HospitalInspections.org

Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to adequately maintain a central log on each patient presenting to the Emergency Department (ED) for seven of 24 medical records reviewed (MR1, MR2, MR3, MR4 ,MR7, MR8, and MR9).

Findings include:

1. Review of facility policy "TUH-ADMIN-950.1025 EMTALA Requirements," effective May 21, 2015, revealed "Policy: ... A Central Log on each individual who 'comes to the Emergency Department' seeking assistance, and whether he or she refused treatment, was transferred, admitted and treated, stabilized and transferred, or discharged will be maintained for six years. The Central Log includes, directly or by reference, patient logs from other areas of the hospital where an individual might present for emergency services or receive a MSE (medical screening exam) instead of the Emergency Department ..."

Review of MR2 revealed that the patient presented to the ED on January 16, 2016, at 2:45 AM, with a chief complainant "Behavioral Health 302."

Review of MR3 revealed that the patient presented to the ED on January 11, 2016, at 4:14 PM, with a chief complainant "Behavioral Health 302."

Review of MR4 revealed that the patient presented to the ED on January 3, 2016, at 2:38 AM, with a chief complainant "Behavioral Health 302."

Review of the facility's ED Central log revealed no documented evidence that these three patients were entered into the facility's ED Central log.

Interview on February 24, 2016, with EMP1 revealed that the facility maintains separate "emergency logs" for the ED, CRC (Crisis Response Center- an area that receives and treats patients presenting with behavioral and psychiatric illness) and Maternity Department. EMP1 confirmed that the patients in MR2, MR3 and MR4 were not documented in the facility's ED Central log.


2. Review of facility policy "Emergency Department Medical Record," last reviewed August 2014, revealed, "...Policy: It is the policy of Temple University Hospital to submit a complete medical record for all persons presenting for treatment. ... II. Outpatient Registration documentation and Responsibility. A. The patient interviewer will complete a quick registration for all patients entering the Emergency Department for treating by assigning a medical record number to the patient and entering specific demographic information via the Siemens Medical Systems. B. The patient Interviewer will register the patient. C. The Patient Interviewer will obtain written consent for treatment when the patient's condition allows. ..."

Review of MR1 revealed no documented evidence the patient was properly registered in the ED central log. There was no medical record number or written consent for treatment.

Review of MR7 revealed no documented evidence the patient was properly registered in the ED central log. There was no medical record number or written consent for treatment.

Review of MR8 revealed no documented evidence the patient was properly registered in the ED central log. There was no medical record number or written consent for treatment.

Review of MR9 revealed no documented evidence the patient was properly registered in the ED central log. There was no medical record number or written consent for treatment.

Interview on February 25, 2016, at 9:15 AM, with EMP3 confirmed staff did not complete a quick registration, assign a medical record number, register the patient, and obtain written consent.

Based on a review of facility documents, review of medical records (MR) and interviews with staff (EMP), it was determined that the facility failed to provide an appropriate medical screening examination for one of 25 medical records reviewed (MR1). This deficiency constitutes an Immediate Jeopardy and a threat to the health and safety of individuals who present to the emergency department and request examination or treatment for an emergency medical condition.



Findings include:

1. Review of facility policy "EMTALA Requirements," last reviewed May 2015, revealed, "...In accordance with the Emergency Medical Treatment and Labor Act, any individual (whether or not eligible for Medicare or Medicaid benefits and regardless of ability to pay) who comes to Temple University Hospital, Inc. and requests examination or treatment of a medical condition is entitled to and will receive a Medical Screening Examination (MSE) within the capability of the hospital's Emergency Department, including ancillary services routinely available to the Emergency Department. ...The Emergency Department AHP (allied health practitioner) will determine whether an emergency condition exists."

Review of MR1 revealed that the patient presented to the Emergency Department on January 7, 2016, at 11:37 AM, and was given a triage level of 3 during triage I. The patient was then sent to the waiting room and an EKG was done at 12:15 PM. The patient was paged overhead at 12:29 PM and again at 12:34 PM to complete triage II. Staff documented both times that there was "No response." Staff then documented at 12:34 PM, "Unable to locate patient, will disposition as left without treatment." There was no further documentation until 8:31 PM.

