HospitalInspections.org

A 2400

Based on record review; review of the emergency department log, facility policies, and staff statements; and staff and emergency department waiting room witness interviews, the hospital failed to comply with the provider agreement as defined in ?489.24(a) for completing a medical screening examination within the hospital capability for 1 of 7 sample patients (#23) with chest pain; failed to comply with the provider agreement as defined in ?489.24(b) for maintaining a central log on each individual who comes to the emergency department for 1 of 23 sample patients (#23); and failed to comply with the provider agreement as defined in ?489.24(b) for retaining a medical record for 1 of 3 sample patients (#13) who left against medical advice. The findings were:

1. Interview on 9/5/12 revealed both facility medical staff and witnesses in the ED waiting area all stated that patient #23 entered the ED on 8/26/12 prior to 1:01 PM in pain. According to interview with the medical staff on 9/5/12, the patient's significant other told the medical staff, a unit coordinator/secretary and the ED physician, the patient was having chest pain. Although interviews with both of the medical staff confirmed a respiratory therapist was paged, neither of the staff present provided any other care or treatment prior to the patient leaving the ED. Three witnesses interviewed on 9/5/12 who were waiting in the ED area at the time of the event confirmed the medical staff never left the area behind the desk to provide any care. The witnesses confirmed hearing the physician make a statement concerning treatment for everyone in the waiting area, in which the physician stated it would take "about two hours". At the time of the announcement, patient #23 and the significant other, along with patient #13 left the ED. Interview with the witnesses in the ED waiting area, and the ED physician, confirmed that no one attempted to stop patient #23 from leaving the ED. Refer to A 2406 for details.

2. A written statement from the ED physician on 8/26/12 at 1:07 PM documented a patient (#23) with chest pain entered the ED "a few minutes ago". Interview with the physician on 9/5/12 at 2:12 PM confirmed the event and revealed the patient had laid down on the floor in the waiting area. He estimated the patient was present in the ED approximately 2 minutes before leaving. Interview with witnesses who were present in the ED waiting area during the event, estimated the patient was present for approximately 5 minutes. Review of the ED log shows no entry for such a patient. Refer to A 2405 regarding details and lack of this entry.

3. Review of the ED log showed on 8/26/12, patient #13 entered the ED at approximately 12:32 PM and left the ED at approximately 1:01 PM. The log showed the patient left against medical advice. When the medical record was requested on 9/4/12, there was no documentation for this patient. Interview with the director of nursing on 9/5/12 at 9:25 AM revealed that when the patient left the ED, a new employee "cancelled" the patient in the computer which removed the charges and the paperwork generated. Refer to A 2403 for details.

Based on review of the emergency department (ED) log, facility policy, and staff interview, the facility failed to ensure it retained a medical record for 1 of 3 patients (#13) who left against medical advice (AMA). The findings were:

Review of the ED log showed on 8/26/12, patient #13 entered the ED at approximately 12:32 PM, and left the ED at approximately 1:01 PM. The log documented the patient left AMA. When the patient's medical record was requested on 9/4/12, there was no documentation for this patient other than the ED log. Interview with the director of nursing on 9/5/12 at 9:25 AM revealed that when the patient left the ED, a new employee "cancelled" the patient in the computer. He stated this removed the charges and the paperwork generated.

When interviewed on 9/4/12 at 2:40 PM, the DON stated the ED process starts with manually writing a sticker which included the patient's name and reason for the visit. The sticker then generates the medical record which results in typed, generated stickers. Review of the ED log for this patient showed the documentation on 8/26/12 was typed and not hand written. Further interview with the DON on 9/6/12 at 11:12 AM revealed the manually written sticker was the log information, and he stated depending on the situation, the nurse typically does the documentation at the time of triage. The DON stated that those patients documented in the ED log have gone through the registration process.

According to the facility's policy, "Triage", effective date December 2010, the registered nurse will evaluate and triage patients within 10 minutes of arrival, determine a triage level, and will obtain other information such as the patient's name and chief complaint.

Based on review of the emergency department (ED) log, written staff statements, and staff interview, the facility failed to document all patients requesting assistance in the ED for 1 of 23 (#23) patients. The findings were:

A written statement from the ED physician on 8/26/12 at 1:07 PM documented a patient [patient #23] with chest pain entered "a few minutes ago" and then left without being seen. Interview with the physician on 9/5/12 at 2:12 PM confirmed the event and revealed the patient had laid down on the floor in the waiting area. He estimated the patient was present in the ED approximately 2 minutes before leaving without being seen. He stated the patient's significant other had approached the desk and stated the patient had chest pain. The physician stated the nurse was not available when he looked for him, so he had respiratory therapy paged. Interview with the unit coordinator/secretary on 9/5/12 at 2:26 PM confirmed the event, and stated the patient was moaning, in pain, and she confirmed the significant other stated the patient had chest pain. Review of the ED log for 8/26/12 showed neither of the staff manually logged the patient into the ED log. In addition, interview with three witnesses on 9/5/12 between 9:33 AM and 12:40 PM confirmed the event and estimated the patient was present in the ED for approximately 5 minutes.

Interview with the director of nursing on 9/6/12 at 11:12 AM revealed the facility did not have a process regarding how to deal with patients who leave without being seen. He stated some patients are documented in the log and some are not. The DON stated the log process starts with a manually written sticker as the log information, and he stated depending on the situation, the nurse typically does the documentation at the time of triage.

