medical condition..."

2. Review of the facility policy, "Triage" revealed, "All individuals presenting to the Emergency Department, regardless of their point of entry, requesting an examination shall be screened and triaged... Trained emergency personnel will complete the initial screening and triage of patients presenting to the Emergency Department. It is the responsibility of the Emergency Department Physician on duty, or his or her designated mid-level provider (PA, NP, or CNS) to fully evaluate and screen all patients who present to the Emergency Department to determine whether any emergency medical condition exits... As a result of that initial screening, the individual will be triaged according to the extent of their illness or injury...
PROCEDURE/SPECIAL INSTRUCTIONS:
1) Each patient will be assessed upon arrival to the Emergency Department.
2) The Nurse will document a triage assessment in Promed...
8) The Triage nurse is responsible for monitoring and re evaluating all patients while they are in the waiting room. The triage nurse will address and document any reports of change in status..."

3. Review of the ED's "Removed from Presentation" log dated 10/22/11 revealed 11 month old pediatric patient #18 arrived to the ED at 6:58 PM with a left foot injury. The patient was removed from presentation 1 hour and 22 minutes after arrival at 8:20 PM. The reason for removal was documented as, "Tired of waiting." There was no medical record established for the patient, no documentation under the comments section of the log to indicate the patient was acknowledged as an ED patient or documentation to indicate assessment of any type had been performed.

4. Review of the ED's "Removed from Presentation" log dated 3/3/12 revealed 2 year old pediatric patient #7 arrived to the ED at 11:59 AM with ear ache and pink eye. The patient was removed from presentation 1 hour and 16 minutes after arrival at 1:15 PM. The reason for removal was documented as, "Tired of waiting." There was no medical record established for the patient, no documentation under the comments section of the log to indicate the patient was acknowledged as an ED patient or documentation to indicate assessment of any type had been performed


5. Review of the ED's "Removed from Presentation" log dated 3/14/12 revealed 3 year old pediatric patient #2 arrived to the ED at 9:06 PM with a foot injury. The patient was removed from presentation 1 hour and 8 minutes after arrival at 10:14 PM. The reason for removal was documented as, "Tired of waiting." There was no medical record established for the patient, no documentation under the comments section of the log to indicate the patient was acknowledged as an ED patient or documentation to indicate assessment of any type had been performed

Review of the ED record for Patient #2 from Hospital #2 revealed the patient was admitted on 3/14/12 at 11:16 PM for an injury to the Right first toe with laceration and nail loss. An x-ray revealed a Comminuted open phalanx fracture of the distal great toe. The patient was stabilized and referred to Hospital #3 for specialized care due to an "open fracture at high risk for Osteomyelitis."

Review of the ED record for patient #2 from Hospital #3 revealed the patient was admitted on 3/15/12 at 2:09 AM. The injury was cleaned, irrigated, antibiotic and a bandage applied. The patient was discharged at 6:39 AM with antibiotics and medication for pain with instructions to follow up with a pediatric orthopedic clinic in one week.

In an interview in the conference room on 4/3/12 at 10:00 AM, the ED Director was asked about Patient #2. The ED DIrector stated he was aware of the case and stated the, "patient presented with a lacerated foot... child was visibly upset... father was upset because several people had been called back before hom..."

A telephone interview was conducted on 4/3/12 at 10:05 AM with Nurse #1, the nurse working triage the night that Patient #2 came to the ED. The nurse stated that on the night in question there were over 20 patients that had been triaged and were waiting to go into the back (ED dept), 2/3 of ED was on hold. He stated he remembered the father of the patient, who came up to the window and said the patient's toe had bled through the bandage. Nurse #1 stated he left a patient in triage and re-applied a compression dressing with a kling wrap to the child's foot. When asked about documentation of the dressing, Nurse #1 stated that he would only document if had a chart.

6. In an interview in the conference room on 4/2/12 at 1:35 PM, the ED Director stated, If a patient is removed from presentation, they may have a record or they may not, it depends on if they are triaged.

In an interview in the conference room on 4/2/12 at 3:50 PM, the ED Director stated that patients removed from presentation do not have a medical record because they have not been triaged. The facility does not get an Against Medical Advise (AMA) form signed if the patient is leaving unless have been triaged because a consent to treat was not done yet.

Based on policy review, document review and interviews, it was determined the hospital failed to ensure risks and benefits of receiving examination and treatment were provided and written refusal of examination or treatment was sought for 3 of 4 (Patient's #2, #7 and #18) sampled patients reviewed who left the Emergency Department (ED) prior to receiving a Medical Screening Examination or treatment (MSE).

The findings included:

1. Review of the facility's "Triage" policy revealed, "It is the responsibility of the Emergency Department Physician on duty, or his or her designated mid-level provider (PA, NP, or CNS) to fully evaluate and screen all patients who present to the Emergency Department to determine whether any emergency medical condition exits... The Triage nurse is responsible for monitoring and re evaluating all patients while they are in the waiting room. The triage nurse will address and document any reports of change in status..."

2. Review of the facility's "Against Medical Advise" policy revealed, "Staff will discuss and document informing the patient and/or family of the potential risks and consequences that may occur if the patient leaves prior to the physician's discharge order... The patient and or legal guardian will be requested to sign the AMA form and a copy will be given to the patient... If the patient or legal guardian refuses to sign the AMA form, staff will complete the form with the exception of the patient's signature and write across the patient signature area that the patient refused to sign."

3. Review of the ED's "Removed from Presentation" log revealed 11 month old pediatric patient #18 arrived to the ED at 6:58 PM with a left foot injury. The patient was removed from presentation at 8:20 PM. The reason for removal was documented as, "Tired of waiting." There was no medical record established for the patient, no Against Medical Advise (AMA) form present and no documentation risks vs benefits of leaving prior to treatment had been explained.

4. Review of the ED's "Removed from Presentation" log dated 3/3/12 revealed 2 year old pediatric patient #7 arrived to the ED at 11:59 AM with ear ache and pink eye. The patient was removed from presentation at 1:15 PM. The reason for removal was documented as, "Tired of waiting." There was no medical record established for the patient, no AMA form present and no documentation risks vs benefits of leaving prior to treatment had been explained.

5. Review of the ED's "Removed from Presentation" log dated 3/14/12 revealed 3 year old pediatric patient #2 arrived to the ED at 9:06 PM with a foot injury. The patient was removed from presentation at 10:14 PM. The reason for removal was documented as, "Tired of waiting." There was no medical record established for the patient, no signed Against Medical Advise (AMA) form present and no documentation of risks vs benefits of leaving prior to treatment having been explained.

6. In an interview in the conference room on 4/2/12 at 1:35 PM, the ED Director stated, If a patient is removed from presentation, they may have a record or they may not, it depends on if they are triaged.

In an interview in the conference room on 4/2/12 at 3:50 PM, the ED Director stated that patients removed from presentation do not have a medical record because they have not been triaged. The facility does not get an Against Medical Advise (AMA) form signed if the patient is leaving unless have been triaged because a consent to treat was not done yet.