Further review of MR1 revealed that the patient was taken back into a trauma bay at 8:31 PM and advanced cardiac life support protocols were initiated. Efforts were eventually ceased and the patient was pronounced dead at 10:02 PM.

A review of the security video for January 7, 2016, revealed the following events and timeline:
11:34 AM Ambulance backs up and patient unloaded into ED, patient has nasal cannula and oxygen tank.
11:35 AM Patient on stretcher and approximately 10 ft away from triage window/nurse.
11:36 AM Fire rescue gives report to RN in window.
11:38 AM Patient is transferred to wheelchair and wheeled to EKG room. No oxygen connected to nasal cannula.
11:45 AM Patient out of EKG and wheeled to waiting room.
12:30 PM Patient wheels himself to EKG room, stays in hallway approximately 10 feet from where he was sitting in waiting room.
2:00-6:45 PM Multiple staff walk by patient, at 6:45 PM a staff member walks up to patient, talks to patient, and moves patient approximately 4 ft into a cubby area out of the direct hallway.
6:47 PM Staff brought oxygen tank and placed it in holder on wheelchair and appears to turn the oxygen on.
6:51 PM Staff gave patient a glass of water.
7:01 PM Patient slightly slouched in wheelchair with some hand movement.
8:02 PM Patient appears to be in same position slightly slouched in wheelchair and head bowing forward slightly.
8:18 PM Staff member comes up to patient and leans in towards patient. Staff member immediately takes patient into the emergency department.

Interview with EMP1 revealed the patient arrived and was triaged as a level 3. EMP1 stated patient did receive an EKG and then was sent out to the waiting room. EMP1 stated the initial triage is a "quick look at the patient." No vital signs were obtained at the initial triage. EMP1 stated the patient was sent out to the waiting room after the initial triage and EKG. EMP1 stated the patient was never "registered" and that the patient was paged twice to be seen by triage II nurse. EMP1 stated that since the patient did not respond when his name was paged overhead, "We assumed the patient left. He was then placed in the 'inactive bucket." EMP1 confirmed the patient was never given a medical record number and did not get an ID band placed because the patient was not registered. EMP1 stated that around 8:30 PM a person sitting near the patient (MR1) alerted a staff member that the patient has not moved in a while. EMP1 stated a staff member went to patient and found him unresponsive. The staff member immediately took the patient into the ED and resuscitation was started. The patient was unable to be resuscitated.

Interview on February 23, 2015, at 10:30 AM, with EMP1 confirmed MR1 did not contain a medical screening exam.

2. Review of facility policy "Triage" last revised January 2016, revealed "Purpose: To provide accurate, efficient classification of patients according to priority of care using the ESI (Emergency Severity Index) 5-level Triage System. ...Scope and Responsibility: The focus of triage is to categorize and assign a priority of care to each patient seen within the triage setting. Triage is to be performed on all patients presenting to the Emergency Department. Upon presentation to the ED, the RN will obtain the patient's name, DOB, Chief Complaint and other relevant information to assign an ESI level. The exception would be ESI level one, who would be directly taken to the treatment area. A history and chief complaint can be ascertained from family or significant other for patients without capacity to verbalize a chief complaint.

A more comprehensive review is completed at Triage 2, which may be either in the waiting area or at bedside, dependent upon volume in the department. This shall include an initial set of vital signs to include: temperature, blood pressure, pulse, and respirations, and pulse oximetry. ... Procedure 1. The triage RN team will be responsible to respond to any changes in patient condition while in the waiting area. ... 4. ... Level 3 patients will have vital signs re-assessed every 4 hours in the event they cannot be brought directly to the treatment area. ..."

Interview on February 25, 2016, at 9:15 AM, with EMP3 confirmed Triage I nurse got report from EMS and "eyeballed" the patient, but did not talk to patient. EMP3 stated, "It is our expectation that staff talk to the patient. We relied on EMS to give us report." Further interview with EMP3 revealed staff "Assumed" patient had eloped after no response from the second overhead page and that triage 2 was not done. EMP3 also confirmed patient was given a triage level of 3 and vitals should have been taken every four hours.

3. Review of "Medical Staff Bylaws," last reviewed November 2015, revealed, "...Patient Care Orders 3.7.1. General. All orders for tests and treatment of patients must be made in writing by physician, podiatrist, dentist, oral surgeon or other health care provider with privileges to do so. Orders must be made in accordance with hospital policy."