Based on review of medical records, the emergency department (ED) log, and facility staff written statements, and staff and emergency department waiting room witness interviews, the facility failed to provide a medical assistance/screening exam for 1 of 7 patients (#23) reviewed for chest pain. The findings were:

Review of written statements from the ED physician working on 8/26/12 revealed prior to 1:01 PM, a patient (#23) entered the ED with chest pain. According to the physician's statement dated and time stamped on 8/26/12 at 1:07 PM, "a patient presented via private vehicle a few minutes ago with chest pain. I called [name of the respiratory therapist] to do an EKG and was looking for [name of registered nurse] to find a room for the patient. Patient layed down on the [ED] floor and asked [the significant other] what was going oon [sic]. I had kept [the significant other] in the loop that we are getting [a] nurse and a room ready for [the patient]. [The significant other] sted [sic] that they are going to [the] other hospital then. They did not even give me a chance to process the patient." The statement also showed that one other patient (#13) with a burn on the hand had left the ED at the same time. The ED log noted that this second patient left against medical advice at 1:01 PM. Further review of the event involving patient #23 revealed concerns for lack of medical screening and care as follows:

a. Review of the ED log failed to show any documentation related to patient #23 who presented with chest pain and left without being seen.

b. Interview with the director of nursing (DON) on 9/5/12 at 8:15 AM revealed two facility staff members, the ED physician and the unit coordinator/secretary, were present during the event on 8/26/12.

1. Interview with the ED physician was done on 9/5/12 at 2:12 PM. He confirmed the written statement. He stated the significant other told the unit secretary that the patient was having chest pain which he overheard. The patient was in the ED about 2 and a half minutes and then the patient and the significant other left. Further interview revealed the physician stated the care he provided was to look around for the nurse, have the secretary page respiratory, and announce to the patients waiting that it would be "awhile" before they could attend to everyone. He stated that after the announcement, the patient and significant other left, as well as, a patient with a minor burn on a hand. He stated he told the significant other that they would get staff and a room for the patient and he believed she stated this to the patient who was now lying on the floor. When asked, the physician stated he did not try to stop them from leaving, stating it happened so fast. He stated the couple left as the respiratory therapist arrived in the ED.

2. Interview with the unit secretary on 9/5/12 at 2:26 PM confirmed she and the ED physician were the only staff present when the significant other of patient #23 approached the desk and asked for help, as the patient was having chest pain. The secretary stated she told the physician that she would page respiratory and did. She confirmed at one point the physician told the couple he was getting a room ready. She stated the physician made a statement to those waiting that they needed to care for those who need the most care and it would be about a 2 hour wait. She stated right after the announcement, the couple left; the significant other stated they were going to the other hospital. She confirmed they were in the ED approximately 2 minutes.

Review of the ED log showed a number of other people were present in the area waiting for care. Interview with three witnesses revealed the following:

1. Interview with witness #1 on 9/5/12 at 9:33 AM confirmed the significant other told both the physician and secretary the patient was having a "heart attack". The patient laid on the floor near the chairs which were filled, and the patient looked "like death warmed over." The witness stated the couple's length of stay to have been approximately 5 minutes at least, and stated no one provided care to the patient. The witness confirmed staff did not come around the desk to take action or provide any assistance. The witness never heard statements concerning getting the patient a room, but heard the physician tell everyone in the waiting area there would be about a 2-hour wait. At which time, the couple got up, the significant other stated they were going to the other hospital, and they, and another patient who held their hand in water left. Witness #1 stated that while the couple was present and the patient was on the floor, witness #2 made a statement out loud. Witness #2 stated "you could give [the patient] Nitro [Nitroglycerine used to dilate the cardiac vessels during a heart attack] and oxygen."

2. Interview with witness #2 on 9/5/12 at 9:57 AM revealed this person was a retired licensed practical nurse. This witness confirmed the conversation with witness #1, and stated the staff remained behind the desk and did not provide action to care for the patient. This person estimated the couple was in the waiting area approximately 5 minutes before leaving. Witness #2 stated the physician told everyone present there was one doctor and one nurse on, so it would be "about a 2 hour wait for some of you." The witness added, "It was obvious [patient #23] was in pain and having trouble breathing." This person described the reaction of the staff at the desk as, "no one really acted like it was urgent."

3. Interview with witness #3 on 9/5/12 at 12:40 PM confirmed previous statements concerning the patient was in obvious pain, had laid on the floor, that staff had not provided any interventions, an announcement was made about a 2 to 2 1/2 hour wait for care, and that the couple left. The witness confirmed the couple's presence in the ED to be approximately 5 minutes.

Interview at 7:10 PM on 9/4/12 with the significant other for patient #23 revealed upon their arrival to the ED, a man and woman were behind the desk. The significant other stated these staff members were told the patient was having a heart attack. While at the desk, the patient went and laid down on the floor near the chairs, as the waiting area was full. The significant other was told by the man that ED was busy, there was only 1 treatment room, the significant other had understood the man to state that there were no doctors, and it would be a two hour wait. The significant other stated no statements were made concerning what care or assistance was going to be provided. After the significant other talked with the patient, they decided to go to the other hospital. The significant other estimated the time in the ED to have been approximately 5 to 10 minutes. After getting to the second hospital, the significant other stated the patient did have a cardiac arrest and was resuscitated.

Review of medical records obtained from hospital #2 confirmed patient #23 arrived to their ED at 1:12 PM on 8/26/12 and by 1:23 PM was being treated for a cardiac arrest.