EMP3 confirmed staff placed oxygen on the patient without an order. EMP3 confirmed that the employee who placed the oxygen was a patient care assistant and asked the triage nurse, "Do you know this patient?" EMP3 sated the nurse said "No, I did not triage this patient." The nurse did not follow-up by checking on the patient. EMP3 stated the PCA then obtained an oxygen canister and connected it to the patient and turned it on without a physician order.

Based on a review of facility documents, review of medical records (MR) and interviews with staff (EMP), it was determined that the facility failed to provide stabilizing treatment for an emergency medical condition for one of 25 medical records reviewed (MR1).

Findings include:

1. Review of facility policy "EMTALA Requirements" last reviewed May 2015, revealed, "...In accordance with the Emergency Medical Treatment and Labor Act, any individual (whether or not eligible for Medicare or Medicaid benefits and regardless of ability to pay) who comes to Temple University Hospital, Inc. and requests examination or treatment of a medical condition is entitled to and will receive a Medical Screening Examination (MSE) within the capability of the hospital's Emergency Department, including ancillary services routinely available to the Emergency Department. ...The Emergency Department AHP (allied health practitioner) will determine whether an emergency condition exists."

Review of MR1 on February 23, 2016, revealed the patient presented to the Emergency Department on January 7, 2016, at 11:37 AM, and was given a triage level of 3 during triage I. The patient was then sent to the waiting room and an EKG was done at 12:15 PM. The patient was paged overhead at 12:29 PM and at 12:34 PM to complete triage II. Staff documented both times that there was "No response." Staff then documented at 12:34 PM, "Unable to locate patient, will disposition as left without treatment." There was no further documentation until 8:31 PM.

Further review of MR1 revealed the patient was taken back into a trauma bay at 8:31 PM and advanced cardiac life support protocols were initiated. Efforts were eventually ceased and the patient was pronounced dead at 10:02 PM.

A review of the security video for January 7, 2016, revealed the following events and timeline:
11:34 AM Ambulance backs up and patient unloaded into ED, patient has nasal cannula and oxygen tank.
11:35 AM Patient on stretcher and approximately 10 ft away from triage window/nurse.
11:36 AM Fire rescue gives report to RN in window.
11:38 AM Patient is transferred to wheelchair and wheeled to EKG room. No oxygen connected to nasal cannula.
11:45 AM Patient out of EKG and wheeled to waiting room.
12:30 PM Patient wheels himself to EKG room, stays in hallway approximately 10 feet from where he was sitting in waiting room.
2:00-6:45 PM Multiple staff walk by patient, at 6:45 PM a staff member walks up to patient, talks to patient, and moves patient approximately 4 ft into a cubby area out of the direct hallway.
6:47 PM Staff brought oxygen tank and placed it in holder on wheelchair and appears to turn the oxygen on.
6:51 PM Staff gave patient a glass of water.
7:01 PM Patient slightly slouched in wheelchair with some hand movement.
8:02 PM Patient appears to be in same position slightly slouched in wheelchair and head bowing forward slightly.
8:18 PM Staff member comes up to patient and leans in towards patient. Staff member immediately takes patient into the emergency department.

Interview with EMP1 revealed the patient arrived and was triaged as a level 3. EMP1 stated patient did receive an EKG and then was sent out to the waiting room. EMP1 stated the initial triage is a "quick look at the patient." No vital signs were obtained at the initial triage. EMP1 stated the patient was sent out to the waiting room after the initial triage and EKG. EMP1 stated the patient was never "registered" and that the patient was paged twice to be seen by triage II nurse. EMP1 stated that since the patient did not respond when his name was paged overhead, "We assumed the patient left. He was then placed in the 'inactive bucket." EMP1 confirmed the patient was never given a medical record number and did not get an ID band placed because the patient was not registered. EMP1 stated that around 8:30 PM a person sitting near the patient (MR1) alerted a staff member that the patient has not moved in a while. EMP1 stated a staff member went to patient and found him unresponsive. The staff member immediately took the patient into the ED and resuscitation was started. The patient was unable to be resuscitated.

Interview on February 23, 2015, at 10:30 AM, with EMP1 confirmed the facility failed to determine that MR1 had an emergency medical condition.

The facility failed to provide stabilizing treatment for one patient with an emergency medical condition.